Transfer of preventive health programs to physicians' practices through medical organizations.

BACKGROUND: Transferring new information to practicing physicians is a complex and often faulty process. Effective transfer is a challenging goal that requires a strategy for reaching large numbers of physicians throughout the country in a short time. However, methods for disseminating preventive health techniques such as smoking cessation have not been well organized. Smoking is the single most important preventable cause of premature mortality, so dissemination of research-based smoking-cessation techniques to physicians' practices is a priority for the National Cancer Institute (NCI). METHODS: NCI recruited national, professional medical organizations to collaborate in disseminating smoking-cessation techniques. The goal was to co-sponsor 50 Train-the-Trainer (TT) seminars that would prepare 2,000 professionals as volunteers to instruct their colleagues in smoking-cessation techniques. NCI provided all materials, faculty (nine professionals), advance logistics, CME credits, and follow-up. The co-sponsor organizations helped develop the training plan, promoted training among their members, enrolled professionals to be trained, and made logistical arrangements for the training sites. RESULTS: During the 4 years of the program, NCI recruited 11 national organizations as co-sponsors; conducted 53 TT seminars in 22 states and Washington, DC; and trained 2,098 professionals as smoking-cessation trainers, who practice nationwide. The many lessons learned provide the basis for recommendations that can assist others who want to work with professional organizations. CONCLUSION: The National Cancer Institute demonstrated that national organizations of medical professionals can help to disseminate effectively a research-based smoking-cessation program. Twelve recommendations are presented to help others disseminate preventive health techniques nationwide.

Tobacco, youth, and sports.

Cigarette smoking constitutes the single largest threat to the health and longevity of American youth. Each year, almost 400,000 people die prematurely from tobacco-related diseases. Moreover, 90% of adult smokers began using tobacco before their eighteenth birthday, and each day 3,000 children and adolescents begin smoking. Smokeless tobacco use is less prevalent than cigarette smoking but has similar deleterious health effects and is often also glamorized by sports figures. This article examines the relationship between tobacco and sports and offers specific steps that physicians (specifically orthopedic surgeons and sports medicine physicians, who interact with athletes at sporting events and in schools as well as at the clinic) can take to help prevent or minimize tobacco use. Although sports have been used by the tobacco industry to promote tobacco products to young people, the authors suggest new ways to prevent its success.

Tobacco addiction: implications for treatment and cancer prevention.

The American Society of Clinical Oncology and the National Cancer Institute convened a symposium in June 1996 on tobacco addiction. Additional support for the symposium was provided by the American Medical Women's Association and the American Society of Preventive Oncology. The goals of this conference were to describe the burden and public health consequences of tobacco addiction, to describe the state of science for the treatment of nicotine dependence, and to explore new strategies to increase quit rates and to prevent the uptake of tobacco use. This article summarizes and integrates the meeting presentations on tobacco addiction and includes the topics of smoking prevalence; psychobiologic aspects of nicotine dependence; and implications for disease, treatment, and prevention. Comments on regulatory approaches and national strategies for reducing dependence are also summarized in presentations by Dr. David Kessler, former Food and Drug Administration Commissioner, and Dr. C. Everett Koop, former U.S. Surgeon General.

Impact of the American Stop Smoking Intervention Study on cigarette consumption.

OBJECTIVE: To obtain an early estimate of the effectiveness of the American Stop Smoking Intervention Study (ASSIST). DESIGN, SETTING, AND PARTICIPANTS: Seventeen American states funded through ASSIST are compared with 32 others regarding per capita cigarette consumption from 1989 to 1995. California, which already had an extensive tobacco control programme, was omitted. ASSIST states were selected competitively (not randomly) based on their proposals' merit, state smoking prevalence, and geographical distribution. INTERVENTIONS: Comprehensive tobacco control programmes, emphasising policy interventions, were implemented in the ASSIST states beginning in 1993. MAIN OUTCOME MEASURES: Trends in aggregated per capita cigarette consumption and inflation-adjusted average price/pack of cigarettes in the intervention states were compared. Percentage change in per capita consumption is also compared with percentage change in inflation-adjusted cigarette price by state in each group from 1992 to 1994. RESULTS: Per capita consumption and inflation-adjusted cigarette price were nearly identical in both groups of states before 1993, when full funding for the ASSIST interventions began. However, by 1996 smokers in the intervention states were consuming about 7% less cigarettes per capita (P<0.05, beginning in 1994), and in 1994 the average price was over $0.12/pack higher in the intervention states. All but three states (all intervention) showed decreases in cigarette price. Nonetheless, 76% of the intervention and 55% of the comparison states showed some decrease in consumption despite decreases in price. The relationship between changes in price and consumption was considerably diminished in the intervention group. CONCLUSIONS: These interim results suggest that the ASSIST programme is associated with a substantial difference in tobacco consumption in a third of the United States, and that increased price from taxation may not be the only programme influence.

