Overcoming barriers to nicotine dependence treatment.

What can you do when your patient does not quit smoking, yet says, "I really want to stop smoking and I am trying my best?" A few common options are: 1Think to yourself, "If they really wanted to quit smoking they would find a way to do it. I've done my part by telling them to quit. I won't waste my time any longer on someone who isn't going to change." 2Say to the smoker, "If you just tried a little harder, I am sure you can do it." Hand them a how to stop smoking brochure and wish them well. 3Ask the smoker, "Why do you think it is so hard for you to quit? What do you really enjoy about smoking that is worth dying for?" Explore their reasons for why they smoke, why they would want to quit, and options for making progress at the present time. 4Feel frustrated and tell the smoker, "How many times have I told you to quit smoking? Don't you know tobacco use is going to kill you?" 5Ignore their tobacco dependence problem and go on to other important issues. The national statistics are very grim. We have not changed the prevalence of smoking in America in half a decade. 3 Every day 6,000 children light a cigarette and begin the experiment. 4 Out of the 3,000 children who become regular smokers every day, one third of them will die prematurely of a tobacco-related death. This is happening to the families in our practices in every city in America, and 70% of all smokers walk into our offices every year where primary care physicians could address the problem and provide effective interventions. 5 Out of 100 smokers who try to quit without the help of their doctor, only 5 are abstinent 1 year later. 12 We must look seriously at the inadequacies of the healthcare system, our attitudes, and the diagnostic and treatment protocols that allow a 95% failure rate for America's most deadly and treatable risk factor. The indictment of our current tolerance for delivering low quality preventive care is judged by the fact that we have the ability to achieve 40% to 60% 1-year quit rates if we put to use all of the effective treatments we have available. We have the knowledge base, behavioral strategies, and effective medications to achieve that success rate nationally and make a lasting difference in the health of America and our health care budget. There are no easy solutions to eliminate the consequences of tobacco use. There are plenty of obstacles between physicians' treatment of nicotine dependence (lack of training to treat hard core smokers and reimbursement) and the goal of helping America quit smoking. Recognition of the importance of identifying and treating nicotine dependence is the first barrier. Only 37% of primary care physicians document smoking status in the charts of patients who are admitted in coronary care units, and cardiologists recorded it only 26% of the time. 14 Although managed care and indemnity insurance plans talk prevention, very few pay for it. If we do not reduce the current prevalence of smoking, but could prevent everyone from starting, we will have the same spiraling health care costs until the year 2030. 25 Brief smoking cessation advice, however, is 30 times more cost effective than treating mild hypertension and 100 times more cost effective than treating hypercholesterolemia. 8 Regardless of this scenario, the most important advocates for smokers are primary care physicians. Treatment for tobacco use, America's most preventable cause of morbidity and mortality, can be incorporated by primary care physicians into everyday medicine, just as hypertension and dyslipidemia were one or two decades ago. The first step is to overcome the obstacle of thinking that smokers have the right to smoke without their doctor's concerned intervention. This article first focuses on how to assess the individual smoker's barriers encountered in becoming tobacco free and then on how physicians can use this knowledge to help patients break free from tobacco.