Tobacco Cessation—We Can Do Better

Tobacco use continues to be the leading preventable cause of mortality in the United States, despite a decrease in the overall prevalence of cigarette smoking. In this issue of JAMA InternalMedicine, Siegel et al1 report that cigarette smoking continues to be the attributable cause of death for nearly half of people dying of 12 different cancers and notably 80% of people dying of lung cancer. Recent data also suggest that focusingonlyonmortality fromconditions inwhich causal relationships have been established underestimates smokingrelatedmortalitybecauseanadditional 17%ofexcess smokingrelated mortality is associated with causes not formally established as attributable to smoking.2 Fortunately, the increased focus on outcomes and populationmanagementowing to thechangescausedbyhealthcare reform has renewed interest in how to improve tobacco cessationefforts. ThearticlebyParket al3 in this issue reveals that we have a long distance to go in improving physiciandelivered tobacco cessation efforts. Participants of the National Lung Screening Trial, who were randomized to lowdose computed tomography vs chest radiography for lung screening, reported on whether their physicians had delivered the 5A’s of tobacco cessation: asking about use, advising users to quit, assessing readiness to quit, assistingwith a quit attempt, and arranging for follow-up.4 Only active smokers were included, and theywere queried 1 year after the screening.Similar topriorwork,8participants reported relativelyhigh rates of asking about use and advising users to quit, with slightly lower rates of assessing readiness to quit. Unfortunately, also similar to prior work,5 assistance with a quit attemptwasprovidedonly 50%of the time, and therewerepoor rates of arranging for follow-up. As expected, only assistance with a quit attempt and arranging for follow-up were associated with cessation at 1 year. Itwouldnot be appropriate to conclude from the studyby Park et al that asking about tobacco use, advising tobacco users to quit, or assessing readiness to quit are not important. They are necessary steps to helping tobacco users with their quit attempts and increase the likelihood of a quit attempt.4 However, these steps by themselves are not sufficient for effective tobacco cessation. The low rates of assisting and arranging for smoking cessation are particularly distressing because physicians andpatientswere provided thewritten results of the lung screening examination. High rates of effective action did not occur despite the teachable-moment opportunity of discussing the results of the lung screening. Park et al note that their findings are based on patient reports of physician actions, which could underestimate actual physician actions. However, what patients hear and remember is likely more important than what is said. More effective actions by physicians are also needed. Handing out a brochureonsmokingcessation,whichwas routinelydone tomeet prior JointCommissionrequirements for inpatient tobaccocessationcounseling,mayfulfill physician requirementsbutalone is not sufficient for significant tobacco cessation. The new Joint Commission inpatient tobacco treatment measures (http://www.jointcommission.org/tobacco _treatment/) and Medicare requirements for paying physicians for tobacco cessation (https://www.cms.gov/Outreach -and-Education/Medicare-Learning-Network-MLN /MLNMattersArticles/downloads/MM7133.pdf ) are welcome recent developments, but more changes are needed to maximize success on tobacco cessation. The new Joint Commissionmeasures expand the priormeasure to include provision Related articles pages 1509 and 1574 Research Original Investigation Smoking Cessation in the National Lung Screening Trial