How Fellows Can Establish a Smoking Cessation Clinic

In this country, an estimated 46 million people—20.6% of all adults—smoke cigarettes. Cigarette smoking also happens to be the leading cause of preventable death in the United States, accounting for approximately 443,000 deaths, or 1 of every 5 deaths each year. Approximately 40% of these deaths are from cancer, of which lung cancer is the most prevalent.

In addition to the disastrous impact that tobacco use has on our collective health as a nation, it wreaks havoc on our economy. Cigarette smoking is estimated to be responsible for $193 billion in annual health-related economic losses in the United States—that’s $96 billion in direct medical costs and approximately $97 billion in lost productivity. Cigarette smoking results in 5.1 million years of potential life lost in the United States annually.

It is estimated that 70% of smokers want to quit completely and that 45% of smokers have tried to quit. Yet we realize from our interactions with patients that this is often a losing battle. Patients, even those with lung cancer, at some point in time will return to smoking. Compared with the billions of dollars that cigarette companies pour into marketing their products, the healthcare system is ill-equipped to respond. Smokers who want to quit often have limited resources available to them. As fellows and residents, we often know how important it is to counsel, yet have limited time with each patient to do so.

There are many smoking cessation interventions available, group sessions being one of them. As effective as they are, they are often an option only for those who can pay for them. As fellows and residents, we not only have a responsibility to help fight this major public health hazard, but we are also in an excellent position to do so. Most training programs are affiliated with community health centers. Approximately 20 million Americans are served by such centers, with 40% of these affiliated with residency programs. The majority of patients that visit such centers are poor—the very people who smoke the most and who therefore need the most help. In the following sections, we provide an overview of how fellows/ residents can set up and successfully run a smoking cessation clinic.

Starting Out

Planning is of paramount importance. You will need to speak with the health center director and ensure that resources are available to run such a clinic, which is held in a group meeting format in 2-hour-long sessions once a week for 4 weeks. The following are needed:

• A large conference room that can hold 10 to 15 people and that is available for a 2-hour slot on a specified day every week for 4 consecutive weeks
• 2 patient exam rooms
• A nurse and a medical assistant (MA) who are available each week for that 2-hour time period
• An attending physician who can be available for 30 minutes per session
• A whiteboard and pens and paper for the patients

Patient Enrollment

Once you have selected a day and a 2-hour time slot, begin by advertising the clinic. Print out flyers, hang them up in the clinic, and give them out to patients. Have a system in place where the MAs ask each patient coming through the clinic about his or her smoking status. If the patients smoke, at checkout have the staff off er to enroll them in your free smoking cessation clinic. Many will take you up on the off er. Once you have 10 to 15 patients enrolled, you are ready to start your very own smoking cessation clinic!

Next, we will describe how you should conduct each of the 4 sessions. Note that the group sessions will last for approximately 1 hour, with the remaining 1 hour used for individual patient counseling in exam rooms. This counseling allows the clinic to bill for the sessions.

Session 1: Committing to Quit

Start off by congratulating the patients for joining. Introduce them to the notion of smoking cessation through behavior modification and group therapy along with pharmacotherapy, if necessary. Stress the importance of follow-up through subsequent sessions. Hand out printed smoking cessation material, if available.

Next, talk about the harmful effects of smoking. Involve the group and ask them how much they know about the dangers associated with smoking. Discuss the heightened risk of cancer and chronic obstructive pulmonary disease (COPD). A useful exercise is to give out straws and ask the patients to pinch their noses and only breathe through the straws in their mouths; explain that if they do not stop smoking, this is how it will feel when they have emphysema.

Discuss in detail the benefits of quitting smoking. Specifically mention the health benefits, such as having more energy and a reduced risk of cancer and heart and lung diseases. Emphasize the psychological benefits, such as increased self-esteem and self-respect and a sense of accomplishment in quitting. Next, talk about the financial benefits, such as reduced insurance premiums, decreased future healthcare costs, and an almost $2000 savings per year from not buying cigarettes.

Wrap up by preparing patients for session 2. Prior to the next session, ask patients to think about what triggers their smoking. They should consider the reasons why they smoke as well as their desire to quit. Have them reflect on their past attempts to quit and why they failed and to start thinking about a quit date. Answer any questions that they may have. At the end of this and each subsequent session will be individualized patient sessions. (These are described at the end of the article.)

Session 2: Exploring the Smoking Habit

This session will help patients understand the psychological aspects of smoking. It is designed to explore in detail the patients’ reasons for smoking and why they want to quit, and to reflect on past experiences with quit attempts.

