Research Original Investigation
Smoking Cessation in the National Lung Screening Trial
23. Aberle DR, Adams AM, Berg CD, et al; National Lung Screening Trial Research Team. Baseline characteristics of participants in the randomized National Lung Screening Trial. J Natl Cancer Inst. 2010;102(23):1771-1779. 24. Biener L, Abrams DB. The Contemplation Ladder: validation of a measure of readiness to consider smoking cessation. Health Psychol. 1991;10 (5):360-365. 25. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict. 1991;86(9): 1119-1127. 26. Goldstein MG, Niaura R, Willey-Lessne C, et al. Physicians counseling smokers: a population-based survey of patients’ perceptions of health care provider–delivered smoking cessation interventions. Arch Intern Med. 1997;157(12):1313-1319. 27. Goldstein MG, DePue JD, Monroe AD, et al. A population-based survey of physician smoking
cessation counseling practices. Prev Med. 1998;27 (5, pt 1):720-729. 28. Schnoll RA, Rukstalis M, Wileyto EP, Shields AE. Smoking cessation treatment by primary care physicians: an update and call for training. Am J Prev Med. 2006;31(3):233-239. 29. Curry SJ, Orleans CT, Keller P, Fiore M. Promoting smoking cessation in the healthcare environment: 10 years later. Am J Prev Med. 2006; 31(3):269-272. 30. Quinn VP, Hollis JF, Smith KS, et al. Effectiveness of the 5-As tobacco cessation treatments in nine HMOs. J Gen Intern Med. 2009; 24(2):149-154. 31. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev. 2005;2(2):CD001292.
health tool: a commentary on Social Science & Medicine’s Stigma, Prejudice, Discrimination and Health Special Issue (67: 3). Soc Sci Med. 2010;70 (6):795-799. 33. Woods SS, Jaén CR. Increasing consumer demand for tobacco treatments: ten design recommendations for clinicians and healthcare systems. Am J Prev Med. 2010;38(3)(suppl):S385S392. 34. Studts JL, Ghate SR, Gill JL, et al. Validity of self-reported smoking status among participants in a lung cancer screening trial. Cancer Epidemiol Biomarkers Prev. 2006;15(10):1825-1828. 35. Velicer WF, Fava JL, Prochaska JO, Abrams DB, Emmons KM, Pierce JP. Distribution of smokers by stage in three representative samples. Prev Med. 1995;24(4):401-411.
32. Bell K, Salmon A, Bowers M, Bell J, McCullough L. Smoking, stigma and tobacco ‘denormalization’: further reflections on the use of stigma as a public
Invited Commentary
Tobacco Cessation—We Can Do Better Michael K. Ong, MD, PhD
Tobacco use continues to be the leading preventable cause of mortality in the United States, despite a decrease in the overall prevalence of cigarette smoking. In this issue of JAMA Internal Medicine, Siegel et al1 report that cigarette smoking continues to be the attributable cause of death for nearly half Related articles pages 1509 of people dying of 12 differand 1574 ent cancers and notably 80% of people dying of lung cancer. Recent data also suggest that focusing only on mortality from conditions in which causal relationships have been established underestimates smokingrelated mortality because an additional 17% of excess smokingrelated mortality is associated with causes not formally established as attributable to smoking.2 Fortunately, the increased focus on outcomes and population management owing to the changes caused by health care reform has renewed interest in how to improve tobacco cessation efforts. The article by Park et al3 in this issue reveals that we have a long distance to go in improving physiciandelivered tobacco cessation efforts. Participants of the National Lung Screening Trial, who were randomized to lowdose computed tomography vs chest radiography for lung screening, reported on whether their physicians had delivered the 5 A’s of tobacco cessation: asking about use, advising users to quit, assessing readiness to quit, assisting with a quit attempt, and arranging for follow-up.4 Only active smokers were included, and they were queried 1 year after the screening. Similar to prior work,8 participants reported relatively high rates of asking about use and advising users to quit, with slightly lower rates of assessing readiness to quit. Unfortunately, also similar to prior work,5 assistance with a quit attempt was provided only 50% of the time, and there were poor rates of arranging for follow-up. As expected, only assistance 1516
