[' ', ' ', ' ', '*', 'Intervention', 'Pian', 'for', 'Patients', 'Who', 'Smoke', 'State', 'your', 'advice', 'clearly,', 'for', 'example,', '“As', 'your', 'physician,', '|', 'must', 'advise', 'you', 'to', 'smoking', 'now"', 'Personalize', 'the', 'be', 'ed', 'follow-up', 'visits', 'Set', 'a', 'follow-up', 'visit', 'within', '1', 'to', '2', 'weeks', 'after', 'the', 'quit', 'le', 'Have', 'a', 'member', 'of', 'the', 'office', 'staff', 'call', 'or', 'write', 'the', 'patient', 'within', '7', 'days', 'after', 'the', 'initial', 'visit,', 'reinforcing', 'the', 'decision', 'to', 'stop', 'and', 'reminding', 'the', 'patient', 'of', 'the', 'quit', 'date', 'Set', 'a', 'second', 'follow-up', 'visit', 'in', '1', 'to', '2', 'months', 'that', 'all', 'patients', 'who', 'smoke', 'are', 'identi-', 'fied,', 'monitored,', 'and', 'appropriately', 'treated', 'at', 'every', 'office', 'visit.', 'Organiza-', 'tional', 'procedures', 'are', 'not', 'complex', 'and', 'usually', 'meld', 'smoothly', 'into', 'a', 'physician’s', 'practice.', 'Such', 'procedures', 'usually', 'include', 'se-', 'lecting', 'a', 'smoking', 'cessation', 'coordinator', 'for', 'the', 'office,', 'making', 'the', 'office', 'tobacco-', 'free,', 'implementing', 'a', 'way', 'to', 'identify', 'and', 'monitor', 'smokers,', 'reminding', 'health', 'professionals', 'to', 'intervene,', 'and', 'using', 'a', 'protocol', 'that', 'involves', 'staff', 'members', 'in', 'the', 'intervention', 'and', 'follow-up.”', 'At', 'min-', 'imum,', 'patients’', 'charts', 'should', 'be', 'plainly', 'marked', 'with', 'a', 'sticker', 'or', 'other', 'visible', 'identifier', 'of', 'the', 'patient’s', 'smoking', 'sta-', 'tus.', 'Many', 'practices', 'use', 'additional', 're-', 'minder', 'systems,', 'including', 'flow', 'sheets,', 'to', 'promote', 'systematic', 'treatment.', 'When', 'treating', 'a', 'patient', 'who', 'smokes,', 'physicians', 'and', 'other', 'health', 'profession-', 'als', 'need', 'a', 'methodical', 'plan.', 'The', 'NCI-', 'recommended', 'approach', '(see', 'Table)', 'is', 'often', 'referred', 'to', 'as', '“the', 'four', 'As”:', '(1)', 'ask', 'about', 'smoking;', '(2)', 'advise', 'smokers', 'tostop;', '(8)', 'assist', 'patients', 'willing', 'to', 'stop;', 'and', '(4)', 'arrange', 'follow-up.®', 'The', 'four', 'As', 'intervention', 'plan', 'is', 'a', 'general', 'approach', 'that', 'can', 'be', 'adapted', 'for', 'use', 'in', 'very', 'little', 'time,', 'often', '3', 'minutes', 'or', 'less.', 'The', 'ap-', 'proach', 'is', 'designed', 'for', 'use', 'in', 'almost', 'any', 'outpatient', 'setting.', 'When', 'a', 'patient', 'de-', 'cides', 'to', 'stop', 'smoking,', 'the', 'recommended', 'JAMA,', 'December', 't1,', '1991—Vol', '266,', 'No.', '22', 'intervention', '(assist.', 'end', 'arrange)', 'is', 'a', 'patient', 'self-help', 'prog:', 'ain', 'that', 'is', 'encour-', 'aged,', 'guided,', 'and', 'supported', 'by', 'physi-', 'cians', 'and', 'nurses.', '.', 'DESCRIPTION', 'OF', 'THE', 'TRAINING', 'PROGRAM', 'From', 'the', 'results', 'of', 'the', 'trials', 'discussed', 'above,', 'the', 'NCI', 'produced', 'a', 'manual', 'of', 'practical', 'smoking', 