Do dentists and physicians advise tobacco users to quit?

To examine dentists' and physicians' effectiveness in advising patients who use tobacco to quit, the authors estimated the percentages of smokers in the United States who visited a dentist or physician in the preceding year, the percentages of those who were advised by their health care provider to quit and the percentages of those who planned to quit smoking. They also estimated the percentage of smokeless tobacco users who were ever advised by their dentist or physician to quit. The results of the study indicate that dentists and physicians may not be maximizing their opportunities to advise their patients who use tobacco to quit, or they are not adequately communicating to their patients the importance of quitting.

Public health approaches to tobacco use prevention and cessation in the U.S.

Tobacco has a long history of use in the U.S., and its serious health effects have been well-documented during the past half century, U.S. efforts to control tobacco use and tobacco-related morbidity and mortality have been reasonably successful over the past 25 years, during which time there has been a 34 percent reduction in adult smoking. Nevertheless, tobacco use remains a significant public health problem in the U.S., with more than 430,000 tobacco-related deaths per year and over one-fourth of the population continuing to smoke. Many organizations are involved in tobacco use control activities, the most broadly focused of which is the National Cancer Institute (NCI). As an example of the type of program needed to address the problem of tobacco use on a national scale, the NCI's public health research plan and activities are described and its emphasis on a data-based decision matrix in its approach to tobacco and cancer control research and applications of research is discussed. Finally, future approaches to tobacco use control in the U.S. are suggested.

Tobacco use among adolescents. Strategies for prevention.

Tobacco use is a major public health problem that has its onset during childhood and adolescence. To prevent the onset, physicians can reach children and their parents in their offices beginning in the prenatal period and continuing through adulthood. For pediatricians and other physicians who care for children, NCI recommends five office-based activities that begin with the letter A. The 5 As include anticipatory guidance, ask, advise, assist, and arrange follow-up visits. Elimination of tobacco use requires a comprehensive strategy that includes health professional interventions, policy changes, advertising restrictions, comprehensive school-based programs, community activities, and advocacy approaches. Physicians and health professionals have major roles to play in each of these interventions.

Prevention of tobacco use during childhood and adolescence. Five steps to prevent the onset of smoking.

BACKGROUND: Most tobacco users become addicted during childhood and adolescence. To reduce the prevalence of tobacco-related illnesses, more emphasis must be placed on preventing the onset of tobacco use. Physicians can play a major role. METHODS: Based on a series of clinical trials, the National Cancer Institute (NCI) developed recommendations to help patients stop smoking. Behavioral and developmental research have identified factors that contribute to the onset of smoking. The American Academy of Pediatrics (AAP) has developed guidelines for health supervision from birth to adulthood, including engaging parents and children as partners in health care. The NCI recommendations, behavioral research results, and AAP guidelines were integrated to develop a strategy to prevent the onset of tobacco use. RESULTS: The NCI proposes five steps to prevent tobacco use during childhood and adolescence. There are five physician activities, beginning with the letter A, including anticipatory guidance, ask, advise, assist, and arrange follow-up. Anticipatory guidance, the practice of counseling for potential problems, is a key part of health care for the young. The nature of these steps varies, depending on the child's age, developmental stage, and behavior, as well as smoking habits of family members. CONCLUSION: Despite the long-term consequences of smoking, onset and addiction to tobacco use usually begins in childhood. Therefore, physicians who care for children have a major role in eliminating tobacco use by preventing its onset.

Youth tobacco use in the United States--problem, progress, goals, and potential solutions.

BACKGROUND: Efforts to control tobacco use and tobacco-related morbidity and mortality in the United States continue to be generally successful. In the quarter century since the publication of the first Surgeon General's Report on Tobacco and Health, adult smoking rates in the United States have been reduced by nearly 34%. Controlling tobacco use among our nation's youth, however, has not been as successful. Although there was considerable success in reducing adolescent tobacco use in the late 1970s and early 1980s, tobacco use among youth has remained essentially stable for the past decade. METHODS: The health and economic burden of tobacco use, current knowledge about youth tobacco use, and youth-related national tobacco reduction goals for the Year 2000 are reviewed. RESULTS: Analysis of the research of the past two decades clearly indicates that there is no "magic bullet" in existence or in sight for the reduction of tobacco use, either among youth or among adults. This does not mean that opportunities for significant advances through, for example, pharmacological therapies or the broad application of media or policy strategies should not continue to be explored, but that for the moment no single approach appears to work best. Rather, a comprehensive approach that applies multiple prevention and cessation strategies simultaneously appears to be most effective in tobacco use control. CONCLUSIONS: Among youth, the combination of tobacco control strategies that may work best includes those that involve the family, primary care physicians, and other health professionals such as nurses and dentists; programs that are carried out in schools and/or through the media; and societal approaches such as access and advertising restrictions and increased taxes.

