Patients who use tobacco often represent a frustrating paradox for the chest physician and other healthcare providers. On the one hand, both physician and patient generally recognize the tremendous incentive to stop: Tobacco dependence is a fatal disease. If not treated, tobacco dependence kills 50% who suffer from it. Moreover, very few remain untouched by the tremendous toll on health and the human suffering tobacco use visits upon family and friends. As many as 90% of tobacco-dependent people identify tobacco use as harmful and want to reduce or stop using it.3, 4
On the other hand, the majority of tobacco-dependent people also experience a visceral reluctance to stop smoking, making only very brief and infrequent attempts to stop. Attempts to stop smoking are frequently private, even covert, for fear of not being able to stop. Few tobacco-dependent people seek a physician’s advice on the best ways to use available over-the-counter medications and, in our experience, even fewer ask for help once their attempts begin to go awry. Unfortunately, since becoming available over-the-counter, Nicotine Replacement Therapy (NRT) has increasingly been used for too short a time and with too low a dose to be effective.5 More than 95% of self-directed attempts to stop smoking will be doomed to fail without some form of additional help.
Physicians are in a powerful position to effect change. Most tobacco-dependent patients relate that physicians’ advice was instrumental in aiding their attempts to stop smoking. Nearly 70% of tobacco-dependent patients see their physicians each year,1 and even brief, 60-second advice from a physician can double to triple the spontaneous stop-smoking rates to 10%.3, 4 One study6 even showed that brief, 60-second advice from a physician increased 1-year, continuous stop-smoking rates from 0.3% to 5.1% (a 17-fold increase). Yet, despite this enormous potential, physicians often cite very significant concerns when it comes to the practical realities of treating tobacco use within their office practice, such as limited time available for a typical visit, poor reimbursement for tobacco-related services, limited knowledge and training specific to tobacco-dependence treatment, and a perceived ineffectiveness of therapy. Physicians and advance practice nurse practitioners generally have a working knowledge of treatment options and recognize the importance of patient intervention. However, patient measures of self-efficacy are generally poor, and relying on our patients’ willpower and ineffective or misused over-the-counter aids is a Sisyphean endeavor. Therefore, most tobacco-dependent patients will be more successful in eliminating tobacco use with the help of a physician or advance practice nurse practitioner or other tobacco-dependence treatment specialist.
Tool Kit Goals
The American College of Chest Physicians (CHEST) recognizes that this position remains untenable as long as the practical realities of tobacco-dependence treatment within medical practice remain unaddressed. To this end, the Tobacco-Dependence Treatment Tool Kit, 3rd Edition has been revised in an attempt to better serve the practicing physician interested in becoming more efficient and more effective in impacting this problem. In addition, in order to remove the negative connotations, stigma, or blame often associated with tobacco dependence, terms such as “tobacco-dependence treatment” and “stopping smoking” will be used in preference to “cessation;” “tobacco-dependent patient” or “tobacco user” instead of “smoker;” “continuous nonsmoking” instead of “abstinence;” and “stop smoking” instead of “quit.”
By using the Tool Kit, clinicians will:
- Get reimbursed for their efforts. Clinicians should expect to be reimbursed for their interventions. Understanding the basic difference between a typical E&M visit and one focused on health counseling is the first step in successfully integrating tobacco-dependence treatment into your practice. Only modest adjustments in style and content are necessary to document the level of service provided. Attention should be paid to including all of the most appropriate ICD-9 codes for the reimbursement problems physicians face, including those that relate to tobacco-dependence treatment. This Tool Kit will help physicians and their billing managers understand how to increase the reimbursement rate associated with tobacco-dependence treatment.
- Address tobacco dependence in the manner of a chronic disease, characterized by long-term relapse and remission. We believe this approach will help relieve the typical awkwardness of “success” vs. “failure,” encourage a medical model for tobacco-dependence treatment, and help engender a more therapeutic doctor-patient relationship. We frequently modeled the recommendations in this Tool Kit after the National Heart and Blood Institute’s (NHLBI’s) National Asthma Education and Prevention Program (NAEPP) Guidelines for the Diagnosis and Management of Asthma7 to help make this Tool Kit’s logic and style more familiar to chest physicians, although the target audience also includes primary care physicians, as well as hospital-based and out-patient nurses and cessation counselors.
- Feel comfortable providing brief counseling. The emotional burden of shame and guilt brought on by the diagnosis of a tobacco-related illness is often all too obvious in the strained examining room or during bedside conversations between physician and patient. Using the general principles and resources presented in this Tool Kit will help clinicians develop an effective approach to evaluation and management by providing useful patient education materials, practical tips, and evidence-based treatment recommendations.
- Develop an aggressive prescribing philosophy for pharmacologic support. The recommendations presented in this Tool Kit are intended to help clinicians make sound pharmacologic decisions based on available evidence and expert advice. In this 3rd edition of the Tool Kit, the Committee sought a model that would adequately guide the clinician while offering choice and individualization of treatment plan. By applying the concept of “Rescue/Reliever” and “Controller” medications (as in the stepwise asthma therapy model) to the treatment of tobacco dependence, we believe that we can increase the comfort level of both the treating healthcare professional and the patient for the use of these medications. Because the motivation to stop smoking is often fleeting, because treatment “failure” often means learned inefficacy, and because these treatments taken together are among the safest class of medications used by physicians, we support a model of therapy where physicians seek to effect control of withdrawal symptoms early, and taper or reduce treatment later based on feedback from the patient.
- Develop efficiencies in practice, making intervention more feasible. By utilizing the system tools, patient education resources, and practices available in this Tool Kit, physicians can reduce the variability in treatment approaches, improve documentation and compliance with evolving regulatory requirements, and be more effective in delivering care within the realistic constraints of a busy practice.