Primary care physicians (PCPs) often think of themselves as being on the front lines of the battle to keep Americans healthy, and nowhere is that more true than in combatting smoking and other forms of tobacco use.
“Helping patients quit smoking is one of the most effective things that family doctors can do both in terms of outcome and cost-benefits for activities in an office,” says Jeffrey Cain, MD, FAAFP, president of the American Academy of Family Physicians. Even a 30-second discussion of the benefits of tobacco cessation doubles the successful quit rate, Cain says.
Moreover, the range of behavioral and pharmacological tools available to PCPs to help their patients stop smoking continues to expand, thanks to ongoing research into the addictive properties of nicotine and best practices for cessation counseling. Tobacco cessation counseling has also gotten a boost from the Affordable Care Act, which requires employer-sponsored insurance plans to cover all preventive services given an ‘A’ or ‘B’ rating by the U.S. Preventive Services Task Force, including tobacco cessation. Medicare also will pay for a limited number of cessation counseling sessions.
Although smoking cessation will rarely be a major source of revenue for a practice, PCPs can and should bill for the time spent on it, experts say. Counseling can be billed under Current Procedural Terminology codes 99406 or 99407. (See “Billing for tobacco cessation counseling, page 39.) Many commercial insurers will also reimburse for the service.
By virtually any measure, the nation’s ongoing effort to reduce smoking has been a major public health success story. In the mid-1960s, when the first Surgeon General report on the harmful effects of smoking was published, about 40% of adults smoked. By 2010, the smoking rate among adults had fallen to just over 19%, according to the Centers for Disease Control and Prevention (CDC). Tobacco advertising now is severely restricted, smoking is prohibited virtually everywhere indoors, and smoking is no longer considered socially acceptable among large segments of the public.
On the other hand, the CDC estimates that tobacco use still is responsible for 443,000 deaths annually, making it the nation’s number one cause of preventable mortality. And although about 70% of the estimated 46 million adult smokers say they would like to quit, that still leaves a core group of some 13.8 million adults who aren’t interested in quitting.
So how do you help patients stop smoking? The first step is to include tobacco use status as part of routine patient screening, making sure the information gets entered in the patient’s chart, and flagging those patients who do smoke. Charles Cutler, ACP, an internist in Norristown, Pennsylvania, and chairman of the American College of Physicians’ Board of Regents, enters smoking status under “social history” in a patient’s electronic health record (EHR). The practice’s EHR system is configured so that social history can be accessed with a single click.
“Before I even go into the reason for the patient’s visit, I’ll open the conversation by reviewing the social history, which includes smoking status. The ‘OK, Mr. Jones, what brings you in today?’ follows that routine screen,” he says.
William Blazey, DO, a family practitioner in Old Westbury and Central Islip, New York, uses the “5 A’s Intervention” developed by the U.S. Public Health Service to begin a conversation with patients about tobacco cessation (See “The 5A’s Intervention,” page 40.) “We found that by making templates [for the intervention] on our EHR system we can do a brief, focused clinical intervention. Most of the time we can get it done in 3 to 5 minutes,” he says.
Another advantage of using the 5 A’s is that it precludes spending too much time counseling patients who aren’t interested in quitting, while ensuring that practitioners at least raise the cessation question at each visit. “Hopefully sooner or later they’ll see the light and when they do, they’ll come to you,” Blazey says.
Assessing a patient’s readiness to quit is a crucial element in cessation counseling, says Sarah Mullins, MD, a family practitioner in the suburbs of Wilmington, Delaware, and a member of the American Academy of Family Practitioner’s (AAFP) tobacco cessation advisory committee.
“When we teach tobacco cessation counseling, we often talk about how you have to roll with the resistance you may get from the patient,” Mullins says. “If the patient has no interest in quitting, it doesn’t mean you don’t counsel, it means saying I’m here for you when you’re ready. That has been shown to be statistically significant to improving their chances of quitting eventually, even if they weren’t ready that particular day.”
