摘要：Objectives. We compared the likelihood that a tobacco user would receive treatment with the likelihood that an adult with another common chronic condition would receive treatment for that condition at an office visit. Methods. We analyzed data from the 2005–2007 National Ambulatory Medical Care Survey to compare the proportion of US office visits at which tobacco users and individuals with hypertension, hyperlipidemia, diabetes, asthma, or depression received condition-specific treatment. We calculated the odds that a visit for a comparison condition would result in treatment relative to a visit for tobacco dependence. Results. From 2005 to 2007, 38 004 patient visits involved at least 1 study condition. Tobacco users received medication at fewer visits (4.4%) than individuals with hypertension (57.4%), diabetes (46.2%), hyperlipidemia (47.1%), asthma (42.6%), and depression (53.3%). In multivariate analyses, the odds for pharmacological treatment of these disorders relative to tobacco use were, for hypertension, 32.8; diabetes, 20.9; hyperlipidemia, 16.5; asthma, 22.1; and depression, 24.0 (all P s < .001). Patients with hypertension, diabetes, or hyperlipidemia were also more likely to receive behavioral counseling. Conclusions. Alternate models of engagement may be needed to enhance use of effective treatments for tobacco use. Tobacco use remains the leading preventable cause of death in the United States. 1,2 Practice guidelines have recommended that physicians address tobacco use with all smokers, and many effective treatments for tobacco dependence are available. 3 These treatments include behavioral counseling (individual, group, telephone) and medications (nicotine patch, gum, lozenge, nasal spray and inhaler, varenicline, bupropion). 3 However, US physicians provide these evidence-based treatments at low rates. In 2001–2003, they offered smoking cessation counseling to smokers at only approximately 20% of office visits and prescribed smoking cessation medication at fewer than 2%. 4 Tobacco screening and brief intervention have been identified as 1 of the most clinically and cost-effective preventive interventions. 5 Using a composite measure of clinically preventable burden and cost effectiveness, the National Commission on Prevention Priorities ranked tobacco screening and intervention at 10 (highest score), higher than screening for hypertension (8), cholesterol (7), obesity (5), depression (4), and diabetes (2). 5 Tobacco use, usually in the form of smoking, bears many similarities to other chronic conditions that contribute to increased cardiovascular risk, such as diabetes, hypertension, and hyperlipidemia. These conditions each show periods of good control and poor control. 6,7 For each condition, multiple effective treatments are available, including medication and behavioral therapy. 7 However, physicians appear to be more likely to treat other chronic conditions than to treat tobacco dependence. For example, the prevalence of treatment of hypertension increased from 60% to 70% between 1999–2002 and 2005–2008, and the prevalence of hypertension remained constant. 8 Similarly, the prevalence of individuals with elevated low-density lipoprotein cholesterol remained constant, and the prevalence of treatment from 1992–2002 to 2005–2008 increased from 28% to 48%. 9 No such increase in the prevalence of treatment of smoking has been documented. 4,10 Of note, smoking does differ in several important ways from these other conditions. For example, smokers can quit without using any cessation medication or counseling; unassisted behavioral change alone may mitigate, but generally does not cure, common chronic conditions such as hypertension, diabetes, or hyperlipidemia. In addition, smokers can purchase effective over-the-counter medications, such as nicotine patches or gum. Nonprescription medications are unavailable for the treatment of these other chronic conditions. In this study, we compared the rates at which a nationally representative sample of physicians treated tobacco use with the rates at which they treated 3 other major risk factors for cardiovascular and cerebrovascular disease (hypertension, hyperlipidemia, and diabetes), as well as 2 other chronic conditions, asthma and depression, that are exacerbated by smoking or more common in smokers. Our hypothesis was that tobacco use would be much less likely to be treated than the other chronic conditions.