with a quit attempt and arranging for follow-up were associated with cessation at 1 year. It would not be appropriate to conclude from the study by Park et al that asking about tobacco use, advising tobacco users to quit, or assessing readiness to quit are not important. They are necessary steps to helping tobacco users with their quit attempts and increase the likelihood of a quit attempt.4 However, these steps by themselves are not sufficient for effective tobacco cessation. The low rates of assisting and arranging for smoking cessation are particularly distressing because physicians and patients were provided the written results of the lung screening examination. High rates of effective action did not occur despite the teachable-moment opportunity of discussing the results of the lung screening. Park et al note that their findings are based on patient reports of physician actions, which could underestimate actual physician actions. However, what patients hear and remember is likely more important than what is said. More effective actions by physicians are also needed. Handing out a brochure on smoking cessation, which was routinely done to meet prior Joint Commission requirements for inpatient tobacco cessation counseling, may fulfill physician requirements but alone is not sufficient for significant tobacco cessation. The new Joint Commission inpatient tobacco treatment measures (http://www.jointcommission.org /tobacco _treatment/) and Medicare requirements for paying physicians for tobacco cessation (https://www.cms.gov/Outreach - a n d - E d u c at i o n / Me d i c a r e - L e a r n i ng - N e t wo r k- M L N /MLNMattersArticles/downloads/MM7133.pdf ) are welcome recent developments, but more changes are needed to maximize success on tobacco cessation. The new Joint Commission measures expand the prior measure to include provision
JAMA Internal Medicine September 2015 Volume 175, Number 9 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
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Smoking Cessation in the National Lung Screening Trial
Original Investigation Research
or offering of tobacco cessation counseling and medications during admission and at discharge. However, it is not mandatory and is only 1 option among 6 that can be selected by organizations for adherence. The expected implementation of the new measures will also not include assessment of tobacco status after discharge because that measure was not endorsed by the National Quality Forum. Insurance coverage for all evidence-based tobacco cessation measures is not yet uniform among health plans, although the Department of Labor has mandated coverage of counseling and medications for at least 2 quit attempts per year for plans associated with the Patient Protection and Affordable Care Act. Furthermore, health care delivery systems could be reconfigured to improve success with tobacco cessation. Advances in health information technologies provide an opportunity to leverage existing resources much more effectively. The University of California has been piloting a bidirectional communication workflow between its 5 health systems’ electronic health records and the California Smokers’ Helpline so that referrals are automatically generated from a templated order set and documentation from the California Smokers’ Helpline’s telephone counseling sessions populate back into the electronic record.6 This is a promising approach to improve the fifth A of arranging for follow-up. Patient education materials ARTICLE INFORMATION Author Affiliations: Division of General Internal Medicine and Health Services Research, University of California, Los Angeles; Veterans Affairs Greater Los Angeles HealthCare System, Los Angeles, California. Corresponding Author: Michael Ong, MD, PhD, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, 10940 Wilshire Blvd, Ste 700, Los Angeles, CA 90024 ([email protected]). Published Online: June 15, 2015. doi:10.1001/jamainternmed.2015.2402. Conflict of Interest Disclosures: Dr Ong reported serving as the chair of the Tobacco Education and Research Oversight Committee for the state of California. No other disclosures were reported.
or videos that have been a key component of public health tobacco control approaches can be targeted toward tobacco users as patient portal use increases. Coordinating and extending our tobacco cessation messaging beyond clinical settings will better prime patients for a tobacco cessation attempt when they meet with a health care professional and tie together population-level approaches with patient-level care. Physicians also cannot go it alone. We need all health care professionals, including nurses, pharmacists, and medical evaluation assistants, to work collaboratively on tobacco cessation. Although nurses and pharmacists with expanded scopes of practice can prescribe tobacco cessation medications, everyone can make a referral to telephone-based counseling from help lines or refer tobacco users to a health care professional for further assistance.7 Despite continued promotional efforts by the tobacco industry, the silver lining for cessation efforts is that most smokers want to quit; national surveys consistently reveal that 70% of smokers want to quit and 50% of smokers have had a quit attempt in the past year.8 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.
