Coverage of "The Great American Smoke-Out" and linking diabetes and heart disease during "American Diabetes Month"

Cardiology Review® Online, November 2006, Volume 23, Issue 11

This month marks the 30th Annual Great American Smoke-Out. Although everyone “knows” the importance of quitting smoking now and even as clinical research in addiction and cessation continues, a question remains as to the practicality of physician-based smoking cessation efforts. Can physicians make a difference?

Primary care physicians urged to play an increased role in tobacco cessation efforts

The answer is simple: without a doubt. With the colossal evidence of the adverse health effects of cigarette smoking, not only are there more reasons, there are also more opportunities for physicians to offer smoking cessation counseling, says Michael Fiore, MD, Director of the University of Wisconsin Center for Tobacco Research and Intervention.

“Smoking will end up killing half of the people who do it. We are not treating our patients with the appropriate standard of care if we allow them to leave our office not knowing if they smoke, and not giving them an evidence-based treatment if they do,” said Fiore, founder of the Center and chair of the US Public Service panel that develops clinical guidelines for treating tobacco dependence.

The Guidelines are also in the process of being updated for the first time since 2000, Fiore said. “A lot has happened since then. For instance, anybody in America can call 800-QUIT NOW and get a live counselor. But that’s not a substitute for what a physician does,” he said.

Fiore pointed to the clinical practice guidelines established in 2000, and available online, as indicating the importance of a physician’s role. “Twenty percent of American adults who smoke need to get an intervention; they need to be advised to quit in a clear, strong, and personalized way,” said Fiore.

Some physicians are focusing on the wrong part of the equation, experts say. Physicians wonder how patients can be made more receptive to the smoking cessation message, instead of looking at their own behaviors and care delivery process.

The Spirit Is Willing…But Patients Are Not Informed

“Seventy percent of patients want to quit smoking,” said Leif Solberg, MD, associate medical director for care improvement research for HealthPartners medical group and clinic, and an adjunct professor at the University of Minnesota. “The issue is how to establish systems that will make it more likely that the doctors will deliver the 5 ‘As’ recommended by the Public Health Service,” noted Solberg (see below).

The 5 ‘As’ emphasize the importance of physician intervention in tobacco cessation efforts and public health. The 5 ‘As’ are:

1. Ask about smoking.

2. Advise to quit.

3. Assess willingness to quit. (Research indicates that half of all patients at every visit would be willing to give it a try if the physician were to urge them to do so.)

4. Assist with counseling and medicine.

5. Arrange follow-up. (Persons are much more likely to quit if doctors arrange for follow-up, either in person or by phone.)

The American Journal of Preventive Medicine

Physician laxity in asking about tobacco use is a big problem, Solberg said. “We have pretty good evidence that physician advice is important, and that it works,” he said, referring to an article he authored in the July—August issue of about giving advice on tobacco screening and cessation counseling in the clinical setting.

“Based on a review of the literature, I found that it is one of the most cost-effective services you can provide,” he said.

The study, sponsored by the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality, found that tobacco cessation advice from physicians is 1 of only 3 recommendations (along with immunizations and gonorrhea screenings in young women) that has a positive cost benefit, according to Solberg.

The study is part of the Prevention Priorities project, and the data are available online at

.

www.prevent.org

Clinical psychologist Jennifer McClure, PhD, associate investigator at the Group Health Cooperative Center for Health Studies, says that the personalized nature of the message physicians can deliver is what carries the greatest impact.

Personalization Helps

“Of the broad population of smokers, we know that only a small percentage are ready to quit at any given time. Most want to quit some day, but for most today’s not the day,” said McClure, who described several ongoing experiments to determine which personalized stop-smoking messages are most effective (see sidebar). Studies involving print materials have indicated that a personalized message carries greater weight, McClure said.

But whatever methods a physician uses to remind a patient to stop smoking, it is important that patients know about the variety of treatments available today, experts say.

The Journal of the American Medical Association

The revised tobacco cessation clinical guidelines will have to take account of at least 2 new drugs, said Fiore, including the Committ nicotine lozenge, and a new medication called varenicline (Chantix, Pfizer), he said, noting several articles in this past summer discussing head-to-head trials of varenicline with buproprion, a preexisting tobacco cessation treatment that is now available in generic form.

