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Defragmenting Healthcare: Science, Medicine and Smoking

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The lag between what we know about helping smokers and what we do to help them opens a window into the gaping hole between scientific knowledge and clinical practice.

Research has developed a way to take the nicotine in the tobacco leaf and turn it into an effective medicine to help smokers. Nicotine replacement therapy (NRT) is very helpful with the physical element of smoking addiction. Clinical researchers have also developed ways to effectively change prevalent behaviors and attitudes bred by chemical dependency on tobacco. This treatment is called cognitive-behavioral therapy (CBT). These scientific advances offer smokers proven pathways to quitting and avoiding relapse. Yet the medical community -- doctors, dentist, health professionals -- has not yet adopted this comprehensive approach, despite adverse effects of smoking on the health of their patients. Rarely is this most effective treatment (NRT plus CBT) offered to smokers, despite the potential leverage of combining both these scientific advances..

What is the magnitude of the consequences of the smoking addiction on our health care system and why should we be concerned about it? Smoking causes a wide variety of illnesses, including 30 percent of cancers and heart disease, as well as a significant percentage of lung disease. 46 million Americans continue to smoke though 70 percent of them say they want to quit. How does this affect medical care? Let's look at the issues. Can a doctor or hospital effectively treat asthma or emphysema, heart disease or cancers without treating smoking? Highly unlikely. An astounding 50 percent of periodontal disease is from smoking. How can a dentist treat oral health without addressing the basic cause of tooth loss? How about mental health? According to an article in the Journal of the American Medical Association by Lasser and colleagues (2000) smokers who abuse alcohol and drugs, and those with psychiatric and mood problems consume 44.3 percent of all the cigarettes smoked in the U.S. The two founders of Alcoholics Anonymous, like many alcoholics, did not die from their earlier alcohol intake, but from smoking.

What is the state of the science of smoking cessation? In a recent study, an experienced smoking cessation researcher named Sharon Hall at the University of California in San Francisco (UCSF) and her colleagues (2009), tested cognitive-behavioral therapy in smokers over 50. These smokers were first treated with five group sessions and provided with 12 weeks of sustained release bupropion (a smoking cessation medication also known as Wellbutrin or Zyban) and 10 weeks of 2mg and 4mg nicotine gum. The authors report that "extended cognitive behavioral treatments can produce high and stable cigarette abstinence for both men and women". In fact, the cessation rates reported by Dr. Hall for extended CBT, are 55 percent at 52 weeks, and 55 percent at 104 weeks as well. Dr. Hall reports that "these rates are strikingly higher than those reported in the recent literature." As a basis for comparison, the "natural" rate of 12 month self-help cessation attempts has historically been about 7 percent or less. For an example, in 2005, among the 19 million American adults who tried to quit, only 4-7 percent reported success. Cessation interventions by physicians and dentists yields 12 month success rates in the range of 10.7-18.7 percent, depending on length of counseling combined with pharmacological prescriptions.

In a recent pilot study at Columbia University Medical Center, we evaluated 40 smokers who, in 2008, were offered a similar combination of CBT plus NRT. These patients had at least one DSM-IV psychiatric diagnosis and 75 percent of the sample also had significant medical conditions. On average, patients in the sample had a history of smoking for 30 years, and smoked an average of 15 cigarettes each day. The majority of the sample was unemployed (77.5 percent) and 40 percent had less than an 8th grade education. In anyone's book, these smokers, would be considered among the most difficult to help. And yet, using the combined treatment approach (NRT with CBT), 60 percent of the sample quit smoking at some point during treatment. Fifty-five percent were still quit at discharge and 47.5 percent reported that they were not smoking at the time of the follow-up phone call. Ninety percent of patients in this sample utilized nicotine replacement therapies.

The U.S. Department of Health and Human Services conducted their own study and issued a paper, "Treating Tobacco Use and Dependence 2008 Update" that corroborates that: (1) " Providing counseling in addition to medication significantly enhances treatment outcomes" (p. 101); and (2) The most effective medication strategy is to combine the nicotine patch "(long-term; > 14 weeks) + ad lib NRT (gum or spray)". Using the patch combined with another form of NRT, as needed, produced an estimated abstinence rate of 36.5 percent (p. 109) in the HHS analysis. Despite this evidence -- which is in the public domain -- many popular self-help books with an anti-NRT bias have dominated the scene.

In an example of the law of unintended consequences, some of the public health measures designed to get people to quit and to protect non-smokers have gotten smokers instead to train themselves to smoke only at certain times and places. This trend, called "intermittent smoking", plays into the deepest wish of many smokers which is to have control over their smoking rather than free themselves of the habit completely.. Studies now show a significant group of smokers are using NRT not to quit but to control their smoking. In contrast to the NRT-only and the anti-NRT approaches, the science of helping smokers strongly suggests taking a comprehensive approach to smokers who want assistance to quit. The evidence is that combining medication and counseling therapies is just better than trying these alone.

What services does our health care system offer smokers? In our current system, paying for smoking cessation is most often left up to the individual, and it is not a priority in medical practice. In fact, in the current debate about the future of health care in America, screening for smoking, and helping smokers has not received much attention. Indeed, when a senate stimulus bill included 75 million dollars for smoking cessation programs, screening practices were considered "frivolous" spending by many legislators (see New York Times February 2, 2009). The funds were widely derided and quickly cut as "pork." While it is true that most smokers who have quit have done so on their own, many who have struggled with smoking and who eventually did quit describe it as the hardest thing they have done in their lives. All smokers are not alike, and many need, and the science suggests would greatly benefit from, appropriate professional assistance.

Why, despite the advances of science, are we not making the best treatments available to those who smoke? Part of the reason is that smoking has deep economic and cultural roots that date back to the beginnings of our republic; so it just seems "normal" despite the medical problems it causes. Another reason is that nowadays smoking is often regarded more as a moral weakness than as an appropriate focus of serious clinical attention just as alcoholism was viewed in the past as a moral failure not a medical problem.

In addition, while the dangers of smoking are widely known by smokers and nonsmokers alike, its true costs to our healthcare system are widely ignored. The Centers for Disease Control estimates that tobacco use costs the United States approximately $193 billion annually.

This figure includes about $97 billion from lost productivity, and $96 billion in direct smoking-related health care costs. One out of five adults in the U.S.-- an estimated 19.8 percent -- continue to smoke. This is down by more than half from 1965, when the smoking rate was 42.4 percent. The impact on the nation's health of just this one change has been phenomenal, including further reductions in cancer deaths published online last month (December 7, 2009) in the journal Cancer. Clearly, declining tobacco use is an important contributor to the progress that has been made.

Those smokers who are also in treatment for serious medical, dental and psychiatric conditions tend to be more addicted to smoking. Many have already been advised by their healthcare professionals to quit, but may require more innovative and targeted clinical services. Further progress on smoking rates will require us, as a nation, to stop viewing tobacco use as a personal weakness and start viewing tobacco cessation treatment as an integral part of the care of all tobacco-related illnesses, and indeed of our healthcare system overall.

As we consider health care reform, let's not forget those one thousand smokers (and the families and friends they leave behind) who die each and every day in the U.S. from disease caused by smoking. Helping smokers quit in a more holistic way is supported by science. It is also likely to be one of the most cost-effective ways to lower the nation's healthcare costs, and help end the tremendous suffering caused by this most prevalent addiction.