Kicking butt: Primary care physicians can help smokers quit

Connecting smokers with the help they need to stop can make all the difference in freeing them from the addictive pull of nicotine.

By Susan J. Landers, amednews staff. Dec. 15, 2003.

This isn't the first time the topic of smoking has come up with this patient. But this time, things are different. Maybe it's the fast-approaching New Year and thoughts of resolutions. Or maybe the patient was primed for action by November's Great American Smokeout. Or maybe this smoker is finally fed up with the idea of spending another winter shivering outside, just to get a nic fix. Regardless of the reason, the patient suddenly seems as ready as ever to kick the habit.

How can you help?

The 5 A's
Easing the path
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It is a critical question. Helping a smoker quit trumps almost anything else a physician can do to improve that patient's health, says Steven Schroeder, MD, director of the Smoking Cessation Leadership Center at the University of California, San Francisco. "If physicians can get 15% to 20% of smokers to quit there are going to be lives saved. It's really dramatic."

Patients who quit will immediately lower their risk of heart disease and bronchitis and, over time, reduce their risk of a long list of cancers, chronic pulmonary diseases and many other illnesses.

Nonetheless, while most of the 47 million adult smokers in the country say they would like to quit, only 5% manage to do so each year. Primary care physicians are in a particularly advantageous position to support efforts to escape the powerful pull of nicotine.

"Smokers don't typically go to intensive programs. What they do is visit their doctors," says Michael Fiore, MD, MPH, an internist and director of the University of Wisconsin Center for Tobacco Research and Intervention in Madison.

47 million adults in the U.S. are smokers.

"Seven out of 10 smokers see a primary care physician every year," says Dr. Fiore. "Nobody has the access we have in primary care and we have to seize upon that."

Specialists also have a huge role to play since smoking affects so many different organ systems, notes AMA Trustee Ronald Davis, MD, director of the Center for Health Promotion and Disease Prevention at the Henry Ford Health Center in Detroit.

"Smoking causes cataracts and macular degeneration so ophthalmologists should discuss smoking with their patients. Smoking causes ulcers and impairs the healing of ulcers so gastroenterologists should ask about smoking. Obviously cardiologists, pulmonologists and oncologists should discuss smoking with their patients." And pediatricians should ask if their young patients with recurring asthma or ear infections are subjected to smoke at home.

What you can do

Clear, strong and personal messages to patients can work. Dr. Fiore provides an example: "Mary, I see from your chart that you are a smoker. You know the best thing you can do for your health today and tomorrow is to quit. You were in today with the third episode of acute bronchitis in the last year and you could really decrease the likelihood of not only getting bronchitis but also of getting emphysema in five or 10 years. And I can help you."

Dr. Fiore also headed the U.S. Public Health Service panel that produced Clinical Practice Guideline on Treating Tobacco Use and Dependence, regarded as the bible on smoking cessation by many physicians for its research-supported recommendations.

Only 5% of smokers successfully quit each year.

Included in the guideline are the five A's that physicians can use to help patients be done with tobacco for good: Ask patients if they smoke, advise them to quit, assess their willingness to quit, assist them and arrange follow-up.

Dr. Fiore began advocating for the incorporation of smoking questions into every office visit more than 10 years ago and now many physicians do ask patients whether they smoke and advise them to quit. "I think we've made enormous progress in that regard," he says.

That's the good news: "We're identifying smokers more."

But when it comes to connecting patients to appropriate medications and other supports, physicians aren't doing as well, says Dr. Fiore. "When we get down to the assist part, which is really the meat of the program, helping those who are willing to make a quit attempt to do it successfully, we've got a long way to go."

Although physicians can provide advice and offer assistance, it is the smoker who does the hard work and they need all the help they can get. Some of the more determined make their way to Rochester, Minn., to participate in the Mayo Clinic's smoking cessation program. "We probably see about 2,500 patients a year and January is almost always the biggest month for us even though total clinic visits are low," says Richard D. Hurt, MD, director of Mayo's Nicotine Dependence Center.

