Counseling to prevent tobacco use – excerpt from “Guide to Clinical Preventive Services”
Counseling to Prevent Tobacco Use
Burden of Suffering
Smoking is responsible for one of every six deaths in the United States.1 It is the most important modifiable cause of death.(2,3) Each year, 390,000 Americans die as a result of smoking.3 More than 130,000 of these deaths are due to smoking-related cancers. In adult men, smoking accounts for 90 percent of all deaths from cancer of the lung, trachea and bronchus; 92 percent of deaths from cancer of the lip, oral cavity and pharynx; 80 percent of deaths from cancer of the larynx; 78 percent of deaths from esophageal cancer; 48 percent of deaths from cancer of the kidney; 47 percent of deaths from bladder cancer; 29 percent of deaths from pancreatic cancer and 17 percent of deaths from stomach cancer.1,3 Each year, smoking is also responsible for more than 115,000 deaths from coronary heart disease and 27,500 deaths from cerebrovascular disease.3 Smoking accounts for nearly 60,000 deaths per year from pulmonary diseases, such as chronic airway obstruction.(2)
Smoking during pregnancy is responsible for about 18 percent of all cases of low birth weight, shortened gestation, respiratory distress syndrome and sudden infant death syndrome.1 Involuntary, or passive, smoking accounts for an estimated 3,800 nonsmoker deaths each year from lung cancer.(4) Cigarettes are also responsible for about 1,500 fire-related deaths and 4,000 injuries each year.5,6 The total direct and indirect costs of smoking may be as high as $200 billion per year.(7,8)
Although smoking has become less common in recent years, nearly one-third of all adults in the United States continue to smoke.(9) Cigarette smoking is more common among blacks and persons of low socio-economic status. Because of the increase in smoking by women during the period between 1940 and the early 1960s, lung cancer mortality in females has been rising steadily since the mid-1960s. Lung cancer recently mortality in females has been rising cause of cancer death in women.(10) Furthermore, between 25 and 40 percent of female smokers do not quit smoking during pregnancy and thus risk fetal damage.(11,12)
Over three-fourths of smokers begin smoking as teenagers. Currently, one out of five high school seniors smokes on a daily basis, and one-third of persons aged 20 to 24 are smokers.(9,13) Smokeless tobacco, a leading cause of oral cancer, is used by more than 10 million Americans.(14,15) Between 8 and 36 percent of male high school and college students are regular users of smokeless tobacco.(16)
Efficacy of Risk Reduction
Beginning with early studies in the 1950s and 1960s, a large body of epidemiologic evidence has accumulated on the health effects of smoking. Major cohort studies, a large number of case-control studies and other data sources have since provided consistent evidence linking the use of tobacco with a variety of serious pulmonary, cardiovascular and neoplastic diseases. The scope of this report does not permit an examination of each study of the health effects of smoking or the nature of the risk relationship (e.g., relative risk, dose-response relationship) between smoking and each disease. Detailed reviews of these studies have been published elsewhere.(2,3,7,8,17-19)
Several consistent findings from this body of evidence are well established. First, tobacco is one of the most potent human carcinogens. The majority of all cancers of the lung, trachea, bronchus, larynx, pharynx, oral cavity and esophagus are attributable to the use of smoked or smokeless tobacco. Smoking also accounts for a significant but smaller proportion of cancers of the pancreas, kidney, bladder and stomach. Second, smoking promotes atherosclerosis. Along with hypertension and hypercholesterolemia, smoking is one of the leading risk factors for myocardial infarction and coronary artery disease and it accounts for up to 30 percent of all coronary events. Smoking is also a risk factor for cerebrovascular disease and peripheral vascular disease. Third, smoking causes chronic obstructive pulmonary disease, and it is an important risk factor for other respiratory illnesses, such as pneumonia and influenza. Fourth, smoking can affect the health of nonsmokers. Involuntary smoking can increase the risk of lung cancer in healthy nonsmokers and the frequency of respiratory illness among children. In utero exposure to maternal smoking increases the risk of miscarriage, stillbirth, low birth weight and retarded growth. Finally, cigarettes are responsible for about 25 percent of deaths from residential fires.
