06 novembre 2009
Treatment effectiveness is irrelevant if tobacco users
Treatment effectiveness is irrelevant if tobacco users are not aware of treatment options,
cannot access them, cannot afford them, or do not use them when they are available. Tobaccocessation
interventions can be delivered in many settings and formats. Health-care providers can
inform patients about the health effects of tobacco use and counsel them about treatment options
during routine appointments, patients can be referred to proactive or reactive telephone quitlines
for counseling and often medications, and patients can access computer-based programs that
offer counseling, support, and medications. Evidence-based systems-level interventions that are
particularly effective include tobacco-use identification systems, provider education, reminder
systems with feedback, and dedicated staff. For patients who are willing to quit, an evidencebased
algorithm known as the 5 A’s uses a decision tree to help health-care providers to
• Ask patients about tobacco use.
• Advise current users to quit.
• Assess smokers’ willingness to quit.
• Assist smokers who are willing to quit by providing appropriate tobacco-dependence
treatments.
• Arrange followup for smokers who want treatment.
That algorithm can be used by all health-care providers, including physicians, nurses,
psychologists, health educators, dentists, and pharmacists. For patients who are unwilling to quit,
health-care providers can use motivational interviewing to increase future cessation attempts.
Motivational interviewing can follow the 5 R’s: relevance (encourage patient to explain why
quitting is relevant to them), risks (ask patients to explain the adverse effects of tobacco use),
rewards (ask patients to identify the benefits of quitting), roadblocks (ask patients about the
barriers to their quitting), and repetition (use a motivational intervention each time a patient is
seen).
Many populations of tobacco users may be reluctant to quit, find it hard to quit, or be at
greater risk for adverse health outcomes from tobacco use; these special populations include
people who have psychiatric and medical comorbidities, deployed military personnel, and
hospitalized people. Tobacco addiction is much more prevalent in people who have mental
illness, including schizophrenia, major depression, posttraumatic stress disorder (PTSD), and
alcohol abuse. That is of concern given the increased numbers of veterans returning from the
conflicts in Iraq and Afghanistan with PTSD and the number of Vietnam veterans who have
PTSD. The PHS clinical-practice guideline provides evidence-based treatment protocols for
many special populations.
The issue of relapse from tobacco abstinence is well known; as many as 75% or 80% of
smokers who quit tobacco use will relapse within 6 months. Relapse-prevention interventions
include social support, use of medications, and avoidance of smoking cues.
Comprehensive tobacco-control programs also require surveillance information to help
staff to modify the programs to meet changing needs or to address disparities. Surveillance can
indicate whether policies are being enforced, medications are being correctly prescribed,
quitlines are being used, public-education campaigns are reaching target audiences, interventions
are improving health outcomes, and funds are being spent appropriately. Established
performance measures should be used to monitor program improvements. Surveillance tools
should be designed and operated to provide the necessary foundation for program evaluation,
which should be periodic and thorough and whose results should be disseminated publicly.