Best practices for smoking cessation interventions in primary care

1Department of Medicine, McMaster University, Firestone Institute for Respiratory Health, St Joseph’s Healthcare, Hamilton, Ontario; 2Montreal Chest Institute, McGill University Health Centre; 3McGill University Health Centre, and PsyMontréal Inc, Montreal, Quebec; 4Department of Family Medicine, Dalhousie University, and Cowie Family Medicine, Halifax, Nova Scotia; 5Hunter Street Medical Centre, Woodstock, Ontario; 6Pharmacist, Montreal, Quebec; 7Asthma Society of Canada, Toronto, Ontario; 8Tobacco Dependence Clinic, Vancouver Coastal Health, Vancouver, British Columbia; 9Ontario Lung Association; 10Etobicoke Medical Centre, Toronto, Ontario Correspondence: Dr Andrew McIvor, McMaster University, St Joseph’s Healthcare, Firestone Institute for Respiratory Health, T2127, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6. Telephone 905-522-1155 ext 35872, fax 905-521-6183, e-mail amcivor@stjosham.on.ca Encouraging smoking cessation is the most effective intervention family physicians and nurse practitioners can make to improve their patients’ quality of life and increase their lifespan (1,2). In as little as 30 s, Canadian family physicians can help their patients double or triple their chances of quitting (3). This can significantly improve patients’ current and future health, as well as the sustainability of public health in Canada. Currently, more than 4.9 million (18.6%) adult Canadians smoke (4). Rates vary by province, with the highest in Saskatchewan (23.7%), and lowest in British Columbia (16.4%) and Ontario (16.6%) (Figure 1). More Canadian men than women are current smokers, but this gap is closing because more men are quitting whereas quit rates among women have plateaued. Overall, smoking prevalence has decreased significantly in the past decade. This is likely due to an increase in tobacco prices, public education about the dangers of smoking, the existence of smoking bans in public places from coast to coast, changes in the public’s and the media’s attitudes toward smoking, and the availability of new and more efficacious treatments for tobacco dependence. Busy practitioners sometimes miss the opportunity for providing smoking cessation interventions because of competing health priorities, lack of confidence and the significant review


Pratiques optimales en matière d'interventions antitabagiques en soins primaires
HISTORIQUE : Au Canada, le tabagisme est la principale cause évitable de mortalité précoce. Les médecins de famille et les infirmières praticiennes occupent une position privilégiée pour encourager l'abandon du tabac. Étant donné que le tabagisme est une dépendance chronique, les interventions répétées à chaque occasion offerte sont les plus efficaces pour corriger la dépendance physique et modifier des comportements et des croyances profondément encrées. Toutefois, seule une petite minorité de médecins de famille offrent un counselling antitabagique complet et moins de la moitié offrent un soutien supplémentaire aux patients. OBJECTIF : Identifier les principales étapes que peuvent suivre les médecins de famille et les infirmières praticiennes pour consolider et rendre plus efficaces leurs interventions antitabagiques auprès de leurs patients. MÉTHODES : Un comité pluridisciplinaire de professionnels de la santé ayant un intérêt pour la lutte au tabagisme s'est réuni afin de discuter de ces pratiques optimales, en s'inspirant de diverses directives internationales, y compris celles des États-Unis, de l'Europe et de l'Australie, et d'autres énoncés pertinents. Les membres du comité, originaires des quatre coins du Canada, ont par la suite synthétisé leurs conclusions pour produire le présent article. RÉSULTATS : Cet article résume les pratiques optimales pour un counselling antitabagique bref et efficace et pour son traitement. Une simple série de questions qui ne demandent pas plus de 30 secondes à trois minutes permet aux professionnels de la santé d'instaurer des interventions antitabagiques. L'intégration de ces stratégies à la pratique quotidienne procure des occasions d'améliorer significativement la qualité et la durée de vie des patients. CONCLUSION : La dépendance au tabac est la plus importante cause évitable de morbidité et de mortalité au Canada. Les médecins de famille, les infirmières praticiennes et autres professionnels de la santé qui se trouvent sur la ligne de front occupent une position idéale pour influencer et aider leurs patients qui souhaitent cesser de fumer, ce qui allègera le fardeau de la maladie tant pour les individus que pour le système de santé public. difficulties patients have in quitting, even in the face of serious smoking-related illnesses (5). Moreover, certain myths persist that prevent some health care providers from following through with smoking cessation advice (Table 1). This helps explain why a survey (6) of family physicians in Montreal, Quebec, found that only 10.5% provided 'thorough' smoking cessation counselling, and less than one-half offered adjunct support to patients. In contrast, a recent survey (7) found that more than one-half of smokers would be interested in nicotine replacement therapy if it were offered free of charge.
Smoking kills one in two smokers (8), and the sequelae of tobacco dependence kill approximately 10% of adults worldwide (9). No other product exists that causes the premature death of 50% of those who use it exactly as intended. Tobacco use is a risk factor for six of the eight leading causes of death worldwide, including ischemic heart disease, cerebrovascular disease, lower respiratory infections, chronic obstructive pulmonary disease, tuberculosis, and cancers of the trachea, bronchus and lung (10). Moreover, recent data from the Nurses' Health Study (11) indicate that current smokers have nearly three times the risk of premature death compared with nonsmokers. The data also show that smokers have more than seven times the risk of developing smoking-related cancers. Another study (12) indicated that when heavy smokers reduced their daily cigarette smoking by as much as 50% without going on to quit, their risk for premature death is not significantly lowered.
In Canada, smoking is the leading preventable cause of premature death (13). It is estimated that 515,608 years of life were lost prematurely in Canada in 2002 -316,417 years in men and 199,191 years in women (14). Family physicians and nurse practitioners are uniquely positioned to initiate smoking cessation because they see their patients more frequently and for longer periods of time than do specialists, and often develop a strong rapport with their patients. Because smoking is a chronic addiction, repeated, opportunity-based interventions are most effective in addressing physical dependence and modifying deeply ingrained patterns of beliefs and behaviour. Simple counselling advice, support and appropriate pharmacotherapy can be effective in many cases (1,2). The present article identifies current international best practices that family physicians and nurse practitioners can use to help their patients stop smoking and discusses them into the context of therapies available in Canada.

