Quitting Smoking

 

Smoking is the sinlge most preventable cause of premature illness and death, and we as health care providers must do our utmost to educate and support smokers.

Ask everyone if they smoke, if they were ever smokers, and how many pack years they smoked (% pack smoked daily x # years smoked).

Every smoker should be offered support in quitting, but wihtout judgement. Every smoker knows smoking is harmful, and will easily get resetful if health care providers push too much.

 

 

Counselling and Motivation

 

Use the five the 5 A's to help patients quit:

The STAR approach:

If patients are unwilling to quit, share the five R's with them:

 

Telling smokers their "lung age" increases quit rates

Evaluating lung function in patients who smoke and giving them the results in terms of their "lung age" -- the age of the average nonsmoker with the same FEV1 as the patient-- increases rates of sustained cessation in patients in primary care who were not interested in quitting. Quit rates were confirmed at 12 months by measuring expired carbon monoxide and also serum cotinine levels. Quit rates were 6.4% of the control group and 13.6% in the intervention group (P = .005). Fourteen people would need to be given their lung age for 1 additional person to quit smoking (number needed to treat = 14). Patients with a greater difference in lung age were no more likely to quit smoking. A similar proportion of patients in both groups used smoking cessation aids (8% - 11%). (Parkes et al, 2008)

 

 

 

Nicotine Replacement Therapy (NRT)

NRTs, together with brief advice from HCPs, has been associated with 6% quit rates, compared with 1-2% of the population who quit wihout any help (WHO, 1998). Though costs are considerable, NRTs are a useful addition to anti-smoking endeavours.

nicotine replacement therapy (OR ~2)

 

 

Medications

 

buproprion (Zyban) (OR~2)

 

varenicline (Champix) (OR~3), but there are some side effects which need to be discussed

Varenicline did not statistically improve success over NRT one year after beginning treatment (Aubin et al, 2008).

 

 

Incentives

Offering up to $750 increases participation in smoking cessation programs and quit rates 15-18 months after (9.4% control vs. 3.6% incentives group, P<0.001) (Volpp et al, 2009).

 

 

Policy, Taxes, and Education

Due to the difficulties accompanying addiction, government intervention is useful. If only one intervention is taken, taxation has the greatest impact and is the most cost-effective. Taxation is an important means of reducing consumption while increasing revenues. For every 10% rise in price, tobacco use generally falls 2-10% (Chaloupka et al, 2000) This appears more true for smokers who are young or with low incomes.

Clean air laws protect non-smokers from the dangers of second-hand smoke, as well as encourage reduction or quitting of smoking.

Bans on advertising can reduce consumption. In countries where advertising is permitted, tobacco companies make advertising and promotion their single largest item of expenditure, often exceeding costs of raw tobacco leaf. (WHO, 2002)

Education, through warning labels, advertising, and other approaches are needed to reach the many people who do not fully understand the risks of tobacco use and benefits of quitting. Important efforts include:

 

 

 

 

 

 

Resources and References

 

Aubin HJ, Bobak A, Britton JR, et al Varenicline versus transdermal nicotine patch for smoking cessation: results from a randomised open label trial. Thorax 2008;63(8):717-724.

Chaloupka FJ, Hu TW, Warner KE, Jacobs R, Yurekli A. The taxation of tobacco products. In: Jha P, Chaloupka FJ, editors. Tobacco control in developing countries. Oxford: Oxford University Press; 2000. p.237-72.

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;336:598-600.

Volpp KG et al. 2009. A randomized, controlled trial of financial incentives for smoking cessation. N Engl J Med. 360(7):699-709.

World Health Organization. Guidelines for controlling and monitoring the tobacco epidemic. Geneva: World Health Organization; 1998.