ChiroACCESS Article

Smoking Cessation Counseling and Health Care Providers: Evidence-Based Review

This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.

Marion Willard Evans, Jr., DC, PhD, MCHES, CWP


Cleveland Chiropractic College

Published on

April 23, 2008

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Developed On: May 14th, 2007

1. Why Counsel Patients on Smoking and Tobacco Use?

Smoking is on the decline in the United States with about 20% of American adults reporting that they currently smoke and although it has declined in adults, it is increasing in certain groups including adolescents and females.1 Still, tobacco use in general remains the most preventable cause of death in the United States leading to over 400,000 deaths and billions of dollars in medical expenses.2 The Centers for Disease Control and Prevention (CDC) stated that it should be the goal of every health care provider to ascertain the use status of their patients and advise them to make a quit attempt.3

2. Smoking Status should be a Vital Sign
Smoking and tobacco use are important to health status of individuals and some have called it a 5th vital sign suggesting that it be tagged as a major factor regarding overall health outcomes among patients similar to high blood pressure or high temperature.4 It is a precursor to various cancers, heart and cardiovascular disease and chronic spine pain.5-10 From an evidence-based perspective perhaps no other health risk factor has been the subject of so much health science research. Peto and Doll first discovered that physicians in Great Britain who smoked had higher incidence rates of lung cancer.11 They further discovered that the dose was a linear one in which those who smoked the most had the greatest risks of developing cancer. In 1964 Surgeon General Luther Terry produced the first paper warning that smoking was a risk factor for negative health outcomes in the United States.12 Today, numerous studies not only confirm this but indicate smokers have a greater risk of poor health and disability and have much higher health insurance costs, lost days from work and lowered productivity.13,14 In 1998 several state Attorneys General settled a suit against large tobacco companies to recover costs they said were levied upon state Medicaid agencies and won what is referred to as the Master Tobacco Settlement (MTS).15 Money from this billion dollar windfall to those partner states was to be used to start schools of public health, generate advertising against smoking and recover costs to states for Medicaid delivered to smokers treated for various diseases caused by smoking.16 However, according to studies, the verdict is still out as to how much good has come from the MTS.

3. Health Care Providers Role in Cessation
Unfortunately, only about 40% of smokers will report that their primary care physician has advised them to quit smoking or using tobacco.17 A study at 9 chiropractic colleges found about the same rates among patients who stated their intern had advised them on cessation and even fewer were given information on cessation beyond a quit message.18 However, health care providers have consistently been found to be powerful “cues to action” when it comes to getting patients to make a quit attempt.19 The CDC report by Fiore and others states that all health care providers should cue patients to make a quit attempt.3 In addition, it doesn’t seem to matter what kind of provider they are. Rechtine and colleagues at an orthopedic spine clinic were able to increase quit attempts in their patients significantly by prioritizing tobacco cessation with patients as 90% of failed surgeries and post-surgical infections were in smokers.20 A study at one chiropractic college increased the amount of information given to patients by 25% in one month when an education campaign was delivered aimed at interns and clinic staff.21

Concern for patients should not be understated and an additional feature of smoking in the household was reported by researchers at the University of Missouri at Kansas City in which adolescents who had a significant other who smoked were much more likely to smoke. When at least 4 significant others smoked adolescents were 161 times more likely to smoke themselves.22 It is imperative that all tobacco users be told to quit for their health and the potential preventive impact on their families. This paper does not begin to address the effects of second-hand smoke on society although there are now numerous studies that indicate it is a significant factor for increased risk of disease.

4. Where Health Care Providers Must Start (Assessment)
First, the CDC recommends a 5 step approach to patients developed by the US Surgeon General’s Office called the “5-A’s.” This is a mnemonic to remind the clinician to “Ask” about their smoking (or tobacco use) status; “Advise” to make a quit attempt; “Assess” their willingness to make such and attempt; “Assist” them in anyway you can; and “Arrange to follow up” so the patient does not drop their focus on the importance of attempting cessation.3 While it should be every provider’s responsibility to “ask” and “advise” clearly, not every smoker will be willing to make a quit attempt. This can be quite difficult to accomplish when a person is in pain for instance. They may actually smoke more. However, this does not mean they may not want to make an attempt at a later date. It becomes important to “stage” patients as to their willingness to make a quit attempt and receive information on the topic of cessation. Because this is crucial to success in counseling patients, particularly in addictive disorders such as tobacco use, health behavioral theory must be considered by providers.

Health Behavioral Theory—The Stages of Change Model

The most common health behavioral model used in smoking cessation advising or materials is called “Stages of Change.” Developed by Prochaska, DiClemente23, this model found that people with addictive behaviors tend to fall into one of 5 categories. The first is the “pre-contemplation.” In this phase they have no intention of taking any action toward cessation within the next 6 months but they should be “cued” to make a quit attempt and made aware that their clinician is there to help. Even providing a brochure on why they should consider cessation may move them toward the next stage. They may have never been told previously by a health care provider to stop.

