Treating patients with tobacco dependence is a medical responsibility. As with asthma, it requires the physician to accurately diagnose the state and severity of tobacco dependence, co-morbid conditions caused by tobacco use, and co-morbid conditions that could complicate the overall management and effective treatment of tobacco dependence. The chest physicians, in particular, but also primary care physicians, need to be on the vanguard, just as they have been for years in accurately diagnosing and effectively treating asthma. After all, tobacco use causes most of the lung diseases physicians treat. Those that it doesn’t cause, it worsens. The Tobacco-Dependence Treatment Tool Kit (3rd Edition) Committee’s [hereafter referred to as the Tool Kit Committee] aim is to provide physicians with proven tools and the scientific background necessary so that physicians and other professional healthcare colleagues can effectively treat tobacco dependence in their patients, and be appropriately paid for those skills, so that in another 10-15 years tobacco use will be fading into history.
What is New in this Version of the Tool Kit
The Tobacco-Dependence Treatment Tool Kit (3rd Edition) was designed primarily for physicians, but also for nurses and tobacco dependence counselors to help their patients stop smoking. This is the 3rd edition produced by the American College of Chest Physicians (CHEST) since 2001. In this edition, clinical information and tools have been updated but many additional content sections and tools have been added, including advice on how to code for reimbursement, interpersonal approaches to yield the most successful partnerships with patients, protocols and tools for pediatricians to use for adolescent smokers and parents of their patients, and advice on treating pregnant women and non-daily smokers. Also new in this edition are sections on advocating for smoke free communities and increased taxes on cigarettes, locating endorsed performance measures, and slides to use for community and professional presentations. The patient education materials have been significantly revised, as have the sections on pharmacologic treatment.
Tool Kit Overview
The Tool Kit contains a variety of background content and suggested Treatment Algorithms intended to provide the practitioner with relevant background information and practical insights into the treatment of tobacco dependence. Reviewing these sections and the video [introductory video] will improve your effectiveness by 1) making you more comfortable discussing tobacco-dependence treatment with your patients, 2) challenging potentially counterproductive pre-existing notions about treatment, and 3) presenting tips from the experts on identifying and dealing with commonly encountered conditions and challenges in stopping smoking.
Section III offers several Patient Assessment Tools that may be useful during the initial intake and evaluation phase of the tobacco-dependence treatment visit. We recommend you choose the instruments that make the most sense for patients within your practice. Several tools developed by other organizations and medical centers are presented as examples but permission has been granted for the owners of this Tool Kit to reproduce these tools for clinical or educational purposes only. In Section IV, the Tool Kit provides Patient Management Tools that may be used for your own organizational purposes, including chart stickers, checklists, a sample consultation report form, and special tools designed for pediatricians. Please modify and personalize these as necessary, so that they can be most useful and effective in your practice.
Section V presents several examples of Communication and Patient Education Tools including patient educational materials and systems instruments for improving communication within your practice and with insurance providers. Physicians and other healthcare providers are encouraged to use the Freedom From Tobacco Action Plan to help patients assess their own symptoms and follow prescribed treatments.
Section VI, Additional Resources, includes a set of slides for presentations to patients, community groups, and professional meetings. This section also contains referral sources for national and state Quit Lines and contact information for other tobacco control organizations and resources.
The Tool Kit Committee encourages physicians and other healthcare providers to take an active role in advocating for smoke free ordinances and other means (e.g., increased tobacco taxes) that effectively prevent or reduce tobacco use and exposure. Physician Advocacy, provides a guide for organizing grassroots advocacy at the local level and supporting references, annotated bibliographies, and talking points. Finally, Section VIII, on CHEST’S Role in Tobacco-Dependence Treatment, contains a historical timeline of the CHEST’s efforts to reduce and prevent tobacco use and exposure and the CHEST No Smoking Pledge that all new Fellows of the College take at convocation.
Where to look for the information you need
Within the background content of Section I, you will find the foundation of the entire Tool Kit. Tobacco-Dependence Treatment Process and Approach, explains the recommended methods for managing chronic tobacco dependence. We encourage a multimodality approach, because treatment effectiveness, such as the proportion of patients who completely stop tobacco use and do not relapse, is higher when pharmacologic and behavioral management are combined. Further, a combination of long- and short-acting medications (Controller and Rescue, or Reliever, Medications) have resulted in even better gains, especially when combined with support and follow-up. The Tobacco-Dependence Treatment Process and Approach section also includes ideas for motivating the resistant patient to agree to a treatment plan for stopping smoking and for dealing with relapse. The Treatment Algorithms in this Tool Kit have been derived from the evidence-based recommendations in the guidelines published by the US Department of Health and Human Services in 20081, the California Thoracic Society in 20052, and supplemented by expert opinion and advice wherever necessary. These algorithms illustrate the process recommended by the Tool Kit Committee.
