This column was originally published in AMA eVoice on May. 9, 2008. Dr. Davis is president of the American Medical Association.
We’ve made great progress in tobacco control in the more than four decades since the U.S. Surgeon General’s landmark 1964 report (PDF, 25MB) confirmed the causal link between smoking and lung cancer. A 2006 survey by the Centers for Disease Control and Prevention (CDC) found that smoking prevalence among adults since then has been cut in half, declining from 42 percent in the mid-1960s to about 20 percent today.
Despite this drop, tobacco use remains a serious health threat. Forty-five million adults in the United States continue to smoke, and tobacco use remains the nation’s leading preventable cause of death. Smoking causes one out of every five deaths in the U.S. each year, and about 440,000 Americans die from tobacco-related illness annually.
Tobacco dependence is a chronic condition that often requires repeated intervention. Studies have found that at least 70 percent of smokers in the U.S. see a doctor each year, so physicians are in a prime position to help these patients quit smoking. A number of effective, evidence-based tobacco dependence treatments are at our disposal that are proven to help people quit, including a newly updated clinical practice guideline just released by the U.S. Public Health Service (PHS).
This past Wednesday the AMA hosted an event unveiling this updated guideline, titled Treating Tobacco Use and Dependence: 2008 Update (PDF, 2MB). Held at the AMA’s Chicago headquarters, the event included some of the nation’s leading public health and medical officials, including former U.S. Surgeon General C. Everett Koop, MD, who is known internationally among health and medical professionals and community advocates for being a tireless champion for policies and programs to eliminate the death and diseases associated with tobacco use.
A 24-member, private-sector panel of leading national tobacco treatment experts developed the updated guideline after reviewing and analyzing more than 8,700 research articles on tobacco dependence published between 1975 and 2007. This is the second update of the original 1996 document; the first update was released in 2000.
The updated guideline is a blueprint for clinicians that identifies pharmacologic and behavioral interventions that can help people quit smoking. It points to seven medications approved by the Food and Drug Administration as smoking cessation treatments that substantially increase the success of quitting: five nicotine-containing medications (gum, inhaler, lozenge, nasal spray, and patch), bupropion SR (Zyban), and varenicline (Chantix). The document also includes evidence that counseling, especially in conjunction with medication, can greatly increase a patient’s success in quitting.
The guideline is built around the “5 A’s” model for treating tobacco use and dependence:
- Ask about tobacco-use status for every patient at every visit (include it as a vital sign).
- Advise to quit (in a clear, strong, and personalized manner).
- Assess willingness to make a quit attempt (and provide motivational messages for those currently unwilling to quit).
- Assist in the quit attempt (medications, counseling, educational materials, etc).
- Arrange follow-up (soon after the quit date, in person or via telephone).
Telephone quit lines are particularly effective and can reach a large number of people. A national network of state quit lines can be reached through 1-800-QUIT-NOW, and physicians should publicize this service to their patients.
The updated guideline discusses motivational interviewing strategies that clinicians can use with patients who are unwilling to quit. Insurers and purchasers should ensure that all insurance plans cover the pharmacotherapy and counseling methods that have been found by the PHS to be effective in helping people quit smoking.
Counseling treatments also have been shown to be effective for adolescent smokers and are now recommended by the PHS. However, more effective interventions and options to use with children, adolescents, and young adults are still needed.
A summary of the updated guideline (PDF, 320KB) is available on the American Journal of Preventive Medicine’s Web site. And the May 7 issue of the Journal of the American Medical Association includes a commentary urging clinicians to use the updated guideline to accelerate progress in reducing tobacco use among patients.
The updated guideline is a remarkable report and a fine example of collaboration within health care. Eight federal and private-sector, nonprofit organizations sponsored the guideline update, including the Agency for Healthcare Research and Quality (AHRQ), which coordinated the update; the CDC; the National Cancer Institute; the National Heart, Lung, and Blood Institute; the National Institute on Drug Abuse; the Robert Wood Johnson Foundation; the American Legacy Foundation; and the Center for Tobacco Research and Intervention at the University of Wisconsin School of Medicine and Public Health. More than 50 broad-based organizations, including the AMA, have endorsed the updated guideline.
The only way these treatment and counseling practices will be effective is if we actually use them with our patients, so I urge all physicians to adopt the guideline in their clinical practices. Medical students should begin using it as well.
A 2007 report from Partnership for Prevention estimated that 42,000 lives in the U.S. could be saved if 90 percent of smokers were advised by a health professional to quit and were offered medication or other assistance. A key strategy for our health care system to help more smokers quit is to incorporate tobacco measures into performance measurement systems, a subject about which I wrote in an editorial in the Annals of Internal Medicine (PDF, 96KB).
The AMA has strong and wide-ranging policies on tobacco, including specific policies on health insurance payment for tobacco cessation treatment and physician responsibilities for tobacco cessation. The AMA’s Office of Alcohol, Tobacco and Other Drug Abuse Prevention offers a wealth of knowledge to help physicians implement the updated PHS guideline.
In addition, the U.S. Surgeon General’s office has developed several smoking cessation materials, including separate guides for clinicians and patients who smoke or use other tobacco products.
If all physicians actively work to help their patients quit smoking, the improvement in our nation’s health would be enormous. So, please, ask your patients—regardless of their reasons for seeing you—if they smoke. If they do, offer counseling and other treatments to help them quit. By working together, we can continue to lower the number of Americans who smoke. And, in turn, we can help protect the lives of millions who are at risk of developing tobacco-related illness.
The lighter side
Physicians will continue to play a key role in implementing the PHS guideline on treating tobacco use and dependence. An interesting historical note is that physicians used to be featured in cigarette advertising.
In a presentation I made at Wednesday’s event releasing the updated guideline, I shared with the audience several advertisements from the 1940s ad campaign proclaiming that “More doctors smoke Camels than any other cigarette.” That claim was purportedly based on a survey of 113,597 “men and women in every branch of medicine.”
One of the ads explained that “three nationally known independent research organizations” asked “every doctor in private practice” what cigarette they smoked. Another ad featured a “Lady with a Lamp,” and celebrated “the intrepid spirit of … 7,250 women doctors.”
A “Young Man in White” was the star of the third ad. According to this ad, the “interne” has hours that are “long and arduous,” but “when he finally hangs out his coveted shingle in private practice he will be a doctor with experience!” A fourth ad showed three physicians—“whose school days are never done”—watching a demonstration of a new method of using penicillin.
This Camel campaign also included commercials on television and radio (MP3).
Most of these print ads and commercials referred to the “T-Zone”: “T for taste … T for throat … that’s your proving ground for any cigarette.” Alan Blum, MD, a leading authority on tobacco marketing and counteradvertising, often notes that the T-Zone is the site for tracheostomy.
Please send comments, questions, and replies to amaprez@ama-assn.org.
Content provided by: Dr. Robert M. Davis, MD