Smoking cessation

A 52 year old man with asthma, hyperlipidaemia, and a family history of early onset heart disease comes to see you because of increased wheezing and dyspnoea. He has smoked a pack per day for 36 years. He tried quitting “cold turkey” but felt irritable and couldn’t concentrate; he tried nicotine gum but it didn’t work. He is willing to try stopping smoking again but wonders if it is too late for him to benefit from quitting and if he ever can quit.

What issues you should cover

The patient’s smoking should be tackled as a standard part of treating his presenting problem, an asthma flare. Tobacco use should be attended to at all patient visits, but respiratory or cardiac symptoms provide a special opportunity. Specific symptoms that can be attributed to tobacco use, rather than risk of future disease, can motivate smokers to change behaviour. In this case, stopping smoking will improve the patient’s asthma control.

What you should do

• Congratulate the patient on willingness to address tobacco use. Assure him that you can help.

• Attend to his concerns and elicit any others. Like many long-time smokers, he wonders if it is too late to benefit from stopping smoking. It is not. Stopping smoking benefits health and extends life at any age, even after many years of smoking or the diagnosis of a smoking related disease. Reassure these patients that most smokers try several times before they succeed. The task is to learn to overcome the difficulties he encountered in past efforts.

• Ask about attempts to stop smoking. Details of the methods tried, strategies that produced longer periods of abstinence, and events preceding the return to smoking will guide your recommendations. Many smokers fail to recognise that non-specific symptoms—irritability, restlessness, trouble concentrating or sleeping, anxiety, and depressed mood—represent nicotine withdrawal that can be relieved with pharmacotherapy. This patient reported that nicotine gum did not help. Medication failure must be distinguished from incorrect medication use or inadequate dosing that represents an inadequate trial of the medication. This often occurs with nicotine replacement products other than the patch.

• Identify characteristics that might lower the patient’s chance of success. Previous nicotine withdrawal symptoms, smoking more cigarettes per day, and smoking within 30 minutes of awakening suggest stronger nicotine dependence. Patients might benefit from a formal stop smoking programme if they live with a smoker or have little social support for quitting or little confidence that they will succeed. Substance abuse or a psychiatric disorder like depression must be dealt with concurrently.

• Elicit the patient’s treatment preferences.

A health professional’s brief discussion of smoking cessation is a medically effective and cost effective intervention. Evidence based clinical guidelines provide a framework for structuring this discussion (box). For smokers willing to try to stop, clinical guidelines recommend combining pharmacotherapy (nicotine replacement products, bupropion, or varenicline) with psychosocial counselling. Practice nurses or other allied health professional may be available to help with this counselling. You can refer your patient to smoking cessation counselling programs such as the UK’s NHS Stop Smoking Service, to telephone counselling, or to web based resources. If these resources are limited, the GP needs to take a more comprehensive approach.

• Ask each patient about tobacco use—Document this in the patient’s record

• Advise each smoker to quit—Make advice strong and positive: focus on benefits of quitting rather than harms of continued tobacco use; link the advice to the smoker’s specific clinical condition or reason for visit

• Assess each smoker’s willingness to make a quit attempt—Is the tobacco user ready to set a “quit date” in the next 30 days? If not, explore his barriers to taking action and help him to overcome them. If so, help him to formulate a plan based on smoker’s experiences in quitting; your assessment of his likelihood of difficulty; and smoker’s preferences about treatment

• Assist each smoker to make a quit attempt—Offer medication and refer to counselling:

• -Smoking cessation counselling can be provided effectively in person or by telephone

• -Drug treatments (nicotine replacement therapy, bupropion SR, varenicline) increase the chance of success of a quit attempt:

  • Nicotine replacement therapy (gum, patch, tablet, lozenge, inhaler, or nasal spray) almost doubles the chance of success, compared with placebo

  • Bupropion SR, an antidepressant, also approximately doubles a smoker’s chance of success

  • Varenicline, a partial agonist of the α4β2 nicotinic receptor, is a new agent that nearly tripled the chance of success compared with placebo and was more effective than placebo and than bupropion in two recent clinical trials

• Arrange follow-up—In your office, either with you or with an allied health professional, or through community services, accessed through http://gosmokefree.co.uk or www.smokefree.gov, or other websites

Useful reading

• National Institute for Health and Clinical Excellence. Smoking cessation. www.nice.org.UK

• US Public Health Service. Treating tobacco use and dependence: clinical practice guidelines. June 2000. www.surgeongeneral.gov/tobacco/

• Lancaster T, Stead LF. Physician advice for smoking cessation. Cochrane Database Syst Rev 2004;(4):CD000165.

• Srivastava P, Currie GP, Britton J. Smoking cessation. BMJ 2006;332:132.

• Jorenby DE, Hays JT, Rigotti NA, Azoulay S, Watsky EJ, Williams KE, et al. Varenicline Phase 3 Study Group. Efficacy of varenicline, an α4β2 nicotinic acteylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: a randomised controlled trial. JAMA 2006;296:56.