In This Issue of Archives of Internal Medicine FREE

Providing smoking cessation advice, counseling, or medication is a quality-of-care measure on which US hospitals are judged. To assess the effectiveness of smoking cessation interventions initiated during a hospital stay, Rigotti et al conducted a meta-analysis of 33 trials. They found that smoking counseling that began in the hospital increased the odds of smoking cessation by 65% (pooled odds ratio, 1.65; 95% confidence interval, 1.44-1.90) at 6 to 12 months after discharge, but only if supportive counseling contact continued for more than 1 month after discharge. Adding nicotine replacement therapy produced a trend toward better efficacy than counseling alone (odds ratio, 1.47; 95% confidence interval, 0.92-2.35).

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This study uses US tuberculosis (TB) surveillance data to describe demographic, risk factor, and treatment outcome information for persons with isoniazid-monoresistant TB compared with persons with TB susceptible to all first-line anti-TB drugs. The number of isoniazid-monoresistant TB cases increased from 303 (4.1%) in 1993 to 351 (4.3%) in 2005. In our multivariate analysis of all TB cases reported from 1993 to 2003, patients with isoniazid-monoresistant TB were significantly more likely to be US-born Asian (adjusted odds ratio [aOR], 1.9; confidence interval [CI], 1.4-2.6), US-born Hispanic (aOR, 1.3; 95% CI, 1.1-1.5), foreign-born Asian (aOR, 1.8; 95% CI, 1.4-2.1), or foreign-born black (aOR, 1.4; 95% CI, 1.1-1.7). Isoniazid monoresistance was also associated with history of TB (aOR, 1.5; 95% CI, 1.3-1.7), failure to complete therapy within 1 year (aOR, 1.7; 95% CI, 1.5-1.8), and correctional facility residence (aOR, 1.5; 95% CI, 1.2-1.7).

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Tobacco quitlines offer clinicians a means to connect their patients to evidence-based cessation treatments. This randomized study examined the effect of a pay-for-performance program on clinician referral to a state tobacco quitline. Usual care clinics (n = 25) received fax referral materials. Pay-for-performance clinics (n = 24) were offered $5000 for making 50 quitline referrals and also received monthly updates on their referral numbers. Intervention clinics referred 11.4% of smokers (n = 1483) seen during the intervention period compared with 4.2% of smokers (n = 441) in usual care clinics (P < .001). Rates of referral were similar in intervention vs usual care clinics with a history of being very engaged with quality improvement but were higher in clinics with a history of less engagement. Of all referrals, 27% resulted in quitline enrollment, corresponding to a marginal cost per additional enrollee of $300. A pay-for-performance program increases referral to quitline services, particularly among clinics with a history of less engagement with quality improvement activities.

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In the face of increasing bacterial resistance, a more judicious use of antibiotics in primary care is paramount. Briel et al assessed the biomarker procalcitonin in a randomized noninferiority trial to guide antibiotic use for acute respiratory tract infections in primary care. Fifty-three primary care physicians recruited 458 patients in Switzerland, each patient with an acute respiratory tract infection and in need of antibiotics. They found that procalcitonin-guided therapy was not inferior to standard therapy with respect to the number of days during which a patient's activities were restricted by a respiratory tract infection. The overall antibiotic prescription rate, however, was 72% lower for procalcitonin-guided therapy. There was no apparent difference in the proportion of patients reporting any symptoms of ongoing or relapsing infection at 28 days in the 2 groups.

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Strandberg et al used the longitudinal data of the Helsinki Businessmen Study, a socioeconomically similar cohort of 1674 initially healthy men, and a validated questionnaire to investigate the associations between midlife smoking and health-related quality of life in old age, 26 years later. Although many had died and more than 2 of 3 subjects had stopped smoking during the follow-up period, midlife smokers attained lower scores in all health-related quality-of-life scales compared with never smokers. An especially large negative effect was seen in heavy smokers (>20 cigarettes daily), who lost approximately 10 years of their life expectancy. Those who survived experienced a significant decline in their quality of life; the impairment of the physical functioning score of smokers was equal to a 10-year age difference in the general population. These results add a new dimension to the negative effects of smoking and should, at the individual level, encourage smokers to quit.

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