G. Initiate Intervention

OBJECTIVE

To provide an office-based approach for the tobacco user who is not referred to an intensive intervention program.

ANNOTATION

Every tobacco user should be offered at least brief or minimal support by the primary care manager (PCM)/ primary care provider (PCP). The success correlates directly with the length of time spent (3 to 10 minutes minimum) with the smoker over multiple visits for a variety of related and non-tobacco related conditions.

The essential elements of the brief visits will include eliciting the patient's interest in quitting, severity of tobacco dependence and withdrawal symptoms, length of previous quit attempts and reasons for relapse, appropriateness of behavioral and pharmacotherapy, the reasons why they use tobacco (stress control, habit, pleasure, etc.), and patients concerns bout consequences about quitting such as weight gain.

The PCM/PCP can provide self-help reading material (see Appendix 4), prescribe the medications than are appropriate (see Appendix 2), establish a quit date, encourage use of behavioral techniques to disrupt the habits and rituals of tobacco use and schedule follow-up visits within 1 to 2 weeks of the quit date.

DISCUSSION

Every tobacco user should be offered at least a minimal or brief intervention, whether or not the individual is referred to an intensive intervention. A variety of visit formats have been shown to improve quit rates, including "minimal self-help" (odds ratio [OR] for successful cessation = 1.2), individual counseling by a clinician (OR = 2.2), and group counseling (OR = 2.2). Tobacco cessation success correlates directly with increasing length of visit from 3 to 10 minutes.⁵ The clinician should capitalize on this fact by addressing as many of the following areas as time and resources permit. Continue to cover appropriate topics at subsequent visits. If time is exceedingly limited, the clinician can skip directly to items #10-12.

1. Every individual entering a health care setting should receive an assessment to determine his or her tobacco use status and interest in quitting. The assessment represents the first step in treatment. The following should include:
   
   
1. Tobacco use history.
2. Information about previous efforts to quit tobacco use:

   i. Number of days, weeks, months, or years of successful abstinence in the past.

   ii. Previous methods that helped or that proved of little value.

   iii. Medications that were helpful or that failed to help.

   iv. Problems contributing to relapse such as withdrawal symptoms, stressful events, or mood disorders.

   v. Problems that occur after cessation, such as weight gain.

3. Setting a quit date and emphasize the importance of total abstinence.
4. Review benefits that are personally relevant to that individual.
5. Addressing specific problems of concern including those listed in 1.b.v.
   
   
2. Tobacco users who express an interest in quitting require assessment for physical or medical conditions that will affect the choice of pharmacotherapy agent to control withdrawal symptoms.
   
   
3. Tobacco users who express an interest in quitting may benefit from assessment using a formal questionnaire, or physiological measures such as carbon monoxide, urine or serum nicotine or cotinine level or pulmonary function tests. For example, the Fagerstrom Nicotine Tolerance Questionnaire can measure nicotine dependence and predict withdrawal symptoms⁶ (see Appendix 1, Fagerstrom Nicotine Tolerance Questionnaire). A score of:
   
   
   1. 0 to 3 is associated with no or minimal nicotine withdrawal symptoms.
   2. 4 to 6 is associated with moderate symptoms.
   3. 7 to 10 is associated with strong or severe symptoms.

Pharmacologic support and counseling measures flow from this information.

4. Use of a self-administered test such as "Why Do I Smoke?" can inform the tobacco user which of the common reasons for tobacco dependence best fits their situation. The test lists healthy alternatives to meet the needs discovered in the quiz without reliance on tobacco products.
   
   
5. Tobacco users considering cessation need to know that withdrawal symptoms will worsen for 2 to 5 days, plateau, and then diminish over the next 14 days. The Psychiatric Diagnostic and Statistical Manual (DSM-IVR, classification number 292.0) provides a list of symptoms commonly encountered. Most individuals exhibit several (often five or more) symptoms within 1 or 2 days after stopping or significantly reducing tobacco use.
   
