Every patient who walks into the clinic must be asked about tobacco usage. One simple way to implement this is to make tobacco use part of vital signs. Usage should also be documented in the chart. In fact, there is strong evidence that the use of “provider reminders” by health care providers improves tobacco cessation rates. These reminders could take the form of a chart sticker, vital sign stamp, medical record flow sheet, or checklist. These represent systems-based reminders to the provider to prompt the provider to discuss tobacco cessation (19).
TABLE 21.1 OVERVIEW OF BRIEF CLINICAL INTERVENTION
Otolaryngologists should advise all patients on the risks of tobacco usage at every clinic visit. This includes nonsmokers, smokers, and former smokers. Doctors should also strongly urge all users of tobacco to quit, advise patients of the risk of continued use, and explain the benefits of quitting. All advice should be stated in a clear and strong statement. The advice should also be personalized. Discussion of personal benefits of successful cessation could include examples such as saving money, decreasing risks to others (kids), cutting personal risk, or living longer. Unfortunately, only 37.2% of smokers reported they received advice to quit during a visit to a health care provider in the last year. This is even more worrisome as 70.2% of all smokers reported seeing a physician during the same time period (15).
It is also important to ask all tobacco users “Are you willing to give quitting a try?” If the patient indicates that he or she is ready to quit now, then provide assistance to do so. At this time, either deliver or set up intensive intervention for the patient. Also initiate pharmacotherapy, and provide resources the patient can use to help. Just telling the patient to quit is not good enough. Intensive intervention has been shown to be far superior than simple advice (20).
For those patients who are not interested in quitting, consider motivational interviewing techniques, or any other intervention geared toward increasing the probability the patient will be ready to quit in the future. It has been demonstrated that these techniques appear to be effective in increasing the likelihood that the patient will make a future quit attempt. To perform these techniques, clinicians must proceed with four basic principles: express empathy, develop discrepancy, roll with resistance, and support self-efficacy. It is also advantageous to utilize the “5Rs,” a concept that helps capture the content areas to be addressed. These include relevance, risks, rewards, roadblocks, and repetition. Under this umbrella, the otolaryngologist can begin to explore the patient’s fears and begin to offer reasons and ideas that lessen the patient’s resistance to change (21).
It is also imperative to assess the patient’s readiness to change. A firm grasp of the transtheoretical model is important when dealing with any process of behavioral change. This model assesses the individual’s readiness to change and is commonly referred to as the “Stages of Change.” Familiarity with this model allows the clinician to more effectively communicate with patients and to tailor both the discussion and recommendations specifically to the individual patient’s willingness to change.
The first stage of change is Precontemplation. This stage is characterized by the individual’s lack of intent to take action in the foreseeable future. Patients may be in this stage because they are uninformed or underinformed, or they may have failed to quit smoking previously and now are demoralized about the prospects of succeeding. These patients will avoid thinking about or may not even be aware of their high-risk behaviors (22).
The second stage of change is the Contemplation stage. This stage is characterized by the individual who intends to change in the next 6 months but remains in a state of chronic contemplation as he or she weighs the pros and cons—with a majority of his or her focus on the cons. This individual may be more open to seeking out information but most likely shows ambivalence (22).
Preparation is the third stage and is defined by the individual who intends to take action in the immediate future, typically within 1 month. These patients have thought about a plan of action and are usually seeking information. These are excellent candidates for action-oriented programs in smoking cessation (22).
The Action stage is when the individual makes the modification to his or her lifestyle and continues it for 6 months. With smoking cessation, this stage represents the quit date, followed by abstinence. Unfortunately, of the six stages, this is the only stage that is actually observable to the outside individual (22).
After 6 months of abstinence, the patient moves into the fifth stage, Maintenance. This stage is characterized by the patient working to prevent relapse, but no longer actively changing. With smoking cessation, this stage can last years with a relapse rate at 12 months of 43%, decreasing to 7% after 5 years. This stage usually lasts as long as the change endures (22).
The final stage, Termination, is a theoretical goal, but not usually attained. It is defined by the individual achieving a state where there is no temptation to revert no matter his or her condition or the situation he or she is in. In this stage, it would be as if the patient had never initially acquired the habit. Unfortunately, this is rarely attained and in the setting of smoking cessation efforts has no practical use (22).
Some patients do relapse and restart smoking. Relapse is not a stage by itself but represents a form of regression with a return to an earlier stage. Luckily, only about 15% of patients return all the way to precontemplation. In the event of relapse, identify what stage the patient has returned to, and then immediately restart the motivational interviewing process (22).
It is important to provide advice and support to those patients interested in quitting. Many steps should be taken to assist the patients in their difficult endeavor, including set a quit date, have the patient tell their family their plan, have the patient tell friends and coworkers so there are more people to provide support and encouragement, encourage the patient to remove all tobacco products, and help the patient change routines and develop a new lifestyle (Table 21.2).
