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Official Guidelines for Smoking Cessation
This Summary is from the updated guideline, Treating Tobacco Use and
Dependence, which reflects new,
effective clinical treatments for clinical treatment of tobacco dependence.
Findings include: Multiple efficacious treatments exist, these treatments
can double or triple the likelihood of
long-term cessation, many cessation treatments are appropriate for
primary care settings, and the use and
impact of cessation treatments can be increased by supportive health
system policies.
Overview / Guideline
Origins / Style and Structure / Findings and Recommendations
Guideline Update: Advances / Coordination of Care / Future Promise
Overview
In America today, tobacco stands out as the agent most responsible for
avoidable illness and death. Millions of
Americans consume this toxin on a daily basis. Its use brings premature
death to almost half a million
Americans each year, and it contributes to profound disability and
pain in many others. Approximately one-third
of all tobacco users in this country will die prematurely because of
their dependence on tobacco. Unlike so
many epidemics in the past, there is a clear, contemporaneous understanding
of the cause of this premature
death and disability—the use of tobacco.
It is a testament to the power of tobacco addiction that millions of
tobacco users have been unable to overcome
their dependence and save themselves from its consequences: perpetual
worry, unceasing expense, and
compromised health. Indeed, it is difficult to identify any other condition
that presents such a mix of lethality,
prevalence, and neglect, despite effective and readily available interventions.
Despite high, sustained tobacco use prevalence, the response of both
clinicians and the U.S. health care
delivery system is disappointing. Studies show that most smokers present
at primary care settings, and they
are not offered effective assistance in quitting. The smoker’s lack
of success in quitting, and the clinician’s
reluctance to intervene, can be traced to many factors. Until recently,
few effective treatments existed, effective
treatments had not been identified clearly, and health care systems
had not supported their consistent and
universal delivery. To single-out the clinician for blame would be
inappropriate, when he or she has typically
received neither the training nor support necessary to treat tobacco
use successfully.
Current treatments for tobacco dependence offer clinicians their greatest
single opportunity to staunch the loss
of life, health, and happiness caused by this chronic condition. It
is imperative, therefore, that clinicians actively
assess and treat tobacco use. In addition, it is imperative that health
care administrators, insurers, and
purchasers adopt and support policies and practices that are aimed
at reducing tobacco use prevalence. The
chief purpose of this document is to provide clinicians, tobacco dependence
specialists, health care
administrators, insurers, and purchasers, and even tobacco users, with
evidence-based recommendations
regarding clinical and systems interventions that will increase the
likelihood of successful quitting.
Guideline Origins
Treating Tobacco Use and Dependence, a Public Health Service-sponsored
Clinical Practice Guideline, is
the product of the Tobacco Use and Dependence Guideline Panel ("the
panel"), consortium representatives,
consultants, and staff. These 30 individuals were charged with the
responsibility of identifying effective,
experimentally validated, tobacco dependence treatments and practices.
This guideline updates the 1996
Smoking Cessation, Clinical Practice Guideline No. 18 that was sponsored
by the Agency for Health Care
Policy and Research, U.S. Department of Health and Human Services.
The original guideline reflected the
extant scientific research literature published between 1975 and 1994.
This guideline was written in response to new, effective clinical treatments
for tobacco dependence that have
been identified since 1994, and these treatments promise to enhance
the rates of successful tobacco
cessation. The accelerating pace of tobacco research that prompted
the update is reflected by the fact that
3,000 articles on tobacco published between 1975 and 1994 were collected
and screened as part of the
original guideline. Another 3,000 were published between 1995 and 1999
and contributed to the updated
guideline. These 6,000 articles were reviewed to identify a much smaller
group of articles that served as the
basis for guideline data analyses and panel opinion.
The updated guideline was sponsored by a consortium of seven Federal
Government and nonprofit
organizations:
Agency for Healthcare Research and Quality (AHRQ).
Centers for Disease Control and Prevention (CDC).
National Cancer Institute (NCI).
National Heart, Lung, and Blood Institute (NHLBI).
National Institute on Drug Abuse (NIDA).
Robert Wood Johnson Foundation (RWJF).
University of Wisconsin Medical School’s Center
for Tobacco Research and Intervention (CTRI).
All of these organizations have the mission to reduce the human costs
of tobacco use. Given the importance of
this issue to the health of all Americans, the updated guideline is
published by the U.S. Public Health Service.
