Article

HELP PATIENTS QUIT SMOKING

PATIENT DESIRE, AFFIRMATIVE RESPONSES AND EDUCATION ON RESOURCES INCREASE THE LIKELIHOOD OF SUCCESS

TWENTY YEARS ago, I made the jump to private practice after teaching public health and pediatric optometry at the New England College of Optometry. Given my background, my patient care emphasized prevention. So, I routinely asked patients about their tobacco use and advised users to quit, explaining that tobacco use is not only linked to systemic disease, but to cataracts and AMD as well.

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To bolster my efforts, I researched local tobacco cessation programs, wrote a brochure that contained the positives of quitting, the negatives of not quitting and contact information for cessation programs. Two years later, I conducted a case-control study to see whether my efforts had any effect. They did not, so I ceased tobacco use questioning until the early 2000s, when CMS began requiring all Medicare providers to screen for, though not intervene with, tobacco use. By 2005, CMS began coverage for tobacco cessation treatment, and in 2012 screening for and counseling current tobacco users became required of Medicare providers through the implementation of the “Meaningful Use” objectives and annual attestation of compliance. (See http://g.cms.gov/2tqkCpD .)

Here, I discuss why my case-control study failed and how cultural and practice changes lead to successful results.

WHY MY STUDY FAILED — A LESSON

When I started asking patients about tobacco use again, I learned the biggest factor in smoking cessation success is patient desire. I didn’t usually address this. Instead, I recommended quitting and provided literature on how to do it.

For those of us who have never smoked, a common assumption is that smokers want to quit but can’t due to nicotine dependency. For many smokers, however, it is the lighting of the cigarette and inhaling of the hot smoke that keeps them coming back. They recognize the cost to their health and wallet, but the pleasure outweighs these costs.

CHANGING MY APPROACH

In recognizing the patient desire factor, I changed my approach to asking whether the patient wanted to quit:

Me: “Do you smoke?”

Patient: “Yes.”

Me: “We recommend all our patients quit. Is there anything I can do to help you with that, like refer you to the hospital’s smoking cessation program?”

If the patient quickly replied, “no,” I was done. That said, a common response was, “Oh, I’ve quit a few times” or, “I tried quitting on several occasions; it just hasn’t worked.” These replies indicated a willingness to discuss the topic and a possible interest in quitting. To make this determination, I asked the patient what he or she had tried, how long the patient was able to cease smoking and what lead him or her to give up. I always replied to the patient’s answers in the affirmative:

Me: “You’ve tried. That’s great! Did you know the more times you try, the more likely you will succeed next time?” Or, “You quit when you were pregnant? Awesome! You did it for nine months, so you know you can do it!”

Next, I educated these patients that research reveals tobacco cessation is most successful when one participates in a smoking cessation program that includes individual counseling, group therapy, active strategies, prescription medication and alternative complimentary therapy. To get specific, I explained that counselors could provide many smoking cessation strategies, such as removing from the house tobacco products, advertisements and media references to smoking (like old movies on streaming services), avoiding social situations where smoking is tempting and developing a tool box of things to do instead of smoking, such as having a refrigerator stocked with celery to munch on to meet the oral fixation need and also minimize weight gain — a significant concern and common consequence of tobacco cessation.

I also probed about the family support system. If others in the household smoked, it would be difficult for the patient to quit unless the others joined the band wagon. Family members must work with the patient during the cessation period. Family members can be the best support network or a barrier toward success, depending on their attitudes.

I also discussed the fact that the patient’s primary care provider or an addiction treatment specialist could prescribe nicotine replacement therapies, such as varenicline tartrate (Chantix, Pfizer) and buproprion hydrochloride (Zyban, GlaxoSmithKline), which can gradually help him or her quit smoking and lack the additional health risks of smoking or chewing tobacco. (Other commonly used treatments include antidepressants and antianxiety medications.)

Further, I highlighted the available alternative therapies, such as acupuncture, hypnosis and herbal remedies. (Consult clinical practice guidelines, professional organizations, and experts, such as the CDC [www.cdc.gov/tobacco/ ] before recommending. Most importantly, only refer to a licensed ethical evidence-based practitioner.) (I continue to follow all these steps today.)

SUCCESSFUL NEXT STUDY

In 2016, I conducted another study on whether implementing tobacco screening and cessation counseling in an eye care practice worked at all. I performed a retrospective cohort study.

Other Optometry and Smoking Cessation Studies

  • Most eye care providers inquire about patients’ smoking status and educate them on the ocular risks of smoking, but half do not ask, or rarely ask, about patients’ willingness to quit smoking, and most do not discuss smoking cessation options. — “Practice Patterns Among Eye Care Providers at US Teaching Hospitals with Regards to Assessing and Educating Patients About Smoking,” June 2017 American Journal of Ophthalmology.
  • Most patients expect their optometrists to assess their eye health, ask about smoking and diet habits and indicated they feel comfortable talking about these topics with their primary eye care provider. — “What Do Patients Think About the Role of Optometrists in Providing Advice About Smoking and Nutrition?,” March 2017 Ophthalmic and Physiological Optics.

Specifically, I reviewed 1,834 records of which 193 were documented tobacco users and received some type of cessation counseling. At the next routine exam, 28, or 14.4% of the 193, had successfully quit tobacco, a rate similar to other health care professions providing cessation counseling. For every 14 users counseled, one quit! (This data was presented at the AAO’s annual meeting, November, 2016.). (See “Other Optometry and Smoking Cessation Studies,” above.)

I can’t say my practice was necessarily responsible for the change. For some smokers, we may have been the one thing that lead them to stop. For others, we are just glad to be part of the sea change occurring.

BE A PART OF THE EFFORT

Cigarette use in U.S. adults has declined from 42.4% in 1965 to 24.7% in 1995 to 16.8% in 2014, according to the CDC. The fact that O.D.s can be a part of this change is rewarding. OM