Smoking cessation counseling is a nightmare for physicians because 1) it feels like a waste of the enormous time and effort required; and 2) it’s not: evidence shows that it’s exactly what we should do, every patient, every time. Even a 90% failure rate results in millions more lives saved than not attempting. Fiore and Baker give the newest lay of the land in a NEJM review:
- Even those not ready to quit do 8% of the time within 6 months, if coached with motivational interviewing by physicians (vs. 2% without coaching).
- Advising patients to cut down the number of cigarettes they smoke, while providing nicotine replacement therapy, resulted in 9% quit rates (vs. 5% without nicotine replacement). Increased nausea was the only adverse effect attributed to smoking while using a nicotine patch or gum.
- The more counseling provided, the higher the quit rates (peaking at 27% quit at 6 months with 30-90 minutes of counseling).
- Up to 1/3 of patients will accept smoking cessation treatment offered on-the-spot, but only 10% will take the steps to start it after they leave your clinic.
- Newer, aggressive drug treatments work best. Monotherapy with bupropion or one form of nicotine replacement results in 19-26% quit at 6 months (14% with counseling alone). But varenicline alone resulted in a 33% quit rate, and combination nicotine replacement (patch plus either gum or lozenges) had a 37% quit rate.
- Prescribe nicotine patches for 2 weeks prior to the quit date to maximize effectiveness. Varenicline during a run-in period also improved quit rates in one trial.
- Varenicline was associated with a nonsignificant small excess risk for cardiovascular events in patients with cardiovascular disease in a 2010 randomized trial in Circulation, and a 2011 meta-analysis in CMAJ also suggested a small risk. The health benefits of quitting smoking may well outweigh these risks (if real), and patients should be allowed to make an informed decision to receive varenicline.
- Bupropion can lower the seizure threshold and shouldn’t be provided to those with a seizure history or who abuse alcohol.
Of course, someone has to pay for this, and Medicare recently extended smoking cessation counseling benefits to all smokers. The reality is, physicians are probably never going to make a habit of taking 45 minutes to coach someone to quit smoking, due to well-described time constraints and financial incentives. Dedicated health counselors in large primary care practices, or health coaches paid by self-insuring corporations or big insurers, seem like a more plausible solution. But 5 or 10 minutes’ physician counseling (half a clinic visit) seem like a bare minimum. Give anyone willing to quit access to resources: 1-800-QUIT NOW, www.smokefree.gov or www.women.smokefree.gov.
The Brits recently proved text messages can help people to quit — pretty cool.
Fiore MC, Baker TB. Treating Smokers in the Health Care Setting. N Engl J Med 2011;365:1222-1231.