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Is It Not Time to Make Smoking a Vital Sign?

      More than 30 years ago, Dr. Luther L. Terry, as surgeon general, concluded that smoking was a risk to health,
      • US Department of Health, Education, and Welfare
      and investigators have since substantiated that advice and assistance to quit smoking increase cessation rates.
      • Kottke TE
      • Battista RN
      • DeFriese GH
      • Brekke ML
      Attributes of successful smoking cessation interventions in medical practice: a meta-analysis of 39 controlled trials.
      Although few physicians now smoke, they continue to fail to advise their patients to stop smoking.
      • Pierce JP
      • Evans N
      • Farkas AJ
      • Cavin SW
      • Berry C
      • Kramer M
      • et al.
      • Pierce JP
      • Gilpin E
      Trends in physicians' smoking behavior and patterns of advice to quit.
      In 1991, Fiore
      • Fiore MC
      The new vital sign: assessing and documenting smoking status.
      proposed making smoking a “vital sign” as a way to remind clinicians to address smoking, and in this issue of the Mayo Clinic Proceedings (pages 209 to 213), he and his coworkers provide an evaluation of this innovation. By defining smoking as a vital sign, they increased by more than 20 percentage points the inquiries about smoking, advice to quit, and advice about how to quit.
      Fiore and associates are not the first to demonstrate that physicians will respond to a reminder to ask about smoking. In 1987, Cohen and associates
      • Cohen SJ
      • Christen AG
      • Katz BP
      • Drook CA
      • Davis BJ
      • Smith DM
      • et al.
      Counseling medical and dental patients about cigarette smoking: the impact of nicotine gum and chart reminders.
      reported that reminders increased the rates at which both physicians and dentists asked their patients about smoking and advised them to quit. In 1992, we
      • Kottke TE
      • Solberg LI
      • Brekke ML
      • Conn SA
      • Maxwell P
      • Brckke MJ
      A controlled trial to integrate smoking cessation advice into primary care practice: Doctors Helping Smokers, Round III.
      reported that a comprehensive office system to address the problem of smoking significantly increased the rates at which advice was given. Fiore,
      • Fiore MC
      The new vital sign: assessing and documenting smoking status.
      however, was the first to introduce the reminder in a context that is already highly familiar and meaningful in the medical setting. By using the term “vital sign,” he intended both to remind clinicians of the effect that smoking has on their patients and to remind them to ask about smoking.
      Of interest, even with this intervention available, almost 20% of patients were not asked about their smoking status and 30% of smokers were not advised to quit. We noted this same ceiling in our trial.
      • Kottke TE
      • Solberg LI
      • Brekke ML
      • Conn SA
      • Maxwell P
      • Brckke MJ
      A controlled trial to integrate smoking cessation advice into primary care practice: Doctors Helping Smokers, Round III.
      We were also unable to interest about half the physicians and their groups in accepting help to address smoking systematically.
      • Kottke TE
      • Solberg LI
      • Conn S
      • Maxwell P
      • Thomasberg M
      • Brekke ML
      • et al.
      A comparison of two methods to recruit physicians lo deliver smoking cessation interventions.
      If cigarette companies can attract teens and preteens by the thousands with their prornotions.
      • Pierce JP
      • Evans N
      • Farkas AJ
      • Cavin SW
      • Berry C
      • Kramer M
      • et al.
      • Pierce JP
      • Lee L
      • Gilpin EA
      Smoking initiation by adolescent girls, 1944 through 1988: an association with targeted advertising.
      why is it so difficult to convince physicians to advise patients to quit smoking? Unfortunately, the fact that an idea is “good” has minimal influence on whether or not it will be adopted by the intended audience.
      Criteria for Successful lnnovations.—In his classic analysis of why some innovations are adopted and others languish, Rogers
      • Rogers EM
      concluded that successful innovations share the following five properties: (1) relative advantage- the innovation is perceived as being better than the idea it supersedes; (2) compatibility-the innovation is perceived as consistent with the existing values, past experiences, and needs of potential adopters; (3) complexity-the innovation is perceived as relatively easy to understand and use; (4) “trialability” innovation lends itself to experimentation on a limited basis; and (5) observability-the results of the innovation are observable to others.
      Smoking as a vital sign meets three of these five criteria. It is compatible with current practice; clinicians understand the concept of a vital sign, and some combination of blood pressure, pulse rate, height, weight, and temperature are already assessed as vital signs at most ambulatory visits. The intervention meets the complexity criteria; the inquirer can easily circle a response stamped in the medical record that corresponds to the patient's reply to the question, “Do you smoke?” Making smoking a vital sign can be tried on a limited basis, perhaps for a period of 4 months as was done by Fiore and colleagues, so that the effect on the practice can be evaluated before the innovation is permanently adopted as a standard of care.
