Increasing consumer demand for tobacco treatments: Ten design recommendations for clinicians and healthcare systems

Disparities in receipt of 5As for smoking cessation in diverse primary care and HIV clinics

Clinical practice guidelines recommend that clinicians implement the 5As (Ask, Advise, Assess, Assist, and Arrange) for smoking cessation at every clinical encounter. We sought to examine the prevalence of patient- and clinician-reported 5As in two primary care and one HIV care clinics in San Francisco, California between August 2013 and March 2014 (n = 462 patients and n = 61 clinicians). We used multivariable logistic regression analysis to identify factors associated with receipt of the 5As, adjusting for patient demographics, patient insurance, clinic site, patient tobacco use, and patient comorbidities. The patient-reported prevalence of 5As receipt was as follows: Ask, 49.9%; Advise, 47.2%; Assess, 40.6%; any Assist, 44.9%; and Arrange, 22.4%. In multivariable analysis, receipt of Advise, Assess, and Assist were associated with older patient age. Whereas patients with HIV had a lower odds of reporting being advised (AOR 0.5, 95% CI 0.3–0.8) or assessed for readiness to quit (AOR 0.6, 95% CI 0.4–0.9), patients with pulmonary diseases had higher odds of reporting being assisted (AOR 1.6, 95% 1.0–2.6) than patients without these diagnoses. Although the majority of clinicians reported asking (91.8%), advising (91.8%), and assessing (93.4%) tobacco use ‘most of the time’ or ‘always’ during a clinical encounter, fewer reported assisting (65.7%) or arranging (19.7%) follow-up. Only half of patients reported being screened for tobacco use and fewer reported receipt of the other 5As, with significant disparities in receipt of the 5As among patients with HIV. Our findings confirm the need for interventions to increase clinician-delivered cessation treatment in primary and HIV care.

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Clinical practice guidelines recommend the use of 5As for smoking cessation.

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Patient reports of Assist and Arrange were low in primary care and HIV care.

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There were significant disparities in the receipt of 5As among patients with HIV.

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Digital interventions could facilitate clinician-delivered 5As for patients.

An Official American Thoracic Society Research Statement: Current Understanding and Future Research Needs in Tobacco Control and Treatment

INTRODUCTION

Since the mid-20th century, the scientific community has substantially improved its understanding of the worldwide tobacco epidemic. Although significant progress has been made, the sheer enormity and scope of the global problem put it on track to take a billion lives this century. Curbing the epidemic will require maximizing the impact of proven tools as well as the development of new, breakthrough methods to help interrupt the spread of nicotine addiction and reduce the downstream morbidity.

METHODS

Members of the Tobacco Action Committee of the American Thoracic Society queried bibliographic databases, including Medline, Embase, and the Cochrane Collaborative, to identify primary sources and reviews relevant to the epidemic. Exploded search terms were used to identify evidence, including tobacco, addiction, smoking, cigarettes, nicotine, and smoking cessation. Evidence was consolidated into three thematic areas: (1) determinants of risk, (2) maternal-fetal exposure, and (3) current tobacco users. Expert panel consensus regarding current gaps in understanding and recommendations for future research priorities was generated through iterative discussion.

RESULTS

Although much has been accomplished, significant gaps in understanding remain. Implementation often lags well behind insight. This report identifies a number of investigative opportunities for significantly reducing the toll of tobacco use, including: (1) the need for novel, nonlinear models of population-based disease control; (2) refinement of "real-world" models of clinical intervention in trial design; and (3) understanding of mechanisms by which intrauterine smoke exposure may lead to persistent, tobacco-related chronic disease.

DISCUSSION

In the coming era of tobacco research, pooled talent from multiple disciplines will be required to further illuminate the complex social, environmental and biological codeterminants of tobacco dependence.

Primary Care Provider-Delivered Smoking Cessation Interventions and Smoking Cessation Among Participants in the National Lung Screening Trial

IMPORTANCE

The National Lung Screening Trial (NLST) found a reduction in lung cancer mortality among participants screened with low-dose computed tomography vs chest radiography. In February 2015, Medicare announced its decision to cover annual lung screening for patients with a significant smoking history. These guidelines promote smoking cessation treatment as an adjunct to screening, but the frequency and effectiveness of clinician-delivered smoking cessation interventions delivered after lung screening are unknown.

