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7.
CIGARETTE USE COUNSELING
Steven Asch, M.D., M.P.H.
We relied on Chapter 48 of the Guide to Clinical Preventive
Services published by the U.S. Preventive Services Task Force (USPSTF,
1989) to construct quality indicators for the prevention of smoking and
the screening and treatment of cigarette use.
When this core reference
cited studies to support individual indicators, we have referenced the
original source.
We also performed narrow MEDLINE literature searches
for articles from 1990 to 1995 to update the literature support for the
proposed indicators.
IMPORTANCE
About one-third of all Americans smoke tobacco.
Even higher
proportions of African Americans and low-income patients smoke.
Although smoking in women decreased from 28 percent to 25 percent
between 1974 and 1992, the rate of decline has been slower among women
than men (American Cancer Society [ACS], 1995; United States Department
of Health and Human Services [USDHHS], 1989).
In 1993, there were
approximately 22 million female smokers and 73 percent wanted to quit
smoking, but only 2.5 percent of all smokers are able to successfully
quit each year (Centers for Disease Control [CDC], 1993; CDC, 1994).
Tobacco abuse has been strongly associated with carcinoma of the lung,
trachea, bronchus, esophagus, kidney, bladder, pancreas and stomach.
Smoking also plays a large role in causing coronary heart disease,
cerebrovascular disease, and obstetrical complications.
As a result,
tobacco abuse is the most important modifiable cause of death in the
United States.
Smoking is related to about 400,000 deaths annually and
the total direct and indirect costs may exceed $200 billion (USDHHS,
1989; Fiore et al., 1989; ACS, 1995).
Patients who stop smoking return
to baseline risk profiles for coronary artery disease within three to
five years (USDHHS, 1989; Rich-Edwards et al., 1995).
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EFFICACY AND/OR EFFECTIVENESS OF INTERVENTIONS
Screening and Initial Evaluation
Many specialty societies and governmental organizations recommend
asking patients if they smoke, including the American College of
Physicians (ACP), American College of Obstetricians and Gynecologists
(ACOG), American Academy of Pediatrics (AAP), and the National Cancer
Institute (NCI), though there is little agreement as to the optimal
interval for screening (ACP, 1986; Health and Public Policy Committee,
1986; ACOG, 1986; Committee on Adolescence, 1987; Glynn and Marley,
1993; USPSTF, 1989).
For our quality indicator, we propose that intake
history and physicals include screening for tobacco abuse.
If the
patient has not had an intake history and physical, at least one
provider over the course of the year should ask about smoking.
Treatment and Prevention
Once a patient has been identified as a smoker, providers have
modest but definite impact in helping them quit (Russell et al., 1979;
Ewart et al., 1983; Wilson et al., 1982; Wilson et al., 1988).
A meta-
analysis of 39 controlled trials found that counseling yielded an 8.4
percent (95 percent CI 5.6-11.2) reduction in the number of smokers at
six months and a 5.8 percent (95 percent CI 3.2-8.4) reduction at one
year (Kottke et al., 1988).
While most of the individual trials did not
demonstrate an effect, the 95 percent confidence limits after pooling
the subjects exclude zero for both time points (Kottke et al., 1988).
A broad-based program to stop smoking appears to be most effective.
The most successful trials were more likely to employ both group and
individual counseling, teams of physicians and nonphysicians, multiple
reinforcement sessions, and face-to-face advice.
Multivariate analysis
of the attributes of successful trials showed that the number of
interventions was strongly associated with the smoking cessation rate
(Table 7.1) (Kottke et al., 1988).
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Table 7.1
Descriptors for Interventions (Continuous Variables) Reporting Results
12 Months After Initiation of Intervention
Range
Mean ± SD
Correlation
With Cessation Rate
1-6
2.1 ± 0.9
.48*
0%-51%
13.8% ±
12.0%
No. of subject contacts with
program
1-15
3.8 ± 4.6
.38*
Months subject in contact with
program
0-12
1.1 ± 2.1
.55*
32-8189
608.2 ±
948.6
.20
No. of times smoking status was
assessed
1-18
4.0 ± 4.5
.13
Months from first contact to last
verification
0-12
7.6 ± 11.8
.16
No. of times cessation claims were
validated
0-6
0.9 ± 1.2
.09
Subjective rating of study quality
0-5
3.2 ± 1.0
-.23
Descriptors
No. of intervention modalities
Participant drop-out rate
No. of participants
*p<.01.
Source:
.05
Kottke et al., 1988.
Adding nicotine replacement therapy may increase the success rate
of counseling alone by up to one-third, particularly in heavy smokers.
A meta-analysis of 14 randomized trials of nicotine gum compared to
placebo gum found that more patients who used nicotine gum had quit
smoking at 6 months (27 percent vs. 18 percent, n=734) and 12 months (23
percent vs. 13 percent), although this study occurred in the setting of
specialized smoking cessation clinics.
The meta-analysis found lower
rates of effectiveness when the treatment occurred in general medical
clinics, however.
