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Complete Summary

GUIDELINE TITLE

Smoking cessation in HIV-infected patients.

BIBLIOGRAPHIC SOURCE(S)

  • New York State Department of Health. Smoking cessation in HIV-infected patients. New York (NY): New York State Department of Health; 2008 Feb. 5 p. [19 references]

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: New York State Department of Health. Smoking cessation in HIV-infected patients. New York (NY): New York State Department of Health; 2005 Jun. 8 p.

** REGULATORY ALERT **

FDA WARNING/REGULATORY ALERT

Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory information has been released:

  • February 1, 2008, Chantix (varenicline): New information has been added to the WARNINGS and PRECAUTIONS sections in Chantix's prescribing information about serious neuropsychiatric symptoms experienced in patients taking this medication.

COMPLETE SUMMARY CONTENT

 ** REGULATORY ALERT **
 SCOPE
 METHODOLOGY - including Rating Scheme and Cost Analysis
 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS
 IMPLEMENTATION OF THE GUIDELINE
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

SCOPE

DISEASE/CONDITION(S)

  • Human immunodeficiency virus (HIV) infection
  • Nicotine dependence (smoking)

GUIDELINE CATEGORY

Counseling
Evaluation
Management
Prevention
Screening
Treatment

CLINICAL SPECIALTY

Allergy and Immunology
Family Practice
Infectious Diseases
Internal Medicine
Psychology

INTENDED USERS

Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Substance Use Disorders Treatment Providers

GUIDELINE OBJECTIVE(S)

To encourage clinicians to use evidence-based interventions to promote smoking cessation in HIV-infected patients

TARGET POPULATION

Human immunodeficiency virus (HIV)-infected smokers

INTERVENTIONS AND PRACTICES CONSIDERED

Screening/Evaluation

  1. Fagerstrom Test for Nicotine Dependence
  2. Assessment for readiness to quit
    • Motivational interviewing techniques
    • Identification of barriers to quitting

Management/Treatment/Counseling/Prevention

  1. Setting a quit date
  2. Pharmacotherapy (nicotine replacement therapy or non-nicotine therapy)
  3. Referral to a counseling program
  4. Patient education about nicotine withdrawal symptoms
  5. Progress monitoring and relapse follow up

MAJOR OUTCOMES CONSIDERED

  • Smoking cessation rates
  • Efficacy and cost-effectiveness of interventions designed to promote smoking cessation

METHODOLOGY

METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

NUMBER OF SOURCE DOCUMENTS

Not stated

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

METHODS USED TO ANALYZE THE EVIDENCE

Review

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

AIDS Institute clinical guidelines are developed by distinguished committees of clinicians and others with extensive experience providing care to people with HIV infection. Committees* meet regularly to assess current recommendations and to write and update guidelines in accordance with newly emerging clinical and research developments.

The Committees* rely on evidence to the extent possible in formulating recommendations. When data from randomized clinical trials are not available, Committees rely on developing guidelines based on consensus, balancing the use of new information with sound clinical judgment that results in recommendations that are in the best interest of patients.

*Current committees include:

  • Medical Care Criteria Committee
  • Committee for the Care of Children and Adolescents with HIV Infection
  • Dental Standards of Care Committee
  • Mental Health Committee
  • Women's Health Committee
  • Substance Use Committee
  • Physician's Prevention Advisory Committee
  • Pharmacy Committee

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

COST ANALYSIS

Cost-effectiveness analyses were reviewed.

Assistance with smoking cessation was found to be a cost-effective intervention that is underused by primary care providers and inadequately covered by health insurers.

METHOD OF GUIDELINE VALIDATION

External Peer Review

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

All guidelines developed by the Committee are externally peer reviewed by at least two experts in that particular area of patient care, which ensures depth and quality of the guidelines.

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Prevalence and Impact

Clinicians should use evidence-based interventions to promote smoking cessation in human-immunodeficiency virus (HIV)-infected patients.