The United States National Cancer Institute and the science of tobacco control research.

U.S. efforts to control tobacco use and tobacco-related morbidity and mortality have been reasonably successful over the past 3 decades, during which there has been a 34% reduction in adult smoking. Nevertheless, tobacco use remains a significant public health problem in the U.S., with more than 430,000 tobacco-related deaths per year and over one fourth of the population continuing to smoke. Many organizations are involved in tobacco-use control activities, the most broadly focused of which is that of the National Cancer Institute (NCI). The NCI's program is described and its emphasis on a data-based decision matrix in its approach to tobacco and cancer control research and applications of research is discussed. Finally, future approaches to tobacco-use control in the U.S. are suggested.

The clinician's role in preventing smoking initiation.

Initiation of tobacco use begins primarily during childhood and adolescence, and physicians can play a major role in preventing the onset of tobacco use. The National Cancer Institute recommends that physicians incorporate the four A's in their practices--four activities that promote smoking cessation and prevention: ask, advise, assist, and arrange follow-up. Physicians who care for children should include a fifth A, anticipatory guidance. Anticipatory guidance is the practice of providing counsel regarding potential problems. By providing messages that are appropriate to the patient's age and developmental stage, physicians can intervene in early stages of tobacco use. As role models and leaders, physicians can also influence attitudes in the schools and community.

The clinician's role in promoting smoking cessation among clinic patients.

Like other chronic conditions, nicotine dependence offers both challenges and rewards to clinicians. The treatment of this condition frequently requires experience in pharmacology, behavioral science, and social aspects of medicine. Physicians are uniquely qualified to assist patients in their efforts to overcome the multifaceted condition of tobacco addiction. In providing this treatment, the clinical challenges are far outweighed by the benefit to patients who stop smoking. For many patients, smoking cessation is, by far, the most important step they can take to improve their health and increase their life span. Physicians who help patients accomplish this difficult goal provide a life-saving service. There is sufficient scientific evidence to guide physicians in their approach to smoking patients. Brief, systematic interventions have been shown to increase patient smoking cessation rates. The intervention can be described in four steps: ask about smoking, advise smokers to stop, assist those who want to stop, and arrange adequate follow-up. These interventions are used consistently when a smoking cessation program is adopted by an entire office practice. The components of this office-based program include defining staff roles, maintaining a smoke-free office, stocking appropriate materials, making use of the medical record to identify smokers and to remind staff to intervene, and monitoring patient progress. The potential public health impact of physician intervention with smoking patients is enormous. Even with very modest expectations of cessation rates, 100,000 physicians using effective intervention can produce over 3 million new ex-smokers in the United States each year. In conjunction with other community-based tobacco control efforts, this physician-lead effort will result in a marked reduction in the morbidity and mortality caused by smoking and, thus, control of "the most important public health issue of our time."

A physicians's guide to preventing tobacco use during childhood and adolescence.

Physicians who care for children can and should help patients avoid the use of tobacco. Physicians are well aware of the health hazards associated with tobacco use, inasmuch as smoking is the chief, single cause of premature mortality in this country. Each day, more than 3000 children in the United States begin to use tobacco. Physicians who care for children have patients at vastly different stages of intellectual and social maturity. Both the theory and practical details of tobacco-related interventions differ among infants, children, and adolescents. The physician is in a unique position to intervene in the early stages. Anticipatory guidance--the practice of providing counsel regarding potential problems--is a key part of health care for the young. If physicians provide messages about tobacco use that are appropriate to the patient's age and developmental stage, the potential for broad public health impact is great. Based on a series of clinical trials, the National Cancer Institute developed a manual to assist physicians in helping their patients stop smoking. The recommendations in this manual include four physician activities that begin with the letter A (four A's): Ask, Advise, Assist, and Arrange follow-up. For physicians who treat children, a fifth A, Anticipatory guidance, is added.

How to help your patients stop smoking.

Family physicians can effectively help their patients stop smoking by using brief intervention and simple office organizational procedures. Intervention involves asking all patients about smoking, advising smokers to stop, assisting with self-help materials, establishing a date for quitting, possibly prescribing nicotine gum and, finally, arranging for follow-up visits. Office procedures include selecting an office coordinator, ensuring a smoke-free office, establishing a mechanism to identify and monitor patients who smoke, and involving the office staff in intervention and follow-up. With this protocol, intervention is possible at every office visit.