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Why do some doctors not treat tobacco dependence?

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Although the US Public Health Service Clinical Practice Guideline for the Treatment of Tobacco Use and Dependence recommends that all patients should be asked about their tobacco use, and all smokers offered an approved medication to help them quit, it is clear that this is not happening (1). An analysis of the 2001-2 national Ambulatory Care Survey (2) found that tobacco counseling occurred in 22.5% of visits by tobacco users, and cessation medications were prescribed on only 2.4% of occasions (with the odds being 15 times higher if the patient requested it). These rates are no higher than were found in this survey in 1991. A study involving direct observation of physician encounters with patients (3) found that of 244 smokers identified, physicians provided assistance with smoking cessation for 38% (range among practices = 0%-100%). Bupropion and nicotine-replacement therapy were discussed with smokers in 31% and 17% of encounters, respectively. Numerous other studies have documented poor adherence of physicians to the basic recommendations in the 1996 and 2000 Tobacco Treatment Guidlines (1) regarding the “5 As” (Ask, Advise, Assess, Assist, Arrange), with particularly low rates of “assisting” on use of medications and “arranging” follow-ups (4,5,6). This partly relates to lack of familiarity with the Guideline (7), but time constraints and the perception that smokers are unreceptive to counseling were the two most common barriers cited by both physicians and office managers in one study (8). Thorndike et al (9) reported that there has been a small increase in physicians' rates of patients' smoking status identification and a small decrease in rates of counseling smokers over the decade 1993-2003. This lack of progress may reflect barriers in the US health care environment, including limited physician time to provide counseling.

A National Commission on Prevention Priorities, led by dormer US Surgeon General Dr David Satcher ranked 25 preventive healthcare interventions for their population impact and cost-effectiveness (10). 3 interventions achieved the top ranking on both of these measures (total score=10): Daily aspirin for people over 40, childhood immunizations, and brief counseling and pharmacotherapy for tobacco use. Of all the interventions evaluated, the tobacco intervention was estimated to have by far the biggest impact on Quality-Adjusted Life Years saved if widely implemented (1.3 million annually). Undertreatment of tobacco dependence therefore represents a major failure in the US healthcare system. So what are the causes and potential remedies? Here are my thoughts:

Causes
1. Although very thorough evidence-based reviews and clinical practice guidelines are available, most clinicians are unaware of them and few healthcare systems require that they be followed in the same way that guidelines on the treatment of other comparable disorders (e.g. hypertension) are followed. If the healthcare system (whether that be the hospital system or the health plan) does not explicitly value tobacco treatment one should not be surprised that busy clinicians are not going out of their way to find and follow clinical guidelines on this issue.

2. Clinicians have found that it is not simple to get paid for tobacco treatment interventions. Where these are covered by health plans there may be high copays or deductibles, and frequently payments are low and certain effective treatment components are not covered (e.g. OTC NRT or group treatment). So for both clinicians and patients there is uncertainty about what (if any) treatment components are covered and this itself is a barrier to treatment provision.

3. Clinicians are unsure about the effectiveness of tobacco treatment. Their experience is that of 50 patients counseled and offered a medication, 40 will still be smoking when they are seen a year later. This can seem unrewarding compared to some other clinical interventions.

Solutions
1. We need to make all the effective components of tobacco treatment covered benefits of all health plans. Model benefit designs have already been described and widespread adoption of these would take away that doubt/barrier. http://www.tobaccoprogram.org/cftfkinsurance.htm
This will require patients and employers to ask for it, as well as insurance companies to offer and provide it.

2. We need to ensure that a new tier of healthcare provider can be trained and eligible for reimbursement for tobacco treatment. MDs and other prescribers’ time is valuable and the counseling component is best provided by counselors who have been trained to specialize in that work. In large hospitals or high population densities this tobacco counseling can be provided face-to-face in specialist clinics, but in more rural areas this can best be provided via telephone quitlines and interactive websites. This will require that more tobacco treatment counselors be trained, and approved for reimbursement by health plans. Standards for Practice for Tobacco Treatment Specialists have been developed by the Association for the Treatment of Tobacco Use and Dependence (ATTUD):
http://www.attud.org/public/survey.php

3. Steps 1 and 2 above will enable MDs to move to a model where they routinely ask patients about tobacco use, advise them to quit and offer to prescribe a med but then refer on to a local counselor or quitline (ideally via an electronic or “fax-to-quit” service). The MD intervention needn’t require more than one or two 15 minute appointments, and the counselor’s intervention would consist of 4-8 30-minute sessions.

I’d be interested to hear from clinicians regarding what they think could be done to improve tobacco treatment provision. For the patients, I think the advice has to be to ask your clinicians for help. Most clinicians see it as part of their role (even without adequate reimbursement) and are happy to help, but are currently working in a reactive rather than proactive mode.

1. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, Gritz ER et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Public Health Service, 2000.
http://www.surgeongeneral.gov/tobacco/tobaqrg.htm
2. Steinberg MB, Akinciquil A, Delnevo C, et al. Gender and age disparities for smoking cessation treatment. Am J Prevent. Med. 2006 May;30(5):405-12. http://www.tobaccoprogram.org/staffarticles.htm
3. Ellerbeck EF, Ahluwalia JS, Jolicoeur DG, Gladden J, Mosier MC. Direct observation of smoking cessation activities in primary care practice.J Fam Pract. 2001 Aug;50(8):688-93.
4.Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA. 1998 Feb 25;279(8):604-8.
5. Longo DR, Stone TT, Phillips RL, Everett KD, Kruse RL, Jaen CR, Hewett JE. Characteristics of smoking cessation guideline use by primary care physicians.Mo Med. 2006 Mar-Apr;103(2):180-4.
6. Cokkinides VE, Ward E, Jemal A, Thun MJ. Under-use of smoking cessation treatments: results from the National Health Interview Survey, 2000. Am J Prev Med 2005;28:119--22.
7. Ward MM, Vaughn TE, Uden-Holman T, Doebbeling BN, Clarke WR, Woolson RF. Physician knowledge, attitudes and practices regarding a widely implemented guideline. J Eval Clin Pract. 2002 May;8(2):155-62.
8. Marcy TW, Skelly J, Shiffman RN, Flynn BS. Facilitating adherence to the tobacco use treatment guideline with computer-mediated decision support systems: physician and clinic office manager perspectives. Prev Med. 2005 Aug;41(2):479-87.
9. Thorndike AN, Regan S, Rigotti NA. The treatment of smoking by US physicians during ambulatory visits: 1994 2003. Am J Public Health. 2007 Oct;97(10):1878-83.
10. Maciosek MV, Edwards NM, Coffield AB, Flottemesch TJ, Nelson WW, Goodman MJ, Solberg LI. Priorities among effective clinical preventive services: methods. Am J Prev Med. 2006 Jul;31(1):90-6. Review
http://www.prevent.org/content/view/130/163/
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About the Author


MA, MAppSci, PhD

Dr. Jonathan Foulds is an expert in the field of tobacco addiction.

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