Grand Rounds Section Editor: David S. Cooper,
MD, Contributing Editor.
Author Affiliation: Department of Medicine
and Smoking Cessation Leadership Center, University of California, San Francisco.
Despite the reality that smoking remains the most important preventable
cause of death and disability, most clinicians underperform in helping smokers
quit. Of the 46 million current smokers in the United States, 70% say they
would like to quit, but only a small fraction are able to do so on their own
because nicotine is so highly addictive. One third to one half of all smokers
die prematurely. Reasons clinicians avoid helping smokers quit include time
constraints, lack of expertise, lack of financial incentives, respect for
a smoker’s privacy, fear that a negative message might lose customers,
pessimism because most smokers are unable to quit, stigma, and clinicians
being smokers. The gold standard for cessation treatment is the 5 As (ask,
advise, assess, assist, and arrange). Yet, only a minority of physicians know
about these, and fewer put them to use. Acceptable shortcuts are asking, advising,
and referring to a telephone “quit line” or an internal referral
system. Successful treatment combines counseling with pharmacotherapy (nicotine
replacement therapy with or without psychotropic medication such as bupropion).
Nicotine replacement therapy comes in long-acting (patch) or short-acting
(gum, lozenge, nasal spray, or inhaler) forms. Ways to counter clinicians’
pessimism about cessation include the knowledge that most smokers require
multiple quit attempts before they succeed, that rigorous studies show long-term
quit rates of 14% to 20%, with 1 report as high as 35%, that cessation rates
for users of telephone quit lines and integrated health care systems are comparable
with those of individual clinicians, and that no other clinical intervention
can offer such a large potential benefit.
Schroeder SA. What to Do With a Patient Who Smokes. JAMA. 2005;294(4):482–487. doi:10.1001/jama.294.4.482