Techniques for smoking cessation: what really works?

Cigarettes (and tobacco) represent the most significant lifestyle risk for cancer, accounting for more than 400,000 deaths in the United States each year. The cancer risk in smokers is proportional to the number of cigarettes smoked in the patient's lifetime; therefore, smoking cessation is always in the best interest of a smoker's health. Physicians can play a crucial role in the success of their patients' smoking cessation programs. Experimental studies, observational studies, and the experience of seasoned physicians have identified a number of effective strategies that any physician can use. This article presents several brief counseling approaches and a summary of pharmacologic treatments that can be incorporated into office and hospital practice.

Assessing nicotine dependence.

Family physicians can assess the smoking behavior of their patients in a few minutes, using carefully chosen questions. The CAGE questionnaire for smoking (modified from the familiar CAGE questionnaire for alcoholism), the "four Cs" test and the Fagerström Test for Nicotine Dependence help make the diagnosis of nicotine dependence based on standard criteria. Additional questions can be used to determine the patient's readiness to change and the nature of the reinforcement the patient receives from smoking. These tools can assist family physicians in guiding patients to quit smoking-the single most important thing smokers can do to improve their health.

Incorporating nicotine dependence into addiction treatment.

An addiction treatment program devoted two years to preparing to become a smokefree treatment unit that addressed nicotine dependence as another drug dependency. Data collected from September 1990 to July 1995 on 263 admissions before becoming smokefree and 2182 admissions after making the transition revealed that going smokefree did not affect the incidence of premature discharges or aggressive behavior, and did not change the overall rate of program completion by either smokers or nonsmokers. During the first three months after going smokefree, the program completion rate dropped for both smokers and nonsmokers; by the fourth month, it had returned to previous levels. Seventeen months after going smokefree, the program completion rate was higher than it had ever been. This suggests that the drop in the program completion rate was due to the disruption caused by a significant programmatic change and not due to the unit's smokefree status, and that the increasing experience of staff in treating nicotine dependence resulted in improved patient outcomes.

Measuring the stages of change in cigarette smokers.

This article describes preliminary reliability testing of an instrument for measuring a smoker's progress toward abstinence or relapse. We have developed a set of visual-analog scales intended to measure subtle changes in the smoking cessation process. These are based on the Stages of Change described by DiClemente and Prochaska and the presentation format suggested by Biener and Abrams. In this study, we presented the scales in two different formats (projected on a screen using an overhead projector or printed on sheets of paper) to 23 subjects, all inpatients in a chemical dependency treatment program. The subjects' response on the two modalities were highly correlated, indicating reliability of the scale between modalities and within the time frame studied. We offer this instrument as an inexpensive and efficient means of evaluating smoking cessation strategies and the progress of individuals in smoking cessation programs.

Screening for patients with alcohol problems: severity of patients identified by the CAGE.

Primary care physicians are well situated to identify patients with substance abuse problems and motivate them to seek appropriate assistance, but active programs are the exception. A study in a community setting was undertaken to assess the CAGE (the first letters of key words in a series of four questions about drinking: cut down; annoyed; guilty; and eye-opener), instrument in the routine screening for alcohol problems in both new and established patients. The screening process identified subjects for a pilot evaluation of a motivational interview designed to encourage problem-solving behavior. This article focuses on the screening results and the use of the CAGE instrument. During June and July of 1990, 687 patients of two primary care physicians belonging to a large group practice were asked to complete a health questionnaire that included the CAGE. Those who responded affirmatively to at least two of the four CAGE questions were requested to participate in follow-up assessment of problems associated with alcohol and health. The type and severity of alcohol problems experienced by patients who scored positive on the CAGE are described. Prevalence of a positive score on the CAGE was 8.6 percent with males, smokers, and blue collar and unemployed persons being more likely to score positive. The positive predictive value was .68. Primarily, persons with moderate alcohol problems were identified. Results show that the CAGE instrument is a useful screening device for identifying those with mild to moderate substance abuse problems, increasing the opportunity for intervention prior to serious medical complications. The instrument is easily administered, and has demonstrated relatively high levels of sensitivity and specificity. When combined with assessment and motivational interviews, the CAGE shows promise in the secondary prevention of substance abuse and related health problems.