• Treating tobacco use and dependence: 2008 update. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2008 May. 257 p.

This is the current release of the guideline.

This guideline updates a previous version: U.S. Department of Health and Human Services, Public Health Service. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. Clinical practice guideline. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2000 Jun. 197 p. [311 references].

The strength of evidence ratings (A-C) are defined at the end of the "Major Recommendations" field.

Guideline Update: Advances

A comparison of the findings of the 2008 Guideline update with the 2000 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 that counseling is an effective tobacco use treatment strategy. Of particular note are findings that counseling adds significantly to the effectiveness of tobacco cessation medications, quitline counseling is an effective intervention with a broad reach, and counseling increases abstinence among adolescent smokers.
• The updated Guideline offers the clinician a greater number of effective medications than were identified in the previous Guideline. Seven different effective first-line smoking cessation medications are now approved by the U.S. Food and Drug Administration (FDA) for treating tobacco use and dependence. In addition, multiple combinations of medications have been shown to be effective. Thus, the clinician and patient have many more medication options than in the past. The Guideline also now provides evidence regarding the effectiveness of medications relative to one another.
• The updated Guideline contains new evidence that health care policies significantly affect the likelihood that smokers will receive effective tobacco dependence treatment and successfully stop tobacco use. For instance, making tobacco dependence a benefit covered by insurance plans increases the likelihood that a tobacco user will receive treatment and quit successfully.

See Appendix D in the original guideline document for key recommendation changes from the 2000 guideline.

Ten Key Guideline Recommendations

The overarching goal of these recommendations is that clinicians strongly recommend the use of effective tobacco dependence counseling and medication treatments to their patients who use tobacco, and that health care systems, insurers, and purchasers assist clinicians in making such effective treatment available.

1. Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long-term abstinence.
2. It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting.
3. Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use the counseling treatments and medications recommended in this Guideline.
4. Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective in this Guideline.
5. Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. Two components of counseling are especially effective, and clinicians should use these when counseling patients making a quit attempt:
   • Practical counseling (problem solving/skills training)
   • Social support delivered as part of treatment
6. Numerous effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempting to quit smoking—except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents).
   • Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates:
     • Bupropion SR
     • Nicotine gum
     • Nicotine inhaler
     • Nicotine lozenge
     • Nicotine nasal spray
     • Nicotine patch
     • Varenicline
   • Clinicians also should consider the use of certain combinations of medications identified as effective in this Guideline.

7. Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication.
8. Telephone quitline counseling is effective with diverse populations and has broad reach. Therefore, clinicians and health care delivery systems should both ensure patient access to quitlines and promote quitline use.
9. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments shown in this Guideline to be effective in increasing future quit attempts.
10. Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in this Guideline as covered benefits.

Counseling and Psychosocial Recommendations

Screening and Assessment

Screen for Tobacco Use

All patients should be asked if they use tobacco and should have their tobacco-use status documented on a regular basis. Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status or the use of other reminder systems such as chart stickers or computer prompts, significantly increase rates of clinician intervention. (Strength of Evidence = A)

Specialized Assessment

Once a tobacco user is identified and advised to quit, the clinician should assess the patient's willingness to quit at this time. (Strength of Evidence = C)

• If the patient is willing to make a quit attempt at this time, interventions identified as effective in this Guideline should be initiated. (see Chapter 3A and 4 in the original guideline document)
• If the patient is unwilling to quit at this time, an intervention designed to increase future quit attempts should be provided. (see Chapter 3B in the original guideline document)

Tobacco dependence treatment is effective and should be delivered even if specialized assessments are not used or available. (Strength of Evidence = A)

Treatment Structure and Intensity

Advice to Quit Smoking

All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates. (Strength of Evidence = A)

Intensity of Clinical Interventions

Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates. Every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to an intensive intervention. (Strength of Evidence = A)

There is a strong dose-response relation between the session length of person-to-person contact and successful treatment outcomes. Intensive interventions are more effective than less intensive interventions and should be used whenever possible. (Strength of Evidence = A)

Person-to-person treatment delivered for four or more sessions appears especially effective in increasing abstinence rates. Therefore, if feasible, clinicians should strive to meet four or more times with individuals quitting tobacco use. (Strength of Evidence = A)

Type of Clinician

Treatment delivered by a variety of clinician types increases abstinence rates. Therefore, all clinicians should provide smoking cessation interventions. (Strength of Evidence = A)