Placebo controlled trials in general practice did not
demonstrate an effect, though uncontrolled trials show that nicotine
replacement had a modest effect at 6 months (17 percent vs. 13 percent;
n=2238) and 12 months (9 vs. 5 percent) in general practice.
Given its
questionable efficacy in the setting of general practice, we propose
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that nicotine replacement be prescribed as second line therapy after
counseling alone has failed (Lam et al., 1987).
There are several contraindications for nicotine replacement
therapy.
Nicotine replacement is contraindicated in women who are
pregnant or nursing because it crosses the placenta and is excreted in
the breast milk.
Patients with recent myocardial infarctions may have
their ischemia exacerbated by nicotine replacement and patients with
temporomandibular joint disease may experience symptomatic worsening.
If the patient continues to smoke, the potential toxicities of nicotine
replacement become much more likely.
Nicotine gum may not be as
effective in the absence of counseling; all the controlled studies
combined gum with some form of advice (Lam et al., 1987; Oster et al.,
1986; Russell et al., 1983; Benowitz, 1988; Wilson et al., 1988;
Fagerström, 1984).
Follow-up
The above-mentioned meta-analysis of 39 clinical trials of smoking
cessation counseling showed that one of the common attributes of
successful programs is reinforcement through follow-up appointments.
Both the number of subject contacts with the program and the number of
months duration of the program were positively correlated with the
cessation rate (see Table 7.1).
We propose that the medical record
should indicate a plan for such reinforcement either by adding tobacco
abuse to the patient’s problem list or through addressing the problem
during at least one subsequent visit.
RECOMMENDED QUALITY INDICATORS FOR CIGARETTE USE COUNSELING
These indicators apply to women aged 18-50.
Screening and Initial Evaluation
Indicator
1.
Enrollees should have the presence or
absence of tobacco use noted in the medical
record at the intake history and physical or at
least once during the course of a year.
Quality of
evidence
III
Literature
Benefits
Comments
ACP, 1986;
AAP, 1987;
ACOG, 1986;
NIH, 1989;
USPSTF, 1989
Decrease smoking-related
morbidity and mortality.*
Recommended by many medical societies
and governmental agencies (see text),
though no consensus on optimal
screening interval. No trials on screening,
but cost is very low. Prerequisite to
counseling. Screening increases likelihood
of detection and subsequent interventions.
Quality of
evidence
I
Literature
Benefits
Comments
Kottke et al.,
1988
Decrease smoking-related
morbidity and mortality.*
Meta-analysis of 39 trials of counseling
showed 8% decrease in smoking rate at
six months and 6% at one year.
Meta-analysis of RCTs of nicotine
replacement therapy demonstrated
efficacy in setting of specialized smoking
clinics; adding nicotine replacement may
increase cessation rate by one third.
Weaker evidence in general practice.
All controlled trials of nicotine replacement
combine it with some form of counseling.
Treatment
Indicator
2.
Current smokers should receive counseling to
stop smoking.**
3.
If counseling alone fails to help the patient quit
smoking, the patient should be offered nicotine
replacement therapy (gum or patch).
I-II
Lam et al.,
1987
Decrease smoking-related
morbidity and mortality.*
4.
Nicotine replacement should only be
prescribed in conjunction with counseling.**
I
Lam et al.,
1987
5.
Nicotine replacement should not be prescribed
if the patient:
a. is pregnant or nursing
b. has had a myocardial infarction in past
year
c. has temporomandibular joint disease
d. continues to smoke
I-II
Benowitz,
1988
Avert potential side effects of
nicotine therapy in patients who
will not benefit without
concomitant counseling.
Decrease smoking-related
morbidity and mortality.*
Avert premature births, birth
defects, potential harm to nursing
newborns, ischemic events.
107
Nicotine crosses placenta and is excreted
into breast milk. It can exacerbate
ongoing ischemia and worsen symptoms
of temporomandibular joint disease.
Continuing to smoke makes side effects of
nicotine replacement much more likely.
Follow-up
Indicator
6.
Tobacco abuse should be added to the
problem list of all current smokers or
addressed within one year.
Quality of
evidence
I
Literature
Benefits
Comments
Kottke et al.,
1988; Wilson
et al., 1988
Decrease smoking-related
morbidity and mortality.*
One of the common characteristics of
successful counseling in the Kottke metaanalysis is reinforcement at subsequent
visits.
*Smoking has been associated with increased risk of cancer of the lung, trachea, bronchus, lip, oral cavity, pharynx, larynx, esophagus, kidney, bladder, stomach, and
pancreas. Smoking also causes or exacerbates COPD, asthma, bronchitis, cerebrovascular accidents and coronary heart disease. Smoking while pregnant is a
contributing factor in low birthweight, shortened gestation, and sudden infant death syndrome. Each of these conditions causes a wide range of morbid symptoms and most
increase mortality.
**We plan a broad operationalization of counseling to include everything from from pamphlets and brief advice in the primary care setting to specialized structured
programs.
Quality of Evidence Codes:
I:
II-1:
II-2:
II-3:
III:
RCT
Nonrandomized controlled trials
Cohort or case analysis
Multiple time series
Opinions or descriptive studies
108
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