No ‘pass/fail’ for smoking cessation
By devoting even a few minutes to exploring a patient's openness to quitting—a “pre-quit approach”—physicians can potentially make a powerful difference.
Two-thirds of people who smoke want to shed their cigarette use, according to the U.S. Surgeon General's 2020 report on smoking cessation. But only one in five are considering quitting within the next 30 days.
Even so, internal medicine physicians can still reach that larger cadre of potential quitters, said Frank Leone, MD, MS, FACP, who directs the Comprehensive Smoking Treatment Program at the University of Pennsylvania in Philadelphia. Studies have shown that early intervention with FDA-approved treatments—offering them before patients are willing to set a quit date—can boost the odds of eventual cessation success, he said.
“That idea is of critical importance in the clinic,” Dr. Leone said. “Mrs. Smith will never be committed to quitting. In the same sentence she will say, ‘I am desperate to stop smoking,’ and ‘I don't want to stop smoking.’ That's the nature of this beast. So, if we're waiting for her to say, ‘Yes, do something. I'm ready,’ we'll wait forever.”
That pre-quit approach is part of a panoply of treatment options that physicians can recommend as they strive to encourage and support the ever-shrinking population of U.S. adults who smoke. By 2022, 11.6% reported smoking cigarettes, according to federal data. By 2035, the national prevalence rate is projected to further decline, approaching 5%, according to an analysis published on April 25 in JAMA Network Open.
Adults who continue to smoke are more likely to have less formal education or lower income and may be living with other conditions, including HIV, substance use disorders, and mental health challenges, according to a review article about smoking cessation treatment published in JAMA in 2022. And geographic differences persist: In Appalachia, 34.1% of adults smoke, three times the national average, according to data published in February in the American Journal of Preventive Medicine.
Clinical guidelines, including those published in 2020 by the American Thoracic Society (ATS), recommend FDA-approved treatments paired with behavioral counseling. However, although more than half of U.S. adults who smoke attempt to quit each year, fewer than one-third incorporate these methods. The best odds of success are rooted in ongoing treatment and conversations about the challenges of nicotine dependence, along with follow-up that involves the broader practice team, according to smoking cessation experts.
By devoting even a few minutes to exploring a patient's openness to quitting, physicians can potentially make a powerful difference, said Audrey Darville, APRN, PhD, a family nurse practitioner and certified tobacco treatment specialist at the University of Kentucky College of Nursing in Lexington. Lean into empathy, and let patients know that smoking cessation is a process and not a pass/fail test, she said.
“The follow-up is really critical,” she said. “We want to normalize relapse. We don't want to stigmatize it. Say, ‘It's really hard to quit. A lot of people go back to smoking after making a quit attempt. So, if this happens to you, be sure to follow up.’”
Talking through motivations
Physicians may be reluctant to discuss smoking cessation, worried not only about the time involved but also inadvertently offending or shaming the patient, said Dr. Leone, who also coauthored the book “Why People Smoke: An Innovative Approach to Treating Tobacco Dependence.” “There is literally an emotional toll that the clinician needs to be willing to pay in order to engage in this conversation,” he said.
But with several questions, physicians and their medical team can gain a better sense of the drivers and underpinnings of a patient's nicotine dependence, Dr. Leone said. He suggested such questions as, “Tell me what smoking means to you. Have you ever tried to stop before?”
Then ask about how their quit attempt went, he said, followed by, “What brought you back to smoking?”
That feedback can help physicians home in on what drives an individual's smoking habits, as well as which cessation approaches didn't work before, providing opportunities to brainstorm about strategies moving forward, Dr. Leone said. For instance, if the patient says that the nicotine patch doesn't work, the physician can suggest a stronger dose along with counseling them that the patch won't eliminate their impulse to smoke, he said.
In some regions of the country, people's smoking behaviors have become entrenched, dating back to before their teens, Dr. Darville said.
“They are super, super dependent on nicotine because their brain developed with it,” she said, noting that heightened anxiety, irritability, and other withdrawal symptoms can be acute. “These folks have probably tried to quit multiple times and feel like failures.”
Smoking also can serve as a coping mechanism, particularly for individuals who are under notable stress, including financial, said Amy Ferketich, PhD, a coauthor on the recent analysis of Appalachian smoking rates and a professor in the division of epidemiology at Ohio State University in Columbus.
Dr. Ferketich, who has conducted focus groups involving individuals who smoke, said they are searching for empathy and support, along with immediately actionable information: How will quitting smoking improve their health here and now? For that reason, she suggests that physicians link the habit's influence to another medical condition a patient may have, such as diabetes or high blood pressure.
“What they don't like is when a health care provider says, ‘It's going to kill you,’” Dr. Ferketich said. “Because they can all give you [the names of] 20 people who smoked and lived until 90.”
Treatment approaches
In its evidence-based treatment guideline, the ATS made several strong pharmacological recommendations, such as varenicline over the nicotine patch, including among individuals with a psychiatric condition, and over bupropion. Another recommendation, described as conditional, suggested combining varenicline with a patch from the start of treatment rather than initiating varenicline alone.
Dr. Leone prefers that combined approach, since it provides the opportunity to target multiple brain pathways involved with nicotine dependence. Rather than giving Mrs. Smith the option to choose between a pill or a patch, he said, “I'm going to give Mrs. Smith the best chance at achieving the outcome that we both desire.”