Key Point:

Cigarette smoking is highly prevalent among both HIV-infected patients and substance users.

Assessment for Readiness to Quit

Clinicians should routinely assess HIV-infected patients' smoking status and readiness to quit.

Clinicians should identify and discuss barriers to quitting smoking for HIV-infected smokers who are not interested in stopping in the immediate future, but may consider it at a later time.

Smoking Cessation Assistance

Clinicians should advise all smokers to quit.

For smokers who are interested in quitting, clinicians should:

  • Offer smoking cessation assistance including pharmacotherapy
  • Help set a quit date
  • Refer to a counseling program
  • Educate patients about symptoms of nicotine withdrawal

(See Appendix VII [see "Availability of Companion Document" field] for information on drugs used for smoking cessation.)

Relapse and Relapse Prevention

Clinicians should monitor the progress of patients who are trying to quit and discuss relapse prevention.

If patients relapse, clinicians should be nonjudgmental. Relapses should be followed up with discussions of new strategies for the next attempt to quit.

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically stated.

BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

POTENTIAL BENEFITS

Overall Benefits

For human immunodeficiency virus (HIV) infected substance users, quitting smoking could decrease the risk of HIV-associated infections and malignancies and reduce the incidence of antiretroviral (ARV)-associated complications.

POTENTIAL HARMS

Side Effects of Pharmacotherapy

Nicotine Replacement Therapy

  • Transdermal patches (Nicoderm CQ and Nicotrol): skin irritation, insomnia
  • Nicotine polacrilex gum (Nicorette): mouth irritation, sore jaw, dyspepsia, hiccups
  • Nicotine polacrilex lozenge: headache, heartburn, hiccups, nausea, cough
  • Vapor inhaler (Nicotrol inhaler): mouth and throat irritation, cough
  • Nasal spray (Nicotrol NS): nasal irritation, sneezing, coughing, teary eyes

Non-Nicotine Therapy

  • Sustained release bupropion (Zyban or Wellbutrin SR): insomnia, dry mouth, agitation, increases risk of seizure (<0.1%)
  • Varenicline HCl (Chantix): nausea, insomnia, abnormal dreams, headache, may exacerbate or cause psychiatric symptoms
  • Nortriptyline (recommended as second line therapy, although not approved by the Food and Drug Administration [FDA] as a smoking cessation aid): dry mouth, sedation, dizziness, should be used with caution in patients with coronary heart disease
  • Clonidine (recommended as second line therapy, although not approved by the FDA as a smoking cessation aid): dry mouth, sedation, dizziness

IMPLEMENTATION OF THE GUIDELINE

DESCRIPTION OF IMPLEMENTATION STRATEGY

The AIDS Institute's Office of the Medical Director directly oversees the development, publication, dissemination and implementation of clinical practice guidelines, in collaboration with The Johns Hopkins University, Division of Infectious Diseases. These guidelines address the medical management of adults, adolescents and children with HIV infection; primary and secondary prevention in medical settings; and include informational brochures for care providers and the public.

Guidelines Dissemination

Guidelines are disseminated to clinicians, support service providers and consumers through mass mailings and numerous AIDS Institute-sponsored educational programs. Distribution methods include the HIV Clinical Resource website, the Clinical Education Initiative, the AIDS Educational Training Centers (AETC) and the HIV/AIDS Materials Initiative. Printed copies of clinical guidelines are available for order from the NYSDOH Distribution Center for providers who lack internet access.

Guidelines Implementation

The HIV Clinical Guidelines Program works with other programs in the AIDS Institute to promote adoption of guidelines. Clinicians, for example, are targeted through the Clinical Education Initiative (CEI) and the AIDS Education and Training Centers (AETC). The CEI provides tailored educational programming on site for health care providers on important topics in HIV care, including those addressed by the HIV Clinical Guidelines Program. The AETC provides conferences, grand rounds and other programs that cover topics contained in AIDS Institute guidelines.