A large body of evidence from prospective studies indicates that many of these health risks can be reduced by smoking cessation. Over a period of 15 to 20 years, the ex-smoker’s risk of dying from lung cancer decreases gradually to a risk comparable to that of a nonsmoker.(20,21) Similarly, a large number of cohort studies of persons with atherosclerotic heart disease have demonstrated that the risk of subsequent myocardial infaction is reduced significantly among persons who stop smoking. These cardiovascular benefits of smoking cessation have been well demonstrated among the young,22 and recent evidence suggests that the risk of cardiovascular disease is also reduced among persons who stop smoking after age 55.(23)
Effectiveness of Counseling
Clinicians have both the opportunity and the means to modify smoking behavior in patients. It has been estimated that about 38 million of the 53 million adult smokers in the United States could be reached by physicians during the course of ongoing medical care.24 Moreover, a number of clinical trials25-30 have demonstrated the effectiveness of certain forms of physician counseling in changing the smoking behavior of patients.
As many as 40 controlled clinical trials have examined different types of clinical smoking cessation techniques involving various combinations of counseling, distribution of literature and nicotine replacement therapy.(31,32) These studies have found that effectiveness depends on a variety of factors, such as the number of contacts with the patients, the number of months of intervention, the use of direct advice and the type of counselor. Characteristics of the patient, such as level of nicotine dependence, personal motivation to stop smoking and confidence in the ability to quit, are also critical variables.(33)
Although some studies have reported a 40 to 50 percent increase in smoking cessation as a result of clinical intervention, a recent meta-analysis of 39 clinical trials31 found that differences in cessation rates of unselected patients who receive treatment average about 8 percent after six months and 6 percent after one year. The most effective techniques are those involving more than one modality (e.g., physician advice, self-help materials), those that involve both physicians and nonphysicians, and those that provide the greatest number of motivational messages for the longest period of time.
The key elements of effective counseling appear to be providing reinforcement through consistent and repeated advice to stop smoking, setting a specific “quit date” and scheduling a follow-up contact or visit.31,34 Providing self-help materials along with counseling appears to further enchance the effectiveness of physician advice.(25,35)
In addition to counselling, the prescription of nicotine gum can facilitate smoking cessation. A number of randomized controlled trials support the efficacy of nicotine replacement theraphy, especially for highly nicotine-dependent smokers.(26,27,32,33,36,37) The evidence suggests, however, that nicotine gum is effective not in isolation but as an adjunct to ongoing smoking cessation counseling.38 When used correctly and when combined with physician advice to stop smoking, nicotine gum may increase long-term smoking cessation rates by about one-third.(39)
The use of nicotine gum is contraindicated in pregnant and nursing women, patients with recent myocardial infarction and patients with temporomandibular joint disease. Nicotine gum may also have adverse effects in patients with peptic ulcer disease, claudication, hypertension, arrhythmias and diabetes.(40) Some patients may use the gum without discontinuing smoking, thereby increasing the risk of nicotine toxicity, while others may continue to chew the gum for more than a year.(41)
Clonidine is another drug of potential value as an adjunct in treating nicotine withdrawal.42 However, further studies are needed before smoking cessation becomes an approved indication for this drug. Few studies support the adjunctive use of anxiolytics and antidepressants in smoking cessation.
The primary prevention of tobacco use in adolescents who do not smoke or use smokeless tobacco is an increasingly important task for the clinician. Use of tobacco as a teenager is an important risk factor for long-term nicotine dependence.(43) The clinician has an opportunity to intervene by providing information on the health effects and addictive potential of tobacco and by providing the adolescent with incentives and skills to resist peer pressure to use tobacco. Early results from programs providing this form of counseling suggest that the use of tobacco can be prevented in at least some teenagers,(44,45) but there are no data from prospective studies on the effectiveness of physicians in achieving these outcomes.