2. Carter BD, Abnet CC, Feskanich D, et al. Smoking and mortality—beyond established causes. N Engl J Med. 2015;372(7):631-640. 3. Park ER, Gareen IF, Japuntich S, et al. Primary care provider-delivered smoking cessation interventions and smoking cessation among participants in the National Lung Screening Trial [published online June 15, 2015]. JAMA Intern Med. doi:10.1001/jamainternmed.2015.2391. 4. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Washington, DC: Public Health Service, US Dept of Health and Human Services; 2008. 5. Solberg LI, Asche SE, Boyle RG, Boucher JL, Pronk NP. Frequency of physician-directed assistance for smoking cessation in patients
receiving cessation medications. Arch Intern Med. 2005;165(6):656-660. 6. Tobacco Education and Research Oversight Committee. Changing Landscape: Countering New Threats, 2015-2017: Toward a Tobacco-Free California Master Plan. Sacramento: California Dept of Public Health; 2015. 7. Sarna L, Bialous SA, Ong MK, Wells M, Kotlerman J. Increasing nursing referral to telephone quitlines for smoking cessation using a web-based program. Nurs Res. 2012;61(6):433-440. 8. Centers for Disease Control and Prevention (CDC). Quitting smoking among adults—United States, 2001-2010. MMWR Morb Mortal Wkly Rep. 2011;60(44):1513-1519.
REFERENCES 1. Siegel RL, Jacobs EJ, Newton CC, et al. Deaths due to cigarette smoking for 12 smoking-related cancers in the United States [published online June 15, 2015]. JAMA Intern Med. doi:10.1001 /jamainternmed.2015.2398.
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(Reprinted) JAMA Internal Medicine September 2015 Volume 175, Number 9
Copyright 2015 American Medical Association. All rights reserved.
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Smoking Cessation in the National Lung Screening Trial
23. Aberle DR, Adams AM, Berg CD, et al; National Lung Screening Trial Research Team. Baseline characteristics of participants in the randomized National Lung Screening Trial. J Natl Cancer Inst. 2010;102(23):1771-1779. 24. Biener L, Abrams DB. The Contemplation Ladder: validation of a measure of readiness to consider smoking cessation. Health Psychol. 1991;10 (5):360-365. 25. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict. 1991;86(9): 1119-1127. 26. Goldstein MG, Niaura R, Willey-Lessne C, et al. Physicians counseling smokers: a population-based survey of patients’ perceptions of health care provider–delivered smoking cessation interventions. Arch Intern Med. 1997;157(12):1313-1319. 27. Goldstein MG, DePue JD, Monroe AD, et al. A population-based survey of physician smoking
cessation counseling practices. Prev Med. 1998;27 (5, pt 1):720-729. 28. Schnoll RA, Rukstalis M, Wileyto EP, Shields AE. Smoking cessation treatment by primary care physicians: an update and call for training. Am J Prev Med. 2006;31(3):233-239. 29. Curry SJ, Orleans CT, Keller P, Fiore M. Promoting smoking cessation in the healthcare environment: 10 years later. Am J Prev Med. 2006; 31(3):269-272. 30. Quinn VP, Hollis JF, Smith KS, et al. Effectiveness of the 5-As tobacco cessation treatments in nine HMOs. J Gen Intern Med. 2009; 24(2):149-154. 31. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev. 2005;2(2):CD001292.
health tool: a commentary on Social Science & Medicine’s Stigma, Prejudice, Discrimination and Health Special Issue (67: 3). Soc Sci Med. 2010;70 (6):795-799. 33. Woods SS, Jaén CR. Increasing consumer demand for tobacco treatments: ten design recommendations for clinicians and healthcare systems. Am J Prev Med. 2010;38(3)(suppl):S385S392. 34. Studts JL, Ghate SR, Gill JL, et al. Validity of self-reported smoking status among participants in a lung cancer screening trial. Cancer Epidemiol Biomarkers Prev. 2006;15(10):1825-1828. 35. Velicer WF, Fava JL, Prochaska JO, Abrams DB, Emmons KM, Pierce JP. Distribution of smokers by stage in three representative samples. Prev Med. 1995;24(4):401-411.
