Tobacco cessation in primary care: beyond just quitting.

The article, “Tobacco Cessation in Primary Care: Maximizing Intervention Strategies”1 does a fine job of summarizing the recommended, yet often not implemented, practices for provider-based smoking cessation. There is no doubt that smoking cessation will begin to improve the health of the individual smoker by decreasing the risk of tobacco-related disease within a short period of time.2,3 The importance of reduced exposure to secondhand smoke and the benefits of reduced tobacco consumption should also be discussed with the patient. One way for healthcare providers to reduce tobacco-related disease is to educate patients about the dangers of secondhand smoke. By providing the smoker with information on secondhand smoke, there is a heightened awareness that his/her decision to smoke also have a negative effect on those in the surrounding area. Secondhand smoke results in increased morbidity and mortality among nonsmokers. The California Environmental Protection Agency and the Surgeon General, among others, concluded that secondhand smoke causes eye and nasal irritation, lung cancer, nasal sinus cancer, heart disease mortality and acute chronic coronary heart disease morbidity; children, in particular, may experience low birth weight, sudden infant death syndrome, acute lower respiratory tract infections, asthma induction and exacerbation, chronic respiratory symptoms and middle ear infections.4,5 In addition to adhering to the cessation recommendations set forth by the Public Health Service6 and asking about the individual patient's smoking status, providers should also ask about the environment in which the patient resides. In conducting the “Five A's,” providers should inquire about the patient's smoking status and exposure to tobacco smoke on a regular basis. If the patient is a nonsmoker living with regular tobacco smoke exposure, the provider should advise the patient to ask the smoker to smoke outdoors. Pediatricians should also be asking parents if they smoke and if so, advise them to quit or smoke away from the children. This offers a positive model for children and increases the likelihood that the children will refrain from smoking in the future.7 One effective step toward cessation is for smokers to move outside to smoke.7 In addition to being a burden to step outside, it changes the act of smoking from a reflex to a conscious decision and reinforces the notion that smoking is not socially acceptable. All of these factors can help a smoker decide to stop smoking and reduce consumption as the smoker may forego smoking some cigarettes. A second way for providers to help smoking patients is to encourage them to reduce their cigarette consumption. Reduced tobacco consumption is a predictor of a successful quit attempt7 and decreases the risk of tobacco-related disease because tobacco-related disease is dose dependent.4,5 A decline in cigarette consumption in California alone between 1989 and 1997 was associated with 59,000 fewer coronary heart deaths.8 This finding is based on a decline in tobacco consumption among smokers and not merely a reduction in the total number of smokers in California. If a patient is a smoker but is not prepared to quit, the provider should advise him/her to reduce the number of cigarettes smoked and explain that this will aid in future quit attempts,7 as the transition from light smoker to nonsmoker is easier than from smoker to nonsmoker. Healthcare providers should keep in mind that complete cessation is not the only way in which to improve the health of smokers. A reduction in tobacco consumption can also provide benefits to the new light smoker and to those around him/her. Effective smoking cessation treatment by a provider should address the negative health effects of smoking and of secondhand smoke and offer ways in which to decrease or eliminate those effects. At a minimum, educating patients on the dangers of secondhand smoke will get them thinking about the need to quit, how their smoking affects the health of the people around them, and may help to reduce tobacco consumption, if not make a quit attempt.