Tobacco-Use Prevention and Cessation (Position Paper)
Smoking or exposure to secondhand smoke causes nearly 440,000 deaths in the United States each year, making tobacco use the leading preventable cause of death.1 Each year, more people in the United States die from smoking than from acquired immunodeficiency syndrome, alcohol, cocaine, heroin, homicide, suicide, motor vehicle crashes, and fires combined.2
The Centers for Disease Control and Prevention (CDC) estimates that tobacco addiction costs the nation $193 billion annually in health-related costs and lost productivity.3 Despite progress in educating the public on the harms of tobacco use, it remains a deadly and costly health threat due, in part, to low utilization of cost-effective, evidence-based treatments.
The Family Physician's Role
Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit.4 Family physicians have a tremendous opportunity to make a significant impact on the tobacco use behavior of Americans because nearly 70 percent of tobacco users see a physician each year.5
The American Academy of Family Physicians (AAFP) strongly encourages its members to:
- Save lives by working toward elimination of all tobacco use
- Document use of tobacco products in patient charts
- Work cooperatively with other health professionals to provide cessation counseling and other treatments
- Discourage tobacco use in all public and workplace settings
- List tobacco use as a cause of death on death certificates when appropriate6
Recent evidence reinforces the impact primary care physicians can have by addressing tobacco use with their patients. A 2007 National Commission on Prevention Priorities report indicates that only 28 percent of smokers receive advice from their physician to quit plus medication or other assistance. If physicians would advise 90 percent of smokers to quit and offer them medication or other assistance, 42,000 lives could be saved each year.7
Of the 46 million current U.S. smokers, 70 percent say that they would like to quit, but without assistance only 5 percent are able to quit.4 Fewer than one half make a quit attempt each year. Most smokers who try to quit do so on their own, without evidence-based programs; more than 95 percent relapse2. Using evidence-based programs can more than double success rates.2 The 2008 Update of the U.S. Public Health Service (USPHS) Clinical Practice Guideline, Treating Tobacco Use and Dependence, calls on physicians to change clinical culture and practice patterns to ensure that every patient who uses tobacco is identified, advised to quit, and offered scientifically sound treatments.4
The AAFP encourages its members to Ask their patients about tobacco use, then to Act to help them quit.
Why Ask and Act?
In the early 1990s the National Cancer Institute developed the publication: How to Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians. The guide recommended that physicians Ask, Advise, Assist and Arrange follow-up to help smokers quit. These four A’s were expanded to five in the 1996 Agency for Health Care Policy and Research guidelines. The USPHS guideline also encourages five A’s (i.e., Ask, Advise, Assess, Assist, and Arrange) as a “brief intervention” for patients who want to quit. Many physicians have found the five A’s cumbersome, hard to remember, and not practical for every patient at every visit.
Several medical specialty organizations have integrated components of the five A’s into an abbreviated intervention: Ask, Advise, Refer. In this model, health professionals ask patients about tobacco use, advise them to quit, and refer them to quitlines or web-based and local cessation programs.
The AAFP encourages its members and their practice teams to Ask all patients about tobacco use, then to Act to help them quit. This easy-to-remember approach, Ask and Act, provides the opportunity for every member of a practice team to intervene at every visit. Interventions can be tailored to a specific patient based on his or her willingness to quit, as well as to the structure of the practice and each team member’s knowledge and skill level. Interventions can include:
- All five A’s
- Advice to quit
- Referring a patient to a quitline, a web-based program, off-site counseling, or other community resources
- Providing self-help materials
- Brief, intermediate, or intensive counseling with or without follow-up visits
- Group visits
The 2008 update of the USPHS guideline specifically recognizes Ask and Act as an alternative format to deliver a brief tobacco cessation intervention. It is consistent with the AAFP policy on tobacco use and smoking, which was updated by Ask and Act advisors and approved by the AAFP Congress of Delegates in 2008.