   
6. Treatment of tobacco dependence is less successful when one or more of the following elements are present. Documenting these issues helps the clinician and person prepare for the challenge. Unfortunately, little research evidence is available to guide treatment based on the results of these assessments:
   
   

   High nicotine dependence	The tobacco user reports severe withdrawal symptoms.
   Psychiatric comorbidity	Depression, schizophrenia, chemical dependency, and/or anxiety is present.
   Low motivation	The tobacco user says that quitting is not a high priority.
   Low readiness to change	The tobacco user says that although quitting is important, now is not the time.
   Low self-efficacy	The tobacco user says that quitting is not possible.
   Environmental risks	The tobacco user says other tobacco users in the home or workplace make abstinence difficult.
   High stress level	Life's events or major life change makes stopping difficult at this time.

    

7. Help tobacco users recognize and solve problems encountered in quitting. Use previous quitting experience to understand which issues to address. Provide personal instruction and self-help reading or viewing material as follows:
   
   
   1. Methods to cope with nicotine withdrawal symptoms.
      
      
   2. Relaxation training and stress management.
      
      
   3. Establishment of a support system. Examples include developing a relationship with an ex-tobacco user, locating a telephone counselor to call when the urge for tobacco is strong, or attending a Nicotine Anonymous meeting.
      
      
   4. Learning about personal "triggers" that contribute to tobacco craving. Examples include association with tobacco users in bars, recreation events, workplace or home. There is a strong association between the consumption of alcohol and relapse.
      
      
8. Use behavioral techniques to disrupt the routines of tobacco use before the quit date. The following have been found helpful:
   
   
   1. Try using a "2-minute time out." Every time the tobacco user feels a craving, he or she should wait two minutes until the desire stops before using tobacco products. This creates confidence and allows the user to control behavior. Craving episodes will become less overwhelming and less frequent.
      
      
   2. Create a setting to avoid "automatic tobacco use." Remove all tobacco products and ignition devices from immediate reach in home, car, and workplace. Place tobacco and lighter in different locations. Since the user must go to another location to retrieve tobacco for use, it becomes easier to observe the "2-minute time out."
      
      
   3. Alter patterns of living to avoid tobacco use. Examples include avoiding locations where tobacco use is comfortable and convenient. Always get up from the table immediately following a meal.
      
      
9. Tobacco addiction has three elements:
   
   
   1. Habit.
   2. Psychological dependence.
   3. Neuro-chemical addiction.
      
      

These three tobacco addiction habits are referred to as the addiction triangle. Knowing that habits must be disrupted before the quit date will help achieve successful cessation. Psychological dependence requires changing attitudes towards tobacco use before the quit date. Neuro-chemical dependence requires treatment by implementing nicotine substitution or modifying the brain's reward system. Help the tobacco user address the elements of the addiction triangle that will most improve their success.

10. Have the person set a firm quit date and master the behavior change tasks before the quit date.
    
    
11. Establish an appropriate pharmacotherapy regimen to use during the quit attempt. (See Annotation H)
    
    
12. Schedule follow-up visits shortly after the planned quit date:
    
    
    1. Most relapses occur in the first two weeks. An early visit allows verification of the quit plan's success and medication compliance. Modify the plan based on progress and current issues.
       
       
    2. A minimum of four visits and a maximum of seven over a 2 to 6-week period are recommended.

Success is measured by the outcome. Elements to measure success or failure of the intervention are:⁷

1. Attendance at sessions/appointments.
2. Abstinence success by self-report or other report or carbon monoxide testing.
3. Reduced tobacco or nicotine use (harm reduction model).

EVIDENCE

Success of tobacco use cessation is directly related to the intensiveness and follow-up intervention.

LE = B, SR = I Fiore et al. 1996

REFERENCES

⁵ Fiore et al. 1996 p 46; ⁶ Fagerstrom 1989; ⁷ Hatziandreu et al. 1990