Overview of smoking cessation management in adults
- Nancy A Rigotti, MD
Nancy A Rigotti, MD
- Professor of Medicine
- Harvard Medical School
- Stephen I Rennard, MD
Stephen I Rennard, MD
- Larson Professor of Medicine
- University of Nebraska Medical Center
- David M Daughton, MS
David M Daughton, MS
- University of Nebraska Medical Center
- Section Editors
- James K Stoller, MD, MS
James K Stoller, MD, MS
- Section Editor — Chronic Obstructive Pulmonary Disease
- Jean Wall Bennett Professor of Medicine, Samson Global Leadership Academy Endowed Chair
- Cleveland Clinic Lerner College of Medicine
- Chairman, Education Institute, Cleveland Clinic
- Mark D Aronson, MD
Mark D Aronson, MD
- Editor-in-Chief — Primary Care (Adult); Hospital Medicine
- Section Editor — General Medicine
- Professor of Medicine
- Harvard Medical School
Cigarette smoking is the leading preventable cause of mortality. Smokers who quit smoking reduce their risk of developing and dying from tobacco-related diseases [1,2]. Approximately 70 percent of smokers say that they want to quit, and over 50 percent of smokers report that they tried to quit in the past year [3,4]. However, only 3 to 6 percent of smokers who make an unaided quit attempt are still abstinent one year later. Only 32 percent of smokers who try to quit seek help and even fewer use the most effective treatments [3,5]. With optimal treatment, one-year abstinence rates after a single quit attempt can exceed 30 percent.
This topic provides an overview of smoking cessation management in adults. This includes a discussion of a simple five-step algorithm called the 5 A's (Ask, Advise, Assess, Assist, Arrange) (table 1 and table 2) with suggestions for implementation in primary care practice. Behavioral counseling and pharmacologic treatments for smoking cessation are discussed in more detail separately. (See "Behavioral approaches to smoking cessation" and "Pharmacotherapy for smoking cessation in adults".)
Management of smoking cessation in adolescents and pregnant women are discussed separately. (See "Management of smoking cessation in adolescents" and "Cigarette smoking and pregnancy", section on 'Smoking cessation'.)
ASSESSMENT OF USE AND EXPOSURE
The United States Preventive Health Services guidelines recommend that clinicians ask all patients about tobacco use and provide tobacco cessation interventions for those who use tobacco at every visit . This practice has been shown to increase the likelihood of smoking-related discussions and increase smoking cessation rates [7-9].
For patients who use tobacco, a full assessment includes the frequency of use, the products used, the degree of nicotine dependence, the history of previous quit attempts (including methods used and their effectiveness), and the smokers’ readiness to stop smoking at this time . Dependence on nicotine can be estimated from the duration of smoking history, the number of cigarettes smoked daily, and how soon after waking up the smoker has his or her first morning cigarette. A smoker's degree of nicotine dependence predicts the difficulty that he or she will have in quitting and the intensity of treatment likely to be required. More dependent smokers started smoking early in life, have smoked for many years, smoke more cigarettes daily, and smoke within the first 30 minutes of awakening [10,11].
- Anthonisen NR, Skeans MA, Wise RA, et al. The effects of a smoking cessation intervention on 14.5-year mortality: a randomized clinical trial. Ann Intern Med 2005; 142:233.
- Jha P, Ramasundarahettige C, Landsman V, et al. 21st-century hazards of smoking and benefits of cessation in the United States. N Engl J Med 2013; 368:341.
- Rigotti NA. Strategies to help a smoker who is struggling to quit. JAMA 2012; 308:1573.
- Centers for Disease Control and Prevention (CDC). Quitting smoking among adults--United States, 2001-2010. MMWR Morb Mortal Wkly Rep 2011; 60:1513.
- Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. US Department of Health and Human Services 2008. Available at: www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf (Accessed on October 17, 2011).
- U.S. Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 2009; 150:551.
- Lancaster T, Stead L. Physician advice for smoking cessation. Cochrane Database Syst Rev 2004; :CD000165.
- 2008 PHS Guideline Update Panel, Liaisons, and Staff. Treating tobacco use and dependence: 2008 update U.S. Public Health Service Clinical Practice Guideline executive summary. Respir Care 2008; 53:1217.
- Boyle RG, Solberg LI, Fiore MC. Electronic medical records to increase the clinical treatment of tobacco dependence: a systematic review. Am J Prev Med 2010; 39:S77.
- West R. Assessment of dependence and motivation to stop smoking. BMJ 2004; 328:338.
- Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict 1991; 86:1119.
- Centers for Disease Control and Prevention (CDC). Vital signs: current cigarette smoking among adults aged ≥18 years--United States, 2005-2010. MMWR Morb Mortal Wkly Rep 2011; 60:1207.