Guideline Style and Structure
This guideline was written to be relevant to all tobacco users—those
using cigarettes as well as other forms of
tobacco. Therefore, the terms "tobacco user" and "tobacco dependence"
will be used in preference to
"smoker" and "cigarette dependence." However, in some cases the evidence
for a particular recommendation
consists entirely of studies using smokers as subjects. In these instances,
the recommendation and evidence
refers to "smoking" to communicate the parochial nature of the evidence.
In most cases though, guideline
recommendations are relevant to all types of tobacco users.
The updated guideline is divided into eight chapters:
Chapter 1, Overview and Methods: Provides the clinical practice and
scientific context of the guideline
update project and describes the methodology used to generate the guideline
findings.
Chapter 2, Assessment of Tobacco Use: Describes how each patient presenting
at a health care setting
should have his or her tobacco use status determined, and how tobacco
users should be assessed for
willingness to make a quit attempt.
Chapter 3, Brief Clinical Interventions: Summarizes effective brief
interventions that can easily be delivered
in a primary care setting. In this chapter, separate interventions
are described for the patient who is willing to try
to quit at this time, for the patient who is not yet willing to try
to quit, and for the patient who has recently quit.
Chapter 4, Intensive Clinical Interventions: Outlines a prototype of
an intensive tobacco cessation
treatment that comprises strategies shown to be effective in this guideline.
Because intensive treatments
produce the highest success rates, they are an important element in
tobacco intervention strategies.
Chapter 5, Systems Interventions Relevance to Health Care Administrators,
Insurers, and
Purchasers: Offers a blueprint to guideline changes in health care
coverage and health care administration
such that tobacco assessment and intervention become "default options"
in health care delivery.
Chapter 6, Evidence: Presents the results of guideline statistical analyses
and the recommendations that
emanate from them. Guideline analyses address topics such as:
The efficacy of different pharmacotherapies and counseling
strategies.
The relation between treatment intensities and treatment
success.
Whether screening for tobacco use in the clinic
setting enhances tobacco user identification.
The guideline panel made specific recommendations regarding future research on these topics.
Chapter 7, Special Populations: Evaluates evidence on tobacco intervention
strategies and efficacy with
special populations (e.g., women, pregnant smokers, racial and ethnic
minorities, hospitalized smokers,
smokers with psychiatric comorbidity and chemical dependency, children
and adolescents, and older
smokers). The guideline panel made specific recommendations for future
research on topics relevant to these
populations.
Chapter 8, Special Topics: Presents information and recommendations
relevant to weight gain after smoking
cessation, noncigarette tobacco products, clinician training, economics
of tobacco treatment, and harm
reduction. The guideline panel formulated specific recommendations
regarding future research on these topics.
Findings and Recommendations
The key recommendations of the updated guideline, Treating Tobacco Use
and Dependence, based on the
literature review and expert panel opinion, follow:
Tobacco dependence is a chronic condition that often requires repeated intervention.
However, effective treatments exist that can produce long-term or even permanent abstinence.
Because effective tobacco dependence treatments are available, every
patient who uses tobacco
should be offered at least one of these treatments.
Patients willing to try to quit tobacco use should
be provided treatments identified as effective in this
guideline.
Patients unwilling to try to quit tobacco use should
be provided a brief intervention designed to increase
their motivation to quit.
It is essential that clinicians and health care delivery systems (including
administrators, insurers, and
purchasers) institutionalize the consistent identification, documentation,
and treatment of every
tobacco user seen in a health care setting.
Brief tobacco dependence treatment is effective, and every patient who
uses tobacco should be
offered at least brief treatment.
There is a strong dose-response relation between the intensity of tobacco
dependence counseling
and its effectiveness.
Treatments involving person-to-person contact (via individual, group,
or proactive telephone counseling) are
consistently effective, and their effectiveness increases with treatment
intensity (e.g., minutes of contact).
Three types of counseling and behavioral therapies were found to be
especially effective and should
be used with all patients attempting tobacco cessation:
Provision of practical counseling (problemsolving/skills
training).
Provision of social support as part of treatment
(intra-treatment social support).
Help in securing social support outside of treatment
(extra-treatment social support).
Numerous effective pharmacotherapies for smoking cessation now exist.
Except in the presence of
contraindications, these should be used with all patients attempting
to quit smoking.
Five first-line pharmacotherapies were identified that reliably increase long-term smoking abstinence rates:
Bupropion SR.
Nicotine gum.
Nicotine inhaler.
