KEY POINTS
■ Tobacco dependence is now considered a chronic disease. Morbidity from tobacco dependence is now the leading preventable cause of death in the United States. Reports show that 70% of smokers want to quit, and 40% said they have tried to do so in the past year.
■ The 5As behavior counseling framework includes ask patients if they smoke, advise them to quit, assess their willingness to quit, assist in the quit attempt, and arrange for follow-up.
■ A more concise strategy is to ask the patient if they use tobacco, advise the patient to stop smoking and offer treatment options, and refer the patient to telephone quitlines and/or community programs.
Tobacco dependence is now considered a chronic disease; therefore, its treatment should be managed as such.1 As with many other chronic diseases, proper management includes education and counseling along with pharmacotherapy. Morbidity from tobacco dependence is the leading preventable cause of death in the United States. Reports show that 70% of smokers want to quit, and 40% said they have tried to do so in the past year.2,3
Long-term tobacco abstinence appears to be an unattainable goal for many patients. Some authors have postulated that the reason is that most tobacco users do not use available treatments.4 Unfortunately, another reason is that counseling patients is very time consuming; and, in a managed care environment, the number of patients seen may count as much as the quality of care that is provided. Therefore, knowing how to counsel patients—briefly, repetitively, and effectively—is a tool all clinicians should master. This article focuses on how to provide clinical intervention for those patients willing to quit.
The first step to treating tobacco dependence is to identify the users. The obvious first question is “Do you smoke?” An even more important question should follow: “Do you want to quit?” A “Yes” can provoke mixed emotions for a clinician. On the one hand, you are happy your patient is willing to take the first step to a healthier lifestyle; but on the other hand, you must adhere to your patient schedule. Severe time restraints can make brief clinical intervention techniques more palatable for clinicians. In fact, interventions as brief as 3 minutes have been shown to significantly increase cessation rates.5 These brief interventions can be used with all patient populations, including pregnant women, adolescents, smokers with comorbidities or mental illness, and ethnic and racial minorities.
CLINICAL PRACTICE GUIDELINE
The Public Health Service (PHS) clinical practice guideline for treating tobacco use suggests that clinicians should consistently identify and document the tobacco-use status of each patient.1 Every tobacco user who receives care in a health care setting should receive some clinical intervention for tobacco use. The PHS guideline was the result of a collaboration of eight government and nonprofit organizations and provides an evidence-based blueprint for effective treatment of tobacco addiction. Meta-analyses in the 2008 update of the PHS guideline definitively showed that counseling and medications work best when used together; each is effective alone, but data are improved when the two are used collaboratively. Outcomes improved when counseling was added to medications, and outcomes improved when medications were added to counseling. Brief tobacco-dependence counseling was also shown to be effective.1 Clinicians should become adept at using brief clinical interventions with appropriate pharmacotherapy when treating patients who are identified as tobacco users.