- Smoking cessation: information for specialists. Agency for Health Care Policy and Research. Clin Pract Guidel Quick Ref Guide Clin 1996; :1.
- Stead LF, Buitrago D, Preciado N, et al. Physician advice for smoking cessation. Cochrane Database Syst Rev 2013; 5:CD000165.
- Solberg LI, Boyle RG, Davidson G, et al. Patient satisfaction and discussion of smoking cessation during clinical visits. Mayo Clin Proc 2001; 76:138.
- Barnfather KD, Cope GF, Chapple IL. Effect of incorporating a 10 minute point of care test for salivary nicotine metabolites into a general practice based smoking cessation programme: randomised controlled trial. BMJ 2005; 331:999.
- Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. BMJ 2008; 336:598.
- Bize R, Burnand B, Mueller Y, et al. Biomedical risk assessment as an aid for smoking cessation. Cochrane Database Syst Rev 2009; :CD004705.
- Steinberg MB, Schmelzer AC, Richardson DL, Foulds J. The case for treating tobacco dependence as a chronic disease. Ann Intern Med 2008; 148:554.
- Kotz D, Wesseling G, Huibers MJ, van Schayck OC. Efficacy of confronting smokers with airflow limitation for smoking cessation. Eur Respir J 2009; 33:754.
- Coleman T. Near patient tests for smoking cessation. BMJ 2005; 331:979.
- DiClemente CC, Prochaska JO, Fairhurst SK, et al. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol 1991; 59:295.
- West R. Time for a change: putting the Transtheoretical (Stages of Change) Model to rest. Addiction 2005; 100:1036.
- Cahill K, Lancaster T, Green N. Stage-based interventions for smoking cessation. Cochrane Database Syst Rev 2010; :CD004492.
- Aveyard P, Lindson-Hawley N, Hastings G, de Andrade M. Should smokers be advised to cut down as well as quit? BMJ 2014; 348:g2787.
- Lindson-Hawley N, Aveyard P, Hughes JR. Reduction versus abrupt cessation in smokers who want to quit. Cochrane Database Syst Rev 2012; 11:CD008033.
- Baha M, Le Faou AL. Gradual versus abrupt quitting among French treatment-seeking smokers. Prev Med 2014; 63:96.
- Henningfield JE, Miyasato K, Jasinski DR. Abuse liability and pharmacodynamic characteristics of intravenous and inhaled nicotine. J Pharmacol Exp Ther 1985; 234:1.
- Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association, Washington, DC 1994.
- Stead LF, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev 2012; 10:CD008286.
- Suls JM, Luger TM, Curry SJ, et al. Efficacy of smoking-cessation interventions for young adults: a meta-analysis. Am J Prev Med 2012; 42:655.
- McAfee T, Babb S, McNabb S, Fiore MC. Helping smokers quit--opportunities created by the Affordable Care Act. N Engl J Med 2015; 372:5.
- Kotz D, Brown J, West R. Prospective cohort study of the effectiveness of smoking cessation treatments used in the "real world". Mayo Clin Proc 2014; 89:1360.
- White AR, Rampes H, Liu JP, et al. Acupuncture and related interventions for smoking cessation. Cochrane Database Syst Rev 2011; :CD000009.
- Tahiri M, Mottillo S, Joseph L, et al. Alternative smoking cessation aids: a meta-analysis of randomized controlled trials. Am J Med 2012; 125:576.
- Barnes J, Dong CY, McRobbie H, et al. Hypnotherapy for smoking cessation. Cochrane Database Syst Rev 2010; :CD001008.
- Cahill K, Hartmann-Boyce J, Perera R. Incentives for smoking cessation. Cochrane Database Syst Rev 2015; 5:CD004307.
- Volpp KG, Troxel AB, Pauly MV, et al. A randomized, controlled trial of financial incentives for smoking cessation. N Engl J Med 2009; 360:699.
- Halpern SD, French B, Small DS, et al. Randomized trial of four financial-incentive programs for smoking cessation. N Engl J Med 2015; 372:2108.
- Aveyard P, Bauld L. Incentives for promoting smoking cessation: What we still do not know. Cochrane Database Syst Rev 2011; :ED000027.
- Hughes JR, Solomon LJ, Naud S, et al. Natural history of attempts to stop smoking. Nicotine Tob Res 2014; 16:1190.
- Hajek P, Stead LF, West R, et al. Relapse prevention interventions for smoking cessation. Cochrane Database Syst Rev 2009; :CD003999.
- Stapleton JA, Sutherland G, Russell MA. How much does relapse after one year erode effectiveness of smoking cessation treatments? Long-term follow up of randomised trial of nicotine nasal spray. BMJ 1998; 316:830.
