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
- 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
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
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.
- 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
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
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 5 A’s9
Ask each patient at every visit about their tobacco use and document the status appropriately
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 each patient’s willingness to make a quit attempt.
Assist in the patient’s quit attempt. If the patient is willing to begin a quit attempt, the physician may prescribe medications, refer the patient to further treatment, counseling and other available resources to help the patient during their quit attempt.
Arrange further follow up for the patient. If the patient is willing to make a quit attempt, the physician should proceed by making a follow up appointment to reevaluate to the patient within the first week of the quit date or direct the patient
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
Rx or OTC
Insomnia and Dry Mouth
Hx of seizures ore eating disorder. Avoid MAO inhibitor two weeks prior to start date of this medication
Brand Name- $197 to $210
Mouth soreness, hiccups, jaw aches, and dyspepsia
Irritation of mouth and throat, cough, and rhinitis
Nausea, hiccups and heartburn, higher doses cause headaches and coughing
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
Local skin reaction, insomnia, vivid dreams
OTC or Rx
Inability to drive or operate heavy machinery *Depressed mood, agitation, changes in behavior, suicidal ideation, and suicides
Hx of kidney disease (creatinine levels of <30mL/min), Patients on dialysis, Hx of psychiatric illness
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
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.
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.
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.
Did you know that the Medicaid population is significantly more likely to use tobacco than the general population? Do you want to enhance your skills at reaching and intervening with Medicaid patients who use tobacco? MDQuit has an online training to teach you the strategies that can be utilized will all patients—regardless of their health insurance status. You can sign-up for this FREE self-paced online training by going to https://HABITSLabTraining.litmos.com/self-signup/ and entering the training code, "medicaid".
- Vogt, F., Hall, S., & Marteau, T. (2005). General practitioners’ and family physicians’ negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review. Addiction, 100(10), 1423-1431. doi:10.1111/j.1360-0443.2005.01221.x.
- Association of American Medical Colleges. (2007). Physician behavior and practice patterns related to smoking cessation – Full report (5/17/2007.) A report prepared in cooperation with the Center for Health Workforce Studies for the American Legacy Foundation, currently Truth Initiative. Available at: https://www.aamc.org/download/55438/data/
- Rutten, L., Wanke, K., & Augustson, E. (2005). Systems and individual factors associated with smoking status: Evidence from HINTS. American Journal of Health Behavior, 29(4), 302-310.
- Tong, E., Strouse, R., Hall, J., Kovac, M., & Schroeder, S. (2010). National survey of U.S. health professionals' smoking prevalence, cessation practices, and beliefs. Nicotine & Tobacco Research, 12(7), 724-733.
- Milch, C., Edmunson, J., Beshansky, J., Griffith, J., & Selker, H. (2004). Smoking cessation in primary care: A clinical effectiveness trial of two simple interventions. Preventive Medicine, 38(3), 284-294. doi:10.1016/j.ypmed.2003.09.045.
- DePue, J., Goldstein, M., Redding, C., Velicer, W., Sun, X., Fava, J., et al. (2008). Cancer prevention in primary care: Predictors of patient counseling across four risk behaviors over 24 months. Preventive Medicine: An International Journal Devoted to Practice and Theory, 46(3), 252-259. doi:10.1016/j.ypmed.2007.11.020.
- American Lung Association. (2011). State Medicaid Data Sources. Available at: http://c.ymcdn.com/sites/www.naquitline.org/resource/resmgr/2011_seminar_series/marylands_story_final.pdf
- The National Center on Addiction and Substance Abuse at Columbia University. (2000). The CASA National survey of primary care physicians and patients on substance abuse. Available at: http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCIQFjAA&url=http%3A%2F%2Fwww.casacolumbia.org%2Fdownload.aspx%3Fpath%3D%2FUploadedFiles%2Fkksvjhvx.pdf&ei=Q7FYUJzjIIXt0gG7gIEw&usg=AFQjCNHpEud5rYQeZId6_L79pmliEsnU2A
- Fiore, M. C., Jaen, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., Curry, S. J., et al. (2008). Treating tobacco use and dependence: 2008 update—Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.
- MarylanD M.D.s Making a Difference (MD3). (2011). Module 4: The Steps of BI [PowerPoint slides]. Retrieved from: http://www.medschool.umaryland.edu/sbirt/module_4/player.html
- MarylanD M.D.s Making a Difference (MD3). (2011). Module 5: Referral to treatment [PowerPoint slides]. Retrieved from: http://www.medschool.umaryland.edu/sbirt/module_5/player.html