Assessment of Tobacco Use
The U.S. Tobacco and Dependence Treatment clinical practice guideline suggests that health care professionals take every opportunity to identify and document tobacco use in all practice settings.3 Because numerous patients are identified for CR/SP programs at the time of hospitalization, this setting serves as an important entryway for smoking cessation intervention. Moreover, at the time of hospitalization, patients are focused on their health; they experience the worst of withdrawal in the first 48 to 72 h of quitting and are forced to follow hospital smoking bans. Thus, a mechanism for identifying all smokers at the time of hospitalization, such as including smoking status as a vital sign and applying the mandated smoking status code on electronic records to identify smokers, is critically important for patient outcomes (guideline 8.1).
In outpatient CR/SP programs, smokers can be identified through intake forms that collect information about risk factors, or through interviews that are often part of taking a medical history. This information should be electronically stored, with efforts directed at cessation. With the enforcement of hospital smoking bans, many smokers view themselves as having stopped smoking once they have entered the hospital. Therefore, it is critical that interviewers ask the appropriate question to identify smokers. The question “Have you smoked or used oral tobacco products in the past 30 days?” is more specific than “Do you smoke or use oral tobacco products?”
Once screening is completed, the next step in intervening is to determine willingness to quit smoking. Staff members may simply ask, “Are you willing to quit smoking now?” or “Are you willing to make an attempt to quit smoking now?” The clinical practice guideline indicates that those patients who are willing to quit tobacco should be provided appropriate treatments.3 In addition, those who are unwilling to make an attempt to quit smoking should be offered a brief intervention designed to enhance their motivation. Ways to enhance motivation include
- encouraging patients to indicate why quitting smoking is personally relevant to them, being as specific as possible;
- helping patients to identify the acute, long-term, and environmental risks associated with continued smoking;
- helping patients determine potential benefits of quitting by selecting personal rewards;
- identifying barriers or roadblocks to quitting; and
- repeating the intervention (motivational interview) every time an unmotivated patient visits a clinic setting (see “Motivational Interview”).
A key to remembering the structure of such an intervention is to focus on the 5 Rs:
For patients who are ready to make an attempt to quit smoking, additional information about their smoking status is helpful and allows individualized counseling. However, the clinical practice guideline also notes that smoking cessation interventions should not depend solely on formal assessments such as questionnaires, the clinical interview, or physiological measures such as carbon monoxide or pulmonary function measures to guide them.3 These assessments do not consistently produce higher long-term quit rates than nontailored interventions of equal intensity. Thus, time allotted to undertake these assessments must be weighed against the time available for counseling and intervention.
A smoking history (see appendix K) may provide additional information that is useful for individualizing counseling about smoking. Documenting whether other household members smoke may help determine the patient level of support and whether family members may also benefit from counseling. Determining past experience with serious attempts to quit and length of cessation, success with previous smoking interventions, and previous use of pharmacologic therapies can be helpful in planning an appropriate intervention. People with a history of depression have more difficulty quitting than those without such a history. Therefore, using standardized tools to measure depression as part of an evaluation of the psychosocial status, or incorporating single-item measures such as the scale depicted in the “Example of a Single-Item Measure of Psychological Status” sidebar, which has been shown to correlate with other clinical measures of depression, can be useful in counseling.6 Moreover, patients who are depressed are appropriate candidates for the use of buproprion SR to help them quit smoking.
Alcohol use is another important question to address when individualizing counseling for people attempting to quit smoking. Smokers who consume large amounts of alcohol or abuse alcohol find it difficult to quit. Success with quitting is extremely low, and little research has been conducted showing the efficacy of smoking interventions in this population. Confronting patients about inappropriate alcohol use may be necessary when intervening with them. Determining the frequency of use and weekly consumption, as well as screening for alcohol abuse, provides important insights useful for counseling. The CAGE Questionnaire (see appendix L) is the most common screening tool for potential alcohol abuse.7 A “yes” response to any of the questions may indicate potential alcohol abuse, and two or more positive responses increases the probability of past or present abuse. Questions in the smoking history (appendix K) related to alcohol consumption are also useful in this regard. The frequent underreporting of alcohol use, and the cardiotoxic effects of high consumption in patients with CVD, require health care professionals to assess and openly discuss this issue.8,9 Referral to an alcoholism treatment program may be warranted.