Physician Intervention

Table 375-3. All patients should be asked whether they smoke, their past experience with quitting, and whether they are currently interested in quitting. Those who are not interested in quitting should be encouraged and motivated to quit; provided a clear, strong, and personalized physician message that smoking is an important health concern; and offered assistance if they become interested in quitting in the future. There is a relationship between the amount of assistance a patient is willing to accept and the success of the cessation attempt. A quit date should be negotiated, usually not the day of the visit but within the next few weeks, and a follow-up contact by office staff around the time of the quit date should be provided.

There are a variety of nicotine-replacement products, including over-the-counter nicotine patch and gum, as well as nicotine nasal and oral inhalers available by prescription.

Recently, antidepressants such as bupropion have also been shown to be effective; some evidence supports the combined use of nicotine-replacement therapy and antidepressants. Nicotine-replacement therapy is provided in different dosages. Clonidine or nortriptyline may be useful for patients who have failed on first-line pharmacologic treatment, or who are unable to use other therapies. Antidepressants are more effective in those with a history of depression symptoms.

Current recommendations are to offer pharmacologic treatment, usually with nicotine replacement therapy and bupropion, to all who will accept it and to provide counseling and other support as a part of the cessation attempt. Cessation advice alone by a physician or his or her staff is likely to increase success compared with no intervention; a more comprehensive approach with advice, pharmacologic assistance, and counseling can increase cessation success by almost threefold.

In order for physicians to incorporate cessation assistance into their practice successfully, it is essential to change the infrastructure in which the physician practices. The following are simple changes: (1) including questions on smoking and interest in cessation on patient-intake questionnaires, (2) asking patients whether they smoke as part of the initial vital sign measurements made by office staff, (3) listing smoking as a problem in the medical record, and (4) automating follow-up contact with the patient on the quit date. These changes are essential to institutionalizing smoking intervention within the practice setting; without this institutionalization, the best intentions of physicians to intervene with their patients who smoke are often lost in the time crush of a busy practice.

Nicotine Addiction

• Disease Manifestations of Cigarette Smoking
• Lower Tar and Nicotine Cigarettes
• Nicotine Addiction: Cessation
• Nicotine Addiction: Introduction
• Nicotine Addiction: Other Forms of Tobacco Use
• Nicotine Addiction: Pharmacologic Interactions
• Nicotine Addiction: Prevention