The Evaluation and Treatment of Tobacco Use Disorder

Tobacco use is the leading cause of preventable diseases and deaths in the United States, accounting for approximately 435,000 deaths yearly.¹ Smoking is responsible for an estimated $100 billion annually in direct medical and indirect nonmedical costs.² Despite widespread efforts to educate the public on the risks of smoking, approximately 50 million American adults still smoke cigarettes.³ Cigarette smoking is an addiction, as powerful in many respects as cocaine or opiate dependence.⁴ Among those who have ever tried even one cigarette, almost one third develop nicotine dependence.⁵ Every year, primary care clinicians have access to 70% of smokers.^6,7 One of the goals of Healthy People 2010⁸ is to increase to 75% the proportion of primary care providers who routinely provide smoking cessation counseling.

Diagnosis

The Smoking Cessation Clinical Practice Guideline was originally published by the Agency for Healthcare Research and Quality (AHRQ) in 1996⁹ and was updated in 2000 by AHRQ and a consortium of 7 government and nonprofit organizations.¹⁰ The 2000 guideline urged clinicians to treat tobacco use disorder as a chronic disease similar in many respects to other diseases like hypertension, diabetes, and hyperlipidemia and to provide patients with appropriate advice and pharmacotherapy. The updated guideline recommends a 5-step approach (the 5A’s: ask, advise, assess, assist, and arrange) to be used by primary care physicians. The first step (ask) is key in the management of tobacco use disorder. Tobacco use status should be asked and documented for all patients at every visit. The AHRQ recommends that tobacco use status be adopted as the “5th vital sign” along with blood pressure, temperature, pulse, and respiration. Data show that only approximately half of physicians in nonresearch settings consistently advise smokers to quit.^11-13

Because the most common presentation of a smoker in the primary care setting is for general medical care not necessarily related to smoking, the recommendation to ask about tobacco use at every visit is a practical method to ensure early identification of smokers. Asking about tobacco use at every visit has been shown to result in better screening^14-16 and increased cessation rates.¹⁷ Screening can be performed by the nurse or other trained member of the office staff who collects clinical information from the patient before being seen by the physician. Physicians should establish office-wide systems to enhance consistent identification and treatment of smokers in their practices. Organizational system approaches are cost-effective and have been shown to increase delivery of cessation interventions.¹⁸

Treatment

After identifying smokers during an office visit (ask), the next step is to strongly urge all smokers to quit (advise). Such initial advice should be given regardless of the patient’s state of readiness to quit. The transtheoretical model of stages of change (SOC)¹⁹ is useful for assessing the patient’s readiness to quit (assess). The SOC model identifies smoking behavior change as a process involving movement through a series of 5 motivational stages including precontemplation (not planning to quit within next 6 months), contemplation (planning to quit within next 6 months), preparation (planning to quit within next 30 days), action (has quit smoking for less than 6 months), and maintenance (has quit smoking for 6 months or longer). Interventions based on the SOC have been shown to enhance motivation²⁰ and predict cessation.²¹ For patients unwilling to quit, physicians should identify reasons for resistance. For example, patients who are misinformed about the health risks of smoking should be provided with information relevant to their (or their family’s) health condition. Patients willing to make a quit attempt should be given specific advice about how to proceed, including setting a quit date and information on pharmacotherapy.

Behavioral interventions are beneficial to the long-term success of smoking cessation. Studies have shown that brief ( 5 minutes) advice on quitting given by physicians to smokers during an office visit have resulted in higher quit rates compared with no advice.²² A review of 20 studies conducted in primary care settings²³ reported that 2% of all smokers who received brief physician advice quit smoking as a direct consequence, compared with less than 1% in smokers who received no advice. With additional encouragement and support (eg, follow-up letters, phone calls, demonstration of spirometry, and additional visits) quit rates increased to 5%.^23,24 A more recent meta-analysis of 7 studies by the Clinical Practice Guideline Panel reported an abstinence rate of 8% when no cessation advice was given, compared with 10% with cessation advice.¹⁷ Although success rates are better with more intensive counseling, brief interventions appear to be more feasible in the primary care setting, given time constraints experienced by primary care physicians during office visits²⁵ and the unwillingness of many patients to enter intensive programs.²⁶