标题：Tobacco Use Screening and Treatment by Outpatient Psychiatrists Before and After Release of the American Psychiatric Association Treatment Guidelines for Nicotine Dependence
摘要：Objectives. We examined tobacco use screening and treatment by US psychiatrists before and after release of the 1996 American Psychiatric Association (APA) nicotine dependence treatment guidelines. Methods. We used data from the National Ambulatory Medical Care Survey to identify rates of tobacco screening and treatment by psychiatrists before the release of the guidelines (1993–1996) and during 2 postguidelines periods: 2001–2005 and 2006–2010. Multiple logistic regression was used to compare preguidelines and postguidelines rates. Results. Psychiatrists screened for tobacco use during 77% of visits from 1993 to 1996, 69% of visits from 2001 to 2005 (odds ratio [OR] = 0.69; 95% confidence interval [CI] = 0.64, 0.75), and 60% of visits from 2006 to 2010 (OR = 0.46; 95% CI = 0.43, 0.50). Psychiatrists provided cessation counseling to 12% of smokers from 1993 to 1996, 11% from 2001 to 2005 (OR = 0.97; 95% CI = 0.74, 1.26), and 23% from 2006 to 2010 (OR = 2.23; 95% CI = 1.74, 2.86). Psychiatrists prescribed nicotine replacement therapy to fewer than 1% of smokers during all 3 time periods. Conclusions. Psychiatrists are screening for tobacco use at declining rates, and the proportion of smokers provided with treatment remains low. Smoking is responsible for 435 000 deaths per year, representing the largest single cause of preventable mortality in the United States. 1 Individuals diagnosed with a mental health disorder have particularly high rates of tobacco use and consume more than 40% of cigarettes sold in the United States each year. 2 There are several smoking cessation treatments available that are effective among smokers with a mental illness, including behavioral counseling, nicotine replacement therapy (NRT), and medications such as bupropion and varenicline. 3 Despite the availability of effective treatment, smokers diagnosed with a mental health disorder face many barriers to quitting, including high levels of nicotine dependence and stronger withdrawal symptoms than the general population, 4 comorbid substance abuse or dependence, difficulties coping with mental health symptoms during a quit attempt, lack of support for quitting, and lack of regular access to preventive medical services. 5 Furthermore, mental health providers often view tobacco cessation as a low priority for their patients, and historically psychiatric treatment settings have promoted the use of tobacco as a form of self-medication or behavioral control for patients with mental health disorders. 6 In 1996, the American Psychiatric Association (APA) published clinical practice guidelines for the treatment of nicotine dependence. 7 The guidelines recommended that all patients with a psychiatric diagnosis be screened for tobacco use and that those interested in quitting be provided with treatment. Prior to the release of the guidelines, the rate at which patients with a psychiatric diagnosis were screened for tobacco use in US outpatient settings was relatively high (76%), but rates of providing counseling and medications to smokers with a psychiatric diagnosis were low (23% and 2%, respectively), and psychiatrists screened and treated their patients for tobacco use at lower rates than other types of physicians. 8,9 It is currently unknown whether there have been any improvements since the release of the APA guidelines in the rates at which psychiatrists screen their patients for tobacco use and provide smokers with evidence-based cessation therapies. We used data from the National Ambulatory Medical Care Survey (NAMCS) to identify national rates of tobacco screening and treatment (provision of counseling, NRT, or both) by psychiatrists during outpatient visits before and after the introduction of the APA guidelines. We also examined associations of key patient and visit factors with tobacco screening and treatment.
