User login
Should we use SSRIs to treat adolescents with depression?
Yes. Based on current evidence, fluoxetine is the most effective selective serotonin reuptake inhibitor (SSRI) for treatment of major depressive disorder in adolescents. It is the only agent approved by the US Food and Drug Administration (FDA) for use in children (strength of recommendation [SOR]: A, based on meta-analysis of RCTs).
All SSRI medications increase the risk of suicidal behavior in adolescents, but do not increase the risk of completing suicide (SOR: A, based on meta-analysis of RCTs).
First, we must spot those at risk
Beth Fox, MD
East Tennessee State University, Johnson City
Family physicians are often the primary providers of healthcare for adolescents. Most health issues affecting this unique population are social and behavioral in origin. By routinely incorporating prevention and screening techniques into the adolescent visit, we can detect at-risk individuals. We need to inquire about sleep, personal interests, eating behaviors, future plans, friends and social activities, school performance, mood, and drug and alcohol use so that we can detect early symptoms of depression.
For those family physicians who like reminders, there are mnemonics and questionnaires that evaluate the social and behavioral aspects of the adolescent visit. Family physicians should also educate parents and family members about depressive signs and symptoms and the potential warning signs of suicidality.
Evidence summary
Major depressive disorder is common among adolescents and is associated with significant morbidity, including substance abuse and eating disorders. One study of survey data from 1769 adolescents found a lifetime prevalence of 15.3% for major depression. The majority of those reporting episodes of major depression in this study had recurrent symptoms and impairment in work or school.1
Fluoxetine and therapy together have the best results
A large, multicenter, randomized controlled trial evaluated the effectiveness of fluoxetine (Prozac), cognitive behavioral therapy (CBT), or the combination of the 2. Researchers evaluated improvement with the Children’s Depression Rating Scale–Revised (CDRSR). The CDRS-R uses adolescent and parent interviews to rate 17 symptom areas: impaired schoolwork, difficulty having fun, social withdrawal, appetite disturbance, sleep disturbance, excessive fatigue, physical complaints, irritability, excessive guilt, low self-esteem, depressed feelings, morbid ideas, suicidal ideas, excessive weeping, depressed facial affect, listless speech, and hypoactivity. Combination treatment with fluoxetine and CBT was statistically superior to placebo, CBT alone, or fluoxetine alone. In addition, fluoxetine alone was superior to CBT alone.2
A meta-analysis including both published and unpublished trials of SSRI medications found that fluoxetine was more likely than placebo to cause remission of symptoms after 7 to 8 weeks of treatment (number needed to treat [NNT]=6). Fluoxetine treatment was also associated with a reduction in symptom scores as measured with the CDRS-R (NNT=5).3
Data were conflicting for the efficacy of paroxetine (Paxil), sertraline (Zoloft), and citalopram (Celexa).3,4 No data were available for escitalopram (Lexapro).
But are SSRIs safe for adolescents?
Considerable controversy surrounds the safety of SSRIs in children due to reports of increased suicidal behavior. In 2004, the FDA conducted a meta-analysis of the suicide related adverse events from the published and unpublished trials of SSRIs including fluoxetine, sertraline, paroxetine, fluvoxamine (Luvox), and citalopram. A team of experts reviewed the adverse events from each trial to evaluate for suicidality including suicidal ideation, preparatory acts, self-injurious behavior, or suicide attempts. They found a risk ratio of 1.66 (95% confidence interval, 1.02–2.68) for suicidality in the treatment arms compared with placebo. There were no completed suicides in any study.5
This review led to the FDA’s October 2004 “black box” warning regarding suicidality and antidepressant medication in adolescents. However, an ecological analysis of prescription data and US Census data found an overall decline in suicide rates as the rate of prescriptions for SSRI medications increased, suggesting a beneficial correlation of SSRI medications on suicide rates.6
Recommendations from others
The American Academy of Child and Adolescent Psychiatry (AACAP) recommends psychosocial and pharmacologic intervention for depression, with psychotherapy as the preferred initial treatment for most adolescent patients.4 This organization reviewed the current published and unpublished data including the FDA analysis to formulate its conclusions regarding safety and efficacy. AACAP concluded that fluoxetine is effective for the treatment of depression in children and adolescents.
1. Kessler R, Walters E. Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey. Depression Anxiety 1998;7:3-14.
2. March J, Silva S, Petrycki S, et al. Treatment for Adolescent Depression Study Team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. JAMA 2004;292:807-820.
3. Whittington CJ, Kendall T, Fonagy P, Cottrell D, Cotgrove A, Boddington E. Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. Lancet 2004;363:1341-1345.
4. Report 10 of the Council on Scientific Affairs. Safety and Efficacy of Selective Serotonin Reup-take Inhibitors (SSRIs) in Children and Adolescents. Available at: www.aacap.org/galleries/psychiatricmedication/CSA_report_10_final.pdf. Accessed August 6, 2007
5. Hammad TA, Laughren T, Racoosin J. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry 2006;63:332-339.
6. Olfson M, Shaffer D, Marcus SC, Greenberg T. Relationship between antidepressant medication treatment and suicide in adolescents. Arch Gen Psychiatry 2003;60:978-982.
Yes. Based on current evidence, fluoxetine is the most effective selective serotonin reuptake inhibitor (SSRI) for treatment of major depressive disorder in adolescents. It is the only agent approved by the US Food and Drug Administration (FDA) for use in children (strength of recommendation [SOR]: A, based on meta-analysis of RCTs).
All SSRI medications increase the risk of suicidal behavior in adolescents, but do not increase the risk of completing suicide (SOR: A, based on meta-analysis of RCTs).
First, we must spot those at risk
Beth Fox, MD
East Tennessee State University, Johnson City
Family physicians are often the primary providers of healthcare for adolescents. Most health issues affecting this unique population are social and behavioral in origin. By routinely incorporating prevention and screening techniques into the adolescent visit, we can detect at-risk individuals. We need to inquire about sleep, personal interests, eating behaviors, future plans, friends and social activities, school performance, mood, and drug and alcohol use so that we can detect early symptoms of depression.
For those family physicians who like reminders, there are mnemonics and questionnaires that evaluate the social and behavioral aspects of the adolescent visit. Family physicians should also educate parents and family members about depressive signs and symptoms and the potential warning signs of suicidality.
