CIGARETTE SMOKING

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THE CLINICIAN'S ROLE IN PROMOTING SMOKING CESSATION AMONG CLINIC PATIENTS Marc W. Manley, MD, MPH, Roselyn Payne Epps, MD, MPH, MA, and Thomas J. Glynn, PhD

Many practicing physicians routinely face a dilemma when treating a patient who smokes. Physicians recognize that smoking is a major threat to the patient's health but typically do not feel skilled enough to intervene effectively to treat this problem. 20, 29 Physicians understand the major risks associated with tobacco use. Most have extensive experience in treating the diseases caused by smoking. In fact, tobacco causes a significant proportion of the morbidity and mortality in this country. Most primary care physicians, as well as many specialists, are sadly familiar with the diagnosis and treatment of diseases caused by smoking, including chronic obstructive pulmonary disease, coronary artery disease, peripheral vascular disease, and cancer. Moreover, physicians recognize the enormous health benefit of quitting smoking, and many routinely recommend this to their patients who smoke. Most physicians, having recognized the danger of this behavior to their own health, have quit smoking themselves. Most physicians, however, have not experienced what they would consider success in helping their patients stop smoking. Most have treated patients with significant smoking-related disease who have been unable to stop, in spite of multiple attempts and many entreaties from health care professionals. These experiences are often discouraging for both From the Cancer Control Science Program, Division of Cancer Prevention and Control, National Cancer Institute, Bethesda, Maryland MEDICAL CLINICS OF NORTH AMERICA VOLUME 76 • NUMBER 2 • MARCH 1992

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the patient and the physician and may deter both from considering further cessation attempts. In addition to these discouraging experiences and a belief that nothing can be done about smoking, other barriers prevent physicians from trying to help their patients stop smoking. Many physicians have received no formal training in effective smoking cessation techniques 20 and quite legitimately feel unprepared to treat this problem effectively. Partly because of this lack of training and experience in effective behavioral change techniques, many physicians believe that smoking cessation advice and intervention are necessarily a very time-consuming process. Because of the many demands on a physician's time, lengthy interventions are often not feasible in a typical practice. In addition, physicians are not reimbursed by most insurers for smoking cessation services. This also discourages active smoking cessation intervention and certainly discourages any intervention of more than a few minutes' time. 19 In spite of these barriers, most physicians recognize that the difficulties in helping patients stop smoking are far outweighed by the benefit to the patient. A concern for the patient's health and longevity drives many physicians to spend time encouraging smokers to stop. A number of recent studies can guide physicians in their approach to this issue. These studies indicate that physicians can help patients stop smoking through the use of brief interventions. These interventions have been used extensively in outpatient practices without disruption of other clinical activities. An understanding of the theoretical basis for these studies, the data generated by these studies, and the recommendations generated by these data can guide a clinician in making the best use of limited time to help patients stop smoking. THEORETICAL BACKGROUND

Unlike many other tasks physicians undertake, the cessation of smoking requires a change in the patient's behavior. It is something a patient must actively choose to do and cannot be accomplished merely by taking a pill or undergoing a procedure. Although many physicians receive some training in behavior change theory and practice, most are more confident of their understanding of pharmacology and physiology. A detailed review of all behavioral theories of smoking cessation is beyond the scope of this article, but several basic principles are directly relevant to patient care. The process of smoking cessation has been divided into several stages21 : 1. Precontemplation is that time when a smoking patient is not

seriously considering the idea of stopping. 2. Contemplation is that time when a smoker is seriously planning to stop.

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3, Action is that time when a smoker is taking the steps necessary to stop. 4. Maintenance is that time after stopping that a smoker is avoiding relapse.

There are several implications of this model for the clinician. Some smoking patients are not contemplating stopping, and a physician may only have time during a single office visit to motivate them to consider the issue more seriously. Other patients may already be very motivated to stop and need advice on cessation techniques and assistance in developing a concrete plan of action. Still other patients may be in the process of stopping and need guidance in maintaining abstinence. Thus, the physician's roles can be most briefly described as helping smoking patients to become motivated to stop and helping motivated patients to succeed in quitting. Both of these roles can be more efficiently accomplished when a clinician has an understanding of the relevant scientific literature. Motivation is a key variable in a behavior change such as smoking cessation. Patients who describe themselves as highly motivated to stop are more successful in stopping than less motivated patients. 18 Because many patients experience uncomfortable withdrawal symptoms (as discussed below), a strong and sustained desire to stop smoking is essential to successful cessation. A clinician alone usually cannot create and maintain such a desire in a patient. Other factors clearly influence the patient's level of motivation, The fear of imminent death appears to be a strong motivator. Patients with recent myocardial infarctions are very successful at stopping smoking when given appropriate assistance. Cessation rates of over 60% have been reported among these patients. 28 Among people without such a fear of death, cessation rates are much lower. Few smokers choose to quit because of a single event or a single conversation, even one with a respected physician. 17 Motivation to stop often is based on input from many sources. Family and friends can influence an individual, as well as coworkers, employers, prominent officials in the news, mass media messages, teachers, and health professionals. There is good evidence from community research trials that stopsmoking messages from a variety of sources are more effective than messages from a single source. 3 , 9 These trials have shown that messages from individuals (such as physicians) can be augmented and reinforced by mass-media campaigns, worksite stop-smoking programs, and other activities in the community. These trials suggest that the most effective programs to help smokers include encouragement to stop and assistance in stopping from a variety of different sources. Some physicians have been lead('rs in community efforts to reduce smoking by promoting smoke-free indoor air and other public policy measures. Physicians have also helped to bring mass-media programs to smokers, encouraging cessation. These activities are vital components of a comprehensive tobacco control program.