Start off by asking patients to discuss the reasons they smoke. Write them down on the whiteboard. Ask them if they think smoking is a psychological need or truly a physical addiction to nicotine. Ask them when they have their first cigarette in the morning. Then ask each patient why he or she likes or dislikes smoking. This exercise will start a discussion among the participants and help them realize the reasons they smoke so that they can plan to gradually eliminate those reasons.

Discuss the circumstances in which they smoke each cigarette. Are they happy, sad, angry, frustrated, nervous, or something else? Make a list on the whiteboard of all the triggers for the different patients. They will soon realize that everyone has fairly similar triggers.

Next, talk about the true desire of the patient to quit. Discuss why it is so important to do so. Make sure they understand that they may have to undergo many months—if not years—of self-reflection and attempts at quitting before finally being successful.

Now, discuss in more detail the patients’ past quit attempts. Discuss the methods used. Ask them how long their quit periods lasted and whether the attempts were successful. Talk about the reasons why the patients feel that specific past interventions did not work.

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A useful exercise is to give out straws and ask the patients to pinch their noses and only breathe through the straws in their mouths; explain that if they do not stop smoking, this is how it will feel when they have emphysema. ”

Toward the end of this session, you will discuss some strategies to cope with urges to smoke. Ask them to remember the “4 Ds” when they feel the need to smoke: delay, deep breath, drink water, and do something else. Ask each patient to come up with 3 situations that made him or her really want to smoke again. Write those on the whiteboard. Then ask them what they could do instead.

Session 3: Arming Patients With the Tools to Quit

Hopefully, by now the patients will have a clear idea of what makes them smoke and what strategies they can use to quit. This session is about dealing with recovery symptoms (ie, nicotine withdrawal) and the correct use and side effects of different smoking cessation products. At the end of this session the product of choice should be prescribed, if appropriate for the patient.

It is important to teach patients how to deal with withdrawal. Explain that after quitting smoking, the body experiences both physical and psychological “recovery symptoms.” These symptoms decrease after the first few days and usually pass within 2 to 4 weeks. Specific interventions that can help are taking fluids for a dry mouth, sipping warm water for a cough, and having low-calorie snacks to combat hunger pangs. Other symptoms that are expected are insomnia, fatigue, headache, irritability, and constipation.

Next, you will review products that can be used for smoking cessation. These include nicotine replacement (eg, patch, gum, lozenge, inhaler), bupropion, and varenicline (Chantix). Based on patient preference, any product or combination can be chosen. If nicotine replacement is chosen, it is best to prescribe the patch plus a short-acting nicotine product (eg, gum, lozenge) to deal with the cravings.

You will need to describe in detail how to correctly use each product, their advantages and disadvantages, and their side effects. This sort of material is easily found on Web sites such as Uptodate.com.

Session 4: Preventing Relapse

At this point, you hope that the patients have quit smoking and are perhaps also on a smoking cessation aid. This is the last session of the series and will mainly focus on relapse prevention and answering any questions that the patients might have about the program and the previous sessions.

First off , discuss relapse-prevention techniques. Relapse prevention requires that patients develop a program that suits them and that they will follow if they begin to slip back to smoking. Talk about avoiding situations that serve as triggers to smoke. Exercising and taking up new hobbies often help. At the end, provide a short recap of all the sessions. If patients are using any of the smoking cessation aids, ensure that they are using them correctly. Answer any questions. Also be sure that you book follow-up visits with the patient’s primary care provider specifically for smoking cessation consultation.

Individual Patient Sessions

These sessions are required for billing purposes. The patients would already have had their vital signs taken by an MA when they registered for the course. The staff will bring them to the exam rooms and each meeting with the fellow or resident should not take more than 3 minutes. Briefly go over the specific reasons that the patient should quit. If the patient has a disease, such as coronary heart disease, the physician should tailor the smoking cessation plan accordingly. Briefly document your discussion and then precept with an attending physician. If needed, other patient complaints or concerns should be addressed on a separate visit. This meeting is only for smoking cessation.

This program serves as a basic outline and can be tailored to your own specific needs and patient population. If you would like more details about running a smoking cessation clinic, please contact Dr Khan at cyruskhan@gmail.com.

This edition of Oncology Fellows is supported by Genentech, a member of the Roche Group.

Cyrus Khan, MD, is a second-year hematology/oncology fellow at the Western Pennsylvania and Allegheny General Hospital in Pittsburgh. Realizing that the lack of smoking cessation services was a major drawback to the efforts of patients who wanted to quit smoking, he helped start his community health center’s very first smoking cessation program. Alice Ulhoa-Cintra, MD, is a second-year hematology/oncology fellow at the Western Pennsylvania and Allegheny General Hospital in Pittsburgh. Her primary interests encompass all aspects of solid tumor oncology, including cancer-preventive strategies with the potential for a significant public health impact, such as smoking cessation initiatives.