Advancing preventive care with clinical tobacco intervention.

Family practice is a unique venue for tobacco intervention because of primary care’s access to the smoking population, its capacity for long-term follow-up, and its being widely regarded by smokers as an appropriate place to get help with smoking cessation. Clinical tobacco intervention, with its multiple components, is a highly effective measure that merits widespread delivery. Clinical tobacco intervention is more descriptive than smoking cessation: only a minority of smokers are ready to stop at a given time but a larger proportion will try proven behavioural or chemotherapeutic approaches to stop or reduce tobacco use. Physicians, primary care funders, and health care policy makers can deploy front-office staff, among other measures, to adapt clinical tobacco intervention to the practice setting. A recent study reported in Canadian Family Physician found that front-office personnel (termed health coordinators) substantially increased the following evidencebased components of clinical tobacco intervention: smoking status chart reminders, advice to quit, selfmanagement plans (including use of medication), target quit dates, referrals, and follow-up appointments.1 The project’s health coordinators comprised existing front-line staff, 1 per practice, who spent 1 day per week enhancing systematic clinical tobacco intervention. Only one other published study used front-office staff to help smokers.2 That study also measured smoking cessation, which rose in the intervention group from 3% at baseline to 11% at follow-up, but which did not change in the control group (4% at baseline and 4% at follow-up). Increases in delivery of clinical tobacco intervention components were very similar in both studies. Most primary care is driven by patients’ symptoms, which cue diagnosis and treatment. But preventive care is designed to avert the condition and its symptoms; thus, the customary driver of care is absent. A systematic, proactive approach is required. Such an approach includes identifying patients’ risks, recognizing their readiness (or hesitancy) to address risk, assessing relevant patient characteristics, supporting patients’ efforts, and following up over the long term. Family physicians, apart from the few who are in community primary care settings, seldom have the resources to do this. Those resources include time, staff, space, funding, information systems, training, and ongoing expert consultation.