Disease Prevention & Health Promotion Table 1–4.

Table 1–4. Actions and strategies for the primary care clinician to help patients quit smoking.

Action                                     -                                                              Strategies for Implementation

                     Step 1. Ask—Systematically Identify All Tobacco Users at Every Visit                            

Implement an officewide system that ensures that for every patient at every clinic visit, tobacco-use status is queried and documented. --- 

                                                                                                                                                                   

Expand the vital signs to include tobacco use.
Data should be collected by the health care team.
The action should be implemented using preprinted progress note paper that includes the expanded vital signs, a vital signs stamp or, for computerized records, an item assessing tobacco-use status.
Alternatives to the vital signs stamp are to place tobacco-use status stickers on all patients’ charts
or to indicate smoking status using computerized reminder systems.                                                      

                     Step 2. Advise—Strongly Urge All Smokers to Quit                                                         
In a clear, strong, and personalized manner, urge every smoker to quit                                                   

Advice should be
Clear: “I think it is important for you to quit smoking now, and I will help you. Cutting down while you are ill is not enough.”
Strong: “As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your current and future health.”
Personalized: Tie smoking to current health or illness and/or the social and economic costs of tobacco use, motivational level/readiness to quit, and the impact of smoking on children and others in the household.
Encourage clinic staff to reinforce the cessation message and support the patient’s quit attempt.

                     Step 3. Attempt—Identify Smokers Willing to Make a Quit Attempt                                 
Ask every smoker if he or she is willing to make a quit attempt at this time                                           


If the patient is willing to make a quit attempt at this time, provide assistance (see step 4).
If the patient prefers a more intensive treatment or the clinician believes more intensive treatment is appropriate, refer the patient to interventions administered by a smoking cessation specialist and follow up with him or her regarding quitting (see step 5).
If the patient clearly states he or she is not willing to make a quit attempt at this time, provide a motivational intervention.


                     Step 4. Assist—Aid the Patient in Quitting                                                                         
A. Help the patient with a quit plan                                                                                                          

Set a quit date. Ideally, the quit date should be within 2 weeks, taking patient preference into account.
Help the patient prepare for quitting. The patient must:
Inform family, friends, and coworkers of quitting and request understanding and support.
Prepare the environment by removing cigarettes from it. Prior to quitting, the patient should avoid smoking in places where he or she spends a lot of time (eg, home, car).
Review previous quit attempts. What helped? What led to relapse?
Anticipate challenges to the planned quit attempt, particularly during the critical first few weeks.       

B. Encourage nicotine replacement therapy except                                                                                  

Encourage the use of the nicotine patch or nicotine gum therapy for smoking cessation                        


C. Give key advice on successful quitting                                                                                               

Abstinence: Total abstinence is essential. Not even a single puff after the quit date.
Alcohol: Drinking alcohol is highly associated with relapse. Those who stop smoking should review their alcohol use and consider limiting or abstaining from alcohol use during the quit process.
Other smokers in the household: The presence of other smokers in the household, particularly a spouse, is associated with lower success rates. Patients should consider quitting with their significant others and/or developing specific plans to maintain abstinence in a household where others still smoke .

D. Provide supplementary materials                                                                                                         

Source: Federal agencies, including the National Cancer Institute and the Agency for Health Care Policy and Research; nonprofit agencies (American Cancer Society, American Lung Association, American Heart Association); or local or state health departments.
Selection concerns: The material must be culturally, racially, educationally, and age appropriate for
the patient.
Location: Readily available in every clinic office.

                      Step 5. Arrange—Schedule Follow-Up Contact                                                                 
Schedule follow-up contact, either in person or via telephone                                                                 

Timing: Follow-up contact should occur soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Schedule further follow-up contacts as indicated.
Actions during follow-up: Congratulate success. If smoking occurred, review the circumstances and elicit recommitment to total abstinence. Remind the patient that a lapse can be used as a learning experience and is not a sign of failure. Identify the problems already encountered and anticipate challenges in the immediate future. Assess nicotine replacement therapy use and problems. Consider referral to a more intense or specialized program.