Health care professionals often lack systems to:
- Track patients to determine who needs preventive services
- Contact those patients to remind them to get the services
- Remind themselves to deliver preventive services when they see their patients
- Ensure services are delivered correctly and that appropriate referrals and follow-up occur
- Make certain that patients understand what they need to do7
Barriers to successful interventions include:
- Lack of patient motivation (63 percent)
- Limited coverage for interventions (54 percent)
- Limited reimbursement (52 percent)
- Limited time with patients (41 percent)
- Limited availability of cessation programs (39 percent)8
The 2008 update of the USPHS guideline calls for systems-level interventions to ensure that tobacco use is systematically assessed and treated at every clinical encounter. The current rates of comprehensive intervention by physicians is well below what is desirable and effective.4 To ensure comprehensive intervention, medical practices need to establish a system with the following integrated components:
- Smoking status as a vital sign
- Chart markers or computer prompts to remind clinicians of the need to discuss smoking
- A clearly-defined, time-limited role for clinicians to assess interest in quitting, encourage quitting for those not currently interested, and encourage use of cessation medications and follow-up
- Systematic ways, which do not require physician time, to provide patients with more information about and support for quitting, such as having an office nurse or educator provide this information, or referral to a quitline or other counseling resource
- Automatic follow-up phone calls by a nurse or educator for those who have set a quit date
- A flow sheet in the chart or computer record so the clinician can see a summary of past smoking discussions and quit attempts9
The transformation of primary care offices from condition- and treatment-centered practices to patient-centered medical homes offers a significant opportunity to improve the rate of interventions for tobacco dependence. This new model of care is based on a continuous relationship between patient and physician, where a team takes collective responsibility for the patient's ongoing care.
Electronic health records (EHRs) allow for integration of the USPHS guideline recommendations into the practice workflow, facilitating system-level changes to reduce tobacco use. The AAFP and the American Academy of Pediatrics developed a joint statement advocating that:
- EHRs include a template that prompts clinicians or their practice teams to collect information about tobacco use, secondhand smoke exposure, cessation interest, and past quit attempts
- EHRs include automatic prompts that remind clinicians to encourage quitting, advise about smoke-free environments, and connect patients and families to appropriate cessation resources
- The automated prompts and template appear when patients present with complaints such as cough, upper respiratory problems, diabetes, ear infections, hypertension, depression, anxiety, and asthma, as well as for well-patient examinations
Tobacco Use in Rural Areas
Within nearly all age, income, and racial and ethnic groups, household smoking rates are higher in rural areas than in metropolitan areas. Exposure to secondhand smoke in the household is considerably more common in rural areas.10 Family medicine is the specialty most likely to be found in rural communities. Family physicians constitute nearly 90 percent of all primary care rural physicians and are the only source of medical care in many remote rural communities.11
Tobacco Use Among Special Populations
In certain populations, the prevalence of tobacco use is higher than that in the general population. Tobacco use poses an immediate, increased health threat to:
- Smokers who are human immunodeficiency virus-positive
- Hospitalized smokers
- Lesbian, gay, bisexual and transgender smokers
- Smokers of low socioeconomic status and/or those with limited formal education
- Smokers with comorbid conditions including cancer, cardiac disease, chronic obstructive pulmonary disease, diabetes, and asthma
- Older smokers
- Smokers with psychiatric disorders, including substance use disorders
- Racial and ethnic minority populations
- Pregnant smokers4
Family physicians are often the primary health care providers for these patients who often want to quit. The AAFP encourages its members to Ask these patients about tobacco use and Act to provide evidence-based treatments to help them quit.