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But physicians can also play a vital role in their clinical realms by providing a clear, consistent message to patients that they should stop smoking. This motivating message may be only one voice in a "chorus" of stop-smoking messages, but for many patients it is a critical voice. A majority of smoking patients say they would try to stop if told to do so by their physician. I As the prevalence of smoking in the United States continues to decline, the social acceptability of this behavior decreases. Legitimate concerns about the dangers of environmental tobacco smoke, concerns among employers about the costs of smoking, and recognition of smoking as a major public health problem have resulted in public and private policies that make smoking less convenient and less acceptable. As more communities and states implement public policies, media campaigns, and other activities designed to reduce tobacco use, physicians will be seeing more smoking patients who are already motivated to stop. The physician's stop-smoking message is still critical and may be more readily accepted by patients now than previously. There are limitations on the physician's ability to motivate patients to stop, given the complex nature of motivation. However, more than 70% of smoking patients already want to stop and have already made at least one serious attempt to quitY The role of the physician as a motivator may be less important with these patients. Instead, the physician can assist these motivated patients by providing advice about effective cessation techniques and by helping the patient prepare for common problems of cessation, including withdrawal symptoms. Nicotine addiction is a problem for many smoking patients who try to stop (see article elsewhere in this issue). Distinct physiologic changes have been documented during withdrawal, although the severity and duration of symptoms vary markedly among patients. These symptoms are frequently reported by patients as the reason for relapse. Typical symptoms include anxiety, difficulty concentrating, craving for a cigarette, mild headache, mild abdominal discomfort, and insomnia. These symptoms often begin within hours of the last cigarette and are most severe during the first 2 to 3 days. Severity diminishes over the next 2 to 3 weeks. Many ex-smokers report recurrences of some symptoms, especially craving for cigarettes, months or years after cessation. The physiologic basis for these cravings has not been established. ls CLINICAL TRIALS OF SMOKING CESSATION

Prior to the early 1980s, very little evidence existed to suggest that physicians could successfully help patients stop smoking. The only controlled trials were from the United Kingdom, and these suggested that brief advice alone from a physician could produce small but significant decreases in the rate of smoking among patients. 23 The impact of additional intervention by physicians was not known.

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In 1984, the National Cancer Institute (NCI) funded five randomized, controlled trials to develop brief intervention protocols for physicians in treating patients who smoke. This research was part of a larger program designed to develop and validate effective methods to reduce smoking through interventions in schools, the mass media, and selfhelp programs in addition to the offices of health professionals. In developing this research, the NCI recognized that the strong involvement of physicians is essential in any effort to reduce national smoking prevalence rates. The purpose of these trials was to test brief clinical techniques to help patients stop smoking. Although other trials had been conducted to explore the effectiveness of physician-delivered smoking cessation interventions, the NCI trials were unique in several aspects. As described in more detail elsewhere,1O they involved a very large number of patients and physicians and were conducted in actual practice settings rather than in a research environment. Additionally, they monitored patients for a long period of time to test the durability of smoking cessation interventions. These trials involved more than 30,000 patients and 1,000 physicians and were conducted in a variety of outpatient medical settings (e.g., in private offices, public clinics, health maintenance organizations, and residency training programs). In all but one trial, entire practices were randomized. In the experimental practices, physicians (and other clinical staff) were trained in smoking cessation techniques. In the control practices, no special training was provided. In this way, the ability of the clinical staff to increase the cessation of smoking among an entire practice was tested. All the trials examined long-term (usually 12-month) cessation rates. Patients who claimed to have stopped smoking were counted as smokers unless their cessation was biochemically validated. There was some variation in the actual interventions used, but in all the trials, physicians were trained in basic behavioral and pharmacologic skills used to treat nicotine dependence. The length of training varied from 2 to 6 hours. Training techniques included lectures, videotape demonstrations, case-history exercises, and role-playing. In one trial, nurses and other office staff also received extensive training. As described in more detail below, the smoking cessation interventions used by the physicians were brief and best described as "physician-guided self-help programs." Brief counseling, the use of self-help booklets, and some use of nicotine gum were the common intervention techniques. In one study, physicians used a somewhat longer intervention, employing a "a patient-centered" counseling approach. Two studies incorporated office-reminder systems to increase the compliance of physicians and other staff in the use of smoking cessation protocols.

