Douglas Arenberg, MD
Tobacco cessation is imperative for patients’ health, especially in the context of lung cancer screening programs. According to Douglas Arenberg, MD, the importance of this matter often falls under oncologists’ radars.
“Oncologists should know that it’s never too late to stop smoking,” says Arenberg, an associate professor in the Department of Internal Medicine at the University of Michigan.
At the University of Michigan, Arenberg and colleagues initiated a formal lung cancer screening study in 2013. The researchers audited selected clinic visits at random to assess adherence to published tobacco cessation guidelines. Those findings then prompted them to initiate a systematic, multi-step program to improve upon tobacco practices, from assessing tobacco use to prescribing pharmacotherapy, and referral to tobacco cessation counselors.
In an interview with OncLive
during the IASLC 17th World Conference on Lung Cancer, held in Vienna, Austria, Arenberg, discusses the preliminary findings of this study, and the critical importance of maintaining quality tobacco cessation practices in healthcare clinics.
OncLive: Please provide an overview of the study you presented here at the meeting.
: This is more of a quality-improvement initiative than it is a research study, which is a bit of a departure from my day-to-day work. It started kind of innocently a few years ago, when I had a research resident that wanted to do a research project. We sat and talked about what she was interested in, and we came up with an idea where she was going to look at what our university health system providers did in terms of the basics of tobacco cessation. We defined what we thought the basics were, which we defined based on something put together by the US Preventive Services Task Force.
They recommend the 5 A’s, which stand for the following: ask every patient about tobacco smoking; advise every smoker to quit; assess the willingness to quit; offer assistance to quit either in terms of motivational interviewing or pharmacotherapy; and then arrange a follow-up. Within the limits of our ability to tell how well we were doing those 5 things in a retrospective review of patient charts, we combined that with a survey of physicians at the University of Michigan. I wouldn’t say it was a well-designed or thorough survey, but it was as good as we could do at the time, simply asking people how well they thought they did, and then comparing that with what we found from reviewing the charts. Not surprisingly, what we found was that we, as physicians, think we do a better job than we actually do.
It was on that background that I came into contact with some people from the Michigan Department of Health, and they asked us to set up a system-wide change in terms of how we approach tobacco cessation. The University of Michigan Health System is distributed over a state that’s 3 times the size of Austria, and we have 150 outpatient centers, 40 clinics, 3 hospitals, and nearly 2 million outpatient visits per year.
It’s a daunting task to try and change all of that in 1 fell swoop. How do you eat an elephant? You take one bite at a time. This quality-improvement project is basically our first or second bite of the elephant, which is to simply start by planting these ideas in the minds of various key leaders in each of these clinical centers that are affiliated with the university.
We provided them with some training, and we took 1 individual from each clinic. As an enticement, we provided them with training through the University of Massachusetts Tobacco Treatment Specialist Training Program that we put on in Ann Arbor. We sent them back to the clinics and said, “Take this expertise, and use it any way you want, but here are the things that were important to us.” We then got monthly reports back on how they did regarding the 5 A’s: ask, advise, assess, assist, arrange.
One of the easiest ways to change behavior is to measure it. Over the last year, we’ve shown people their performance and the performance of other clinics. If they wanted to make changes, we came to their clinics and gave 5 or 10 minute talks at their staff meetings, but the most important thing we did was simply tell them that this was something we felt was important.
Everyone recognizes the importance of tobacco cessation, but trying to squeeze that into the context of primary care, where doctors are trying to take care of patients with diabetes, high blood pressure, heart disease, high cholesterol, etc. We were trying to put this into a context that was both easy and convenient for them to carry out—kind of the bare-minimum basics. We felt that was one of the biggest challenges, just to get this on people’s radars.
What are the major takeaways from your study?
The initial results of our study have shown that there was, in the first month, a dramatic increase in some of the more relevant measures. All of our measures about tobacco cessation are made remotely by using a reporting system through our electronic health records. We are really using surrogate measures of the actual outcomes, and that’s, from a research perspective, probably one of the biggest weaknesses here.
We’re not really measuring tobacco cessation at the individual level, and we’re not even really measuring individual provider behavior. We’re looking at population-based data.
However, within the context of a very low-budget process, we have made some progress in terms of raising the importance of tobacco cessation on the radar of our providers, and making it easier for them by having expertise available in the clinic—somebody they can grab and say, “Hey, what do you think about this patient or this medication?” A few minutes of motivational interviewing for a patient on site is at least as effective as a one-time phone call from a centralized system, which we previously used for providing tobacco cessation advice.
Prior to this project, our tobacco treatment specialists were all located in a very centralized location, in one obscure, hard-to-find building in Ann Arbor, Michigan. When you’re trying to provide service to a statewide distribution of patients and providers, we thought that was a recipe for failure, so what we’re really trying to do is de-centralize the expertise and put best practices on everybody’s radars.
With that, we have made some progress, though we still have a long way to go. We have learned that there is still a lot more of the elephant there to take bites of, but there are more strategic ways to increase this important aspect of provider primary care.
What are the next steps?
We have tried to establish a monthly rotation of appearing in these clinics with our reports. Each of these clinics operates differently. We have learned a few things from some of the more successful clinics in terms of what they did that worked, and we take that practice and bring it to other clinics and say, “You may want to try this really simple solution.”
We’re not there to judge their performance. There are so many masters, if you will, in this quality improvement environment that we work in. People are measuring things, and you’re constantly being assessed by payers, supervisors, patients, and what we really want people to know is that we’re not there as part of that judgmental process. We’re there to make their jobs easier.
We’ve learned about some really simple interventions. In one clinic, for example, every patient who was a smoker was handed a real simple piece of paper asking, of course, about their smoking history, but specific questions asked, “Are you ready to quit?” and “Do you want to meet with a tobacco cessation specialist?”
And just that simple piece of paper, the second the physician walks in the room, they know that patient is anxious to quit, and that creates an opportunity in that 5- or 10-minute clinic visit for an intervention that can be pretty effective. This is just simple advice from a physician, which we often forget to do in the context of a busy primary care clinic. Simple advice from a physician goes a long way towards motivating quit attempts. Of course, we want to back that up with follow-up phone calls, and/or with providers’ prescriptions of pharmacotherapy.
We’re trying to take all these best practices and assemble it into a Frankenstein, if you will, of effective, low-cost practices. I look at this as an opportunity to create long-term relationships. Think of a wheel with its spokes. At the center of the wheel is the tobacco treatment specialist program in Ann Arbor, which is full of some very highly qualified, highly motivated individuals. The spokes are these various clinics distributed throughout Michigan. That simple relationship will pay dividends in the long run. The hard part is measuring success, and we have to believe we’re going to be successful, because we’re only measuring surrogates right now.
What would you like the community oncologist to ultimately take away from these findings?
Oncologists should know—and this is part of the mission of the IASLC Tobacco Control and Smoking Cessation Committee, to make this widely known—that it’s never too late to stop smoking. There isn’t a patient out there, either with or without cancer, who can’t benefit in some way from tobacco cessation. Even patients who are undergoing the palliative care phase of their cancer journey can benefit from tobacco cessation.
These are people who are on oxygen and they’re at danger if they’re smoking, but even quality of life can be improved in the short-term with tobacco cessation. However, it has to be done right; it has to be done with compassion, not judgment. Despite all of the wonderful things that my colleagues in oncology do, they lose sight of the fact that it’s never too late to stop smoking, and engaging their patients with tobacco cessation experts is in both theirs and their patients’ best interests.
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