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30 Seconds to Save a LifeABIGAIL HALPERIN MD, MPH, DEPT OF FAMILY MEDICINE, UNIVERSITY OF WASHINGTON, SEATTLETIM MCAFEE MD, MPH, CHIEF MEDICAL OFFICER, FREE & CLEAR, INC., SEATTLE One of the greatest joys for us, as family physicians, with their care than those who are not. Further, referral is to help patients make behavior changes that will allow to a convenient, evidence-based treatment program can them to live happier, healthier and longer lives. Perhaps support patients in self-management within the planned the most rewarding (and plentiful) of these opportuni- ties is to assist someone in successfully quitting tobacco It is not realistic for most of us to incorporate the use. Nearly one-fifth (18%) of adults in Washington complete ‘5 As’ treatment protocol (Ask, Advise, Assess, State currently smoke cigarettes and more than 70% say Assist, Arrange) into a routine visit, as outlined in the they plan to quit in the next year.1 Of those who want US Public Health Service Clinical Practice Guideline for to quit, more than half make a serious quit attempt Treating Tobacco Use and Dependence (the Guideline).
within the current year. Unfortunately, fewer than 5% However, with office systems in place to streamline of those who try to quit on their own, without counsel- the process, in 30 seconds we are capable of asking,
ing, nicotine replacement therapy (NRT) or other advising and referring patients who want to quit to medication, will be quit at the end of that year.2 our state’s Tobacco Quit Line, which is among the What can we do to help? Thirty seconds of advice best in the nation. Many physicians are not aware that from their family doctor will double smokers’ chances of the Washington Quit Line (WAQL) provides free
quitting, and counseling combined with use of pharma- Guideline-based tobacco treatment for all WA State
cotherapy (NRT or the FDA-approved first-line pre- residents. This valuable resource enhances our ability scription medications bupropion [Zyban] or varenicline to provide comprehensive services to the families we [Chantix]) can increase their success rate five-fold, up to 25%.3 4 5 6 This brief intervention can be easily integrated A single phone call by patients to an easy-to-remem- into both preventive and acute care visits, using a team ber toll-free number (800.QUIT.NOW) will get them approach that starts with nursing staff asking about to a live WAQL intake specialist, who will be able to tobacco use and recording smoking status as a vital sign, determine their eligibility for one of a range of support and follows up with the physician including nicotine services offered by Free & Clear, the WAQL’s provider of dependence on the patient’s problem list for addressing cessation treatment. Everybody over 18 years of age in the state of WA is eligible for at least a single 20-30 While almost all of us know that stopping tobacco minute counseling session with a highly-trained Quit use is one of the most important things patients can do Coach, plus mailed materials tailored to the caller’s indi- to protect and improve their health, few physicians pro- vidual characteristics and needs. All WA residents who vide routine assistance for this difficult task. In addition are uninsured, have Medicaid coverage, are pregnant, to increasing demands on our time, other perceived bar- were referred by the VA hospital, or are covered by the riers prevent us from helping patients quit smoking.
Washington Basic Health Plan or Indian Health Service, These include not feeling competent to deliver an are eligible for up to five proactive counseling calls and appropriate brief intervention, believing that patients free nicotine patches or gum (NRT mailed to their don’t want or aren’t able to quit, and fearing that we home). Those who are insured by certain health plans may alienate patients by bringing up a stigmatized per- (e.g., Group Health, Uniform Medical Plan, PacifiCare) sonal issue.7 The truth is, patients who are asked and or employed by some of our state’s largest employers counseled about their tobacco use are more satisfied (e.g., Boeing, Microsoft, Washington Mutual) are covered for the same proactive counseling calls, NRTand often bupropion or varenicline as well. The WAQLalso keeps an updated list of local resources available to 30 Seconds to Save a Life continued When we see patients who smoke, since we are unlikely to have the time or ability to personally treat them with an intensive ‘5 As’ intervention, we owe it to them – and to our profession – to take the 30 seconds to advise them to quit and refer them to the WAQL. If we do nothing, and they remain smokers, half of them will die prematurely from a smoking-related illness, with an average loss of 10-14 years from their life expectancy.8If we help them quit, they will begin to accrue health benefits immediately and reduce their risks of all tobac- co-related diseases and death, regardless of their age or how long they smoked. Even a 65-year-old patient who Clinical Practice Guideline (free clinician quits smoking stands to gain an extra four years of life compared to someone of a similar age who continues to smoke.9 Once patients stop smoking, while they may experience a transient increase in coughing as they clearexcess mucous and tobacco-related residues from their Free & Clear, Inc. www.freeclear.com lungs, other respiratory symptoms, pulmonary function and exercise tolerance will improve measurably within weeks. Within the first year, cardiovascular disease risk falls to half that of a continuing smoker. Lung and other tobacco-related cancer rates, while never returning tothose of a lifetime non-smoker, will drop by 50% in It is important for physicians and patients to (free online CME courses for treatment of acknowledge that addiction to tobacco is very powerful and it often takes multiple attempts for a patient to suc- University of Wisconsin Center for Tobacco ceed in quitting and remaining abstinent for the long Research and Intervention (CTRI) (provider term. There are many things we can do to help our patients beyond asking, advising and referring. The most important is to provide encouragement and a sense that no matter how many times they have tried before, nomatter how much and how long they have smoked, astheir physician we believe that if they keep trying, theycan, and will, succeed. ■ 1. Washington State Behavioral Risk Factor Surveillance Survey (BRFSS) 2005, www.doh.wa.gov2. Fiore MC et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville MD: Dept of Health and Human Services; June 20003. Silagy C et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2000(2); CD0001464. Stead LF et al. Telephone Counseling for Smoking Cessation. Cochrane Database Syst Rev. 2004(4);CD001655. Jorenby DE et al. A controlled trial of sustained release bupropion, a nicotine patch or both for smoking cessation. New Engl J Med. 1999;340:685-6916. Oncken C, Gonzales D, Nides M, Rennard S, Watsky E, Billing CB, Anziano R, Reeves K. Efficacy and safety of the novel selective nicotinic acetylcholine receptor partial agonist, varenicline, for smoking cessation. Arch Intern Med. 2006 Aug 14-28;166(15):1571-7.
7. Shroeder SA. What to do with a patient who smokes. JAMA. 2005;294(4):482-4878. Annual smoking-attributable mortality, years of potential life lost, and economic costs—United States, 1995-1999 MMWR 2002;51:300-3039. Taylor DH Jr et al. Benefits of smoking cessation for longevity. Am J Public Health. 2002;92:990-99610.The Health Consequences of Smoking: A Report of the Surgeon General. Washington DC: CDC Office on Smoking and Health; 2004

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