Am Fam Physician. 2001 Dec 1;64(11):1881-1882.
JT is a 54-year-old man who presents for a follow-up office visit. He requests refills on his prescriptions for enalapril and atorvastatin. You are aware that he is a smoker. Before you can initiate a discussion about his tobacco use, he excitedly reports that he has set a quit date for three weeks from today. He asks about medications that might help him to quit smoking.
Although you and your colleagues see many patients like JT, your office currently has no policy for identifying and approaching patients who use tobacco products. In the past, you and your colleagues have addressed tobacco use during office visits with your patients, as needed. You have been researching how your practice might systematically help patients to reduce their tobacco consumption, using medication and smoking cessation counseling. At an upcoming office meeting, you plan to present recommendations for treating tobacco use among your patients.
The case study and answers to the following questions on counseling for tobacco cessation are based on the recommendations presented in the recently published U.S. Public Health Service (PHS) Clinical Practice Guideline, “Treating Tobacco Use and Dependence,”1 which is an updated version of the 1996 “Smoking Cessation” Clinical Practice Guideline No. 18.2 The update was written to include new, effective clinical treatments for tobacco dependence that have become available since the original guideline was developed. The complete guideline is available online at http://www.surgeon-general.gov/tobacco/default.htm.
Most of the case studies presented in this series are based on the recommendations of the U.S. Preventive Services Task Force, sponsored by the Agency for Healthcare Research and Quality; however, this case study is based on the PHS Clinical Practice Guideline, “Treating Tobacco Use and Dependence.” Specific journal references cited in the answers are provided in the discussion.
This case study is part of AFP's CME. See “Clinical Quiz” on page 1805.
Case Study Question
1. Which one of the following statements is correct?
A. Smoking cessation counseling by telephone does not work.
B. Most physicians advise all of their patients to stop using tobacco products.
C. Tobacco dependence is considered to be an acute disease.
D. Brief counseling interventions for smoking cessation are only effective when delivered by physicians.
E. Effective interventions for tobacco cessation can be delivered during a typical 10-minute office visit.
1. The answer is E: as described, the evidence shows that brief interventions of three minutes or less are effective. Two critical questions—“Do you smoke?” and “Do you want to quit?”—can ultimately save a patient's life when asked by clinicians and followed with interventions.1–3
Strong evidence suggests that smoking cessation treatments delivered by clinicians increase abstinence, whether the clinician is a physician or nonphysician (e.g., nurse practitioner, psychologist, nurse, dentist, or counselor). Therefore, all clinicians should provide smoking cessation interventions.1
“Proactive” telephone counseling is also an effective intervention for helping patients to stop smoking. In proactive telephone counseling, the clinician initiates a call to the patient and counsels him or her over the telephone. In contrast, simply providing multiple types of self-help resources, including pamphlets, booklets, videotapes, and reactive telephone hot-lines/helplines, does not significantly enhance the likelihood of smoking cessation.1
It is important to comprehensively assess each patient's tobacco use, including traditional types of tobacco (e.g., cigarettes, cigars, pipes, and smokeless tobacco) and nontraditional forms (e.g., bidis and kreteks), which have become more commonly used among adolescents and young adults.4,5 Recent surveys of middle school and high school students have indicated increasing use of both bidis (hand-rolled, flavored cigarettes imported from Asia) and kreteks (cigarettes imported from Indonesia consisting of a blend of cloves and tobacco).4,6
Although a small number of tobacco users achieve permanent abstinence during their initial attempt to quit, most persist in tobacco use for many years and typically cycle through multiple periods of relapse and remission. A chronic disease model, therefore, is appealing because it recognizes the long-term nature of the disorder and acknowledges that patients may have periods of relapse and remission. If tobacco dependence is recognized as a chronic condition, clinicians will better understand the relapsing nature of the ailment and the requirement for ongoing intervention rather than just acute care.
Several national and regional studies have shown that despite the stated intentions of clinicians, only about 25 percent of eligible smokers seen in primary care, on average, receive advice on tobacco cessation. The rates are higher during well visits and for patients with chronic diseases associated with tobacco, but there is much room for improvement.7,8 With the dissemination of the PHS guideline,1–3 all physicians have access to a valuable resource to enhance their skills to successfully deliver office-based tobacco cessation assessment and counseling.
1. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, Gritz ER, et al. Treating tobacco use and dependence. Clinical practice guideline. Washington, D.C.: U.S. Dept. of Health and Human Services, Public Health Service. June 2000. AHRQ publication no. 00–0032. Available at: http://www.surgeongeneral.gov/tobacco/.
2. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, Gritz ER, et al. Smoking cessation: clinical practice guideline no. 18. Rockville, Md.: U.S. Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Centers for Disease Control and Prevention, 1996. AHCPR publication no. 96–0692.
3. Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. A clinical practice guideline for treating tobacco use and dependence. A U.S. Public Health Service report. JAMA. 2000;283:3244–54.
4. Celebucki C, Turner-Bowker DM, Connolly G, Koh HK. Bidi use among urban youth—Massachusetts, March-April 1999. MMWR Morb Mortal Wkly Rep. 1999;48:796–9.
5. Ahern CH, Batchelor SM, Blanton CJ, Law M, Loo CM. Youth tobacco surveillance—United States, 1998–1999. MMWR Morb Mortal Wkly Rep. 2000;49(SS10):1–93.
6. Healton C, Messeri P, Reynolds T, Wolfe C, Stokes C, Ross J, et al. Tobacco use among middle and high school students—United States, 1999. MMWR Morb Mortal Wkly Rep. 2000;49:49–53.
7. Jaén CR, Stange KC, Tumiel LM, Nutting PA. Missed opportunities for prevention: smoking cessation advice and the competing demands of practice. J Fam Pract. 1997;45:348–54.
8. Jaén CR, Crabtree BF, Zyzanski SJ, Goodwin MA, Stange KC. Making time for tobacco cessation counseling. J Fam Pract. 1998;46:425–8.
Copyright © 2001 by the American Academy of Family Physicians.
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