Tobacco Addiction
Cigarette smoking is the major preventable cause of death in the United States. Strong evidence documents benefit from cessation of smoking, even for the elderly and patients in whom chronic tobacco-related disease has already developed. Although the health risks of smoking are widely recognized and the prevalence of smoking has fallen dramatically in the past two decades (from 40% to about 25%), millions of Americans continue to smoke, a substantial fraction more heavily than ever, and adolescents continue to take up the habit in large numbers. Nevertheless, many people are eager to quit and often come to the primary physician for advice. Numerous studies have shown that physicians can change a patient’s smoking habits. Extensive evidence indicates that pharmacotherapy increases the likelihood of successful quitting. The primary care physician needs to be expert in motivating patients to quit and in advising them on the best means to accomplish their goal. This requires knowledge about available smoking cessation techniques and an appreciation of how and when to use them.
Since 1964, when the Surgeon General’s Report first publicized the health risks of smoking, cigarette smoking by adults in the United States has declined. This decline in the percentage of the population that smokes is averaging about 1.1 percentage points per year, with the percentage of smokers falling to about 25%. This decrease is largely attributable to the increasing number of smokers who have quit, rather than to a fall in the number of smokers taking up the habit. About 30% of smokers report attempting to quit each year. As less addicted smokers quit, the proportion of heavy smokers (>25 cigarettes per day) has increased from about one in four to one in three. Smoking in adolescence—the time when smoking usually begins—has fallen little since its peak in the 1970s. Adolescent girls are smoking in numbers comparable with those in boys; the historical gender difference continues to narrow. This is worrisome because women who smoke during the reproductive years incur special risks with pregnancy and oral contraceptive use. Smoking is increasingly prevalent among populations that are nonwhite, poor, or of low educational status.
Most smokers claim that they are aware of the health hazards of smoking and would like to quit but have difficulty doing so. Although the success rate for any single attempt at quitting is low, smokers who repeatedly try to quit increase their likelihood of success. Lighter smokers are more successful than heavier smokers. Smokers most likely to quit are those who expect their attempt to succeed, have a strong belief in their personal control over events, feel competent and personally secure, and have a good social support system. The smoking habits of the spouse and, in some studies, friends are important; those with nonsmoking spouses are more likely to succeed. Patients with depression or a history of depression have a hard time initiating smoking cessation and a poor success rate (40% that of patients who are not depressed) when they try.
More than 90% of former smokers quit on their own without assistance from physicians, groups, patches, gum, hypnosis, acupuncture, or psychological counseling. Those who benefit most from an assisted method are heavy, more addicted smokers. Their chance of successfully quitting is about half that of smokers who quit on their own. Receiving advice from a physician about smoking cessation doubles the chance of a patient making an attempt to quit. Smokers who quit using the “cold turkey” approach are more likely to remain abstinent than those who taper. Reducing cigarette consumption somewhat and switching to a different brand can be part of a smoker’s preparation for quitting—being especially helpful in building a sense of confidence and control—but are no substitute for setting a definite date for abrupt and total cessation.
Health concerns are the most common reasons given by former smokers for quitting. However, the risks for lung cancer and heart disease are less often cited than are minor smoking-related ailments such as cough, dyspnea, and sore throat. Minor symptoms may successfully motivate a smoker to quit by making personally salient the more serious health risks of smoking. Illness in one smoker can influence other smokers to quit (e.g., the friend or family member in the intensive care unit), as can personally sustaining a serious smoking-related illness, such as a heart attack. The likelihood that a smoker will quit increases with the severity of the illness. Although fewer than 5% of smokers in the general population quit each year, cessation rates are higher among persons with newly diagnosed coronary heart disease. Many studies report that approximately one third of smokers surviving a myocardial infarction stop smoking permanently. Increased rates of cessation are also reported in smokers with chronic obstructive pulmonary disease. During pregnancy, 20% of women smokers stop smoking, but the majority resume smoking after delivery. Many smokers quit temporarily when they have an acute respiratory illness.
Other reasons for quitting cited by former smokers include a desire to exert self-control over one’s life, aesthetic objections to the smoking habit, and fear of setting a bad example for others. The cost of cigarettes exerts little influence among adults.
Smoking is a complex behavior initiated and maintained for different reasons. The influence of peers and parents appears to be most important in the initiation of smoking. Adolescents whose parents and friends smoke are more likely to begin smoking. Once the smoking habit is established, it is sustained by many factors.
