简单干预帮助病人戒烟

ranchgirl

简单干预帮助病人戒烟

大家好，我是疾病控制与预防(CDC)中心吸烟与健康办公室主任Tim McAfee博士。

非常高兴今天与你们一起走进Medscape CDC专家短评系列栏目。今天我将谈论如何对病人进行简单干预，以帮助他们戒烟。

作为一名大夫，我治疗过成千上万的吸烟者。从第一手经验我了解到，常规采取一些简短、简单的行动，医生可以帮助病人戒烟。好消息是大多数吸烟者说他们想戒烟，同时每年有一半以上的吸烟者试图戒烟。并且成功戒烟的吸烟者，寿命能够延长10年。作为一名医生，在帮助患者成功戒烟的过程中，你扮演着极其关键的角色。当你建议患者戒烟，哪怕是非常简单的劝告，都能够显著增加他/她戒烟的可能性。

吸烟者将医生的戒烟建议作为尝试戒烟的重要动力。尽管在今天大多数的医生都会问病人是否吸烟，但是很少有医生能够为患者戒烟提供切实的帮助。也许你会认为，“我根本没有时间同我的病人谈论关于戒烟的事情。”但是，你可以询问关于烟草的使用情况，建议病人停止使用，同时你可以推荐病人去咨询顾问，上课，或者致电戒烟热线，而这些只需要花不到1分钟的时间。

三个步骤(询问、建议和介绍)有时又称为“2A和R”简要烟草干预。此外，一些步骤可分配到你的健康护理团队的其他成员那里或社区转介资源，以进一步减少占用你的时间。

第一步：询问。在采集重要体征的同时，护士或医疗助理可以询问患者是否吸烟或使用其它形式的烟草，在图表中或电子健康记录中记录患者烟草的使用情况。现在美国的大多数做法都是这样的。

第二步：建议。你可以通过说一些类似这样的话简单地建议患者戒烟，“我看到你吸烟。为了你的健康，戒烟是一件你现在能够做到的非常重要的事情。你有考虑过戒烟吗？”当这一建议以一种非批判性的语气来表达时效果非常好。你可以使你的建议个性化，变得更加引人注意：例如，将建议与患者就诊的原因连在一起。

第三步：介绍。对于有兴趣试图戒烟的患者，你、护士或你们组的其它成员可以推荐患者拨打国家的戒烟热线或查阅其它社区咨询资源。戒烟热线是免费的电话戒烟服务，它能有效帮助吸烟者戒烟。每个州都有自己的戒烟热线，国家号码1-800-QUIT-NOW可以将来电者无缝转接到他们的州戒烟热线。关于你们州的戒烟热线或一般戒烟热线的更多信息，可到网址：www.naquitline.org进行了解。

越来越多的医院、保险公司和诊所提供烟草戒烟咨询资源。此外，你可以讨论使用非处方或处方戒烟药，如果使用适合的话，能够有助于缓解戒断症状。当然，如果在你建议病人去寻求其它资源帮助之前，花几分钟时间向病人提供一些简短的咨询，那就更好了，它将会有很大的不同。

对于那些对戒烟不感兴趣的患者，说一些类似这样简单的话，如“不论何时你准备戒烟，我在这里随时恭候”，为患者在将来准备戒烟时留着敞开的大门，同时让他们知道你是负责的。你也可以探查阻碍患者戒烟兴趣的障碍，探索怎样使他们感兴趣的方法。

除了在医疗保健成员中分配这些步骤，你也可以做一些适合你的诊疗系统的特殊的改变，以方便你解决烟草使用问题。例如，在电子健康记录中添加提示或者标记吸烟或使用其它形式烟草的患者来作为一种有用的提醒，以解决这个问题。使每个患者房间备有关于资源方面信息的小册子或传单，也将会使得转介过程变得更加容易。

一些提供者关心的问题是，烟草使用教育会使他们的病人心烦意乱。事实上，调查发现吸烟者希望他们的医生解决他们的吸烟问题，如果对他们进行烟草教育，他们对提供者的护理会更加满意，只要是怀着同情心做这件事情。许多提供者同样也关心关于戒烟治疗不能报销的问题。一个好消息是许多保险公司已经开始报销戒烟治疗，包括药物、咨询和医生时间，尽管这仍将是具有挑战性的。

提及这个话题时，一些提供者显得很不自在，因为他们不知道如何去做。在2013年早期，CDC计划进行第二轮“前吸烟者提示”运动，这是一个全国性的烟草教育媒体运动，2012年时首次举行。这项运动的特征是具备强有说服力的前吸烟者的证明书，他们都患有严重的吸烟相关的疾病，现今仍活着。这项运动让你与病人更容易进入吸烟话题。例如，你可以通过询问吸烟病人是否看到了这个广告打开谈话，如果病人看了这个广告，你可以问他们对这个广告有何感想。如果你的病人没有看这则广告，你可以鼓励他们访问该项运动的主页，在那里可以浏览到这则广告。你也可以在你的接待室和检查室张贴该广告的海报。

总而言之，作为一个提供者，帮助你的病人戒烟，你在其中起着重要的作用。哪怕是简短的建议都会大不相同。你不必亲自做这一切，你可以推荐到团队的其它成员那里和使用州和社区的转介资源，来支持你的努力，减少对你的时间的占用。你所给出的直接的和间接的建议以及所提供的支持，都会给病人额外的动力，支持他们为了健康必须戒烟。

关于与病人所谈论的更多的烟草信息，请访问本页中的链接网址。提供者也可通过参与更广泛的社区工作帮助他们的病人戒烟，以减少烟草使用和二手烟暴露，包括支持你所在社区的全面的烟草控制工作。

ranchgirl

Hello, I am Dr. Tim McAfee, Director of the Office on Smoking and Health at the Centers for Disease Control and Prevention (CDC).

