Physician's Weekly Article - Tobacco Dependence: Guidelines for All Providers

       New tobacco dependence guidelines provide a blueprint for clinicians and healthcare systems to help smokers access effective treatments. They provide information on how to administer treatments quickly and effectively while supporting smoking cessation efforts.

      In May 2008, the United States Public Health Service released Clinical Practice Guideline Treating Tobacco Use and Dependence: 2008 Update, a guideline which describes how clinicians and healthcare systems can help reduce tobacco use. During the past 40 years, the smoking quit rate has outstripped the rate of initiation so much so that there are now more former smokers than current smokers in the United States. “Since tobacco use rates peaked in the 1960s, smoking prevalence among adults has decreased by half,” says Michael C. Fiore, MD, MPH, chair of the tobacco dependence guideline panel. “We’ve made remarkable progress in the last 50 years, especially considering that tobacco use kills about half of all users prematurely. However, current estimates suggest that about 45 million adults still smoke. If physicians aren’t successful in helping these people kick their habit, more than 20 million of these Americans will die prematurely because of their tobacco dependence.”

      Physicians Must Take the Lead

      More than 70% of smokers visit a healthcare setting each year, and Dr. Fiore says that clinicians are ideally situated to increase tobacco cessation rates and reduce patients’ risk of tobacco-related diseases. “The clinical visit represents an unequaled opportunity for physicians to provide effective interventions. Despite the fact that smoking is a substantial health threat and the availability of clinically- and cost-effective interventions, many clinicians do not consistently provide these treatments. The hope is that the 2008 guideline update will further enhance our efforts to increase the delivery of effective tobacco dependence treatments to patients who smoke.”

      The 2008 tobacco guideline update builds upon evidence from previous guidelines and provides recommendations based on systematic reviews of clinical trials, meta-analyses, and expert summaries. It serves as a blueprint on how to help smokers access effective treatments, how to provide these treatments quickly and effectively, and how healthcare systems can support smokers and clinicians in cessation efforts. “The new guidelines challenge physicians and healthcare systems to identify and document every smoker,” Dr. Fiore says, “and to then urge those smokers to quit. For patients willing to make a quit attempt, a combination of counseling and medications can optimize our ability to help smokers quit successfully. These efforts require clinicians to have a basic understanding of effective evidence-based counseling messages that are brief and knowledge on how best to use smoking cessation medications.”

      Use the 5 A’s

      Brief interventions are a critical component to the new guidelines, says Dr. Fiore. “Brief interventions are exemplified by the 5 A’s—ask, advise, assess, assist, and arrange [Table 1]. Physicians need to ask about tobacco use at every patient visit, advise smokers to quit, assess readiness of smokers to make a quit attempt at this time, assist smokers with quit plans, and then arrange follow-up visits. The 5 A’s are an effective protocol for managing smokers. It can be administered cost-effectively throughout healthcare systems to all smokers, regardless of their intention to quit. It sets a clinical standard that promotes consistent identification and documentation of tobacco use status. It also guides physicians on how to provide evidence-based treatments to every tobacco user seen in healthcare settings.”

      Dr. Fiore points out that only about one out of every five people who visit their physician smoke. “Performing brief interventions for these individuals will not substantially increase physician workloads,” he says. “Once smokers are identified, it’s imperative that brief counseling messages are provided, encouraging them to nail down a quit date, ideally within the next 2 weeks. These brief interventions should also include asking patients about their past quitting attempts and anticipating factors that may increase or decrease their chances for quitting. It’s also important to discuss alcohol use, including reducing or abstaining from alcohol for the first month or so after quitting smoking, because this may increase relapse risk. Furthermore, efforts should be made to get household members to quit smoking together or set ground rules at the patient’s home. These messages can be covered in just a few minutes during patient visits, but are tremendously helpful, especially when used in combination with medications approved for smoking cessation [Table 2].”

      A Task for All Providers

      Other caregivers and specialists, particularly surgeons, should also review the 2008 tobacco dependence guidelines and implement these recommendations, according to Dr. Fiore. “Studies have demonstrated that surgery patients who quit smoking have improved mortality rates, shorter hospitalizations, and fewer postoperative complications. In general, all clinicians must share the responsibility and address our leading cause of preventable illness and death.”

      Michael C. Fiore, MD, MPH, has indicated to Physician’s Weekly that in the last 5 years he has lectured and consulted for Pfizer and has served as an investigator on research studies at the University of Wisconsin (UW) that were supported by GlaxoSmithKline, Nabi, Pfizer, and sanofi-aventis. In 1998, he was appointed Chair at UW funded by a gift to UW by GlaxoWellcome.