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Editorial |

Don’t Wait for COPD to Treat Tobacco Use FREE TO VIEW

Michael C. Fiore, MD, MPH; Douglas E. Jorenby, PhD; Timothy B. Baker, PhD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

FUNDING/SUPPORT: This work was supported by National Institutes of Health [Grants PO1 CA180945 and R35 CA197573], and National Heart, Lung, and Blood Institute [Grant RO1 HL09031].

CORRESPONDENCE TO: Michael C. Fiore, MD, MPH, Center for Tobacco Research and Intervention, University of Wisconsin School of Medicine and Public Health, 1930 Monroe St, Suite 200, Madison, WI 53711


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(3):617-618. doi:10.1016/j.chest.2015.09.024
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In this month’s issue of CHEST (see page 676), Schauer and colleagues from the US Centers for Disease Control report some encouraging findings: More than 50% of current smokers with a diagnosis of COPD reported that they had been offered assistance to quit during their last clinic visit. This represents progress; in virtually all prior reports of primary care patients, only about one-third or fewer smokers reported that they were offered assistance with tobacco cessation. Because smoking is directly responsible for most cases of COPD and continued smoking after diagnosis accelerates the subsequent decline in pulmonary function, it is vital that all patients with COPD who smoke be provided with evidence-based cessation assistance.

FOR RELATED ARTICLE SEE PAGE 676

The findings of Schauer and colleagues, however, offer cause for despair along with hope. Certainly, the findings indicate that a large proportion of patients with COPD receive treatment for smoking and often relatively intense intervention such as cessation medication. This suggests that many physicians are taking this critical health threat seriously—at least with their patients with COPD. However, the findings of Schauer and colleagues also echo the results of many prior studies showing that for smokers in general, physicians far too infrequently offer and deliver smoking cessation treatment. In fact, Schauer and colleagues reported that only 34% of such patients were offered any assistance with cessation. This is concerning because the great majority of smokers are never diagnosed with COPD.

Of course, even patients without COPD are at great risk of developing serious smoking-caused harm, and there are many such patients. Despite declines in smoking rates in the United States over the past 50 years, more than 40 million adult Americans continue to smoke. Moreover, smoking is now concentrated among those with the least resources to overcome tobacco addiction: the poorest, the least educated, and those with mental health and substance abuse diagnoses. The grim reality of tobacco use is that half of all smokers who do not quit successfully will be killed prematurely by tobacco dependence, which will rob them of 10 to 15 years of life on average. This translates into an estimated 20 million preventable premature deaths in the United States over the next few decades if today’s smokers are unable to quit.

Numerous evidence-based treatments for tobacco dependence have been identified, are well described, and are readily available. The most recent US Public Health Service Clinical Practice Guideline for treating tobacco use and dependence identified a variety of effective counseling and medication options that meaningfully increase quit rates among smokers who are willing to quit. In particular, the Public Health Service Guideline emphasized combining counseling with medications to increase cessation rates and reported that two medication regimens (varenicline and combination nicotine replacement therapy) are especially effective. In addition, there are effective interventions for smokers who are unwilling to quit: interventions that can motivate them to make the attempt to quit and be more successful when they do. Therefore, there is no shortage of effective smoking interventions. Rather, our challenge is that we do not deliver these evidence-based treatments to most smokers who visit health care settings.

Opportunities to intervene with patients who smoke have been enhanced as a result of the Affordable Care Act (ACA). Specifically, recent federal guidance on the ACA insurance coverage mandate for tobacco dependence treatment clarified that every insurance plan must include coverage (without a co-pay) for two courses of cessation treatment each year for all tobacco users. Each course of treatment would include: (1) at least four counseling sessions of at least 10 min each, and (2) cessation medication for at least 90 days. Such coverage removes past barriers to smoking treatment resulting from an inability to pay. These ACA changes have been enhanced by Meaningful Use criteria that highlight the importance of identifying patients who smoke as a core reporting requirement. Finally, the Joint Commission now includes a performance measure that mandates documentation of the tobacco use status of all hospitalized patients and the delivery of bedside and discharge cessation counseling and medications to hospitalized patients who use tobacco. These changes will begin to address the observation of Schauer and colleagues that many smokers are “asked” about their tobacco use but relatively few are “assisted” with quitting. Collectively, these legislative and regulatory changes provide a much more supportive environment for treating tobacco use and dependence.

The key message is that physicians should intervene with every patient who smokes: those who want to quit, those who do not, those who have COPD, and those who do not. Indeed, smoking intervention is not a zero sum game because the potential payoffs for cessation are universal. By increasing smoking abstinence, smoking treatment can mitigate, reverse, or arrest virtually all pulmonary conditions, including upper and lower respiratory tract infections, dyspnea, respiratory tract cancers, and compromised pulmonary function, as well as many other medical conditions. Whereas some of the lung parenchymal damage of COPD is irreversible, as noted above, it is clear that cessation can slow the progress of that disease. Moreover, the earlier that physicians intervene in the patient’s smoking career, the better. It is inestimably better to prevent COPD than to try to mitigate it. Smoking directly causes about 80% of COPD deaths each year in the United States (about 93,000 deaths) as well as morbidity and mortality from other smoking-related pulmonary disease. Thus, among the known benefits of smoking cessation, its potential to prevent pulmonary disease and dysfunction may be the greatest.