Trial Results

The primary goals of these trials were to change the way physicians treated their smoking patients, to reduce patient smoking behavior,

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and to test the usefulness of the interventions for dissemination to other medical practices. The first goal of the trial was accomplished. In all the trials, the physicians who were trained in smoking cessation techniques used them and thus improved their treatment of smoking patients. In comparison with untrained physicians, trained physicians were more likely to advise patients to stop30 and to ask their patients to select a specific date to stop. In addition, their patients were more likely to agree to this "quit date."6 Trained physicians prescribed nicotine gum more appropriately, and it was used more appropriately by their patients. 30 The trials also provided information about types of smoking patients and their willingness to stop. As expected, those patients who were initially most motivated to stop actually did stop more than less motivated patients. 18 Patients who returned for follow-up visits were also more likely to stop smoking. 30 This may be partly a direct result of the follow-up visits and partly because motivated patients are more likely to return for follow-up visits. Patients who returned for several follow-up visits had long-term cessation rates of almost 30%.30 Smoking cessation rates for the trials were calculated for entire practices, not for individual patients. Thus, all smokers seen in a practice were followed, not just those who received advice and other interventions from a physician. In all the trials, long-term cessation was confirmed biochemically. Even with these very strict evaluation criteria, cessation rates of up to 15% were documented. 4 This means that up to 15% of all smokers seen in the offices of trained physicians were smokefree at the end of 1 year. Although training did increase the use of smoking cessation interventions by physicians, training in the brief intervention techniques alone did not significantly alter smoking cessation rates among patients. 6 Only when trained physicians were routinely reminded to intervene with all smoking patients (through chart stickers or other mechanisms) did smoking cessation rates among patients significantly increase.4, 30 Results across all five trials may be summarized as follows: Training physicians in brief interventions to treat nicotine dependence results in more consistent and effective care of smoking patients. When trained physicians are routinely prompted to intervene with smoking patients, significant increases in patient smoking cessation rates can be achieved. Patients of physicians trained in smoking cessation techniques are more likely to stop smoking than patients of control physicians. Patients in trials in which physicians received routine reminders were up to six times more likely to stop smoking than usual care patients. These conclusions are consistent with the recommendations pro-

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duced by Kottke et aP7 through a formal meta-analysis of 39 studies which examined the impact of clinical interventions with smoking patients. This analysis showed that the most effective interventions employed more than one modality (e.g., physician advice, self-help materials, nicotine gum), involved both physicians and nonphysicians, and included frequent discussions of smoking over a long period of time. 17 In addition to these primary outcomes, one NeI trial included an analysis of the cost-effectiveness of smoking cessation intervention by physicians. Using extremely conservative estimates of effectiveness, smoking cessation interventions were found to be considerably more cost-effective than other valuable preventive practices, such as treatment for hypertension or hypercholesterolemia. 7 NCI RECOMMENDATIONS FOR PHYSICIANS

At the completion of these trials, a consensus development process was used to produce recommendations for practicing physicians. These recommendations were given in How to Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians. 11 A summary is provided here. These recommendations are consistent with those of the US Preventive Services Task Force. Physician Intervention

An effective smoking cessation intervention includes a brief physician intervention supported by office staff using simple procedures that ensure the efficient, systematic treatment of smoking patients at all office visits. The recommended intervention can be described as a self-help program that is encouraged, guided, and supported by physicians, nurses, and support staff. It is important for both the physician and the patient to realize that smoking cessation is a process that takes place over time, not a single event of stopping. Since quitting smoking is a process, it is important for the physician and office staff to maintain continuity, provide a repeated and consistent message, and, most importantly, offer appropriate treatment at every visit. The treatment of smokers is analogous to the treatment of patients with mild or moderate hypertension: Screening is a continuing integral activity done routinely by the office staff at every office visit, with physician treatment and follow-up of those identified as having the risk factor and requiring treatment. The physician intervention consists of the four As of clinical activities: ask, advise, assist, arrange. This intervention plan describes a general approach to smoking patients and can be used in almost any outpatient encounter. A typical intervention can be accomplished in a

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very short period of time, often 3 minutes or less. Each element of the intervention is described below and is summarized in Table 1. 1. Ask about smoking at every clinic visit. A nurse or other staff member can easily ask patients "Do you smoke?" or "Are you still smoking?" at each visit, usually while measuring vital signs. Once it is known that a person smokes (or previously smoked), an identifier should be prominently placed on the chart to remind the physician and staff to discuss smoking at each visit. 5 This is discussed in more detail in the office organization section. The physician only needs to ask the patient this question if other staff members have not already done so. 2. Advise all smokers to stop. A clear statement of advice (for example, "As your physician, I must advise you to stop smoking Table 1. SYNOPSIS FOR PHYSICIANS: HOW TO HELP YOUR PATIENTS STOP SMOKING Ask a. b. c. d. e.

about smoking at every opportunity. "Do you smoke?" "How much?" "How soon after waking do you have your first cigarette?" "Are you interested in stopping smoking?" "Have you ever tried to stop before?" If so, "What happened?"

