How Physicians Can Motivate Smokers to Give Up Cigarettes

ANNAPOLIS, Md—“Showing sick patients the direct connection between smoking and their disease symptoms can powerfully motivate them to quit,” said Daniel E. Ford, MD, MPH, associate professor of medicine, epidemiology, and health policy and management, Johns Hopkins School of Medicine.

Tobacco is a difficult addiction to quit, he said at a meeting on clinical preventive medicine. Nicotine, a tertiary amine, crosses the blood-brain barrier, and both stimulates and calms. At low doses, it serves as a ganglionic stimulant and at high doses, as a ganglionic blockade. Tolerance develops quickly with use.

“The tobacco companies have known all along that they were producing an attractive delivery device for an addictive drug,” he said.

The mere number of cigarettes is not indicative of actual nicotine intake, and self-reported numbers are rarely accurate, anyway, he said. Patients trying to quit may have indeed reduced the number of cigarettes smoked, but may be smoking with more puffs and deeper inhalation. In one small study, subjects smoked 36 cigarettes a day, but their nicotine intake varied from 10 to 79 mg.

“Quitting completely, rather than cutting down, is the safest and surest way to better health,” Dr. Ford said. “Since most people who smoke start as teenagers, if you can get people to the age of 22 without starting, you have a good chance of keeping them off cigarettes all their lives.”

To move patients along the road to smoking cessation, Dr. Ford suggested physicians follow the Four A’s: Ask, Advise, Assist, Arrange.

Ask—Barely half of all smokers have ever been asked by their physicians if they smoke, he said.

Advise—When advising patients to quit, he said doctors should “be clear, speak strongly, personalize advice as much as possible, and be empathetic and optimistic, stressing benefits, not fear.”

Assist—When the patient is ready to quit, assist in setting a quit date within 2 weeks. Have the patient remove cigarettes from his or her environment to minimize temptation and inform friends, family, and coworkers of the decision so as to create a support system.

The physician should review with the patient his or her previous attempts to quit and analyze what went wrong. Also, the physician should anticipate chal-lenges to quitting, including situations likely to trigger relapse, and discuss with the patient how those moments can be anticipated and avoided.

Arrange—The physician should arrange a first follow-up contact within 2 weeks of the quit date. “Remind the patient that while relapse can happen quickly, one slip does not represent failure. The patient must keep going,” Dr. Ford commented.

The Agency for Health Care Policy and Research (AHCPR) now recommends nicotine replacement—whether by transdermal patch, chewing gum, inhaler, or nasal spray—with every quit attempt. “There have been no head-to-head comparisons of replacement modalities. Offer the patient a choice. If one fails, try another,” Dr. Ford said. “Don’t worry about prescribing replacements. The patient will almost always be getting less nicotine with them than by smoking.”

Bupropion (Zyban) can help keep smokers off cigarettes with short-term use (up to 6 weeks). The drug should be started 1 week before the quit date and is contraindicated in patients with a history of seizures, bulimia, or anorexia, or those on monoamine oxidase (MAO) inhibitors, he said. One study showed that patients taking the antidepressant nortriptyline maintained a higher quit rate even 6 months after use had stopped.

“In general,” Dr. Ford said, “the physician should make the adverse health effects of tobacco known to the patient, utilize a full range of pharmacologic interventions, help the smoker to be a better observer of his/her behavior, and encourage the patient to keep a long-term perspective.