Tc obacco Use Stephen F. Rothemich Tobacco use remains the leading cause of preventable death in the United States, a rank that it has held ever since deaths were first quantified by risk factors in the early 1990s(1, 2). In the United States, cigarette smoking and exposure to tobacco smoke account for approximately one in five deaths (438,000 people)each year, as well as 5.5 million years of potential life lost(3) Although overweight(the product of a combination of poor diet and physica inactivity) runs a close second as a leading cause, tobacco use causes more than twice as many deaths as alcohol consumption, motor vehicle accidents firearm use, unsafe sexual behavior, and illicit drug use combined. In addition to this staggering loss of life as of 2001 tobacco use cost society more than $167 billion per year through smoking-attributable health care expenditures ($76 billion)and adult productivity losses ($92 billion). Helping smokers quit is ranked by the National commission on Prevention Priorities as among the top three most effective and cost effective clinical preventive services that clinicians can offer patients (4) Smoking harms nearly every organ of the body, has been causally linked to dozens of adverse health effects(see Table 9.1), and reduces overall health status(5). Cigarette smoking alone is responsible for more than 30% of U.S cancer deaths(6). Smokeless tobacco use causes oral cancer and other ora lesions. Environmental tobacco smoke, a known human carcinogen, causes premature death and disease in children and in adults who do not smoke; scientific evidence indicates no risk-free level of exposure to secondhand smoke exists (7). Quitting smoking has both immediate and long-term benefits, reducing the risk of diseases caused by tobacco and improving health in general In 2004, 44.5 million Americans, or 20.9%0 of the adult population, smoked cigarettes; 23.4% of men smoked compared with 18.5% of women Among whites, 22. 2% smoked compared with 20.2% of blacks. The highest levels of smoking were among people aged 25-44 years(23.8%); American Indians and Alaskan Natives(33.4%); people who had earned a General Educational Development(GED) but not a standard high-school diploma (39.6%); and people living below the poverty threshold (29. 1%6)(8). Although 235
236SECT|ON‖!· WHAT TO DO WITH THE|NF○ RMATION TABLE 9. 1 Adverse Health Effects of Smoking Supported by Strong evidence Cance Bladder Cervical Esophageal Kid Leukemia L g Pancreatic Respiratory Effects Asthma(poor control) Asthma-related symptoms Chronic obstructive pulmonary disease Impaired lung gro ng function Respiratory symptoms(coughing, phlegm, wheezing, dyspnea) Cardiovascular Effe Abdominal aortic aneurysm Ath Cerebrovascular disease Coronary heart disease Reproductive Effects Low birth weigh Placental abruption Placenta previa Preterm birth Reduced fertility Sudden infant death syndrome
CHAPTER9·T○ BACCO∪SE237 TABLE 9. 1(Continued) Other Effe Cataract Hip fractures Increased absenteeism Increased health services usage Low bone density Peptic ulcer disease(Helicobacter pylori positive) Poor surgical outcomes Poor wound healin Adapted from U.S. Centers for Disease Control and Prevention. The health consequences of smoking report of the surgeon general. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2004: 2-6 the national smoking rate is slowly declining, it is still well above the national goals set in Healthy People 2010: less than 12% for adults and 16% for adolescents (9). This chapter provides clinicians and their associates with the necessary information to institute effective smoking cessation techniques in their practices. Although this chapter emphasizes smoking cessation, these interventions may be used to help smokeless tobacco users quit as well The interventions described are based on the u. S. Public Health Service (PHS) guidelines, with additional emphasis on the role of telephone"quit lines, now available in every state in the United States. Although one option for clinicians is to deliver intensive counseling as the primary focus of a series of clinic visits, an alternative is to offer simple advice to quit coupled with referral to a quit line, a 30-second option that many clinicians may find easier to incorporate into their daily practice. BACKGROUND Many clinicians recognize smoking as a major threat to a patient's health but do not feel confident in their ability to intervene effectively. Most clinicians have not experienced success in helping paticnts to stop smoking.Most have treated patients with significant tobacco-related diseases who have been unable to stop despite multiple attempts, even as they became sicker. Repeated failures to help patients stop smoking frequently cause clinicians to become discouraged and reinforce the belief that nothing can be done