Evidence summary
Major depressive disorder is common among adolescents and is associated with significant morbidity, including substance abuse and eating disorders. One study of survey data from 1769 adolescents found a lifetime prevalence of 15.3% for major depression. The majority of those reporting episodes of major depression in this study had recurrent symptoms and impairment in work or school.1
Fluoxetine and therapy together have the best results
A large, multicenter, randomized controlled trial evaluated the effectiveness of fluoxetine (Prozac), cognitive behavioral therapy (CBT), or the combination of the 2. Researchers evaluated improvement with the Children’s Depression Rating Scale–Revised (CDRSR). The CDRS-R uses adolescent and parent interviews to rate 17 symptom areas: impaired schoolwork, difficulty having fun, social withdrawal, appetite disturbance, sleep disturbance, excessive fatigue, physical complaints, irritability, excessive guilt, low self-esteem, depressed feelings, morbid ideas, suicidal ideas, excessive weeping, depressed facial affect, listless speech, and hypoactivity. Combination treatment with fluoxetine and CBT was statistically superior to placebo, CBT alone, or fluoxetine alone. In addition, fluoxetine alone was superior to CBT alone.2
A meta-analysis including both published and unpublished trials of SSRI medications found that fluoxetine was more likely than placebo to cause remission of symptoms after 7 to 8 weeks of treatment (number needed to treat [NNT]=6). Fluoxetine treatment was also associated with a reduction in symptom scores as measured with the CDRS-R (NNT=5).3
Data were conflicting for the efficacy of paroxetine (Paxil), sertraline (Zoloft), and citalopram (Celexa).3,4 No data were available for escitalopram (Lexapro).
But are SSRIs safe for adolescents?
Considerable controversy surrounds the safety of SSRIs in children due to reports of increased suicidal behavior. In 2004, the FDA conducted a meta-analysis of the suicide related adverse events from the published and unpublished trials of SSRIs including fluoxetine, sertraline, paroxetine, fluvoxamine (Luvox), and citalopram. A team of experts reviewed the adverse events from each trial to evaluate for suicidality including suicidal ideation, preparatory acts, self-injurious behavior, or suicide attempts. They found a risk ratio of 1.66 (95% confidence interval, 1.02–2.68) for suicidality in the treatment arms compared with placebo. There were no completed suicides in any study.5
This review led to the FDA’s October 2004 “black box” warning regarding suicidality and antidepressant medication in adolescents. However, an ecological analysis of prescription data and US Census data found an overall decline in suicide rates as the rate of prescriptions for SSRI medications increased, suggesting a beneficial correlation of SSRI medications on suicide rates.6
Recommendations from others
The American Academy of Child and Adolescent Psychiatry (AACAP) recommends psychosocial and pharmacologic intervention for depression, with psychotherapy as the preferred initial treatment for most adolescent patients.4 This organization reviewed the current published and unpublished data including the FDA analysis to formulate its conclusions regarding safety and efficacy. AACAP concluded that fluoxetine is effective for the treatment of depression in children and adolescents.
Yes. Based on current evidence, fluoxetine is the most effective selective serotonin reuptake inhibitor (SSRI) for treatment of major depressive disorder in adolescents. It is the only agent approved by the US Food and Drug Administration (FDA) for use in children (strength of recommendation [SOR]: A, based on meta-analysis of RCTs).
All SSRI medications increase the risk of suicidal behavior in adolescents, but do not increase the risk of completing suicide (SOR: A, based on meta-analysis of RCTs).
First, we must spot those at risk
Beth Fox, MD
East Tennessee State University, Johnson City
Family physicians are often the primary providers of healthcare for adolescents. Most health issues affecting this unique population are social and behavioral in origin. By routinely incorporating prevention and screening techniques into the adolescent visit, we can detect at-risk individuals. We need to inquire about sleep, personal interests, eating behaviors, future plans, friends and social activities, school performance, mood, and drug and alcohol use so that we can detect early symptoms of depression.
For those family physicians who like reminders, there are mnemonics and questionnaires that evaluate the social and behavioral aspects of the adolescent visit. Family physicians should also educate parents and family members about depressive signs and symptoms and the potential warning signs of suicidality.
Evidence summary
Major depressive disorder is common among adolescents and is associated with significant morbidity, including substance abuse and eating disorders. One study of survey data from 1769 adolescents found a lifetime prevalence of 15.3% for major depression. The majority of those reporting episodes of major depression in this study had recurrent symptoms and impairment in work or school.1
Fluoxetine and therapy together have the best results
A large, multicenter, randomized controlled trial evaluated the effectiveness of fluoxetine (Prozac), cognitive behavioral therapy (CBT), or the combination of the 2. Researchers evaluated improvement with the Children’s Depression Rating Scale–Revised (CDRSR). The CDRS-R uses adolescent and parent interviews to rate 17 symptom areas: impaired schoolwork, difficulty having fun, social withdrawal, appetite disturbance, sleep disturbance, excessive fatigue, physical complaints, irritability, excessive guilt, low self-esteem, depressed feelings, morbid ideas, suicidal ideas, excessive weeping, depressed facial affect, listless speech, and hypoactivity. Combination treatment with fluoxetine and CBT was statistically superior to placebo, CBT alone, or fluoxetine alone. In addition, fluoxetine alone was superior to CBT alone.2
A meta-analysis including both published and unpublished trials of SSRI medications found that fluoxetine was more likely than placebo to cause remission of symptoms after 7 to 8 weeks of treatment (number needed to treat [NNT]=6). Fluoxetine treatment was also associated with a reduction in symptom scores as measured with the CDRS-R (NNT=5).3
Data were conflicting for the efficacy of paroxetine (Paxil), sertraline (Zoloft), and citalopram (Celexa).3,4 No data were available for escitalopram (Lexapro).
But are SSRIs safe for adolescents?
