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Rigorous research has identified the tobacco intervention with adults as one of the most cost-effective interventions available. The Institute of Medicine, in a 2004 report, identified the treatment of smoking as a top priority for health care. Proven treatments that improve success with quitting include counseling, medications, and social support.
Counseling: Individual or group counseling have been shown to improve outcomes. Brief counseling provided by any health professional can lead to greater motivation to quit, more serious quit attempts, and greater abstinence. Behavioral counseling delivered over the phone is also evidenced-based treatment. The Maine Tobacco HelpLine is a free, convenient source for multiple-session counseling for Maine residents of any age. This HelpLine has proven effectiveness and reach across Maine [click here to learn about HelpLine quit rates].
Medications: Nicotine replacement therapy (NRT), including patches, gum, inhaler, nasal spray, and lozenges, have been found to double quit rates in randomized trials. Bupropion (Zyban, Wellbutrin) has also been shown to increase success with quitting. If patients are without health insurance, refer to the Maine HelpLine for access to nicotine patches or gum. Providing counseling simultaneously with counseling achieves the best outcomes.
Social Support: Positive, non-judgmental messages provided by health professionals have been shown to enhance quitting. In fact, discussing smoking and quitting can lead to greater levels of patient satisfaction with their care [Abstract]. Support for smokers can also come from family, friends, and co-workers.
Approach tobacco use as a chronic condition. Smoking can be chronic and relapsing, similar to diabetes, asthma, heart failure and depression. All health professionals play a role in fostering quitting with smoking patients, by offering consistent dialog about the most effective interventions. At each clinical encounter, clinicians should deliver brief counseling, encourage self-management goals, and refer to community programs for additional assistance.
Assess the smoker. Is he interested in quitting? Is she ready to make a serious quit attempt? What is their prior experience with quitting? Are there preferences for treatment? Are there co-morbidity issues that may negatively impact quitting, such as depression or other substance use? Patients with higher levels of nicotine dependence tend to smoke >1 pack/day, smoke within 15 minutes of waking, or are unable to abstain for 24 hours or more.
Set realistic goals. Trying to quit can be daunting and frightening. While most smokers want to quit, a minority are prepared to do so at any given time. For smokers ready to quit, a professional's goal should be to offer effective therapies (counseling, medications, and social support). When a smoker is not yet ready to nose-dive into abstinence, a professional's goal should be to encourage thinking about it. For those unable to quit or relapsed, asking about renewed interest in quitting is important. Exploring a recent quit attempt provides important information that can be used for the next time.
Be empathic. Some health professionals might anticipate tense interactions when talking about quitting smoking. Yet, patients receiving brief counseling about smoking have been shown to have greater satisfaction with their providers. [Quinn V et al. AJPM August paper] Non-judgmental language fosters patient receptivity to talking about their smoking. Open-ended questions - those not needing a "yes" or "no" response - can explore patient beliefs. Questions such as, "What are your thoughts about quitting?", or "What have you tried before?" are examples of questions that can diminish tension and encourage discourse. Please click here to see more examples of tailoring messages to smokers.
Tailor assistance and ensure follow-up. Clinicians can certainly influence patient decisions about treatment. Smokers ready to quit should be encouraged to use the evidenced-based methods to quit. Less than 10% who quit "cold turkey" (without assistance) are found to be not smoking 1 year later. Medications and counseling should be offered to all tobacco users preparing for a quit attempt. For more dependent smokers, combining medications and intensive behavioral counseling should be encouraged. [link to treatment services for smokers]
National guidelines for the treatment of tobacco recommend all smokers trying to quit use an FDA-approved medication, unless there is a medical reason for not doing so. There is no specific period of time required for therapy, but at least 6 to 8 weeks is recommended. If cost is a problem, a product can be prescribed for a shorter time, e.g. 2 weeks. If the smoker achieves short-term abstinence, medications can be refilled. Combination therapy has been used for motivated patients experiencing significant nicotine withdrawal symptoms. For detailed dosing information, click here.
Nicotine Patch: Patches offer transdermal continuous-release of nicotine for 16 to 24 hours, depending on product. This therapy is simple to use. The patch is available via prescription or over the counter. Common side effects include redness and itching at the site of application, and vivid dreams. For these symptoms, use 1% cortisone cream and remove patch before bedtime.
Nicotine Gum and Lozenges: Available in 2 mg and 4 mg doses, smokers absorb nicotine in the mouth and throat. Products are used with smokers who desire self-dosing or prefer an oral sensation. For those smoking >1 pack per day, use the 4 mg dose. Using a scheduled dosing, such as 1 piece every 1-2 hours (depending on level of smoking), is recommended. Gum or lozenge can be added to nicotine patch or bupropion for those needing greater replacement.
Nicotine Inhaler: While the inhaler looks like a cigarette, it delivers only nicotine and is absorbed in the mouth and throat (not a true inhaler). Requiring a prescription, this product is effective but tends to cost more than other products.
Nicotine Nasal Spray: This prescription product supplies nicotine that is absorbed through the nasal passages, therefore, absorption is more rapid than other NRT products. It is recommended for smokers having greater levels of dependence. Dosing should be scheduled, up to 2 sprays per hour.
Bupropion SR: Also known as Zyban®, Wellbutrin®, a generic is now available. It can reduce cravings for nicotine, and may relieve symptoms of depression for some patients. Avoid use in those with increase risk of seizure (risking drinking, eating disorder, major head trauma), or with uncontrolled hypertension.
Beginning in 2001, the Maine Tobacco HelpLine provides free, intensive behavioral counseling delivered over a series of phone contacts. Supported by the Fund for Healthy Maine (Tobacco Settlement) and Maine Bureau of Health, the HelpLine has serviced over 25,000 callers. Smokers assisted by HelpLine specialists have significantly higher long-term quit rates than those quitting on their own. Quitting has been found to be highest with counseling combined with nicotine therapy [Power Point graph]. The HelpLine also offers information to professionals and friends and family members of tobacco users.
Click here for more information about Maine's statewide tobacco prevention and treatment programs.
In the greater Portland area, call CTI at 662-7154 for information about face to face outpatient treatment services.
Outside the Portland area, refer to the Tobacco Treatment Services Guide to find a program near you.
CTI Quick Clinician Guide [pdf]
PHS Clinical Practice Guideline Provider Guide [pdf]
Helping Smokers Quit: A Guide for Nurses [pdf]
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