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Smokers take heart when doctors believe they can quit

Survey finds physicians devote little time to counseling and rarely give smokers the cessation tools they need to quit

From the November ACP Observer, copyright 2006 by the American College of Physicians.

By Stacey Butterfield

Counseling patients about smoking cessation is one of the simplest ways to have a dramatic impact on their health. But the encouragement and information smokers receive from their doctors often falls far short of the mark, according to the results of a national physician survey.

"There's really no other intervention that a clinician can do to make such a difference in a patient's health," said Steven A. Schroeder, MACP, director of the Smoking Cessation Leadership Center at the University of California, San Francisco. While most physicians believe that talking about smoking cessation is important, the vast majority devote very little time to counseling and often fail to steer patients to resources that might help them quit.

The study, sponsored by the American Legacy Foundation and conducted by the American Association of Medical Colleges, surveyed over 3,000 U.S. family physicians, internists, ob/gyns and psychiatrists about their smoking intervention practices. In a September 2006 report on the results, surveyors concluded that many physicians lacked knowledge about available smoking cessation resources and often failed to offer enough encouragement or morale support to patients attempting to quit.

Belief vs. practice

In the study, more than 90% of physicians said they consider it their role to help both motivated and unmotivated patients quit smoking. However, in practice, far fewer physicians reported actually engaging in smoking cessation activities with patients, the survey found.

Only 37% of surveyed physicians said they discuss counseling options, and even fewer (31%) said they recommend nicotine replacement therapy to patients. Just 13% reported referring patients to others for smoking cessation treatment, while only 7% said they referred patients to a quitline. Yet, these treatment options are among the top recommendations of smoking cessation experts, said Dr. Schroeder, who served on the national advisory committee that oversaw the survey.

Ideally, physicians should get an in-depth smoking history from patients and then create a tailored treatment regimen, including counseling and medication, said Dr. Schroeder.

"Unfortunately, most internists don't do that," he said. Since the surveyed physicians reported spending between two and 10 minutes of the visit, on average, dealing with smoking cessation, Dr. Schroeder suggested using that time to connect patients with appropriate treatment resources. He encouraged larger practices to develop internal facilities to provide smoking counseling to patients. At the absolute minimum, he said, refer patients to telephone quitlines, available across the country at 1-800-QUIT-NOW.

To make quitlines more effective, use their fax referral service, said Nancy Rigotti, FACP, director of the Tobacco Research and Treatment Center at Massachusetts General Hospital and Harvard Medical School. "We know that smokers, by and large, if you just give them the quitline number, they throw it out and never use it," Dr. Rigotti said. With the fax referral service, a quitline counselor will call the smoker and offer mailed materials, telephone counseling and other cessation resources.

Barriers to treatment

The survey found that physicians perceived patients' lack of motivation to quit as the biggest barrier to successful smoking cessation.

"It is true that rates of quitting even with the best treatment are no more than 25%, which means that three-quarters of the smokers that the internist will confront are going to keep smoking," said Dr. Schroeder. "It's really important to reframe the issue from a glass partly empty to a glass partly full."

The study found that physicians who viewed incremental reduction in levels of tobacco use as successful outcomes were more likely to participate in cessation activities than those who defined success more narrowly as total abstinence. Physicians who participated in more cessation activities were also more likely to believe in the effectiveness of intervention.

As a whole, the surveyed physicians underrated the effectiveness of available interventions. While 32% of physicians felt they were very effective in treating patients' cholesterol problems, only 10% felt that way about smoking.

"Clearly, physicians are more comfortable dealing with cholesterol," said Edward Salsberg, director of the AAMC's Center for Workforce Studies. "Smoking is more difficult. If the patient doesn't quit on the third try, the fourth try, don't get discouraged. Keep working with them and keep following up. The average smoker takes nine or 10 trys to quit."

Dr. Schroeder advised physicians to avoid negative attitudes toward patients who smoke by approaching nicotine addiction as a problem with structural exchanges in the brain.

Two new drugs—bupropion and varenicline—act on areas of the brain affected by nicotine, based on the idea that most smokers got hooked in their teens, when the judgment centers in the brain are not fully developed. Bupropion (brand names: Zyban and Wellbutrin) has been available for some time, while varenicline (brand name: Chantix) was just approved by the FDA in August.

Even with medication and counseling, smoking cessation is a continuous project, said Dr. Schroeder. "Smoking ought to be on the problem list, for every current or former smoker, every time they come in [to the physician's office]," he said. "If they're smoking, you need to go back to asking if they are ready to quit. If they've stopped, you should support them."

"I've always been surprised at what sometimes works [to get patients to quit]," said Dr. Rigotti at the Tobacco Research and Treatment Center. Sometimes it's a serious cold, or a tobacco-related illness, but other times the trigger is less obvious.

She recalled conducting a routine physical exam on one of her patients who smoked and commenting to the patient about the smell of smoke on his clothing. On his next visit, the patient said that he had quit smoking because of her. "I asked, 'Why? What did I say?'" said Dr. Rigotti. "He said, 'I'm a very fastidious person and I didn't realize people could smell smoke on me.'"

"It would be nice if I could snap my fingers and make everybody quit, but that's not the reality," she said. "We need to give ourselves intermediate goals and congratulate ourselves for getting to those goals, just like we tell smokers not to be too hard on themselves."

Moving forward

"Assessing Physician Knowledge, Attitudes and Practice Patterns Related to Smoking Cessation," a report based on the survey results, offers an array of steps to improve smoking cessation. There are suggested improvements at every level—from government programs to individual physician practices.

Because more than half of the physicians listed lack of insurance coverage and reimbursement as a significant barrier to getting patients to quit, the report urges expanded coverage for cessation treatment and support, as well as broadening the services that are reimbursable for physicians. To increase physicians' general knowledge of tobacco control, medical schools and CME programs should expand their smoking cessation curriculum, the study concluded.

On a practice level, the report suggests requiring physicians to document their attempts to help patients quit smoking and tracking patients' use of tobacco with electronic health records. Since the study found a relationship between state investment in tobacco control and physicians' use of smoking cessation resources, tobacco control programs are encouraged to involve physicians more closely in their efforts.

To begin the publicity effort, the study will be submitted to peer-reviewed journals and data will be shared with the different specialties that were surveyed, said Mr. Salsberg. The Legacy Foundation is also launching a public information campaign, called EX, which will publicize quitlines and provide online resources for smokers trying to quit. Advertisements for the campaign, now running in select pilot markets, follow ex-smokers as they deal with the commonplace challenges of quitting.

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Smoking Cessation: Treatments usually used by surveyed physicians

Advise patients to stop smoking/86%
Ask about smoking status/84%
Discuss pharmacotherapies/68%
Assess patient willingness to quit/63%
Discuss counseling options/37%
Recommend nicotine replacement therapy/31%
Discuss enlisting support for quitting/29%
Monitor patient progress/27%
Prescribe other medication/25%
Provide brochures/self-help material/24%
Schedule follow-up visits/17%
Refer patient for cessation treatment/13%
Refer patient to a quitline/7%

Source: Assessing Physician Knowledge, Attitudes and Practice Patterns Related to Smoking Cessation, September 2006.

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