Teaching Smoking Cessation: An Expert Interview With Vikas Batra, MD, and Frank T. Leone, MD

December 30, 2002

Introduction

Editor's note:

According to an article written by Stephen Lazarus, MD, based on the 12th Annual Congress of the European Respiratory Society,[1] people continue to smoke, and the impact of smoking-related diseases continues to increase despite incontrovertible evidence regarding the risks of smoking. It is well established that chronic obstructive pulmonary disease (COPD) accounts for 4% of all deaths worldwide, and the number of deaths attributed to COPD has increased 185% over the last 2 decades.[2] In 1990, COPD was ranked 12th in terms of overall burden of disease. The World Health Organization (WHO) projects that by the year 2020, it will be fifth.[3] According to WHO estimates, 1.1 billion people worldwide smoke. This is expected to increase to 1.6 billion by the year 2025, with the greatest increase in low- and middle-income countries, and in teenagers and young adults.

A study published in 1999 by Ferry and colleagues[4] found that a majority of US medical school graduates felt that they were not adequately trained to treat nicotine dependence. They found that the major deficit was the lack of smoking cessation instruction and evaluation in the clinical years. The researchers also recommended that a model core tobacco curricula that meets national recommendations should be developed and implemented in all US medical schools.

More recently, an abstract was presented at Chest 2002: 68th Scientific Assembly of the American College of Chest Physicians, in San Diego, California,[5] by a group from the Center for Tobacco Research and Treatment at Thomas Jefferson University in Philadelphia, Pennsylvania. The group wanted to assess the attitudes and beliefs of physicians-in-training regarding nicotine addiction and treatment. The following is a discussion with Vikas Batra, MD, who presented the group's findings at Chest 2002 and Frank Leone, MD, the Director of the Center for Tobacco Research and Treatment at Thomas Jefferson University.

Medscape: Dr. Batra, could you provide a short synopsis of some of the main points of your presentation at Chest 2002?

Dr. Batra: We interviewed physicians-in-training who were internal medicine residents across postgraduate year 1 to postgraduate year 3 to assess their attitudes and beliefs about smoking cessation and nicotine addiction and tested their knowledge content about that -- how to treat these patients and how they would like to improve the teaching of smoking cessation techniques. The key results were that residents were right that smoking is a big problem and the role for physicians is to help patients to quit. They felt kind of helpless. They were not confident that they could help their patients to quit smoking. There were some obvious deficiencies in their knowledge content regarding some of the basic concepts about treating their smokers. They thought that the teaching was not adequate and they thought that teaching should be increased in the form of more didactic teaching, 1-day workshops to improve their skills while interacting with the patients. Those were the main findings.

Medscape: Dr. Leone, could you talk a bit about what you see as physicians' experiences in trying to get their patients to quit smoking?

Dr. Leone: Physicians want to get their patients to quit. There is no question in my mind that physicians are well meaning and they want to be able to do this. We have failed physicians in terms of medical education in the past by simply focusing on the whole "adult choice" aspect of smoking. Physicians are people first, and people in general in this culture have been taught that smoking is an adult choice, that it is a person's right to smoke if they choose to do so, that everyone should know that smoking is no good for you, and that if you decide to smoke anyway, that is up to you. Those kinds of biases really affect the way physicians approach this with their smoking patients. So, after the first interaction fails -- Are you a smoker? Would you like to quit? -- physicians don't really have a well-developed skill set to deal with that sort of situation. The other problem is that we view success solely on whether we get a smoker to quit. That's the most difficult outcome to come by. If we start to refocus how we think about success and we give physicians a few skills to deal with the more subtle aspects of cessation, people will feel a lot less helpless.

Medscape: Could you provide a few statistics about the success rate for people who decide to quit smoking?

Dr. Leone: The spontaneous quit rate for smokers, people who just decide to quit and put their cigarettes down, is about 3%. That's 3 people out of 100 who quit on impulse and stay that way. If a smoker talks to a physician about some reasonable methods for quitting, perhaps talks to a counselor over the phone or something like that, you can boost that rate up to 10%. Ten percent doesn't sound like much, but that is a 3-fold increase in success just by talking to someone for a few minutes. If you move to the next level and you do an organized approach with either medicines or counseling, you can expect to get about a 20% to 25% success rate. The more sophisticated you get, the more integrated your approach with combination medications, applying some directed behavior modifications. You can get upwards of 55% to 60% success rate. Success in this situation is defined as 1 year of abstinence.

Medscape: Do you have any statistics as to how many people are smoking today vs 20 years ago?

Dr. Leone: At its peak in the United States, the prevalence of smoking among males was about 55%. In females, it hit about 40% to 45% a few years later. And that was in the 1950s. Since then, the prevalence has been declining, but it plateaued over the past decade or so. Currently, the prevalence of smoking across the United States is about 24% -- that is, 24% of adults over 18 years old smoke.

Medscape: Is there a bias as far as gender at this point?

Dr. Leone: It depends. Overall, across the United States, men still smoke slightly more frequently than women, but if you start breaking it down by region or by ethnic group, those proportions change. For example, African American females in Philadelphia smoke at an exceedingly high rate at 36%, whereas white males in Philadelphia smoke at a much lower rate -- somewhere around 20% or so. There is a lot of geographic variability, and the farther you cut the data, the more disparity there is. One thing that is happening is that the rate at which white female adolescents are experimenting with smoking is probably higher now than at any point in history.

Medscape: To what do you think that rise can be attributed?

Dr. Leone: If I knew the answer to that, I'd get a Nobel Prize. I am sure that it is multifactorial; it is a complex answer. I am sure that there are cultural influences that promote experimentation. I am sure in female adolescents that concerns about weight control and stress are important motivators for experimentation. But always keep in mind that regardless of why people are experimenting, how experimentation translates into uptake and maintenance of the smoking behavior really depends an awful lot on biology and at what point in their developmental process people start experimenting. It is a very complicated equation.

Medscape: Am I correct in saying that the rate of smoking is still coming down?

Dr. Leone: It has been coming down over the past several decades. We hit a plateau at around 24% or so of the population in general. In California, the rate of smoking has been going down quite dramatically over the past decade, and that's probably a result of all of these tobacco control efforts and a lot of social awareness of tobacco and a shift in cultural expectation regarding tobacco.

Medscape: Despite this decline in smoking, we are seeing a dramatic increase in the amount of COPD that is being diagnosed. Is that because of the previous highs in cigarette smoking?

Dr. Leone: Right. COPD is the kind of illness that happens after an individual has been smoking for 20 or 30 years. The other thing is that we are diagnosing it better. There is also a shifting of what COPD is in the medical community. You put those 2 things together, and even if everyone stopped smoking today, you would still see COPD being diagnosed 20 or 30 years into the future. The same thing is true with lung cancer, for example.

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