'cessation', 'techniques', 'for', 'use', 'by', 'clinicians.”', 'Based', 'on', 'infor-', 'mation', 'in', 'the', 'manual,', 'a', '38-hour', 'course', 'for', 'physicians', 'and', 'nurses', 'was', 'designed.', 'To', 'teach', 'physicians', 'throughout', 'the', 'nation,', 'the', 'NCI', 'has', 'established', 'and', 'con-', 'tinues', 'to', 'seek', 'collaborative', 'relationships', 'with', 'organizations', 'that', 'share', 'a', 'commit-', 'ment', 'to', 'cancer', 'prevention', 'and', 'can', 'reach', 'practicing', 'physicians.', 'Collaborating', 'or-', 'ganizations', 'to', 'date', 'include', 'the', 'Ameri-', 'can', 'Cancer', 'Society,', 'American', 'Medical', 'Association,', 'Association', 'of', 'American', 'Medical', 'Colleges,', 'American', 'Medical', 'Wo-', 'men’s', 'Association,', 'Society', 'of', 'Teachers', 'of', 'Family', 'Medicine,', 'Association', 'of', 'Teachers', 'of', 'Preventive', 'Medicine,', 'Amer-', 'ican', 'College', 'of', 'Preventive', 'Medicine,', 'many', 'state', 'medical', 'societies,', 'and', 'sev-', 'eral', 'large', 'health', 'maintenance', 'organi-', 'zations.', 'The', 'goal', 'of', 'the', 'program', 'is', 'to', 'train', '"100000', 'physicians.', 'An', 'evaluation', 'of', 'the', 'training', 'program’s', 'impact', 'is', 'now', 'in', 'progress.', 'COMMENT', 'There', 'is', 'a', 'tremendous', 'disparity,', 'be-', 'tween', 'the', 'magnitude', 'of', 'the', 'health', 'pfob-', 'lems', 'caused', 'by', 'smoking', 'and', 'the', 'exper-', 'tise', 'of', 'physicians', 'in', 'treating', 'this', 'addic-', 'tion.', 'Clinical', 'trials', 'have', 'clearly', 'established', 'that', 'physicians', 'can', 'significantly', 'reduce', 'smoking', 'among', 'their', 'patients', 'by', 'using', 'brief', 'intervention', 'techniques.', 'Adoption', 'of', 'a', 'routine', 'intervention', 'by', 'physicians', 'nationwide', 'will', 'result', 'in', 'marked', 'reduc-', 'tion', 'in', 'smoking', 'prevalence', 'and,', 'there-', 'fore,', 'reduced', 'incidence', 'of', 'cancer', 'and', 'other', 'diseases', 'caused', 'by', 'smoking.', 'There', 'are.', 'documents', 'now', 'available', 'that', 'encapsu-', 'late', 'findings', 'from', 'the', 'clinical', 'trials', 'for', 'easy', 'use', 'by', 'practicing', 'physicians.', 'u', '™', 'te', 'A', 'training', 'program', 'now', 'in', 'progress', 'will', 'train', '100000', 'US', 'physicians', 'in', 'smok-', 'ing', 'intervention', 'techniques.', 'If', 'each', 'trained', 'physician', 'can', 'help', 'just', '10%', 'of', 'his', 'or', 'her', 'patients', 'who', 'smoke', 'to', 'stop', 'each', 'year,', 'the', 'United', 'States', 'will', 'have', '8', 'million', 'more', 'ex-smokers', 'annually.', 'The', 'NCI', 'training', 'program', 'is', 'a', 'major', 'effort', 'to', 'reduce', 'the', 'prevalence', 'of', 'smoking', 'by', 'rapidly', 'implementing', 'nationwide', 'the', 're-', 'sults', 'of', 'definitive', 'clinical', 'trials.', 'Individual', 'physicians', 'and', 'professional', 'organiza-', 'tions', 'throughout', 'the', 'nation', 'are', 'welcome', 'to', 'partic-', 'ipate', 'in', 'this', 'project', 'and', 'can', 'get', 'information', 'by', 'calling', '1-800-4-CANCER.', '(Individual', 