‘Doc, I’m ready to quit’: Evidence-based approaches to smoking cessation

Clinical pearls for frontline PCPs

A 50-year-old man has been a patient in the practice for the past 25 years.

Over the years, he was mainly seen for minor injuries and infections. At age 25 years, he came in for an evaluation of an upper respiratory infection (URI). The physician asked him at the time if he used tobacco. He smoked one pack per day and tended to smoke more when he was hanging out with friends and went to bars. His girlfriend at the time really didn’t like that he smoked. In a note at that time, the physician put down his exact words:

“It is not a problem for me, doc. I actually kind of like smoking.”

He would also often smoke cigars while golfing with his buddies.

Philip A. Bain

Looking back through the chart, he was seen again at age 35 years after he presented with a health scare — coughing up some blood. This occurred in the context of a URI. His chest X-ray was normal. The physician again asked if the patient wanted to quit.

“Yes, I know that I should quit,” he said. “My wife doesn’t like it. I have to hide it from the kids. I’m sure that I could put the money to much better use. I know that I should quit, but I just can’t.”

He tried smokeless tobacco and a pipe as a substitute, but that did not help him reduce his cigarette use.

He presents today at age 50 for his annual physical exam. He just became a grandfather. His next-door neighbor recently died from lung cancer, and he swears that he never wants to go through what his neighbor did.

“Doc, you’ve been after me to quit all of these years,” the patient says. “With all that’s going on, I need to quit. It’s a stupid habit, and I’m ready to finally give it up. I’m worried about how I am going to finally do it.”

“I’m clearly addicted,” the patient continues. “I have to have my first cigarette right after I shower — probably about 45 minutes after I wake up. That first cig is the one that I crave most. I’m now smoking one to one and a half packs per day. It’s pathetic that I have to go outside when it’s 10 below zero to smoke, just to quiet my nerves. I can’t smoke inside at work, but I really need to have a cigarette to calm down. Last fall, when I had the flu, I was sicker than a dog, but I still had to smoke, even as sick as I was. I want to quit!”

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The physician calculates his Fagerstrom Test for Nicotine Dependence and agrees that he is dependent on tobacco.

The patient tried vaping to cut down, but that didn’t seem to help. The physician continues: “Tom, you’re pretty dependent on tobacco. I’m glad that you’re ready to quit. Let’s have you pick a quit day within the next 2 weeks. I see that you haven’t tried nicotine patches. Once you have chosen the quit day, I would like you to try using the 21 mg nicotine patch if you are smoking 10 or more cigarettes per day. Put it on as soon as you wake up on the morning of the quit day. I will also recommend that you use nicotine gum for breakthrough cravings. I am going to refer you to the tobacco quit line. They’re experts in helping people quit using tobacco. If you call 1-800-QUIT NOW, they’ll help you figure out what will work best for you. They’ll help you pick a specific quit day. If you smoke more during the week than on the weekend, it might make sense to have your quit day begin on Saturday. Until that time, it’ll be very helpful to cut down by specifically figuring out how “necessary” each particular cigarette is and only smoking the “necessary” ones. If you light up your smokes with a lighter, switch to matches or vice versa. If you typically smoke with your right hand, switch to your left hand (or vice versa). By focusing on each cigarette and switching up your routine, you become more aware of your smoking and this often helps people cut down before they quit. It is easier to quit from a half pack per day than it is from a full pack per day. On the night before the quit day, smoke your last cigarette and then throw out all of the reminders, like the ash trays, matches, lighters. Take the lighter out of the car. Cut up some carrot or celery sticks to have on hand on the quit day for your hands and fingers to have something to fiddle with. Brush your teeth extra-long on the night before the quit day. Some people find that having a professional cleaning on the quit day helps them get a clean slate. Wake up a nonsmoker. Change up your morning routine. I would also recommend that you put a jar on the kitchen table with your granddaughter’s name on it. Every morning, put in the equivalent amount of money that you spend on cigarettes every day. I will give you a sheet outlining these tips with a place for you to add others that you might have. Be sure to let your wife, friends and kids know that you are quitting — having people who can support you can help.”

