Part Four: Smoking Cessation (The “S” of ABCS)

The 2004 Office of the Surgeon General’s report, The Health Consequences of Smoking, concluded that “smoking harms nearly every organ of the body.”⁸⁹ In its 2014 report, the Office notes that evidence gathered in the previous 50 years supports a causal relationship between smoking and a variety of cancers, cardiovascular diseases, respiratory disorders, reproductive effects, kidney disease, and diabetes.⁹⁰ Emerging evidence suggests that active smoking increases the risk of developing T2DM and that this risk increases with the level of smoking intensity.⁹⁰ To this end, the ADA recommends that physicians/clinicians advise all patients to avoid using cigarettes or other tobacco products (Evidence Rating: A).³⁴ Although e-cigarettes are advertised as an alternative to smoking, no rigorous studies have demonstrated that these products are healthier or that they can facilitate smoking cessation. As such, the ADA advises that non-smokers refrain from using e-cigarettes (Evidence Rating: E).³⁴ Furthermore, physicians/clinicians should include smoking cessation counseling and other forms of treatment as a routine component of diabetes care (Evidence Rating: B).

While a thorough discussion of smoking cessation interventions is beyond the scope of this monograph, this section will outline basic strategies to assess a patient’s degree of nicotine addiction and review evidence to support counseling in primary care settings. Comprehensive overviews of smoking cessation interventions are available through other publications.^{91, 92}

Nicotine dependence is a chronic condition, and smoking cessation requires behavioral modifications and lifestyle adjustments. Merely wanting to quit does not lead all smokers to actually attempt it; slightly more than half of those who want to stop will actually attempt to do so in a given year.⁹³ Of those, only about 3% will remain abstinent for 12 months. Most smokers will attempt to quit several times before achieving success, cycling though several periods of remission and relapse.^{94, 95} The physician/clinician should initially assess a patient’s degree of addiction and be prepared to offer encouragement, assistance, and guidance as the smoker adjusts to the lifestyle changes associated with successful interventions.

Assessing Nicotine Addiction. The cigarette provides a highly efficient, engineered vehicle to deliver nicotine, facilitating a complex addiction that involves physical, biochemical, psychological, behavioral, and social aspects.^{96, 97} The act of smoking becomes incorporated into daily routines and is often associated with ritualized behaviors. The degree of nicotine dependence has been identified as the key predictor of cessation success in several large-scale prospective studies.^{98, 99} The health care provider can assess the degree of nicotine addiction by asking three questions:

• How much do you smoke (e.g., how often, how many cigarettes/day)?
• When do you smoke your first cigarette of the day?
• What is the longest period of time between cigarettes before you crave another cigarette?

Patients who smoke more than 20 cigarettes per day, and those who smoke 10-20 cigarettes per day with the first cigarette within the first 30 minutes of waking, are likely to be addicted to nicotine. Those who smoke 10-20 cigarettes per day, with the first cigarette more than 30 minutes after waking, are less likely to be addicted. Fewer than ten cigarettes per day suggests social smoking rather than addiction, although patients in this category may demonstrate moderate amounts of addiction. The pattern of smoking during the course of the day may also provide insight into the level of addiction; e.g., a person who smokes only during the evening is likely less addicted than one who smokes a cigarette immediately upon waking.

Patients who are embarking upon a regimen of lifestyle/behavioral changes will arrive at the office in various stages of readiness. The provider can use the office model of the “5 A’s” (Table 4) as an approach when designing an appropriate intervention. It should be noted that relapse is common among smokers as they attempt to quit. The critical timeframe for relapse is during the first three months of abstinence with the first few days following the quit date being especially crucial.¹⁰⁰ To help prevent relapse, the provider should counsel the patient about the benefits, milestones, and difficulties of stopping smoking and encourage continued abstinence for those who have quit. Unsuccessful attempts to quit should also be supported by the provider, as these forays indicate that the patient is willing to take action. Intervention strategies that enhance partner support as an adjunct to a smoking cessation program may also increase the likelihood of success. Meta-analysis of available data indicates that intervention strategies that focus on enhancing supportive behaviors from live-in, married, and equivalent-to-married partners may enhance abstinence from six months to one year after treatment.¹⁰¹

Smokers who wish to quit have numerous non-pharmacologic options, including counseling and self-help materials, which are briefly reviewed here. In addition to these options, FDA-approved first-line smoking cessation therapies for adults can be divided into three categories: nicotine replacement therapy (NRT), the antidepressant bupropion, and the nicotine partial receptor agonist varenicline. NRT is available in three over-the-counter forms (gum, dermal patch, and lozenge) and two prescription formulations (inhaler and nasal spray). Evidence-based guidelines support multi-component interventions that combine behavioral and pharmacologic therapies, which have been shown to be more effective than single-component interventions.^{91, 92, 102} By targeting numerous aspects of nicotine addiction (e.g., teaching coping skills, providing withdrawal relief), multi-component therapies may enhance overall compliance and affect patients who would otherwise not respond to certain isolated strategies.

