Abstract
Corresponding Author(s)
Angela Cole Westhoff, Maine Osteopathic As- sociation, 693 Western Ave., #1, Manchester, ME 04274.
E-mail address: awesthoff@mainedo.org.
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A generation of transformation
This year President Obama signed into law historic legisla- tion1 to allow FDA regulation of tobacco. The bipartisan support of this legislation echoes the paradigm shift in our approach to treating tobacco use, highlighting the cultural transformation that has swept our nation in the last generation with regard to our perception of tobacco use and dependence. This review is presented in conjunction with the American Cancer Society’s Great American Smokeout, which in 2009 celebrates its 34th Anniversary. Held annually on the third Thursday in November, this year the Smokeout is planned for November 19, 2009. The initial purpose of the event was to set aside a day to help smokers quit using both cigarettes and other tobacco products for at least one day, with the hope that they would eventually become motivated to quit completely. Trans- formed over time, the overall goal of this event is to broaden Americans’ collective consciousness about the broad and crit- ical campaign to support those afflicted by this addiction in their effort to quit using tobacco products. Not only does the event challenge people to stop using tobacco, it helps to raise awareness about the multifaceted dangers of smoking and the many effective means currently available to quit smoking per- manently.
How it started: A simple concept
In 1971, Arthur Mullaney, a Massachusetts resident, asked people to give up smoking for a day and to donate the money they would have spent on tobacco to a local high school. Then in Minnesota, Lynn Smith, editor of the Mon- ticello Times, led the charge to create the state’s first D-Day, simply called “Don’t Smoke Day”. The idea gained mo- mentum, and the California chapter of the American Cancer Society encouraged nearly one million smokers to quit for the day on November 18, 1976.2
The Great American Smokeout was inaugurated in 1976 to inspire and encourage smokers to quit for one day. Now, 39.8% of the 43.4 million Americans who smoke have attempted to quit for at least one day in the past year,3 and the Great American Smokeout remains a meaningful oppor- tunity to encourage people to commit to making a long-term plan to quit for good.
Contemporary approaches
The experience of the past four decades has culminated in a transformed culture that maintains as its social norm a plethora of public, private, and nonprofit venues of antito- bacco infrastructure. Current data suggest that smokers are most successful in kicking the habit when they have some means of support, whether it is nicotine replacement prod- ucts to curb cravings, counseling, prescription medicine, guide books, or the encouragement of friends and family members.4 The health benefits of quitting tobacco have been well documented and are now well publicized and readily available to clinicians and patients. Figure 1 outlines the health benefits of quitting over time.
Popular online social networks such as Facebook5 are also becoming support channels for people who want to quit, and American Cancer Society Smokeout–related downloadable desktop applications are available on these networks to help people quit or join the fight against to- bacco.
Epidemiology
Tobacco is the single greatest cause of disease and prema- ture death in the United States and is responsible for more than 435,000 deaths annually.6 Approximately 20% of adult Americans currently smoke,7 and 4000 children and ado- lescents smoke their first cigarette each day.8
The financial cost of tobacco-related death and disease approaches $96 billion annually in medical expenses and $97 billion in lost productivity.9 However, more than 70% of all current smokers express a desire to quit.10 There are many short-term benefits and long-term health improve- ments that will result from quitting smoking, and clinicians play a vital role in helping smokers quit.
The Surgeon General: Advocating for the public’s health
The Office of the Surgeon General has a long history of advocating on behalf of the public by exposing the risks of tobacco use. In 1964, Surgeon General Luther Terry issued the groundbreaking report on smoking and health.11 The primary responsibility of the Surgeon Gen- eral is to protect and maintain the health of the American people, and Surgeon General Terry recognized that to meet that obligation, he would have to call for a funda- mental change in how our country viewed tobacco use. Dr. Terry also knew that by issuing the results of the research available to him at the time— data that demon- strated causality between smoking and three diseases: lung cancer, atherosclerotic heart disease, and cerebro- vascular disease— he was taking aim at one of the per- vasive symbols of American life, the cigarette.