Advise all smokers to stop. a. State your advice clearly, for example: "As your physician, I must advise you to stop smoking now." b. Personalize the message to quit. Refer to the patient's clinical condition, smoking history, family history, personal interests, or social roles. Assist the patient in stopping. a. Set a quit date. Help the patient pick a date within the next 4 weeks, acknowledging that no time is ideal. b. Provide self-help materials. The smoking cessation coordinator or support staff member can review the materials with the patient if desired (call 1-800-4CANCER for NCI's Quit for Good materials). c. Consider prescribing nicotine gum, especially for highly addicted patients (those who smoke one pack a day or more or who smoke their first cigarette within 30 minutes of waking). d. Consider signing a stop-smoking contract with the patient. e. If the patient is not willing to quit now: Provide motivating literature (call 1-800-4CANCER for NCI's Why Do You Smoke? pamphlet). Ask again at the next visit. Arrange follow-up visits. a. Set a follow-up visit within 1 to 2 weeks after the quit date. b. Have a member of the office staff call or write the patient within 7 days after the initial visit, reinforcing the decision to stop and reminding the patient of the quit date. c. At the first follow-up visit, ask about the patient's smoking status to provide support and help prevent relapse. Relapse is common; if it happens, encourage the patient to try again immediately. d. Set a second follow-up visit in 1 to 2 months. For patients who have relapsed, discuss the circumstances of the relapse and other special concerns. From Glynn T, Manley M: How to Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians. Bethesda, MD, National Institutes of Health, 1989.

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now") is essential. Many patients do not recall receiving this advice from their physician,12 so the statement must be easy to understand and memorable. Personalization of the message by referring to the patient's clinical condition, social roles, personal interests, or family history may add to the effectiveness of the advice. What motivates one person to stop smoking might not influence another person at all. Smokers are more motivated to stop if they have specific information about the effects of smoking on their life and the well-being of their family, as well as reinforcement of their personal reasons for stopping. A list of reasons people might give for stopping is provided in Table 2. 3. Assist the patient in stopping. When a patient is discussing smoking, his or her level of interest in stopping is usually evident (if it isn't, ask if he or she wants to stop). For patients who do not want to stop, nagging is rarely of benefit. Physicians must accept the patient's decision, make sure the patient is making an informed decision, and attempt to maintain the patient's trust and confidence so that smoking can be discussed at future visits. If the conversation is noted in the medical record, it can be referred to in future discussions. For patients who express a sincere desire to stop smoking (70% or more of smokers), the physician should help them to Table 2. GOOD REASONS TO STOP SMOKING* For teenagers Bad breath Stained teeth Cost Lack of independence-controlled by cigarettes Sore throats Cough Dyspnea (might affect sports) Frequent respiratory infections For pregnant women Increased rate of spontaneous abortion and fetal death Increased risk of low birth weight For parents Increased coughing and respiratory infections among children of smokers Poor role model for child For new smokers Easier to stop now For asymptomatic adults Twice the risk of heart disease Six times the risk of emphysema Ten times the risk of lung cancer

5-8 year shorter Iifespan Cost of cigarettes Cost of sick time Bad breath Less convenient and socially unacceptable Wrinkles For symptomatic adults Upper respiratory infection Cough Sore throat Gum disease Dyspnea Ulcers Angina Claudication Osteoporosis Esophagitis For any smoker Money saved by stopping Feel better Improved ability to exercise May live long enough to enjoy retirement, grandchildren, etc.

'Adapted from Glynn T. Manley M: How to Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians. Bethesda, MD, National Institutes of Health, 1989.