I am happy to be with you today as part of the CDC Expert Commentary Series on Medscape. Today I will be talking about how to conduct a brief intervention to help patients quit smoking.

As a physician, I have treated thousands of smokers. I know from first-hand experience that by routinely taking a few brief, simple actions, doctors can help patients to quit smoking.

The good news is that most smokers say they want to quit, and more than one half try to quit each year. And smokers who succeed at quitting gain as much as 10 years of their life expectancy back.

As a doctor, you can play a critical role in helping your patients to successfully quit smoking. When you advise a patient, even briefly, to quit smoking, you significantly increase his or her chances of quitting.

Smokers cite physician advice to quit as an important motivator for trying to stop smoking. Although most physicians today ask patients whether they smoke, fewer doctors provide patients with practical help in quitting.

You may be thinking, "I just don't have time to talk to my patients about quitting." However, you can ask about tobacco use, advise the patient to quit, and refer the patient to a counselor, class, or telephone quitline in less than 1 minute.

These 3 steps -- ask, advise, and refer -- are sometimes called the "2A and R" brief tobacco intervention. In addition, some steps can be handed off to other members of your healthcare team or to community referral resources, further reducing the demand on your time.

Step 1: Ask. While collecting vital signs, a nurse or medical assistant can ask the patient whether he or she smokes or uses other forms of tobacco, and document the patient's tobacco use status in the chart or electronic health record. Most practices in the United States now do this.

Step 2: Advise. You can briefly advise the patient to quit by saying something like, "I see that you smoke. Quitting smoking is one of the most important things you can do for your health right now. Have you thought about quitting?" This advice works best when delivered in a nonjudgmental tone.

You can make the advice more compelling by personalizing it: for example, by linking it to the reason for the patient's visit.

Step 3: Refer. For patients who are interested in trying to quit, you, a nurse, or other members of your team can refer patients to your state's quitline or other community counseling resources. Quitlines are free telephone cessation services that have been found to be effective in helping smokers quit. Every state has its own quitline, and the national number 1-800-QUIT-NOW seamlessly routes callers to their state quitline. For more information on your state quitline or on quitlines in general, see www.naquitline.org.

More and more hospitals, insurers, and clinics are providing tobacco cessation counseling resources. In addition, you can discuss the use of over-the-counter or prescription smoking cessation medications, if appropriate, to help relieve withdrawal symptoms.

Of course, if you take just a few minutes to offer the patient some brief counseling before referring them to another resource, this is even better and can make a big difference.

For patients who are not interested in quitting, saying something as simple as, "I'm here to help you whenever you are ready to quit" can leave the door open for them to raise this issue in the future while letting them know that you care. You can also probe for the barriers that are preventing patients from being interested in quitting and explore what it would take to make them more interested.

In addition to dividing these steps up among members of the healthcare team, you can make specific changes to your clinic system to make addressing tobacco use easier for you. For example, adding a prompt in the electronic health record or flagging patients who smoke or use other forms of tobacco serves as a helpful reminder to address the issue. Keeping brochures or flyers in each patient room with information about resources can also make the referral process easier.

Some providers are concerned that bringing up tobacco use could upset their patients. In fact, surveys have found that smokers expect their doctor to address their smoking and are more satisfied with their care if this happens, as long as it is done empathetically.

Many providers are also concerned about lack of reimbursement for cessation treatment. The good news is that many more insurers are starting to reimburse for cessation treatment, including medications, counseling, and physician time, although this can still be challenging.

Some providers are uncomfortable raising this topic and don't know how to do so. In early 2013, the CDC is planning to conduct a second round of " Tips From Former Smokers," the national tobacco education media campaign that we first conducted in 2012. This campaign features powerful testimonials from former smokers who are living with serious smoking-related diseases.

The campaign could make it easier to bring up the topic of smoking with your patients. For example, you could open the conversation by asking patients who smoke if they have seen the ads. If patients have seen the ads, you could ask them what they thought about the ads.

If your patients haven't seen the ads, you could encourage them to visit the campaign Website, where the ads are available for viewing. You could also display posters of the ads in your reception area and in examination rooms.

In conclusion, as a provider, you can play a critical role in helping your patients quit smoking. Even brief advice can make a big difference. You don't have to do it all; you can turn to other members of your team and use referral resources that already exist in your state and community to support your efforts and reduce the demand on your time. Your advice and the support you provide, directly and through referrals, can give patients the extra motivation and support they need to quit for good.

For more information on talking to patients about tobacco, please visit the links provided on this page. Providers can also help their patients quit by getting involved in broader community efforts to reduce tobacco use and secondhand smoke exposure, including supporting comprehensive tobacco control efforts in your community.