Section 1.7, Pharmacologic Treatment, is designed to help the provider determine an appropriate, unique, individual treatment plan for each patient. The accompanying Quick Reference Guide to Pharmacotherapy provides critical facts about the use of available tobacco-dependence medications, as well as contraindications and side effects for both over-the-counter and prescription-only medications.
Pediatricians and others who provide services to children should read Section 1.10, The Role of Pediatric Health Care Providers in Tobacco-Dependence Treatment and Secondhand Smoke Exposure Reduction. This section also covers identification and reduction of secondhand smoke exposure and the treatment of tobacco dependence in the parents. The provision of healthcare services to children accompanied by their parents provides a very opportune and teachable discussion point about the adverse health effects of tobacco use, both primary and secondary, and for then initiating tobacco-dependence treatment in tobacco-dependent parents.
Section 1.3, Coding and Reimbursement, may be one of the most important sections in the CHEST Tool Kit. It shows you how you can appropriately be reimbursed – at your usual and customary fees – for diagnosing and treating tobacco dependence, using standard, existing CPT and ICD-9-CM codes.
Section 6.3, General & Referral Resources includes addresses, telephone numbers, and Web sites of professional organizations that provide information and services that may be of use to your practice. Though the majority of listed resources are geared toward the clinician, a few sites also provide resources for patients and their families. A table of Quit Lines available in each state is also included.
A word about using the CHEST Tool Kit tools
The remaining sections of this Tool Kit are consumable “tools” and the CHEST grants permission for these tools to be printed from this CD to assist you in the treatment and education of your patients and others. Materials may not be used for commercial purposes without the express written consent of the CHEST.
The CHEST Tool Kit Committee has designed most materials to be easily printed on standard 8 1/2″ x 11″ paper. You may print the chart stickers on standard Avery laser labels #5267. The Patient Education Brochures may also be downloaded from http://tobaccodependence.chestnet.org/communication-and-education/patient-education-brochures/.
The physicians, nurses, and medical assistants within your practice, each with his or her defined role in encouraging the tobacco-dependence treatment process, should be able to easily implement the information and resources within this Tool Kit in regular office and hospital practice. All of the tools provided in this Tool Kit have been used in actual clinical practice by at least one of the members of the CHEST Tool Kit Committee.
Although this Tool Kit is written for the physician office setting, tobacco-dependence treatment counselors and hospital-based treatment programs can readily incorporate the concepts and most of the tools to work in these settings.
The “1-2-3” Approach to Implementing this Tool Kit
The volume of material in this Tool Kit may seem overwhelming at first. However, realize that this is a comprehensive set of tools, not all of which you will use. The Tool Kit Committee chose to include multiple examples of resources so that all users of this Tool Kit can chose those most relevant to their practice. Also, some tools are only applicable to certain patient types.
Physician oversight is recommended for optimal integration of this Tool Kit into the office practice. However, the nurse or certified medical assistant also will use this Tool Kit on a day-to-day basis. Each physician will select those tools most appropriate for their practice and will need to assign the office staff the responsibility of ensuring those tools are available to the right personnel, as needed. For example, the receptionist and/or medical record managers should assure that the patients are provided with the appropriate assessment tools (e.g., the Fagerstrom Test of Nicotine Addiction) for completion in the reception area or early in the office visit.
The process of implementing this Treating Tobacco Dependence Tool Kit approach into your practice is as simple as 1-2-3:
Step 1 – Review the Treating Tobacco Dependence Tool Kit with your staff.
- Review your motivation for change – identify your current practice patterns: is there room to improve your practice efficiency in dealing with tobacco-dependence treatment?
- Discuss the proposed system changes and set some simple. Keep it simple, take baby steps, and reiterate the rationale for change.
- Think about how you can use the CHEST Tool Kit to help augment your existing tobacco-dependence treatment routines.
Step 2 – Identify roles.
- Make a list of the new tasks required of your team.
Two such examples follow:
- Identify tobacco use status, give smoking patients an
- initial assessment form, e.g., the Fagerström Test for
- Nicotine Dependence (FTND) or the Nicotine Withdrawal Symptom (NWS) scale
- Deliver patient educational materials, including resource list
- Decide who in your office will perform each of the critical tasks.
- Discuss roles with office staff and make sure each staff member is comfortable with each assigned task.
Step 3 – Go for it!
- Just try it… see what happens!
- Remember to get feedback from your staff. Make modifications as necessary but do not give up on the goals.
- Give feedback to the American College of Chest Physicians. The College is always trying to improve services to its members. You may send your comments and suggestions to Science@chestnet.org.