METHODS
To better understand effective best practices for family physicians, nurse practitioners and other health care professionals, an expert multidisciplinary panel was convened in March 2008 in Toronto, Ontario. The panel represented the fields of respirology, family practice, nursing, psychology (behaviour and addiction) and nongovernmental association representatives.
The panel reviewed published literature, clinical evidence and established international guidelines from the United States (1,2), Europe (15) and Australia (16), and discussed approaches from these sources proven to aid health care professionals in executing successful smoking cessation interventions. The best practices described in the present article are the result of these discussions.
The authors' intent was not to create new guidelines for smoking cessation, but instead to interpret existing guidelines for front-line clinicians in Canada. Our objective was to identify the key steps Canadian family physicians and nurse practitioners can take to strengthen effective smoking cessation interventions for their patients. Because the existing guidelines have thoroughly analyzed thousands of relevant studies, they serve as the primary source material for the present review but are supplemented by key recent studies that were suggested by the writing group to highlight key points in the guidelines and to underscore clinical best practices based on the authors' clinical experience.

Initiating smoking cessation behavioural interventions
Encouraging smoking cessation has been recognized for many years as one of the most effective and least time-consuming methods in which physicians can improve personal and public health. Recent American (1,2), European (15) and Australian (16) guidelines provide evidence-based recommendations on tobacco dependence. They summarize the more than 6000 English-language, peer-reviewed articles and abstracts regarding smoking assessment and treatment that have been published in the past 25 years (1,2,15,16). The American guidelines are the most comprehensive; more than 50 meta-analyses were conducted as part of the process (1,2). These reviews demonstrate conclusively that the most successful smoking cessation efforts combine brief counselling, support and appropriate pharmacotherapy (1,2). The American guidelines stress that tobacco use should be addressed at every patient visit using the '5 As' (Ask, Advise, Assess, Assist and Arrange) (1,2). The guidelines note that the 5 As can be covered in as little as 3 min. Separately, the American Academy of Family Physicians summarizes the steps in a simpler and easier to use format called the '2 As' (ie, Ask and Act) (17). Figure 2 summarizes and compares the two approaches.
Evidence from two randomized controlled trials (18,19) supports the greater effectiveness of motivational interviewing, compared with simply providing brief advice to quit smoking if time is available. Motivational interviewing is defined as a direct, patient-centred counselling intervention guided by four general principles that include expressing empathy, developing discrepancy (to help smokers appreciate the value of change by exploring the discrepancy between how they want their lives to be versus how they are curently), rolling with resistance and supporting self-efficacy (2). The American guidelines recommend the use of motivational interviewing for patients unwilling to quit smoking because this technique has been found to be effective in increasing future quit attempts (2). It is recommended that clinicians receive training in the use of this specialized technique (2). Further guidance on motivational interviewing is contained in the American guidelines (2).
To guide clinicians in using a motivational-based intervention most efficiently and effectively in the little time they have available, we have created an intervention algorithm as a flashcard for use during patient encounters ( Figure 3). It can be used with all individuals regardless of whether they are prepared to quit smoking immediately.
According to the American guidelines, more intensive support is more effective and can be delivered by treatment specialists. Such support may include intensive counselling, culture-specific counselling, visits to more than one consulting physician, intratreatment social support, group counselling sessions and other areas of support that are beyond what a single clinician may be able to offer (2). In addition, the guidelines emphasize that unless contraindicated, pharmacological aids should be offered to every patient who smokes because these aids approximately double cessation rates (also referred to as 'quit rates') (1,2). When smokers are ready to quit and request help to do so, the best results occur from combining pharmacotherapy with a comprehensive behavioural change program. Thus, patients who would like to quit -or who have recently quit and could benefit from support in maintaining abstinenceshould be encouraged to visit a smoking cessation centre if one exists in their area or access a help line. These centres and helplines specialize in helping patients move toward change using state-of-the-art motivational and behavioural approaches.
Clinicians should also keep in mind that they can enhance quit rates by encouraging all of their patients to change to a healthy lifestyle, which includes regular exercise, eating more fruits and vegetables, and limiting alcohol consumption (20).
The key intervention is one in which physicians should ask all patients whether they smoke at each appropriate opportunity and, if they are current smokers, encourage them to quit. This simple intervention can double or triple quit rates (3), and is endorsed by the Canadian Cancer Society (21) and the Canadian Medical Association (22). Physicians should consider it their medical responsibility to intervene and offer treatment to their patients who smoke. The family physician visit Arrange follow-up -schedule followup contact, either in person or via the telephone.