In 1964, more than 42% of Americans smoked.12 In fact, until he started work on his smoking Report, the Surgeon General was himself a smoker.
Since that time, the culture of tobacco use in the United States has been transformed dramatically. Smoking, once the accepted norm, even in hospitals and doctor’s offices, is now unlawful in many public places,13 which in some states like Maine and California includes bars, restaurants, state parks, and public beaches.14
Recently, the US Department of Health and Human Services, in partnership with the US Public Health Ser- vice, updated the Clinical Practice Guideline Treating Tobacco Use and Dependence to further assist practicing clinicians in addressing tobacco use with their patients.
Explicit evidence-based methodology and expert clinical judgment were combined to develop the recommenda- tions on treating tobacco use and dependence. The Guide- line is based on an exhaustive systematic review and analysis of the extant scientific literature from 1975 to 2007, incorporating the results of more than 50 meta- analyses.
Treating Tobacco Use and Dependence: 2008 Update
Several authorities with recognized policy statements ad- dressing tobacco use continue to support the evidence-based approach of the US Public Health Service’s Guideline, includ- ing the American College of Preventive Medicine (ACPM), American Academy of Family Physicians (AAFP), and the United States Preventive Services Task Force (USPSTF). Al- though not yet updated with the 2008 data, the ACPM clinical recommendations on tobacco cessation and counseling can be viewed at http://www.acpm.org/polstmt_tobacco.pdf. The re- cently updated AAFP policy statement on tobacco and smok- ing can be viewed at http://www.aafp.org/online/en/home/ policy/policies/t/tobacco.html.
As published this spring in Annals of Internal Medicine, the USPSTF reviewed the new evidence in the 2008 Up- dated Guideline and has determined that the net benefits of screening and tobacco cessation interventions in adults and pregnant women remain well established.15
The following recommendations are taken directly from the US Public Health Service’s updated Guideline, which can be found on the US Surgeon General’s website.16
Key findings
The Treating Tobacco Use and Dependence guideline high- lights a number of key findings that clinicians should con- sider in their practice:
Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can sig- nificantly increase rates of long-term abstinence.
It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting.
Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encour- age every patient willing to make a quit attempt to use the recommended counseling treatments and medica- tions in the Guideline.
Brief tobacco dependence treatment is effective. Clini- cians should offer every patient who uses tobacco at least the brief treatments shown to be effective in the Guideline.
Individual, group and telephone counseling are effec- tive and their effectiveness increases with treatment intensity. Two components of counseling are especially effective and clinicians should use these when counsel- ing patients making a quit attempt:
ΠPractical counseling (problem-solving/skills training).
ΠSocial support delivered as part of treatment.
There are numerous effective medications for tobacco dependence and clinicians should encourage their use by all patients attempting to quit smoking, except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers and adolescents). See Figure 2 for the clinical use of medication for tobacco dependence treatment. ΠSeven first-line medications (5 nicotine, 2 non-nic-
otine) reliably increase long-term smoking absti- nence rates:
Bupropion SR
Nicotine gum
Nicotine inhaler
Nicotine lozenge
Nicotine nasal spray
Nicotine patch
Varenicline
ΠClinicians should also consider the use of certain combinations of medications identified as effective in the Guideline.
Counseling and medication are effective when used by themselves for treating tobacco dependence. However, the combination of counseling and medication is more effective than either alone. Thus, clinicians should en- courage all individuals making a quit attempt to use both counseling and medication.
Telephone quitline counseling is effective with diverse populations and has broad reach. Therefore, clinicians and health care delivery systems should both ensure patient access to quitlines and promote quitline use.
If a tobacco user is currently unwilling to make a quit attempt, clinicians should use the motivational treat- ments shown in the Guideline to be effective in increas- ing future quit attempts.