Nicotine nasal spray. Nicotine patch.
Two second-line pharmacotherapies were identified as efficacious and
may be considered by clinicians if
first-line pharmacotherapies are not effective:
Clonidine.
Nortriptyline.
Over-the-counter nicotine patches are effective relative to placebo, and their use should be encouraged.
Tobacco dependence treatments are both clinically effective and cost-effective
relative to other
medical and disease prevention interventions.
As such, insurers and purchasers should ensure that:
All insurance plans include as a reimbursed benefit
the counseling and pharmacotherapeutic treatments
identified as effective in this guideline.
Clinicians are reimbursed for providing tobacco
dependence treatment just as they are reimbursed for
treating other chronic conditions.
Guideline Update: Advances
A comparison of the findings of the year 2000 guideline with the previous
1996 guideline reveals the
considerable progress made in tobacco research over the brief period
separating these two works. Among
many important differences between the two documents, the following
deserve special note:
The updated guideline has produced even stronger
evidence of the association between counseling
intensity and successful treatment outcomes, and
also has revealed evidence of additional efficacious
counseling strategies. These include telephone counseling
and counseling that helps smokers enlist
support outside the treatment context.
The updated guideline offers the clinician many
more efficacious pharmacologic treatment strategies than
were identified in the previous guideline. There
are now seven different efficacious smoking cessation
medications, allowing the clinician and patient
many more treatment options. Further information also is
available on the efficacy of combinations of nicotine
replacement therapies and pharmacotherapies that
are obtained over-the-counter.
The updated guideline contains strong evidence that
smoking cessation treatments shown to be
efficacious in this guideline (both pharmacotherapy
and counseling) are cost-effective relative to other
routinely reimbursed medical interventions (e.g.,
treatment of hyperlipidemia and mammography
screening).
The guideline panel concluded, therefore, that smoking cessation treatments
should not be withheld from
patients when other less cost-effective medical interventions are routinely
delivered.
Coordination of Care: Institutionalizing the Treatment of Tobacco
Dependence
There is increasing evidence that the success of any tobacco dependence
treatment strategy cannot be
divorced from the health care system in which it is embedded. Data
strongly indicate that the consistent and
effective delivery of tobacco interventions requires coordinated interventions.
Just as a clinician must intervene
with his or her patient, so must the health care administrator, insurer,
and purchaser foster and support tobacco
dependence treatment as an integral element of health care delivery.
Health care purchasers should demand
that tobacco intervention be a contractually covered obligation of
insurers and providers. Health care
administrators and insurers should ensure that clinicians have the
training and support, and receive the
reimbursement necessary to achieve consistent, effective intervention
with tobacco users.
Future Promise
About 20 years ago, data indicated that clinicians too frequently failed
to intervene with their patients who
smoke. Recent data confirm that this picture has not changed markedly
over the past two decades. One recent
study reported that only 15 percent of smokers who saw a physician
in the past year were offered assistance
with quitting, and only 3 percent were given a followup appointment
to address this topic. These data are
disheartening.
The updated guideline reports a family of findings that creates tremendous
tension for change. This guideline
reveals that multiple efficacious treatments exist, these treatments
can double or triple the likelihood of
long-term cessation, many cessation treatments are appropriate for
the primary care setting, cessation
treatments are more cost-effective than many other reimbursed clinical
interventions, and the utilization and
impact of cessation treatments can be increased by supportive health
system policies (e.g., coverage through
insurance plans). In sum, the updated guideline identifies and describes
scientifically validated treatments and
offers clear guidance on how such treatments can be consistently and
effectively integrated into health care
delivery.
The guideline panel is optimistic that this updated guideline is a harbinger
of a new and very promising era in
the treatment of tobacco use and dependence. The guideline codifies
an evolving culture of health care—one in
which every tobacco user has access to effective treatments for tobacco
dependence. This new standard of
care provides clinicians and health care delivery systems with their
greatest opportunity to improve the current
and future health of their patients by assisting those addicted to
tobacco. Tobacco users and their families
deserve no less.
This information is presented as a public service by:
Action on Smoking and Health
(ASH)
2013 H Street NW / Washington, DC
20006 / (202) 659-4310
A national nonprofit, scientific and educational organization founded
in 1967.
All donations are fully tax deductible.
Material on this page may be freely reproduced,
distributed, and circulated
with attribution given to Action on Smoking and
Health.
Dedicated to Mr. and Mrs. Warren Wells