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pick a specific date for this action. There is evidence that patients who set a "quit date" are more likely to make a serious attempt to stop. This date should be soon (generally within 4 weeks), but not immediately, giving the patient the necessary time to prepare to stop. Once a patient has selected a specific date to stop, information must be provided so that he or she can prepare for that date. For patients who can read, this is easily done by providing them with a self-help brochure. Effective brochures provide the patient with necessary information about smoking cessation (e.g., symptoms and time course of withdrawal, tips about stopping, good reasons for stopping, answers to common questions). These kinds of brochures have been used by millions of people to stop smoking, and the importance of the information must be emphasized to the patient. Self-help materials can be obtained from a variety of sources (e.g., the American Cancer Society, the American Lung Association, the National Cancer Institute). Physicians new to the topic of smoking cessation can quickly add to their own knowledge by reading one of these brochures. Time-honored and scientifically validated techniques for stopping are described. The office staff can emphasize that the physician wants this material to be read, review this material with the patient, and answer any questions about it. With this information, the patient can leave the office with a concrete plan for stopping, including a quit date, and information about preparing for that date and successfully stopping. Several pharmacologic agents have been proposed as adjunctive therapy in smoking cessation. At the time of this writing, only one drug, nicotine polacrilex gum, had been approved by the Food and Drug Administration for this use. Nicotine polacrilex has been shown to be helpful for some patients when combined with behavioral interventions. 8 , 16,22,24 Highly addicted patients (those smoking one pack per day or more or smoking their first cigarette within 30 minutes of waking) may be particularly suited for this drug. Nicotine polacrilex should not be chewed like regular gum but instead chewed intermittently and then held in contact with the oral mucosa, where the nicotine is absorbed. Unless patients receive careful instruction in the use of this unusual drug delivery system, they will derive little benefit from it. Patients should be instructed in the "chew and park, chew and park" technique of nicotine gum use. This includes chewing the gum 5 to 10 chews until a burning, peppery taste is noted, then parking the gum between the teeth and buccal mucosa so that the nicotine can be absorbed. After a few minutes of parking, the peppery taste diminishes. The patient should again chew the gum a few times, then park it between the teeth and buccal mucosa in another part of the mouth. A piece of the gum lasts for about 30 minutes and patients can use up to 30 pieces

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per day, although most use 10 to 15 pieces per day. Patients should use a piece of the gum whenever they experience a strong urge to smoke a cigarette. The office staff can review its use with the patient. When it is used appropriately, withdrawal symptoms are reduced. The use of this drug for 3 months is recommended, followed by a gradual tapering. Use for more than 6 months is not recommended. A small percentage of successful quitters use the gum for longer than this recommended time. Physicians should warn patients of their intent to taper the dose of gum after 3 months. Transdermal nicotine patches are currently under development. These devices deliver nicotine through the skin and may prove easier for patients to use. This product appears to be helpful in alleviating the acute withdrawal effects of tobacco cessation14 and may be an effective adjuvant for long-term smoking cessation. 25 Effectiveness of a transdermal patch as an aid to cessation has not yet been directly compared to that of nicotine polacrilex. 27 4. Arrange follow-up visits. When patients know their progress will be reviewed, their chances of successfully stopping are improved. This monitoring may include a letter or phone call from the office staff just before the quit date, reinforcing the decision to stop. In addition, clinical trials strongly suggest that a visit with the physician or staff soon after a patient has stopped smoking is extremely important to the patient's ability to remain a nonsmoker. Merely scheduling the visit may help the patient by providing a short-term goal (2 weeks) that appears more manageable than "forever." Most relapses occur in the first weeks after cessation,13 and a person who comes to the office after stopping smoking for 1 to 2 weeks has a much improved chance of remaining abstinent. Follow-up visits should include an assessment of the patient's progress, discussion of any problems encountered or anticipated, and discussion of nicotine replacement therapy, if prescribed. It is important to set up a second follow-up visit with the physician or staff member in 1 to 2 months. Studies show that the quit rate improves as the number of follow-up visits increases. 30 A flow sheet or permanent progress card in the chart (discussed more fully under Office Organization) provides an easy way to keep informed about the patient's current smoking status and allows continued follow-up and reinforcement to be done, both at specifically scheduled smoking visits and when the patient is seen for other problems. Office Organization

A team approach in helping patients to stop smoking is significantly more effective for several reasons. The intervention is more systematic,

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increasing the number of patients screened and treated. Involvement of the office staff means more patient support, increasing the likelihood of patient success. A team effort also means that less physician time is required. 12 Some simple changes in office procedures markedly increase the physician's effectiveness in treating patients who smoke. Every practice is different, so the exact procedures adopted vary somewhat, but the goal is to ensure that all patients who smoke are routinely identified, monitored, and appropriately treated. Office organizational procedures include selecting an office smoking-cessation coordinator, prClviding self-help information, making the office tobacco-free, systematically identifying and monitoring smokers, and involving staff members with the intervention and follow-up. These procedures are summarized in Table 3. To function as a coordinated team, all members of the office staff need to know their roles and responsibilities; clear definitions of these must be negotiated with staff. The team approach is facilitated by naming a smoking cessation coordinator, usually a nurse, who incorporates the intervention into the day-to-day activities of the practice. With the help of the other staff members, the coordinator maintains Table 3. SYNOPSIS FOR OFFICE STAFF: HOW TO DEVELOP OFFICE PROCEDURES TO HELP PATIENTS STOP SMOKING Select an office smoking cessation coordinator to be responsible for seeing that the office smoking cessation program is carried out. Create a smoke-free office. a. Select a date for the office to become smoke free. b. Advise all staff and patients of this plan. c. Post no-smoking signs in all office areas. d. Remove ashtrays. e. Display nonsmoking materials and cessation information prominently. f. Eliminate all tobacco advertising from the waiting room. Identify all patients who smoke. a. Ask all patients, "Do you smoke?" or "Are you still smoking?" at each visit. b. Prominently place a "Smoker" identifier on the charts of all smoking patients. c. Attach a permanent progress card to each patient's chart. Review self-help materials (provided by either the physician or the coordinator) and nicotine gum use (if a prescription has been given) with each smoking patient. Assist the physician in making follow-up visits. a. With each patient who has agreed to a quit date, schedule a follow-up visit 1-2 weeks after the quit date. b. Call or write the patient within 7 days after the initial visit to reinforce the decision to quit. c. Schedule a second follow-up visit approximately 1-2 months after the first follow-up visit. From Glynn T, Manley M: How to Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians. Bethesda, MD, National Institutes of Health, 1989.