New Year's resolutions almost certainly propel smokers into the deep freeze of a Minnesota winter. But this demonstration of determination is only the first step; quitting is a long process. Dr. Hurt knows. He was a heavy smoker in earlier years and can recite the date and time that he quit -- Nov. 22, 1975, 3:30 p.m. "It was the hardest thing I ever did."

Medications can help

Today, physicians can make it a little less hard by offering nicotine patches, inhalers, gum, nasal spray and lozenges, all approved by the Food and Drug Administration for smoking cessation, along with certain pills.

Medications can greatly improve the odds of a patient's success. "If a person tries to quit on their own, cold turkey, only about 3% of them stay quit for a year," Dr. Hurt notes.

70% of smokers see their primary care physician every year.

However, "In a clinician's office, with brief advice and a three-month course of medicine we can get that up to 20% to 25%. We're talking about a dramatic increase with a very minimal investment of time."

The patient has a lot to say about which medicine to use, according to Dr. Hurt. Most patients have tried to stop smoking at least once before and physicians can ask about those attempts. "Have you stopped before? Tell me about it. What did you do? Was it very successful? How long did it last? What kind of medicine did you use?"

"If they say, 'I used the nicotine patch and it was so good, that's all I think I'll need,' then you go with that. If they say, 'I used the nicotine patch and it just irritated my skin and didn't do any good at all,' then you go to other options."

Combining treatments is also a strategy that works for some patients, says Dr. Davis, a former director of the Centers for Disease Control and Prevention's Office on Smoking and Health. For example, "The patch would give a steady supply of nicotine and when [a patient] has an acute craving they could chew a piece of gum and get an extra bolus of nicotine."

Dr. Schroeder counsels patience to both smokers and their physicians. "Don't be discouraged," he says. While most smokers are unable to quit the first time they try, they should be encouraged to keep trying. There are now more former smokers than there are current smokers. "Celebrate the triumphs."

Physicians can also take advantage of toll-free telephone quit lines that are available in more than 30 states and cover 90% of the population, says Dr. Schroeder. Some are staffed by trained counselors and some can help supply nonprescription medication.

The phone-line counselors can motivate smokers who are wavering and help devise a workable strategy for those ready to quit. They can also advise a caller to consult with a doctor if prescription-only medications are in order.

With limited time to spend with each patient, it's important to understand that physicians don't have to do it all, says Dr. Fiore. Health educators, nurses or community resources can help.

"But even talking for a minute or two and prescribing a medicine for a smoker willing to quit has been shown to markedly increase the quit rate," he says. "And that effort goes further if we hook that person up to somebody in our clinic who knows about tobacco and is willing to give them more extensive counseling."

However, he cautions physicians to make the connections as smooth as possible for the patient. "The more hoops you make a smoker jump through the less likely it is they are going to do it."

Stop that relapse

Smoking is obviously addicting. Nicotine withdrawal can include headache, nausea, difficulty concentrating, irritability and cravings. "All of these symptoms are particularly acute in the first several hours after a quit attempt," says Dr. Davis. "The first 48 to 72 hours are the most critical."

Urges to smoke are biologically mediated through the nicotine receptors, says Dr. Hurt. "Autopsy studies have been done to show that these are brain changes." While withdrawal symptoms last only about two weeks, cravings can go on for months, notes Dr. Hurt. "But they last just a few minutes and as time goes on the intervals between cravings gets longer and in time they just extinguish themselves."

Given the difficulty of staying quit, physicians and patients need to be thinking about relapse prevention from the very beginning, says Dr. Hurt. Physicians might ask: "So you stopped smoking before and you started again in a couple or three months, what happened?

"You need to be figuring out what those danger situations are and what you can do differently this time," he suggests.

Patients should be cautioned to avoid situations that pose particular peril. Dr. Hurt recommends that follow-up visits be encouraged within the first week or two of quitting. A telephone follow-up is OK but a face-to-face meeting is best, he says.

"Everyone has to recognize that this is a disease that is a relapsing, remitting sort of condition," Dr. Hurt says. "So relapse is the rule rather than the exception."