We may have heard the reports and statistics many times over, but they still bear repeating. Smoking sits in the number one spot as the most preventable cause of sickness and death in the United States, and has been in that position for more than 30 years. Some 440,000 deaths each year are due to smoking, and it is the primary cause of deaths due to lung cancer, coronary artery disease, COPD, and stroke. In addition, smoking is linked to cancer of the larynx, oral cavity, esophagus, bladder, kidney, and pancreas.1 Smoking causes more deaths than the total of all deaths due to AIDS, homicide, suicide, motor vehicle accidents, fire, and substance abuse (including alcohol, cocaine, and heroin).2 Approximately 20.5% of the population, or some 44.5 million adult Americans, smoke. There had been a steady decline in smoking rates in adults from the mid-1990s, but that decline has leveled off, and rates have held steady over the years 2004-2005.1 The Centers for Disease Control and Prevention has estimated that in the adolescent population about 28%, or 3.1 million, are regular smokers.2

Given the impact that smoking has on morbidity and mortality, smoking cessation is becoming a major focus among health care professionals, health care systems, and both state and federal governments. This article will take a look at the most recent guidelines and research related to smoking cessation.

Where to Start?

In 2000, the US Department of Health and Human Services recommended asking patients about smoking cessation using what is called the five A’s: Ask, Advise, Assess, Assist, and Arrange.3

  • Ask: Ask all patients about their tobacco use: “Do you ever smoke or use any other tobacco products?”
  • Advise: All who answer yes to the first question should be strongly advised to totally quit using any/all tobacco products.
  • Assess: Assess the tobacco user’s readiness to quit: “How willing are you to quit?”
  • Assist: Give practical assistance and tips on quitting and provide medications that aid in the effort to quit (cover topics such as setting a quit date, removing all tobacco products, planning for alternative activities to change smoking-related habits, etc).
  • Arrange: Arrange for follow-up to give encouragement and boost motivation during the first week, first month, and first 6 months of quitting.

Emphasis has been placed on talking to all patients about their tobacco use and moving through the complete counseling process using the five A’s to provide a framework. This should be part of any contact with smokers for physicians, dentists, nurses, and respiratory therapists. If in the assessment step a health care professional uncovers a smoker who is unwilling to quit, the American College of Chest Physicians recommends that the professional who is counseling the smoker work jointly with the patient to identify and define what is called the five R’s: Relevance, Risk, Rewards, Roadblocks, and Repetition.4

  • Relevance: Identify the patient’s personal reasons for quitting—make it relevant to their lives.
  • Risk: Discuss the increased risk of illness and declining health if smoking continues.
  • Rewards: Identify rewards and benefits for the patient of quitting smoking.
  • Roadblocks: Identify the roadblocks for the patient that may hinder quitting.
  • Repetition: With each visit or encounter, use repetition to increase the motivation to quit.

Giving Up Is Hard to Do

Many smokers go through a cycle of saying they are going to quit, decreasing the number of cigarettes smoked or stopping altogether, and then restarting. This often happens several times before a truly successful attempt occurs. In the meantime, the responsibility for working through the counseling steps mentioned above (the five A’s and the five R’s) falls on the patient’s physician, nurse, or respiratory therapist. Many physicians have little time to spend with patients, however, and they use that time to engage in one-way communication where the focus is on providing information and not eliciting response.5 A systematic review published in 2005 looked at general practitioners (GPs) and family practice physicians (FPs) and their attitudes about discussing smoking cessation. The researchers found that a sizeable minority of GPs and FPs have negative beliefs and attitudes, with the following taking the top three spots: 1) They felt discussing smoking cessation is too time-consuming; 2) they didn’t believe that these discussions were effective; and 3) the physicians had no confidence in their ability to discuss smoking cessation.6 Nurses can and often do step into the role for counseling, but many nurses may not have time or expertise in smoking cessation counseling. Given this background, it makes sense for respiratory therapists to pursue a much bigger role in smoking cessation (just as we are currently doing in asthma education and management and in pulmonary rehabilitation, and are moving forward to do in COPD education and management).

It is useful to have some measure of the patient’s addiction to the various chemicals in cigarettes. The Fagerström Test for Nicotine Dependence is a well-known six-question questionnaire for measuring the degree of dependence and is useful for predicting the severity of withdrawal symptoms as well as measuring the need for pharmacologic treatment to quit (Table). Nicotine is a powerful substance that rushes to the brain and begins working on the receptors within 7 seconds of the first inhalation. It works on the pleasure receptors by stimulating the release of dopamine and creates a physical and emotional dependence in the addicted smoker. For those trying to break free of the addiction, withdrawal symptoms such as moodiness and irritability, insomnia, headache, and difficulty concentrating work together to sabotage the attempts to quit. Attempting to quit totally on your own with no counseling and no pharmacotherapy has not been the recommended approach. Rather than going “cold turkey,” the experts recommend approaching the attempt to quit by treating three areas of addiction—the physical, emotional, and behavioral.7

What Is the Best Approach?

