Despite Gains in Managing Tobacco Use, Obesity, More Is Needed

AAFP Delegates to AMA Voice Family Medicine's Perspectives

July 12, 2013 04:02 pm Cindy Borgmeyer

AAFP President Jeff Cain, M.D., questions the wisdom of withholding any therapeutic option that could help smokers kick the habit during the 2013 annual meeting of the AMA House of Delegates.

There's probably not a patient panel in the world that doesn't include its share of patients affected by tobacco use or obesity. Given the extreme morbidity and mortality associated with these two public health scourges -- to say nothing of the immense sums expended each year on medical care related to these issues -- it's hard to imagine that policymakers would hesitate to pull out all the stops to combat them.

Yet it wasn't until 2011, after passage of the Patient Protection and Affordable Care Act, that Medicare began paying for tobacco cessation counseling for all tobacco users covered by the federal benefit program rather than only for those diagnosed with a tobacco-related disease or symptoms of such a disease. And it took until November of that year for CMS to announce it would begin paying for preventive services to reduce obesity(

Even in the medical community, questions still remain about how best to approach management of patients with these issues. That became clear during the 2013 annual meeting of the AMA House of Delegates, June 15-19 in Chicago, when AAFP delegates helped shape new policy in the aptly named "House of Medicine."

Don't Restrict Smoking Cessation Options

As one of the creators of Tar Wars, an AAFP tobacco-free education program for fourth- and fifth-grade students that is now in its 25th year, smoking cessation is a major issue for AAFP President Jeff Cain, M.D., of Denver. So when a resolution that seemed to question the usefulness of key anti-tobacco interventions came up for debate, Cain was quick to protest.

Story Highlights
  • Although Medicare has begun paying for tobacco cessation counseling and some preventive services to reduce obesity, many private health insurers still don't.
  • Recent actions by the AMA House of Delegates show that questions about how best to approach management of these public health issues remain among members of the medical community.
  • At last month's annual meeting, AAFP delegates to the AMA staunchly defended patient access to anti-tobacco pharmacotherapy and supported a measure declaring obesity to be a disease.

As originally submitted, the resolution asked the AMA to

  • inform physicians and public health professionals about the documented long-term efficacy of nonpharmaceutical abrupt-cessation smoking cessation protocols;
  • encourage research on and evaluation of smoking cessation protocols that promote abrupt cessation of smoking without reliance on pharmaceuticals; and
  • petition The Joint Commission to amend (its) requirement regarding smokers being discharged from hospitals to recognize smoking cessation protocols with documented efficacy, not reliant on pharmaceuticals, as smoking cessation options.

Pointing to the extreme morbidity and mortality caused by tobacco use in the United States in reference committee testimony on June 16, Cain questioned the wisdom of withholding any therapeutic option that could help smokers and other tobacco users kick the habit.

"To discourage the public from using pharmacotherapy would be a disservice to our patients," Cain said, citing recent findings from the Cochrane Reviews( and information from the U.S. Preventive Services Task Force's recommendations on preventing tobacco use in adults and pregnant women(, each of which upheld the efficacy of both pharmaceutical options and counseling interventions to help smokers quit.

American Association of Public Health Physicians delegate Kevin Sherin, M.D., added his perspective, saying that when positive patient outcomes are the goal, it's important to not let the means overshadow the end. "With pharmaceuticals, without pharmaceuticals -- that's up for debate. But if there's an intensive therapy that will help our patients -- well, that's the bottom line," said Sherin.

Other speakers also raised concerns about the effectiveness of abrupt cessation compared with pharmaceutical interventions and counseling, noting that the AMA has endorsed the U.S. Public Health Service's clinical practice guideline, Treating Tobacco Use and Dependence: 2008 Update(, which concluded that clinical interventions significantly increase long-term quit rates compared with those among patients who quit "cold turkey." Still others objected to the idea that the AMA was being asked, in effect, to advocate (i.e., expend funds on) smoking cessation protocols already being promoted by their own industry backers.

Those concerns and others led to the resolution's author offering an amendment to strike the first and third resolved clauses, leaving only the call to encourage closer examination of abrupt cessation protocols that don't include use of pharmaceuticals.

"By recognizing obesity as a disease, we can better focus treatment for our patients," AAFP resident delegate Michelle Cooke, M.D, tells AMA delegates.

In the end, delegates agreed, voting to adopt the amended measure.