Both pharmacologic and psychological models have been proposed to explain what maintains smoking behavior. The psychological model regards smoking as a learned behavior that continues because it is rewarding to the smoker. Certain situations, such as finishing a meal, become strongly associated with smoking and trigger the urge to smoke. Smokers also use cigarettes to handle environmental stress and regulate emotions, especially strong negative emotions like anger.
A strong association between depression and smoking has been documented. Depressed patients are more likely to be smokers and, as noted above, less likely to attempt quitting or succeed at quitting. It is hypothesized that smoking may represent a form of self-medication for the depressed patient, with nicotine alleviating a dysphoric mood through activation of central neuroreceptors. Such a response would strongly reinforce smoking and might trigger a craving for cigarettes during times of depressed mood. Moreover, withdrawal of nicotine during an attempt at smoking cessation might trigger symptoms of depression, which has been reported in studies of patients with a history of depression who attempt to quit.
The pharmacologic model emphasizes physical addiction to nicotine. The evidence for smoking as an addiction is strong, and nicotine has been established as the addicting substance in tobacco smoke. According to this model, the smoker smokes to maintain a constant blood level of nicotine and thereby avert the withdrawal syndrome, characterized by falls in heart rate, blood pressure, and basal metabolic rate and changes in electroencephalographic rhythms and rapid-eye-movement (REM) sleep patterns. Craving for nicotine is the most common subjective symptom of withdrawal, but other symptoms include restlessness, irritability, inability to concentrate, daytime drowsiness and fatigue, sleep disturbances, headache, nausea, alteration in bowel habits, and increased appetite. Symptoms begin within hours after cessation of smoking, but their duration and severity are highly variable, representing different degrees of nicotine addiction among smokers. No simple test is available to measure nicotine addiction, but heavily addicted smokers tend to have their first cigarette shortly after arising (i.e., within 30 minutes), smoke more and stronger cigarettes, and have difficulty not smoking for even a few hours.
The pharmacologic model can explain initial difficulties with cessation but cannot explain why smokers have difficulty remaining abstinent after the first few days or weeks. In fact, the majority of smokers who stop temporarily resume smoking within a few months.
The methods of smoking cessation range from unassisted “cold turkey” to formal treatment programs administered in a group setting, with a host of interventions in between. As noted, the majority of smokers quit in unassisted fashion. As might be expected from the multidimensional nature of the smoking problem, no single method suffices. The most effective approaches address both principal components of the smoking problem: (a) nicotine addiction and (b) behavioral dependency on cigarettes. Combining a number of approaches into a personalized, comprehensive program appears to be the most successful strategy.
Strategies that combine pharmacologic and behavioral techniques appear to be the most effective. Pharmacologic methods are used to relieve symptoms of nicotine withdrawal, freeing the patient to focus on behavioral efforts
Maintaining long-term tobacco abstinence remains the challenge in smoking cessation treatment. Short-term cessation rates of 70% to 80% are common among programs. However, a predictable and rapid return to smoking follows initial cessation. A 1-year cessation rate of 30% to 35% is considered the standard for an effective smoking cessation program.
The principal pharmacologic approach is to relieve symptoms of withdrawal by continuing some nicotine exposure, although at reduced and tapered doses. Nicotine delivery is most often achieved transdermally with nicotine patches or through the oral mucosa with nicotine chewing gum. Newer approaches include nicotine nasal spray and nicotine inhalers. Other pharmacologic approaches to minimizing withdrawal symptoms have included the use of clonidine, minor tranquilizers, and drugs that mimic the autonomic effects of nicotine. An alternative pharmacologic approach is the use of antidepressants, especially bupropion, an atypical antidepressant with both dopaminergic and adrenergic effects. Bupropion became available as a prescription drug in 1998 as Zyban, a trade name specific for smoking cessation.
Transdermal Nicotine (“the patch”) represents a second-generation form of nicotine reduction therapy, developed after the introduction of nicotine gum more than a decade ago (see below). It provides a convenient means of maintaining nicotine exposure and preventing nicotine withdrawal symptoms while the smoker addresses the behavioral component of the smoking problem. Once the habit is broken, nicotine supplementation is stopped. A smoker on nicotine reduction therapy is already being weaned from nicotine because the pharmacokinetic properties of the patch differ from those of inhaled smoke. The levels of nicotine delivered transdermally are more constant than the peaks and troughs characteristic of smoking.