In the “contemplation” stage, they have an intention to make a quit attempt, but perhaps in the next 6 months or so. Motivate them to consider serious action and to make some specific plans like setting a quit date. A person in the “preparation” stage is one who is actively making an effort to take action within 30 days. They may have made some behavioral changes already like reading about cessation or nicotine replacement therapy (NRT). Assist them with solid action plans and help them set gradual goals. In the “action” stage, the patient has changed their behavior. Perhaps they have put away ashtrays in their home or stopped buying tobacco. This activity has been changed for less than 6 months. The clinician should “assist” the patient with problems, offer support and reinforce their decision with positive comments.

In the last stage, they have “maintained” the behavior for at least 6 months. Remind them they made the right decision, assist with messages of reinforcement and help them learn to avoid relapse. For example, smokers tend to smoke more when consuming alcohol or when their spouse is also a smoker so these could represent challenges to them and they should be made aware of this and how they might handle these situations. Assist them with a plan for these events.

Special Considerations on Advising Tobacco Users

Forms and Talking to Smokers
Forms should not only ask about tobacco use but should ask about previous tobacco use.18 Risk factors from its use do not go away over night. A smoker who smoked for 30 years but quit 5 years ago still needs to be labeled as a former smoker to adequately know risks. In broaching the subject, Rimer and Glanz24, recommend asking “Are you interested in trying to quit smoking?” Perhaps another way would be to ask, “How open are you to us discussing quitting?” They may state yes, no or that they are currently making a quit attempt whereby the clinician can properly “stage” the patient. Ask how they can be assisted. Also, many groups such as the American Lung Association, the American Cancer Society, the CDC and others have “stage-based” brochures for smokers that take into account where they are on the stages scale and provide targeted information to them based on the stage they are in. After all, one does not want to provide information on taking “action” to a “pre-contemplator”. Let them know you are there to help and be aware that many want to quit but don’t know where to start.

Treatment--Smoking Cessation Programs and Medication
It is essential that the patient’s primary care doctor be involved in any cessation attempt. Medications, contraindications to NRT and the fact that smoking has a negative effect on overall health means that they must be including in this process. Studies show that medications and cessation counseling, along with NRT stands the greatest chance of helping them be successful.25-27 A list of area smoking cessation programs that are for free and for fee can often be obtained from the local chapter of the American Lung Association or American Cancer Society. Many successful quit attempts are made at the beginning of a new year as a resolution or as part of the Great American Smoke-Out held in November of each year. Cueing patients to take action at these times may render greater success rates as more attention is being focused on this process.

Other Behavioral Theory Models to Understand
Stages of Change is perhaps the best known of behavioral theories used in smoking cessation advising. However, in getting patients to take a single step, often health scientists take into account a simple behavioral model called the Health Belief Model (HBM).28 Developed in the 1950’s to try and understand what it would take to get a person to go for a tuberculosis screening; this model looks at factors that get people to act. The constructs of this model come into play for virtually every health behavior. First, perception is the basis for all decisions. In the HBM “perceived susceptibility” is a key to getting a patient motivated. As one might imagine, counseling of adolescents doesn’t always work when they don’t feel “susceptible” to lung cancer. With this in mind, cueing a patient to take action after a friend or family member has come down with a disease can be effective based on this construct of the HBM.

The next factor HBM takes into account is “perceived severity.” If a patient feels that the condition they may suffer is not very severe they may not change their behavior. This should be taken into account but with tobacco use, it is fairly well known by most patents that there is a severe risk as the pack tells them this on the side. “Barriers” come into play as well. Helping them identify them will help them change. “Benefits” of quitting or changing a behavior typically must be perceived to be greater than not changing. It is usually a good idea to stress the “benefits of changing” versus the negatives of not changing. And “cue to action” is another key factor in the HBM. The cue to take action must come from some one the patient perceives as credible. The health care provider is best. And last, “self-efficacy.” Not to be confused with self-esteem, self-efficacy is the feeling or lack of it, that a person has concerning their ability to take the action that is being suggested—in this case quitting smoking. Giving them support and resources can be a key factor in having them perceive they have the “self-efficacy” to be successful.

Using evidence-based cessation advising is the best way to help patients change their behavior. Every health care provider should be interested in helping them reduce the preventable causes of disease where they exist.

“The US Preventive Services Task Force strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products.”29 Evidence rating of “A” which is the strongest available from this guide.

5. Recommendations

• Determine smoking and tobacco use status of ALL patients
• Follow the 5-A’s and advise ALL to make a quit attempt
• Stress the BENEFITS of cessation as opposed to negatives of continuance
• Let them know you are a resource for them
• Involve their primary care doctor
• Be patient and supportive and encourage them and praise them when successful

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