Considerable controversy surrounds the safety of SSRIs in children due to reports of increased suicidal behavior. In 2004, the FDA conducted a meta-analysis of the suicide related adverse events from the published and unpublished trials of SSRIs including fluoxetine, sertraline, paroxetine, fluvoxamine (Luvox), and citalopram. A team of experts reviewed the adverse events from each trial to evaluate for suicidality including suicidal ideation, preparatory acts, self-injurious behavior, or suicide attempts. They found a risk ratio of 1.66 (95% confidence interval, 1.02–2.68) for suicidality in the treatment arms compared with placebo. There were no completed suicides in any study.5
This review led to the FDA’s October 2004 “black box” warning regarding suicidality and antidepressant medication in adolescents. However, an ecological analysis of prescription data and US Census data found an overall decline in suicide rates as the rate of prescriptions for SSRI medications increased, suggesting a beneficial correlation of SSRI medications on suicide rates.6
Recommendations from others
The American Academy of Child and Adolescent Psychiatry (AACAP) recommends psychosocial and pharmacologic intervention for depression, with psychotherapy as the preferred initial treatment for most adolescent patients.4 This organization reviewed the current published and unpublished data including the FDA analysis to formulate its conclusions regarding safety and efficacy. AACAP concluded that fluoxetine is effective for the treatment of depression in children and adolescents.
1. Kessler R, Walters E. Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey. Depression Anxiety 1998;7:3-14.
2. March J, Silva S, Petrycki S, et al. Treatment for Adolescent Depression Study Team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. JAMA 2004;292:807-820.
3. Whittington CJ, Kendall T, Fonagy P, Cottrell D, Cotgrove A, Boddington E. Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. Lancet 2004;363:1341-1345.
4. Report 10 of the Council on Scientific Affairs. Safety and Efficacy of Selective Serotonin Reup-take Inhibitors (SSRIs) in Children and Adolescents. Available at: www.aacap.org/galleries/psychiatricmedication/CSA_report_10_final.pdf. Accessed August 6, 2007
5. Hammad TA, Laughren T, Racoosin J. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry 2006;63:332-339.
6. Olfson M, Shaffer D, Marcus SC, Greenberg T. Relationship between antidepressant medication treatment and suicide in adolescents. Arch Gen Psychiatry 2003;60:978-982.
1. Kessler R, Walters E. Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey. Depression Anxiety 1998;7:3-14.
2. March J, Silva S, Petrycki S, et al. Treatment for Adolescent Depression Study Team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. JAMA 2004;292:807-820.
3. Whittington CJ, Kendall T, Fonagy P, Cottrell D, Cotgrove A, Boddington E. Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. Lancet 2004;363:1341-1345.
4. Report 10 of the Council on Scientific Affairs. Safety and Efficacy of Selective Serotonin Reup-take Inhibitors (SSRIs) in Children and Adolescents. Available at: www.aacap.org/galleries/psychiatricmedication/CSA_report_10_final.pdf. Accessed August 6, 2007
5. Hammad TA, Laughren T, Racoosin J. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry 2006;63:332-339.
6. Olfson M, Shaffer D, Marcus SC, Greenberg T. Relationship between antidepressant medication treatment and suicide in adolescents. Arch Gen Psychiatry 2003;60:978-982.
Evidence-based answers from the Family Physicians Inquiries Network
What predicts a successful smoking cessation attempt?
Quit date abstinence (strength of recommendation [SOR]: B, based on low-quality randomized controlled trial [RCT] of healthy subjects) and refraining from tobacco products within the first 2 weeks after an attempt (SOR: A, based on 2 RCTs) predict long-term abstinence from smoking. Inconsistent studies variously identify being married, a diagnosis of coronary artery disease (CAD) within the past 2 years, a higher education level, advanced age, and social status (such as being a homeowner) as factors correlated with successful smoking cessation (SOR: C, based on prospective cohort studies with conflicting results).
Smoking cessation rates increase in a dose-response relationship with minutes per counseling session, number of counseling sessions, and total minutes of counseling time (SOR: A, based on good-quality meta-analyses). Among counseling techniques, providing smokers with practical counseling (problem-solving skills), providing social support as part of treatment, helping smokers obtain social support outside of treatment, and use of aversive smoking interventions (eg, rapid smoking) seem to be efficacious (SOR: B, based on limited-quality meta-analyses).
Address a patient’s smoking in every encounter and at every opportunity
Stephen Elgert, MD
New Hampshire-Dartmouth Family Practice Residency, Concord, NH
The studies reviewed here do not show a stellar record of success in ridding patients of tobacco addiction. Few studies have success rates over the break-even point. Does this mean we should be nihilistic about this problem? Of course not!
I try to address a patient’s smoking in every encounter and at every opportunity. I ask them why they smoke and often get quizzical looks in return. I often ask them to do homework and write down the exact reason(s) they smoke each cigarette through the course of a day. Many times, one reason (such as stress) dominates the list. Others may have many reasons. Helping patients quit smoking is difficult unless we address the underlying reasons with creative alternatives and interventions.
Problem-solving with your patient can help. Suggesting alternative ways of dealing with stress can be enabling. Many of our patients are conscious of the relationship with weight gain and smoking, and give suggestions to counterbalance this notion.
Behavioral modification may help those resistant to change. Patients cannot help but wince as I describe the image of licking a dirty ashtray as they puff away. Smoking is a complex behavioral activity seldom cured by simple interventions, however. Tailoring efforts to meet our patients’ needs in a creative manner, tuned to their specific circumstances, is what we should aim to do.
Evidence summary
This answer focuses on the behavioral and sociodemographic factors involved in smoking cessation and does not review the pharmacologic approaches to a successful smoking cessation attempt.