The patient contacts the quit line, and they give him a lot of good information about quitting and reiterate many of the suggestions that were provided in the office. About 2 weeks after the quit day, the physician asks his nurse to contact the patient to see how it was going. She reports that, despite it being pretty tough, especially in the first few days after the quit day, he has been able to stop smoking. He still has significant cravings and has “sneaked” a cigarette or two every few days.

The physician recommends that he begin varenicline in addition to the nicotine replacement. In another 2 weeks, he asks the nurse to follow up with the patient. She reports that his cravings have significantly decreased on the varenicline, and that he has not had any tobacco in that 2-week period. He reports feeling less irritable and is actually surprised and proud that he was able to remain tobacco free. He continues to follow up with the tobacco quit line for 3 months. He is seen in the office 6 months from the original quit day for an unrelated problem, and he reports that he has remained a nonsmoker, squirreling away almost $1,000 for his granddaughter’s college fund.

Lessons learned

1. Cigarette smoking is the No. 1 preventable cause of mortality in the United States. It is expensive, socially stigmatized and contributes to significant costs — personally and societally.
2. Smoking cessation is attainable; 68% of smokers want to quit, but only 8.8% can quit completely, according to a recent MMWR. It is important to ask about tobacco use at every encounter with the health care system. Patients’ readiness to change fluctuates throughout the life span and is related to a variety of motivations for quitting.
3. Using the ask-advise-refer strategy. Advise that they cut down or quit, offer evidence-based treatments and refer to the national quit line.
4. Tobacco use, like many other addictions, are best addressed with combination counseling and pharmacotherapy. The old “You need to quit” paternalistic approach is outdated and ineffective. Base your approach on how close the patient is to quitting. Evidence shows that only about 30% of patients who use tobacco products are “ready” to quit, so inviting all patients you screen who use tobacco into a conversation about “addressing” their tobacco use “at their own pace” can expand your reach and move people along the continuum to being ready to quit someday. Offer to be available to provide prescriptions for evidence-based medications if needed. The action stage — “Doc, I’m ready to quit” — is when the primary care physician can help the patient identify what may work for them, provide evidenced-based medications, offer suggestions about what has been shown to help, and refer the patient to the quit line. Finding out the “why” regarding the patient’s desire to stop using tobacco can be very helpful.
5. As with any addiction, relapses are to be anticipated. A relapse-prevention strategy, as well as steps to take when relapses occur — whom to call, how to attain abstinence again and determining why the relapse occurred — are essential.
6. There are numerous effective smoking cessation medications available. See Table. Studies suggest that starting medication such as varenicline in those not ready to quit helps people reach eventual cessation.
7. Data show that although lung cancer rates are lower with pipe and cigar smoking than cigarette smoking, rates are still higher than nonsmokers. Many types of cancer (eg, lung, oral, lip, throat and esophagus) are linked to pipe and cigar smoking.
8. Data show that vaping can be a safer alternative to smoking, but it clearly has health risks. It can sometimes be used as an interim step to cutting down and ultimately quitting. According to a study from The Ohio State University, extended dual use of smoking and vaping products quadrupled the risk for lung cancer beyond those of people who only smoked. Thus, be sure patients avoid long-term dual use.
9. Quitting smoking reduces the risk of premature death and can add as much as 10 years to life expectancy. Research shows that even patients with cancer have much better chances for recovery and healing if they quit smoking — even after a diagnosis.
10. Helping someone to stop using tobacco for good can be one of the most rewarding aspects for a PCP. It takes expertise in behavior change, and it is a skill that can definitely be learned.

References:

• CDC. Benefits of quitting smoking. Available at: https://www.cdc.gov/tobacco/about/benefits-of-quitting.html. Accessed Oct. 31, 2024.
• Leone FT, et al. Am J Respir Crit Care Med. 2020;doi: 10.1164/rccm.202005-1982ST.
• Reid RD, et al. CMAJ. 2016;doi:10.1503/cmaj.151510.
• VanFrank B, et al. MMWR Morb Mortal Wkly Rep. 2024;doi:10.15585/mmwr.mm7329a1.