What is the current trend in smoking cessation treatment?
In 2008, the U.S. Department of Health and Human Services (DHHS) published an update of clinical practice guidelines entitled Treating Tobacco Use and Dependence. It provided 10 key recommendations, which are listed here. Guidelines are available online for free at http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/factsheet.html
The overarching goal of these recommendations is that clinicians strongly recommend the use of effective tobacco dependence counseling and medication treatments to their patients who use tobacco, and that health systems, insurers, and purchasers assist clinicians in making such effective treatments available.
Ten key Guideline Recommendations
1. Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long-term abstinence.
2. It is essential that clinicians and healthcare delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a healthcare setting.
3. Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use the counseling treatments and medications recommended in this Guideline.
4. Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective.
5. Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. Two components of counseling are especially effective, and clinicians should use these when counseling patients making a quit attempt:
• Practical counseling (problem solving and skills training)
• Social support delivered as part of treatment
6. Numerous effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempting to quit smoking. Clinicians also should encourage their use by all patient populations attempting to quit for whom there is insufficient evidence of effectiveness (that is, pregnant women, smokeless tobacco users, light smokers, and adolescents). Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates:
• Bupropion SR (Zyban or Wellbutrin)
• Nicotine gum
• Nicotine inhaler
• Nicotine lozenge
• Nicotine nasal spray
• Nicotine patch
• Varenicline (Chantix)
Clinicians also should consider the use of certain combinations of medications identified as effective in this Guideline.
7. Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either therapy alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication8. Telephone “quit line” counseling is effective with diverse populations and has a broad reach. Therefore, both clinicians and healthcare delivery systems should ensure patient access to quit lines and promote quit line use.
9. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments shown to be effective in increasing future quit attempts.
10. Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in this Guideline as covered benefits.
In addition to the 10 key recommendations, the Guideline also cites “The Five A’s” as a model for treating alcohol use and dependence. They are listed here:
The Five A’s model for Treating Tobacco Use and Dependence
1. Ask about tobacco use. Identify and document tobacco use status for every patient at every visit.
2. Advise to quit. In a clear, strong, and personalized manner, urge every tobacco user to quit.
3. Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at this time?
4. Assist in quit attempt. For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit. For patients unwilling to quit at the time, provide interventions designed to increase future quit attempts.
5. Arrange follow-up. For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the first week after the quit date. For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at the next clinic visit.
Lisa’s comment:
I feel, after trying various processes to quit in the past, that it was having all my “forces” lined up behind me. In retrospect, I see that I had so many layers of support that mentally, I was thinking if one thing didn’t work, I had another thing to fall back on; there was one layer after another. I utilized every “tool” available to me: my doctor, a therapist, a cessation program, medication (Zyban, at that time), nicotine supplements (patch and gum), a self-hypnosis tape, a quiz to determine what kind of smoker I was, homework, acupressure, and a support group. I, who smoked two and a half packs a day for 30 years, have successfully lived my life entirely smoke-free now for 6 years. Before the combination of tools listed, I had only managed to struggle to 14 days before falling apart and smoking again.
What are the qualifications of professionals who run smoking cessation groups?
Qualifications of those who run smoking cessation groups vary. People who run smoking cessation programs may be health professionals, health educators, or skilled volunteers.
Others have a background in substance abuse, are ex-smokers, and those who have witnessed the ill-effects of smoking, such as nurses and respiratory therapists. The American Cancer Society encourages people to make sure that the program leader has had training in smoking cessation counseling. Some people are interested in alternative therapies, such as acupuncture, laser acupuncture treatment, electro stimulation, and hypnotherapy. Studies have not shown that these alternative or complementary therapies are effective in the treatment of tobacco use. Additionally, an independent review of nine hypnotherapy trials by the Cochrane Group found insufficient evidence to support hypnosis as a treatment for smoking cessation. Credentialing of these professionals should be carefully investigated. Most accredited acupuncture schools require at least two years of undergraduate study prior to admission; others require students to complete a bachelor’s degree. Other training facilities do not require any prior education or experience. It is important to note that there are differences in success rates depending upon the type and number of clinicians utilized.
What is my healthcare professional’s role in my smoking cessation?
The role of the healthcare professional is to assist you in selecting the quit assist method that is best for you, teach you tips on how to help yourself with the challenges of quitting, guide you through the steps to stop smoking, and support you during the withdrawal phase. If you are in a smoking cessation group, the counselor or professional will facilitate the group discussion and assist the group members to support each other.
Prior to your decision to quit smoking, your primary healthcare provider should have assessed your smoking history in order to make recommendations about the various resources that are available to help you to quit. Fifty to seventy percent of smokers see their primary healthcare provider each year. All clinicians, particularly primary healthcare providers, are uniquely poised to intervene with patients who use tobacco.
Smokers frequently cite a physician’s advice to quit as an important motivator for attempting to stop smoking. A physician’s advice to quit can increase the odds for success by 30%. A population-based survey found that less than 15% of smokers who saw a physician in the past year were offered assistance to stop smoking and only 3% had a follow-up appointment to address tobacco use. Health professionals should follow the Five A’s with every patient:
1. Ask about smoking.
2. Advise quitting.
3. Assess willingness to make a quit attempt.
4. Assist in a quit attempt.
5. Arrange a timely follow-up.
A physician’s advice to quit can increase the odds for success by 30%.
