J. Pevention

Introduction

Smoking cessation is the most effective treatment for COPD, and the only way to prevent it. The social and economic costs of smoking are enormous. A patient who is successful in stopping smoking will eventually need to be seen less often and hospitalized less frequently, thus reducing a significant portion of these costs.

The Lung Health Study revealed that some patients with early COPD experienced an improvement of pulmonary function after smoking cessation. As already emphasized, this landmark study should encourage every physician to do simple spirometric assessments in all smokers. The rate of decline of pulmonary function was dramatically reduced in patients who stopped smoking in the Lung Health Study. All smokers should quit. Those with decreased pulmonary function are at a particular risk for adverse consequences, including accelerated losses in ventilatory function that result in premature morbidity and mortality from COPD.

The time is ripe for the primary care physician to capitalize on years of public health education about the benefits of smoking cessation. Most persons who smoke know about the economic and health consequences of smoking. The young, however, are especially prone– despite public education efforts–to feel that “it won't happen to me.” Some of the many available free smoking cessation resources, appropriate for smokers from all socioeconomic groups, are listed in Table 10 and Table 11.

Office Strategy

A physician's office smoking cessation plan need not be complicated, time consuming, or costly. A brief intervention, as short as one or two minutes, can be effective.

The Agency for HealthCare Research and Quality suggests the Five A’s approach to smoking cessation intervention. Always Ask if the patient smokes, Advise smokers to quit, Assess the patient’s willingness to try to quit, Assist the smoker in quitting, and Arrange follow-up. Patients expect physicians to advise them to stop, and they will listen. The perception of smokers is that the majority of them have not been told by their physicians to stop smoking!

Any behavioral change progresses through stages. Smokers can be categorized by stage and treated accordingly:

1. Pre-contemplation stage–Smokers at this stage are not seriously considering quitting within six months. Give these smokers pamphlets on the hazards of smoking and the benefits of quitting, which may be obtained from the sources listed in Tables 10 and 11 . Tell the patient that you are recording in his or her chart the fact that you have prescribed stopping smoking. Some physicians reinforce this by handing the patient a written prescription for smoking cessation.
2. Contemplation stage–Patients in this stage are seriously considering quitting smoking within six months. Urge them to set a quit date and schedule a visit a month or so prior to that date. Give appropriate smoking information (available from many sources).
3. Preparation stage–This includes those who plan to quit within the next thirty days; they have made a quit attempt lasting 24 hours or longer during the past year. As soon as the patient has set a quit date, evaluate the patient's need for nicotine replacement. Nicotine patches usually double the quit rate and should be considered for nicotine-dependent smokers.

The Fagerstrom Nicotine Tolerance Score (Figure 8) is an easy way to evaluate dependence. Patients scoring 6 points or more are highly dependent and will probably need nicotine replacement. A simpler and more practical evaluation method has also been developed; it postulates that the most addicted smokers smoke one to two packs per day and have their first smoke within thirty minutes after arising.

Nicotine patches are easy to explain and cause relatively few problems in addicted patients. Pharmaceutical companies include good information packages along with their products . The American Cancer, Heart, and Lung Associations also provide excellent information (Table 10).

Bupropion is an antidepressant which is useful in smoking cessation alone or in combination with nicotine replacement (see Table 2).

Education about quitting techniques and coping skills improves success. A knowledgeable nurse or assistant can explain techniques and offer reinforcement. This reinforcement can also be very effectively provided during essential follow-up visits at one and three weeks. The best support is understanding guidance, not negative reinforcement. Emphasize that success improves when the patient has a plan to cope with the urge to smoke. If the patient is interested in group sessions, give him or her the number of the local branch of the American Lung Association for information regarding its support groups (Table 10).

Relapse is common in first-time quitters. Approximately 25% succeed, so 75% need to try again. The good news is that success increases with each effort! Encourage the patient to view each unsuccessful quit attempt as a single step in the learning process. Help the patient to see relapse as a trial rather than a failure.

Even those who succeed in quitting tobacco use need continuing support and encouragement from their families and from you and your staff. The primary care physician, is therefore a catalyst for an ongoing process that may last years. Physicians and the entire health team can motivate smokers to quit and teach them how to quit successfully. Many materials are available to help the primary care physician develop a program. The Agency for HealthCare Research and Quality (1-800- 358-9295) publishes booklets and pamplets on the topic of smoking cessation for health professionals and the general public.

Other Causes of COPD

Certain industrial (e.g., isocyanates used in plastics and paints) and agricultural pollutants (e.g., grain dusts) have a small but causative role in the development of some COPD cases. These risk factors may be reduced by avoiding such substances when possible or wearing appropriate well-fitting masks, by increasing ventilation in work situations, and ultimately by calling for a reduction of these pollutants.

Conclusion

Prevention is the key to reducing and even eliminating COPD in the future. Public forums, including elementary schools, should be utilized by all physicians to spread the word that tobacco is a lethal substance. Many deadly diseases in addition to COPD, such as heart disease, vascular disease, and many cancers, result from tobacco smoking.

It has taken more than thirty years of aggressive action to spread the word about the dangers of tobacco use. The task is getting easier, and is finally meeting with some success in certain countries like the United States. Remind all patients that the substance that kills over 460,000 U.S. citizens each year is worthy of widespread discussion. Encourage them to participate actively in teaching young people never to start using tobacco.

References

Anda RF, Remington PL, Sienko DG, et al. Are physicians advising smokers to quit? The patient's perspective. jama 1987;257:1916-1919. This article gives evidence that patients do not perceive that their physicians are giving them strong advice to stop smoking.

Fiore MC, Baily WC, Cohen SJ, et al. A clinical practice guideline for treating tobacco use and dependence. A U.S. Public Health Service report. jama 2000; 283:3244-3253. A concensus statement of updated guidelines for brief and intensive tobacco cessation interventions. Assessment and treatment of tobacco use are also summarized.

Fiore MC, Smith SS, Jorenby DE, et al. The effectiveness of nicotine patch for smoking cessation. jama 1994;271:1940-1947. This classic meta-analysis strongly suggests the use of nicotine patches in virtually all smoking cessation clinics. Use of the patch greatly augments advice to quit smoking and other behavioral modification techniques.

Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol 1983;51:390-395. Excellent smoking cessation guidelines. Russell MAH, Wilson C, et al. Effect of general practitioners’ advice against smoking. bmj1979;2:231- 235. A general description of a classic effective plan for smoking cessation.

U.S. Department of Health and Human Services. Treating Tobacco Use and Dependence. Public Health Service 2000. 179 pages. Clinical practice guidelines identify effective, experimentally validated tobacco dependence treatments and practices.