Smoking Cessa�on Flash Card for a Mo�va�onal-Based Interven�on
Ask: "Do you smoke?" "Yes" Ask: "Do you want to quit?" "Yes" (Mo�vated)   for smoking-cessation treatment is covered by provincial health insurance in every province except Alberta. Moreover, family physicians can act in concert with nurses, pharmacists and other members of the health care team to ensure that every strategy relating to smoking cessation is used effectively. A list of smoking cessation resources is provided in Table 2.

Pharmacotherapy
Clinicians should offer to prescribe pharmacotherapy to anyone attempting to quit smoking, except to those with contraindications such as certain medical conditions or pregnancy. Therapies that have been shown to be effective for smoking cessation and are recommended as first-line treatment in Canada include the following (  (23) concluded that nicotine replacement therapy, bupropion and varenicline were all more efficacious than placebo in promoting smoking cessation.
Nicotine gum is recommended for smokers motivated to reduce the amount they smoke.
The 'Reduce to Quit' program (24) tailors nicotine-gum use and gradual reduction in the number of cigarettes smoked per day to the individual smoker's habits, aiming at smoking cessation in eight to 12 weeks.

Additional pharmacotherapy
The combination of bupropion and nicotine replacement can be considered if bupropion alone is ineffective (1,15,20). Long-term treatment with all forms of pharmacotherapy are gaining increasing acceptance in clinical tobacco dependency treatment, and various combinations of treatments -particularly those involving nicotine replacement therapy -are earning a place in relapse prevention (1,2). Relapse is defined in the American guidelines as "a return to regular smoking by someone who has quit" (2).
The 2008 American guidelines point to the need to titrate nicotine replacement therapy in some patients using combinations of therapy such as a daily nicotine patch plus the use of an inhaler as needed, gum or lozenge, or the use of two patches in patients smoking more than one pack of cigarettes per day (1,2). Many statements from patients such as "the patch doesn't work at all", reflect the fact that their personalized nicotine needs are not being met, rather than a lack of efficacy of the treatments.

Recommended follow-up during pharmacotherapy treatment
Because of the potential side effects from all medications, the sometimes severe withdrawal symptoms experienced by recent ex-smokers, and the high risk of early relapse, patients should be seen again by the physician or a nurse practitioner within approximately two weeks after the patient's quit date (ie, the date scheduled for the start of their smoking cessation) for brief relapse-prevention treatment or be instructed to contact the office if they are having difficulties (20). This follow-up has been particularly emphasized in warnings issued by Health Canada regarding the use of varenicline in patients with a neuropsychiatric history (25), but it is prudent in all treatment regimens to ensure adequate medication to control withdrawal and to address and support cessation efforts.
Most alternative therapies such as laser treatment, acupuncture and hypnosis have not been found to be effective for smoking cessation, although they do not cause harm and may have a positive placebo effect (1,15,20,26).

CONCLUSION
The promotion of smoking cessation must be a top priority for clinicians and for governments. The Canadian government has contributed to the declining prevalence of smoking by means of high taxation on tobacco products, a greater number of smoke-free environments and advertising bans. However, much remains to be accomplished. The family physician is central to reaching as many smokers as possible and helping them quit. The combination of brief, empathetic and appropriate interventions, support and pharmacological therapies can help encourage smokers to quit and give them their best chance to live smoke-free.