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staff commitment to the program and ensures that the system is operating smoothly. In large practices, the tasks of smoking cessation may be divided among several staff members, so that no one is unduly burdened with these important tasks. Materials necessary for effective intervention must be stocked and maintained in the clinic. This includes self-help brochures and chart reminder materials and, depending on the preference of the clinic, may also include stop-smoking patient contracts, posters, and other motivational materials. A smoke-free office makes a powerful statement about the staff's strong commitment to nonsmoking and allows the office staff to serve as role models for their patients. Steps for making an office tobaccofree include selecting a date (with appropriate notice), posting nosmoking signs, removing ashtrays, displaying tobacco cessation/prevention information prominently, and eliminating tobacco advertising from the office, either by subscribing to magazines that do not carry this advertising2,11 or by crossing out the tobacco advertisements with bright markers. The team approach also includes staff identification of all patients who smoke. When patients are identified as smokers, their charts should be marked in a prominent manner. The typical identifier is a brightly colored sticker or stamp. The regular use of these chart reminders has been shown to signifkantly increase cessation rates in office practices. 4 The staff should also attach a progress card or flow sheet to the chart, providing an easy way for the entire team to keep informed about the patient's current smoking status. In this way, brief cessation advice can become a routine part of every office visit for the patient. It is important that all staff members understand and implement this type of charting system for it to be effective. A staff member often schedules the follow-up visits, makes the contact just prior to the "quit date," and frequently conducts some or all of the actual follow-up visits. Staff members can also review with patients their self-help materials and instructions for use of nicotine polacrilex, if prescribed. In addition to these basic tasks, many clinics have adopted mechanisms to track their success at helping patients to stop smoking. Providing feedback to staff helps to maintain interest and commitment to smoking cessation. Simple counts of successful cessation can be accomplished using the medical records. Some clinics have created signs or posters for the reception area that shows the current count of successful quitters. This demonstrates to patients the clinic staff's concern for smoking and encourages other smoking patients to stop smoking by offering prizes for cessation. This kind of contest has been used to attract new patients to a clinic by demonstrating the organization's concern for health promotion.

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COMMON PROBLEMS IN SMOKING CESSATION AND POSSIBLE SOLUTIONS Weight Gain

The issue of weight gain is extremely important to many patients who try to stop smoking. The average weight gain after cessation is approximately 5 pounds. 26 Some patients gain no weight after cessation, but a small proportion of people gain large amounts of weight. Only 3.5% of ex-smokers gain more than 20 pounds. 26 The typical gain in weight is the result of both a change in body metabolism caused by the absence of nicotine and a tendency to consume more food. 26 Some patients cite weight gain as the reason for relapse after previous attempts to stop. For many smokers, the risk of future health problems from smoking is outweighed by their perceptions of the adverse consequences of weight gain. There is enormous societal pressure, especially on young women, to be thin. Cigarette advertisers have reinforced those pressures with advertisements showing slim women with slim cigarettes. Weight gain might simply be unacceptable to smokers who are concerned about their appearance. There may also be large costs to the individual who gains weight and must purchase a new wardrobe. In advising a patient who is concerned about preventing weight gain, two tactics can be suggested. First, high-calorie foods should be avoided. Carrot sticks and cinnamon sticks are time-honored lowcalorie foods used by new ex-smokers whenever the urge to eat occurs. Attention to caloric intake can be recommended to patients to avoid weight gain. However, it is generally not recommended that patients try to lose weight during the initial period of cessation. In later months, when relapse is less likely, weight reduction may be attempted. The second tactic to recommend is an increase in exercise to help offset weight gain caused by a reduction in body metabolism. Most exercise activities are more difficult to perform while smoking and often involve other nonsmokers. For both these reasons, a regular exercise program is sensible for almost anyone trying to stop smoking. History of Multiple Relapses

Many smoking patients, especially adults over 40, have made several serious attempts to stop but have always relapsed. These patients frequently have tried various stop-smoking products and programs, all without success. Such patients are often discouraged by these failed attempts to stop and therefore less willing to try again. For a patient who has failed in unaided attempts to stop, as well as in attempts using hypnosis, over-the-counter products, nicotine gum, or group cessation programs, skepticism about their ability to stop successfully may be difficult to overcome. The physician's offer of a self-

