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Treatment is more likely to be offered and used if integrated into healthcare systems that have procedures in place to identify smokers or tobacco users.



As noted in the 2014 Surgeon General’s Report and set forth by the 2007 IOM report (Bonnie et al. 2007), treatment strategies and policies need to be coordinated across all levels of health care and public health systems in order to dramatically increase the number of smokers who quit each year. However, to date, few countries have implemented smoking cessation and treatment programs for smokers as part of their health care systems.

There is some evidence that institutional changes such as training, pharmaceutical availability, and stickers to identify smokers increased the amount of time physicians spent intervening with smokers and increased the likelihood of successful cessation (US Department of Health and Human Services, 2000). Fiore (1991) proposed making assessment of tobacco use a "new vital sign" and showed that this increased the proportion of patients reporting being asked and counseled about smoking cessation (e.g. Fiore et al., 1995). While the use of such a vital signs stamp on patient charts has been shown to increase identification of smokers (Piper et al., 2003), it may not be sufficient in itself to increase the frequency of physician intervention with their patients who smoke. This suggests the vital sign stamp must be coupled with other strategies as part of any systematic approach to addressing smoking (Papadakis et al., 2010).  More recent developments include the success of automated (electronic) clinical reminder systems such as the Tobacco Use Cessation (TUC) Automated Clinical Practice Guideline (ACPG), a variation of the US Department of Health and Human Services Clinical Practice Guideline on Treating Tobacco Use and Dependence (e.g. Szpunar et al., 2006). As recommended in the USPHS Clinical Practice Guideline: “All clinicians and clinicians-in-training should be trained in effective strategies to assist tobacco users willing to make a quit attempt and to motivate those unwilling to quit. Training appears to be more effective when coupled with systems changes.” (Fiore et al., 2008).

In England, following the publication of a government policy paper in 1998, smoking cessation services were made available to all smokers motivated to make a quit attempt on the National Health Service in 2000/2001. Between April 2006 and March 2007, nearly 600,000 people set a quit date through these services. At the four-week follow up, just over half (53%) of these reported successfully stopping smoking (ONS 2007).

In developing nations, integration of tobacco cessation services into existing programs such as those for tuberculosis, HIV/AIDS, maternity care, etc. seems more likely to reach persons who smoke than specialist clinics devoted to smoking cessation (Jha et al., 2000).



Bonnie RJ, Stratton KR, Wallace RB, editors. In: End­ing the Tobacco Problem: A Blueprint for the Nation. Washington: National Academies Press, 2007.

Fiore MC. The new vital sign: assessing and documenting smoking status. JAMA. 1991; 266: 3183-3184.

Fiore MC, Jorenby DE, Schensky AE, et al. Smoking status as the new vital sign: effect on assessment and intervention in patients who smoke. Mayo Clinic Proc. 1995; 70: 209-213.

Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

Jha P, Paccaud F, Nguyen S. Strategic priorities in tobacco control for governments and international agencies. In: Jha P, Chaloupka F, eds. Tobacco control in developing countries. New York: Oxford University Press, 2000: 449-464.

Office for National Statistics Information for health. Statistics on Smoking: 2007.

Papadakis S, McDonald P, Mullen KA, Reid R, Skulsky K, Pipe A. Strategies to increase the delivery of smoking cessation treatments in primary care settings: A systematic review and meta-analysis.  Prev Med. 2010; 51: 199-213. 

Piper ME, Fiore MC, Smith SS et al
. Use of the vital sign stamp as a systematic screening tool to promote smoking cessation. Mayo Clin Proc. 2003; 78(6): 716-722.

U.S. Department of Health and Human Services. The Health Consequences of Smoking — 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

Szpunar SM, Williams PD, Dagroso D, et al
. Effects of the tobacco use cessation automated clinical practice guideline. Am J Manag Care. 2006; 12(11): 665-673.

US Department of Health and Human Services. Treating tobacco use and dependence. A report of the Surgeon General. Rockville, MD: Agency for Healthcare Research Quality. 2000.

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