[' ', ' ', ' ', 'or', 'Special', 'Communications', 'Se', '£668', 'B6L05', ' ', '|', ',', 'Clinical', 'Interventions', 'in', 'Tobacco', 'Control', 'A', 'National', 'Cancer', 'Institute', 'Training', 'Program', 'for', 'Physicians', 'Marc', 'Manley,', 'MD;', 'Roselyn', 'P.', 'Epps,', 'MD;', 'Corinne', 'Husten,', 'MD;', 'Thomas', 'Glynn,', 'PhD;', 'Donald', 'Shopland', 'SMOKING', 'is', 'the', 'leading', 'preventable', 'cause', 'of', 'death', 'in', 'our', 'country.', 'Smoking', 'kills', '434000', 'people', 'a', 'year,', 'more', 'than', '1000', 'every', 'day’;', 'it', 'accounts', 'for', 'about', '85%', 'of', 'all', 'lung', 'cancer', 'deaths,', 'about', '80%', 'ofall', 'chronic', 'obstructive', 'pulmonary', 'dis-', 'ease', 'deaths,', 'and', '30%', 'of', 'all', 'heart', 'disease', 'deaths.', 'In', 'addition,', 'smoking', 'costs', 'this', 'country', '$52', 'billion', 'annually', 'in', 'health', 'care', 'and', 'other', 'costs.?', 'See', 'also', 'pp', '3139', 'and', '3183.', 'OSS', 'SSSA', 'In', 'spite', 'of', 'the', 'magnitude', 'of', 'this', 'health', 'hazard,', 'most', 'physicians', 'have', 'never', 're-', 'ceived', 'training', 'in', 'techniques', 'to', 'help', 'pa-', 'tients', 'stop', 'smoking.', 'Many', 'physicians', 'believe', 'they', 'are', 'unprepared', 'and', 'unsuc-', 'cessful', 'in', 'treating', 'patients', 'addicted', 'to', 'nicotine.*“', 'However,', 'recent.', 'scientific', 'evidence', 'suggests', 'that', 'physicians', 'can', 'help', 'smokers', 'stop', 'and', 'thus', 'reduce', 'the', 'incidence', 'of', 'smoking-related', 'diseases.', 'In', '1989,', 'the', 'National', 'Cancer', 'Insti-', 'tute', '(NCI)', 'used', 'clinical', 'trial', 'results', 'and', 'consensus', 'development', 'to', 'produce', 'rec-', 'ommendations', 'for', 'physicians', 'who', 'treat', 'patients', 'who', 'smoke.', 'The', 'trial', 'results', 'and', 'subsequent', 'recommendations', 'are', 'described', 'briefly', 'below;', 'more', 'details', 'have', 'been', 'published', 'elsewhere.®', 'There', 'is', 'now', 'a', 'national', 'program', 'to', 'train', 'phy-', 'sicians', 'in', 'these', 'brief', 'but', 'effective', 'smok-', 'ing', 'cessation', 'techniques.', 'SCIENTIFIC', 'BASIS', 'FOR', 'THE', 'TRAINING', 'In', '1984,', 'the', 'NCI', 'began', 'support', 'of', 'five', 'randomized,', 'controlled', 'intervention', 'trials', 'of', 'brief', 'training', 'and', 'intervention', 'protocols', 'for', 'physicians', 'to', 'use', 'with', 'pa-', 'From', 'the', 'Cancer', 'Contro!', 'Science', 'Program,', 'Division', 'ot', 'Cancer', 'Prevention', 'and', 'Control,', 'National', 'Cancer', 'In-', 'Stitute,', 'Bethesda,', 'Md.', ':', 'Reprint', 'requests', 'to', 'the', 'National', 'Cancer', 'Institute,', '9000', 'Rockville', 'Pike,', 'EPN-241,', 'Bethesda,', 'MD', '20892', '(Or', 'Maniey).', '3172', 'JAMA,', 'December', '11,', '1991—Vol', '266,', 'No,', '22', 'tients', 'who', 'smoke.**', 'The', 'trials,', 'involv-', 'ing', 'more', 'than', '1000', 'physicians', 'and', '30000', 'patients,', 'were', 'conducted', 'in', 'various', 'med-', 'ical', 'care', 'provision', 'settings', 'across', 'North', 'America', '(eg,', 'private', 'offices,', 'public', 'clin-', 'ies,', 'health', 'maintenance', 'organizations,', 'and', 'residency', 'programs).', 'Although', 'con-', 'ducted', 'in', 'nonresearch', 'environments,', 'these', 'were', 'randomized,', 'controlled', 'trials.', 'In', 'all', 'but', 'one', 'trial,', 'smoking', 'cessation', 'rates', 'were', 'calculated', 'for', 'a', 'physician’s', 'entire', 'practice,', 'not', 'for', 'individual', 'pa-', 'tients.', 'Thus,', 'all', 'smokers', 'in', 'each', 'phy-', 'sician’s', 'practice', 'were', 'followed,', 'not', 'just', 'those', 'who', 'received', 'interventions', 'from', '@', 'physician.', 'Long-term', 'cessation', 'was', 'confirmed', 'biochemically.', 'Even', 'with', 'these', 'very', 'strict', 'evaluatiqn', 'criteria,', 'ces-', 'sation', 'rates', 'of', 'up', 'to', '15%', 'were', 'docu-', 'mented', 'in', 'the', 'trials;', 'ie,', 'up', 'to', '15%', 'of', 'patients', 'who', 'smoked', 'were', 'verified', 'as', 'smoke-free', 