238SECT|○N‖· WHAT TO DO V| TH THE|NF○RMAT|ON about smoking. Another barrier preventing clinicians from trying to help patients quit smoking includes a lack of formal training in tested cessation techniques. Perhaps most important, many office practices are not organized to support the delivery of smoking cessation interventions However, the evidence is clear: advice from clinicians helps smokers quit. Even providing brief, simple advice increases the likelihood that a smoker will successfully quit and remain abstinent 12 months later(10). The methods outlined here show how best to use the limited time available to impact smoking behavior among patients METHODS Treating Tobacco Use and Dependence, which is available online in its entirety(11)and in a summary for clinicians(12), details the PhS clinical practice guidelines for promoting smoking cessation among patients Clinician Intervention The clinician intervention recommended in the phs guideline comprises five activities, each beginning with the letter"A"(often referred to as the 5 As, as discussed in Chapter 5) Ask all patients about smok Advise smokers to stop Assess if the smoker is willing to make a quit attempt Assist their efforts with self-help materials, a quit date, and possibl cessation medication Arrange follow-up This intervention plan describes a general approach to patients who smoke and can be used in almost any outpatient encounter, whether th clinician and patient have 30 seconds or 30 minutes for the discussion (13/ c Ask about smoking at every opportunity. For example, a nurse or other staff member should routinely ask patients“ Do you smoke?”or“ re you still smoking?"at each visit, usually while measuring vital signs. Once it is known that a person smokes, an identifier should be placed prominently on the patient's chart to remind the clinician and staff to discuss smoking at each visit (see Fig 9. 1).(See Chapters 21 and 22 for further information about chart alert stickers, automated prompts, and other clinician reminder systems. )Patients who have never smoked or who formerly smoked should be congratulated on their decision Advise all smokers to stop. A clear statement of advice(e. g, "As your physician, I must advise you to stop smoking now)is essential. Many patients do not recall receiving this advice from their clinician. Therefore, the statement must be
CHAPTER9. TOBACCO USE 239 Tobacco use:(circle one) ret)→ Advised to quit Former Ready to M quit in next Never 30days?□N Figure 9.1. A tobacco-use "vital sign"stamp, which can appear prominently on the patient's chart where vital signs are recorded to remind the clinician and staff to systematically assess smoking status at each visit. The traditional version, illustrated in the U.S. Public Health Service guideline(12), only contains the information in the left-most column of the version shown here(the first of the 5 As, "Ask"). This second generation stamp,courtesy of Stephen F. Rothemich, MD, MS, is designed for also obtaining and documenting the second and third as(“ Advise”and“ Assess”). short, clear, and memorable. Personalization of the message by referring to the patient's clinical condition or family history may add to the effectiveness of the advice. The type of motivation that will help smokers quit varies greatl from patient to patient. Although almost any clinical encounter provides an opportunity to discuss smoking, timing of the advice can be very important The so-called teachable moment is that time when a patient's circumstances make him or her more receptive to advice. Teachable moments occur when patients are affected by diseases caused by smoking, but they may also occur following auscultation or pulmonary function testing, or when a friend or relative is Assess if the smoker is willing to make a quit attempt. Patients'level ofinterest in stopping smoking is usually evident in discussions with the clinician. Ifit is not, ask patients if they want to stop. See Chapter 5 for further information about the transtheoretical model and stages of readiness to change, which includ precontemplation, contemplation, preparation, action, and maintenance(see pages 132-133) Patients not ready to make a quit attempt (precontemplation or contemplation stages)may respond to a motivational intervention. Th clinician can motivate patients to consider a quit attempt with the 5 Rs Relevance- encourage the patient to indicate why quitting is personally relevant Risks-ask the patient to identify potential negative consequences of tobacco use Rewards--ask the patient to identify potential benefits of stopping tobacco Roadblocks--ask the patient to identify barriers or impediments to quitting Repetition--repeat motivational intervention at every clinic visit