Tobacco use “vital sign” helps patients quit
Dr. Kenneth Cohen, MD, FACP, Chief Medical Officer
New West Physicians
New West Physicians is one of the largest physician groups in Colorado and has grown to 18 offices located throughout the Denver metro area.
The Family Practice and Internal Medicine offices of New West Physicians are Patient Centered Medical Home (PCMH) certified Level 3, and all eligible providers are National Committee for Quality Assurance (NCQA) recognized for Heart/Stroke and Diabetes.
The highly-qualified group of board certified family practice and internal medicine physicians, hospitalists, cardiologist, gastroenterologist, psychiatrist, endocrinologist, neurologist, physician assistants and nurse practitioners are committed to providing excellent service to every patient … every time.
Over the past 50 years, policy and changing social norms have more than halved the percentage of tobacco users in the United States1 — a significant accomplishment for public health.
Still, the nearly twenty percent of people who continue smoking account for the largest number of preventable deaths in the U.S.2 Tobacco use is a major factor in four of the top five causes of death: heart disease, cancer, lung disease and stroke.3
As the front line of preventive health, primary care clinicians are committed to improving the health by lowering tobacco use. Clearly, there is still work to be done.
The New West intervention
Evidence-based practices for reducing patient smoking are available, but implementation across primary care nationwide has been incomplete.
New West Physicians adopted clinical guidelines from the United States Public Health service4 to implement in a busy and multi-site primary care practice.
Resigning to the health risks of smoking due to busy practices — and the difficulties of addressing the stigma of smoking — was not an option.
Across the primary care group of 13 clinics and a hospital, New West created a system to address and document history of tobacco use at each visit. Medical assistants (MAs) were trained to document tobacco use as a vital sign and engage patient through use of the “5 As.”5
- Ask: Identify and document tobacco use status for every patient at every visit. (You may wish to develop your own vital signs sticker, based on the sample below).
- Advise: In a clear, strong and personalized manner and urge every tobacco user to quit.
- Assess: Is the tobacco user willing to make a quit attempt at this time?
- Assist: For the patient willing to make a quit attempt, use counseling and pharmacotherapy to help him or her quit.
- Arrange: Schedule follow-up contact, in person or by telephone, preferably within the first week after the quit date.
These questions were designed to empower staff in their role in patient smoking cessation. A redesign of the EMR to include tobacco use as a box to be checked as part of the vital signs screen supported the routine and enabled data gathering.
With tobacco status documented along with willingness to quit data, primary care clinicians use their time to address the issue with recommendations for further counseling, lifestyle change, and pharmacotherapy.
The heart of this intervention was meaningful education for clinic staff on evidence-based methods and patient-centered ways to talk about quitting tobacco. By having MAs gather data, documentation on smoking status rates increased from 75 percent to 93 percent.
Changing the rooming process to include the smoking vital sign and employing the "5 A’s” yielded a 42 percent decrease in smoking over a 17-month period. Secondhand smoke exposure decreased by over half, from 7.5 percent to 3.5 percent.6
These positive results from the process change intervention at the clinic level are self-perpetuating: New West Physicians has taken the burden of tobacco and comorbid disease and reduced them by more than half. They continue to whittle down the patient population of smokers.
With considerable benefits in evidence, what are the barriers to adopting the tobacco vital sign and “5 As” across primary care? Patients need access to resources such as health insurance that covers tobacco cessation consultation and pharmacotherapy.
When these resources are available, the most significant barrier to patient quitting is simply health professionals’ missed opportunities to ask about tobacco habits and appropriately support efforts to quit.
The key to the success of this study -- and the quitting efforts of patients — has been the work of the MAs. Renee Whicher, LPN, recalled how her reticence to ask patients about tobacco changed after the study training:
"I am more comfortable with asking about tobacco habits now. I try to be mindful of my tone and facial expression so as to not make (patients) feel judged for a possible 'yes' answer.
"If they do respond ‘yes’, I try to ask caringly if they would like to quit and if we can help them with it. Being more sympathetic and letting them know through my voice, facial expressions and body language that I am not here to scold, judge or push my opinion on to them has helped."
Opening a conversation about smoking and tobacco use through the routine of collecting vital signs creates the opportunity to move toward cessation.
The educational sessions that included the whole practice staff encouraged a culture that recognizes the importance of quitting and gives staff confidence and competence in using non-judgmental language to start a quitting dialogue.
New West Physicians’ efforts to curtail the smoking habit have yielded great results, for the practice and their patients. Their work shows that by following clinical guidelines, even at busy practices across networks of clinics, tobacco use can be dramatically reduced.
Clinics that make the effort will continue to reap the rewards in reduced cost burden and healthier, happier, longer-lived patients.
The views and opinions expressed herein are those of the authors and do not necessarily represent the views of OptumCare®. The views and opinions expressed may change without notice.
- Trends in Current Cigarette Smoking Among High School Students and Adults, United States, 1965–2014. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking/index.htm. Published March 30, 2016. Accessed February 20, 2018.
- Yoon PW, Bastian B, Anderson RN, Collins JL, Jaffe HW. Potentially Preventable Deaths from the Five Leading Causes of Death--United States — 2008-2010. Vol 63. Atlanta, GA: Centers for Disease Control and Prevention; 2014:369-374.
- Frieden DT. CDC: 5 things cause two-thirds of U.S. deaths. CNN. https://www.cnn.com/2014/05/01/health/frieden-preventable-deaths/index.html. Published May 1, 2014. Accessed February 20, 2018.
- Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein, MG, Gritz ER, et al. Quick reference Guide for Clinicians: Treating Tobacco Use and Dependence. 2000. USPHS.
- Five Major Steps to Intervention (The "5 A's"). AHRQ — Agency for Healthcare Research and Quality: Advancing Excellence in Health Care. https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/5steps.html. Published December 1, 2012. Accessed February 20, 2018.
- Maier DE, Cohen KR, Sanders T, Kelly Danahey. Tobacco Cessation Improvements in Primary Care: A Successful Model Using Combined Interventions and Evaluations. Tobacco Cessation Improvements in Primary Care: A Successful Model Using Combined Interventions and Evaluation. 2008.