At least 70 percent of smokers see a physician each year, and almost one-third see a dentist.^19,110 Other smokers see physician assistants, nurse practitioners, nurses, physical and occupational therapists, pharmacists, counselors, and other clinicians. Therefore, virtually all clinicians are in a position to intervene with patients who use tobacco. Moreover, 70 percent of smokers report wanting to quit,¹¹¹ and almost two-thirds of smokers who relapse want to try quitting again within 30 days.¹¹² Finally, smokers cite a physician's advice to quit as an important motivator for attempting to stop smoking.^113–118 These data suggest that most smokers are interested in quitting, clinicians and health systems are in frequent contact with smokers, and clinicians have high credibility with smokers.

Unfortunately, clinicians and health systems do not capitalize on this opportunity consistently. According to the National Committee for Quality Assurance's (NCQA) State of Health Care Quality Report,¹¹⁹ there has been some improvement in tobacco dependence clinical intervention for the insured population. In 2005, 71.2 percent of commercially insured smokers received cessation advice (up slightly from 69.6% in 2004); and 75.5 percent of Medicare smokers received advice to quit, up 11 percentage points from 2004 for this group. Despite this progress, there is a clear need for additional improvement. Only 25 percent of Medicaid patients reported any practical assistance with quitting or any ensuing followup of their progress.²² Only one-third of adolescents who visited a physician or dentist report receiving counseling about the dangers of tobacco use, according to the 2000 National Youth Tobacco Survey.¹²⁰ Pregnant women who smoke were identified at 81 percent of physician visits but received counseling at only 23 percent of these visits.¹²¹ In addition, few smokers get specific help with quitting. Recent Healthcare Effectiveness Data and Information Set (HEDIS) data showed that only 39 percent of smokers reported that their clinician discussed either medications or counseling strategies to quit (www.web.ncqa.org/tabid/59/Default.aspx). To capitalize on this opportunity, the 2008 Guideline update provides empirically validated tobacco treatment strategies designed to spur clinicians, tobacco treatment specialists, and health systems to intervene effectively with patients who use tobacco.

The first step in treating tobacco use and dependence is to identify tobacco users. As the data analysis in Chapter 6 shows, the identification of smokers itself increases rates of clinician intervention. Effective identification of tobacco use status not only opens the door for successful interventions (e.g., clinician advice and treatment), but also guides clinicians to identify appropriate interventions based on patients' tobacco use status and willingness to quit. Based on these findings, the Guideline update recommends that clinicians and health care systems seize the office visit for universal assessment and intervention. Specifically, ask every patient who presents to a health care facility if s/he uses tobacco (Ask), advise all tobacco users to quit (Advise), and assess the willingness of all tobacco users to make a quit attempt at this time (Assess) (the first 3 of the 5 A's; see Chapter 3).

Screening for current or past tobacco use will result in four possible responses: (1) the patient uses tobacco and is willing to make a quit attempt at this time; (2) the patient uses tobacco but is not willing to make a quit attempt at this time; (3) the patient once used tobacco but has since quit; and (4) the patient never regularly used tobacco. This Clinical Practice Guideline is organized to provide the clinician with simple but effective interventions for all of these patient groups (see Figure 2.1).

Figure

Figure 2.1. Algorithm for treating tobacco use.