ANNAPOLIS, MdShowing sick patients the direct connection
between smoking and their disease symptoms can powerfully motivate
them to quit, said Daniel E. Ford, MD, MPH, associate professor
of medicine, epidemiology, and health policy and management, Johns
Hopkins School of Medicine.
Tobacco is a difficult addiction to quit, he said at a meeting on
clinical preventive medicine. Nicotine, a tertiary amine, crosses the
blood-brain barrier, and both stimulates and calms. At low doses, it
serves as a ganglionic stimulant and at high doses, as a ganglionic
blockade. Tolerance develops quickly with use.
The tobacco companies have known all along that they were
producing an attractive delivery device for an addictive drug,
The mere number of cigarettes is not indicative of actual nicotine
intake, and self-reported numbers are rarely accurate, anyway, he
said. Patients trying to quit may have indeed reduced the number of
cigarettes smoked, but may be smoking with more puffs and deeper
inhalation. In one small study, subjects smoked 36 cigarettes a day,
but their nicotine intake varied from 10 to 79 mg.
Quitting completely, rather than cutting down, is the safest
and surest way to better health, Dr. Ford said. Since
most people who smoke start as teenagers, if you can get people to
the age of 22 without starting, you have a good chance of keeping
them off cigarettes all their lives.
To move patients along the road to smoking cessation, Dr. Ford
suggested physicians follow the Four As: Ask, Advise, Assist,
AskBarely half of all smokers have ever been asked by their
physicians if they smoke, he said.
AdviseWhen advising patients to quit, he said doctors should
be clear, speak strongly, personalize advice as much as
possible, and be empathetic and optimistic, stressing benefits, not fear.
AssistWhen the patient is ready to quit, assist in setting a
quit date within 2 weeks. Have the patient remove cigarettes from his
or her environment to minimize temptation and inform friends, family,
and coworkers of the decision so as to create a support system.
The physician should review with the patient his or her previous
attempts to quit and analyze what went wrong. Also, the physician
should anticipate chal-lenges to quitting, including situations
likely to trigger relapse, and discuss with the patient how those
moments can be anticipated and avoided.
ArrangeThe physician should arrange a first follow-up contact
within 2 weeks of the quit date. Remind the patient that while
relapse can happen quickly, one slip does not represent failure. The
patient must keep going, Dr. Ford commented.
The Agency for Health Care Policy and Research (AHCPR) now recommends
nicotine replacementwhether by transdermal patch, chewing gum,
inhaler, or nasal spraywith every quit attempt. There
have been no head-to-head comparisons of replacement modalities.
Offer the patient a choice. If one fails, try another, Dr. Ford
said. Dont worry about prescribing replacements. The
patient will almost always be getting less nicotine with them than by smoking.
Bupropion (Zyban) can help keep smokers off cigarettes with
short-term use (up to 6 weeks). The drug should be started 1 week
before the quit date and is contraindicated in patients with a
history of seizures, bulimia, or anorexia, or those on monoamine
oxidase (MAO) inhibitors, he said. One study showed that patients
taking the antidepressant nortriptyline maintained a higher quit rate
even 6 months after use had stopped.
In general, Dr. Ford said, the physician should
make the adverse health effects of tobacco known to the patient,
utilize a full range of pharmacologic interventions, help the smoker
to be a better observer of his/her behavior, and encourage the
patient to keep a long-term perspective.