Across the United States, roughly 1,300 people will die today as a result of cigarette smoking. Multiply that over the course of a year, and the death toll is higher than the populations of many large U.S. cities, with almost one person dying every minute of every hour of every day.
Adam Goldstein, M.D., M.P.H.
Compounding the tragedy is the fact that nearly 70 percent of smokers want to quit(www.cdc.gov), and more than half will try to stop at least once during a given year. A large majority, however, will need strong support to overcome an addiction that, many experts say, is more powerful than addiction to heroin.
We know that patients who are advised to quit smoking by their physicians have a 66 percent higher rate of success than those who receive no such counseling. Yet less than half of tobacco users get a strong quit message from their physician. That's unfortunate, because evidence has shown that appropriate counseling and medication significantly increase the likelihood of success.
Physicians may soon notice an uptick in the number of patients who proactively ask for help. Earlier this month, the CDC resumed its national Tips From Former Smokers(www.cdc.gov) campaign. The nine-week effort will include advertisements on television, radio, billboards, online and in print publications and movie theaters. The messages once again will feature real people who have suffered severe consequences of smoking, including gum disease, lung cancer, head and neck cancer, and preterm birth.
As part of the Tips campaign, the CDC has created a Web page(www.cdc.gov) to spotlight numerous tobacco-cessation resources -- both its own and those of other health care organizations, including the AAFP -- that are available to health care professionals
Past experience shows that these CDC initiatives work. During the airing of a previous series of Tips From Former Smoker advertisements, calls to quitlines more than doubled(www.cdc.gov).
Coinciding with the CDC's efforts, the FDA launched an initiative earlier this year aimed at youth ages 12-17. The Real Cost campaign(therealcost.betobaccofree.hhs.gov) is designed to educate children about the loss of control and other costs associated with smoking, including how it alters their appearance. A list of the cancer-causing constituents in cigarettes is also featured on the campaign's website.
So what can we all do to help teens and adults quit smoking? There's never been a better time to get involved. Provisions of the Patient Protection and Affordable Care Act (ACA) ensure not only that more patients will have access to tobacco-cessation products and services, but that physicians can be paid for counseling(www.lung.org). The ACA also requires that Medicaid programs expand eligibility for tobacco-cessation services to all low-income adults beginning this year, and it also requires coverage of tobacco-cessation medications in all states. Given that nearly one-third of Medicaid enrollees smoke, this is a huge step forward.
The ACA also requires most health plans to cover, with no cost-sharing by patients, preventive services that have received an A or B grade recommendation from the U.S. Preventive Services Task Force. It was initially unclear how this would be applied to tobacco cessation, but HHS clarified in May(www.lung.org) that most health plans will be required to cover screening for tobacco use and two quit attempts (with four counseling sessions each) per year, including medications.
Patients often need more than one attempt to succeed in quitting. Fortunately, we family physicians are well-positioned to help in this endeavor because we build relationships -- and trust -- with patients over time. At the University of North Carolina, we recently completed focus groups with patients in which we asked tobacco users what they want from physicians regarding this issue.
Overwhelmingly, we heard that patients want their physicians to be genuine, caring and respectful -- not judgmental. So, how should we proceed? Here's a realistic plan of action:
- Ask patients whether they want to quit.
- Give a strong message that quitting is important to their health and to the health of the people around them, that you care, and that you and your staff are there to help.
- Offer one of the seven FDA-approved medications that can double or triple quit rates.
- Offer a referral to national and state-supported quit lines (800-QUIT NOW [784-8669]) for free support services.
- Then, prove you care by following up.
Incredibly, lifesaving conversations can happen in as little as three minutes. We also can provide social support with patient education materials and self-help goal-setting relevant to meaningful use criteria and the patient-centered medical home.
In addition, patients need to develop their own strategies to combat the behavioral cues that prompt them to smoke, whether it is boredom, stress or an after-meal craving. It's important for them to determine what they can do for a few minutes until the urge subsides. If we suggest a few strategies -- such as going for a short walk or deep breathing -- they likely will be able to come up with more on their own.
On Aug. 7, the AAFP and the American Academy of Pediatrics will offer a webinar for clinicians(www3.gotomeeting.com) about how the CDC and FDA campaigns can bolster discussions with patients and families about tobacco cessation. Please join us for this important discussion.
Adam Goldstein, M.D., M.P.H., is a professor of family medicine at the University of North Carolina at Chapel Hill School of Medicine and founded and directs the university's Tobacco Intervention Programs, including its Nicotine Dependence Program.