'at', 'the', 'end', 'of', 'approximately', '1', 'year.', 'Certain', 'groups', 'of', 'patients', 'had', 'even', 'higher', 'cessation', 'rates.', 'In', 'one', 'study,', 'patients', 'who', 'agreed', 'to', 'stopsmok-', 'ing', 'and', 'returned', 'for', 'several', 'follow-up', 'visits', 'had', 'long-term', 'cessation', 'rates', 'of', 'almost', '30%.8', 'Although', 'physician', 'training', 'did', 'in-', 'crease', 'the', 'use', 'of', 'smoking', 'interventions,', 'the', 'training', 'alone', 'did', 'not', 'significantly', ';', 'alter', 'smoking', 'cessation', 'rates', 'among', 'pa-', ';', 'tients.7', 'Only', 'when', 'trained', 'physicians', 'were', 'routinely', 'reminded', 'to', 'intervene', 'with', 'all', 'patients', 'who', 'smoked', '(by', 'using', 'chart', 'stickers', 'or', 'other', 'devices)', 'did', 'smok-', 'ing', 'rates', 'among', 'patients', 'significantly', 'decrease,', '468', ':', 'Results', 'across', 'all', 'five', 'trials', 'may', 'be', 'summarized', 'as', 'follows:', '©', 'Training', 'physicians', 'in', 'the', 'treat-', 'ment', 'of', 'nicotine', 'deperidence', 'will', 'result', 'in', 'more', 'consistent', 'and', 'more', 'effective', 'patient', 'care.', '@', 'When', 'trained', 'physicians', 'are', 'rou-', 'tinely', 'prompted', 'tointervene', 'with', 'patients', 'who', 'smoke,', 'they', 'can', 'achieve', 'significant', 'reductions', 'in', 'smoking', 'prevalence.', '®', 'Patients', 'of', 'trained', 'physicians', 'who', 'received', 'routine', 'reminders', 'were', 'up', 'to', 'six', 'times', 'more', 'likely', 'to', 'stop', 'smoking', 'than', 'patients', 'of', 'control', 'physicians.', 'SUMMARY', 'OF', 'NCI', 'RECOMMENDATIONS', 'It', 'is', 'important', 'for', 'both', 'the', 'physician', 'and', 'the', 'patient', 'who', 'smokes', 'to', 'realize', 'that', 'smoking', 'cessation', 'is', 'not', 'a', 'single', 'event;', 'rather,', 'it', 'is', 'a', 'process', 'that', 'takes', 'place', 'over', 'time.', 'A', 'person', 'who', 'smokes', 'moves', 'through', 'stages', 'from', 'beirig', 'unin-', 'terested', 'in', 'stopping,', 'to', 'thinking', 'about', 'change,', 'to', 'making', 'a', 'concerted', 'effort', 'to', 'stop,', 'to', 'finally', 'maintaining', 'abstinence.“', 'Most', 'people', 'make', 'sev-', 'eral', 'attempts', 'before', 'succeeding', 'com-', 'pletely,', 'and', 'relapse', 'is', 'a', 'normal', 'part', 'of', 'the', 'smoking', 'cessation', 'process.', 'Since', 'stopping', 'smoking', 'is', 'a', 'process,', 'the', 'physician', 'and', 'office', 'staff', 'must', 'pro-', 'vide', 'a', 'repeated,', 'consistent', 'message', 'and', 'offer', 'appropriate', 'treatment', 'at', 'every', 'visit.', 'The', 'treatment', 'of', 'smokers', 'is', 'anal-', 'ogous', 'to', 'the', 'management', 'of', 'patients', 'with', 'mild', 'or', 'moderate', 'hypertension:', 'screening', 'is', 'an', 'integral', 'activity', 'for', 'the', 'office', 'staff', 'at', 'every', 'office', 'visit,', 'with', 'physician', 'treatment', 'and', 'follow-up', 'for', '.', 'patients', 'who', 'exhibit', 'the', 'risk', 'factor.', 'As', 'with', 'hypertension,', 'successful', 'in-', 'tervention', 'involves', 'the', 'office', 'staff', 'and', 'requires', 'effective', 'use', 'of', 'the', 'patient’s', 'medical', 'record.', 'In', 'tobacco', 'control,', 'ef-', 'fective', 'clinical', 'intervention', 'requires', 'rou-', 'tine', 'discussion', 'of', 'the', 'subject', 'by', 'as', 'many', 'health', 'professionals', 'as', 'possible.', 'Such', 'discussions', 'may', 'be', 'brief,', 'but', 'they', 'must', 'be', 'frequent', 'and', 'routine.', 'Health', 'professionals', 'should', 'be', 're-', 'minded', 'to', 'intervene', 'whenever', 'they', 'see', '@', 'patient', 'who', 'smokes.', 'The', 'NCI', 'recom-', 'mendations', 'include', 'a', 'reminder', 'system', 'Within', 'each', 'office', 'practice.', 'Medical', 'prac-', 'tices', 'differ,', 'so', 'office', 'procedures', 'will', 'vary,', 'but', 'the', 'goal', 'of', 'organizing', 'an', 'office', 'for', 'smoking', 'intervention', 'is', 'to', 'ensure', 'Clinical', 'Interventions', 'in', 'Tobacco', 'Contro!--Manley', 'et', 'al', ' ']