Frustrated About How to Help Patients Quit Smoking?

FPs Offer Tips on How to Motivate Smokers to Quit

November 17, 2011 09:55 am Jessica Pupillo

Patrick Conway, of Elkton, Md., was a lifetime smoker. In fact, he was one of those patients many doctors might have stopped counseling to quit smoking.

Conway began smoking cigarettes when he was a teenager. By the time he was in his late 40s, he had asthma, and he was showing early signs of chronic obstructive pulmonary disease.

[Stock photo-cigarette butt extinguised/Great Am. Smokeout]

"My mother died when I was 48, and she died of lung cancer," Conway told AAFP News Now. But even after she died, he added, "I didn't want to quit."

Despite his professed desire to continue smoking, Conway's family physician, Robert Monteleone, M.D., of Kennett Square, Pa., continued to ask him about his smoking habits. Monteleone made it clear to Conway that he was available to help his patient quit smoking when he was ready.

"I don't know that he ever really disciplined or tried to make me feel bad," Conway said of his doctor. "He tried to get some common sense into my head that the best thing for me to do was to quit."

By age 50, more than 30 years after he started smoking, Conway was ready to quit. His respiratory issues were escalating. When Monteleone shared Conway's chest X-ray with him, it plainly showed that his lungs looked worse than they had the year before.

"His persistence -- and because he treated me as an equal -- I think that was the key in me quitting," Conway said. "I went home and had two packs of cigarettes left in the house. I smoked both packs, and I haven't had a cigarette since."

Now, seven years later, Conway's asthma is under control without medication. He also feels better overall and hasn't been afflicted with the recurrent respiratory illnesses he had when he was smoking.

story highlights

  • According to the CDC, more than 45 million Americans smoke, making tobacco use the leading cause of preventable death in the United States.
  • Studies have shown that physicians who advise their patients to quit smoking significantly increase their patients' odds of quitting.
  • Physicians can begin this process by asking patients about their smoking status and offering smokers help in quitting -- a message that can be delivered in fewer than 30 seconds.
  • After patients who smoke have been identified, it's important to have a structured plan and a streamlined process for counseling, assisting and following up with this population.

How Physicians Can Help Smokers Quit

According to the CDC, nearly one in five U.S. adults were smokers last year -- that's more than 45 million Americans. Tobacco use remains the leading cause of preventable death in the country, according to the agency.

But studies have shown that physicians who advise their patients to quit smoking can significantly increase their patients' odds of quitting.

"We have a huge impact on our patients who are smokers by encouraging them to quit and being persistent about it at each and every office visit," said Monteleone, a member of the AAFP Tobacco Cessation Advisory Committee.

Specifically, he advises family physicians to treat smoking status as one more vital sign. He asks patients about their smoking status during each visit, and documents the discussion in the patient's medical record.

Taking as few as 30 seconds to deliver a stop-smoking message really does help patients quit, said family physician Sarah Mullins, M.D., who also is a member of the AAFP Tobacco Cessation Advisory Committee.

Her favorite quick message to patients who smoke: "Smoking is harmful to you. I really would like you to quit. I'm ready to help you quit."

Mullins recognizes that delivering this message time and time again to the same patient can feel frustrating, but she reminds herself that 20 percent of her patients will quit, at least in part, because of her persistent counsel.

"My patients, they are very used to me at this point," said Mullins, who practices at Stoney Batter Family Medicine in Wilmington, Del. She routinely tells her patients who smoke that their illnesses, and their kids' illnesses, are worse because of their tobacco use. "They can recite it with me. It makes me less afraid to say it out loud."

After patients who smoke have been identified, a structured plan and a streamlined process for counseling, assisting and following up with this population can be helpful, said Monteleone.

He recommends that family physicians take a small amount of time to prepare to discuss and prescribe tobacco-cessation medications and help patients with strategies that improve success at quitting. Nurses or other staff can serve as "office champions" for smoking cessation and help patients connect with resources, including state quitlines or HHS' national quitline, (800) QUIT-NOW.

"We focus a lot on quitlines because they are very successful," Mullins said. The patient can tailor how he or she wants to receive support, whether that is through phone calls, text messages or e-mails. Mullins also has offered small tobacco-cessation group visits. She has found that her female patients, in particular, take advantage of these visits and seem to benefit from the social support provided by a group.

Resources for Family Physicians

In addition to the Great American Smokeout on Nov. 17, November is designated as Lung Cancer Awareness Month and COPD Awareness Month in recognition of two of the leading causes of death in the United States. These awareness events present an opportunity to review your practice's smoking-cessation protocols and processes, with an eye toward enhancing the tobacco-cessation services you provide. Two key Academy programs can help:

  • Ask and Act provides resources to encourage family physicians to "ask" their patients about tobacco use and "act" to help them quit. The program offers practice toolkits and relevant billing information, as well as office resources and patient education materials.
  • Tar Wars(www.tarwars.org), the AAFP's tobacco-free education program, is designed to motivate fourth- and fifth-graders via classroom presentations and other activities to be tobacco-free. Key to that mission is mobilizing family physicians and other health care professionals to take an active part in their community's health education and encouraging overall community support for tobacco-free education.

Incorporating Existing Resources

Olabisi Kuti, M.D., is another physician focused on working with patients to help them quit smoking. As part of her practice management training as a resident at St. Francis Family Medicine Residency Program in Wilmington, Del., Kuti is helping her clinic streamline its efforts to help patients quit smoking. Her practice is institutionalizing the "5As" of smoking cessation as outlined in the U.S. Public Health Service-sponsored clinical practice guideline Treating Tobacco Use and Dependence(bphc.hrsa.gov).

The 5As consist of

  • asking patients if they smoke,
  • advising smokers to quit,
  • assessing each patient's willingness to quit,
  • assisting the patient in quitting and
  • arranging for follow-up.

Thanks to careful documentation in the practice's electronic health record, or EHR, system and the assistance of an office champion who calls patients who are attempting to quit each week, more of the practice's physicians are following the 5A protocol.
Before the practice standardized its smoking cessation protocol, Kuti found that of the clinic's population of smokers, patients' medical records only indicated that 29 percent had been advised to quit and only 10 percent had an assessment of their willingness to quit.

"Now, more doctors are aware of what we need to do," Kuti said. "Especially because we have the (EHR), it's easier to go back and look because we're documenting when we've spoken to this person and what we've said. We'll keep assessing until they are ready to stop."

"The most important thing a physician can convey to a patient is that they're there, they're supportive and they're ready to help them quit," Mullins said.

"Ninety-five percent of people can't quit smoking alone. It's not a sign of weakness to go to your physician for help; it's the norm," Mullins said. "The big misconception is that quitting smoking is easy, and you can do it on your own if you're strong enough. The data doesn't reflect that at all."


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