The effectiveness of the patch is related to its ease of administration. In randomized clinical trials of at least 6 months’ duration, nicotine patches have been shown to be superior to placebo in helping smokers to stop smoking; the cessation rates of smokers using the nicotine patch were approximately double the rates of smokers receiving placebo patches. In 1996, nicotine patches became available without a prescription. The rationale for this decision of the Food and Drug Administration was to make replacement therapy more accessible because of its proven effectiveness in multiple trials. Since then, several trials have demonstrated the 6-month quit rates obtained with over-the-counter nicotine patches to be 2.5 to 2.8 times those achieved with placebo patches.
Patches are not a panacea, nor are they appropriate for everyone. They should be used only by smokers who (a) want to quit and are willing to set a quitting date; (b) have a significant amount of nicotine addiction (i.e., smoke more than one pack per day, smoke their first cigarette within 30 minutes of arising, had withdrawal symptoms on prior attempts at quitting); (c) will not smoke while using the patch; and (d) will follow a behavioral program (individual or group) in conjunction with patch use.
Proper use of nicotine patches involves beginning patch application on the day of quitting. The patch is applied to any nonhairy skin site and worn for 16 or 24 hours. Because of possible skin irritation, the patch site should be rotated. Once applied, the patch is impervious to external water (shower, swimming), but it can come loose with perspiration. For this reason, it should put on after exercise. Most patches come in multiple strengths. Most smokers should use the patch for 2 to 3 months and start with the strongest dose (21 mg/d), then gradually taper to lower-dose patches (14 mg/d and 7 mg/d). Those who weigh less than 100 lb are advised to begin with the 14 mg/d strength. A typical program might use the 21 mg/d patch for 4 to 6 weeks, with a switch to the 14 mg/d strength for 2 to 4 weeks and then to the 7 mg/d patch for 2 to 4 weeks. Some argue that patients who smoke less than one pack per day can begin with a 14 mg/d patch, but such patients may not be sufficiently addicted to nicotine to need the patch in the first place.
Side effects are relatively few. The most common is skin irritation, which is usually minor. It is reduced by frequent changes in patch location. Insomnia is also reported, probably caused by the stimulant effect of a constant level of nicotine. The 16-hour patch might be useful for patients bothered by insomnia, or a 24-hour patch can be removed at bedtime. Rash, headache, nausea, vertigo, myalgia, and dyspepsia have been reported, but dependence and abuse have not, although experience is still too limited to rule out the possibility. Isolated cases of myocardial infarction have been reported in patients who continue to smoke while using the patch. In clinical trials, only 5% of patients stopped therapy because of side effects. Because of the vasoconstrictive action of nicotine, patients with recent myocardial infarction, unstable angina, peripheral vascular disease, or serious arrhythmias and women who are pregnant or breast-feeding should avoid patch use.
Patient education is critical. Many patients view the patch as a simple, passive means of quitting, one that requires little effort on their part. Some even continue to smoke while using the patch, under the mistaken belief that it should be used for tapering. Proper patient selection and education are essential to the safe and effective use of the patch. The effectiveness of the patch is enhanced by behavioral smoking cessation therapy.
Nicotine Chewing Gum was the original form of nicotine reduction therapy. It also provides an oral substitute for cigarettes. Nicotine is released from the gum during chewing and absorbed through the oral mucosa, resulting in blood levels lower but more constant than those achieved by smoking. Exposure to the other harmful constituents of cigarette smoke is avoided. In some studies, patients using the gum also gained less weight after cessation of smoking than smokers not using the gum. The preparation initially available contained 2 mg of nicotine. A 4-mg gum was approved for use in 1993 and is probably more effective. Both 2-mg and 4-mg preparations became available without a prescription in late 1995.
Nicotine gum is more effective than placebo when used in conjunction with a behavioral program for self-selected, motivated smokers attending a smoking withdrawal clinic; 1-year cessation rates of 30% to 50% have been reported, representing an advance over rates attained with behavioral treatments alone. The gum, like the patch, may be especially useful in smokers heavily addicted to nicotine. When the gum is used by less motivated patients, cessation rates are lower, and its effectiveness is less certain. Like the patch, the gum is effective only for helping the patient to quit; it is not a substitute for behavioral therapy. Studies of long-term abstinence show little benefit from gum use without a behavioral program.
To use the gum, smokers are instructed to pick a target date when they will stop smoking. After that, they chew the gum whenever they have an urge to smoke, usually consuming a dozen pieces daily at the onset. Gum use should continue for 2 to 3 months. Dependence develops in 5% to 10% of users, who have difficulty stopping. It is important to emphasize to the patient that the best results are obtained when gum use is accompanied by a program that teaches behavioral skills.