In 2008, the US Surgeon General released a 276-page update on quitting smoking. This update on treating tobacco use and dependence emphasizes that there is no single best approach but provides 10 key recommendations that should be taken as a set of actions with none left out.

The 10 Key Recommendations:

1.) Quitting smoking may take several attempts and often calls for intervention, but long-term success is possible.

2.) Monitoring for and documentation of smoking must be done in a consistent manner by health care professionals and health care systems. All smokers need to be treated for tobacco use.

3.) All who are willing to quit should be encouraged to use the recommended counseling treatments and medications found in the 2008 guideline.

4.) Brief treatment (taking less than 10 minutes) is effective.

5.) Use the five A’s mentioned above. Individual, group, and telephone counseling activities work. Two particular pieces that need to be included are practical counseling (giving problem solving/skills training) and social support.

6.) Make use of the proven medications unless contraindicated or in areas that lack proof of effectiveness (eg, pregnant women, smokeless tobacco users, light smokers, and adolescents). Combinations of certain medications should also be considered. The proven medications are:

  • bupropion SR (sustained-release)
  • nicotine replacement therapy (NRT)
    • nicotine gum
    • nicotine inhaler
    • nicotine lozenge
    • nicotine nasal spray
    • nicotine patch
  • varenicline (Chantix)

7.) Counseling and medication are effective when used individually but are even more effective when combined.

8.) Telephone quit-line counseling should be encouraged.

9.) Smokers who are unwilling to quit should be addressed with motivational treatments to encourage a change in attitude.

10.) Smoking cessation involving counseling and medication administration is cost-effective. All insurance plans should include coverage of the proven approaches described in the guideline.

Also from the 2008 Surgeon General’s Update: The FDA has added a warning regarding varenicline regarding possible attitude/mood changes including depression, agitation, thoughts of suicide, and suicidal activity. The FDA recommends that patients share any history of psychiatric illness before taking varenicline and that prescribing physicians monitor for mood or behavioral changes in patients taking this medication. With this in mind, whenever interviewing a smoker regarding their history or doing follow-up with patients taking varenicline, questions regarding psychiatric problems should be included. Also, varenicline should not be used in combination with NRT.8 This is a disappointing change for what has turned out to be one of the most effective medications yet to help smokers quit (reflected in a systematic review and meta-analysis published in 2006 examining the effectiveness of smoking cessation using medication).9 Varenicline is a partial agonist that acts on the a4b2 nicotinic acetylcholine receptor (nAChR). The medication causes a moderate increase in the level of dopamine, thus activating the pleasure pathway (like nicotine) and blunting the cravings and withdrawal symptoms. Being a partial agonist at the receptor site, it ties up the receptor and blocks the positive effects of smoking a cigarette; the smoker’s expected pleasure from “sneaking a smoke” does not happen so the reward of cheating while trying to quit is removed.10 Three other treatments for smoking should be mentioned: acupuncture, laser therapy, and hypnotherapy. A Cochrane review of acupuncture concluded that it showed no benefit when compared to sham acupuncture. Laser therapy has not had enough research to support it, and hypnotherapy has also had a Cochrane review that has shown it to have no advantage over other behavioral interventions.7

Breaking News

As this article was being prepared, the announcement was made that the US House of Representatives had passed a bill to give the FDA the authority to regulate tobacco products, including cigarettes and smokeless tobacco. The bill allows control of nicotine levels and flavoring with menthol, and prohibits candy-flavored cigars and cigarettes. Restrictions would be placed on marketing and sales to kids and the use of misleading terms such as light and low tar. Another piece of the legislation brings about disclosure of all the contents in tobacco products. The bill will head to the Senate for consideration.11,12 There is ongoing debate regarding the federal government’s role in regulating tobacco and a variety of opinions as to the impact on issues such as the rate of smoking in women, kids, and minorities.

In my opinion, however, federal oversight is needed and giving the FDA this role makes sense.


Quitting smoking is difficult and often takes several attempts to finally succeed. Based on the guidelines, health care professionals need to take an active role in counseling and encouraging smokers to quit. The guidelines give specific steps and measures to aid in the success, but they are complex and take time to apply. Respiratory therapists need to become experts in the counseling and teaching, and be competent regarding knowledge and application of pharmacotherapy. We also need to make the time to teach, advise, and motivate smokers to quit. When smokers receive expert advice and teaching combined with adequate time to listen, empathize, etc, they have a better chance of quitting successfully. Smoking cessation information is readily available and good counseling, ongoing monitoring, and a motivated health care worker who takes the time to really talk and listen.

William C. Pruitt, RRT, AE-C, CPFT, is senior instructor, Department of Cardiorespiratory Sciences, University of South Alabama, and PRN respiratory therapist at Springhill Medical Center and Mobile Infirmary Medical Center, Mobile. For further information, contact [email protected]


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