Smoking Cessation: Intensive Interventions by PCPs Help

Marcia Frellick

June 15, 2015

Smokers were more likely to quit when primary care physicians used intensive interventions including recommending medications and counseling and arranging follow-up, but less-intensive interventions were ineffective, new research shows.

Elyse R. Park, PhD, MPH, from the Tobacco Research and Treatment Center at Massachusetts General Hospital in Boston, and colleagues assessed how often physicians were using each of the "5 As" (ask about status, advise quitting, assess willingness to quit, assist [talk about quitting or recommend medication or counselling], and arrange follow-up), and whether these interventions increased chances of quitting smoking after screening.

They used a matched case-control study (cases were quitters and controls were continued smokers) of 3336 National Lung Screening Trial participants who were smokers at enrollment.

As to prevalence, physician use of the 5 were as follows: ask, 77.2%; advise, 75.6%; assess, 63.4%; assist, 56.4%; and arrange follow-up, 10.4%.

The least-used interventions (assist and arrange) were the most effective. Ask, advise, and assess had no significant link to quitting when researchers adjusted for sociodemographic characteristics, medical history, screening results, nicotine dependence, and motivation to quit.

However, assist was associated with a 40% increase in the odds of quitting (odds ratio, 1.40; 95% confidence interval, 1.21 - 1.63), and arrange was linked with a 46% increase in the odds of quitting (odds ratio, 1.46; 95% confidence interval, 1.19 - 1.79). Results were published online June 15 in JAMA Internal Medicine.

"Our findings confirm the need for and benefit of clinicians taking more active intervention steps in helping patients who undergo screening to quit smoking," the authors conclude.

In an accompanying editorial, Michael K. Ong, MD, PhD, from the Division of General Internal Medicine and Health Services Research at University of California, Los Angeles, cautions against concluding that the first three interventions are not important. Rather, he says, they need to be used in conjunction with assist and arrange.

He says the low number of effective interventions is particularly disappointing because physicians seemed to be missing the teachable moment that came when both physicians and patients received the results of the lung screening.

More such opportunities will arise as the number of screenings likely grows after a decision in February 2015 by Medicare to cover annual lung screening for former and current smokers (aged 55 - 77 years) with a smoking history of at least 30 pack-years.

With more screenings come more opportunities to combine discussion of test results and smoking cessation strategies.

Dr Ong notes that physicians have something working in their favor: most patients want to quit.

"[N]ational surveys consistently reveal that 70% of smokers want to quit and 50% of smokers have had a quit attempt in the past year," he writes. "We need to ensure that we are offering tobacco cessation assistance, whether counseling or medication prescription or referral to a tobacco cessation resource, to every tobacco user every time that user encounters the health care system."

The study was funded by the American Cancer Society and the Veterans Affairs Clinical Sciences Research and Development award program. Dr Park is expected to receive royalties from UpToDate. One coauthor has reported receiving royalties from UpToDate and working as an unpaid consultant to Pfizer Inc for smoking cessation. The other authors have disclosed no relevant financial relationships. Dr Ong reports serving as the chair of the Tobacco Education and Research Oversight Committee for the state of California.

JAMA Intern Med. Published online June 15, 2015. Article abstract, Editorial extract

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