Smoking Cessation and the Influence of the Navigator

August 2021 Vol 12, No 8

Categories:

Smoking Cessation

Cigarette smoking is the single most important cause of disease and premature death in the United States. “Let that sink in,” said Kevin Scott Ferentz, MD. “It’s not hypertension, diabetes, or other drug abuse; it’s cigarette smoking.”

Smoking kills more people each year than alcohol, cocaine, crack, heroin, homicide, suicide, car accidents, fires, and AIDS combined. But according to Dr Ferentz, who ran the smoking cessation program at the University of Maryland for 25 years, healthcare providers receive very little, if any, training on how to help people quit smoking. At the AONN+ Virtual Midyear Conference, he set out to change that.

In the United States, smoking kills about half a million people per year, including about 40,000 who die of illnesses related to second-hand smoke. “Half of all smokers will die a tobacco-related death, costing hundreds of billions of dollars in medical care and lost productivity,” he said. “And if you add it up, every pack of cigarettes smoked costs society about $60.”

The Stats

In 2019, about 14% of Americans (~34 million people) were smoking, down from 43% in 1966. “So a whole lot of people have indeed quit smoking,” he said. But although there has been a gradual decline in cigarettes smoked per day in the United States, Dr Ferentz noted that this statistic is not as cheery as it may seem, as smokers have actually changed the way they smoke.

“As cigarettes have become more expensive, smokers have learned to inhale deeper and hold their breath longer so they can maintain their nicotine levels, smoking fewer cigarettes,” he noted.

According to Dr Ferentz, about 1.3 million people quit smoking in the United States every year, but about 2000 kids start smoking every day. And although there are fewer kids smoking cigarettes, the overall use of nicotine is actually increasing in children due to the use of smokeless tobacco, or e-cigarettes. E-cigarette use eventually leads to cigarette use: e-cigarette users are 4 times more likely to smoke cigarettes 2 to 3 years down the road.

Stay Positive

“Getting people to quit smoking is about being positive; it’s not about negativity,” he said. “When you try to scare a person into quitting smoking, they get anxious. And when a smoker gets anxious, they smoke a cigarette.”

Always accentuate the positive aspects of quitting rather than dwelling on the dangers of continuing to smoke. He encourages talking to smokers about how much better they’re going to feel and how much money they’re going to save. “One of the great messages to give to smokers is that there are now more people in America who have quit smoking than are smoking,” he added.

What’s in a Cigarette?

A cigarette contains about 4000 chemicals, including tar, carbon monoxide, and nicotine. Tar is the major cancer-causing substance, carbon monoxide makes oxygen unavailable to tissues (leading to a multitude of other disease processes), and nicotine is what causes the addiction.

Cigarettes, (or more specifically nicotine), fulfill the 3 criteria for what makes a drug addictive: dependence, tolerance, and withdrawal.

“When you smoke nicotine, it crosses your blood-brain barrier twice as fast as IV heroin, and it stimulates your sympathetic nervous system while at the same time stimulating your parasympathetic nervous system,” he said. “So you feel stimulated and relaxed at the same time, and it’s the only drug of abuse that does this. That’s why people use nicotine.”

But There’s Good News

The effects on health from smoking are reversible if a smoker stops smoking. After quitting, cough and exercise tolerance improve within days to weeks, the risk of heart disease is reduced by 50% within 1 year, the risk of lung cancer is reduced by 50% within 10 years, and within 10 to 15 years, mortality rates of ex-smokers are the same as never-smokers.

“You hear from patients all the time, ‘Oh, it’s too late. I don’t have to quit smoking because I know I’m going to die,’” he said. “That’s just not true. The oldest person I ever got to quit smoking was 82 years old. She had been smoking for 70 years, and 2 weeks after she quit smoking, she said, ‘I can’t believe how much better I feel.’”

According to Dr Ferentz, every single patient who smokes should be counseled on how to quit smoking. Research has shown that at least 70% want to quit, about half make an attempt each year, and even minimal input from a health professional almost doubles the quit rate.

“Our influence as health professionals is really amazing,” he said. “People see us as being in positions of authority, we’re credible sources of health information, and we’re able to personalize the damaging health effects of smoking.”

Starting the Conversation

For people who are going to try to quit smoking, it’s incredibly important that they receive some written materials, he said, citing as his favorite a booklet called Clearing the Air: Quit Smoking Today (available at www.cancer.gov), as well as websites like www.smokefree.gov and www.smokingstopshere.com. Additionally, quit lines (1-800-QUIT-NOW) have been shown to help people quit smoking.