In this greater Seattle-area trial, McClure hopes to finish recruiting about 650 patients, regardless of their willingness to quit, by the fall of 2007. Those in the treatment arm will receive a spirometry test to measure their lung function, and be given a health assessment, a stop-smoking recommendation, and access to Free and Clear, a free phone-based cognitive behavioral counseling program. The trial is not exclusively a Group Health project, McClure said.

Get PHIT (Proactive Health Intervention for Tobacco Users)

Project Quit

This collaborative study involving the University of Michigan and the Henry Ford Health System is experimenting with the delivery of interventions over the Internet. Phase I looked at the use of testimonials, message source, outcome, and efficacy expectations. “Patients with high-level individual tailoring had a 41% cessation rate at 6 months, compared to 27% in those who received low-depth tailoring in those factors,” McClure said, noting that all 900 patients in Phase I also had access to the nicotine replacement patch. Another thousand or so patients will be recruited for Phase II, she said.

This trial is a collaborative study between Group Health, Free and Clear, and SRI International (which is not formally affiliated with Stanford University, according to McClure). All patients will receive varenicline in addition to behavioral interventions such as the standard Free and Clear program available via the telephone, or a newly developed Internet-based Free and Clear program. The institutions are recruiting about 1200 people, and the study is expected to end in about 3 years, according to McClure.

The COMPASS Trial

Readers interested in learning more about these trials can contact Dr. McClure at

mcclure.j@ghc.org.

“The action of varenicline is innovative,” said Fiore. “It serves as a nicotine blocker with both antagonist and agonist properties.” The new drug both stimulates brain receptors and blocks withdrawal symptoms, in addition to blocking the binding of the nicotine on the receptors, so that cigarettes become less reinforcing, Fiore said.

Physicians pressed to “make the link” between diabetes and heart disease As part of American Diabetes Month this November, physicians are once again being encouraged to increase their patients’ awareness of diabetes and the health risks associated with it, especially the relationship between diabetes and heart disease.

According to prior research, one half of those diagnosed with diabetes already had a complication, such as vascular disease, but also including eye, kidney, or nerve damage at the time of diagnosis, according to John Buse, MD, PhD, director of the diabetes center at the University of North Carolina, and president-elect of the American Diabetes Association (ADA).

A huge part of the problem has been that those at risk for diabetes oftentimes don’t realize that they are also at risk for heart disease. To remedy this, the ADA and the American College of Cardiology (ACC) have engaged in a joint effort since the turn of the millennium to make patients and providers more aware of this connection.

“In 2001, 38% of those with diabetes realized they were at risk for high blood pressure,” said James Galloway, MD, director of the Native American cardiology program and associate professor at the University of Arizona. Since the initiation of the ACC and ADA efforts, that number has gone up to 69%, Galloway said. In terms of awareness of the link between diabetes and cholesterol problems, the numbers are 37% and 64% in that same time period, Galloway said.

When it comes to awareness of the link between cardiovascular disease and diabetes, efforts have been less successful. Awareness increased from 32% to only 45% during the relevant time period. But studies show that patients with diabetes have as high a risk for cardiovascular disease as someone who already has cardiovascular disease, Galloway said.

“One of the things we can do as doctors to prevent cardiovascular disease in patients with diabetes is to follow the ABCs established by the pertinent authorities,” said Galloway. According to Galloway, the ABCs represent the following principles:

A stands for hemoglobin A1c, a long-term indicator of how well the patient’s glucose is controlled.

B stands for blood pressure—less than 130/80 mm Hg as a goal.

C stands for cholesterol—especially, the bad cholesterol. Low-density lipoprotein levels should be less than 100 mg/dL, according to Galloway.

It’s the time of the year for the Great American Smoke-Out, and that means that tobacco cessation researchers like Jennifer McClure will be advertising to take advantage of the smoke-out as an opportunity to recruit smokers who want to quit for participation in research trials. McClure discussed a number of ongoing tobacco cessation trials.