Smoking Cessation Review
Smoking cessation counseling may feel like a waste of the time and effort required, since most smokers don't quit. But evidence shows that even the <10% success rate of smoking cessation counseling saves millions of lives, compared to doing nothing. According to a recent smoking cessation review in the NEJM:
Even those not ready to quit do 8% of the time within 6 months, if coached with motivational interviewing by physicians (vs. 2% without coaching).
Advising patients to cut down the number of cigarettes they smoke, while providing nicotine replacement therapy, resulted in 9% quit rates (vs. 5% without nicotine replacement). Increased nausea was the only adverse effect attributed to smoking while using a nicotine patch or gum.
The more counseling provided, the higher the quit rates (peaking at 27% quit at 6 months with 30-90 minutes of counseling).
Up to 1/3 of patients will accept smoking cessation treatment offered on-the-spot, but only 10% will take the steps to start it after they leave your clinic.
Newer, aggressive drug treatments work best. Monotherapy with bupropion or one form of nicotine replacement results in 19-26% quit at 6 months (14% with counseling alone). But varenicline alone resulted in a 33% quit rate, and combination nicotine replacement (patch plus either gum or lozenges) had a 37% quit rate.
Prescribe nicotine patches for 2 weeks prior to the quit date to maximize effectiveness. Varenicline during a run-in period also improved quit rates in one trial.
Varenicline was associated with a nonsignificant small excess risk for cardiovascular events in patients with cardiovascular disease in a 2010 randomized trial in Circulation, and a 2011 meta-analysis in CMAJ also suggested a small risk. The health benefits of quitting smoking may well outweigh these risks (if real), and patients should be allowed to make an informed decision to receive varenicline. The statistical reality of these effect is disputed by some researchers.
Bupropion can lower the seizure threshold and shouldn't be provided to those with a seizure history or who abuse alcohol.
Of course, someone has to pay for this, and Medicare recently extended smoking cessation counseling benefits to all smokers. The reality is, physicians are probably never going to make a habit of taking the time required to coach someone to quit smoking, due to the already-compressed time allotted for most office visits. Dedicated health counselors in large primary care practices, or health coaches paid by self-insuring corporations or big insurers, seem like a more plausible solution. But 5 or 10 minutes' physician counseling, repeated until it feels ad nauseum, should save a few lives per physician over a career. Free resources include 1-800-QUIT NOW, www.smokefree.gov or www.women.smokefree.gov.
Fiore MC, Baker TB. Treating Smokers in the Health Care Setting. N Engl J Med 2011;365:1222-1231.