Support service providers are targeted through the HIV Education and Training initiative which provides training on important HIV topics to non-physician health and human services providers. Education is carried out across the State as well as through video conferencing and audio conferencing.

The HIV Clinical Guidelines Program also works in a coordinated manner with the HIV Quality of Care Program to promote implementation of HIV guidelines in New York State. By developing quality indicators based on the guidelines, the AIDS Institute has created a mechanism for measurement of performance that allows providers and consumers to know to what extent specific guidelines have been implemented.

Finally, best practices booklets are developed through the HIV Clinical Guidelines Program. These contain practical solutions to common problems related to access, delivery or coordination of care, in an effort to ensure that HIV guidelines are implemented and that patients receive the highest level of HIV care possible.

IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms
Personal Digital Assistant (PDA) Downloads

For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

IOM CARE NEED

Living with Illness
Staying Healthy

IOM DOMAIN

Effectiveness
Patient-centeredness

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • New York State Department of Health. Smoking cessation in HIV-infected patients. New York (NY): New York State Department of Health; 2008 Feb. 5 p. [19 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2004 (revised 2008 Feb)

GUIDELINE DEVELOPER(S)

New York State Department of Health - State/Local Government Agency [U.S.]

SOURCE(S) OF FUNDING

New York State Department of Health

GUIDELINE COMMITTEE

Substance Use Committee

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Chair: Marc N Gourevitch, MD, MPH, New York University School of Medicine , New York, New York

Members: Bruce D Agins, MD, MPH, New York State Department of Health AIDS Institute, New York, New York; Julia H Arnsten, MD, MPH, Montefiore Medical Center, Bronx, New York; Lawrence S Brown, Jr, MD, MPH, FASAM, Addiction Research and Treatment Corporation, Brooklyn, New York; Brenda Chabon, PhD, Montefiore Medical Center, Bronx, New York; Barbara H Chaffee, MD, MPH, Binghamton Family Care Center, Binghamton, New York; Michael L Christie, MD, AIDS Community Health Center, Rochester, New York; Chinazo O Cunningham, MD; Montefiore Medical Center, Bronx, New York; Nereida L Ferran-Hansard, MD, Jacobi Medical Center, Bronx, New York; Steven S Kipnis, MD, FACP, FASAM, New York State Office of Alcoholism and Substance Abuse Services, Orangeburg, New York; Joseph P Merlino, MD, MPA, Mount Sinai School of Medicine, New York, New York; Nancy Murphy, NP, St. Luke's Roosevelt Hospital Center, New York, New York; Edward Nunes, MD, New York State Psychiatric Institute, New York, New York; David C Perlman, MD, Beth Israel Medical Center, New York, New York; Sharon L Stancliff, MD, Harm Reduction Coalition, New York, New York; Robert Whitney, MD, Erie County Medical Center, Buffalo, New York

Liaisons: Daliah I Heller, MPH, Liaison to the New York City Department of Health and Mental Hygiene, New York, New York

AIDS Institute Staff Liaisons: Diane M Rudnick, MEd, Liaison to the New York State Department of Health AIDS Institute, New York, New York

AIDS Institute Staff Physician: Eunmee H Chun, MD, New York State Department of Health AIDS Institute, New York, New York

Principal Contributor: Julia Arnsten, MD, MPH, Montefiore Medical Center, Bronx

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: New York State Department of Health. Smoking cessation in HIV-infected patients. New York (NY): New York State Department of Health; 2005 Jun. 8 p.

GUIDELINE AVAILABILITY

AVAILABILITY OF COMPANION DOCUMENTS

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI on February 2, 2005. This NGC summary was updated by ECRI on August 16, 2005. This summary was updated by ECRI Institute on November 9, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This NGC summary was updated by ECRI Institute on June 12, 2008.

COPYRIGHT STATEMENT

DISCLAIMER

NGC DISCLAIMER

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Readers with questions regarding guideline content are directed to contact the guideline developer.


 

 

   
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