'copies', 'of', 'the', 'NCI', 'manual”', 'can', 'be', 'obtained', 'through', 'calls', 'to', 'this', 'number.', 'Continuing', 'medical', 'education', 'credit', 'is', 'routinely', 'offered', 'for', 'participation', 'in', 'the', 'NCI', 'training.)', 'References', '1,', 'Schultz', 'JM.', 'Smoking-attributable', 'mortality', 'and', 'years', 'of', 'potential', 'life', 'lost—United', 'States,', '1988.', 'MMWR.', '1991;40:62-71.', '2.', 'US', 'Department', 'of', 'Health', 'and', 'Human', 'Services.', 'Smoking', 'and', 'Health:', 'A', 'National', 'Status', 'Report.', '2nd', 'ed.', 'Rockville,', 'Md:', 'US', 'Department', 'of', 'Health', 'and', 'Hu-', 'man', 'Services;', '1990:38.', 'US', 'Dept', 'of', 'Health', 'and', 'Human', 'Services', 'publication', '(CDC)87-8396.', '3.', 'Wells', 'KB,', 'Ware', 'JE,', 'Lewis', 'CE.', 'Physicians’', 'attitude', 'in', 'col', 'ing', 'patients', 'about', 'smoking.', 'Med', 'Care.', '1984;22:360-365.', '4.', 'Ockene', 'JK,', 'Kristellar', 'J,', 'Goldberg', 'R,', 'et', 'al.', 'Increas-', 'ing', 'the', 'efficacy', 'of', 'physician-delivered', 'smoking', 'inter-', 'oe', 'arandomized', 'clinical', 'trial.', 'J', 'Gen', 'Intern', 'Med.', '1991;6:1-8.', '6.', 'Cohen', 'SJ,', 'Stookey', 'GK,', 'Katz', 'BP,', 'Drook', 'CA,', 'Smith', 'DM.', 'Encouraging', 'primary', 'care', 'physicians', 'to', 'help', 'amokers', 'quit:', 'a', 'randomized,', 'controlled', 'trial.', 'Ann', 'In-', 'tern', 'Med.', '1989;110:', '.', '7.', 'Cummings', 'SR,', 'Coates', 'TJ,', 'Richard', 'RJ,', 'et', 'al.', 'Training', 'physicians', 'in', 'counseling', 'about', 'smoking', 'ces-', 'sation:', 'a', 'randomized', 'trial', 'of', 'the', '“Quit', 'for', 'Life”', 'program.', 'Ann', 'Intern', 'Med.', '1989;110:640-647.', '8.', 'Wilson', 'DMC,', 'Taylor', 'DW,', 'Gilbert', 'JR,', 'et', 'al.', 'A', 'ran-', 'domized', 'trial', 'of', 'a', 'family', 'physician', 'intervention', 'for', 'smoking', 'cessation.', 'JAMA.', '1988;260:1570-1574.', '§.', 'Kottke', 'TE,', 'Brekkle', 'ML,', 'Solberg', 'LI,', 'Hughes', 'JR.', 'Arandomized', 'trial', 'to', 'increase', 'smoking', 'intervention', 'by', 'physicians:', 'doctors', 'helping', 'smokers,', 'round', 'I.', 'JAMA.', '1989;261:2101-2106.', '10.', 'Glynn', 'T,', 'Manley', 'M.', 'How', 'To', 'Help', 'Your', 'Patients', 'Stop', 'Smoking:', 'A', 'National', 'Cancer', 'Institute', 'Manual', 'for', 'Physicians.', 'Bethesda,', 'Md:', 'US', 'Department', 'of', 'Health', 'and', 'Human', 'Services;', '1989.', 'National', 'Institutes', 'of', 'Health', 'publication', '89-3064.', '11,', 'Prochaska', 'J,', 'DiClimente', 'C.', 'Stages', 'and', 'processes', 'of', 'self-change', 'in', 'smoking:', 'toward', 'an', 'integrative', 'model', 'of', 'change.', 'J', 'Consult', 'Clin', 'Psychol.', '1983;51:390-395.', '12.', 'Glynn', 'TJ,', 'Boyd', 'GM,', 'Gruman', 'JC.', 'Essential', 'ele-', 'ments', 'of', 'self-help/minimal', 'intervention', 'strategies', 'for', 'smoking', 'cessation.', 'Health', 'Edue', 'Q.', '1990;17:329-345.', 'Clinical', 'Interventions', 'in', 'Tobacco', 'Control—Manley', 'et', 'al', '_', '3173', ' ', '—“===', '0608', '86106', ' ']