Schauer and colleagues highlight progress made in providing smoking cessation assistance to patients diagnosed with COPD. Paradoxically, these findings may shine an even brighter light on the larger population left behind: patients who do not yet have COPD and for whom cessation could prevent catastrophic disease and early death.

References

Schauer G.L. .Wheaton A.G. .Malarcher A.M. .Croft J.B. . Health-care provider screening and advice for smoking cessation among smokers with and without COPD: 2009-2010 National Adult Tobacco Survey. Chest. 2016;149:676-684 [PubMed]journal
 
US Department of Health and Human Services The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.  2014;:- [PubMed] US Dept of Health and Human Services Atlanta, GAjournal
 
Liu Y, Pleasants RA, Croft JB, et al. Smoking duration, respiratory symptoms, and COPD in adults aged ≥45 years with a smoking history [published online ahead of print July 21, 2015].Int J Chron Obstruct Pulmon Dis. doi:10.2147/COPD.S82259.
 
Fiore M.C. .Jaen C.R. .Baker T.B. .et al Treating Tobacco Use and Dependence: 2008 Update.  2008;:- [PubMed] US Dept of Health and Human Services, US Public Health Service Rockville, MDjournal
 
Fiore M.C. .Baker T.B. . Treating smokers in the health care setting. N Engl J Med. 2011;365:1222-1231 [PubMed]journal. [CrossRef] [PubMed]
 
McAfee T. .Babb S. .McNabb S. .Fiore M.C. . Helping smokers quit—opportunities created by the Affordable Care Act. N Engl J Med. 2015;372:5-7 [PubMed]journal. [CrossRef] [PubMed]
 
HealthIT.gov. Step 5: Achieve meaningful use stage1. Record smoking status. 2014.http://www.healthit.gov/providers-professionals/achieve-meaningful-use/core-measures/record-smoking-status. Accessed January 6, 2016.
 
Fiore M.C. .Goplerud E. .Schroeder S.A. . The Joint Commission’s new tobacco-cessation measures—will hospitals do the right thing? N Engl J Med. 2012;366:1172-1174 [PubMed]journal. [CrossRef] [PubMed]
 
Centers for Disease Control and Prevention Smoking-attributable mortality, years of potential life lost, and productivity losses—United States - 2000-2004. MMWR. 2008;57:1226-1228 [PubMed]journal. [PubMed]
 

Figures

Tables

References

Schauer G.L. .Wheaton A.G. .Malarcher A.M. .Croft J.B. . Health-care provider screening and advice for smoking cessation among smokers with and without COPD: 2009-2010 National Adult Tobacco Survey. Chest. 2016;149:676-684 [PubMed]journal
 
US Department of Health and Human Services The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.  2014;:- [PubMed] US Dept of Health and Human Services Atlanta, GAjournal
 
Liu Y, Pleasants RA, Croft JB, et al. Smoking duration, respiratory symptoms, and COPD in adults aged ≥45 years with a smoking history [published online ahead of print July 21, 2015].Int J Chron Obstruct Pulmon Dis. doi:10.2147/COPD.S82259.
 
Fiore M.C. .Jaen C.R. .Baker T.B. .et al Treating Tobacco Use and Dependence: 2008 Update.  2008;:- [PubMed] US Dept of Health and Human Services, US Public Health Service Rockville, MDjournal
 
Fiore M.C. .Baker T.B. . Treating smokers in the health care setting. N Engl J Med. 2011;365:1222-1231 [PubMed]journal. [CrossRef] [PubMed]
 
McAfee T. .Babb S. .McNabb S. .Fiore M.C. . Helping smokers quit—opportunities created by the Affordable Care Act. N Engl J Med. 2015;372:5-7 [PubMed]journal. [CrossRef] [PubMed]
 
HealthIT.gov. Step 5: Achieve meaningful use stage1. Record smoking status. 2014.http://www.healthit.gov/providers-professionals/achieve-meaningful-use/core-measures/record-smoking-status. Accessed January 6, 2016.
 
Fiore M.C. .Goplerud E. .Schroeder S.A. . The Joint Commission’s new tobacco-cessation measures—will hospitals do the right thing? N Engl J Med. 2012;366:1172-1174 [PubMed]journal. [CrossRef] [PubMed]
 
Centers for Disease Control and Prevention Smoking-attributable mortality, years of potential life lost, and productivity losses—United States - 2000-2004. MMWR. 2008;57:1226-1228 [PubMed]journal. [PubMed]
 
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