In 1999, 41.3% of current smokers (95% confidence interval [CI], 39.8–42.8) reported quit attempts of at least 1 day during the preceding 12 months.1 In a 1994 survey of 2000 United Kingdom adults, 70% of smokers reported a desire to quit smoking, and 89% of smokers reported at least 1 quit attempt.2 Cochrane Library meta-analyses have found that brief advice from physicians (odds ratio [OR]=1.69; 95% CI, 1.45–1.98), individual counseling or group counseling (OR=1.55; 95% CI, 1.27–1.90), self-help materials (OR=1.23; 95% CI, 1.02–1.49), and nicotine replacement therapy (OR=1.71; 95% CI, 1.60–1.83) enhanced quit rates over a 6-month or greater period.3
However, relapse from smoking cessation is a significant problem. In the 1996 California Tobacco Survey of 4480 Californians, only 15.2% of those who used smoking cessation assistance (self-help, counseling, or nicotine replacement therapy), and 7.0% who used no assistance were abstinent from tobacco in 12 months.4
Smoking during the first 2 weeks of an attempt predicts decreased long-term cessation rates. In 2 independent randomized, double-blinded, placebo-controlled studies, 200 subjects were placed on various doses of nicotine replacement (study one: 22-mg nicotine patch for 8 weeks, study two: 22-mg patch for 4 weeks then 11 mg patch for 2 weeks). Of those who remained abstinent during the first 2 weeks while on a patch, 46.2% and 40.9% maintained abstinence at 6 months (OR=4.3 and 23.5, respectively) while abstinent subjects on placebo maintained abstinence at a rate of 43.8% and 30% (OR=9.7 and 18.9, respectively). Conversely, of those who were on a patch and smoked during the first 2 weeks of an attempt, 83.3% and 97.1% were smoking 6 months out while 92.6% and 97.8% of those in the placebo groups who smoked during the first 2 weeks were smoking at 6 months.5
In 2 randomized, non-placebo-controlled clinical trials of 200 subjects, 41.3% of smokers placed on nicotine replacement that were abstinent on their quit date and had a low tobacco dependence score (based on the Fagerström Test for Nicotine Dependence) were able to maintain abstinence at the 6-month mark (OR=4.1). Those who smoked on the quit date were 10 times less likely to have long-term success (OR=0.1).6
In a retrospective survey of 2000 subjects those with less than 5 previous cessation attempts as well as perceived helpful support from friends had a greater likelihood of successful smoking cessation.7 In a retrospective review of socioeconomic factors associated with tobacco cessation among 3575 subjects of the CEASE trial, being a homeowner (OR=1.62) and male gender (OR=1.38) increased likelihood of tobacco cessation at 6 months.8 In a retrospective review of 2684 subjects from the Framingham study, women who smoked less that 1 half-pack per day (OR=2.6) and males who were diagnosed with CAD within the past 2 years (OR=1.9) were more likely to maintain abstinence 1 year after the cessation attempt.9 The TABLE summarizes results from 5 studies focusing on a variety of factors and their effects on smoking cessation.
Counseling frequency and duration impact smoking cessation. In a meta-analysis of 23 studies, the odds ratio for cessation was 1.3 (95% CI, 1.01–1.6) for minimal counseling (<3 minutes), 1.6 (95% CI, 1.2–2.0) for low-intensity counseling (3 to 10 minutes), and 2.3 (95% CI, 2.0–2.7) for high-intensity counseling (>10 minutes).10 In a meta-analysis of 35 studies, smoking cessation increased as total contact time for all counseling sessions increased, peaking at 90 minutes (OR=3.0; 95% CI, 2.3–3.8).10 In a meta-analysis of 45 studies, smoking cessation increased as number of person-to-person counseling sessions increased from 2 to 3 sessions (OR=1.4; 95% CI, 1.1–1.7) to 4 to 8 sessions (OR=1.9; 95% CI, 1.6–2.2) to >8 sessions (OR=2.3; 95% CI, 2.1–3.0).10
A meta-analysis of 62 studies found no impact of relaxation/breathing techniques, contingency contracting, weight/diet counseling, cigarette fading, or negative affect counseling on smoking cessation.10 Successful counseling techniques included providing smokers with problem solving skills (OR for successful smoking cessation=1.5; 95% CI, 1.3–1.8), providing intra-treatment social support (OR=1.3; 95% CI, 1.1–1.6), helping smokers obtain extra-treatment social support (OR=1.5; 95% CI, 1.1–2.1), use of rapid smoking (OR=2.0; 95% CI, 1.1–3.5), and use of other “aversive smoking techniques” (OR=1.7; 95% CI, 1.04–2.8).
TABLE
Factors predicting success or failure for a smoking cessation attempt
| PREDICTING SUCCESS | PREDICTING FAILURE | NONCONTRIBUTING | |
|---|---|---|---|
| Lennox and Taylor1 | Fewer previous attempts to stop | Withdrawal symptoms | Age |
| Increased perceived helpful supports from friends | Cravings | Sex | |
| Increased motivation | Smoke exposure (ie, in restaurants with smoking) | Type of support (smoker vs nonsmoker friends) | |
| Heavy smokers (>1 ppd) | Smoking 1/2-1 ppd | Health issues | |
| Reasons for current attempt | |||
| Westman et al2 | Quit date abstinence (OR=10.6) | ||
| Low tobacco dependence (OR=0.7) | |||
| Kenford et al3 | Abstinence of smoking at 2 weeks after a cessation attempt (OR=4.3 and 23.5 in study 1and 2, respectively) | Any use of tobacco within first 2 weeks of a cessation attempt | Number of cigarettes/day |
| Number of years smoked | |||
| Freund et al4 | Men: increased age (OR=1.3), CAD diagnosed in past 2 years (OR=1.9) | Diagnosis of cancer | |
| Women: low number of cigarettes per day (<2 ppd [OR=0.14]; <1/2 ppd [OR=2.6]) higher education level (OR=1.1) | Decreased FEV1 | ||
| Both: married (OR=1.6); hospitalized in past 2 years (OR=1.3) | Baseline alcohol use | ||
| Gender | |||
| Baseline weight (OR=1.1) | |||
| Monsó et al5 | Low number of cigarettes/day (OR=0.80) | CAD (OR=0.48) | Chronic disease (OR=0.95) |
| Older age (OR=1.17) | Lung disease (OR=0.79) | Depression (OR=0.82) | |
| Males (OR=1.38) | |||
| Homeowners (OR=1.62) | |||
| Ppd, packs per day; CAD, coronary artery disease; FEV1, forced expiratory volume in 1 second; OR, odds ratio | |||
Recommendations from others
The US Public Health Service Clinical Practice Guideline (2000)10 supports the following recommendations, based on rigorously conducted meta-analyses: use of office screening systems to identify smokers; physician advice to quit; use of multiple clinician types in smoking cessation counseling; and treatments delivered by telephone counseling, group counseling, and individual counseling, used alone or in combination, as opposed to self-help materials for smoking cessation.