Tobacco Use Prevention
Each day, more than 3,500 children in the United States try their first cigarette; another 1,000 become new regular, daily smokers.12 About one third of all youth smokers will eventually die prematurely from smoking-caused disease.13 In addition to the well-known, long-term health effects, children who smoke may immediately experience increased heartbeat and blood pressure, respiratory problems, reduced immune function, increased illness, tooth decay, gum disease, and precancerous gene mutations.14
The tobacco industry spends more than $13.1 billion each year to promote use of their products. Much of that marketing directly reaches and influences children.15, 16
The AAFP encourages its members to talk to children and adolescents about the risks of tobacco use and to participate in community prevention programs, such as Tar Wars. Tar Wars is a tobacco-free education program for fourth and fifth grade students. It teaches children about the short-term consequences of tobacco use, the cost associated with using tobacco products, and the advertising techniques used by the tobacco industry to market their products to children. This massive state and national initiative culminates in an annual national poster contest in Washington, DC, where state winners network with family physicians, constituent chapter staff, Tar Wars coordinators, and other national tobacco control advocates. The children also visit their legislators, share their winning posters, and advocate for tobacco control and prevention issues.
Tar Wars provides an opportunity for family physicians, residents, and medical students to introduce family medicine to their community. These health professionals serve as role models in their communities as volunteer presenters in elementary schools. Tar Wars is the only tobacco prevention program for children offered by a medical specialty organization in the United States, and has reached more than 8 million children. It has been active in all 50 states, several territories, and 16 other countries.17
Repeated clinical tobacco-cessation counseling is one of the three most important and cost-effective preventive services that can be provided in medical practice.9 The AAFP strongly advocates for health plan coverage and appropriate reimbursement for evidence-based physician services for treatment of tobacco use. The AAFP recommends that all tobacco users in the United States be aware of the existence of and have barrier-free access to all evidenced-based U.S. Food and Drug Administration (FDA)-approved therapies and counseling as described in the USPHS guideline.
The Centers for Medicare and Medicaid Services (CMS) has paid physicians for smoking cessation counseling provided to Medicare beneficiaries since 2005.
Research and Development
The available budgets in the public and private sectors for development of new technologies and approaches to treatment are not commensurate with the size of the tobacco use epidemic. The AAFP encourages increased funding for the pursuit of innovative approaches to helping people quit, including medications, counseling, policy change, and improvements in primary care clinic systems.
Few health care professionals know the guidelines for treating tobacco dependence.18 The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) and the 2008 update of the USPHS guideline recommend that all health care professionals, including students in health care training programs, receive education in the treatment of tobacco use and dependence.4,19 Despite these recommendations, students in the health professions receive inadequate training for treating tobacco use and dependence. In an international survey assessing the tobacco-related content in medical school curricula, only 34 percent of schools reported that they provide training on smoking cessation techniques.20
The AAFP strongly advocates in-depth, effective education in prevention and cessation of tobacco use in medical schools and residency programs, and encourages family physicians to participate in continuing medical education (CME) activities and programs related to prevention or cessation of tobacco use. The AAFP also strongly encourages organizations involved in the creation of CME to integrate tobacco use treatment. Organizations involved in the ongoing credentialing of primary care physicians, such as the American Board of Family Medicine, should include questions about tobacco dependence treatment in examinations and test preparation materials. The AAFP provides educational materials for members at www.askandact.org.
The AAFP strongly supports prohibiting the use of tobacco products in all public places. Family physicians should advise their patients, especially those with cardiovascular diseases or other chronic conditions, to avoid establishments that permit smoking and to request that family members not smoke in their home or vehicle. Family physicians should specifically address the problems of exposure of children to tobacco smoke, as well as encourage cessation for all adult household members. The AAFP urges all employers to provide smoke-free work environments and incentives for employees who participate in cessation programs. Family physicians and AAFP constituent chapters are encouraged to work with local governments and agencies to advocate for clean indoor air ordinances and regulations.
Taxation and Subsidies
The AAFP recognizes that most states and the federal government tax cigarettes and believes that increasing taxes on tobacco products provides a major disincentive to potential buyers, especially youth. The AAFP encourages the development of health education and other tobacco control programs funded by the taxes collected on cigarettes, and it strongly opposes all federal price support of the tobacco industry.
