FOUR. Treatment

How successful will I be at quitting smoking?

Epidemiologic data report that 70% of the 45 million smokers in the United States today want to quit, and approximately 44% try to quit each year. The vast majority of these attempts are without support and are unsuccessful. Only 4% to 7% will actually succeed. These statistics may discourage both smokers and clinicians because the majority of smokers struggle through multiple periods of abstinence and relapse.

Because of the chronic, relapsing nature of tobacco dependency, the most effective way to understand and treat it is by recognizing it as a chronic disease. By approaching it as a chronic disease, clinicians will better accept its relapsing nature and the requirement for ongoing, long-term care, which includes continued patient education, counseling, and advice over time. These strategies are similar to the way you would approach other chronic diseases such as diabetes, hypertension, or asthma. The introduction of numerous effective treatments in the past 15 to 20 years now gives the clinician and patient many additional options over the long haul. Clinicians should provide tobacco-dependent patients with brief advice, counseling, and appropriate medication. Assessing and treating tobacco use as a chronic disease generally leads to greater patient satisfaction and improved success at eventually quitting.

Joseph's comment:

The introduction of numerous effective treatments in the past 15 to 20 years now gives the clinician and patient many additional options over the long haul.

Quite honestly, while I was smoking, I did not think I could be successful. Something inside me kept making me try different techniques. It wasn't until I put the cigarette down for a few 24 hour periods that I really started to believe I could be successful, and there was hope for me becoming a nonsmoker.

What is the current trend in smoking cessation treatment?

In 2008, the U.S. Department of Health and Human Services (DHHS) published an update of clinical practice guidelines entitled Treating Tobacco Use and Dependence. It provided 10 key recommendations, which are listed here. These practice guidelines are available online for free at surgeongeneral .gov/tobacco/.

The overarching goal of these recommendations is that clinicians strongly recommend the use of effective tobacco dependence counseling and medication treatments to their patients who use tobacco, and that health systems, insurers, and purchasers assist clinicians in making such effective treatments available.

Ten Key Guideline Recommendations

Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long-term abstinence.

It is essential that clinicians and healthcare delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a healthcare setting.

Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use the counseling treatments and medications recommended in this Guideline.

Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective.

Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. Two components of counseling are especially effective, and clinicians should use these when counseling patients making a quit attempt:

Practical counseling (problem solving and skills training)

Social support delivered as part of treatment

Numerous effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempting to quit smoking. Clinicians also should encourage their use by all patient populations attempting to quit for whom there is insufficient evidence of effectiveness (that is, pregnant women, smokeless tobacco users, light smokers, and adolescents). Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates:

Bupropion SR (Zyban or Wellbutrin)

Nicotine gum

Nicotine inhaler

Nicotine lozenge

Nicotine nasal spray

Nicotine patch

Varenicline (Chantix)

Clinicians also should consider the use of certain combinations of medications identified as effective in this Guideline.

Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either therapy alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication.

Telephone "quitline" counseling is effective with diverse populations and has a broad reach. Therefore, both clinicians and healthcare delivery systems should ensure patient access to quitlines and promote quitline use.

If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments shown to be effective in increasing future quit attempts.

Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in this Guideline as covered benefits.

In addition to the 10 key recommendations, the Guideline also cites "The Five A's" as a model for treating alcohol use and dependence. They are listed here:

The Five A's Model for Treating Tobacco Use and Dependence

Ask about tobacco use. Identify and document tobacco use status for every patient at every visit.

Advise to quit. In a clear, strong, and personalized manner, urge every tobacco user to quit.

Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at this time?

Assist in quit attempt. For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit. For patients unwilling to quit at the time, provide interventions designed to increase future quit attempts.

Arrange follow-up. For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the first week after the quit date. For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at the next clinic visit.

Lisa's comment:

I feel, after trying various processes to quit in the past, that it was having all my "forces" lined up behind me. In retrospect, I see that I had so many layers of support that mentally, I was thinking if one thing didn't work, I had another thing to fall back on; there was one layer after another. I utilized every "tool" available to me: my GP, a therapist, a cessation program, medication (Zyban, at that time), nicotine supplements (patch and gum), a self-hypnosis tape, a quiz to determine what kind of smoker I was, homework, acupressure, and a support group. I, who smoked two and a half packs a day for 30years, have successfully lived my life entirely smoke-free now for 6 years. Before the combination of tools listed, I had only managed to struggle to 14 days before falling apart and smoking again.

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