Recommendations of Others
Official recommendations for physicians to encourage smoking cessation have been made by the American College of Physicians, (46,47) the American Academy of Family Physicians,(48) the American Academy of Pediatrics,(49) the American College of Obstetricians and Gynecologists,(50) the National Heart, Lung, and Blood Institute (51,52) and many other medical organizations and agencies. Specific recommendations on the use of smokeless tobacco have been issued by the American Academy of Otolaryngology, Head and Neck Surgery,(53) the American Academy of Oral Medicine, the American Medical Association, and the American Dental Association.(54)
Although the significant health benefits of smoking cessation are well established, studies suggest that many physicians fail to advise smokers to quit.(55,56) This reluctance to intervene may be the result of a number of variables, including lack of confidence in the ability to provide adequate counseling, skepticism about the ability to achieve behavior change through counseling, and concern about the effectiveness of devoting time to smoking cessation during the clinical encounter.
As mentioned earlier, however, a number of studies have shown that physician counseling can change behavior, even when the advice consists of a relatively simple message. Moreover, even a modest effect on smoking rates can have significant public health implications when multiplied by the estimated 38 million smokers seen annually by U.S. physicians. Cost-effectiveness studies also support the clinical value of offering smoking cessation counseling during the routine office visits of patients who smoke.(57)
A complete history of tobacco use should be obtained on all adolescent and adult patients. Smoking cessation counseling should be offered on a regular basis to all patients who smoke cigarettes, pipes or cigars, or who use smokeless tobacco. Patients who do not currently use tobacco but who are at increased risk of adopting such behavior (e.g., adolescents) should be advised to resist pressure to begin smoking or to use smokeless tobacco. Pregnant women and parents with young children should receive information on the potential harmful effects of smoking on fetal and child health.
The optimal frequency for performing smoking cessation counseling has not been determined with certainty and is left to clinical discretion. The combination of certain strategies can increase the effectiveness of counseling on tobacco use.
Direct, face-to-face advice and suggestions: The most effective physician message is a brief, unambiguous and informative statement on the need to stop using tobacco. If possible, the clinician should review the short- and long-term health, social and economic benefits of quitting and foster the smoker’s belief in the ability to stop. The message should address the patient’s concerns and any barriers presented by age, social environment, nicotine dependence and general health.
The physician should try to get the patient to agree to a specific quit date and should prepare the patient for withdrawal symptoms. Patients who have experienced a relapse after previously quitting should be reassured that most smokers achieve long-term cessation only after several unsuccessful attempts.
Scheduled reinforcement: Scheduled support visits or follow-up telephone calls, especially during the first four to eight weeks, make cessation more effective. Use of register system for smokers increases the probability that a smoking message is delivered at each visit.
Self-help materials: Clinicians can dispense a variety of effective self-help packages to aid the majority of smokers who quit on their own. These materials are available from voluntary organizations in most communities.
Referral to community programs: Local hospitals, health departments, community health centers, work sites, commercial services and voluntary organizations frequently offer smoking cessation programs to which patients can be referred. However, clinicians should not refer patients to programs providing treatment of unproven efficacy (e.g., electric shock therapy, chemical treatment).(58)
Drug therapy: When coupled with other interventions, the prescription of nicotine gum may facilitate cessation by relieving withdrawal symptoms. Patients should be provided with information on the proper use of nicotine gum.(59) Specifically, smokers should be advised to stop smoking completely before they start to use the gum, and they should be instructed to chew the gum slowly and intermittently to allow proper absorption by the buccal mucosa. The gum should be used as needed for at least three months, when the risk of relapse is greatest, but it is not recommended for use beyond six months. NOTE: See the relevant U.S. Preventive Services Task Force background paper: Kottke TE, Battista RN, DeFriese GH, Brekke ML. Attributes of successful smoking cessation interventions in medical practice. A meta-analysis of 39 controlled trials. JAMA 1988; 259:2883-9.
Information about this report may be obtained from the Office of Disease Prevention and Health Promotion, National Health Information Center, P.O. Box 1133, Washington, DC 20013-1133. Phone: (800) 336-4797; in Maryland, (301) 565-4167.
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