Undertreatment of Tobacco Use Relative to Other Chronic Conditions

Consider the following: A 53-year-old man visits his internist for an initial visit. He has hypertension and type 2 diabetes mellitus, and he smokes 10 cigarettes a day. When the patient leaves his doctor’s office, which of these conditions—hypertension, diabetes, or nicotine addiction—is most likely to have been treated?

Smoking remains the leading cause of death in the US.¹ Tobacco kills more than 400,000 Americans every year, about 20% of all deaths, making it the leading cause of preventable morbidity and mortality. The list of ailments associated with smoking is lengthy and continues to grow: acute myeloid leukemia, cataracts, and periodontal disease were identified in the 2004 Surgeon General’s report as being tobacco-related, joining the more prevalent cardiovascular, respiratory, cerebrovascular, and oncological diseases, which are the country’s leading causes of death.² Direct and indirect costs associated with smoking now total $200 billion a year.

One might expect, then, that treating tobacco use would be a leading priority for physicians. The reality is that this is not the case. Although most physicians routinely ask their patients about tobacco use, far fewer routinely offer treatment. The reasons for this are complex.

A newer model of tobacco dependence treatment considers smoking to be a chronic relapsing disease.³ Similar to patients with diabetes and hypertension, smokers may have periods of good control (ie, abstinence) and periods of poor control. According to this model, pharmacological and behavioral treatments should be offered as long as needed to promote and maintain abstinence.

We therefore decided to study whether physicians are, in fact, treating smoking like other chronic diseases.⁴ We chose to examine data from the 2005-2007 National Ambulatory Care Medical Survey (NAMCS) [PDF]. The NAMCS is an annual survey of visits to 3000 outpatient physician offices. It is conducted by the CDC National Center for Health Statistics and uses a complex, multistage design to ensure representative sampling of practices from across the country. About 20,000 visits are sampled each year and are weighted to provide national estimates. Of note, each case in the NAMCS represents a visit, not a patient, so one must be cautious in making inferences about overall care provided to individual patients.

The NAMCS records a variety of data, including basic demographics, ICD-9 codes associated with the visit, use of tobacco products, and medications and other interventions prescribed at the visit. We examined data for the years 2005 to 2007 and extracted visits for patients with any of the following conditions: tobacco use, hypertension, diabetes, hyperlipidemia, asthma, or depression. We recorded whether the patient received a medication for any of these conditions during the visit. We also recorded whether any behavioral treatment was ordered. The NAMCS allows us to do this by recording whether patients received health education or counseling, categorized as none, asthma education, tobacco use or exposure, diet or nutrition, exercise, weight reduction, growth or development, injury prevention, stress management, and other.

We counted patients with asthma who received asthma education as having received behavioral counseling. Smokers who received counseling on tobacco use or exposure were recorded as having been counseled. We recorded patients with hypertension, diabetes, or hyperlipidemia as having received behavioral counseling if any of the following were discussed: diet or nutrition, exercise, or weight reduction. Behavioral counseling was not defined for depression because none of the available responses were evidence-based therapies for depression.