The AAFP supports its constituent chapters as they seek to ensure that funds from the Master Settlement Agreement or excise taxes on tobacco products be used for tobacco prevention, cessation, education, and other elements of comprehensive tobacco control. Suggested spending levels from the CDC’s “Best Practices for Comprehensive Tobacco Control Programs” should be followed in funding of these activities across the nation.
FDA Regulation of Tobacco Products
The AAFP believes the FDA should have authority to regulate the manufacturing, sale, labeling, distribution and marketing of tobacco products and nicotine delivery devices, including products such as nicotine water. FDA decisions should be subject to the same standard of review that generally applies under the Food, Drug, and Cosmetic Act. The tobacco industry should respond to the same regulatory forces that govern other similar industries and should not be able to choose the amount of regulation they accept.
FCTC Health Treaty
Across the world, tobacco use claims more than 5 million lives each year, with projections that by 2030, the toll will rise to about 8 million annual deaths.21 Because of shifts in consumption trends away from developed nations like the United States, most of this pandemic will occur in developing nations in Asia, South America, and Africa, where health care systems are inadequate for addressing prevention, cessation, and disease management issues.22
The FCTC is the world’s first global public health treaty that requires nations to adopt a comprehensive range of measures designed to reduce the devastating health and economic impact of tobacco use. Work on the treaty began in 1999 at the WHO, and in 2003 was unanimously adopted by the World Health Assembly and opened for signature.23 Among many other medical and health care organizations, the FCTC is supported by the American Medical Association, the American Cancer Society, the American Thoracic Society, and the American Society of Clinical Oncologists. The World Organization of Family Doctors added its support to the FCTC in 2004.24
The FCTC demand reduction provisions are:
- Price and tax measures to reduce the demand for tobacco products
- Non-price measures to reduce the demand for tobacco products address:
- Protection from exposure to tobacco smoke
- Regulation of the contents of tobacco products
- Regulation of tobacco product disclosures
- Packaging and labeling of tobacco products
- Education, communication, training, and public awareness
- Tobacco advertising, promotion, and sponsorship
- Demand reduction measures concerning tobacco dependence and cessation
The core supply reduction provisions address:
- Illicit trade in tobacco products
- Sales to and by minors
- Provision of support for economically viable alternative activities to tobacco farming and production19
The United States signed the treaty in 2004, but it has yet to be sent to the Senate for ratification. The AAFP supports the FCTC, and urges Senate ratification and presidential signature of the treaty.
Call to Action
The AAFP urges all state, federal, and private sector institutions involved in tobacco prevention and cessation treatment to increase and coordinate their efforts. Bold new initiatives to dramatically and rapidly decrease the harm caused by tobacco use are called for. The AAFP and its individual members will work in partnership to help stem the epidemic of tobacco-related death and disease.
- Centers for Disease Control and Prevention. Smoking & tobacco use. Data highlights 2006: Document abstract. Atlanta, Ga.: U.S. Department of Health and Human Services. http://www.cdc.gov/tobacco/data_statistics/state_data/data_highlights/2006/index.htm(www.cdc.gov). Accessed March 12, 2009.
- Bonnie RJ, Stratton KR, Wallace RB. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: Institute of Medicine, National Academies Press, 2007.
- Centers for Disease Control and Prevention. Smoking-attributable mortality, morbidity, and economic costs (SAMMEC). http://apps.nccd.cdc.gov/sammec/(apps.nccd.cdc.gov). Accessed March 12, 2009.
- Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical practice guideline. Rockville, Md.: U.S. Dept. of Health and Human Services. Public Health Service, 2008.
- Centers for Disease Control and Prevention (CDC). Physician and other health care professional counseling of smokers to quit—United States, 1991. MMWR Morb Mortal Wkly Rep. 1993;42 (44):854-7.
- American Academy of Family Physicians. Tobacco and smoking. http://www.aafp.org/about/policies/all/tobacco-smoking.html. Accessed March 12, 2009.
