Promoting smoking cessation in the healthcare environment: 10 years later.
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ABSTRACT: BACKGROUNDSmoking remains the leading cause of preventable mortality in the US. The national clinical guideline recommends an intervention for tobacco use known as the 5-As (Ask, Advise, Assess, Assist, and Arrange). Little is known about the model’s effectiveness outside the research setting. OBJECTIVETo assess the effectiveness of tobacco treatments in HMOs. PARTICIPANTSSmokers identified from primary care visits in nine nonprofit health plans. DESIGN/METHODSSmokers were surveyed at baseline and at 12-month follow-up to assess smoking status and tobacco treatments offered by clinicians and used by smokers. RESULTSAnalyses include the 80% of respondents who reported having had a visit in the previous year with their clinician when they were smoking (n = 2,325). Smokers were more often offered Advice (77%) than the more effective Assist treatments–classes/counseling (41%) and pharmacotherapy (33%). One third of smokers reported using pharmacotherapy, but only 16% used classes or counseling. At follow-up, 8.9% were abstinent for >30days. Smokers who reported being offered pharmacotherapy were more likely to quit than those who did not (adjusted OR = 1.73, CI = 1.22–2.45). Compared with smokers who didn’t use classes/counseling or pharmacotherapy, those who did use these services were more likely to quit (adjusted OR = 1.82, CI = 1.16–2.86 and OR = 2.23, CI = 1.56–3.20, respectively). CONCLUSIONSSmokers were more likely to report quitting if they were offered cessation medications or if they used either medications or counseling. Results are similar to findings from clinical trials and highlight the need for clinicians and health plans to provide more than just advice to quit.Journal of General Internal Medicine 01/2009; 24(2):149-154. DOI:10.1007/s11606-008-0865-9 · 3.42 Impact Factor
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ABSTRACT: Cigarette smoking and exposure to secondhand smoke cause coronary heart disease. Cessation dramatically reduces the incidence of primary and secondary cardiac events. The review presents up-to-date information regarding nicotine dependence, recent findings related to its treatment, and recommendations for addressing smoking cessation for the primary and secondary prevention of coronary heart disease. Bans on smoking in public places are associated with significant reductions in the incidence of acute myocardial infarction. Counseling and pharmacotherapy (nicotine replacement therapy, bupropion) are proven, effective treatments for nicotine dependence. Clinical trials of two new pharmacotherapies, varenicline and rimonabant, have recently been reported. Varenicline is a safe and efficacious medication for smoking cessation, and has been approved in the US, Canada and Europe. Rimonabant has shown mixed results for smoking cessation and is undergoing further evaluation. All patients should be screened for tobacco use. Clinicians can effectively treat nicotine dependence in the general population using counseling and first-line pharmacotherapies (nicotine replacement therapy, bupropion, varenicline). These same treatments, with some modification, are appropriate for smokers with coronary heart disease; however, brief interventions without follow-up are not effective in this population. For smokers with coronary heart disease, the best time to intervene may be during hospitalization.Current Opinion in Cardiology 08/2007; 22(4):280-5. DOI:10.1097/HCO.0b013e328236740a · 2.59 Impact Factor
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ABSTRACT: More adults in the United States have quit smoking than remain current smokers. But 45 million adults (20.9%) continue to smoke, with highest rates among low socioeconomic status (SES), blue-collar, and Native American populations. More than two thirds (70%) of adult smokers want to quit, and approximately 40% make a serious quit attempt each year, but only 20%-30% of quitters use an effective behavioral counseling or pharmacologic treatment. The lowest rates of treatment use are seen in the populations with the highest rates of tobacco use. Fully harvesting the last 4 decades of progress in tobacco-control science and policy to increase smokers' demand for and use of cessation treatments represents an extraordinary opportunity to extend lives and reduce healthcare costs and burden in the next 30-40 years. This paper uses the "push-pull capacity" model as a framework for illustrating strategies to achieve this goal. This model recommends: (1) improving and communicating effective treatments for wide population use; (2) building the capacity of healthcare and other systems to deliver effective treatments; and (3) boosting consumer, health plan, and insurer demand for them through policy interventions shown to motivate and support quitting (e.g., clean indoor-air laws, tobacco tax increases, expanded insurance coverage/reimbursement) and efforts to improve treatment access and appeal, especially for smokers who use them least. Innovations recommended by the National Consumer Demand Roundtable for achieving "breakthrough" improvements in cessation treatment demand and use are described.American Journal of Preventive Medicine 01/2008; 33(6 Suppl):S340-8. DOI:10.1016/j.amepre.2007.09.003 · 4.28 Impact Factor