A small amount of time spent with more smokers will yield more ex-smokers than intensive efforts with a few. “What that means is, you’ve got to spend a couple of minutes with every person you see who smokes,” he said. “Everything I’m teaching you today, you can do in 5 minutes.”

At a minimum, counseling should include firm, unambiguous advice (“I’m your doctor; I’m telling you to QUIT!”), written materials, setting a quit day, and setting a follow-up visit (or warning the patient you will ask about progress at a future visit).

“You want to personalize the damaging health effects for that person, but you also want to say that you’re going to get better if you quit smoking,” he said. “Again, you don’t want to scare them, but anytime I see a smoker who has any symptom I can possibly attribute to smoking—on their history, physical exam, or labs—I do.”

People may also consider nonhealth reasons for quitting, the primary reason being cost. Adding up the yearly price of a pack of cigarettes a day and showing them that number can really make an impact.

People quit when they have confidence in their ability to quit. “How do you give them confidence? You express your confidence,” he said. “You say, ‘Of course you can quit smoking! Millions of people have quit smoking; there are now more ex-smokers in America than people who smoke!’ If they tell you they’ve tried, tell them that’s great, because every time you try to quit, you’re more likely to succeed.”

Reassure them that past attempts are learning experiences, he added, and that you as the healthcare provider can help with the physical and psychological dependence issues. “All patients who are trying to quit smoking should be offered drugs—nicotine replacement therapy, bupropion (Zyban) or varenicline (Chantix)—they all work,” he said. “If you use medication and behavioral counseling, you’ll at least double a person’s chances of quitting.” But unfortunately, less than one-third of adults who try to quit smoking are offered both.

Common concerns around quitting include withdrawal (tell them it’s short-lived, about 2-3 days), cravings (only last 3-5 minutes and diminish rapidly), tension (validate and normalize it, help them find other ways to cope), and weight gain (this is not inevitable, and about one-third of people who quit actually lose weight).

“Tell all patients how important it is that they quit smoking and not cut down,” he emphasized. “Cutting down doesn’t work; when people cut down, they inhale deeper, hold their breath longer, smoke more of the cigarette, and maintain their nicotine levels. You have to set a quit day.”

“Studying” for Quit Day

Preparing to quit smoking requires behavior modification. “I tell patients that stopping smoking is like taking a test: if you study, you pass, if you don’t study, you fail,” he said. “So I want them to study for a week before they quit smoking.”

“Studying” requires them to address the 3 components of addiction: physiological (feeling sick after quitting), psychological (I smoke because I’m stressed), and behavioral (I smoke when I’m in the car). “The psychological and the behavioral aspects are what keep people smoking,” he said.

Before actually attempting to quit, he asks patients to write down their reasons for quitting on an index card (writing them down makes people take quitting more seriously, but the card also serves as motivation when a craving hits). Next, they identify their triggers over the course of 4 days by writing down where they were, who they were with, what they were doing, etc, every time they smoked a cigarette. Finally, next to each trigger, they write down how they can avoid or cope with that trigger.

“This is not nuclear physics; this is the essence of behavior modification,” he said. “Why do I do something? What can I do instead? That’s it. If you smoke after eating, get the hell up from the table and go for a walk.”

Next, they have to change their habit and buy packs only (no cartons) of brands different from what they usually smoke. “If you normally smoke Virginia Slims 100 light menthols, and 1 day you smoke a Camel with no filter, you’ll puke—too much tar,” he said.

They have to develop a support system (tell everyone they’re quitting), set up a self-reward system (for a day, week, month, year without smoking), and importantly, make a written commitment to a quit day.

The last thing to do is set a follow-up visit with all patients patients 1 month after the quit day. “If they don’t show up in a month, they didn’t quit smoking, and you talk about it the next time,” he said.

“If they show up in a month, you got them; they’re going to quit smoking, because 1 of 2 things happened,” he continued. According to Dr Ferentz, the patient either hasn’t smoked in that month (If so, encourage them! Tell them they’re the greatest person who ever lived! Tell the people in the waiting room! Get them to applaud!), or they slipped up and smoked. “Tell them that’s ok, identify the trigger, and ask what they could do to either avoid or cope with that trigger,” he said. “Then set another quit day. That’s how it works.”

Slips happen, but just like with any other addiction, Dr Ferentz encourages providers to take it 1 day at a time with their patients. “Don’t worry about not smoking tomorrow,” he said. “Just worry about not smoking right now.”

Last modified: August 10, 2023

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