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Smoking and Tobacco Addiction

OVERVIEW

Smoking is the single greatest preventable cause of death and disease in the nation today. More than 400,000 persons die each year from tobacco-related deaths. Most of these deaths are from cardiovascular disease and lung cancer, but other causes of death include emphysema, household fires, and other cancers. There is good evidence that nonsmokers die from the adverse effects of environmental tobacco smoke (ETS). The Environmental Protection Agency (EPA) released a report in 1993 stating that ETS is a class A carcinogen and causes many other forms of non-cancer disease. More people die each year from tobacco-related disease than from AIDS, alcoholism, and drug abuse combined.

There are currently increasing social pressures for people to quit smoking. Local, state, and federal legislation is being passed to ban smoking in public places. However, with more than 1,000 people dying each day and more than 2,000 people quitting each day, the tobacco industry is out to addict more than 3,000 new young smokers daily. Therefore, the tobacco industry spends $4 billion/year advertising its deadly products to the public. Advertising is targeted at youth because the tobacco industry knows that the median age of smoking initiation is age 12, and more than 90% of smokers start smoking before age 21. Tobacco advertising tells children that it is cool, sexy, glamorous, athletic, and macho to smoke.

Although quit rates are increasing, the relapse rates remain high. Many pharmacological methods exist to help patients quit smoking. Long- term relapse rates still remain high. Prevention of smoking initiation is therefore an essential component to the physician's role. Health professionals can fight the tobacco pandemic by helping patients to stop smoking and then to avoid relapse; to be proactive in supporting local, state, and federal legislation that protects the public from passive smoking, and to help prevent young people from becoming addicted to tobacco.

TOPIC LEARNING GOALS AND OBJECTIVES

(Organized by ACGME Competencies)

Patient Care

GOAL: Students will value the importance of asking patients about smoking status and be able to perform smoking cessation counseling for patients who smoke.

OBJECTIVES: Students will be able to:

  • Apply the 5 A's approach to smoking cessation counseling: asking, advising, assessing, assisting, and arranging follow-up for patients.
  • List valuable components involved in smoking cessation counseling, including using the teachable moment, setting a quit date, and using exercise and diet changes to prevent weight gain.
  • Describe the principles of behavior change including:
    • Individualize the counseling to the patient.
    • Build on the patient's inherent motivation.
    • Identify barriers to behavior change and make plans to overcome them.

Medical Knowledge

GOAL: Students will understand the addictive nature of nicotine and the use of nicotine replacement and pharmacological assistance to help patients quit smoking.

OBJECTIVES: Students will be able to:

  • Describe how tobacco addiction, like all addictions, is characterized by 3 Cs: (1) Compulsion to use, (2) Lack of Control, (3) Continued use despite adverse consequences.
  • Discuss how to use bupropion and nicotine replacement products to treat the nicotine withdrawal symptoms and prevent relapse.

GOAL: Students will understand the major negative health effects of tobacco, including smokeless tobacco.

OBJECTIVES: Students will be able to:

  • Describe the health effects of smoking and passive smoking on individuals and populations, including heart disease and lung cancer.
  • Describe the health effects of smokeless tobacco, including oropharyngeal cancer.

Practice-Based Learning and Improvement

GOAL: Students will understand the barriers to dealing with patients who are addicted to unhealthy substances and those who continue to use these substances despite adverse consequences.

OBJECTIVES: Students will be able to:

  • Discuss why it can be so hard for physicians to deal with patients who are addicted to tobacco.
  • Describe how physicians can help patients quit smoking despite the strength of tobacco addiction.
  • Understand how other office staff can help identify smokers and flag the chart by making smoking status one of the vital signs that are assessed before the patient is seen by the physician.
  • Appreciate how smoking should be a problem to add to the problem list as one would add alcoholism or cocaine addiction.
  • Predict that patients who have quit smoking are at risk for relapse and plan to ask patients about their smoking status even after they have quit.

Interpersonal and Communication Skills

GOAL: Students will communicate effectively with patients concerning the importance of smoking cessation and the tremendous beneficial health effects of quitting.