Treatments delivered by multiple types of clinicians are more effective than interventions delivered by a single type of clinician. Therefore, the delivery of interventions by more than one type of clinician is encouraged. (Strength of Evidence = C)

Formats of Psychosocial Treatments

Proactive telephone counseling, group counseling, and individual counseling formats are effective and should be used in smoking cessation interventions. (Strength of Evidence = A)

Smoking cessation interventions that are delivered in multiple formats increase abstinence rates and should be encouraged. (Strength of Evidence = A)

Tailored materials, both print and Web-based, appear to be effective in helping people quit. Therefore, clinicians may choose to provide tailored self-help materials to their patients who want to quit. (Strength of Evidence = B)

Follow-up Assessment and Procedures

All patients who receive a tobacco dependence intervention should be assessed for abstinence at the completion of treatment and during subsequent clinic contacts. (1) Abstinent patients should have their quitting success acknowledged, and the clinician should offer to assist the patient with problems associated with quitting (see Chapter 3C, For the Patient Who Has Recently Quit, in the original guideline document). (2) Patients who have relapsed should be assessed to determine whether they are willing to make another quit attempt. (Strength of Evidence = C):

• If the patient is willing to make another quit attempt, provide or arrange additional treatment (see Chapter 3A, For the Patient Willing To Quit, in the original guideline document.)
• If the patient is not willing to try to quit, provide or arrange an intervention designed to increase future quit attempts (see Chapter 3B, For the Patient Unwilling To Quit, in the original guideline document).

Treatment Elements

Types of Counseling and Behavioral Therapies

Two types of counseling and behavioral therapies result in higher abstinence rates: (1) providing smokers with practical counseling (problem solving skills/skills training), and (2) providing support and encouragement as part of treatment. These types of counseling elements should be included in smoking cessation interventions. (Strength of Evidence = B)

Combining Counseling and Medication

The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore, whenever feasible and appropriate, both counseling and medication should be provided to patients trying to quit smoking. (Strength of Evidence = A)

There is a strong relation between the number of sessions of counseling, when it is combined with medication, and the likelihood of successful smoking cessation. Therefore, to the extent possible, clinicians should provide multiple counseling sessions, in addition to medication, to their patients who are trying to quit smoking. (Strength of Evidence = A)

For Smokers Not Willing To Make a Quit Attempt At This Time

Motivational intervention techniques appear to be effective in increasing a patient's likelihood of making a future quit attempt. Therefore, clinicians should use motivational techniques to encourage smokers who are not currently willing to quit to consider making a quit attempt in the future. (Strength of Evidence = B)

Medication Evidence

Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). (Strength of Evidence = A)

Recommendations Regarding Individual Medications: First-Line Medications

First-line medications are those that have been found to be safe and effective for tobacco dependence treatment and that have been approved by the FDA for this use, except in the presence of contraindications or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). These first-line medications have an established empirical record of effectiveness, and clinicians should consider these agents first in choosing a medication. For the 2008 update, the first-line medications are listed in Table 6.26 in the original guideline document by size of the odds ratio and in the text alphabetically by generic name.

Bupropion SR (Sustained Release)

Bupropion SR is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A)

Nicotine Replacement Therapies (NRTs)

Nicotine Gum

Nicotine gum is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A)

Clinicians should offer 4 mg rather than 2 mg nicotine gum to highly dependent smokers. (Strength of Evidence = B)

Nicotine Inhaler

The nicotine inhaler is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A)

Nicotine Lozenge

The nicotine lozenge is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = B)

Nicotine Nasal Spray

Nicotine nasal spray is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A)

Nicotine Patch

The nicotine patch is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A)

Varenicline

Varenicline is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A)

Recommendations Regarding Second-Line Medications

Second-line medications are medications for which there is evidence of effectiveness for treating tobacco dependence, but they have a more limited role than first-line medications because: (1) the FDA has not approved them for a tobacco dependence treatment indication; and (2) there are more concerns about potential side effects than exist with first-line medications. Second-line medications should be considered for use on a case-by-case basis after first line treatments (either alone or in combination) have been used without success or are contraindicated. The listing of the second-line medications is alphabetical by generic name.