The US Department of Health and Human Services11 recommends that physicians ask and record tobacco-use status and offer smoking cessation advice and treatment at every office visit. They also recommend the “5 A’s” (Ask, Advise, Assess, Assist, and Arrange) for patients who desire smoking cessation and the “5 R’s” motivational intervention (Relevance, Risks, Rewards, Roadblocks, and Repetition) for those who are not ready to quit smoking.
1. Cigarette smoking among adults—United States, 1999. MMWR Morb Mortal Wkly Rep 2001;50:869-873.
2. Lennox AS, Taylor RJ. Factors associated with outcome in unaided smoking cessation, and a comparison of those who have never tried to stop with those who have. Br J Gen Pract 1994;44:245-250.
3. Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ 2000;321:355-358.
4. Zhu SH, Melcer T, Sun J, Rosbrook B, Pierce JP. Smoking cessation with and without assistance: a population-based analysis. Am J Prev Med 2000;18:305-311.
5. Kenford SL, Fiore MC, Jorenby DE, Smith SS, Wetter D, Baker TB. Predicting smoking cessation: who will quit with and without nicotine patch. JAMA 1994;271:589-594.
6. Westman EC, Behm FM, Simel DL, Rose JE. Smoking behavior on the first day of a quit attempt predicts long-term abstinence. Arch Intern Med 1997;157:335-340.
7. Kowalski SD. Self-esteem and self-efficacy as predictors of success in smoking cessation. J Holist Nurs 1997;15:128-142.
8. Monsó E, Campbell J, Tønnsen P, Gustavsson G, Morera J. Sociodemographic predictors of success in smoking intervention. Tob Control 2001;10:165-169.
9. Freund KM, D’Agostino RB, Belanger AJ, Kannel WB, Stokes J, 3rd. Predictors of smoking cessation: The Framingham study. Am J Epidemiol 1992;135:957-964.
10. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, Md: US Department of Health and Human Services, Public Health Service, 2000.
11. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, Md: US Department of Health and Human Services, Public Health Service; October 2000.
Quit date abstinence (strength of recommendation [SOR]: B, based on low-quality randomized controlled trial [RCT] of healthy subjects) and refraining from tobacco products within the first 2 weeks after an attempt (SOR: A, based on 2 RCTs) predict long-term abstinence from smoking. Inconsistent studies variously identify being married, a diagnosis of coronary artery disease (CAD) within the past 2 years, a higher education level, advanced age, and social status (such as being a homeowner) as factors correlated with successful smoking cessation (SOR: C, based on prospective cohort studies with conflicting results).
Smoking cessation rates increase in a dose-response relationship with minutes per counseling session, number of counseling sessions, and total minutes of counseling time (SOR: A, based on good-quality meta-analyses). Among counseling techniques, providing smokers with practical counseling (problem-solving skills), providing social support as part of treatment, helping smokers obtain social support outside of treatment, and use of aversive smoking interventions (eg, rapid smoking) seem to be efficacious (SOR: B, based on limited-quality meta-analyses).
Address a patient’s smoking in every encounter and at every opportunity
Stephen Elgert, MD
New Hampshire-Dartmouth Family Practice Residency, Concord, NH
The studies reviewed here do not show a stellar record of success in ridding patients of tobacco addiction. Few studies have success rates over the break-even point. Does this mean we should be nihilistic about this problem? Of course not!
I try to address a patient’s smoking in every encounter and at every opportunity. I ask them why they smoke and often get quizzical looks in return. I often ask them to do homework and write down the exact reason(s) they smoke each cigarette through the course of a day. Many times, one reason (such as stress) dominates the list. Others may have many reasons. Helping patients quit smoking is difficult unless we address the underlying reasons with creative alternatives and interventions.
Problem-solving with your patient can help. Suggesting alternative ways of dealing with stress can be enabling. Many of our patients are conscious of the relationship with weight gain and smoking, and give suggestions to counterbalance this notion.
Behavioral modification may help those resistant to change. Patients cannot help but wince as I describe the image of licking a dirty ashtray as they puff away. Smoking is a complex behavioral activity seldom cured by simple interventions, however. Tailoring efforts to meet our patients’ needs in a creative manner, tuned to their specific circumstances, is what we should aim to do.
Evidence summary
This answer focuses on the behavioral and sociodemographic factors involved in smoking cessation and does not review the pharmacologic approaches to a successful smoking cessation attempt.
In 1999, 41.3% of current smokers (95% confidence interval [CI], 39.8–42.8) reported quit attempts of at least 1 day during the preceding 12 months.1 In a 1994 survey of 2000 United Kingdom adults, 70% of smokers reported a desire to quit smoking, and 89% of smokers reported at least 1 quit attempt.2 Cochrane Library meta-analyses have found that brief advice from physicians (odds ratio [OR]=1.69; 95% CI, 1.45–1.98), individual counseling or group counseling (OR=1.55; 95% CI, 1.27–1.90), self-help materials (OR=1.23; 95% CI, 1.02–1.49), and nicotine replacement therapy (OR=1.71; 95% CI, 1.60–1.83) enhanced quit rates over a 6-month or greater period.3
However, relapse from smoking cessation is a significant problem. In the 1996 California Tobacco Survey of 4480 Californians, only 15.2% of those who used smoking cessation assistance (self-help, counseling, or nicotine replacement therapy), and 7.0% who used no assistance were abstinent from tobacco in 12 months.4
Smoking during the first 2 weeks of an attempt predicts decreased long-term cessation rates. In 2 independent randomized, double-blinded, placebo-controlled studies, 200 subjects were placed on various doses of nicotine replacement (study one: 22-mg nicotine patch for 8 weeks, study two: 22-mg patch for 4 weeks then 11 mg patch for 2 weeks). Of those who remained abstinent during the first 2 weeks while on a patch, 46.2% and 40.9% maintained abstinence at 6 months (OR=4.3 and 23.5, respectively) while abstinent subjects on placebo maintained abstinence at a rate of 43.8% and 30% (OR=9.7 and 18.9, respectively). Conversely, of those who were on a patch and smoked during the first 2 weeks of an attempt, 83.3% and 97.1% were smoking 6 months out while 92.6% and 97.8% of those in the placebo groups who smoked during the first 2 weeks were smoking at 6 months.5
In 2 randomized, non-placebo-controlled clinical trials of 200 subjects, 41.3% of smokers placed on nicotine replacement that were abstinent on their quit date and had a low tobacco dependence score (based on the Fagerström Test for Nicotine Dependence) were able to maintain abstinence at the 6-month mark (OR=4.1). Those who smoked on the quit date were 10 times less likely to have long-term success (OR=0.1).6
In a retrospective survey of 2000 subjects those with less than 5 previous cessation attempts as well as perceived helpful support from friends had a greater likelihood of successful smoking cessation.7 In a retrospective review of socioeconomic factors associated with tobacco cessation among 3575 subjects of the CEASE trial, being a homeowner (OR=1.62) and male gender (OR=1.38) increased likelihood of tobacco cessation at 6 months.8 In a retrospective review of 2684 subjects from the Framingham study, women who smoked less that 1 half-pack per day (OR=2.6) and males who were diagnosed with CAD within the past 2 years (OR=1.9) were more likely to maintain abstinence 1 year after the cessation attempt.9 The TABLE summarizes results from 5 studies focusing on a variety of factors and their effects on smoking cessation.
