We read with interest the article by Scognamiglio et al[1
] “Impact of hepatitis C virus infection on lifestyle”, World J Gastroenterol
2007; 13(19): 2722-2726, which reveals that a greater number of patients with hepatitis C virus (HCV) infection could modify their behavior and lifestyle habits with regard to alcohol consumption when compared to tobacco use after the diagnosis of HCV infection. The authors also emphasized the importance of counseling patients about the effects of both tobacco and alcohol use on the liver in patients with HCV infection. Tobacco use and alcohol consumption alone have been shown to accelerate the progression of hepatitis C toward chronic hepatitis[1-3
]. Furthermore, multiple studies have shown a synergistic effect of alcohol and tobacco use on the progression of hepatitis C to hepatocellular carcinoma (HCC)[1,4
]. Independently, tobacco use is also associated with a decreased response to interferon treatment[1,3
]. Given the above evidence of lifestyle factors on progression of hepatitis C toward chronic hepatitis or HCC, it is imperative that patients with HCV infection not only receive counseling on alcohol consumption but also on tobacco use. We evaluated the frequency of alcohol and smoking counseling of patients with HCV infection by their primary care internists and gastroenterologists.
A retrospective medical record review of patients with HCV infection who were referred by internists to gastroenterologists for management of their liver disease was conducted. The records were evaluated for documentation of alcohol consumption, tobacco use and physician counseling during an evaluation by internists or during consultation by gastroenterologists. One hundred and twenty three records (75 females, 48 males) were reviewed. There were 105 African-Americans, 12 Caucasians and six patients of other races. Of the 123 patients, 36 (29%) were admitted to smoking, 24 (20%) reported daily alcohol consumption, and 10 (8%) were using both tobacco and alcohol. Ten of the 36 patients who were admitted due to tobacco use were counseled by their primary care internist about the dangers of smoking and were offered assistance in cessation. None of the patients who used tobacco were counseled by their gastroenterologist on the effects of smoking. There was a statistically significant difference (P = 0.0022) between the internists’ and gastroenterologists’ frequencies of consultation on the effects of smoking. Of the 24 patients who drank alcohol daily, 14 (17%) were counseled about the effects of alcohol on the liver by gastroenterologists. Only one of the daily alcohol consumers was counseled about alcohol use by their internists (P = 0.0002). There was a statistically significant difference in the frequency of alcohol counseling between gastroenterologists and internists.
It is essential that physicians counsel patients on the effects of both tobacco and alcohol use in the setting of HCV infection[1
]. Additionally, the discrepancy between the frequencies of addressing smoking and alcohol cessation in patients with HCV infection by internists and gastroenterologists is interesting. This study is important because it reveals that physicians inadequately counsel patients with HCV infection about tobacco and alcohol use despite the overwhelming evidence that these factors accelerate the progression of HCV-induced liver disease toward chronic hepatitis or HCC. The potential fragmentation of counseling may be due to a presumed transfer of responsibility of alcohol counseling by the internist to the gastroenterologist. This can result in decreased counseling by internists about alcohol cessation. Similarly, gastroenterologists may presume that smoking cessation counseling is the internist’s responsibility. It is crucial that efforts are made to ensure that all physicians counsel patients about the effects of alcohol and tobacco use. It is uncertain whether the lapse in counseling is a result of a lack of knowledge about the synergistic effect of tobacco and alcohol use on the progression of HCV-induced liver disease toward chronic hepatitis or HCC, or whether there is simply a failure of both specialties to document their counseling practice.
Although this study is small, it may offer a partial explanation on the findings in study by Scognamiglio et al[1
] on the decreased incidence of smoking modification vs
alcohol modification in hepatitis C patients. Since hepatitis C treatment is often managed by specialty physicians, alcohol cessation may be emphasized rather than tobacco cessation. Further studies investigating counseling barriers on lifestyle modifications in patients with HCV infection, in both primary care and gastroenterology offices, are necessary to prevent progression of hepatitis C toward an already increasing incidence of HCC.