Tobacco remains the number one underlying cause of death in the United States, Maryland and in Anne Arundel County. While obesity and inactivity continue to rapidly close the gap and will likely become the leading killer of County residents, it will probably not do so for the next decade. Lung cancer continues to be the leading cause of cancer death in the County. In 1990, Anne Arundel County had the highest rate of lung cancer deaths in the nation. Improvements to that rate have largely come as smoking rates have declined. Approximately one-third of all tobacco users will die prematurely because of their dependence on tobacco. One third of all cancers, 20 -25 percent of all cardiovascular disease, 80 percent of all lung cancer and 20 percent of all deaths in this country are attributable to smoking. Smoking is also the largest contributor to years of potential life lost. Alarmingly, 40 percent of all children in the county live in a household where there is at least one smoker. In 2001, tobacco use killed 675 County residents, 19 percent of the County's deaths. Unlike so many epidemics in the past, there is a clear, contemporaneous understanding of the cause of this premature death and disability. The cause is tobacco use.
It is a testament to the power of tobacco addiction that millions of tobacco users have been unable to overcome their dependence and are faced with the expense and compromised health resulting from tobacco use. Indeed, it is difficult to identify any other condition that presents such a mix of lethality, prevalence and neglect, despite effective and readily available interventions. The most important thing you can do with your smoking patients is to address their nicotine addiction. It is likely the thing that will kill them.
Patients that are users of tobacco tend to accurately report smoking when asked by their physician. Seventy percent of those smoking report that they would like to quit smoking and 53 percent report having attempted to quit. Additionally, 75 percent of all smokers will visit their physician at least once a year. However, only about one-third report having had a conversation with their doctor about quitting smoking. One recent study showed that only 15 percent of smoking patients were asked about their smoking and that only 3 percent received a follow-up appointment to address smoking or a prescription for smoking cessation medications. In fact, in a recent poll of County residents, smokers were asked why they had not quit. The most prevalent response was, "My doctor hasn't told me to!"
Current treatments for tobacco dependence offer clinicians their greatest single opportunity to staunch the loss of life and health caused by this chronic condition. It is imperative, therefore, that clinicians actively assess and treat tobacco use. Current recommendations from the U.S. Preventive Services Task Force recommend that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. On every visit, each patient with a history of smoking should be asked if he or she smokes. The USPSTF found evidence that brief smoking cessation interventions, including screening, brief behavioral counseling (less than 3 minutes), and pharmacotherapy delivered in primary care settings are effective in increasing the proportion of smokers who successfully quit smoking and remain abstinent after 1 year. In fact, by merely asking patients if they smoke and, as their physician, advising them to quit, their chances of quitting double over the next year. Tobacco dependence is a chronic condition that often requires repeated intervention. Patients willing
to try to quit tobacco use should be provided effective treatment. Patients unwilling
to try to quit tobacco use should be provided a brief intervention designed to increase their motivation to quit.
Current best practices from the Office of the Surgeon General suggest using the 5 A’s. Ask, Advise, Assess, Assist
. These are designed to be used with the smoker who is willing to quit.
- Systematically identify all tobacco users at every visit. Implement an office-wide system that ensures that, for every patient at every visit, tobacco-use status is queried and documented. This could be done as easily as expanding the vital signs to include tobacco use.
- Strongly urge all tobacco users to quit. In a clear, strong
manner, urge every tobacco user to quit.
- Clear - "I think it is important for you to quit smoking now and I can help you. Cutting down while you are ill is not enough."
- Strong - "As your doctor, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The staff and I will help you."
- Personalized - Tie tobacco use to current health/illness, and/or its social and economic costs, motivation level/readiness to quit, and/or the impact of tobacco use on children and others in the household.
- Determine willingness to make a quit attempt.
Ask every tobacco user if he or she is willing to make a quit attempt at this time (e.g., within the next 30 days). Assess patient's willingness to quit:
- If the patient is willing to make a quit attempt at this time, provide assistance.
- If the patient will participate in an intensive treatment, deliver such a treatment or refer to an intensive intervention. The county's health department and hospitals provide excellent resources for referral.
- If the patient clearly states he or she is unwilling to make a quit attempt at this time, provide a motivational intervention.
- If the patient is a member of a special population (e.g., adolescent, pregnant smoker, racial/ethnic minority), consider providing additional information.
- Aid the patient in quitting. Help the patient with a quit plan.
A patient's preparations for quitting:
- Set a quit date - ideally, the quit date should be within 2 weeks.
- Tell family, friends, and coworkers about quitting and request understanding and support.
- Anticipate challenges to planned quit attempt, particularly during the critical first few weeks. These include nicotine withdrawal symptoms.
- Abstinence - total abstinence is essential. "Not even a single puff after the quit date."
- Past quit experience - review past quit attempts including identification of what helped during the quit attempt and what factors contributed to relapse
- Consider checking with the patient on their quit date as a reminder/reinforcement
- make provisions for referral or follow-up by you or your staff.
Recommend and prescribe the use of approved pharmacotherapy, except in special circumstances. Provide supplementary materials. Materials available from the Department of Health can help, for more information on what is available, click here
Brief tobacco dependence treatment is effective and every patient who uses tobacco should be offered at least brief treatment. There is a strong dose-response relation between the intensity of tobacco dependence counseling and its effectiveness. Treatments involving person-to-person contact (via individual, group or proactive telephone counseling) are consistently effective and their effectiveness increases with treatment intensity (e.g., minutes of contact).
Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking.
pharmacotherapies were identified that reliably increase long-term smoking abstinence rates:
- Bupropion SR.
- Nicotine gum.
- Nicotine inhaler.
- Nicotine nasal spray.
- Nicotine patch.
Nicotine lozenges are also available by prescription, and are promising as well.
pharmacotherapies were identified as efficacious and may be considered by clinicians if first-line pharmacotherapies are not effective:
Over-the-counter nicotine patches, gum and lozenges are effective relative to placebo and their use should be encouraged.
In short, brief interventions by physicians offer the best hope for increased cessation by smoking patients. Asking about smoking status and advising a patient to quit doubles their chance of quitting during the coming year. Adding therapy and quitting aids doubles that chance yet again. The addition of buproprion and behavioral counseling increases that chance even higher. Evidence clearly shows that one year quit rates of as high as 25 percent can be achieved using available resources. Smoking treatment is addiction medicine and as such, requires addiction treatment methods and persistence. Fortunately, current smoking rates show that with the help of physicians, America is winning the battle against tobacco!