Most medical schools do not teach the basic pathology causing tobacco dependence, the mechanisms of action of effective tobacco-dependence medications, how to treat tobacco dependence effectively, or how to develop a clinical management plan for tobacco dependence and monitor the results. Classes cover asthma, diabetes, hypertension, and a long list of other diseases, but not tobacco dependence. Until medical school curricula, clinical clerkships, medical residency training programs, and pulmonary fellowship training programs rectify these omissions, this Tool Kit can provide Patient Assessment Tools and Patient Management Tools to guide your effective treatment of tobacco dependence. Members of the ACCP Tool Kit Committee have developed and have been using these tools in their clinical practice and treatment of tobacco dependence.
It is not necessary to use all the tools for every patient. The clinician should evaluate the tools and use those that make sense and are most useful to effectively treat tobacco dependence in clinical practice. These tools can be modified to suit your personal practice needs and/or electronic medical records.
Chart Identification Stickers
Printable Chart Identification Stickers (use AVERY Laser 5267 labels) clearly identify a patient as a Current Smoker, Former Smoker, Never Smoker, or Secondhand Smoke Exposed on their chart. These labels will alert the clinician in the future to the patient’s tobacco use status as of the previous visit.
The Encounter Checklist is a means to track a patient’s tobacco-use status and progress for each patient encounter, before and during treatment. It has been used in clinical tobacco-dependence practice for over 5 years.
Tobacco-Dependence Pre-Treatment Checklist
The Tobacco-Dependence Pre-Treatment Checklist may be used to track topics to discuss with the patient, to ensure that you cover all the relevant topics that a patient needs to know about before the Target Stop Date (TSD), before treatment begins.
Where to Find the Topical Information Listed in the Pre-Treatment Checklist
Educational information that you or your nurse need to discuss with the patient can be found in this Tool Kit, as noted by the relevant “hot-linked” section number by each topic on the checklist. Also, the Patient Education Brochures can be helpful and save time in your office.
Some topics (such as reasons for stopping smoking, problems with past attempts, barriers to successful stopping, and concerns about weight gain) are part of the basic medical history. The information can be gathered using the Assessment of Tobacco Use and Exposure form, as a guided medical history, and/or via other Patient Assessment Tools. The sections Physician Notes and Treatment Planning and Tobacco-Dependence Consultation Report Form, described below, may be useful in recording this information and reporting it to referring or primary care physicians.
Some of the topics listed (such as destroying all tobacco products, anticipating challenges, and developing an action plan) are suggested actions for the patient to follow before the target stop date (TSD). The physician should discuss these suggestions with the patient and explain how to follow them. Tools that can help include the Behavioral “Homework” Worksheet and the Freedom From Tobacco Action Plan.
The AAFP CD-ROM Audiobook (full title: Dr. Art Ulene: How to Stop Smoking) and the 30-minute Biology of Nicotine Addiction DVD are available directly from the Palo Alto Center for Pulmonary Disease Prevention.
Tobacco-Dependence Relapse-Prevention Checklist
The Tobacco-Dependence Relapse-Prevention Checklist may be used to track topics to discuss with the patient, 1-6 months after TSD, to ensure that you cover key relapse-prevention strategies with patients. Covering this information before TSD distracts the patient’s attention from where it needs to be: identifying Trigger Settings and developing Action Strategies for each and every trigger. Revisit the patient’s action plan to confirm that it addresses the patient’s fears and disincentives to stop smoking, including any new concerns that may have arisen, then discuss these relapse prevention strategies. Again, refer to the Behavioral “Homework” Worksheet and the Freedom From Tobacco Action Plan.
How to Use the Pre-Treatment and Relapse-Prevention Checklists
Check the “Y” column when you have fully covered the topic, consistent with the patient’s needs. Check the “±” column when you have partially covered the topic but have elected to defer completing the discussion to a later or better time (e.g., when the patient will be better able to actually hear the information and process it). Check the “N” column when you have decided that you do not need to cover the topic with that patient.
The Physician Notes and Treatment Planning form and Tobacco-Dependence Consultation Report Form document preliminary patient encounters and aid the clinician in the development and communication of an effective treatment plan.
Tools for the Pediatric Healthcare Provider facilitates an assessment of secondhand smoke exposure in children, as well as an inquiry into adolescent tobacco use.
The Carboxyhemoglobin versus Exhaled Carbon Monoxide Graph shows the linear relationship between exhaled-air carbon monoxide levels, in parts per million (ppm), and blood levels of carboxyhemoglobin as %COHb. Exhaled air carbon monoxide is easily measured in the office and is a CPT-codeable service that is reimbursed by some insurance plans.
The section on Performance Measures in Tobacco Dependence Treatment describes initiatives taken by government and private entities, including the National Quality Forum (NQF), to develop and implement a national strategy for health care quality improvement through measurement and reporting. NQF has endorsed performance measures for tobacco dependence screening, treatment, and counseling.