32. Bell K, Salmon A, Bowers M, Bell J, McCullough L. Smoking, stigma and tobacco ‘denormalization’: further reflections on the use of stigma as a public
Invited Commentary
Tobacco Cessation—We Can Do Better Michael K. Ong, MD, PhD
Tobacco use continues to be the leading preventable cause of mortality in the United States, despite a decrease in the overall prevalence of cigarette smoking. In this issue of JAMA Internal Medicine, Siegel et al1 report that cigarette smoking continues to be the attributable cause of death for nearly half Related articles pages 1509 of people dying of 12 differand 1574 ent cancers and notably 80% of people dying of lung cancer. Recent data also suggest that focusing only on mortality from conditions in which causal relationships have been established underestimates smokingrelated mortality because an additional 17% of excess smokingrelated mortality is associated with causes not formally established as attributable to smoking.2 Fortunately, the increased focus on outcomes and population management owing to the changes caused by health care reform has renewed interest in how to improve tobacco cessation efforts. The article by Park et al3 in this issue reveals that we have a long distance to go in improving physiciandelivered tobacco cessation efforts. Participants of the National Lung Screening Trial, who were randomized to lowdose computed tomography vs chest radiography for lung screening, reported on whether their physicians had delivered the 5 A’s of tobacco cessation: asking about use, advising users to quit, assessing readiness to quit, assisting with a quit attempt, and arranging for follow-up.4 Only active smokers were included, and they were queried 1 year after the screening. Similar to prior work,8 participants reported relatively high rates of asking about use and advising users to quit, with slightly lower rates of assessing readiness to quit. Unfortunately, also similar to prior work,5 assistance with a quit attempt was provided only 50% of the time, and there were poor rates of arranging for follow-up. As expected, only assistance 1516
with a quit attempt and arranging for follow-up were associated with cessation at 1 year. It would not be appropriate to conclude from the study by Park et al that asking about tobacco use, advising tobacco users to quit, or assessing readiness to quit are not important. They are necessary steps to helping tobacco users with their quit attempts and increase the likelihood of a quit attempt.4 However, these steps by themselves are not sufficient for effective tobacco cessation. The low rates of assisting and arranging for smoking cessation are particularly distressing because physicians and patients were provided the written results of the lung screening examination. High rates of effective action did not occur despite the teachable-moment opportunity of discussing the results of the lung screening. Park et al note that their findings are based on patient reports of physician actions, which could underestimate actual physician actions. However, what patients hear and remember is likely more important than what is said. More effective actions by physicians are also needed. Handing out a brochure on smoking cessation, which was routinely done to meet prior Joint Commission requirements for inpatient tobacco cessation counseling, may fulfill physician requirements but alone is not sufficient for significant tobacco cessation. The new Joint Commission inpatient tobacco treatment measures (http://www.jointcommission.org /tobacco _treatment/) and Medicare requirements for paying physicians for tobacco cessation (https://www.cms.gov/Outreach - a n d - E d u c at i o n / Me d i c a r e - L e a r n i ng - N e t wo r k- M L N /MLNMattersArticles/downloads/MM7133.pdf ) are welcome recent developments, but more changes are needed to maximize success on tobacco cessation. The new Joint Commission measures expand the prior measure to include provision
JAMA Internal Medicine September 2015 Volume 175, Number 9 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a GAZI UNIVERSITESI User on 04/05/2016
jamainternalmedicine.com
Smoking Cessation in the National Lung Screening Trial
Original Investigation Research
