This Quick Reference Guide summarizes the guideline strategies for providing appropriate treatments for every patient. Effective treatments for tobacco dependence now exist, and every patient should receive at least minimal treatment everytime he or she visits a clinician. The first step in this process—identification and assessment of tobacco use status—separates patients into three treatment categories: Patients willing to quit, patients unwilling to quit, and patients who have recently quit.
Printed copies of Treating Tobacco Use and Dependence are available from any of the following Public Health Service clearinghouses: the Agency for Healthcare Research and Quality (800-358-9295); Centers for Disease Control and Prevention (800-CDC-1311); and the National Cancer Institute (800-4-CANCER).
Front Matter
Purpose
Key Findings
Identification and Assessment of Tobacco Use
Tobacco Users Willing To Quit
Tobacco Users Unwilling To Quit
Former Smokers—Preventing Relapse
Conclusion
Guideline Availability
The Public Health Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and Dependence, on which this Quick Reference Guide for Clinicians is based was developed by a multidisciplinary, non-Federal panel of experts, in collaboration with a consortium of tobacco cessation representatives, consultants, and staff.
Panel members and guideline staff were:
Guideline Panel
Michael C. Fiore, MD, MPH (Panel Chair)
William C. Bailey, MD
Stuart J. Cohen, EdD
Sally Faith Dorfman, MD, MSHSA
Michael G. Goldstein, MD
Ellen R. Gritz, PhD
Richard B. Heyman, MD
Carlos Roberto Jaen, MD, PhD
Thomas E. Kottke, MD, MSPH
Harry A. Lando, PhD
Robert E. Mecklenburg, DDS, MPH
Patricia Dolan Mullen, DrPH
Louise M. Nett, RN, RRT
Lawrence Robinson, MD, MPH
Maxine L. Stitzer, PhD
Anthony C. Tommasello, MS
Louise Villejo, MPH, CHES
Mary Ellen Wewers, PhD, RN
Guideline Staff
Timothy Baker, PhD
Victor Hasselblad, PhD
Brion J. Fox, JD
An explicit, science-based methodology was employed along with expert clinical judgment to develop recommendations on treating tobacco use and dependence. Extensive literature searches were conducted and critical reviews and syntheses were used to evaluate empirical evidence and significant outcomes. Peer review was undertaken to evaluate the validity, reliability, and utility of the guideline in clinical practice.
This Quick Reference Guide for Clinicians presents summary points from the Clinical Practice Guideline. The guideline provides a description of the development process, thorough analysis and discussion of the available research, critical evaluation of the assumptions and knowledge of the field, more complete information for health care decisionmaking, and references. Decisions to adopt particular recommendations from either publication must be made by practitioners in light of available resources and circumstances presented by the individual patient.
As clinicians, you are in a frontline position to help your patients by asking two key questions: "Do you smoke?" and "Do you want to quit?" followed by use of the recommendations in this Quick Reference Guide for Clinicians.
This Quick Reference Guide for Clinicians contains strategies and recommendations from the Public Health Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and Dependence. The guideline was designed to assist clinicians; smoking cessation specialists; and health care administrators, insurers, and purchasers in identifying and assessing tobacco users and in delivering effective tobacco dependence interventions. It was based on an exhaustive systematic review and analysis of the extant scientific literature from 1975 to 1999, and uses the results of more than 50 meta-analyses.
This Quick Reference Guide summarizes the guideline strategies for providing appropriate treatments for every patient. Effective treatments for tobacco dependence now exist, and every patient should receive at least minimal treatment every time he or she visits a clinician. The first step in this process—identification and assessment of tobacco use status—separates patients into three treatment categories:
This document is in the public domain and may be used and reprinted without special permission. The Public Health Service appreciates citation as to source, and the suggested format is provided below:
Fiore MC, Bailey WC, Cohen SJ, et. al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. October 2000.
Tobacco is the single greatest cause of disease and premature death in America today, and is responsible for more than 430,000 deaths each year. Nearly 25 percent of adult Americans currently smoke, and 3,000 children and adolescents become regular users of tobacco every day. The societal costs of tobacco-related death and disease approach $100 billion each year. However, more than 70 percent of all current smokers have expressed a desire to stop smoking; if they successfully quit, the result will be both immediate and long-term health improvements. Clinicians have a vital role to play in helping smokers quit.
The analyses in the Clinical Practice Guideline, Treating Tobacco Use and Dependence, demonstrate that efficacious treatments for tobacco users exist and should become a part of standard caregiving. Research also shows that delivering such treatments is cost-effective. In summary, the treatment of tobacco use and dependence presents the best opportunity for clinicians to improve the lives of millions of Americans nationwide in a cost-effective manner.
The guideline identified a number of key findings that clinicians should utilize:
The single most important step in addressing tobacco use and dependence is screening for tobacco use. After the clinician has asked about tobacco use and has assessed the willingness to quit, he or she can then provide the appropriate intervention, either by assisting the patient in quitting (the "5A's") or by providing a motivational intervention, the ("5 R's"). Figure 1 (22 KB) can be used as a guide to identify both current and former tobacco users and to provide the appropriate treatment of all patients. The following three sections address the main three groups of patients:
The "5 A's," Ask, Advise, Assess, Assist, and Arrange, are designed to be used with the smoker who is willing to quit.
Action | Strategies for Implementation |
Implement an officewide system that ensures that, for every patient at every clinic visit, tobacco-use status is queried and documented.a | Expand the vital signs to include tobacco use or use an alternative universal identification system.b |
Vital Signs Blood Pressure:__________________________________________ Pulse: _____________________ Weight: _____________________ Temperature: ____________________________________________ Respiratory Rate: ________________________________________ Tobacco Use: (circle one) Current Former Never |
a Repeated assessment is not necessary in the case of the adult who has never used tobacco or has not used tobacco for many years, and for whom this information is clearly documented in the medical record.
b Alternatives to expanding the vital signs are to place tobacco-use status stickers on all patient charts or to indicate tobacco use status using electronic medical records or computer reminder systems.
Action | Strategies for Implementation |
In a clear, strong, and personalized manner, urge every tobacco user to quit. | Advice should be:
|
Action | Strategies for Implementation |
Ask every tobacco user if he or she is willing to make a quit attempt at this time (e.g., within the next 30 days). | Assess patient's willingness to
quit:
|
Action | Strategies for Implementation |
Help the patient with a quit plan. | A patient's preparations for quitting:
|
Provide practical counseling (problem solving/training). |
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Provide intra-treatment social support. |
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Help patient obtain extra-treatment social support. |
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Recommend the use of approved pharmacotherapy, except in special circumstances. |
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Provide supplementary materials. |
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Assist Component—Three Types of Counseling
Assisting patients in quitting smoking can be done as part of a brief treatment or as part of an intensive treatment program. Evidence from the guideline demonstrates that the more intense and longer lasting the intervention, the more likely the patient is to stay smoke-free; even an intervention lasting fewer than 3 minutes is effective.
The following three tables provide further detail and examples of the three forms of counseling that were found to be effective in treating tobacco use and dependence:
Practical counseling (problemsolving/skills training) treatment component |
Examples |
Recognize danger situations—Identify events, internal states, or activities that increase the risk of smoking or relapse. |
|
Develop coping skills—Identify and practice coping or problemsolving skills. Typically, these skills are intended to cope with danger situations. |
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Provide basic information—Provide basic information about smoking and successful quitting. |
|
Supportive treatment component | Examples |
Encourage the patient in the quit attempt. |
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Communicate caring and concern. |
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Encourage the patient to talk about the quitting process. |
Ask about:
|