If it is as simple as AAAAA B C, why don't we do it?

In 2000, the U.S. Public Health Service released a clinical practice guideline for promoting smoking cessation that called on health care providers to follow a 5-A protocol: Ask about smoking at every visit; Advise all tobacco users to quit; Assess willingness to make a quit attempt; Assist the patient in quitting (i.e., helping set a quit date, referring to a special program, and prescribing pharmacotherapy tailored to their addiction level and habits); and Arrange a follow-up contact within one week after quit date to provide further assistance.1 The updated 2008 guideline confirmed the effectiveness of treatments and highlighted the importance of the healthcare system in the success of tobacco treatment strategies.2 Although the majority of smokers are identified at clinic visits and report receiving advice during these visits, effective smoking cessation assistance such as counseling and pharmacotherapy are generally underutilized.3 There is much room for improvement to increase the reach of existing evidenced-based smoking cessation practices. In the current issue of JGIM, Quinn et al. present findings from HMOs Investigating Tobacco (HIT) study conducted within the National Cancer Institute-funded Cancer Research Network.4 More than 4,000 smokers were identified from nine HMOs. A 12-month follow-up survey (65% response rate), among smokers who had a primary care visit, assessed smoking status and report of tobacco treatments offered by their provider. Smokers were more often offered Advice (77%) than Assist (33-41%) and Arrange (13%). At follow-up, 9% were abstinent for 30 days or longer. Smokers who used classes/counseling or pharmacotherapy (Assist) were twice as likely to quit compared with smokers not using these services. The major strength of these findings is documenting the utilization and effectiveness of the 5-A model in a non-research setting. Unfortunately, these results are based on reports from patients (collected 1999-2001) and do not reflect the perspective of clinicians or notations from the medical record. If it is as simple as AAAAA B C, why don’t we do it? The study by Quinn et al. highlights that smoking cessation treatment using the 5-A protocol relies, in part, on a provider’s willingness and time to Assist and Arrange which may explain why these treatments are not highly utilized in primary care.4 Next steps should include the implementation of standardized 5-A protocols that do not rely on physicians and can be administered by nursing or administrative staff. Modified 5-A protocols (shortcuts) have been proposed to achieve this goal. At check in, a patient could receive Ask, Advise, and Refer.5 This referral could involve a fax to a telephone quit line or an appointment for a nurse-based or pharmacy-based smoking cessation clinic. Quit lines are now available in all 50 States. This effective method of providing counseling increases the odds of smoking cessation by 60% compared to no counseling.2 Because the most successful treatments combine counseling and pharmacotherapy, standardized protocols for prescribing nicotine replacement therapies (available without prescription) could also be administered by non-physician staff. Another potential approach is Ask, Advise, and e-mail.6 A member of the health care team could send an e-mail to the patient with links to Internet-based smoking cessation programs or offer to provide ongoing e-mail support. Smoking cessation treatment may be particularly well suited to delivery via the Internet through on-line chat groups, bulletin boards, e-mail contacts with experts, individually tailored information and feedback regarding behavioral skills, problem solving training, and advice regarding medication usage.7 Initial evidence examining the Internet-based smoking cessation interventions have documented cessation rates ranging from 13% to 43%.8 The U.S. Surgeon General’s report “Reducing Tobacco Use” (http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2000/index.htm) concluded the lack of progress in tobacco control is attributable more to the failure to implement proven strategies than it is about what to do. Many practices have now developed systems to Ask and Advise. Since we know that successful interventions involve systematic processes using multiple members of the primary care team, and not just relying on the physician alone, more systems need to be developed to either shortcut or address Assess, Assist and Arrange.