Treating Tobacco Use and Dependence

Tobacco is the agent most responsible for avoidable illness and death in America today. Millions of Americans consume this toxin on a daily basis. It brings premature death to almost half a million Americans each year, and contributes to profound disability and pain in many others. About one-third of all tobacco users in this country will die prematurely because of their dependence on tobacco. Unlike so many epidemics in the past, this one has a clear, well-understood cause -- the use of tobacco.

Data from 20 years ago indicated that physicians too frequently failed to intervene with their patients who smoke. This hasn't changed much over the past two decades. One recent study reported that only 15% of smokers who saw a physician in the past year were offered assistance with quitting, and only 3% were given a follow-up appointment to address this topic.

Health care professionals have new evidence and tools to help patients quit using tobacco, according to a set of guidelines, "Treating Tobacco Use and Dependence: A Clinical Practice Guideline," issued in June 2000 by the US Public Health Service. The authors, a private-sector panel of experts convened by the federal government, challenge clinicians, insurance plans, and medical school officials to use the evidence in the report to make treating tobacco dependence a top priority in the primary care setting.

Background: facts about tobacco use and dependence

1. Recent surveys show that 25% of all American adults smoke.
2. More than 430,000 deaths in the United States each year are attributable to tobacco use, making tobacco the No. 1 cause of death and disease in this country.
3. Smoking prevalence among adolescents has risen dramatically since 1990, with more than 3,000 additional children and adolescents becoming regular users of tobacco each day.
4. Nationwide, medical care costs attributable to smoking (or smoking-related disease) have been estimated by the Centers for Disease Control and Prevention to be more than $50 billion annually. In addition, they estimate the value of lost earnings and loss of productivity to be at least another $47 billion a year.
5. It would cost an estimated $6.3 billion annually to provide 75% of smokers 18 years and older with the intervention-counseling, nicotine patches, nicotine gum, or a combination-of their choice. This would result in 1.7 million new quitters at an average cost of $3,779 per quitter-a move that would be cost-effective in relation to other medical interventions such as mammography or blood pressure screening.
6. Epidemiologic data suggest that more than 70% of the 50 million smokers in the United States today have made at least one prior quit attempt, and approximately 46% try to quit each year. Most smokers make several quit attempts before they successfully kick the habit.
7. Only 21% of practicing physicians say that they have received adequate training to help their patients stop smoking, according to a recent survey of US medical school deans published in the Journal of the American Medical Association. The majority of medical schools do not require clinical training in smoking cessation techniques.

Key findings

Tobacco dependence is a chronic condition that often requires repeated intervention. However, effective treatments exist that can produce long-term or even permanent abstinence.

Every patient who uses tobacco should be offered at least one of these treatments. It is essential that clinicians and health care delivery systems (including administrators, insurers, and purchasers) institutionalize the consistent identification, documentation, and treatment of every tobacco user seen in a health care setting.

• Patients willing to try to quit tobacco use should be provided treatments identified as effective in this guideline.
• Patients unwilling to try to quit tobacco use should be provided a brief intervention designed to increase their motivation to quit.

Brief tobacco dependence treatment is effective, and every patient who uses tobacco should be offered at least brief treatment. However, there is a strong dose-response relation between the intensity of tobacco dependence counseling and its effectiveness.

Treatments involving person-to-person contact (via individual, group, or proactive telephone counseling) are consistently effective, and their effectiveness increases with treatment intensity (e.g., minutes of contact).

Three types of counseling and behavioral therapies are be especially effective and should be used with all patients attempting tobacco cessation:

1. Provision of practical counseling (problem solving/skills training).
2. Provision of social support as part of treatment (intra-treatment social support).
3. Help in securing social support outside of treatment (extra-treatment social support).

Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking.

Five first-line pharmacotherapies were identified that reliably increase long-term smoking abstinence rates: Bupropion SR; Nicotine gum; Nicotine inhaler; Nicotine nasal spray; and the Nicotine patch . Two second-line pharmacotherapies may be considered by clinicians if first-line pharmacotherapies are not effective: Clonidine and Nortriptyline. Over-the-counter nicotine patches are also effective, and their use should be encouraged.

Tobacco dependence treatments are both clinically effective and cost-effective relative to other medical and disease prevention interventions. As such, insurers and purchasers are urged to ensure that:

• All insurance plans include as a reimbursed benefit the counseling and pharmacotherapeutic treatments identified as effective in the guidelines.
• Clinicians are reimbursed for providing tobacco dependence treatment just as they are reimbursed for treating other chronic conditions.

A guide for consumers, "You Can Quit Smoking" is available by calling 1-800-358-9295 or writing to Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907-8547, or from the office of the Surgeon General.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.