Counseling frequency and duration impact smoking cessation. In a meta-analysis of 23 studies, the odds ratio for cessation was 1.3 (95% CI, 1.01–1.6) for minimal counseling (<3 minutes), 1.6 (95% CI, 1.2–2.0) for low-intensity counseling (3 to 10 minutes), and 2.3 (95% CI, 2.0–2.7) for high-intensity counseling (>10 minutes).10 In a meta-analysis of 35 studies, smoking cessation increased as total contact time for all counseling sessions increased, peaking at 90 minutes (OR=3.0; 95% CI, 2.3–3.8).10 In a meta-analysis of 45 studies, smoking cessation increased as number of person-to-person counseling sessions increased from 2 to 3 sessions (OR=1.4; 95% CI, 1.1–1.7) to 4 to 8 sessions (OR=1.9; 95% CI, 1.6–2.2) to >8 sessions (OR=2.3; 95% CI, 2.1–3.0).10
A meta-analysis of 62 studies found no impact of relaxation/breathing techniques, contingency contracting, weight/diet counseling, cigarette fading, or negative affect counseling on smoking cessation.10 Successful counseling techniques included providing smokers with problem solving skills (OR for successful smoking cessation=1.5; 95% CI, 1.3–1.8), providing intra-treatment social support (OR=1.3; 95% CI, 1.1–1.6), helping smokers obtain extra-treatment social support (OR=1.5; 95% CI, 1.1–2.1), use of rapid smoking (OR=2.0; 95% CI, 1.1–3.5), and use of other “aversive smoking techniques” (OR=1.7; 95% CI, 1.04–2.8).
TABLE
Factors predicting success or failure for a smoking cessation attempt
| PREDICTING SUCCESS | PREDICTING FAILURE | NONCONTRIBUTING | |
|---|---|---|---|
| Lennox and Taylor1 | Fewer previous attempts to stop | Withdrawal symptoms | Age |
| Increased perceived helpful supports from friends | Cravings | Sex | |
| Increased motivation | Smoke exposure (ie, in restaurants with smoking) | Type of support (smoker vs nonsmoker friends) | |
| Heavy smokers (>1 ppd) | Smoking 1/2-1 ppd | Health issues | |
| Reasons for current attempt | |||
| Westman et al2 | Quit date abstinence (OR=10.6) | ||
| Low tobacco dependence (OR=0.7) | |||
| Kenford et al3 | Abstinence of smoking at 2 weeks after a cessation attempt (OR=4.3 and 23.5 in study 1and 2, respectively) | Any use of tobacco within first 2 weeks of a cessation attempt | Number of cigarettes/day |
| Number of years smoked | |||
| Freund et al4 | Men: increased age (OR=1.3), CAD diagnosed in past 2 years (OR=1.9) | Diagnosis of cancer | |
| Women: low number of cigarettes per day (<2 ppd [OR=0.14]; <1/2 ppd [OR=2.6]) higher education level (OR=1.1) | Decreased FEV1 | ||
| Both: married (OR=1.6); hospitalized in past 2 years (OR=1.3) | Baseline alcohol use | ||
| Gender | |||
| Baseline weight (OR=1.1) | |||
| Monsó et al5 | Low number of cigarettes/day (OR=0.80) | CAD (OR=0.48) | Chronic disease (OR=0.95) |
| Older age (OR=1.17) | Lung disease (OR=0.79) | Depression (OR=0.82) | |
| Males (OR=1.38) | |||
| Homeowners (OR=1.62) | |||
| Ppd, packs per day; CAD, coronary artery disease; FEV1, forced expiratory volume in 1 second; OR, odds ratio | |||
Recommendations from others
The US Public Health Service Clinical Practice Guideline (2000)10 supports the following recommendations, based on rigorously conducted meta-analyses: use of office screening systems to identify smokers; physician advice to quit; use of multiple clinician types in smoking cessation counseling; and treatments delivered by telephone counseling, group counseling, and individual counseling, used alone or in combination, as opposed to self-help materials for smoking cessation.
The US Department of Health and Human Services11 recommends that physicians ask and record tobacco-use status and offer smoking cessation advice and treatment at every office visit. They also recommend the “5 A’s” (Ask, Advise, Assess, Assist, and Arrange) for patients who desire smoking cessation and the “5 R’s” motivational intervention (Relevance, Risks, Rewards, Roadblocks, and Repetition) for those who are not ready to quit smoking.
Quit date abstinence (strength of recommendation [SOR]: B, based on low-quality randomized controlled trial [RCT] of healthy subjects) and refraining from tobacco products within the first 2 weeks after an attempt (SOR: A, based on 2 RCTs) predict long-term abstinence from smoking. Inconsistent studies variously identify being married, a diagnosis of coronary artery disease (CAD) within the past 2 years, a higher education level, advanced age, and social status (such as being a homeowner) as factors correlated with successful smoking cessation (SOR: C, based on prospective cohort studies with conflicting results).
