Smoking Cessation: A Guide for Primary Care Clinicians

Smoking kills more than 400,000 persons a year in the United States. Every office visit is an opportunity to promote smoking cessation.

This Clinician’s Guide is based on the Clinical Practice Guideline on
Smoking Cessation, Number 18. It was
prepared by a panel of experts convened by the Agency for Health Care Policy and Research,
and reflects a thorough review of evidence from clinical studies spanning 1978 to 1994.

Helping Smokers Quit

1. Every person who smokes should be offered smoking cessation treatment at every office
   visit.
2. Clinicians should ask about and record the tobacco-use status of every patient.
3. Cessation treatment even as brief as 3 minutes a visit is effective.
4. The more intense the treatment, the more effective it is in producing long-term abstinence
   from tobacco.
5. Nicotine replacement therapy (nicotine patches or gum), social support, and skills
   training are effective components of smoking cessation treatment.
6. Health care systems should be modified to routinely identify and intervene with all
   tobacco users at every visit.

Ask, Advise, Assist

Ask about smoking

Implement an officewide system that ensures that tobacco-use status is obtained and recorded for
every patient at every office visit.

Include tobacco use in vital signs data collected. Or place tobacco-use status stickers on all
patient charts or indicate smoking status using computer reminder systems.

Advise tobacco users to quit

• In a clear, strong, and personalized manner, urge every smoker to quit.

• Be clear. (“I think it is important for you to quit smoking now, and I will help you.”)

• Speak strongly. (“As your clinician, I need you to know that quitting smoking is the most
  important thing you can do to protect your current and future health.”)

• Personalize your advice. (“You’ve already had one heart attack.”) Mention the impact of
  smoking on children or others in the household. (“You know your children need you.”)

Assist the patient with a quit plan

Advise the smoker to:

• Set a quit date, ideally within 2 weeks.

• Inform friends, family, and coworkers of plans to quit, and ask for support.

• Remove cigarettes from home, car, and workplace and avoid smoking in these places.

• Review previous quit attempts—what helped, what led to relapse.

• Anticipate challenges, particularly during the critical first few weeks, including nicotine
  withdrawal.

Give advice on successful quitting:

• Total abstinence is essential—not even a single puff.

• Drinking alcohol is strongly associated with relapse.

• Having other smokers in the household hinders successful quitting.

Encourage use of nicotine replacement therapy (for more information on prescribing,
precautions, and side effects, see the Clinical Practice Guideline):

• Both the nicotine patch and nicotine gum are effective pharmacotherapies for smoking
  cessation.

• The nicotine patch may be easier to use than the gum in most clinical settings.

Make culturally and educationally appropriate materials on cessation techniques readily
available in your office.

Intensive Programs

Offer intensive smoking cessation programs

If your patient prefers intensive treatment or you think such a program is appropriate, refer him
or her to an intensive smoking cessation program administered by a specialist. Always followup
with the patient about quitting.

• Intensive programs are strongly correlated with cessation success.

• Information obtained in the assessment (e.g., comorbidity, stress level) is useful in
  counseling.

• Many different types of clinicians (e.g., nurses, dentists, psychologists) are effective in
  increasing quit rates.

• Intensive programs should offer 4-7 sessions, each at least 20-30 minutes in length,
  lasting at least 2 weeks.

• Counseling should offer problem solving and skills training as well as social support.

• Counseling should reinforce motivation to quit and relapse prevention. Individual and
  group counseling are both effective.

• Every smoker should be offered nicotine replacement therapy (patch or gum), except
  when medically contraindicated.

If a smoker doesn’t want to quit, clinicians should ask questions at each visit that help the
patient identify (1) reasons to quit and (2) barriers to quitting. Pledge to assist the patient when
he or she is ready to quit.

Key Treatment Strategies

Three treatment strategies are particularly effective:

Nicotine replacement therapy—Should be encouraged for most patients. Although
the
patch and gum are both effective, the patch is associated with fewer compliance problems and
requires less effort to train patients in its use.

• Patch: Plan on 8 weeks of therapy. Starting on the quit day, place a new patch, each
  morning, on a relatively hairless place between the neck and the waist. Consult the
  package insert for dosing suggestions and precautions.

• Gum: Use for up to 3 months. Patients often do not use enough gum to get
  maximum
  benefit. Use one piece every 1-2 hours. Chew and “park” gum (between cheek and gum)
  intermittently for about 30 minutes to allow nicotine absorption. Use 4 mg (vs. 2 mg)
  dose for highly dependent smokers.

• Nasal Spray: Recently approved by FDA. Consult package insert for dosing and
  precautions.

Clinician-provided social support—Should communicate caring and concern by
being
open to the patient’s fears and difficulties.

Skills training/problem-solving techniques—Should review previous quit successes
and
failures, anticipate relapse risk situations, and stress total abstinence starting on the quit day.

Followup

Schedule followup contact, either in person or by telephone

Timing:

• First followup contact within 2 weeks of the quit date, preferably during the first week.

• Second contact within the first month.

• Further followup contacts as needed.

Actions during followup visits:

• Congratulate success.

• If a lapse occurred, ask for recommitment to total abstinence.

• Remind the patient that a lapse can be used as a learning experience and review the
  circumstances that caused it. Suggest alternative behaviors.

• Identify problems encountered and anticipate challenges in the immediate future.

All treatment strategies apply to adolescents who smoke. Clinicians should be
empathetic
and nonjudgmental and should personalize the encounter to the adolescent’s individual situation.
Nicotine replacement therapy may be considered in adolescents addicted to nicotine.

Prevent Relapse

To prevent relapse, offer ex-smokers reinforcement

• Congratulate, encourage, and stress importance of remaining abstinent.

• Review the benefits, including potential health benefits, to be derived from cessation.

• Review the patient’s success in quitting.

• Inquire about problems encountered in maintaining abstinence and offer possible
  solutions.

• Anticipate problems or threats to maintaining abstinence.

Discuss specific problems, such as:

• Weight gain.

• Negative mood/depression.

• Prolonged nicotine withdrawal.

• Lack of support for cessation.

Fear of weight gain is an impediment to smoking cessation. Inform smokers that
many people gain weight when they stop smoking. Tell them that weight gain is a
minor risk compared with the risks of continued smoking. Tell patients to tackle one
problem at a time. First, be confident that they have quit smoking for good, then work
on reducing weight gain. Nicotine gum may delay weight gain.

For printed copies of this guide, the complete Clinical Practice Guideline, a
Quick Reference
Guide for Smoking Cessation Specialists, a Consumer Version (available in
English and
Spanish), or a list of other AHCPR guidelines, call 800-358-9295 or write:

AHCPR Publications Clearinghouse
P.O. Box 8547
Silver Spring, MD 20907

These and other guidelines are available through the Internet (http://www.ahcpr.gov/guide/).
Copies of this and other brochures are free through InstantFAX, which operates all day every
day. Using a fax machine equipped with a touchtone telephone, dial (301) 594-2800, push 1, and
then press the start button for instructions and a list of publications.

U.S. Department of Health and Human Services
Public Health Service
Agency for Health Care Policy and Research
2101 East Jefferson Street, Suite 501
Rockville, MD 20852

AHCPR Publication No. 96-0693
April 1996

Guidelines and Medical Outcomes
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