Cigarette smoking is a modifiable risk factor which means that people have to option of quitting if they like and change their health. Tobacco is a known carcinogen that can cause cancers, as well as lung disease and heart disease, making it important to promote smoking cessation.
Smoking cessation can be promoted by using a technique called motivational interviewing, which is comprised of the five A’s. These days, smoking history is actually treated as a vital sign, which prompts the provider to inquire about smoking during each and every visit with their patients. It’s a technique to motivate patients to consider quitting and each physician should repeat the importance of quitting and offer nicotine replacement, along with pharmacological therapies such as Wellbutrin or Chantix.
Some patients can use more than one nicotine replacement for example the patch plus method, with or without Wellbutrin, which adds success to quitting. In heavy smokers increasing the nicotine dosage, as well as offering a combination can help. For example, methods of nicotine replacement include the patch plus method. As the patient approaches a quit date, it is good to repeat the cessation messages from the physician and counsel the patients that the average smoker will quit approximately five times before permanent success and that every time they have a relapse they’re getting closer and closer to permanent success.
The five A’s in motivating cigarette smoking cessation include:
“Ask” occurs in every visit where the physician inquires about their past history of tobacco use, current history of tobacco use as well as asking how much they are smoking or have ever smoked in their lifetime.
“Advise” is to help a patient to quit at as opposed to not giving any advice at all because advising has been linked to improved quit rates and has to be done by a physician.
“Assess” is basically the physician trying to gauge how willing the patient is to quit. Not all patients are created equal and behavior changes need to occur in patients such as the five stages. Stage one is pre-contemplation where the patient is either unaware that they need to change, they’re reluctant, they’re rebellious to the idea of changing, they resign or rationalize such that they are aware of the consequences of their behavior but in their mind it does not apply to themselves.
The next stage is contemplation, where they considering change followed by preparation. Preparation is where they are planning to take an action followed by action and this where they’re starting to change and there’s a new behavior that has begun. The key here is to prevent a relapse and encourage the momentum towards quitting, followed by the last stage which is maintenance and this is when the physician comes in and reminds them about high risk situations where you keep them away and continue them on the path to quitting forever.
The difference here is that motivational intervention is that you’re not confronting these patients as it’s very ineffective and the patient might actually retaliate or take it personally and rebel to the idea of quitting. Motivational interviewing, on the other hand is where a physician is in position to be very empathetic and respects the patient, allowing the patient to be in charge while the physicians role here is to just support the patient.
Now there are five strategies to help patients become motivated and it begins with the physician discussing the 5 R’s.
Relevance where a physician will encourage the patient to find reasons to quit. Examples include pregnancy or they have family around them that will be exposed or somebody has asthma and it’ll worsen their asthma. Basically find relevant reasons from the patient that apply to their personal lives as motivation to quit.
Risks involves advising the patient about the harms of smoking to themselves and to others. Reasoning about what it might do to their family and friends as well as colleagues at work.
Rewards includes asking the patient to identify what the benefits are of quitting such as improved health or saving money because cigarettes are expensive, so on and so forth.
Roadblocks and that is where you explore what are the barriers for them to quit such asking them if they are around other people who are smoking around them that prevents them from quitting. Asking if they have failed in the past or do they become stressed or put on weight. What are their reasons that are become barriers in in smoking cessation?
Repeat. Basically you repeat the five R’s in each contact with the patient. If they’re unmotivated every time they come in, you repeat these five R’s. Now that leads us to away from the assess because these five R’s happen during the assessment phase. These five R’s come in the assist part where you ask the patient who are willing to quit to set a quit date to prompt that change and allow the patient and physician to anticipate obstacles such as depression and weight gain and nicotine withdrawal.
The 4th A is Assist and you may chose to prescribe therapies discussed later as well as individual and group counseling.
The last A is arrange which allows a physician to follow up as the patient gets closer and closer to their quit date. Congratulating them on their abstinence and supporting them, offering them pharmacological therapies and behavioral counseling if they go into relapse. You need to encourage them to set a new quit date and go right into it all over again and this time with medications such as nicotine gum for example.
Nicotine gum is available in 2 mg and 4 mg doses. Patients who smoke less than25 cigarettes a day can manage with the 2 mg dose of gum, if they smoke more than 25 cigarettes a day, then you want to offer them 4 mg of gum but do not exceed 24 pieces a day. Other nicotine replacement methods are the patch for example, the patch can help relieve their cravings and relieve their withdrawal symptoms as well. There are slow release skin patches, compared to the more rapid release forms like the gum, the spray, the inhalers and the lozenges. Sometimes you want to do the patch plus method where you have a slow release patch in combination with a rapid release to prevent breakthrough cravings.
There is also a medication called Chantix, which is a nicotine partial agonist, and it reduces cravings and withdrawal symptoms as well as increases chances of quitting. Chantix is considered superior to Bupropion also known as Wellbutrin which is an anti depressant and it’s effective as smoking cessation aid.
Second line therapies would be one of our antihypertensives, such as clonidine, which is used to treat blood pressure but it is a therapy that’s effective in smoking cessation, as well as nortriptyline. Nortriptyline is aka Pamelor, which is a tricyclic anti depressant. They can become first line medications if the others are contraindicated or have not been effective.
Special considerations for pregnancy:
Tobacco is a known carcinogen that can harm the developing fetus resulting in low birth weight, preterm birth and even infant mortality. Nicotine replacement especially in the early stages of pregnancy can also increase the risk of birth defects.
What happens in people with coronary artery disease?
Smoking cessation help reduce the coronary heart risk. It’s important to know that Bupropion is cardiotoxic and it should not be considered in anybody who has a wide QRS complex on their EKGs. Chantix can also increase cardiovascular risk of the disease, increases angina and myocardial infarction that’s non fatal. Nicotine replacement for smoking cessation outweigh the risks. Nicotine Replacement can trigger cardiac events in the immediate post myocardial infarction, arrhythmias and worsening angina.
Special Considerations for Adolescents
95% of adult smokers began smoking as adolescence or pre adolescence and usually physicians may want to consider intervening in adolescent smokers, even though the USPSTF has insufficient evidence to recommend screening and intervening in the adolescent. Nicotine is considered safe in the adolescent and you should consider using the same five A’s and five Rs in motivation enhancing strategies to help lower tobacco use.