Side effects are mostly a consequence of overly vigorous chewing and release of excess nicotine—sore jaw, mouth irritation or ulcers, nervousness, dizziness, nausea, vomiting, hiccups, intestinal distress, headache, and excess salivation. To reduce these symptoms, smokers should chew the gum very slowly, just enough to detect a slight tingling taste in the mouth. Contraindications to use are the same as those for the transdermal patch (see above).
In addition to side effects, factors limiting effectiveness include poor compliance (as many as 35% use the gum for too short a period), improper chewing technique, and adherence to dental appliances and bridgework. Smokers starting the gum need detailed instruction in its proper use. Nicotine absorption may be compromised by the consumption of acidic beverages (e.g., coffee, carbonated drinks). By lowering the pH of saliva, they block nicotine absorption when ingested during or immediately before gum use. Not drinking acid beverages around the time of gum use solves the problem.
Nicotine Nasal Spray was developed to provide more rapid delivery of nicotine and thereby mimic more closely the effect of smoking a cigarette. The delivery device is similar to a nasal antihistamine spray, and one or two doses are taken per hour for a period of about 3 months. As with gum and transdermal patches, the quit rates with the device have proved to be about twice those attained with placebo. Nasal and throat irritation, rhinitis, sneezing, and tearing are common side effects. The role of the nasal spray as an alternative to gum and patches is yet to be defined. It is available only by prescription at the beginning of 2000.
Nicotine Inhalers were introduced as a prescription drug in 1998. The inhaler is a plastic rod with a nicotine plug that delivers nicotine to the buccal mucosa when drawn upon. The pharmacokinetics are similar to those of nicotine gum, as is the effect on quit rates. Its role as an alternative to gum and patches also remains to be defined.
Bupropion, an antidepressant, has proved to be as effective as nicotine replacement therapy, doubling quit rates in comparison with placebo. It is the ideal pharmacologic approach for smokers who prefer not to use nicotine replacement or who have been unable to quit with nicotine replacement. It is equally effective among persons with and without a history of depression. Bupropion is generally started 1 week before the ordained quit date. The usual dosage is 300 mg/d, and treatment is generally continued for 2 to 3 months. Bupropion has been used together with nicotine replacement, and some evidence suggests that the combination is more effective than either approach alone, although results have been conflicting. The most common side effects are dry mouth and insomnia. An increased risk for seizure was an early concern, but that has faded with use of the slow-release preparation at the dosage of 300 mg/d. Nevertheless, alternative treatment is advisable in patients with a history of seizure or other risk factors.
Other Agents. Clonidine, the centrally acting adrenergic blocker, has been shown to lessen the symptoms of opiate and alcohol withdrawal and has been tried for smoking cessation. Results of initial studies were encouraging, but randomized, controlled studies with sufficient follow-up found clonidine to be no better than placebo.
Lobeline (Nikoban), a non-nicotine substitute with autonomic effects that mimic those of nicotine, is no more effective than placebo. Minor tranquilizers have been prescribed as a means of blunting the anxiety and irritability of nicotine withdrawal, but they are no better than placebo. Furthermore, because daily use of these agents for more than a few days is associated with significant risks for tolerance and dependency, they are not appropriate for use in smoking cessation, in which daily use for several weeks is required.
Antidepressant therapy with agents other than bupropion may have a role in the pharmacologic support of smoking cessation. Nortriptyline proved effective in a small, randomized trial, producing a quit rate of 14% at 6 months versus 3% for placebo. Other controlled trials of antidepressant therapy are in progress.
The behavioral model of smoking has inspired a host of techniques to manipulate environmental cues that trigger or reward smoking. These techniques form the core of most smoking cessation programs.
Strategies for Stimulus Control require smokers to identify and control the environmental stimuli that trigger smoking. Cues are first identified by self-monitoring. For example, smokers might be asked to carry a sheet of paper wrapped around their cigarette pack on which they record the circumstances in which each cigarette is smoked. Environmental cues, identified from this daily log, are then progressively avoided or modified so that they no longer trigger smoking. The behavior is separated from the triggers by progressive restriction of the situations in which smoking is permitted. At a point in the relearning process, smoking stops altogether.
Controlled studies have not demonstrated impressive long-term cessation with this approach alone. Smokers may decrease their cigarette consumption but are less successful at total cessation, and those who stop have a high relapse rate. By itself, the technique is more effective in preparing the smoker to quit than in achieving long-term cessation.
