Shirley Sze, BMSc, MD, CCFP, FCFP (biography and disclosures)
What I did before
I generally inquired about smoking in my patients and tried to help them quit. I would offer smoking cessation advice if patients were ready to accept it and proceed to offering pharmacotherapy if appropriate.
What changed my practice
I first became aware of the Canadian Tobacco Use Monitoring Survey which highlights that tobacco use remains the number one preventable cause of illness and death in our society and that tobacco kills twice as many people in BC as motor vehicle crashes, alcohol, suicide and homicide combined. I then became aware of the recent updated Guidelines of the US Public Health Service in 2008 for “Treating Tobacco Use and Dependence” which in brief states:
- Tobacco dependence is a chronic disease.
- It is essential that clinicians and health care systems consistently identify and document tobacco use status and treat every tobacco use seen in a health care setting.
- Tobacco dependence treatments are effective and every patient willing to make a quit attempt should be encouraged to use recommended counseling treatments and medications.
- Brief tobacco dependence treatment is effective.
- Individual, group, and telephone counseling are effective and their effectiveness increases with treatment intensity.
- Numerous effective medications are available for tobacco dependence – (5 nicotine and 2 non-nicotine). Their use increases long-term smoking abstinence rates.
- Counseling and medication are effective when used alone but is more effective when used in combination.
- Telephone quitline counselling is effective.
- For tobacco user unwilling to quit, motivational treatments can be effective in increasing future quit attempts.
- Providing coverage for clinically effective and cost-effective tobacco dependence treatment increases quit rates.
Link to full text of guideline https://bphc.hrsa.gov/buckets/treatingtobacco.pdf
Separate link for references https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/references/tobaccogenrefs.pdf
The additional insights I have gained is that this addictive behaviour is very much hard-wired into the patient’s brain neurobiology especially if they started into tobacco use early. Treatments may need to be life-long and at adequate doses.
I also became aware that tobacco use is particularly problematic for the mentally ill population in two ways:
- They are particularly susceptible to tobacco addiction and accounts for nearly half of the tobacco market.
- That withdrawal of nicotine in these patients can prompt exacerbation of psychiatric disorders, cause relapse, mimic or worsen medication side effects, and increase blood levels of several medications.
What I do now
This has changed my focus from episodic checking for tobacco use to systematization of the process as well as offering both the counselling and appropriate medications for patients. I understand that even providing a brief intervention of 3 minutes will double the chance of patients quitting. Once patients express willingness to quit, referral to The Quit Now program with the telephone counselling www.quitnow.ca will assist patients with this difficult disease. I also put in more intensive effort to provide my patients with mental illness the necessary counselling, social supports and help to obtain financial coverage for effective tobacco cessation pharmacotherapy. This group will also require closer monitoring with tobacco cessation strategies. Further information is provided by a resource developed by PHSA through www.healthyheart.bc.ca → Tobacco Intervention → Health Professionals.
Additional Reading:
Dr. Fred Bass, Special Feature: Training the Inner Alligator. BCMJ 2010; 52: 23 (Full Article)
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interesting article. I have been documenting smoking status in my patients for many years and have been doing cessation counselling. I will be trying to make more referrals to the Quit Now program
In the two year Health Coordinator Pilot we worked closely with one front-line staff in each of six BC practices to systematically deliver clinical tobacco intervention. We offered, secondarily, brief clinical intervention for depression, at-risk alcohol use, and physical inactitivy. We measured baseline and one year follow-up levels of documentation of six intervention components: smoking-status chart-reminder, advice to quit, self-management plan (including stop-smoking medication), target date, referral to community program, and follow-up date. We supported the ‘health coordinators’ with training, clinical materials, payment (a day a week), and weekly telephone conference calls. At follow-up all were increased (statistically) significantly. So we have very tangible evidence of change for the six components of CTI (and less for the other three risks). Further, the front-line staff, the patients, and the physicians all valued what the ‘health coordinators’ were doing. What is important in this work is that it shows that (selected) front-line staff can make a very substantial difference in the delivery of clinical preventive services.
As quitting smoking is the most important lifestyle change anyone can ever make, having medications covered that will support this would be a big step
somewhat worried about varenicline and CV risk. thank you for the online resource, most patients tend to do Internet research these days