The U.S. Preventive Services Task Force (USPSTF) grades its recommendations (A, B, C, D or I) and the quality of the overall evidence for a service (good, fair, poor). The definitions of these grades can be found at the end of the "Major Recommendations" field.
The USPSTF strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products (A recommendation).
The USPSTF found good evidence that brief smoking cessation interventions, including screening, brief behavioral counseling (less than 3 minutes), and pharmacotherapy delivered in primary care settings, are effective in increasing the proportion of smokers who successfully quit smoking and remain abstinent after 1 year. Although most smoking cessation trials do not provide direct evidence of health benefits, the USPSTF found good evidence that smoking cessation lowers the risk for heart disease, stroke, and lung disease. The USPSTF concluded that there is good indirect evidence that even small increases in the quit rates from tobacco cessation counseling would produce important health benefits, and that the benefits of counseling interventions substantially outweigh any potential harms.
The USPSTF strongly recommends that clinicians screen all pregnant women for tobacco use and provide augmented pregnancy-tailored counseling to those who smoke (A recommendation).
The USPSTF found good evidence that extended or augmented smoking cessation counseling (5-15 minutes) using messages and self-help materials tailored for pregnant smokers, compared with brief generic counseling interventions alone, substantially increases abstinence rates during pregnancy,
and leads to increased birth weights. Although relapse rates are high in the post-partum period, the USPSTF concluded that reducing smoking during pregnancy is likely to have substantial health benefits both for the baby and the expectant mother. The USPSTF concluded that the benefits of smoking cessation
counseling outweigh any potential harms.
The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for tobacco use or interventions to prevent and treat tobacco use and dependence among children or adolescents (I recommendation).
The USPSTF found limited evidence that screening and counseling children and adolescents in the primary care setting are effective in either preventing initiation or promoting cessation of tobacco use. As a result, the USPSTF could not determine the balance of benefits and harms of tobacco prevention or cessation interventions in the clinical setting for children or adolescents.
Clinical Considerations
- Brief tobacco cessation counseling interventions, including screening, brief counseling (3 minutes or less), and/or pharmacotherapy, have proven to increase tobacco abstinence rates, although there is a dose-response relationship between quit rates and the intensity of counseling. Effective interventions may be delivered by a variety of primary care clinicians.
- The "5-A" behavioral counseling framework provides a useful strategy for engaging patients in smoking cessation discussions: (1) Ask about tobacco use; (2) Advise to quit through clear personalized messages; (3) Assess willingness to quit; (4) Assist to quit; and (5) Arrange follow-up and support. Helpful aspects of counseling include providing problem-solving guidance for smokers to develop a plan to quit and to overcome common barriers to quitting and providing social support within and outside of treatment. Common practices that complement this framework include motivational interviewing, the 5 R's used to treat tobacco use (relevance, risks, rewards, roadblocks, repetition), assessing readiness to change, and more intensive counseling and/or referrals for quitters needing extra help. Telephone "quit
lines" have also been found to be an effective adjunct to counseling or medical therapy.
- Clinics that implement screening systems designed to regularly identify and document a patient's tobacco use status increased their rates of clinician intervention, although there is limited evidence for the impact of screening systems on tobacco cessation rates.
- FDA-approved pharmacotherapy that has been identified as safe and effective for treating tobacco dependence includes several forms of nicotine replacement therapy (i.e., nicotine gum, nicotine transdermal patches, nicotine inhaler, and nicotine nasal spray) and sustained-release bupropion. Other medications, including clonidine and nortriptyline, have been found to be efficacious and may be considered.
- Augmented pregnancy-tailored counseling (e.g., 5-15 minutes) and self-help materials are recommended for pregnant smokers, as brief interventions are less effective in this population. There is limited evidence to evaluate the safety or efficacy of pharmacotherapy during pregnancy. Tobacco cessation at any point during pregnancy can yield important health benefits for the mother and the baby, but there are limited data about the optimal timing or frequency of counseling interventions during pregnancy.
- There is little evidence addressing the effectiveness of screening and counseling children or adolescents to prevent the initiation of tobacco use and to promote its cessation in a primary care setting, but clinicians may use their discretion in conducting tobacco-related discussions with this
population, since the majority of adult smokers begin tobacco use as children or adolescents.
Definitions
The Task Force grades its recommendations according to one of 5 classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms):
A
The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.
B
The USPSTF recommends that clinicians provide [this service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.
C
The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D
The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.
I
The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that [the service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor):
Good
Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.
Fair
Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.
Poor
Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.