Tobacco dependence treatments are both clinically ef- fective and highly cost-effective relative to interven- tions for other clinical disorders. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans in- clude the counseling and medication identified as ef- fective in the Guideline as covered benefits.
Tobacco dependence as a chronic health condition
Tobacco dependence is a chronic health condition that often requires multiple, discrete interventions by a clinician or team of clinicians. The updated Guideline takes a straight- forward approach, offering clinicians a practical framework of how to best assess and address patients’ needs with regard to tobacco use. First, ask two key questions: “Do you smoke?” and “Do you want to quit?” Second, offer simple recommendations to assist the patient.
This approach helps to reinforce the conceptualization of tobacco use as a chronic disease, and in doing so helps to ensure the continuous improvement in recognition and treat- ment of this pervasive contributor to worldwide morbidity and mortality.
Tobacco dependence often requires repeated interven- tions and multiple attempts to quit before the patient re- mains abstinent. Effective treatments do exist and it is critical that health care providers consistently ask and doc- ument tobacco use status and treat every tobacco user in the health care setting. Even brief interventions have been shown to be effective.
The first step in this process—identification and assess- ment of tobacco use status—separates patients into three treatment categories:
Tobacco users who are willing to quit should receive interventions to help in their quit attempt.
Those who are unwilling to quit now should receive interventions to increase their motivation to quit.
Those who recently quit using tobacco should be pro- vided relapse prevention treatment.
The “5 As” of treating tobacco dependence—Ask, Advise, Assess, Assist, and Arrange for follow up—are a useful way to organize any clinician’s approach to tobacco treatment. Al- though a single clinician can provide all 5 As, it is often more clinically and cost effective to have the 5 As implemented by a team of clinicians and ancillary staff. However, when a team approach is used or when clinician extenders such as quitlines, web-based interventions, and local quit programs are used, the coordination of efforts is essential, with a single clinician retaining overall responsibility for the interventions (Figs. 3 and 4). For a more detailed discussion of implementing the 5 As, please visit the National Library of Medicine’s Health Services/Technology Assessment text website: http://www. ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.28163.
Quick Reference Guide for Clinicians
The comprehensive 2008 Guideline includes The Quick Reference Guide for Clinicians, which is designed as a user-friendly and readily available resource to enable the practicing clinician to gain point-of care access to the most up-to-date information to assist patients in the clinical set- ting. The Quick Reference Guide for Clinicians is organized conceptually around the 5 As. However, each clinical situ- ation may require that the components be ordered differ- ently or reformatted to fit the unique needs of the patient.
Tobacco users unwilling to quit at this time
Ask, Advise, and Assess every tobacco user at every visit. If the patient is unwilling to make a quit attempt, use the motivational strategies outlined next to increase the likeli- hood of the patient quitting in the future.
Such interventions might include the “5 Rs”: Rele- vance, Risk, Rewards, Roadblocks, and Repetition. In these interventions the clinician can introduce the topic of quitting and allow the patient to address the topic in their own words (Fig. 5).
Clinicians should also use open-ended questions and reflective listening to discuss the possibility of quitting with patients. Expressing empathy, asking questions, rolling with resistance, and offering support are all important in creating a culture of safety and support for the patient. More than one motivational intervention may be needed before the tobacco user commits to a quit attempt. It is essential that the patient trying to quit has a scheduled follow-up to discuss what strategies worked well and what the patient might do dif- ferently to best move forward.
Tobacco users who have recently quit should also re- ceive counseling from the clinician to determine relapse potential and for encouragement to stay abstinent. Offer congratulations and strong encouragement for the patient to remain tobacco-free. All patients who have recently quit or still face challenges should receive follow-up care for con- tinued assistance and support.
For a more detailed discussion of implementing the 5 Rs, please visit the National Library of Medicine’s Health Services/ Technology Assessment text website: http://www.ncbi.nlm. nih.gov/books/bv.fcgi?rid=hstat2.chapter.28163.