What's in a Name?

Two measures that came before the same reference committee dealt with the concept of obesity as a disease state.

One, an AMA Council on Science and Public Health (CSPH) report, determined that in the absence of a single, authoritative definition of disease, the lack of "a sensitive and clinically practical diagnostic indicator of obesity," and uncertainty regarding whether this recognition would improve or exacerbate patient outcomes, the AMA would be premature in labeling obesity a disease. Council members recommended, rather, that the AMA reaffirm earlier policies naming obesity as "a major public health problem" and supporting research and education regarding the efficacy of obesity screening and interventions.

AAFP Offers Resources, Tools to Address Tobacco Use, Obesity

In addition to the AAFP's Tar Wars program, which focuses on reaching fourth- and fifth-graders through a tobacco-free educational curriculum that volunteers -- many of them family physicians -- present in school classrooms across the nation, the Academy's Ask and Act program encourages family physicians to ask their patients about tobacco use, then act to help them quit.

The Ask and Act practice toolkit provides a comprehensive coding reference(139 KB PDF) that gives CPT and ICD-9 codes related to tobacco cessation counseling; a one-page chart that explains the new tobacco cessation Medicare benefits; numerous guides to help family physicians manage patients who are tobacco users; and more.

Americans in Motion-Healthy Interventions (AIM-HI) focuses on fitness as the treatment of choice for preventing and managing overweight, obesity and many other chronic conditions. AIM-HI defines fitness as encompassing three key components: physical activity, healthy eating, and emotional well-being.

The AAFP offers multiple tools for implementing AIM-HI in physician practices. Another key resource published in May, the e-book Diagnosis and Management of Obesity(0 bytes), is available as a free download.

The second, a resolution asking the AMA to officially designate obesity as a disease brought AAFP resident delegate Michelle Cooke, M.D., of Atlanta, to the microphone during the reference committee hearing. Specifically, the proposal asked the AMA to "recognize obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention."

"In addition to the significant comorbid conditions associated with obesity -- heart disease, stroke, type 2 diabetes, to name a few -- obesity has significant costs to our health care system," Cooke testified, citing a CDC statistic that estimated the nation spent $147 billion in 2008 on obesity-related care. "By recognizing obesity as a disease, we can better focus treatment for our patients," she said.

Others, including Illinois State Medical Society delegate Theodore Kanellakes, M.D., pointed out that regardless of the causes of obesity, which some opponents held out as a rationale for denying it disease status, "In order to get reimbursed, we need to take this step." His remarks referred to the fact that although Medicare covers a series of primary care visits for obesity counseling, private health insurers often do not provide the same coverage.

Cain seconded that notion, saying that classifying obesity as a disease would go a long way toward convincing health insurers to pay for treatment.

Robert Gilchick, M.D., M.P.H., an American College of Preventive Medicine delegate and a member of the CSPH, spoke against the measure, however, saying it would stigmatize obese patients.

"Why would we accept a definition of disease that would affect one-third of our population?" In some areas, he added, "one out of five kids would be affected by such a definition."

"We need to address the problems that are leading to that. Further medicalization isn't helping."

"If it's not a disease, what is it?" countered former CSPH chair and California Medical Association alternate delegate Melvyn Sterling, M.D., citing a litany of health conditions closely linked to obesity, such as diabetes and cardiovascular disease. "Obesity is a disease. It's harmful to patients; it's harmful to the economy. Let's call it what it is."

Despite the reference committee's recommendation that the resolution be adopted, the June 18 business session saw more spirited discussion on both sides of the issue, with one delegate offering an amendment that would add the words "medically complicated" to the resolution.

"Waiting to call obesity a disease until it's medically complicated is like waiting for a retinopathy to call diabetes a disease," Cain responded. His remarks sparked applause, and numerous other delegates chimed in, supporting the position that obesity is a bona fide disease that should be addressed before medical complications arise.

Ultimately, the amendment was defeated and the original resolution was adopted, along with the policy reaffirmation recommendations contained in the CSPH report.

There may be more to come on the obesity front: On June 19, Sen. Tom Carper, D-Del., introduced legislation that would direct HHS to develop a coordination plan for federal efforts to reduce obesity, as well as allow Medicare Part D coverage of obesity-related medications. The AAFP just this week announced its support of that proposal, known as the Treat and Reduce Obesity Act (S. 1184).