Smoking cessation rates increase in a dose-response relationship with minutes per counseling session, number of counseling sessions, and total minutes of counseling time (SOR: A, based on good-quality meta-analyses). Among counseling techniques, providing smokers with practical counseling (problem-solving skills), providing social support as part of treatment, helping smokers obtain social support outside of treatment, and use of aversive smoking interventions (eg, rapid smoking) seem to be efficacious (SOR: B, based on limited-quality meta-analyses).
Address a patient’s smoking in every encounter and at every opportunity
Stephen Elgert, MD
New Hampshire-Dartmouth Family Practice Residency, Concord, NH
The studies reviewed here do not show a stellar record of success in ridding patients of tobacco addiction. Few studies have success rates over the break-even point. Does this mean we should be nihilistic about this problem? Of course not!
I try to address a patient’s smoking in every encounter and at every opportunity. I ask them why they smoke and often get quizzical looks in return. I often ask them to do homework and write down the exact reason(s) they smoke each cigarette through the course of a day. Many times, one reason (such as stress) dominates the list. Others may have many reasons. Helping patients quit smoking is difficult unless we address the underlying reasons with creative alternatives and interventions.
Problem-solving with your patient can help. Suggesting alternative ways of dealing with stress can be enabling. Many of our patients are conscious of the relationship with weight gain and smoking, and give suggestions to counterbalance this notion.
Behavioral modification may help those resistant to change. Patients cannot help but wince as I describe the image of licking a dirty ashtray as they puff away. Smoking is a complex behavioral activity seldom cured by simple interventions, however. Tailoring efforts to meet our patients’ needs in a creative manner, tuned to their specific circumstances, is what we should aim to do.
Evidence summary
This answer focuses on the behavioral and sociodemographic factors involved in smoking cessation and does not review the pharmacologic approaches to a successful smoking cessation attempt.
In 1999, 41.3% of current smokers (95% confidence interval [CI], 39.8–42.8) reported quit attempts of at least 1 day during the preceding 12 months.1 In a 1994 survey of 2000 United Kingdom adults, 70% of smokers reported a desire to quit smoking, and 89% of smokers reported at least 1 quit attempt.2 Cochrane Library meta-analyses have found that brief advice from physicians (odds ratio [OR]=1.69; 95% CI, 1.45–1.98), individual counseling or group counseling (OR=1.55; 95% CI, 1.27–1.90), self-help materials (OR=1.23; 95% CI, 1.02–1.49), and nicotine replacement therapy (OR=1.71; 95% CI, 1.60–1.83) enhanced quit rates over a 6-month or greater period.3
However, relapse from smoking cessation is a significant problem. In the 1996 California Tobacco Survey of 4480 Californians, only 15.2% of those who used smoking cessation assistance (self-help, counseling, or nicotine replacement therapy), and 7.0% who used no assistance were abstinent from tobacco in 12 months.4
Smoking during the first 2 weeks of an attempt predicts decreased long-term cessation rates. In 2 independent randomized, double-blinded, placebo-controlled studies, 200 subjects were placed on various doses of nicotine replacement (study one: 22-mg nicotine patch for 8 weeks, study two: 22-mg patch for 4 weeks then 11 mg patch for 2 weeks). Of those who remained abstinent during the first 2 weeks while on a patch, 46.2% and 40.9% maintained abstinence at 6 months (OR=4.3 and 23.5, respectively) while abstinent subjects on placebo maintained abstinence at a rate of 43.8% and 30% (OR=9.7 and 18.9, respectively). Conversely, of those who were on a patch and smoked during the first 2 weeks of an attempt, 83.3% and 97.1% were smoking 6 months out while 92.6% and 97.8% of those in the placebo groups who smoked during the first 2 weeks were smoking at 6 months.5
In 2 randomized, non-placebo-controlled clinical trials of 200 subjects, 41.3% of smokers placed on nicotine replacement that were abstinent on their quit date and had a low tobacco dependence score (based on the Fagerström Test for Nicotine Dependence) were able to maintain abstinence at the 6-month mark (OR=4.1). Those who smoked on the quit date were 10 times less likely to have long-term success (OR=0.1).6
In a retrospective survey of 2000 subjects those with less than 5 previous cessation attempts as well as perceived helpful support from friends had a greater likelihood of successful smoking cessation.7 In a retrospective review of socioeconomic factors associated with tobacco cessation among 3575 subjects of the CEASE trial, being a homeowner (OR=1.62) and male gender (OR=1.38) increased likelihood of tobacco cessation at 6 months.8 In a retrospective review of 2684 subjects from the Framingham study, women who smoked less that 1 half-pack per day (OR=2.6) and males who were diagnosed with CAD within the past 2 years (OR=1.9) were more likely to maintain abstinence 1 year after the cessation attempt.9 The TABLE summarizes results from 5 studies focusing on a variety of factors and their effects on smoking cessation.
Counseling frequency and duration impact smoking cessation. In a meta-analysis of 23 studies, the odds ratio for cessation was 1.3 (95% CI, 1.01–1.6) for minimal counseling (<3 minutes), 1.6 (95% CI, 1.2–2.0) for low-intensity counseling (3 to 10 minutes), and 2.3 (95% CI, 2.0–2.7) for high-intensity counseling (>10 minutes).10 In a meta-analysis of 35 studies, smoking cessation increased as total contact time for all counseling sessions increased, peaking at 90 minutes (OR=3.0; 95% CI, 2.3–3.8).10 In a meta-analysis of 45 studies, smoking cessation increased as number of person-to-person counseling sessions increased from 2 to 3 sessions (OR=1.4; 95% CI, 1.1–1.7) to 4 to 8 sessions (OR=1.9; 95% CI, 1.6–2.2) to >8 sessions (OR=2.3; 95% CI, 2.1–3.0).10
A meta-analysis of 62 studies found no impact of relaxation/breathing techniques, contingency contracting, weight/diet counseling, cigarette fading, or negative affect counseling on smoking cessation.10 Successful counseling techniques included providing smokers with problem solving skills (OR for successful smoking cessation=1.5; 95% CI, 1.3–1.8), providing intra-treatment social support (OR=1.3; 95% CI, 1.1–1.6), helping smokers obtain extra-treatment social support (OR=1.5; 95% CI, 1.1–2.1), use of rapid smoking (OR=2.0; 95% CI, 1.1–3.5), and use of other “aversive smoking techniques” (OR=1.7; 95% CI, 1.04–2.8).
