How to Get More Smokers to Quit?
How to Get More Smokers to Quit?
Abstract & Commentary
By Rahul Gupta, MD, MPH, FACP, Assistant Professor, Department of Medicine, Meharry Medical College; Assistant Clinical Professor, Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN. Dr. Gupta reports no financial relationship to this field of study.
Synopsis: A higher intensity of comprehensive disease management for smoking cessation, similar to other chronic diseases, may yield superior results.
Source: Ellerbeck EF, et al. Effect of varying levels of disease management on smoking cessation. Ann Intern Med 2009;150:437-446.
One of the success stories of the past 40 years in the field of clinical practice and public health has been the decline in the prevalence of tobacco use among adults in the United States from about 44% in the 1960s to about 21% today.1 However, while physicians come in contact with more than two-thirds of all smokers each year, there is no consistent intervention, despite awareness of the health risks of tobacco use and knowledge of effective interventions. Conceivably, this is because it is well known that most smokers will not quit after a single intervention. Since nicotine addiction is a chronic condition and demands much more than a single prescription or a counseling session, perhaps it should be managed in such a manner with repeat cycles of quit attempts and relapses.
In their multicenter randomized trial involving rural primary care practices, Ellerbeck et al studied the cessation rates in 750 persons who smoked more than 10 cigarettes per day and were randomly assigned to either the pharmacotherapy (nicotine patch or bupropion) group (pharmacotherapy-alone group), pharmacotherapy supplemented with up to 2 calls from trained counselors (moderate-intensity group), or pharmacotherapy supplemented with up to 6 counseling calls (high-intensity group). Smoking abstinence was self-reported at up to 24 months. The use of pharmacotherapy was similar across all 3 groups.
The authors found that abstinence rates increased throughout the study, and overall analyses demonstrated higher abstinence among the high-intensity disease management group than the moderate-intensity disease management group (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.00-2.03) and among the combined disease management groups than the pharmacotherapy-alone group (OR, 1.47; CI, 1.08-2.00). Self-reported abstinence at 2 years was 27.9%, 23.5%, and 23% for participants in the high-intensity, moderate-intensity, and pharmacotherapy-alone disease management groups, respectively. The data analyses suggest that more intensive disease management was associated with higher rates of smoking abstinence throughout the study.
This study demonstrates the practicability of considering smoking addiction as a chronic illness, approaching it in a comprehensive manner to include more frequent counseling as an adjunct to pharmacotherapy, and the physician understanding that a more intensive approach to smoking cessation management may lead to higher rates of smoking abstinence.
Commentary
On June 22, 2009, President Obama signed a bill known as the Family Smoking Prevention and Tobacco Control Act into law. This law recognizes that tobacco use presents a special circumstance where a commercially available product has been shown to be a significant health threat and grants the FDA the authority to regulate tobacco products. This law is certain to adversely impact the economics of the tobacco industry by limiting advertising and providing more effective health warnings, as well as by appropriately coming under the purview of the FDA. However, as clinicians, we must do our part to evaluate and provide smokers with the most up-to-date evidence-based information on effective smoking-cessation programs.
Although the success of tobacco-cessation programs has been unrivaled, one of the future challenges we face is how to further lower the prevalence of tobacco use. Americans living in rural America have among the highest smoking rates in the country.2 The current study demonstrates the significance of developing tobacco control programs to reach those at-risk populations that have not yet entirely benefitted from existing programs. Therefore, each time we discuss tobacco cessation with our patients or write a prescription, considering intensive counseling is sure to augment the likelihood of the effort becoming successful.
References
1. Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; 2008.
2. Northridge ME, et al. The importance of location for tobacco cessation: Rural-urban disparities in quit success in underserved West Virginia Counties. J Rural Health 2008;24:106-115.
A higher intensity of comprehensive disease management for smoking cessation, similar to other chronic diseases, may yield superior results.Subscribe Now for Access
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