Clonidine

Clonidine is an effective smoking cessation treatment. It may be used under a physician's supervision as a second-line agent to treat tobacco dependence. (Strength of Evidence = A)

Nortriptyline

Nortriptyline is an effective smoking cessation treatment. It may be used under a physician's supervision as a second-line agent to treat tobacco dependence. (Strength of Evidence = A)

Combination Medications

Certain combinations of first-line medications have been shown to be effective smoking cessation treatments. Therefore, clinicians should consider using these combinations of medications with their patients who are willing to quit. Effective combination medications are:

• Long-term (>14 weeks) nicotine patch + other NRT (gum and spray)
• The nicotine patch + the nicotine inhaler
• The nicotine patch + bupropion SR (Strength of Evidence = A)

The number and variety of analyzable articles was sufficient to assess the effectiveness of five combinations of medications relative to placebo. Only the patch + bupropion combination has been approved by the FDA for smoking cessation. See the original guideline document for evidence regarding the following combinations:

• Nicotine patch + bupropion SR
• Nicotine patch + nicotine inhaler
• Long-term nicotine patch use + ad libitum NRT
• Nicotine patch + nortriptyline
• Nicotine patch + second generation antidepressants

Medications Not Recommended by the Guideline Panel

• Antidepressants other than bupropion SR and nortriptyline
• Selective serotonin re-uptake inhibitors (SSRIs)
• Anxiolytics/benzodiazepines/beta-blockers
• Opioid antagonists/naltrexone
• Silver acetate
• Mecamylamine
• Extended use of medications
• Use of NRT in cardiovascular patients

Use of Over-the-Counter Medications

Over-the-counter nicotine patch therapy is more effective than placebo, and its use should be encouraged. (Strength of Evidence = B)

Systems Evidence

Clinician Training and Reminder Systems

All clinicians and clinicians-in-training should be trained in effective strategies to assist tobacco users willing to make a quit attempt and to motivate those unwilling to quit. Training appears to be more effective when coupled with systems changes. (Strength of Evidence = B)

Cost-Effectiveness of Tobacco Dependence Interventions

The tobacco dependence treatments shown to be effective in this Guideline (both counseling and medication) are highly cost-effective relative to other reimbursed treatments and should be provided to all smokers. (Strength of Evidence = A)

Recommendation: Sufficient resources should be allocated for systems support to ensure the delivery of efficacious tobacco use treatments. (Strength of Evidence = C)

Tobacco Dependence Treatment as a Part of Assessing Health Care Quality

Provision of Guideline-based interventions to treat tobacco use and dependence should remain in standard ratings and measures of overall health care quality (e.g., National Committee for Quality Assurance [NCQA] Healthcare Effectiveness Data and Information Set [HEDIS]). These standard measures should also include measures of outcomes (e.g., use of cessation treatment, short- and long-term abstinence rates) that result from providing tobacco dependence interventions. (Strength of Evidence = C)

Providing Treatment for Tobacco Use and Dependence as a Covered Benefit

Providing tobacco dependence treatments (both medication and counseling) as a paid or covered benefit by health insurance plans has been shown to increase the proportion of smokers who use cessation treatment, attempt to quit, and successfully quit. Therefore, treatments shown to be effective in the Guideline should be included as covered services in public and private health benefit plans. (Strength of Evidence = A)

Special Populations and Other Topics

The interventions found to be effective in this Guideline have been shown to be effective in a variety of populations. In addition, many of the studies supporting these interventions comprised diverse samples of tobacco users. Therefore, interventions identified as effective in this Guideline are recommended for all individuals who use tobacco, except when medication use is contraindicated or with specific populations in which medication has not been shown to be effective (pregnant women, smokeless tobacco users, light smokers, and adolescents). (Strength of Evidence = B)

See the original guideline document for a discussion of clinical issues for specific populations, including human immunodeficiency virus (HIV)-positive smokers; hospitalized smokers; lesbian/gay/bisexual/transgender (LGBT) smokers; smokers with low socioeconomic status (SES)/limited formal education; smokers with comorbid conditions, including cancer, cardiac disease, chronic obstructive pulmonary disease (COPD), diabetes, and asthma; older smokers; smokers with psychiatric disorders, including substance use disorders; racial and ethnic minority populations, and women.

