Posted by Keith Ruskin, M.D.
“Thank you for calling the Tobacco Quitline. Press 1 if you smoke cigarettes. Press 2 if you smoke cigars. Press 3 if you’ve had a bad day in the OR and need to step outside for a cigarette right now
Everyone, including smokers, understands that tobacco is bad for your health. The surgical procedure that a smoker needs may, in many cases, be directly related to tobacco use. Smokers undergoing surgery have higher carbon monoxide levels and are at greater risk for pulmonary complications after surgery. They are also at increased risk for wound infections and other surgical complications. It makes sense, therefore, to use the perioperative period as a “teachable moment” to educate our patients about the benefits of quitting as well as to give them a tool to assist them in quitting. Anesthesiologists interact patients for only a limited period of time, but while they are our patients, we may have an ideal opportunity to help them cease smoking.
The United States Public Health Service has developed clinical practice guidelines around a technique called the “5 A’s”:
- Ask about tobacco use.
- Advise the patient to quit.
- Assess the patient’s willingness to quit.
- Assist each patient with a specific cessation plan.
- Arrange for follow-up.
Although this particular technique has been shown to be effective, we see most patients for only a brief period of time in the presurgical testing clinic and then again on the day of their surgery. Most of our patients’ time in the clinic may be spent with physician extenders such as advanced practice nurses and physician assistants. We, as anesthesiologists, require a tobacco intervention that is both brief and one that can be delivered by any healthcare provider.
Warner et al
. may have filled that need by developing an intervention called “Ask, Advise, and Refer,” in which patients are asked about tobacco use, advised to quit, and then referred to a telephone quitline. In this month’s issue of Anesthesiology
, an article by Warner et al.
discusses the effectiveness of a brief intervention designed to get patients who smoke to call a telephone quitline. The study group was composed of patients who smoked. They were advised to quit, educated about quitline services, and then referred to a tobacco quitline. In many cases, a referral was faxed during the visit. Patients who called the quitline were given counseling and tobacco replacement therapy (e.g., nicotine gum or patches). Patients in the control group were advised to abstain, educated about the benefits of quitting, and then given a brochure with information about telephone counseling services. The primary outcome of the study was whether or not the patients made that first call; secondary outcomes included smoking cessation for 30 and 90 days.
Warner’s tobacco cessation intervention was effective: Almost 20% of the patients who received the quitline referral made the call and completed the first counseling session. Fewer reported that they had ceased smoking altogether; in fact, there was no statistical significance between the groups. However, the intervention group trended to greater effectiveness and a larger and more statistically representative study in the future might reveal a subtle benefit. Both healthcare providers and a focus group of surgical patients helped to develop the intervention, which is probably one reason why it was as effective as it was. This paper is important because convincing a smoker to seek help is the first step towards quitting, and a short, focused intervention is what we can do best in the presurgical testing clinic.