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July 10, 2009

Smoking Cessation Counseling: Too Effective to Ignore

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Smoking Cessation Counseling: Too Effective to Ignore

Photo by Graham Ramsay

Joseph Ladapo

Despite recent passage of the farthest-reaching tobacco legislation ever to become law, smoking remains an important policy issue with an unfinished public-health agenda. For patients hospitalized with smoking-related illnesses, such as pneumonia, heart attack, or stroke, the steps that hospitals take to mitigate the behavior are frequently nominal and almost never evidence-based. Moreover, while Medicare has established the provision of smoking cessation counseling as a measure of a hospital’s quality of care, incentives do not exist to support the efforts needed to maximize a hospitalized smoker’s chances of successfully quitting. This treatment paradigm translates into the loss of a critical opportunity to make a meaningful difference in a smoker’s life.

It is difficult to understate the extent of health problems related to smoking. With the exception of ulcerative colitis, an inflammatory bowel disease characterized by abdominal pain and bloody stool, and whose symptoms can be somewhat alleviated by smoking, there are few major diseases for which smoking is neither a risk factor nor an aggravating behavior. Responsible for the majority of lung cancer incidence in both smokers and nonsmokers exposed to secondhand smoke, smoking is the single most important modifiable risk factor for heart disease, cancer, and other non-cancerous lung conditions, such as emphysema and bronchitis.

Patients admitted to the hospital with their first heart attack are almost twice as likely to be smokers as the rest of the population. Though it is well known that smoking is a major risk factor for heart disease, most of these patients will continue to smoke one year after discharge. Not surprisingly, these patients are at much higher risk for future heart attacks and death.

Medicare and private insurers have a pivotal opportunity to improve the health of millions of smokers by realigning goals and expectations surrounding their inpatient care.

This serious public-health problem has a potential solution that remains largely unexploited. The simple initiation of nurse-led smoking cessation counseling for hospitalized patients interested in quitting, followed by the continuation of this service for at least one month after discharge, nearly doubles a smoker’s chances of being smoke-free one year later. These patients also enjoy the health advantages of abstaining from tobacco, which include a lower risk of heart attack, stroke, and death.

Despite the substantive evidence supporting this intervention, structured smoking cessation counseling is infrequently implemented and has received only a fraction of the attention it deserves. The reasons for this, I suspect, are largely rooted in our society’s infatuation with high technology and cutting-edge interventions, which do not include smoking cessation counseling. Yet given its proven efficacy, low cost of implementation, and highly favorable cost-effectiveness, some researchers and policymakers believe it should play a more central role in the care of hospitalized patients.

According to Nancy Rigotti, HMS professor of medicine and director of the Tobacco Research and Treatment Center at MGH, “a major barrier to implementing smoking cessation counseling for these patients is that the intervention model does not fit neatly into existing care models. It requires coordinating care across inpatient and outpatient settings, and this remains a challenge in the management of chronic diseases.”

Medicare and private insurers have a pivotal opportunity to improve the health of millions of smokers by realigning goals and expectations surrounding their inpatient care. A more codified and integrated application of evidence-based smoking cessation interventions can achieve this goal, and to identify sources of funding, one needs to look no further than the plethora of markedly more expensive but less cost-effective tests and treatments.

Perhaps most important from a policy perspective, encouraging and incentivizing highly cost-effective treatments sends a clear message about priorities. Such a message is especially necessary during the current healthcare reform debate, in which the focus has been expanding coverage to the 46 million Americans without insurance. Equally important, however, is the need to contend with the rapidly increasing costs of care, which jeopardize healthcare access for insured and uninsured Americans alike.

—Joseph Ladapo, HMS ’08, is an intern in internal medicine at Beth Israel Deaconess Medical Center.

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions or Harvard University.

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