Practice Guidelines

Breaking a nicotine addiction is difficult; any smoker will tell you that. But physicians can lend a hand to the 46 million Americans who just haven't been able to throw away that last cigarette.

"It's difficult to identify a condition in the United States that presents such a mix of lethality, prevalence and neglect on the part of the health care system — in spite of the fact that effective interventions are so readily available," says Michael Fiore, M.D., associate director of the Center for Tobacco Research and Intervention at the University of Wisconsin Medical School.

But what works best? To eliminate guesswork, the Agency for Health Care Policy and Research convened a multidisciplinary panel to draw up a set of guidelines describing the most effective interventions.

"The guidelines are a call to action to clinicians to approach smoking as a chronic condition that is very difficult but not impossible to treat," says Douglas Kemerow, M.D., AHCPR's director of clinical practice guideline development.

The guidelines, endorsed by the American Academy of Family Physicians and the AMA, offer specific techniques that physicians can use. The take-home message: AHCPR urges doctors to encourage all patients to quit and to offer practical advice about behavior that makes smokers want to stop. Treat smoking status as if it's a vital sign, says the panel.

Astonishingly, AHCPR reports that only about half of the smokers who see a doctor for whatever reason have ever been encouraged to quit, even though the medical profession is united on the dangers of smoking.

Three proven methods, used alone or in combination, were endorsed by the panel, including nicotine replacement therapies, social support and practical advice to cope as a nonsmoker. Other alternatives such as antidepressants, acupuncture and hypnosis were not endorsed because studies have not proven their benefits.

A pocketful of advice

The guidelines committee developed a pocket guide for primary care physicians that summarizes its findings. It will be distributed to 200,000 primary care doctors by the AMA through an educational grant from the Robert Wood Johnson Foundation. To start, the pocket guide recommends that physicians offer a smoking cessation treatment at every office visit for smokers. Treatment may include recommending one of the prescription or nonprescription nicotine replacement therapies and/or referring the patient to an intensive smoking cessation program.

Smoking cessation specialists say that pharmaceutical products alone aren't enough to curb a smoker's craving. Patients need counseling to help them resist the temptation to smoke and learn to live as nonsmokers.

Research has found that the more vigorous the support program, the more responsive the patient. Intensive treatment programs should meet for 30 minutes, four to seven times over at least two weeks, but preferably for eight. Counseling sessions should address topics that smokers will be faced with, such as coping with those who still smoke, learning to reduce stress and fear of weight gain.

— Paul Wynn

To order the guidelines, call or write AHCPR for the "Smoking Cessation Clinical Practice Guidelines": (800) 358-9295, or AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907-8547.

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