      For most clinicians, however, no relative advantage is associated with making smoking a vital sign because neither fellow physicians nor the purchasers of health care consider advice to quit smoking a criterion of high-quality professional performance. Moreover, when physicians are rated by their employers primarily on the basis of patient satisfaction, they learn to avoid the issues that can potentially antagonize patients. Smoking is certainly one of these issues.
      The other barrier to the adoption of smoking status as a vital sign is that the positive effects of advice on smoking cessation are not naturally observable. Unless a program is specifically designed to provide clinicians with positive feedback for asking about smoking, the naturally occurring negative feedback will tend to extinguish the behavior. Few smokers thank their clinicians for asking them about smoking, and failed attempts to quit smoking outnumber the successes by at least 5 to 1. Unfortunately, this ratio etches a personal sense of impotence in the minds of clinicians, and they eventually discontinue the activity.
      Two events must occur if smoking is to attain the status of blood pressure and temperature as a vital sign. To confer relative advantage on smoking as a vital sign, persons who purchase health-care contracts must make smoking a contractual issue. They must demand that smoking be addressed by clinicians who care for their clients, and they must reward clinicians when they do address the issue of smoking. In Minnesota, this sequence of events has happened with the Business Health Care Action Group and the Institute for Clinical Systems Integration. As part of a guidelines development process, a working group was assembled to determine how smoking should be addressed in the ambulatorycare setting and to recommend how adequate performance should be defined and evaluated. When an evaluation component was included in the guidelines, the effect of making smoking a vital sign became observable.
      Historical Lessons.—Physicians' reactions (or lack thereof) to the reports on smoking from the surgeon general remind us of the reactions of 19th century obstetricians and surgeons to the observations made by Semmelweis and Lister. In their fascinating book, The Rise of Surgery, Wangensteen and Wangensteen
      • Wangensteen OH
      • Wangensteen SD
      noted that, until the end of the 19th century, almost all obstetricians and surgeons tried to enhance surgical outcomes by improving their technical skills while they stropped their lancets on their boot heels
      • Wangensteen OH
      • Wangensteen SD
      and held their ligatures in their mouths.
      • Wangensteen OH
      • Wangensteen SD
      For most surgeons, operative mortality from wound infection ranged from 30 to 60%.
      • Wangensteen OH
      • Wangensteen SD
      Mortality from puerperal sepsis was typically all and 10% and could be as high as 90 to 100% during epidemics.
      • Wangensteen OH
      • Wangensteen SD
      The innovations of aseptic obstetric delivery advocated by Semmelweis and surgical antisepsis advocated by Lister were ignored by most obstetricians and surgeons. They were vigorously resisted by all but a few of the rest. In 1847, Semmelweis demonstrated that hand washing prevented puerperal sepsis, but not until 20 years later (and after his death) did his observations become accepted as standard practice by leading Austrian and German professors of obstetrics.
      • Wangensteen OH
      • Wangensteen SD
      Lister published his account of antiseptic treatment of compound fractures in 1867, but only during the next 25 years did surgeons begin to appreciate the importance of an aseptic wound.
      • Wangensteen OH
      • Wangensteen SD
      Even so, Halsted first ordered rubber gloves at Johns Hopkins in 1889—not to prevent wound infection but because his scrub nurse was allergic to corrosive sublimate hand rinse.
      • Wangensteen OH
      • Wangensteen SD
      Not until 1920 were rubber gloves accepted by most of the first-rank surgeons around the world, and the wearing of surgical masks was not accepted by many European and British surgeons until almost the beginning of World War II.
      • Wangensteen OH
      • Wangensteen SD
      Wangensteen and Wangensteen blamed the slow progress in surgery over the centuries on two problems. The first deterrent was that surgeons were reluctant to subject suggested innovations to trial, preferring instead to evaluate them with debate and argument.
      • Wangensteen OH
      • Wangensteen SD
      The second barrier was that until the final 2 decades of the 19th century, surgeons shunned accountability for operative mortality.
      • Wangensteen OH
      • Wangensteen SD
      Conclusion.—Currently, more than 30 years since Dr. Terry concluded that smoking kills, the risk is projected to be twice as great as originally estimated: half of all smokers will die of their habit.
      • Doll R
      • Peto R
      • Wheatley K
      • Gray R
      • Sutherland I
      Mortality in relation to smoking: 40 years' observations on male British doctors.
      In this issue of the Proceedings, we are shown once again that a reminder system for ambulatorycare clinicians increases the rates at which they address smoking. We have the trial data that simple interventions such as these affect the rate of smoking cessation. Is it not yet time for ambulatory-care clinicians to accept accountability for their outcomes just as surgeons did for theirs a century ago? Is it not yet time to treat smoking as the vital sign that it certainly is?

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