In addition, the ATS guideline strongly recommended a pre-quit treatment approach for patients not yet ready to abstain but willing to try a pharmacological option. Studies involving varenicline have shown that the prescribing approach enabled 308 more people to quit out of every 1,000 who attempted, the authors wrote.
The approach is “particularly helpful for the group that is contemplative, on the cusp, and they're not quite ready to take this action tomorrow,” said Maya Vijayaraghavan, MD, MAS, an internal medicine physician who directs the Smoking Cessation Leadership Center at the University of California, San Francisco.
“You can use medication to prime cessation. You are getting them ready,” Dr. Vijayaraghavan said. The hope is that the medication will reduce cravings and withdrawal symptoms enough that patients will later set a quit date, she said.
Physicians should be prepared to try various cessation strategies, working with patients over time, Dr. Leone said. Maintain focus on reducing a patient's nicotine dependence, he stressed, rather than the outcome of smoking cessation. “Imagine a clinician that engages in an asthma conversation by saying something like, ‘You know what, you really should stop wheezing,’” he said.
E-cigarette uncertainties
The promising decline in cigarette smoking has been offset by the emergence of other nicotine products, including e-cigarettes. By 2022, 19.8% of adults used some type of tobacco products, including 11.6% who reported smoking cigarettes and 6% who used e-cigarettes, according to federal data.
The use of e-cigarettes as a smoking cessation tool is “an area of active debate and consideration,” said Gina Kruse, MD, MPH, MS, an associate professor of medicine in the division of general internal medicine at the University of Colorado School of Medicine–Anschutz Medical Campus. A Cochrane Review analysis, published earlier this year, found that people were more likely to abstain from cigarettes for at least six months if they used e-cigarettes to quit rather than nicotine replacement therapy options, such as a patch or gum. The authors cautioned, however, that more research is needed, particularly involving newer products that deliver more nicotine.
To date, the e-cigarettes used in studies have varied, with many of those studies conducted in other countries where there's an upper limit on nicotine levels, unlike in the U.S., which has no cap on nicotine content, Dr. Kruse said. Thus, it's difficult for U.S. physicians to know which product to recommend, as they can't necessarily access the products studied in those trials, she said.
Other research indicates that, while individuals may be more successful in abstaining from smoking cigarettes with e-cigarettes, they may then struggle to stop using them, Dr. Kruse said.
She pointed to one randomized study in the United Kingdom, published in 2021 in Addiction, which found that after six months, 26.5% of participants had cut back or quit smoking in the e-cigarette group versus 6% in the nicotine replacement group. But the proportions of those who reported still using e-cigarettes or nicotine replacement were 47.1% versus just 10.5%, respectively.
While some of the cessation data about e-cigarettes can be compelling, uncertainties remain, Dr. Kruse said. “I do have concerns about the persistence of use, and just all that we don't know about the long-term health effects.”
Moreover, real-world data outside of a controlled study setting indicates that e-cigarettes may not be as promising for cessation, Dr. Vijayaraghavan said. She cited a study, published March 5 in JAMA Network Open, finding that adults who vaped daily were 4.1% less likely to remain abstinent from cigarettes after 12 months than those who didn't use e-cigarettes.
If a patient wants to try e-cigarettes, Dr. Vijayaraghavan explores first which FDA-approved methods they've already used and suggests changes in dose or approach that may work better. If they insist on e-cigarettes as the optimal route, she encourages them to stop cigarettes first. “Dual use is harmful, too,” she said, including potential cardiovascular harms.
Crucial counseling, follow-up
Other members of a medical practice can assist with smoking cessation education and support, including follow-up, Dr. Vijayaraghavan said. Since the risk of relapse is highest within the first few weeks, ideally clinicians could check in by phone or a follow-up office visit at that point, she said.
Behavioral counseling and support are crucial. Some resources may be free, such as smoking cessation groups or programs offered through local health departments. Clinicians can refer patients to state or national quit lines, which offer support in several languages. Other tailored resources, including guidance on various stages of quitting, are available.
If feasible, set up a referral to the quit line so that someone reaches out to the patient, Dr. Darville said. “We know that if the quit line calls the patient, they're more likely to engage than if we just hand them a phone number.”
When a patient relapses, validate the strides that they did make, Dr. Leone said, by saying something like, “‘Two weeks is great. Listen, relapse happens. Life is complicated. Let's talk about it. What brought you back?’”
Sometimes patients may not be ready to quit but are open to cutting back, Dr. Darville said. “Some programs don't even use the word ‘quit’ because it feels too confrontational or too anxiety producing,” she said. “So they approach the conversation by saying, ‘Are you interested in changing your tobacco use?’”
In recent months, federal commitment to driving down the smoking rate has eroded amid cutbacks to grant funding, as well as the elimination of the CDC's Office on Smoking and Health. “It's all the more reason that the professional medical workforce, the internists, family practitioners, everyone, should step in to provide the treatment, because there's going to be a void,” Dr. Vijayaraghavan said.
Above all, keep in mind that a patient who appears to be resistant may instead be only reluctant to take that leap, Dr. Leone said. “In the face of reluctance, we cannot pack our bags and walk away and say, ‘Let me know when you're ready.’ Reluctance is not something to be afraid of; it's something to embrace,” he said, by trying to gain more insight.
“The place where reluctance is,” Dr. Leone said, “is the place where I get to develop that therapeutic relationship with people. ‘I respect where you're coming from, I understand why it's happening. I'm not looking to push you. To achieve my goal, we've got to try to achieve your goal. Here's how I understand the problem. Here are the recommendations I'd like to make.’”