OBJECTIVES: Students will be able to:

  • Ask patients if they smoke or use smokeless tobacco.
  • Speak in a nonjudgmental manner with patients who smoke and offer them help to quit smoking.
  • Assess patients' readiness to quit smoking.
  • Not lecture patients who are not ready to quit but encourage them to ask for help from their physician when they are ready.
  • Describe available pharmacological and nonpharmacological methods for smoking cessation.
  • Use optimism with patients based upon the information that most patients can quit smoking if they are motivated to try - reframe previous quit attempts as preparation for ultimate success.
  • Discuss how relapse prevention is critical to success because most smokers will relapse within one year of a quit attempt.
  • Discuss the use of family and peer support to help patients succeed in smoking cessation efforts.

Professionalism

GOAL: Students will establish and adhere to high personal standards in the care of patients with addictions.

OBJECTIVES: Students will be able to:

  • Communicate honestly and openly with patients about their addiction in a nonjudgmental manner.
  • Show empathy to patients who are struggling to quit smoking and have found it difficult to succeed.

Systems-Based Practice

GOAL: Students will appraise and utilize the best evidence in caring for patients with tobacco use and addiction.

OBJECTIVE: Students will:

  • Find and use high-quality Web sites that provide evidence about various methods of smoking cessation and strategies to help patients quit.

GOAL: Students will understand that smoking is the single greatest preventable cause of death and disease in our nation today.

OBJECTIVE: Students will:

  • Discuss the importance of public policy issues such as smoke-free ordinances in protecting the health of the public.

GOAL: Students will understand why young people begin to smoke and what can be done to prevent smoking initiation.

OBJECTIVE: Students will:

  • Describe the influential factors that lead to smoking including: advertising, image, peer influence, easy access to tobacco, and parental smoking.
  • Discuss smoking education efforts aimed at school children such as TAR wars.

EDUCATIONAL METHODS AND RESOURCES

Teaching Strategies

  • Demonstration of smoking cessation counseling in front of a student group using a real smoker or a standardized patient (often an ex-smoker works well)

Integration Strategies

Clinical Experience

  • Diagnose and treat patients with tobacco use and addiction in clinical settings.

Small-Group Learning

  • Doctoring Case on Smoking Cessation Counseling (one- or two-part case using real smokers or standardized patients) can be used in any year of the curriculum
  • Contact Richard Usatine, MD for case materials

Problem-Based Learning

  • Doctoring Case on Smoking Cessation Counseling (one- or two-part case using real smokers or standardized patients) can be used in any year of the curriculum
  • Contact Richard Usatine, MD for case materials. It is case-based, small-group learning, but can be used in a PBL format.

Learning Units

Published Material

  • Rigotti NA. Clinical practice. Treatment of tobacco use and dependence. N Engl J Med. 2002 Feb 14; 346(7):506-12.
    Reference at PubMed
  • Brown RL, Pfeifer JM, Gjerde CL, Seibert CS, Haq CL. Teaching patient-centered tobacco intervention to first-year medical students. J Gen Intern Med. 2004 May; 19(5 Pt 2):534-9.
    Reference at PubMed

Web Sites

Videotapes of Smoking Cessation Counseling

ASSESSMENT STRATEGIES

  • OSCE case - counseling for smoking cessation in patient presenting with acute exacerbation of bronchitis - Alexander Chessman, MD
  • OSCE case - smoking cessation in a patient who is a Russian immigrant - David Gaspar, MD

 

Lead Author: Richard Usatine, MD
Clerkship/Post-Clerkship Workgroup members: Ann O'Brien-Gonzales, PhD (Chair), Alexander Chessman, MD (EC Liaison), Caryl Heaton, DO, Janice Nevin, MD, MPH, Lauren Oshman, MD, Deborah McPherson, MD, Mark. E Quirk, EdD, David Schneider, MD, MSPH, William B. Shore, MD, Richard Usatine, MD

Family Medicine Curriculum Resource (FMCR) Project HRSA Contract 240-00-0107.

Revised November 6, 2003
 

For questions or comments, please contact Webmaster or Ardis Davis

This page last updated October 17, 2005