The latest on smoking cessation: 8 things physicians should know

Tobacco use is the No. 1 cause of preventable disease, disability and death in the United States. That sobering statistic is widely known, so it is no surprise that more than two-thirds of U.S. adults who smoke are interested in quitting. During the COVID-19 pandemic, quitting is even more important because smoking reduces lung capacity and increases the risk for many respiratory infections. But what can physicians do to help their patients quit smoking?

“There've been more than 20 studies, which have looked at smoking status and COVID-19 complications,” said AMA member Michael Fiore, MD, MPH, MBA, Hilldale Professor of Medicine at the University of Wisconsin and director of the Center for Tobacco Research and Intervention at the University of Wisconsin School of Medicine and Public Health in Madison. “Whether you measure the outcomes as death or using a severity index, like going to the ICU or being intubated, in more than 80% of those studies, smoking resulted in a statistically significant increase of adverse outcomes.”

“Everything we know about the impacts of smoking—which includes an increased risk of upper and lower respiratory tract infections—suggests that it is a substantial risk for COVID-19 infections and complications,” said Dr. Fiore who was a contributing author of the 2020 U.S. Surgeon General’s smoking cessation report—the first from that office in 30 years. The report outlines the latest science available to help people quit smoking.

Here are eight major conclusions physicians should know about to help their patients quit smoking.

When a physician speaks to a patient about smoking, it is one of the most powerful prompts for them to think about quitting. The electronic health record can be used to prompt physicians and the rooming staff to query the patient on smoking. “This technology can also help downstream, with the EHR programmed to electronically refer patients to a health system cessation program, the state Quitline (1-800-QUIT-NOW), the National Cancer Institute’s smokefree.gov suite of cessation resources (including SmokefreeTXT) or something in the community,” said Dr. Fiore.

Over half of smokers try to quit every year, but they typically try on their own cold turkey and fail. This is where a physician can make a big difference. One way to overcome this barrier is to “recognize smoking as a drug of dependence that requires medical treatment—both counseling and medication,” said Dr. Fiore.

“So many smokers relapse—that’s why I view tobacco dependence as a chronic disease. Our goal is to help patients achieve remission with medical treatment, rather than convince them that they can do it on their own with enough willpower,” he said.

More than 60% of U.S. adults who have ever smoked cigarettes have quit. But, almost 35 million adults in the U.S. continue to smoke. Among them, two-thirds who try to quit do not use Food and Drug Administration (FDA)-approved cessation medications or behavioral counseling.

“When patients tell me they want to quit on their own, I try to build on their enthusiasm. What I say is, ‘It's great that you want to quit cold turkey, but I want to give you a couple tools that will increase the likelihood that your cold turkey effort to quit is successful. I want you to talk to the state Quitline and I want you to take this nicotine lozenge to take the edge off of your withdrawal symptoms when you're quitting cold turkey,’” said Dr. Fiore. “I don't try to change their mind. I just try to reframe what cold turkey can be.”

The Community Preventive Services Task Force, which includes the AMA as a liaison member, recommends internet-based interventions to increase the number of adult tobacco users who successfully quit. Evidence shows interventions increase cessation among adults interested in quitting when measured six or more months following intervention.

We have seen historic lows in smoking, but many groups are left behind. Smoking was found to be highest among LGBTQ adults, people with mental health conditions, and Native American and Alaska Native individuals.

“We also have found over time that smoking, which used to be an equal opportunity killer, is now concentrated in certain subpopulations of our society such as the poor, those with the least education, and those with mental health and substance abuse diagnoses,” said Dr. Fiore. “Those four groups account for the great majority of smokers in the U.S. today. Those individuals often are the same who are dealing with other major challenges in their lives, thus making quitting even harder.”

Through smoking cessation, risk for many adverse health effects is reduced. This includes reproductive health outcomes, cardiovascular diseases, chronic obstructive pulmonary disease and cancer.

“Cessation should be discussed with every patient that smokes at every visit. We need to urge our patients who smoke to quit in an equivocally strong, personalized way, often linking it to the health issues that they're addressing,” said Dr. Fiore.

Read more from the AMA about how 20% of lung cancer deaths are preventable.

A person’s chance of successfully quitting doubles when FDA-approved cessation medication and counseling are used in combination. Counseling is available in different forms, including individual and group. Text message and web-based interventions also work.

“What we know are the two things in particular that are important and it’s important to use them both—some brief counseling and one of the seven FDA-approved medications,” said Dr. Fiore. “When we combine these two, they work better than either alone.”

A diverse group of products are available in e-cigarette form and are used in a variety of ways. This makes it difficult to generalize about efficacy for cessation based on one type of e-cigarette. We don’t yet know whether e-cigarettes or vaping aid in smoking cessation or not because inadequate evidence is available.

“We always urge our patients to use the evidence-based public health service guideline recommended counseling and medications that we know are both safe and effective,” said Dr. Fiore.

Learn more about e-cigarettes and vaping, which the AMA has declared a public health epidemic.

Many physicians find it difficult to address smoking with their patients because they are “asked to see more patients in less time” and struggle with how to “open that can of worms of counseling the patient to quit,” said Dr. Fiore.

Physicians can weave it into their health systems and clinical practice by using members of the care team to refer patients to treatment extenders such as the Quitline and smokefree.gov.

“Among our patients who are currently smoking and don’t quit, 50% will be killed prematurely by their tobacco dependence,” he said. “There is nothing that I deal with as a physician that carries a similar 50% mortality rate.

“We can’t ignore it. We can’t push it off to others,” said Dr. Fiore. “It has to be part of primary and other care. We’ve got to help our patients quit smoking.”