Medicare is finally legitimizing smoking cessation counseling by underwriting up to eight counseling sessions per year for smokers who are struggling to quit. This benefit is regardless of whether smokers are already ill from tobacco use or not. The naysayer's response is "what a waste," declaring that only physical approaches such as replacement of nicotine or other prescription medicines will help. One critic of the new benefit is Dr. Elizabeth Whelan of the American Council on Science and Health (ACSH), who says the expansion in coverage seems "nothing short of pathetic. Attempts to assist smokers quit must focus on satisfying the nicotine addiction by offering it in another form. Simply counseling long-term smokers to get them to quit? A joke- a cruel one at that."
However, research and clinical experience tell quite an opposite story. Even ACSH's own website states:
Counseling and medication -- especially if they're used together -- can increase the likelihood that a smoker will be able to quit permanently. Given the substantial costs of smoking and its effects on health and healthcare costs, smoking cessation treatment should be encouraged and integrated into the healthcare system.
I couldn't agree more. In fact, the announcement on August 25, 2010, by Medicare firmly recognizes the solid research that backs adding the counseling benefit:
The Centers for Medicare and Medicaid Services (CMS) has determined that the evidence is adequate to conclude that counseling to prevent tobacco use, which is recommended with a grade of A by the U.S. Preventive Services Task Force (USPSTF) for all adults and pregnant women who use tobacco, is reasonable and necessary for prevention of illness or disability and is appropriate for individuals entitled to benefits...
The crucial question is therefore not whether many smokers trapped in their addiction need counseling, but whether they will receive effective, state-of-the-art help or just warmed-over lectures about their health.
Physicians, dentists and other healthcare clinicians have been trained to deliver a brief intervention for smokers developed by the National Cancer Institute called the five A's. They are: (1) Ask about tobacco use at each visit; (2) Advise smokers to quit in a nonjudgmental (which means non- lecturing) way; (3) Assess their "readiness" to quit; (4) Assist them in quitting and (5) Arrange for follow-up to help support their non-smoking efforts. Clinicians are usually told "this is not rocket science," but the astute ones know that smokers who don't need much help quit on their own, and the ones who do need help can present some of the greatest challenges a clinician encounters. While it's true that this may not be rocket science, well-meaning clinicians with little skill in helping smokers may find themselves in over their heads, while adding little of real value.
How can we make sure this new benefit is used to its best advantage? First by making sure that the cessation protocol is used to its best advantage. While medical professionals make the mistake of seeing smoking addiction as a largely physical problem, in the realm of popular books on how to stop smoking, the field is dominated by the opposite mistake: smoking addiction is seen as purely a matter of mistaken psychological beliefs. The book that has dominated the field for the last 25 years, The Easy Way to Quit Smoking, comes out strongly against using any form of nicotine replacement as a failed strategy that only prolongs the addiction!
So what are a struggling smoker and a well-meaning nonspecialist clinician to do?
When I teach medical and dental students at Columbia University Medical Center, I tell them the three most important ways they can add value in brief counseling is to help smokers learn productive ways to cope with stress and emotional upset without automatically reaching for a cigarette. In the process of trying out new alternatives when stressed, smokers begin to challenge, and move beyond, the belief that they need to smoke to get by in life. A second way to add value is to prepare a smoker who wants to quit with ways to cope with the other smokers in their lives. One smoker I worked with could visit her smoking relatives for a day but after that always relapsed. Now smoke-free, she only visits them in smoke-free places! Smoking is contagious and smoking cessation programs have always known the importance of becoming assertive with other smokers. Finally, the third common trigger many smokers need help with is alcohol. Even those smokers who are not big drinkers often find that alcohol triggers the wish to smoke.
Clinicians who want to help smokers need to be knowledgeable about the different forms of nicotine replacement and other medicines to help build their patients' confidence and make quitting as easy and permanent as possible. For instance, many clinicians don't realize that doubling up on two forms of nicotine replacement therapy (NRT) is far more effective than using only one or the other NRT product alone. Combining two forms of NRT is the most successful medication strategy currently available according to the most recent US government clinical practice guidelines!
With brief counseling now available to all smokers on Medicare who want to quit, clinicians will be better able to provide the information and support for the transformative change that quitting smoking brings to their patient's lives.
Note: An earlier version of this post mispelled the acronym for the American Council on Science and Health (ACSH) and gave an incorrect web address. These are now corrected.
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