Other Specific Populations and Topics

Children and Adolescents

Clinicians should ask pediatric and adolescent patients about tobacco use and provide a strong message regarding the importance of totally abstaining from tobacco use. (Strength of Evidence = C)

Counseling has been shown to be effective in treatment of adolescent smokers. Therefore, adolescent smokers should be provided with counseling interventions to aid them in quitting smoking. (Strength of Evidence = B)

Secondhand smoke is harmful to children. Cessation counseling delivered in pediatric settings has been shown to be effective in increasing abstinence among parents who smoke. Therefore, to protect children from secondhand smoke, clinicians should ask parents about tobacco use and offer them cessation advice and assistance. (Strength of Evidence = B)

Light Smokers

Light smokers should be identified, strongly urged to quit, and provided counseling cessation interventions. (Strength of Evidence = B)

Noncigarette Tobacco Users

Smokeless tobacco users should be identified, strongly urged to quit, and provided counseling cessation interventions. (Strength of Evidence = A)

Clinicians delivering dental health services should provide brief counseling interventions to all smokeless tobacco users. (Strength of Evidence = A)

Users of cigars, pipes, and other noncigarette forms of smoking tobacco should be identified, strongly urged to quit, and offered the same counseling interventions recommended for cigarette smokers. (Strength of Evidence = C)

Pregnant Smokers

Because of the serious risks of smoking to the pregnant smoker and the fetus, whenever possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit. (Strength of Evidence = A)

Although abstinence early in pregnancy will produce the greatest benefits to the fetus and expectant mother, quitting at any point in pregnancy can yield benefits. Therefore, clinicians should offer effective tobacco dependence interventions to pregnant smokers at the first prenatal visit as well as throughout the course of pregnancy. (Strength of Evidence = B)

Weight Gain After Smoking Cessation

For smokers who are greatly concerned about weight gain, it may be most appropriate to prescribe or recommend bupropion SR or NRT (in particular nicotine gum and nicotine lozenge), which have been shown to delay weight gain after quitting. (Strength of Evidence = B)

Definitions:

Strength of Evidence Grades

1. Multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielded a consistent pattern of findings.
2. Some evidence from randomized clinical trials supported the recommendation, but the scientific support was not optimal. For instance, few randomized trials existed, the trials that did exist were somewhat inconsistent, or the trials were not directly relevant to the recommendation.
3. Reserved for important clinical situations in which the Panel achieved consensus on the recommendation in the absence of relevant randomized controlled trials.

Clinical algorithms are provided in the original guideline document for the following:

• Model for treatment of tobacco use and dependence
• Treating tobacco use

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

The Panel's recommendations primarily are based on published, evidence-based research. When the evidence was incomplete or inconsistent in a particular area, the recommendations reflect the professional judgment of Panel members.

• Treating tobacco use and dependence: 2008 update. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2008 May. 257 p.

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

1996 (revised 2008 May)

Public Health Service (U.S.) - Federal Government Agency [U.S.]

The updated guideline was sponsored by a consortium of eight Federal Government and nonprofit organizations.

United States Government

Tobacco Use and Dependence Guideline Panel

Panel Members: Michael C. Fiore, MD, MPH (Panel Chair); Carlos Roberto Jaén, MD, PhD, FAAFP (Panel Vice Chair); Timothy B. Baker, PhD (Senior Scientist); William C. Bailey, MD, FACP, FCCP; Neal L. Benowitz, MD; Susan J. Curry, PhD; Sally Faith Dorfman, MD, MSHSA; Erika S. Froelicher, PhD, RN, MA, MPH; Michael G. Goldstein, MD; Cheryl G. Healton, DrPH; Patricia Nez Henderson, MD, MPH; Richard B. Heyman, MD; Howard K. Koh, MD, MPH, FACP; Thomas E. Kottke, MD, MSPH; Harry A. Lando, PhD; Robert E. Mecklenburg, DDS, MPH; Robin J. Mermelstein, PhD; Patricia Dolan Mullen, DrPH; C. Tracy Orleans, PhD; Lawrence Robinson, MD, MPH; Maxine L. Stitzer, PhD; Anthony C. Tommasello, PhD, MS; Louise Villejo, MPH, CHES; Mary Ellen Wewers, PhD, MPH, RN

The evaluation of conflict for the 2008 Guideline Update comprised a two-stage procedure designed to obtain increasingly detailed and informative data on potential conflicts over the course of the Guideline development process. See Appendix A in the original guideline document for a description of the procedure, including the criteria used to determine if a potential conflict is "significant."

Three Panel members whose disclosures exceeded the Public Health Service (PHS) criteria for significant financial interest were recused from Panel deliberations relating to their areas of conflict; one additional Panel member voluntarily recused himself.

Panel Members

The following is a summary listing for any of the years 2005, 2006, and 2007 of all significant financial interests as defined above, as well as any additional disclosures Panel members chose to make.

