Despite that fact that smoking rates have declined in the United States, with prevalence rates down by over 20% since 1960, smoking remains an enormous public health problem. Over 70% of all current smokers have reported a preference to stop smoking, however, only 3% to 20% of smokers succeed in achieving a sustained nicotine-free status. Importantly, clinicians can play a key role in helping their patients achieve this goal, producing marked improvements not only in their physical health but also in their quality of life. 

Obviously, striking physical and emotional reasons exist for promoting smoking cessation at any point in one’s life. Quitting smoking at any age results in a decrease in the risk of developing heart disease, stroke, and 14 types of cancer.¹  It is worth noting that stopping smoking before age 35 may reduce almost 90% of the health risks attributable to tobacco.¹

As seen in the table below, the immediate and long-term benefits of smoking cessation are profound – beginning just 20 minutes into behavior change and extending out 15 years post-quitting.

Given these benefits and an acknowledgement that tobacco dependence is a chronic condition requiring repeated interventions; the U.S. Public Health Service Clinical Practice Guideline² recommended that health care professionals attempt to reach every smoker to promote abstinence.  Unfortunately, many clinicians, including mental health providers, feel ill-equipped to address smoking-related concerns with patients e.g.,³ because of several factors including time constraints, lack of expertise, a desire to respect smokers' privacy, a fear of alienating patients, and a pessimistic attitude about whether smokers can quit.⁴

The U.S. Public Health Service Report, Clinical Practice Guideline for Treating Tobacco Use and Dependence, is considered a seminal publication in the field of smoking cessation and describes important features of comprehensive counseling for tobacco cessation drawn from a literature review of over 6000 studies and detailed consideration of more than 500 empirical examinations.² The report, intended for use by health care professionals in a variety of clinical practice settings, serves as an invaluable roadmap for structuring brief counseling interventions. Moreover, clinical compliance with the guideline was associated with higher patient satisfaction ratings in a large-scale survey of participants in nine health maintenance organizations.⁵ By having a solid understanding of the guideline, mental health providers are in a much better position to assist their smoking patients with successful cessation.

Featured Course

Cigarettes and Addiction: Helping Patients Quit Smoking

(5 CEs) Laura Wilhelm, PhD & Elizabeth Moore, PhD

Although specific treatment algorithms do not presently exist, the notion of stepped-care⁶, where less intensive, less timely, and less expensive interventions are tried before more intensive and costly strategies are incorporated is widely accepted. As such, screening for tobacco use and motivation to quit are the essential first steps in addressing tobacco use and dependence. 

A smoker who is more addicted to or dependent on nicotine may have greater difficulty quitting smoking and may benefit from more intensive counseling and pharmacological treatment than smokers who are not as dependent.² The Fagerström Test for Nicotine Dependence⁷ is a widely used, solidly validated, and easy-to-administer questionnaire for acquiring data about the patient's level of nicotine dependence. Higher levels of nicotine dependence are generally associated with stronger cravings for cigarettes. Cravings refer to the desire to consume nicotine.  As a result of cravings, smokers pursue behaviors aimed at obtaining tobacco-containing products (e.g., going out at 3:00 am to buy cigarettes) or actually engage in smoking. During assessment, it is useful for clinicians to educate patients that cravings are not all-or-none phenomena and to train patients to distinguish levels of craving. A relevant question would be “On a scale of 0 to 10, where 0 is no craving at all, and 10 is the most intense craving imaginable, how strong is your smoking craving right now?”

With regard to motivation to quit, or their “readiness”, clinicians determine whether the patient fits into one of three main categories:  1) smokers willing to make a quit attempt (within the next 30 days); 2) smokers unwilling to make a quit attempt at this time; and 3) former smokers.  In the general population of adult smokers, 70% report they want to quit, but most (80%) are not ready to quit within 30 days, and 30-40% do not intend to quit within the next 6 months.^8-9  Niaura and Shadel's¹⁰ Readiness Ladder below can provide quick and useful assessment data to inform treatment.

Using information grounded in The U.S. Public Health Service Report, Clinical Practice Guideline for Treating Tobacco Use and Dependence this online CE/CEU course provides health professionals with information about nicotine dependence and its dangers, as well as the physiological and psychological contributors to smoking. In addition, the course elaborates on the key components of basic assessment and provides detailed guidance regarding treatment plans for cessation, and several specialized intervention strategies for smokers with complicated presentations.