TABLE 21.2 EXAMPLES OF PRACTICAL TOPICS FOR COUNSELING
Activities that can increase the risk of relapse include stress, being around other tobacco users, or drinking alcohol.
The patient should be warned to anticipate experiencing urges and should learn behaviors to cope with them, including distracting attention and changing routines.
Patients should be aware of their smoking cues and the availability of cigarettes.
Patients should learn to avoid trigger situations.
Reduce negative moods by developing cognitive strategies.
Change lifestyle to reduce stress and reduce exposure to smoking cues.
Any smoking increases the chance of a full relapse.
Withdrawal symptoms peak within 1-2 wk and include problems with concentration, mood, or urges. These can last for many months.
Reinforce the idea that smoking is an addiction.
Assure the patient effective treatments are available.
Reinforce the reasons the patient wants to quit.
Note that half of all people who have ever smoked have now quit.
Encourage the patient to talk about the quitting process.
Communicate your concern for the patient. Encourage the patient and build confidence in the patient.
Adapted from Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A Clinical Practice Guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report. Am J Prev Med 2008;35(2):158-176.
When offering practical advice, it should be done with specific consideration to problem-solving skills. Have the patient commit to total abstinence. Review past attempts and why they did not work, what could be done differently, and use any positives from those experiences to bolster the patient’s resolve. Anticipate triggers and challenges and develop strategies about how to overcome them. Encourage the patient to limit or abstain from alcohol, as the use of alcohol is associated with higher incidence of relapse. Diminish exposure to secondhand smoke, including identifying other smokers with whom the patient may have contact. Encourage other individuals at home to quit at the same time to provide both a smoke-free environment and a support system.
One of the most important steps in assisting the patient is to set them up with counseling, specifically intensive intervention. Also, if possible, use pharmacotherapy in conjunction with the counseling. Multimodality treatment has been proven to have a higher success rate than single modality treatment. Provide supplementary materials to patients with additional information on resources and smoking cessation. Also provide support to the patient by offering your office and time as available to assist with any problems. Telephone support as a component of the intervention is strongly recommended and has been demonstrated to increase success rates for tobacco cessation (19). This could include followup telephone calls or informational messages left for the patient.
Every state in the United States has a tobacco quitline. These lines offer free counseling and are able to get patients in contact with other local programs. These services can be accessed by calling either 1-800-QUIT-NOW or 1-877-2NO-FUME. The National Cancer Institute of the National Institute of Health also sponsors a quitline, 1-800-44U-QUIT. In a meta-analysis, these quitlines have been found to be effective methods of treating tobacco dependence (21).
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Tobacco Cessation: How-to Guidance and Resources for Practitioners
Tobacco Cessation: How-to Guidance and Resources for Practitioners
Henry R. Diggelmann
Grant S. Hamilton III
Smoking tobacco is the single most preventable cause of death and disease in the United States (1). In 2005, smoking tobacco was responsible for 467,000 deaths, accounting for about 1 in 5 deaths in US adults (1). In the United States, an additional 8.6 million people have serious illnesses that are caused by smoking—chronic bronchitis and emphysema account for more than half of them. For every person who dies from tobacco use, another 20 suffer with at least 1 serious tobacco-related illness (2). Tobacco use also represents a huge economic burden. During the time period from 2000 to 2004, cigarette smoking was estimated to be responsible for $96 billion in direct medical costs and $97 billion in lost productivity (3).
Unfortunately, it is estimated that 46 million American adults currently smoke cigarettes (4). Even though the numbers remain high, there has been a significant decrease in cigarette smoking over the last 40 years (5). From 1965 to 2008, the percentage of the US population who smoke decreased from approximately 42% down to 20.6% (4,5). However, this decrease has leveled off over the last 5 years (4). Fortunately, of the estimated 94 million people who have ever smoked, 51.1% have now quit, and since 2002, the number of former smokers outnumbers the number of current smokers (4).
Smoking has historically been more common in men. Centers for Disease Control and Prevention data from 2008 suggest a prevalence of smoking in the United States of 23.1% among men and 18.3% among women. There is also some variability with regard to age. In general, the percentage of smokers 18 to 65 years of age does not vary significantly from the national average—however, there are significantly fewer adults over age 65 who smoke. This age group has a smoking prevalence of only 9.3%.
Tobacco use patterns also vary by socioeconomic status. The prevalence of smoking among adults with a graduate degree is only 5.7%, while the prevalence of smoking is highest among adults who had only earned a General Education Development certificate. This is consistent with data demonstrating that individuals with higher education also have a much higher awareness of the risks associated with smoking (6). Smoking is also much more common in adults living below the poverty level compared to those living above the poverty level, with a prevalence of 31.5% and 19.6%, respectively. Tobacco use is also not uniform between different ethnic groups. Asians have the lowest prevalence at 9.9%, followed by Hispanics at 15.8%, non-Hispanic blacks at 21.3%, non-Hispanic whites at 22.0%, and American Indians the highest at 32.4% (4).