- National Commission on Prevention Priorities. Preventive Care: A National Profile on Use, Disparities, and Health Benefits. Washington, DC: Partnership for Prevention, August 2007. http://www.prevent.org/data/files/initiatives/sanchezslides9-20-07.pdf(www.prevent.org). Accessed March 12, 2009.
- Physician Behavior and Practice Patterns Related to Smoking Cessation Summary Report. Washington, DC: American Association of Medical Colleges, May 2007. http://www.aamc.org/download/55438/data/(www.aamc.org). Accessed March 12, 2009.
- Solberg LI, Maciosek MV, Edwards NM, Khanchandani HS, Goodman MJ. Repeated tobacco-use screening and intervention in clinical practice: health impact and cost effectiveness. Am J Prev Med. 2006;31(1):62-71.
- Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of Children's Health 2003. Rockville, Md.: U.S. Dept. of Health and Human Services, 2005.
- National Rural Health Association Issue Paper: Recruitment and Retention of a Quality Health Workforce in Rural Areas. November 2006.
- Substance Abuse and Mental Health Services Administration. 2007 National survey on drug use and health: detailed tables. Washington, DC: U.S. Dept. of Health and Human Services. http://www.oas.samhsa.gov/NSDUH/2k7NSDUH/tabs/Sect4peTabs10to11.pdf(www.oas.samhsa.gov). Accessed March 12, 2009.
- Centers for Disease Control and Prevention (CDC). Projected smoking-related deaths among youth—United States. MMWR Morb Mortal Wkly Rep. 1996;45(44):971-974.
- Campaign for Tobacco-Free Kids. Smoking’s immediate effects on the body. http://tobaccofreekids.org/research/factsheets/pdf/0264.pdf(tobaccofreekids.org). Accessed March 12, 2009.
- Cigarette report for 2004 and 2005. Washington, DC: U.S. Federal Trade Commission, 2007. http://www.ftc.gov/reports/tobacco/2007cigarette2004-2005.pdf(www.ftc.gov). Accessed March 12, 2009.
- Smokeless Tobacco Report for the Years 2002–2005. Washington, DC: U.S. Federal Trade Commission, 2007. http://www.ftc.gov/reports/tobacco/02-05smokeless0623105.pdf(www.ftc.gov). Accessed March 12, 2009.
- American Academy of Family Physicians. About Tar Wars. http://www.aafp.org/patient-care/public-health/tobacco-cessation/tar-wars.html. Accessed May 12, 2009.
- Reichert VC, Folan P, Bartscherer D, et al. Healthcare providers (prescribers vs nonprescribers) knowledge of tobacco-related issues including drug interactions with nicotine. Chest. 2008;134:s53003. http://journal.publications.chestnet.org/article.aspx?articleid=1095174(journal.publications.chestnet.org). Accessed March 12, 2009.
- WHO Framework Convention on Tobacco Control. Geneva, Switzerland: World Health Organization, 2005. http://whqlibdoc.who.int/publications/2003/9241591013.pdf(whqlibdoc.who.int). Accessed April 17, 2009.
- Richmond RL, Debono DS, Larcos D, Kehoe L. Worldwide survey of education on tobacco in medical schools. Tob Control. 1998;7(3):247-252.
- WHO Report on the Global Tobacco Epidemic, 2008. http://www.who.int/tobacco/mpower/mpower_report_tobacco_crisis_2008.pdf(www.who.int). Accessed April 16, 2009.
- Framework Convention Alliance, Why have a treaty? http://www.fctc.org/index.php?option=com_content&view=article&id=9&Itemid=7(www.fctc.org). Accessed May 1, 2009.
- World Health Organization (WHO) Framework Convention on Tobacco Control. http://www.who.int/fctc/en/(www.who.int). Accessed May 1, 2009.
- Global Family Doctor. Educational resources on tobacco. http://www.globalfamilydoctor.com/links/link/tobacco.asp?refurl=ed. Accessed May 1, 2009.