TABLE
Factors predicting success or failure for a smoking cessation attempt
| PREDICTING SUCCESS | PREDICTING FAILURE | NONCONTRIBUTING | |
|---|---|---|---|
| Lennox and Taylor1 | Fewer previous attempts to stop | Withdrawal symptoms | Age |
| Increased perceived helpful supports from friends | Cravings | Sex | |
| Increased motivation | Smoke exposure (ie, in restaurants with smoking) | Type of support (smoker vs nonsmoker friends) | |
| Heavy smokers (>1 ppd) | Smoking 1/2-1 ppd | Health issues | |
| Reasons for current attempt | |||
| Westman et al2 | Quit date abstinence (OR=10.6) | ||
| Low tobacco dependence (OR=0.7) | |||
| Kenford et al3 | Abstinence of smoking at 2 weeks after a cessation attempt (OR=4.3 and 23.5 in study 1and 2, respectively) | Any use of tobacco within first 2 weeks of a cessation attempt | Number of cigarettes/day |
| Number of years smoked | |||
| Freund et al4 | Men: increased age (OR=1.3), CAD diagnosed in past 2 years (OR=1.9) | Diagnosis of cancer | |
| Women: low number of cigarettes per day (<2 ppd [OR=0.14]; <1/2 ppd [OR=2.6]) higher education level (OR=1.1) | Decreased FEV1 | ||
| Both: married (OR=1.6); hospitalized in past 2 years (OR=1.3) | Baseline alcohol use | ||
| Gender | |||
| Baseline weight (OR=1.1) | |||
| Monsó et al5 | Low number of cigarettes/day (OR=0.80) | CAD (OR=0.48) | Chronic disease (OR=0.95) |
| Older age (OR=1.17) | Lung disease (OR=0.79) | Depression (OR=0.82) | |
| Males (OR=1.38) | |||
| Homeowners (OR=1.62) | |||
| Ppd, packs per day; CAD, coronary artery disease; FEV1, forced expiratory volume in 1 second; OR, odds ratio | |||
Recommendations from others
The US Public Health Service Clinical Practice Guideline (2000)10 supports the following recommendations, based on rigorously conducted meta-analyses: use of office screening systems to identify smokers; physician advice to quit; use of multiple clinician types in smoking cessation counseling; and treatments delivered by telephone counseling, group counseling, and individual counseling, used alone or in combination, as opposed to self-help materials for smoking cessation.
The US Department of Health and Human Services11 recommends that physicians ask and record tobacco-use status and offer smoking cessation advice and treatment at every office visit. They also recommend the “5 A’s” (Ask, Advise, Assess, Assist, and Arrange) for patients who desire smoking cessation and the “5 R’s” motivational intervention (Relevance, Risks, Rewards, Roadblocks, and Repetition) for those who are not ready to quit smoking.
1. Cigarette smoking among adults—United States, 1999. MMWR Morb Mortal Wkly Rep 2001;50:869-873.
2. Lennox AS, Taylor RJ. Factors associated with outcome in unaided smoking cessation, and a comparison of those who have never tried to stop with those who have. Br J Gen Pract 1994;44:245-250.
3. Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ 2000;321:355-358.
4. Zhu SH, Melcer T, Sun J, Rosbrook B, Pierce JP. Smoking cessation with and without assistance: a population-based analysis. Am J Prev Med 2000;18:305-311.
5. Kenford SL, Fiore MC, Jorenby DE, Smith SS, Wetter D, Baker TB. Predicting smoking cessation: who will quit with and without nicotine patch. JAMA 1994;271:589-594.
6. Westman EC, Behm FM, Simel DL, Rose JE. Smoking behavior on the first day of a quit attempt predicts long-term abstinence. Arch Intern Med 1997;157:335-340.
7. Kowalski SD. Self-esteem and self-efficacy as predictors of success in smoking cessation. J Holist Nurs 1997;15:128-142.
8. Monsó E, Campbell J, Tønnsen P, Gustavsson G, Morera J. Sociodemographic predictors of success in smoking intervention. Tob Control 2001;10:165-169.
9. Freund KM, D’Agostino RB, Belanger AJ, Kannel WB, Stokes J, 3rd. Predictors of smoking cessation: The Framingham study. Am J Epidemiol 1992;135:957-964.
10. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, Md: US Department of Health and Human Services, Public Health Service, 2000.
11. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, Md: US Department of Health and Human Services, Public Health Service; October 2000.
1. Cigarette smoking among adults—United States, 1999. MMWR Morb Mortal Wkly Rep 2001;50:869-873.
2. Lennox AS, Taylor RJ. Factors associated with outcome in unaided smoking cessation, and a comparison of those who have never tried to stop with those who have. Br J Gen Pract 1994;44:245-250.
3. Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ 2000;321:355-358.
4. Zhu SH, Melcer T, Sun J, Rosbrook B, Pierce JP. Smoking cessation with and without assistance: a population-based analysis. Am J Prev Med 2000;18:305-311.
5. Kenford SL, Fiore MC, Jorenby DE, Smith SS, Wetter D, Baker TB. Predicting smoking cessation: who will quit with and without nicotine patch. JAMA 1994;271:589-594.
6. Westman EC, Behm FM, Simel DL, Rose JE. Smoking behavior on the first day of a quit attempt predicts long-term abstinence. Arch Intern Med 1997;157:335-340.
7. Kowalski SD. Self-esteem and self-efficacy as predictors of success in smoking cessation. J Holist Nurs 1997;15:128-142.
8. Monsó E, Campbell J, Tønnsen P, Gustavsson G, Morera J. Sociodemographic predictors of success in smoking intervention. Tob Control 2001;10:165-169.
9. Freund KM, D’Agostino RB, Belanger AJ, Kannel WB, Stokes J, 3rd. Predictors of smoking cessation: The Framingham study. Am J Epidemiol 1992;135:957-964.
10. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, Md: US Department of Health and Human Services, Public Health Service, 2000.
11. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, Md: US Department of Health and Human Services, Public Health Service; October 2000.
Evidence-based answers from the Family Physicians Inquiries Network