The chemical primarily responsible for tobacco dependence is nicotine. Nicotine is a highly addicting drug. Its main targets in the central nervous system are neuronal nicotinic acetylcholine receptors. It also acts on the mesolimbic dopamine system, resulting in reward signaling and addiction. Its effects on the brain reduce anxiety and relieve stress, in addition to slight cognitive enhancement and increased ability to fight fatigue (7,8). Interestingly, there is a strong genetic component to nicotine dependence (9). The bioavailability of nicotine is around 12% in cigarette smoke, representing an uptake of about 1 mg of nicotine per cigarette. However, this uptake is variable depending on the method used to smoke the cigarette and can be increased to up to 40% bioavailability. It is generally considered that a dose of 5 mg of nicotine per day can result in addiction, but this is variable among individuals. Nicotine is metabolized in the liver and the principal metabolite is cotinine. Cotinine levels in blood, urine, hair, saliva, or nail can be measured and are directly proportional to the amount of nicotine the patient has recently been exposed to. Per cigarette, smokers produce 14 ng of cotinine per milliliter of blood. It is generally considered that a nonsmoker should have 3 ng/mL or less of cotinine in his or her bloodstream (10,11). The clinician can verify cessation of smoking using this test.
Tobacco cessation is a critical part of the patient encounter for the otolaryngologist. Smoking impacts patients in a multitude of ways, and efforts directed toward cessation provide the foundation of preventive medicine for all areas in the field of otolaryngology. In fact, tobacco abuse can lead to decreased olfaction, thyroid disease, rhytids, tooth discoloration, gum disease, cancer, decreased taste, voice changes, sore throat, hearing loss, and many of other conditions. Smoking also increases the rate of postoperative complications and impairs wound healing.
Head and neck cancer is directly caused by tobacco use. Smoking cessation efforts are fundamental to efforts to decrease the incidence of head and neck cancer. Multiple studies conclude that quitting smoking can lower the incidence of second malignant lesions in head and neck cancer patients from 40% down to 5% to 20%. However, this is controversial. Other data suggest that patients who have reached a critical level of damage due to prolonged tobacco exposure will not see this benefit. In this model, it is hypothesized that after a certain level of exposure, the damage caused by tobacco exposure is irreversible, even with cessation. This model also proposes that, for this reason, individuals who have the least amount of tobacco exposure will have the most benefit from cessation (12).
Secondhand smoke also poses a significant health risk. In fact, there is no level of secondhand smoke that is riskfree and the presence of any secondhand smoke carries risk of developing complications. Secondhand smoke has been proven to cause premature death and disease in both children and adults who are nonsmokers. In children, secondhand smoke results in increased risk for sudden infant death syndrome, acute respiratory infections, ear infections, and asthma. Children exposed to smoking by their parents also demonstrate slowed lung growth and suffer from respiratory symptoms. Adults exposed to secondhand smoke can develop coronary artery disease and lung cancer (13).
THE CLINICAL INTERVENTION
Smoking cessation is an integral part of today’s medical practice and has received extensive investigation in the medical literature. Consequently, this area has been investigated on a scale rarely achieved in the field of otolaryngology.
In 2008, among current cigarette smokers, an estimated 45.3% of smokers tried to quit and managed to stop smoking for 1 or more days (4). Unfortunately, an unassisted attempt at smoking cessation only has a success rate of around 4%. Interventions that have been demonstrated to effectively decrease the use of tobacco include increasing price of tobacco products, instituting smoke-free policies, limiting advertisements and promotions, controlling access, and assisting and promoting users to quit (14). Herein lies the role of the physician, to assist and promote users to quit.
The physician occupies an important and unique position to intervene in smoking cessation. Unfortunately, physicians often do not take advantage of their authority, as only 37.2% of smokers reported they received advice to quit during a visit to a health care provider in the last year. This is significant as 70.2% of all smokers reported seeing a physician during the same time period (15). The responsibility of the physician is emphasized by Kreuter et al. (16), who found that smokers were 54% more likely to try to quit if a physician told them to quit. With this in mind, and with 70% of smokers reporting that they want to quit (17), a positive interaction in the physician’s office is a key portion of the tobacco cessation process.
Therefore, all patients should receive guidance and advice concerning tobacco usage at every clinical visit, including current smokers, former smokers, or nonsmokers. For current smokers, it has been demonstrated that interventions that are as short as 3 minutes can significantly increase rates of tobacco cessation. This intervention should include a combination of counseling and the initiation of pharmacotherapy. It has been demonstrated that there are improved outcomes when counseling and pharmacotherapy are used in combination. While each is effective alone, cessation rates are significantly improved when used in combination (18).
BRIEF CLINICAL INTERVENTION
The Public Health Service has published extensive literature on smoking cessation and endorses the intervention commonly referred to as the “5As” (Table 21.1). This is a brief intervention to be performed in clinic that requires only 2 to 3 minutes and has demonstrated excellent results. It is composed of five parts: ask, advise, assess, assist, and arrange.