Simplicity matters: Using system-level changes to encourage clinician intervention in helping tobacco users quit

Abstract

The articles in this supplement explore the fundamental problem of how to design systems-level changes that make it easier for clinicians to help more tobacco users quit. Smoking remains a huge problem among Americans, with 46 million still smoking and 440,000 dying each year from smoking-related illness (Schroeder, 2004). Another 8.6 million are debilitated by tobacco-caused diseases (Centers for Disease Control and Prevention, 2000). Seventy percent of smokers want to quit, but few succeed, and advice from a health professional can double their chances of quitting (Fiore et al., 2000). Even so, most clinicians do not intervene with smoking patients, though this single step could lengthen and improve many patients’ lives. When asked why they do not intervene, clinicians offer at least eight reasons: (1) They are too busy; (2) they lack expertise in smoking cessation; (3) they have no financial incentive to do so; (4) they know most smokers won’t succeed in quitting; (5) they think smoking is the smokers’ own fault; (6) they respect smokers’ privacy and don’t want to interfere; (7) they are afraid of scaring away patients with a negative message; and (8) they themselves smoke. (http:// smokingcessationleadership.ucsf.edu) None of these reasons justify failing to offer this beneficial health advice, and each can be easily rebutted. Too busy? Effective interventions such as referring smokers to quitlines require only seconds. Lack expertise? Little expertise is needed to refer a patient to a quitline or other evidence-based treatment service. Not paid? This should be part of the basic service for any office visit. Small chance of success? With help from a clinician, quitting attempts double, and quitlines can double or triple cessation rates (Zhu et al., 2002). Stigma attached to smokers? Most tobacco users became dependent in their youth, and nicotine is notoriously addictive. (Ossip-Klein et al., 2003) Privacy concerns? More than valuing their privacy, patients want clinicians to be concerned about their health. Afraid of scaring off patients? Studies verify that smokers, even those not intending to quit, want to be encouraged to quit by health professionals (Barzilai, Goodwin, Zyzanski & Stange, 2001). Many smokers are concerned about the effects of secondhand smoke on their loved ones, and most know about the effects of smoking on their own health and are worried about it. Clinicians who themselves use tobacco? Fewer do all the time, and those that do also need help and support in quitting. (http://smokingcessationleadership.ucsf.edu) The possibility of mobilizing large armies of clinicians of all kinds—not just physicians and dentists, but dental hygienists, respiratory therapists, nurses, physicians’ assistants, pharmacists, pharmacy technicians, mental health counselors and many others—offers hope of driving down the number of tobacco users dramatically. This requires creative changes in the systems in which these professionals operate and requires changing institutional practices. Researchers and system reformers now have a keener appreciation of what is needed to help clinicians’ encourage patient behavior change. Wagner’s Chronic Care Model (Wagner, 1998) details system characteristics that optimize patient-provider