Self-Help Materials. A recent meta-analysis of studies that include self-help materials, in the format of booklets, handouts, or pamphlets, indicates that these materials may have a slight impact relative to no intervention, but they are marginally effective when provided in the absence of advice or counseling.¹⁰³ However, these materials are more effective when tailored to the individual. Self-help materials should be readily available in the office and provided to all smokers as one component of a holistic cessation strategy.

Brief Advice. The primary care setting offers numerous opportunities for brief (< 3 min) advice, a relatively easy intervention that may be offered by a physician or nurse. Such advice should include a firm quit recommendation and call attention to health outcomes and practical issues with cessation. Brief advice increases the odds of quitting when compared with no advice or usual care,¹⁰⁴ although its absolute benefit appears greater for motivated patients. Moreover, more intensive advice and follow-up may improve odds of quitting more substantially than brief advice.

Individual Counseling. Tobacco-cessation counseling by health care providers improves quit rates among adults.¹⁰⁵ Counseling has also been recommended by the U.S. Public Health Service for adolescents who smoke.¹⁰⁶ Approximately 3% of smokers will quit per year without the benefit of counseling intervention from the provider. However, as few as three minutes of counseling from the provider is sufficient to enable 6% of smokers to quit for at least six months.¹⁰⁵ A meta-analysis of randomized clinical trials has also demonstrated that one or more face-to-face counseling sessions (> 10 minutes) with a trained specialist can help smokers quit.¹⁰⁷ Evidence also supports the additive effect of behavioral counseling as an adjunct to pharmacotherapy.¹⁰⁸

Elements of a Counseling Intervention. All counseling interventions should contain a series of standard elements, including discussing previous quit experience, anticipating challenges, assessing the patient’s alcohol use and household environment, and providing the patient with alternatives/options for dealing with nicotine cravings. When discussing individual strategy with a patient, the provider should identify elements that aided and discouraged the smoker during previous attempts to quit, challenges that may trigger the desire for a cigarette, and ways that the patient will overcome them. Since alcohol can promote relapse, the provider should suggest that the patient consider limiting or abstaining from alcohol while stopping smoking. Finally, quitting is more challenging when other smokers are in the household. As such, smokers should encourage housemates either to quit with them or not to smoke in their presence during the attempt to quit.

Telephone Counseling. Telephone counseling initiated by health care personnel has also been identified as an effective intervention, especially when multiple contacts are timed with the smoker’s attempt to quit.¹⁰⁹ Telephone counseling is also effective as part of a multi-component intervention; one study (n=616) indicated that basic advice to quit, when combined with either telephone-based motivational advice or reduction counseling plus nicotine replacement therapy (NRT), increased the likelihood of future cessation compared to no treatment.¹¹⁰ This evidence is supported by a randomized, controlled trial of 2,163 adult smokers who received phone counseling as part of a holistic approach that included an offer of free nicotine-replacement therapy, use of a modified vital signs stamp, and tutorial and feedback for primary care providers.¹¹¹

Quitlines and External Counseling. Toll-free quitlines and referral to individual or group counseling are options that may be appropriate for select patients. Such external counseling may include cognitive/behavioral therapies, practical problem solving, and social support. Cessation rates for users of telephone quitlines and integrated health care systems are comparable with those counseled by individual physicians/clinicians.¹¹²

Additional Resources for Patients and Providers

Numerous resources for patients and healthcare providers are available online for the management of T2DM and the maintenance of cardiovascular and metabolic health (Table 10).

Additional Resources

DSME/DSMS Programs: American Association of Diabetes Educators https://www.diabeteseducator.org/patient-resources/find-a-diabetes-educator.

Design and track a healthy personal eating/activity plan: “MyPlate/MiPlato” - US Department of Agriculture

https://www.cnpp.usda.gov/myplate

Self-management goal-setting forms and tools for patients and providers (in English and Spanish): Robert Wood Johnson Foundation’s Diabetes Initiative http://diabetesnpo.im.wustl.edu/resources/topics/GoalSetting.html.

Certified diabetes educators (CDEs): American Association of Diabetes Educators https://www.diabeteseducator.org/living-with-diabetes/find-an-education-program.

Ten-year ASCVD risk estimator: American Heart Association and the American College of Cardiology

http://tools.acc.org/ASCVD-Risk-Estimator/.