New recommendations for the 2008 guideline
Most, but not all, of the new recommendations appearing in the 2008 Update resulted from review of the recent metaanalyses chosen to be included by the Guideline Expert Panel. For additional information on the safe and effective use of medication, please visit the FDA website: http:// www.fda.gov.
Formats of psychosocial treatments
Recommendation: Tailored materials, both in print and Web-based, appear to be effective in helping people quit. Therefore, clinicians may choose to provide tailored, self- help materials to their patients who want to quit.
Combining counseling and medication
Recommendation: The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore, when- ever feasible and appropriate, both counseling and med- ication should be provided to patients trying to quit smoking.
Recommendation: There is a strong relationship be- tween the number of sessions of counseling when it is combined with medication and the likelihood of success- ful smoking abstinence. Therefore, to the extent possible, clinicians should provide multiple counseling sessions, in addition to medication, to their patients who are trying to quit smoking.
For tobacco users not willing to quit now
Recommendation: Motivational intervention techniques appear to be effective in increasing a patient’s likelihood of making a future quit attempt. Therefore, clinicians should use motivational techniques to encourage smokers who are not willing to quit to consider making a quit attempt in the future.
Nicotine lozenge
Recommendation: The nicotine lozenge is an effective smoking cessation treatment that patients should be encour- aged to use.
Varenicline
Recommendation: Varenicline is an effective smoking cessation treatment that patients should be encouraged to use.
Specific populations
Recommendation: The interventions found to be ef- fective in this Guideline have been shown to be effective in a variety of populations. In addition, many of the studies supporting these interventions comprised diverse samples of tobacco users. Therefore, interventions iden- tified as effective in this Guideline are recommended for all individuals who use tobacco, except when medically contraindicated or with specific populations in which medication has not been shown to be effective (pregnant women, smokeless tobacco users, light [<10 cigarettes/ day] smokers, and adolescents).
Light smokers
Recommendation: Light smokers should be identified, strongly urged to quit, and provided counseling treatment interventions.
Resources
In an effort to support clinicians in their use of Treating Tobacco Use and Dependence: 2008 Update, the Public Health Service has made the information included in the updated Guideline available in several frameworks:
The Quick Reference Guide for Clinicians
http://www.ahrq.gov/clinic/tobacco/tobaqrg.htm
Helping Smokers Quit: A Guide for Clinicians
http://www.ahrq.gov/clinic/tobacco/clinhlpsmksqt.htm
Additional resources and contact information are listed following the conclusion of this article.
Conclusion
Tobacco dependence is a chronic disease that deserves treat- ment. Effective treatments have now been identified and should be used with every current and former smoker. The Quick Reference Guide for Clinicians provides the tools necessary to effectively identify and assess tobacco use, and to treat:
tobacco users willing to quit,
those who are currently unwilling to quit, and
those who are former tobacco users.
There is likely no clinical treatment available today that has the potential to reduce illness, prevent death, and in- crease quality of life more profoundly than the tobacco treatment interventions outlined in this Guideline.
As we are about to embrace the broadest health reform measures our nation has ever witnessed, it has become paramount to institute those health care interventions that have proven efficacious and are widely available for patient use. The analyses contained in the 2008 updated Guideline demonstrate that evidence-based treatments for tobacco us- ers exist and should become a part of standard caregiving.
By incorporating these methodologies for the treatment of tobacco use and dependence into daily patient care, the osteopathic family physician has the opportunity to improve the lives of individual patients while positively affecting the overall health of our nation.
By definition, primary care physicians are charged with the task of confronting chronic disease management head-on, with the objective of maintaining the best quality of life possible for our patients. The goal of bringing the 2008 updated Guideline to the attention of the osteopathic family physician community in conjunction with the Great American Smokeout this No- vember is to raise our collective awareness of thinking about tobacco use as a chronic disease, while expanding recognition of the proven clinical strategies available. By doing so, we more effectively position ourselves to decrease the magnitude of effect of the number one preventable cause of morbidity and mortality.