or offering of tobacco cessation counseling and medications during admission and at discharge. However, it is not mandatory and is only 1 option among 6 that can be selected by organizations for adherence. The expected implementation of the new measures will also not include assessment of tobacco status after discharge because that measure was not endorsed by the National Quality Forum. Insurance coverage for all evidence-based tobacco cessation measures is not yet uniform among health plans, although the Department of Labor has mandated coverage of counseling and medications for at least 2 quit attempts per year for plans associated with the Patient Protection and Affordable Care Act. Furthermore, health care delivery systems could be reconfigured to improve success with tobacco cessation. Advances in health information technologies provide an opportunity to leverage existing resources much more effectively. The University of California has been piloting a bidirectional communication workflow between its 5 health systems’ electronic health records and the California Smokers’ Helpline so that referrals are automatically generated from a templated order set and documentation from the California Smokers’ Helpline’s telephone counseling sessions populate back into the electronic record.6 This is a promising approach to improve the fifth A of arranging for follow-up. Patient education materials ARTICLE INFORMATION Author Affiliations: Division of General Internal Medicine and Health Services Research, University of California, Los Angeles; Veterans Affairs Greater Los Angeles HealthCare System, Los Angeles, California. Corresponding Author: Michael Ong, MD, PhD, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, 10940 Wilshire Blvd, Ste 700, Los Angeles, CA 90024 ([email protected]). Published Online: June 15, 2015. doi:10.1001/jamainternmed.2015.2402. Conflict of Interest Disclosures: Dr Ong reported serving as the chair of the Tobacco Education and Research Oversight Committee for the state of California. No other disclosures were reported.
or videos that have been a key component of public health tobacco control approaches can be targeted toward tobacco users as patient portal use increases. Coordinating and extending our tobacco cessation messaging beyond clinical settings will better prime patients for a tobacco cessation attempt when they meet with a health care professional and tie together population-level approaches with patient-level care. Physicians also cannot go it alone. We need all health care professionals, including nurses, pharmacists, and medical evaluation assistants, to work collaboratively on tobacco cessation. Although nurses and pharmacists with expanded scopes of practice can prescribe tobacco cessation medications, everyone can make a referral to telephone-based counseling from help lines or refer tobacco users to a health care professional for further assistance.7 Despite continued promotional efforts by the tobacco industry, the silver lining for cessation efforts is that most smokers want to quit; national surveys consistently reveal that 70% of smokers want to quit and 50% of smokers have had a quit attempt in the past year.8 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.
2. Carter BD, Abnet CC, Feskanich D, et al. Smoking and mortality—beyond established causes. N Engl J Med. 2015;372(7):631-640. 3. Park ER, Gareen IF, Japuntich S, et al. Primary care provider-delivered smoking cessation interventions and smoking cessation among participants in the National Lung Screening Trial [published online June 15, 2015]. JAMA Intern Med. doi:10.1001/jamainternmed.2015.2391. 4. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Washington, DC: Public Health Service, US Dept of Health and Human Services; 2008. 5. Solberg LI, Asche SE, Boyle RG, Boucher JL, Pronk NP. Frequency of physician-directed assistance for smoking cessation in patients
receiving cessation medications. Arch Intern Med. 2005;165(6):656-660. 6. Tobacco Education and Research Oversight Committee. Changing Landscape: Countering New Threats, 2015-2017: Toward a Tobacco-Free California Master Plan. Sacramento: California Dept of Public Health; 2015. 7. Sarna L, Bialous SA, Ong MK, Wells M, Kotlerman J. Increasing nursing referral to telephone quitlines for smoking cessation using a web-based program. Nurs Res. 2012;61(6):433-440. 8. Centers for Disease Control and Prevention (CDC). Quitting smoking among adults—United States, 2001-2010. MMWR Morb Mortal Wkly Rep. 2011;60(44):1513-1519.
REFERENCES 1. Siegel RL, Jacobs EJ, Newton CC, et al. Deaths due to cigarette smoking for 12 smoking-related cancers in the United States [published online June 15, 2015]. JAMA Intern Med. doi:10.1001 /jamainternmed.2015.2398.
jamainternalmedicine.com
(Reprinted) JAMA Internal Medicine September 2015 Volume 175, Number 9
Copyright 2015 American Medical Association. All rights reserved.
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1517