- Mikkelsen KL, Tønnesen P, Nørregaard J. Three-year outcome of two- and three-year sustained abstainers from a smoking cessation study with nicotine patches. J Smok Rel Dis 1994; 5:95.
- Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA 1994; 272:1497.
- Agboola S, McNeill A, Coleman T, Leonardi Bee J. A systematic review of the effectiveness of smoking relapse prevention interventions for abstinent smokers. Addiction 2010; 105:1362.
- Hajek P, Stead LF, West R, et al. Relapse prevention interventions for smoking cessation. Cochrane Database Syst Rev 2013; 8:CD003999.
- Fu SS, Partin MR, Snyder A, et al. Promoting repeat tobacco dependence treatment: are relapsed smokers interested? Am J Manag Care 2006; 12:235.
- Prochaska JJ. Smoking and mental illness--breaking the link. N Engl J Med 2011; 365:196.
- Cavazos-Rehg PA, Breslau N, Hatsukami D, et al. Smoking cessation is associated with lower rates of mood/anxiety and alcohol use disorders. Psychol Med 2014; 44:2523.
- Barth J, Critchley J, Bengel J. Psychosocial interventions for smoking cessation in patients with coronary heart disease. Cochrane Database Syst Rev 2008; :CD006886.
- Rigotti NA, Munafo MR, Stead LF. Smoking cessation interventions for hospitalized smokers: a systematic review. Arch Intern Med 2008; 168:1950.
- Keenan PS. Smoking and weight change after new health diagnoses in older adults. Arch Intern Med 2009; 169:237.
- Shi Y, Warner DO. Surgery as a teachable moment for smoking cessation. Anesthesiology 2010; 112:102.
- Rigotti NA, Clair C, Munafò MR, Stead LF. Interventions for smoking cessation in hospitalised patients. Cochrane Database Syst Rev 2012; 5:CD001837.
- Rigotti NA, Regan S, Levy DE, et al. Sustained care intervention and postdischarge smoking cessation among hospitalized adults: a randomized clinical trial. JAMA 2014; 312:719.
- Prescott E, Scharling H, Osler M, Schnohr P. Importance of light smoking and inhalation habits on risk of myocardial infarction and all cause mortality. A 22 year follow up of 12 149 men and women in The Copenhagen City Heart Study. J Epidemiol Community Health 2002; 56:702.
- Thomsen T, Villebro N, Møller AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev 2014; 3:CD002294.
- Lee SM, Landry J, Jones PM, et al. Long-term quit rates after a perioperative smoking cessation randomized controlled trial. Anesth Analg 2015; 120:582.
- Ministry of Health. New Zealand Smoking Cessation Guidelines. Ministry of Health, Wellington 2007. Available at www.moh.govt.nz/moh.nsf/indexmh/nz-smoking-cessation-guidelines?Open. Accessed September 27, 2011.
- Schroeder SA. What to do with a patient who smokes. JAMA 2005; 294:482.
- Silfen SL, Farley SM, Shih SC, et al. Increases in smoking cessation interventions after a feedback and improvement initiative using electronic health records -- 19 community health centers, New York City, October 2010-March 2012. MMWR Morb Mortal Wkly Rep 2014; 63:921.
- Boyle R, Solberg L, Fiore M. Use of electronic health records to support smoking cessation. Cochrane Database Syst Rev 2014; 12:CD008743.
- Haas JS, Linder JA, Park ER, et al. Proactive tobacco cessation outreach to smokers of low socioeconomic status: a randomized clinical trial. JAMA Intern Med 2015; 175:218.
- Fu SS, van Ryn M, Sherman SE, et al. Proactive tobacco treatment and population-level cessation: a pragmatic randomized clinical trial. JAMA Intern Med 2014; 174:671.
- ASSESSMENT OF USE AND EXPOSURE
- ADVISE SMOKING CESSATION
- ASSESS READINESS TO QUIT
- ASSIST SMOKERS READY TO QUIT
- Setting a quit date
- Addressing barriers to quit
- - Nicotine withdrawal syndrome
- - Other barriers
- Treatment options
- - Behavioral counseling
- - Pharmacologic treatments
- - Alternative therapies
- ARRANGE FOLLOW UP
- Difficulty quitting
- Relapse prevention
- ASSIST SMOKERS NOT READY TO QUIT
- ISSUES IN SPECIFIC POPULATIONS
- Psychiatric illness
- Cardiovascular disease
- Hospitalized smokers
- Light smokers
- Preoperative smokers
- IMPLEMENTATION IN PRIMARY CARE PRACTICE
- Team-based approach
- Proactive offer of treatment
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS