Physicians

Physicians

Smoking Cessation Counseling in the doctor’s office

 

Physician Beliefs & Perceived Barriers:

Myth: Discussing smoking cessation with patients is too time-consuming, not effective and not the physician’s responsibility.

Surveys show that physicians perceive many barriers to discussing smoking cessation during patient visits.

• 42% of physicians believe it’s time consuming¹
• 39% of physicians believe that time with patients is limited²
• 38% of physicians believe it’s not effective¹
• 5% of physicians believe it’s not their professional duty¹

^​Truth: All physicians can make a difference by taking 5 minutes or less to talk with their patients regarding smoking cessation.

• Sustained quitters
  • reported fewer depressive symptoms³
  • were more likely to have health insurance and a usual doctor that they had seen within the last year³
  • were more likely to trust their doctor³
• Physicians and nurses with an understanding of the Public Health Service guidelines, previous cessation training, and a belief that treatment of patients with substance abuse is a professional responsibility self-reported performing multiple components of the 5 A’s during a National survey of US health professionals.⁴
• Negative factors associated with the self-reported performance of the 5 A’s include the health professional currently smoking, not working as a primary care physician and feeling uncomfortable while talking with patients regarding substance use.⁴

Myth: A conversation with patients regarding smoking cessation can be unpleasant and typically a waste of time because most patients lie.

Physicians may also worry about the interpersonal or counseling aspect to a smoking cessation conversation.

• 58% of physicians believe patients lie¹
• 18% of physicians consider the discussions regarding smoking cessation to be an unpleasant experience¹

Truth: Research supports that a conversation with a physician can positively affect a patient’s smoking cessation efforts. 

• Self-reported patient smoking cessation was higher when PCPs were trained to do an “enhanced” intervention vs. “minimal” or no intervention.⁵
• In a survey of physician screening for smoking and other cancer risk behaviors, higher patient satisfaction was associated with more  thorough counseling.⁶

Myth: Talking with patients about smoking cessation is not cost effective and physicians are not reimbursed for their time spent with the patient while discussing substance use.

Many physicians believe there are several financial limitations to speaking with patients regarding smoking cessation.²

• 54% of physicians believe there are limitations on coverage for counseling and quitlines²
• 52% of physicians believe there are limitations on reimbursements for the physician’s time²
• 39% of physicians believe that time with patients is limited²

Truth: Smoking cessation is often covered by healthcare.⁷

• Services may be billable in two different time increments (e.g., 3 – 10 minutes and >10 minutes).
• It is important to check with your patient’s specific Medical Care Organization (MCO) plan as limits of coverage can vary.
  • Physician Fee Schedule look-up for Medicare services
• Services covered may also need to be associated with a diagnosis of a Tobacco Use Disorder.

Myth: There are no smoking cessation resources or programs for physicians to offer their patients.

• 39% of the population within a study agreed that a significant barrier to smoking cessation was connected to a limitation in the amount of programs and resources available.²

Truth: Discussing smoking cessation with patients may be easier than physicians think.  Physicians have access to numerous resources and methods when assisting patients with arranging follow up appointments and further referrals to treatment.

 

How Physicians can help their patients:

A survey demonstrates patient’s impression based on their interactions with primary care physicians during appointments.⁸

• 53.7% of patients reported their primary care physician did nothing about their substance abuse.⁸
• 10.7% of patients believe the physician knew about the substance abuse but did not provide treatment, referrals, or the necessary resources. ⁸

In another survey targeting adolescents and their smoking habits it was found that¹²:

• Only 49% of adolescents were screened for tobacco use by their physicians, which translates to an estimated 36% screening rate at the population level¹²
  • Of these adolescents, almost 57% were female, 60% White, 83% in late adolescence, and 64% had private insurance. ¹²
• When controlling for sociodemographic characteristics and cigarette use, screening for tobacco use was highly correlated (12-fold higher odds) with physician advice to quit smoking¹²
• Hispanic adolescents were significantly less likely to receive physician advice to quit.¹²
• Only 26% of past 30-day smokers received screening and advice from physicians to quit.¹²

In older adults only 50% of smokers reported that they “usually” or “always” received smoking cessation advice from their clinicians¹³

• Of these older adults, smokers with 8th grade or less education reported receiving less advice from physicians to quit¹³
• Advice was more often given to the young, those in low-smoking regions, Asians, and women¹³

There are several actions physicians can take in order to help their patients with smoking cessation.

1. Have a conversation with the patient using the Ask, Advise, Assess, Connect ⁹

Ask	Ask each patient at every visit about their tobacco use and document the status appropriately
Advise	Advise the patient to quit using tobacco. The physician can clearly and personably speak with the patient about connections between the tobacco use and any current medical problems. Remind the patient that any level of tobacco use can be dangerous to their health.
Assess	Assess each patient’s willingness to make a quit attempt.
Connect	Determine referral need, identify, options, and make a direct referral.

2. Arrange to check in with patients after the initial visit.¹⁰

After creating a specific plan with the patient, the physician is encouraged to arrange a follow up appointment.

During a follow up visit, the physician and patient are able to discuss any progress made with accomplishing the goals created during the previous visits.

• If any change has occurred since the last appointment, it is important for the physician to praise the patient on their efforts and reinforce persistence and dedication to the established plan.
• If change has not occurred since the last visit, the physician should recognize the difficulty of change and communicate with the patient about any obstacles or need for adjustments in the current plan.

3. Prescribe medications.^{9, 10}

Physicians are encouraged to consider prescribing medications to the patient during follow up appointments to assist with the cessation process.⁹

Here is a list of several FDA approved medications available for physicians to prescribe to their patients.⁹           

Medications	Side Effects	Contraindications	Rx or OTC	Cost
Bupropion SR (Zyban)	Insomnia and Dry Mouth	Hx of seizures ore eating disorder. Avoid MAO inhibitor two weeks prior to start date of this medication	Rx	Generic- $97 Brand Name- $197 to $210
Nicotine Gum	Mouth soreness, hiccups, jaw aches, and dyspepsia		OTC	$48-$63
Nicotine Inhaler	Irritation of mouth and throat, cough, and rhinitis		Rx	$196
Nicotine Lozenge	Nausea, hiccups and heartburn, higher doses cause headaches and coughing		OTC	$34-$39
Nicotine Nasal Spray	Nasal irritation, nasal congestion, changes in sense of smell *Highest dependence potential-uses higher peak nicotine levels	Hx of severe reactive airway disease	Rx	$49
Nicotine Patch	Local skin reaction, insomnia, vivid dreams		OTC or Rx	$37-$48
Varencicline (Chantix)	Inability to drive or operate heavy machinery *Rare side effects: Depressed mood, agitation, changes in behavior, suicidal ideation, and suicides	Hx of kidney disease (creatinine levels of <30mL/min), Patients on dialysis. Interactions with alcohol	Rx	$131

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table Abstracted from: Treating Tobacco Use and Dependence, Clinical Practical Guideline, 2008 Update⁹

4. Refer the patient to another facility for further treatment.^{9, 10, 11}

After performing a brief intervention with a patient, a physician may realize that a follow up appointment will not adequately help the patient during their attempt to quit.¹⁰

In these cases, a physician may provide the patient with a referral to further treatment.  Several circumstances may influence a referral to treatment for a patient including…¹⁰

• Need for detox or intensive treatment
• Current substance use problem is too severe for a brief intervention
• The patient requests more assistance during the intervention

 

Effective Referrals

A successful referral requires the physician to plan and connect the patient with the referred services. There are three different types of connections made between the physician and the facility when referring a patient.¹⁰

• Hot Handoff: Patient and new provider are appropriately matched with the current physician establishing direct contact between the new provider and the patient.

• Warm Handoff: possible matching of patient with another provider or facility. An electronic notification in the chart may be used to contact the new provider.

• Cold Handoff: Patient not matched with another provider or facility.

Quitline Referral

Physicians can extend their counseling time with patients through a Quitline referral.

• Fax to Assist gives patients up to 4 calls of 10 minutes each with a quitline coach
• Any HIPPA covered facility can join the Fax to Assist program.
• Other healthcare providers in the office may also be trained in Fax to Assist.

 

Resources

The American Medical Association A private sector panel of experts developed a How-To Guide for Clinicians which provides information on first-line pharmacologic therapies and counseling to help clients quit using tobacco.

The American Academy of Family Physicians (AAFP) "Ask and Act Practice Toolkit" includes a number of tobacco cessation resources that can be utilized to help your patients quit.

The National Cancer Institute offers an entire monograph regarding information on smoking interventions for medical and dental practices.

Learn more about the link between Smoking and Mesothelioma from the Asbestos and Mesothelioma Center.

Drs. Fiore and Baker (2011) present a review of formal guidelines and clinical recommendations for treating smokers in the health care setting.  View the article, published in The New England Journal of Medicine.