Susan Bradshaw, MD, MPH, TTS

Background

Over the past 50 years, tremendous progress has been made in the United States in reducing the prevalence of smoking. In 1965, just after the release of the first Surgeon General’s Report on the hazards of smoking, 42% of adults 18 years and older in the U.S. smoked.¹ By 2015, smoking prevalence among adults in the U.S. had fallen to 15%.² California and Los Angeles County have been national leaders in instituting effective tobacco control policies and programs, resulting in even lower rates of smoking statewide (12% in 2016) and in the county (13% in 2015).^3,4 Despite this progress, over one million adults and adolescents in LA County continue to smoke.⁴

In the 2016 election, a California ballot initiative (Proposition 56) was passed by the voters that raised the tax on cigarettes sold in the state by $2 per pack (with an equivalent tax for e-cigarettes and other tobacco products). The new tax, which went into effect on April 1, 2017, may motivate more smokers to quit, creating a window of opportunity for health care providers to offer tobacco cessation interventions.

Implementing smoking cessation strategies can be difficult in a busy primary care practice. This article presents some simple steps health care providers and their teams can take to help their patients stop smoking.

Ask Advise Refer (AAR)

The “Ask, Advise, and Refer” protocol is a brief intervention for health care providers in promoting tobacco cessation with their patients.⁵ The protocol can be incorporated into the medical office or clinic routine as follows:

Step 1: Ask. While collecting vital signs, a nurse or medical assistant can ask the patient whether he or she smokes or uses other forms of tobacco and can then document the patient's tobacco use status in the chart or electronic health record. Framing the question in a multiple-choice format may increase the likelihood of disclosure among patients hesitant to report their smoking status. In addition, the use of a vital sign stamp or an electronic prompt, or placing a sticker on the chart may be helpful in making tobacco-use screening a regular part of one’s practice.

Step 2: Advise. Smokers often report that their clinician’s advice and encouragement is an important motivator to stop smoking. Evidence shows that cessation rates increase when clinicians advise their patients to stop using tobacco. Advice should be clear and strong, for example, “As your physician and someone who cares about you and your health, I would encourage you to stop smoking because it is the most important thing you can do to protect your health.” This advice works best when delivered in a non-judgmental tone and is personalized where possible, such as, linking the advice to the reason for the patient's visit.

After advising and offering encouragement, providers should ask the patient if he or she is interested in quitting. For those who are interested, clinicians can provide brief counseling (e.g., encourage the patient to set a quitting date and remove all tobacco products from the home; discuss some of the challenges the patient may face, such as stress and weight gain; and how to overcome these challenges). Providers who do not have the time or expertise to provide this counseling can refer the patient to the California Smokers' Helpline and should then continue to offer encouragement and support at future encounters with the patient.

Step 3: Refer. For patients who are interested in trying to quit, referrals can be made to the California Smokers’ Helpline for counseling and other behavioral support services. The Helpline services are free of charge and can be accessed by directing patients to call 1-800-NO-BUTTS or to visit www.nobutts.org. The Helpline provides self-help materials and up to six counseling sessions with a trained counselor. Counseling is provided in English, Chinese (Mandarin and Cantonese), Korean, Spanish, Vietnamese, and TDD for the hearing and speech impaired. Services are also available for pregnant women, teens, and those who chew tobacco. Other free tools include online help for tobacco users and their family and friends, a text messaging program, and No Butts, a new mobile app that helps smokers quit (www.nobutts.org/free-services-for-smokers-trying-to-quit).

Additional Actions to Promote Smoking Cessation

Recommend FDA-approved medication. Pharmacotherapy, with or without behavioral counseling, substantially increases the odds of successful smoking cessation. Seven medications have been approved by the FDA for smoking cessation, including⁷:

• Nicotine patch
• Nicotine gum
• Nicotine inhaler
• Nicotine lozenges
• Nicotine nasal spray
• Sustained-release bupropion
• Varenicline

Provide relapse prevention and support to recent quitters.^8,9 Relapses (a return to smoking at or near previous level of use) and slips (return to a much lower level of use) are common for patients attempting smoking cessation and should not be viewed as a failure. Clinicians are encouraged to initiate a brief discussion with recent quitters focused on the following⁹:

• Any success the patient has had in quitting (duration of abstinence, reduction in withdrawal, etc.)
• Issues encountered (e.g., weight gain, stress, other smokers)
• A medication check-in, including correct use of any medication prescribed and side effects.

Implement health system changes. Structural and operational changes in medical care settings can improve the effectiveness of smoking cessation services, including⁸:

• Implementing a standardized system and workflow for identifying and tracking patients who are tobacco users, and for following up with those attempting to quit;
• Incorporating tobacco cessation decision support tools into the electronic health record;
• Providing feedback to individual clinicians and clinic sites on their rate of tobacco use identification and intervention;
• Defining specific roles for office staff in providing or supporting tobacco cessation services, including staff training on these roles, and assessing the provision of these services in staff performance evaluations.

Conclusions

Physicians and other healthcare professionals play an important role in helping patients quit smoking. The tax increase on cigarettes and other tobacco products presents a timely opportunity to intensify efforts to promote tobacco cessation, particularly among patients who are more price sensitive. Use of the team-based AAR protocol, referrals to support services, and prescription of medications can greatly increase the odds that a smoker quits, one of the most important things they can do to improve their prospects for a long and healthy life.

References

1. Centers for Disease Control and Prevention. Ten great public health achievements—United States, 2001-2010. Morbidity and Mortality Weekly Report. 2011;60:619-623.
2. Centers for Disease Control and Prevention. Current cigarette smoking among adults—United States, 2005-2015. Morbidity and Mortality Weekly Report. 2016;65:1205-1211.
3. UCLA Center for Health Policy Research. California Health Interview Survey (unpublished data).  Available at: http://healthpolicy.ucla.edu/Pages/AskCHIS.aspx.
4. Los Angeles County Department of Public Health. 2015 Los Angeles County Health Survey (unpublished data). Available at: http://www.publichealth.lacounty.gov/ha/LACHSDataTopics2015.htm.
5. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/tobacco/campaign/tips/partners/health/materials/twyd-5a-2a-tobacco-intervention-pocket-card.pdf.
6. The Community Preventive Services Task Force. The Community Guide. Available at: https://www.thecommunityguide.org/findings/tobacco-use-and-secondhand-smoke-exposure-quitline-interventions.
7. Fiore MC, and Baker TB.  Treating smokers in the health care setting. N Engl J Med. 2011; 365(13): 1222–1231.
8. Centers for Disease Control and Prevention. Identifying and Treating Patients Who Use Tobacco: Action Steps for Clinicians. US Department of Health and Human Services; 2016. Available at: https://millionhearts.hhs.gov/files/Tobacco-Cessation-Action-Guide.pdf.
9. Treating Tobacco Use and Dependence.  Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/index.html. Published May 2008. Reviewed April 2013. Accessed January 2018.