to the editor: The article, “Interventions to Facilitate Smoking Cessation,” in American Family Physician1 is a good primer on the subject for family physicians; however, it contains some inaccuracies and perpetuates several misconceptions about smoking cessation interventions in primary care.
The five A's (Ask, Advise, Assess, Assist, and Arrange) model is a good organizational framework, and was promoted by the U.S. Department of Health and Human Services (HHS) 2000 clinical practice guideline;2 however, this model may not be practical or achievable during every office visit because of time constraints.3 A team approach that integrates physicians and support staff with community resources such as smoking cessation hotlines is likely to be more effective.4 The article also notes that brief smoking cessation counseling is covered by Medicare part B but incorrectly states that the minimal time for such face-to-face counseling is five minutes.1 Medicare regulations allow reimbursement for encounters lasting three minutes or more,5 a time frame that is supported by the HHS clinical practice guideline.2
Although the article1 suggests using the “stages of change” model of cessation treatment, the HHS guidelines do not support this approach due to insufficient evidence.2 Finally, the authors did not discuss the evidence supporting nonpharmacologic interventions such as intra-treatment social support, extra-treatment social support, and practical counseling about how to avoid relapse and promote abstinence.
in reply: The purpose of our article1 was to provide a summary of evidence-based smoking cessation interventions for family physicians. The 2000 Clinical Practice Guideline, “Treating Tobacco Use and Dependence,” sponsored by the U.S. Public Health Service,2 is based on a systematic review of 6,000 articles using rigorous scientific methods. One of the guideline's major recommendations is that nicotine addiction should be treated as a chronic condition that requires repeated intervention using the five A's model. While Drs. Jaén and Houston agree that the five A's model is a good organizational framework, they believe the model may not be practical or achievable in primary care settings.
Drs. Jaén and Houston seem to be suggesting an alternative approach whereby each physician decides when to apply the five A's model depending on time or other system-level constraints. This argument is not supported by current evidence, which suggests that the five A's model is effective and that it can and should be implemented in primary care settings.2,3 Their position also runs counter to how other major chronic medical conditions such as hypertension and diabetes are to be addressed. A physician would be expected to address elevated blood pressure or blood glucose levels in a clinical encounter regardless of the primary purpose of the encounter.
We agree that a team approach that integrates physician and support staff be used to address tobacco use. However, this approach should be implemented as an addition, not a replacement to, the five A's guideline.
Regarding Drs. Jaén and Houston's concern about insufficient evidence for the use of the “stages of change” 4,5 model, our discussion of this model was in the context of physicians being aware that patients have varying levels of motivation/readiness to quit smoking. Any information or advice given should take into account a patient's motivation to quit. In addition, assessing patients' motivation to quit smoking is implied in the five A's model. Finally, nonpharmacologic interventions are an important component of the smoking cessation process, and we included a brief discussion of some of them in the article(1); however, we chose to focus on pharmacologic interventions because these are more widely used by family physicians.
