The Health Care Provider's Role in Helping Smokers Quit
Tobacco use is the leading preventable cause of death in the United States. Cigarette smoking is responsible for the vast majority of lung cancer deaths, and it is a major contributor to deaths from coronary artery disease, chronic obstructive pulmonary disease, and stroke. In 2004, approximately 160,440 people will die from lung cancer - the leading cause of cancer mortality. Cigarette smoking also causes cancers of the larynx, mouth, esophagus, pharynx, and bladder. In addition, it plays a role in cancers of the pancreas, kidney, and cervix. Seventy percent of smokers say they would like to quit, but the interaction of nicotine addiction and behavioral and social factors makes quitting very difficult.
The good news is that current evidence serves to remind us that health care providers can play a key role in helping smokers quit. As reported in the April 21 Journal of the National Cancer Institute, Katz et al. found that providers who used a brief intervention to help their patients quit smoking significantly increased abstinence rates six months later, especially among heavy smokers. The authors noted that for the 70 percent of American smokers who visit their physicians at least once a year, exposure to an intervention could lead to smoking cessation for approximately 2 million patients annually.
The study highlights both the effectiveness of interventions and barriers to implementing behavioral risk- reduction strategies in health care settings. It was based on the 1996 Agency for Healthcare Research and Quality (AHRQ) Smoking Cessation Clinical Practice Guideline, which has since been updated and expanded in the 2000 U.S. Public Health Service publication, Treating Tobacco Use and Dependence (http://www.surgeongeneral.gov/tobacco/
National data suggest that many smokers are not advised to stop smoking or offered assistance with smoking cessation during a given visit with a health care provider. Providers are encouraged to review and use Treating Tobacco Use and Dependence. It contains evidence-based information about effective behavioral counseling, first-line pharmacologic therapies (bupropion SR, nicotine gum, patches, inhalers, and nasal sprays) and second-line pharmacologic therapies (clonidine and nortriptyline). It also recommends a simple five-step approach to cessation counseling: ASK about smoking; ADVISE smokers to quit; ASSESS willingness to quit; ASSIST the patient in trying to quit; and ARRANGE follow-up. This approach can save lives. And it is important to note that an intervention need not be delivered by a physician to be effective. Katz et al. utilized intake staff: nurse practitioners and physician's assistants.
In this week's guest commentary, Dr. Carolyn Clancy, director of AHRQ, offers insights on the clinical practice guidelines and the importance of provider-patient interaction in achieving smoking cessation success. One of NCI's many collaborations with AHRQ was the partnership effort on the National Blueprint for Disseminating and Implementing Evidence-Based Clinical and Community Strategies to Promote Tobacco Use Cessation (http://www.ctcinfo.org/upload/blueprint_adult.pdf). NCI continues to work with AHRQ, NIH colleagues, and many other partners to ensure that providers have the resources they need to learn about and implement effective cessation strategies in clinical settings.
NCI has long supported tobacco use and treatment research. Studies range from transdisciplinary approaches to understanding the complex interactive determinants of tobacco use initiation, maintenance, and cessation to the development of more effective behavioral and pharmacologic approaches to tobacco use cessation. NCI's clinical trials include several smoking cessation trials (http://clinicaltrials.gov/ct/search?term=smoking+cessation) to which we encourage health care providers to refer patients. Through state-of-the-art research efforts, the opportunity exists to improve health directly while identifying clinical applications, successful interventions, and knowledge that can be used in health care settings around the world.
NCI offers several options for smokers who are trying to quit. The information and professional assistance available at http://www.smokefree.gov helps support smokers as they become - and remain - nonsmokers. The site provides immediate assistance in the form of an online step-by-step cessation guide; access to local and state telephone quitlines; NCI's personalized telephone-based service (1-877-44U-QUIT) and instant messaging; and targeted publications, which may be downloaded, printed, or ordered. In addition, providers will find a section with evidence-based resources they can use to help patients quit.
Clearly, NCI cannot achieve its goal to eliminate suffering and death due to cancer without dramatically reducing and treating tobacco use and tobacco-related cancers. Health care providers must be full and active partners in these efforts to take the steps necessary to reduce tobacco use in the United States.