Effect on Cessation Counseling of Documenting Smoking Status as a Routine Vital Sign: An ACORN Study

Rothemich et al. documented only a “modest” increase of 8.9% on “advise” (A2) giving for smoking cessation in general medical practice in a randomized trial comparing trained vs. non-trained clinicians and staff. Their results are consistent with other reports of practice patterns on smoking cessation in primary care practice (1). The authors did emphasize, however, that the advise given in the intervention practices was to a higher group of identified smokers (79.5% vs. 49.4% between intervention and controls). Therefore, the relative number of smokers exposed to A2 was higher in the intervention than the controls, since there was significantly less identification of smoking status in the controls. We discovered similar findings in our baseline exit surveys before training staff and clinicians in a randomized trial on the impact of referral feedback (2). Our baseline data showed only a 58% Ask (A1) rate and, of that group, only 42% Advise (A2) rate. These findings emphasize the difficulty of delivering important preventive measures, such as simple brief advise for smoking cessation and prescribing efficacious pharmacotherapies in busy primary care practice generally paid in a discounted “fee-for-service” system. Clinicians are forced to address the “urgency of the acute complaint”. Systematic chances need to occur to incentivize smoking cessation counseling in general medical practice, such as direct “fee-for-service” payments. The new Medicare codes—97803 and 97804—may be a beginning. Also, practices need to facilitate staff to ASK and ACT as recommended by the AAFP (American Academy of Family Physicians) (3). Nursing staff would be trained and empowered by physician-approved protocols allowing direct referrals to smoking cessation services (quitlines) and prescribing of tailored pharmacotherapies. Practices should be redesigned to receive system-wide or electronic feedback on smoking cessation referrals (2, 4) and patient outcomes. Preventing tobacco use and facilitating smoking cessation remains one of the most “vital” activities for preventing morbidity and mortality by family physicians.

References

1. Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA. 1998;279(8):604 -608.

2. Wadland WC, Holtrop JS, Weismantel D, Pathak PK et al. Evidence- based referrals to a tobacco cessation quit line: assessing the impact of comparative feedback vs general reminders. Ann Fam Med. 2007;5(2):135- 142.

3. Ask and Act. Available at: http://www.aafp.org/online/en/home/clinical/publichealth/tobacco/askandact.html.

4. Bentz CJ, Bayley B, Bonin KE, Fleming L et al. Provider feedback to improve 5A’s tobacco cessation in primary care: A cluster randomized clinical trial. Nicotine Tob Res. 2007;9(3):341-349.

Competing interests:   None declared