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help pamphlet, a brief conversation, and nicotine gum, all of which may have been used in previous quit attempts, may not be viewed by the patient as a new or promising avenue to cessation, These patients (and their physicians) need to be aware of the typical course of a patient trying to stop. Many patients who successfully stop smoking do so only after several serious but unsuccessful attempts. Relapse is typically part of cessation. Rather than viewing relapse as a normal part of the cessation process, many patients attribute their relapse to personal weakness, lack of will power, or other equally negative personal traits. A physician can offer a more productive perspective to the patient. Both must recognize that whereas smoking cessation is apparently an easy task for some people, for most addicted smokers it is a very difficult and uncomfortable process. For these patients, cessation takes practice (like learning to ride a bike), and continued practice is the only way they will learn to be nonsmokers. A physician can help a patient benefit from past relapses, rather than viewing them as a personal failure and a reason to avoid future cessation attempts. The physician can help the patient identify both the circumstances that led to past relapses and strategies either to avoid those circumstances or to respond to them in a different manner. A simple question from the physician such as "Where did your first cigarette come from?" starts the discussion of the reason for relapse. There are several very common reasons offered for relapse, including withdrawal symptoms, weight gain, "stress" at work or home, alcohol intoxication, and social pressure. Once the patient has described the circumstances of the relapse, the physician can ask, "How would you deal with that situation if it happened again?" or "How could you avoid that situation in the future?" The physician can offer advice about some situations and help with withdrawal symptoms, but the patient must develop a specific plan for responding to most circumstances that have caused past relapses. Usually this can be accomplished during very brief conversations. When patients realize that they can learn from relapse and are more likely to stop smoking because of these past experiences, they are often willing to try again. Repeated attempts and relapses may be discouraging to patients and physicians, but they are far preferable to the fatal diseases that await many smokers. Patients' chances of stopping may be only 10% to 15% on any quit attempt, but if they fail, they can try again, thereby increasing their chance of success. These statistics are better than those for lung cancer patients, who have only a 10% to 15% chance of living for 5 years after diagnosis. Physicians who recognize nicotine dependence as a chronic condition that requires attention throughout a patient's life can avoid the discouragement that may accompany treatment of this problem. The recognition that brief but repeated intervention can be effective helps physicians both avoid discouragement and persist in motivating their relapsed patients to make another quit attempt.

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Lack of Social Support for Stopping

As with any addiction, nicotine dependence is characteri2ed by social as well as physiologic and psychological factors. In fact, social factors are frequently given as a reason for relapse. A common relapse story is that of the smoker who successfully stops during a vacation but relapses upon returning to work with his smoking colleagues. Parties and other social gatherings are also common sites of relapses, especially among patients who consume alcohol at these events. During the time of a brief office visit, major changes in the level of a patient's social skills and support cannot be expected. However, all patients should be encouraged to tell their family, friends, and coworkers of their decision to stop smoking. This may not be easy for patients who have relapsed in previous quit attempts because almost no one likes to fail in public. However, by telling people of his or her plan to quit, the patient has more reason to actually make the attempt and will probably receive more support during the withdrawal period. Patients with little support for stopping can be referred to group cessation programs, if they are willing to attend. Referral to a counselor or other health professional may also be useful. It is often very difficult for a smoking patient to stop if his or her spouse also smokes and is unwilling to stop. The unwilling spouse should be encouraged to join in the quit attempt. If he or she refuses, the smoking spouse should at least be encouraged to smoke only outside of the house. Extra support for the patient attempting to stop should also be sought. SUMMARY

Like other chronic conditions, nicotine dependence offers both challenges and rewards to clinicians. The treatment of this condition frequently requires experience in pharmacology, behavioral science, and social aspects of medicine. Physicians are uniquely qualified to assist patients in their efforts to overcome the multifaceted condition of tobacco addiction. In providing this treatment, the clinical challenges are far outweighed by the benefit to patients who stop smoking. For many patients, smoking cessation is, by far, the most important step they can take to improve their health and increase their life span. Physicians who help patients accomplish this difficult goal provide a life-saving service. There is sufficient scientific evidence to guide physicians in their approach to smoking patients. Brief, systematic interventions have been shown to increase patient smoking cessation rates. The intervention can be described in four steps: ask about smoking, advise smokers to stop, assist those who want to stop, and arrange adequate follow-up. These interventions are used consistently when a smoking cessation program is adopted by an entire office practice. The components of

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this office-based program include defining staff roles, maintaining a smoke-free office, stocking appropriate materials, making use of the medical record to identify smokers and to remind staff to intervene, and monitoring patient progress. The potential public health impact of physician intervention with smoking patients is enormous. Even with very modest expectations of cessation rates, 100,000 physicians using effective intervention can produce over 3 million new ex-smokers in the United States each year. In conjunction with other community-based tobacco control efforts, this physician-lead effort will result in a marked reduction in the morbidity and mortality caused by smoking and, thus, control of "the most important public health issue of our time." References 1. American Cancer Society: A Survey Concerning Cigarette Smoking, Health Check-

2. 3.