William C. Bailey reported significant financial interests in the form of compensation from three different pharmaceutical companies in 2006 and two in 2007 for speaking engagements.

Timothy B. Baker reported no significant financial interests. Under additional disclosures, he reported that he has served as a co-investigator on research studies at the University of Wisconsin that were sponsored by four pharmaceutical companies.

Neal L. Benowitz reported significant financial interest in the form of compensation from one pharmaceutical company for each of the years 2005–2007, as well as stock ownership in one pharmaceutical company. Under additional disclosures, he reported providing expert testimony in lawsuits against tobacco companies.

Susan J. Curry reported no significant financial interests and no additional disclosures.

Sally Faith Dorfman reported no significant financial interests. Under additional disclosures, she reported her employment by Ferring Pharmaceuticals, Inc., a company whose business does not relate to treating tobacco dependence.

Michael C. Fiore reported no significant financial interests. Under additional disclosures, he reported that he served as an investigator on research studies at the University of Wisconsin (UW) that were supported wholly or in part by four pharmaceutical companies, and in 2005 received compensation from one pharmaceutical company. In addition, he reported that, in 1998, the UW appointed him to a named Chair, which was made possible by an unrestricted gift to the UW from GlaxoWellcome.

Erika S. Froehlicher reported no significant financial interests and no additional disclosures.

Michael G. Goldstein reported no significant financial interests. Under additional disclosures, he reported that his employer received support from Bayer Pharmaceutical prior to 2005 and that he was employed by Bayer Pharmaceutical Corporation prior to January 1, 2005. His organization received payments for his professional services from two pharmaceutical companies and one commercial Internet smoking cessation site during the period 2005–2007.

Cheryl Healton reported no significant financial interests and no additional disclosures.

Patricia Nez Henderson reported no significant financial interests and no additional disclosures.

Richard B. Heyman reported no significant financial interests and no additional disclosures.

Carlos Roberto Jaén reported no significant financial interests and no additional disclosures.

Howard K. Koh reported no significant financial interests and no additional disclosures.

Thomas E. Kottke reported no significant financial interests and no additional disclosures.

Harry A. Lando reported no significant financial interests. Under additional disclosures, he reported serving on an advisory panel for a new tobacco use cessation medication and attending 2-day meetings in 2005 and 2006 as a member of this panel.

Robert E. Mecklenburg reported no significant financial interests. Under additional disclosures, he reported assisting Clinical Tools, Inc., through a governmental contract to develop a PHS 2000 Guideline-based Internet continuing education course.

Robin Mermelstein reported no significant financial interests and no additional disclosures.

Patricia Dolan Mullen reported no significant financial interests and no additional disclosures.

C. Tracy Orleans reported significant financial interests in the form of a dependent child who owns pharmaceutical stock, and no additional disclosures.

Lawrence Robinson reported no significant financial interests and no additional disclosures.

Maxine L. Stitzer reported no significant financial interests. Under additional disclosures, she reported participation on a pharmaceutical scientific advisory panel for a new tobacco use cessation medication.

Anthony C. Tommasello reported no significant financial interests and no additional disclosures.

Louise Villejo reported no significant financial interests and no additional disclosures.

Mary Ellen Wewers reported no significant financial interests and no additional disclosures.

Liaisons

Liaisons followed the same process as Panel members in reporting significant financial interests. Their disclosures are summarized below:

Glen Bennett reported no significant financial interests and no additional disclosures.

Stephen Heishman reported no significant financial interests and no additional disclosures.

Corinne Husten reported no significant financial interests and no additional disclosures.

Glen Morgan reported no significant financial interests and no additional disclosures.

Ernestine W. Murray reported no significant financial interests and no additional disclosures.

Christine Williams reported no significant financial interests and no additional disclosures.

Peer Reviewers

Peer reviewers were required to report significant financial interests at the time they submitted their peer reviews. The interests were reviewed prior to the adjudication of each reviewer's comments. Any significant financial interests are noted below their listing in the Contributors Section of the original guideline document.

This is the current release of the guideline.

This guideline updates a previous version: U.S. Department of Health and Human Services, Public Health Service. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. Clinical practice guideline. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service; 2000 Jun. 197 p. [311 references].

This NGC Summary was completed by ECRI on June 26, 2000. It was reviewed by the guideline developer as of June 27, 2000. This NGC summary was updated by ECRI Institute on May 12, 2008.

The contents of these Clinical Practice Guidelines are in the public domain and may be used and reproduced without special permission.