For those who are ready to quit, counseling can take place either individually or in group sessions. Mullins uses a cognitive behavioral therapy approach to her individual counseling sessions with patients. She talks to patients about specific steps they can take to prepare for “the quit,” such as removing ashtrays from the home, vacuuming rugs, and removing the lighter from the car. She also advises smokers to switch brands the week before their quit date. “It tastes bad, they don’t like it, and it becomes easier to give up than their usual brand,” she says.
From there, Mullins segues into a discussion of what the patient can expect on quit day, especially the side effects of nicotine withdrawal and strategies for coping with them. Among her suggestions: keeping lozenges or gum handy for nicotine cravings, deep-breathing exercises, and drinking water while on the phone as a substitute for smoking.
“You troubleshoot the very practical issues, then think about what are the bigger triggers,” Mullins says. “For most smokers quitting smoking relapse occurs when they’re around other smokers, or when they’re drinking alcohol. So we look at ways to minimize being in those situations.”
Involving a spouse or partner in the quit process also is key, says Cutler, especially if that person smokes too. That’s because the chances of a successful quit diminish significantly with another smoker in the home. “In that case you need to ask the patient, ‘Can you and your spouse work together on this? Can you at least get your smoking spouse not to smoke in the house?’ says Cutler.
Another approach to helping patients quit is through group sessions. The procedure is similar to those used for patients with diabetes, hypertension, and other chronic diseases: Pick dates and times, invite patients who are ready to quit, and prepare a meeting space in your practice’s offices.
Mullins has her patients check in as they would for a regular office visit, after which a nurse takes the patient’s vital signs and brings the patient to the group meeting room. Mullins then talks about the health risks of smoking and has patients do some exercises in a workbook and talk about their experiences with using tobacco. Then she takes each patient to an exam room to prescribe pharmacotherapy.
(Detailed instructions for conducting group sessions are available in the AAFP’s “Guide to Tobacco Cessation Group Visits,” available for download at www.aafp.org/dam/AAFP/documents/patient_care/tobacco/GrpVisitGuide2012.pdf).
“The patients were really glad to have the opportunity to spend an hour with their doctor working on this 3 weeks in a row,” Mullins says. “And we know that the more intense the intervention-the longer the duration, the more involved the activities-the more likely they are to have a successful quit.”
Cain emphasizes that others in a practice besides the physician should be involved in cessation efforts. “It’s important for
doctors to remember they don’t have to do everything, in fact, cessation is a good example of where a Patient-Centered Medical Home’s team-based model works,” he says.
As part of its “Ask and Act” program, the AAFP encourages medical practices to identify an “office champion,” with the authority to recommend and implement ways of integrating tobacco cessation into the practice’s routine.
Yet another option for helping patients, says Mullins, is to inform them of the dangers of smoking and the importance of quitting, then referrin them to the universal telephone quitline number, 1-800-784-8669 (1-800-QUITNOW.) The patient will be connected to a counselor in his or her state who will help the patient through the quit process.
Mullins says some of her colleagues will have the patient call the quitline from the doctor’s office. Another option is to fax a referral sheet with the patient’s contact information, and a quitline counselor will contact the patient. Some quitlines will provide a free 1-month supply of nicotine patches or medication to help the patient get started.
Combining counseling or behavior modification with some form of pharmacotherapy often can improve a patient’s chance of quitting successfully. The U.S. Public Health Service recommends seven first-line medications that it says have been found to reliably increase long-term smoking abstinence rates:
The medications can be tried in various combinations, says Cain. “The trick is to figure out what the patient has tried before, and help them find a more effective combination,” he says.
Even with the widespread knowledge of smoking’s dangers and advances in pharmacotherapy, quitting is almost always difficult. (The average smoker makes six attempts before he or she succeeds, according to the CDC.) That can be frustrating for PCPs, says Cain, but doctors can overcome those feelings by thinking of smoking as a chronic disease, rather than an acute issue.
“If you think of smoking like a condition where you give an antibiotic and the patient is fine, you’re going to fail,” he says. “But if you change your mindset to one of helping someone with a chronic disease to live a longer and better life, both you and the patient are much more likely to succeed.”