4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

ups, Cancer Detection Tests. A Summary of the Findings. New York, American Cancer Society, 1977 Anonymous: Here's a list of magazines that don't carry cigarette ads. American Medical News, Nov 24, 1989, pg 17-18 Blackburn H, Luepker RV, Kline FG, et al: The Minnesota Heart Health Program: A research and demonstration project in cardiovascular disease prevention. In Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York, John Wiley & Sons, 1984 Cohen SJ, Stookey GK, Katz BP, et al: Encouraging primary care physicians to help smokers quit: A randomized, controlled trial. Ann Intern Med 110:648, 1989 Cohen S, Christen A, Katz B, et al: Counseling medical and dental patients about cigarette smoking: The impact of nicotine gum and chart reminders. Am J Public Health 77:313, 1987 Cummings SR, Coates TJ, Richard RJ, et al: Training physicians in counseling about smoking cessation: A randomized trial of the "Quit for Life" program. Ann Intern Med 110:640, 1989 Cummings SR, Rubin SM, Oster G: The cost-effectiveness of counseling smokers to quit. JAMA 261:75-79, 1989 Fagerstrom K: Effect of nicotine chewing gum and follow-up appointments in physician-based smoking cessation. Prev Med 13:517, 1984 Farquhar JW: The community-based model of life style intervention trials. Am J Epidemiol 108(2):103, 1978 Glynn TJ, Manley MW, Pechacek TF: Physician-initiated smoking cessation program: The National Cancer Institute Trials. In Advances in Cancer Control: Screening and Prevention Research. New York, Wiley-Liss, 1990, pp 11-25 Glynn T, Manley M: How to Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians. Bethesda, MD, National Institutes of Health, 1989, p 14 Hollis JF, Lichtenstein E, Mount K, et al: Nurse-assisted smoking counseling in medical settings: Minimizing demands on physicians. Prev Med 20:497, 1991 Hunt W, Barnet L, Branch L: Relapse rates in addiction programs. J Clin Psychiatry 27:455, 1977 Hurt RD, Lauger GG, Offord KP, et al: Nicotine-replacement therapy with use of a transdermal nicotine patch-a randomized double-blind placebo-controlled trial. Mayo Clin Proc 65:1529, 1990 Jarvik ME, Henningfield JE: Pharmacological treatment of tobacco dependence. Pharmacol Biochem Behav 30:279, 1988 Jarvis M, Raw M, Russell M, et al: Randomized controlled trial of nicotine gum. Br Med J 285:537, 1982

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17. Kottke T, Battista R, DeFriese G, et al: Attributes of successful smoking cessation intervention in medical practice: A meta-analysis of 39 controlled trials. JAMA 259:2882, 1988 18. Kottke TE, Brekke ML, Solberg Li, Hughes JR: A randomized trial to increase smoking intervention by physicians: Doctors Helping Smokers, Round 1. JAMA 281:2101, 1989 19. Orlandi MA: Promoting health and preventing disease in health care settings: An analysis of barriers. Prev Med 16:119, 1987 20. Orleans CT, George LH, Houpt JL, et al: Health promotion in primary care: A summary of US family practitioners. Prev Med 14:636, 1985 21. Prochaska JO, DiClemente CC: Stages and processes of self-change of smoking: Toward an integrative model of change. J Consult Clin Psychol 51(3):390, 1983 22. Russell M, Merriman R, Staple ton J, et al: Effect of nicotine chewing gum as an adjunct to general practitioner's advice against smoking. Br Med J 287:1782, 1983 23. Russell MAH, Wilson C, Taylor C: The effects of general practitioners' advice against smoking. Br Med J 2:231, 1979 24. Schwartz J: Review and evaluation of smoking cessation methods: The United States and Canada, 1978-1985. Bethesda, MD, National Cancer Institute, 1987, p 40 25. Tonnesen P, Norregaard J, Simonsen K, et al: A double-blind trial of a 16-hour transdermal nicotine patch in smoking cessation. N Engl J Med 325(5):311, 1991 26. US Department of Health and Human Services: The Health Benefits of Smoking Cessation. A Report of the Surgeon General. Rockville, MD, Department of Health and Human Services, 1990, p 505 27. US Department of Health and Human Services: Tobacco Use in 1986: Methods and Basic Tabulations from Adult Use of Tobacco Survey. Rockville, MD, Department of Health and Human Services, 1990, p 41 28. US Department of Health and Human Services: Role of the Physician in Smoking Cessation. In The Health Consequences of Smoking: Chronic Obstructive Lung Disease. Rockville, MD, Department of Health and Human Services, 1984, p 471 29. Wells KB, Ware JE, Lewis CE: Physicians' attitude in counseling patients about smoking. Med Care 22:360, 1984 30. Wilson DMC, Taylor DW, Gilbert JR, et al: A randomized trial of a family physician intervention for smoking cessation. JAMA 260:1570, 1988

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