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Am Fam Physician. 2011;84(2):162-164

Author disclosure: No relevant financial affiliations to disclose.

Despite significant advances in pharmacotherapy and counseling techniques, tobacco use remains the leading cause of death in the United States, accounting for 443,000 premature deaths annually.1 Previous declines in smoking rates have stalled over the past five years.2 Family physicians are in an ideal position to influence cessation rates because more than 70 percent of smokers see a physician each year, and even two or three minutes of physician advice can lead to smoking cessation.3 The National Commission on Prevention Priorities ranks tobacco screening plus brief intervention as the preventive service with the greatest potential for saving quality-adjusted life-years. Offering such counseling to 90 percent of smokers would save an additional 42,000 lives annually.4

Unfortunately, significant barriers to counseling exist, including lack of time, knowledge, skills, staff, and reimbursement. As a result, only one in five smokers receives counseling during physician visits. 5 In 2004, the U.S. Department of Health and Human Services created a national quitline number (800-QUIT-NOW), making smoking cessation counseling available in every state. The quitline gives physicians a viable referral option that is easily integrated into their counseling strategy and that is consistent with the principles of the patient-centered medical home.6

Referral to telephone quitlines is an attractive alternative for physicians who lack the time and resources to provide effective counseling. A recent U.S. Public Health Service clinical practice guideline recommends that medical practices systematically identify and counsel smokers and also refer them to a quitline. 7 With the ability to perform counseling outside the time constraints of an office encounter and over a series of sessions, quitlines are well positioned to provide more intensive counseling. Information about each state's quitline, including hours, eligibility requirements, and services provided, is available from the North American Quitline Consortium at

Physicians can arrange counseling by advising patients to call or by making fax referrals to the quitline. Advising patients to call a quitline is an approach advocated by a number of initiatives, including the American Academy of Family Physician's Ask and Act tobacco cessation program. 8 Fax referral (available in most states) can be initiated while the patient is in the office, prompting the quitline to attempt reaching the patient for intake screening and enrollment. These referrals usually involve preprinted forms, which require the patient's name, address, age, sex, telephone numbers, best time to call, and consent to be contacted. In addition, links to electronic medical records are being developed and evaluated.

The effectiveness of quitline counseling is well established. A Cochrane review reported successful cessation in patients who received counseling from quitlines (number needed to treat = 32).9 Quitline counseling combined with smoking cessation medications is particularly effective, with a cessation rate of 28.1 percent (more than three times the rates with minimal or no counseling or with self-help).7

There are a number of things family physicians can do to improve their collaboration with quitlines. Now is the time to implement a systematic, team approach to smoking cessation counseling in your office. Promote 800-QUIT-NOW to any patient who wants to quit. Posters, prescriptions, and wallet cards with the toll-free number are available at Enroll your practice in your state's fax referral program. Be aware that tracking down patients costs quitlines time and money, so save fax referrals for those who are ready to make a quit attempt in the next 30 days and willing to talk with the quitline. Cessation medications have a synergistic effect with counseling, so recommend/prescribe them when appropriate before the referral, or make it easy for patients to call back for a prescription after discussing medication options with the quitline. Motivational interviewing can ready patients for quitlines. Another Cochrane review found that this directive, patient-centered counseling style was most effective when delivered by primary care physicians (number needed to treat = 18). 10

Tobacco dependence is a chronic disease, so do not get discouraged. Although only some smokers who undergo counseling will quit in the short-run, the decreased morbidity and mortality for each patient who succeeds steadily improves the health of your practice population.

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