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Research indicates that even brief physician advice on a regular basis can increase quit rates for patients who smoke.1 This is particularly important in mental health settings, where there are more smokers than in the general population (50% to 90% vs 25% to 27%, respectively) but quit rates are lower.2
There is no “one size fits all” solution to quitting smoking; there are many individual factors to take into account for each patient. In addition to environmental factors that can make quitting smoking more challenging—eg, the patient’s partner also smokes—a patient’s genetic makeup can make it easier or harder to become addicted or to quit smoking, and can make pharmacologic approaches to cessation more or less successful.3,4 A patient’s failed attempt to quit in the past does not indicate that quitting is impossible.
Although we encourage the use of traditional mnemonics such as the “5 A’s”5 and the “5 R’s,”5 we introduce QUIT as an easy-to-remember, compassionate, realistic way of discussing smoking cessation with patients.
Question each patient to understand the pros and cons of quitting. Ask your patients about the “benefits” of smoking and understand what role cigarettes serve in their lives. Remind patients of immediate benefits that would make quitting smoking a “trade” rather than a loss—eg, how would they use the extra $200 a month they would save by giving up cigarettes?
If patients say they are not interested in quitting, find out why they are not motivated to quit and collaborate with them to try to address their concerns. Additionally, ask if they would be comfortable discussing smoking cessation at each visit, even if they are not expressing interest.
Understand the nature of addiction. The trajectory of tobacco dependence—similar to other addictions—involves a chronic and relapsing course. Most patients require multiple quit attempts using several strategies before they succeed. Find out what they have tried in the past and build on previous successes. Be persistent in offering evidence-based treatments to help patients quit, even when motivation is low and patients have multiple failed attempts.
Keep in mind that only 4% to 7% of unaided quit attempts are successful.6 Most patients require counseling and/or medication, as well as help from a caring physician. By understanding the nature of addiction, you can be optimistic and supportive of your patients as they face the often disheartening process of quitting.
Identify risk factors and triggers. Studies have demonstrated that stimuli related to smoking increase a patient’s craving to smoke; this response is stronger than triggers encountered by patients addicted to alcohol or opiates.7 A plan for handling cravings and avoiding triggers can empower your patients and help them stay on track.
Talk with—not to—your patient. Discussing smoking can help clarify your patient’s feelings rather than avoiding them. Although patients may aspire to eventually quit smoking, the unspoken concerns they harbor combined with the “benefits” of smoking may lead to a failure to act.
Talk is powerful and with training, physicians can move patients toward change. Motivational interviewing is evidence-based and offers techniques that enable physicians to use conversation with their patients as a way of overcoming ambivalence about unhealthy behaviors and eliciting talk about changing these behaviors, and eventually help them to change.
You can make an impact
Physicians need to recognize their potential impact on this life-threatening behavior. Through an active, conversational style, develop a big-picture understanding of your patient’s pros and cons of quitting smoking; strengths and weaknesses; past failures and successes; barriers to success; available supports; etc. This information, combined with encouragement, support, and knowledge of evidence-based practices, can yield a thorough plan for quitting.
Although quitting smoking can be extremely challenging for clinicians and patients, expanding your knowledge in this area will allow you to help your patients make life-saving changes. The best care comes from direct communication and unconditional support.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.