Aversive Conditioning Techniques pair an unwanted act like smoking with an unpleasant stimulus to make the act less likely to occur. The most effective aversive stimulus is cigarette smoke, which is unpleasant even to a heavy smoker. In the best-known technique, rapid smoking, the smoker is required to inhale every 6 seconds until unable to tolerate further smoking because of nausea, headache, or light-headedness. Smoke holding is a variation on rapid smoking, believed to produce similar aversive effects with less health risk. A related technique is satiation; smokers purposely double or triple their base smoking rate for up to a day before cessation. The safety of rapid smoking and satiation has been a concern because of the smoker’s intense exposure to nicotine and carbon monoxide. However, no serious medical complications have been reported with supervised use of rapid smoking among healthy people and even those with mild cardiopulmonary disease, although the technique is not advised for those with more symptomatic heart or lung disease.
Rapid smoking and other aversive techniques are effective for initial abstinence, producing high rates of short-term cessation, but relapse occurs soon unless other techniques are employed.
Hypnosis is of great interest to patients, many of whom hope it offers an effortless way to stop smoking. Most studies evaluating hypnosis have been uncontrolled, with small samples and brief follow-up; they report abstinence rates of 20% to 25% at 1 year, comparable with the standard achieved by behavioral programs. The elements identified as most predictive of success include multiple sessions, supportive therapists, motivated clients, and individualized hypnotic suggestions based on specific motivations for smoking.
Acupuncture, like hypnosis, is widely requested by smokers. Needles are inserted at acupuncture points, often around the ear. Advocates claim the procedure can reduce the urge to smoke and even lead to long-term cessation. Success appears related to belief in the efficacy of acupuncture. Randomized, control trials are few; those that are available found no long-term benefit when acupuncture was used alone. Acupuncture might prove useful for the temporary relief of withdrawal symptoms in addicted patients.
Organized Group Programs. Both nonprofit and commercial organizations offer group programs for smoking cessation. Most programs have a high dropout rate and have not been adequately evaluated. The oldest and best known is the Five-Day Plan, developed in 1963 with the sponsorship of the Seventh Day Adventist Church. Participants meet on five consecutive nights, and the program is low in cost. Techniques used are health education, encouragement to quit, and nonspecific support.
Adding behavior modification techniques to group programs has improved their effectiveness. SmokEnders, a commercial program, consists of weekly meetings run by former smokers. In one long-term study, 70% of participants were not smoking at the end of the program, and 39% remained abstinent 4 years later. However, on repeated analysis, the long-term cessation rate was 24%, equivalent to the standard rates achieved with other behavioral programs. The American Cancer Society and the American Lung Association offer similar group programs at lower cost. More intensive group programs with extended follow-up offered in the medical setting have achieved better results. Patients who appear to benefit most from such programs are women, middle-aged persons, those who are heavy smokers and have made multiple attempts to quit, and persons who are better educated. Overall, however, fewer than 5% of smokers who successfully quit use a group program.
Individual Aids. Booklets, audiovisual aids, telephone services, and nonprescription filters are available to help smokers who wishes to quit on their own. Few have been evaluated. Self-help manuals range from booklets with practical tips on how to quit to longer books containing comprehensive programs of behavior modification. Many are available at minimal cost through nonprofit organizations like the American Cancer Society, the American Lung Association, and the National Cancer Institute.
These groups also sponsor telephone services that provide education, encouragement, advice, and referrals. Use of the American Lung Association manuals has produced cessation rates of 12% at 1 month and 5% at 1 year.
A series of progressively stronger filters, which gradually restrict the delivery of tar and nicotine from a smoker’s own cigarettes, has not proved effective.
