September 2007 | Back to Table of Contents

Quality Rounds

Up in Smoke

By Scott D. Smith

Smokers have a better chance of quitting if they have the help of physicians who use a structured approach.

During the 1980s, Minneapolis family physician Leif Solberg, M.D., managed to get 25 percent of his patients who smoked to quit for a year. That’s much higher than the 6 percent to 12 percent quit rate that experts say most physicians achieve with brief counseling and nicotine patches or gum. Solberg attributes his success to using a structured program in which nurses and physicians talked to patients about smoking at every visit and the nurses followed up with phone calls to encourage and support patients who were trying to quit.

Today, Minnesotans have access to an array of structured smoking-cessation programs, including free telephone counseling offered either through their insurance provider or QuitPlan Services (a free service provided by Clearway Minnesota for those without health insurance or who don’t have insurance coverage for smoking cessation treatment). Yet many smokers fail to take advantage of these resources, and many physicians fail to refer smokers to them.

Fast Fax A new service created by Call It Quits, a coalition of some of the state’s largest health insurers, care providers, and ClearWay Minnesota, is designed to make sure physicians don’t miss opportunities to help their patients stop using tobacco. The Minnesota Clinic Fax Referral Program will begin operating October 1, the same day the statewide smoke-free workplaces law goes into effect.Here’s how the program works: If a patient is interested in quitting smoking, his or her physician can fax a one-page form that includes the name of the patient’s insurer (or if they have no insurance), information about how and when to reach the patient, and the patient’s preferred language to a central clearinghouse. The clearinghouse will then dispatch that information to the appropriate quit line for that patient. A counselor from the quit line will then call the patient and provide information about available smoking-cessation services. The idea is that by calling the patient, rather than placing the onus on the patient to make the call, he or she will be more likely to follow through and attempt to quit. In a pilot study conducted at 50 Fairview primary care clinics, the program proved promising. Physicians referred 3,062 patients to the clearinghouse. Of those, 832 followed up by using a telephone counseling service during a period that started in September 2005 and ended in June 2007. Blue Cross and Blue Shield of Minnesota’s Rhonda Evans, who is project manager for the Minnesota Clinic Fax Referral Program, considers the number of participants who used the counseling service impressive. Physicians who register to take part in the program will receive a start-up kit that includes patient brochures explaining the program, a poster, fact sheets, fax forms, and other information. To sign up, contact Evans at 651/662 4054 or 800/382-2000, ext. 24054.—S.D.S.

Increasing Quit Rates
The quit rate for smokers who don’t use any assistance is 10 percent or less, according to recent reports. However, that rate can be substantially improved with treatment. According to the Treating Tobacco Use and Dependence guideline issued by the U.S. Public Health Service, which is based on an analysis of 43 studies from 1975 through 1999, brief counseling sessions lasting less than three minutes resulted in an average quit rate of 13.4 percent, and counseling that totaled more than 10 minutes resulted in an average abstinence rate of 22.1 percent. Roughly 10 percent of the smokers involved in the studies quit without any assistance.

Solberg, who is now medical director for HealthPartners, led another literature review that focused on interventions that could be used in a busy primary care practice. Solberg and colleagues found that primary care physicians can boost the annual quit rate of patients by about 2.4 percent with a brief (less-than-five-minute) counseling session and by 5 percent when combining counseling with pharmacotherapy above that for those who attempt to quit without any assistance (less than 3 percent, according to Solberg). Those findings were published in May 2006 as a technical report on tobacco use screening and counseling for the National Commission on Prevention Priorities.

Solberg adds that continuing to have annual discussions with patients about quitting smoking plus having those who are interested use medications has a cumulative effect that results in quit rates of 20 percent to 25 percent over several years.

In general, the more types of interventions made available to patients—counseling sessions, drugs, follow-up calls—the better the outcome, says Richard Hurt, M.D., director of Mayo Clinic’s Nicotine Dependence Center. Hurt says there is a dose-response: the more that is done, the more often it is done, and the longer the treatment, the better the outcome. Mayo’s eight-day residential program, which offers patients individual and group counseling, medications, physician supervision, and long-term follow-up, has a quit rate of approximately 45 percent—about double that of outpatient programs, according to Hurt.

But the program has limited reach. Only about 100 people a year use it.

Although other strategies have lower quit rates, they tend to reach more people. And that can have a more significant impact on reducing the number of people who smoke, Hurt notes.

Telephone quit lines in general have a 25 percent annual success rate for smokers who are motivated to use them, and the rate for the one to which Blue Cross and Blue Shield of Minnesota refers subscribers is about 29 percent, says Marc Manley, M.D., vice president and medical director of population health at Blue Cross. The Blue Cross program consists of five 10-minute telephone counseling sessions. In addition, participants can request nicotine patches or other nicotine replacements.

Several prescription medications also appear to be promising and are becoming more widely used. One is varenicline (a nicotinic receptor partial agonist). Two studies published in the July 5, 2006, issue of the Journal of the American Medical Association found varenicline more effective than either sustained-release bupropion (an inhibitor of the reuptake of norepinephrine and dopamine) or placebo. The multicenter studies were led by Douglas E. Jorenby, Ph.D., of the University of Wisconsin and David Gonzalez, Ph.D., of the Oregon Health and Science University.
No one has done a head-to-head comparison of sustained-release bupropion with nicotine replacement, but another study led by Jorenby found a 30 percent one-year quit rate for smokers who used bupropion in addition to a nicotine patch, which was about double that of nicotine therapy alone. The results of the controlled trial were published in the March 4, 1999, New England Journal of Medicine.

Talk is Key
Solberg says that in order to provide patients with as much help as possible, clinics need to establish procedures for asking patients about their habits and desire to quit smoking at every visit and reminding physicians to provide support to those who may want to quit. Getting physicians to make a concerted effort to talk to their patients, regardless of their reason for the visit, is key. “People rarely go to the doctor specifically for quitting smoking, so it can be hard to fit it in to visits for other reasons,” he notes. MM

Scott Smith is a staff writer for the Minnesota Medical Association.