References
H.R. 1256 –111th Congress: Family Smoking Prevention and Tobacco Control Act. (2009). In GovTrack.us (database of federal legislation). http://www.govtrack.us/congress/bill.xpd?bill=h111-1256. Accessed Oct 10, 2009
American Cancer Society: All About the Great American Smokeout. Available at: http://www.cancer.org/docroot/subsite/greatamericans/content/ All_About_Smokeout.asp. Accessed August 19, 2009
American Cancer Society: American Cancer Society Marks 33rd Great American Smokeout. Available at: http://www.cancer.org/docroot/sub- site/greatamericans/content/Media.asp. Accessed August 19, 2009
NIH State-of-the-Science Conference Statement on Tobacco Use: Pre- vention, Cessation, and Control. Ann Int Med 145:839-844, 2006
Tobacco Free Florida: Facebook site. Available at: http://www.facebook. com/TobaccoFreeFlorida. Accessed August 19, 2009
Mokdad AH, Marks JS, Stroup DF, Gerberding JL: Actual causes of death in the United States, 2000. JAMA 291:1238-1241, 2004
Centers for Disease Control and Prevention: Cigarette smoking among
adults—United States, 2007. MMWR 57:1221-1226, 2008
Centers for Disease Control and Prevention: Incidence of initiation of cigarette smoking—United States, 1965-1996. MMWR 47:837-840, 1998
Centers for Disease Control and Prevention: Tobacco Use: Targeting the Nation’s Leading Killer: At a Glance 2009. Available at: http://www.cdc. gov/nccdphp/publications/aag/osh.htm. Accessed October 2, 2009
Centers for Disease Control and Prevention: Cigarette smoking among
adults—United States, 2000. MMWR 51:642-645, 2002
Centers for Disease Control and Prevention: History of the Surgeon General’s Reports on Smoking and Health. Available at: http://www.cdc.gov/tobacco/ data_statistics/sgr/history/index.htm. Accessed October 2, 2009
Office of the Surgeon General: The Health Consequences of Smoking: A Report of the Surgeon General. 2004. Speech by Vice Admiral Richard H. Carmona, MD, MPH, FACS, United States Surgeon Gen- eral. Available at: http://www.surgeongeneral.gov/news/speeches/ SgrSmoking_05272004.htm. Accessed August 19, 2009
Tobacco.org: Reaction mixed to possible anti-smoking bill. Available at: http://www.tobacco.org/articles/category/outdoors/. Accessed Au- gust 19, 2009
WABI News–Maine: Smoking Ban on Beaches. Available at: http:// www.wabi.tv/news/5680/smoking-ban-on-beaches. Accessed August 19, 2009
Counseling and interventions to prevent tobacco use and tobacco- caused disease in adults and pregnant women: U.S. Preventive Ser- vices Task Force Reaffirmation Recommendation Statement. Ann In- tern Med 150:551-555, 2009
US Department of Health and Human Services. Office of the Surgeon General: Tobacco Cessation—You Can Quit Smoking Now! Available at: http://www.surgeongeneral.gov/tobacco/. Accessed on October 2, 2009
Additional Resources
Agency for Healthcare Research and Quality (AHRQ) 800-358-9295; www.ahrq.gov
Centers for Disease Control and Prevention (CDC) 800-CDC-1311; www.cdc.gov
National Cancer Institute (NCI)
800-4-CANCER; www.cancer.gov American Cancer Society (ACS)
800-ACS-2345; www.cancer.org
CME Resource: Osteopathic Family Physician offers 2 hours of 1-B CME
ACOFP members who read the Osteopathic Family Physician can receive two hours of Category 1-B continuing medical education credit for completing quizzes in the journal. Visit acofp.org/resources/publications.aspx to access the quizzes. | |
September/October 2009 CME Quiz Answers: 1.B, 2.A, 3.B, 4.B, 5.C, 6.A, 7.C, 8.A, 9.B, 10.D | |