Counseling Smoking Cessation. Because health is the most common reason given by former smokers for quitting, the physician is in a unique position to encourage smoking cessation. The potential importance of the physician’s role is underscored by the fact that smokers in whom symptoms of cardiopulmonary disease develop or who become pregnant are more likely to quit. Such patients are particularly motivated to quit and are more responsive to intervention efforts. The chances of making an attempt to quit are doubled by a physician’s urging and advice. Providing no more than brief advice to stop smoking to all patients has been shown to be more effective than doing nothing to promote cessation, and it is a cost-effective medical practice. Doing more (i.e., brief, structured smoking cessation counseling) has, in randomized controlled trials, increased patients’ efforts to stop smoking and, in some trials, their rates of long-term smoking cessation as well. Surveys indicate that physicians are not taking advantage of their opportunity to alter their patients’ smoking habits. Fewer than one half of current smokers recall being told to quit by a physician. In fact, a physician’s advice can make a difference. Physicians who devote more time to counseling smokers can expect to be even more effective. In one study, a regularly scheduled follow-up visit for smoking counseling was more effective than one-time advice. The physician can be most effective by advising all smokers to quit and providing additional counseling to susceptible smokers—those with respiratory symptoms or a recently diagnosed serious, smoking-related disease. Physician components identified by the National Cancer Institute as particularly helpful to the cessation effort include making the office a smoke-free site, identifying all smokers in the practice, asking them at each visit about smoking and advising cessation at every appropriate opportunity, helping them set a quit date, providing them with educational and self-help materials, advising nicotine reduction therapy or bupropion when indicated, and arranging follow-up to sustain cessation. A team approach in which a nurse provides more in-depth counseling and follow-up after the physician’s introduction to cessation can enhance outcomes and reduce the expenditure of the physician’s time.
Preventing Relapse. Follow-up is critical. Studies of physician intervention show that scheduling follow-up visits to discuss smoking increases patients’ cessation rates. The importance of continuing to work with the former smoker throughout the first year of cessation cannot be overemphasized, particularly the person with evidence of nicotine addiction. Such patients need to be prepared by the physician to recognize and manage nicotine withdrawal symptoms, prescribed a nicotine reduction program, and followed up within 2 weeks of quitting. Only after a full year of cessation can the patient be considered an ex-smoker. In the interim, repeated visits for reinforcement and support are essential to a successful outcome.
Weight gain must be addressed. Failure to do so risks ignoring a major cause of late relapse. Weight gain may be particularly upsetting to the person who quits out of a desire to improve appearance and personal hygiene. Nicotine increases energy expenditure. After cessation, the loss of such excess expenditure leads to weight gain unless caloric intake is decreased or physical activity is increased. Most smokers gain some weight after they stop smoking, with men averaging 2.8 kg and women 3.8 kg. The risk for large weight gain (>13 kg) is low; it occurs in about 10% of men and 13.5% of women. African-Americans and heavy smokers (>15 cigarettes per day) are also at increased risk. However, weight gain does not cancel the health benefits of smoking cessation. The physician needs to prepare the patient who plans to quit for the risk of weight gain. Prescribing a program of exercise can be one of the best complements to the smoking cessation effort, facilitating weight control and providing an enhanced sense of well-being.
Depression also requires attention. Before the patient attempts to quit, the physician should evaluate the patient for an underlying depression because it can be a major cause of smoking and a barrier to successful cessation (see above). If major depression is present, it must be treated before smoking cessation is attempted. As noted above, bupropion has proved to be equally effective at supporting cessation in patients with and without a history of depression, which suggests that its effectiveness in smoking cessation is independent of any beneficial effects on depression. Nevertheless, bupropion may well be the drug of choice in these situations because of the potential for both salutary effects. Patients with a history of depression, but who are not depressed before quitting, are at increased risk for a relapse during the withdrawal period. Depression needs to be watched for and responded to.
The asymptomatic smoker may be the most difficult one to motivate. Most smokers do have minor smoking-related symptoms that would improve with cessation, such as morning cough or limited exercise tolerance. Smokers unable to quit for their own sake may do so for their children’s health or to ensure a safe pregnancy.
Smokers with an acute respiratory illness commonly stop smoking for a few days on their own. The physician can suggest that the smoker take advantage of the period of reduced desire to stop smoking permanently. For the smoker with a chronic disease associated with smoking, the physician should point out the potential for reduced symptoms, improved function, and slowed progression of disease. Radiologic or pulmonary function tests are not recommended for asymptomatic smokers because they do not detect early disease, and normal results may falsely reassure smokers that their health is not being jeopardized.
Smokers reluctant to attempt cessation often harbor a specific concern, such as a fear of failure, weight gain, withdrawal symptoms, or the loss of a pleasurable habit or way to handle life stresses. Helping the smoker to clarify this concern and develop arguments to the contrary can be helpful. If the smoker remains unwilling to consider cessation, the physician should stop with a strong antismoking recommendation but should make a renewed effort at subsequent visits.
Most smokers will initially elect to stop on their own, and an individual attempt should be the physician’s initial recommendation. These smokers will benefit from self-help material. For heavy smokers who have failed unassisted quitting attempts, consideration of an assisted program is indicated. Providing information about and referral to such community smoking cessation programs is important.
If an underlying depression is present, it should be treated specifically before cessation is attempted. If depression develops subsequently, it too should be treated directly.