OBJECTIVE

To determine the association between the reported clinician-delivered 5As (ask, advise, assess, assist [talk about quitting or recommend stop-smoking medications or recommend counseling], and arrange follow-up) after lung screening and smoking behavior changes.

DESIGN, SETTING, AND PARTICIPANTS

A matched case-control study (cases were quitters and controls were continued smokers) of 3336 NLST participants who were smokers at enrollment examined participants' rates and patterns of 5A delivery after a lung screen and reported smoking cessation behaviors.

MAIN OUTCOMES AND MEASURES

Prevalence of the clinician-delivered 5As and associated smoking cessation after lung screening.

RESULTS

Delivery of the 5As 1 year after screening were as follows: ask, 77.2%; advise, 75.6%; assess, 63.4%; assist, 56.4%; and arrange follow-up, 10.4%. Receipt of ask, advise, and assess was not significantly associated with quitting in multivariate models that adjusted for sociodemographic characteristics, medical history, screening results, nicotine dependence, and motivation to quit. Assist was associated with a 40% increase in the odds of quitting (odds ratio, 1.40; 95% CI, 1.21-1.63), and arrange was associated with a 46% increase in the odds of quitting (odds ratio, 1.46; 95% CI, 1.19-1.79).

CONCLUSIONS AND RELEVANCE

Assist and arrange follow-up delivered by primary care providers to smokers who were participating in the NLST were associated with increased quitting; less intensive interventions (ask, advise, and assess) were not. However, rates of assist and arrange follow-up were relatively low. Our findings confirm the need for and benefit of clinicians taking more active intervention steps in helping patients who undergo screening to quit smoking.

Utilization of evidence-based smoking cessation treatments by psychiatric inpatient smokers with depression

OBJECTIVES

Although smoking is a major health issue among depressed psychiatric inpatients and interest in quitting is high, successful quit rates remain low among this population. We sought to understand preferences that depressed inpatient smokers may have for cessation treatments.

METHODS

Eighty smokers (60% women, mean age 38.75 ± 11.20) with major depressive disorder and nicotine dependence receiving psychiatric inpatient services provided information on current depressive symptoms, smoking status and nicotine dependence, quit attempts, perceived barriers to quitting, and smoking consequences.

RESULTS

Almost half (46%) of participants endorsed a past-year quit attempt. Emotional barriers to quitting were uniquely associated with fewer past-year quit attempts, and depression severity was related to greater emotional barriers to quitting. Nicotine dependence severity was related to a variety of emotional, financial, weight concern, and self-efficacy barriers, but only weight gain concern was associated with decreased odds of making a past-year quit attempt. The number of lifetime quit attempts was positively associated with negative smoking consequences. With regard to interest in smoking cessation treatment, 86% and 92% of smokers reported a willingness to try behavioral counseling and nicotine replacement products, respectively, but fewer smokers reported a willingness to try medication, print or Web-based materials, or an unaided quit attempt.

CONCLUSIONS

Although half of our sample reported recent quit attempts, many people did not make an attempt using an evidence-based treatment. On the basis of consumer preferences identified herein, clinical recommendations for reinforcing the use of evidence-based smoking cessation treatments for depressed psychiatric inpatient smokers are provided.

The Gap between Tobacco Treatment Guidelines, Health Service Organization, and Clinical Practice in Comprehensive Cancer Centres

Smoking cessation is necessary to reach a higher quality of life, and, for a cancer patient, it represents an important step in improving the outcome of both prognosis and therapy. Being a cancer patient addicted to nicotine may be a critical situation. We conducted a survey to monitor how many comprehensive cancer centres in Italy have an outpatient smoker clinic and which kinds of resources are available. We also inquired about inpatient services offering psychological and pharmacological support for smoking cessation, reduction, or care of acute nicotine withdrawal symptoms. What we have witnessed is a significant gap between guidelines and services. Oncologists and cancer nurses are overscheduled, with insufficient time to engage in discussion on a problem that they do not consider directly related to cancer treatment. Furthermore, smoking habits and limited training in tobacco dependence and treatment act as an important barrier and lead to the undervaluation of smokers' needs.