The recommendations for tobacco use prevention and cessation for adults and mature adolescents are presented in the form of an algorithm Tobacco Use Prevention and Cessation for Adults and Mature Adolescents, with 16 components, accompanied by detailed annotations. Clinical highlights and selected annotations (numbered to correspond with the algorithm) follow.
Class of evidence (A-D, M, R, X) and conclusion grade (I-III, Not Assignable) definitions are provided at the end of the "Major Recommendations" field
Clinical Highlights
- Ask about tobacco use and secondhand smoke exposure at every opportunity. (Annotations #2 and 2a)
- Advise all tobacco users to stop. (Annotations #13 and 15)
- Assess tobacco user's willingness to make a quit attempt. (Annotations #12 and 14)
- Assist tobacco user's efforts to quit. (Annotations #8 and 9)
- Arrange for follow-up. (Annotations #9 and 16)
Tobacco Use Prevention and Cessation for Adults and Mature Adolescents Algorithm Annotations
- Community Intervention
Key Points:
- Tobacco use is the single most preventable cause of disease and death in our society.
- The guideline developers urge Institute for Clinical Systems Improvement (ICSI) participating medical groups, clinicians, insurance plans and employers to actively intervene within their community to reduce tobacco use.
Tobacco use is the single most preventable cause of disease and death in our society. The Centers for Disease Control recommend that tobacco control programs be established that are comprehensive, sustainable, and accountable. The goal of a comprehensive tobacco control program is to reduce disease, disability, and death related to tobacco use by:
- preventing the initiation of tobacco use among young people
- promoting cessation among young people and adults
- eliminating nonsmokers exposure to secondhand smoke
- identifying and eliminating the disparities related to tobacco use and its effects among different population groups.
The components of a comprehensive tobacco control program include:
- community programs to reduce tobacco use
- chronic disease programs to reduce the burden of tobacco-related diseases
- school programs
- enforcement
- statewide programs
- counter-marketing
- cessation programs
- surveillance and evaluation
- administration and management
The guideline developers urge ICSI participating medical groups, clinicians, insurance plans and employers to actively intervene within their community to reduce tobacco use. The establishment of smoke-free public spaces, limiting youth access to tobacco, restrictions on advertising, counter-advertising, and increasing economic disincentives to tobacco use are among the most effective community actions to be supported.
Evidence supporting this recommendation is of classes: M, R
- Establish Tobacco Use for All Patients and Reassess Users at Every Clinic Visit
Key Points:
- Adults who have not used tobacco for at least 12 months and who have an easily visible mark on their chart to that effect should be asked about their tobacco use status yearly until abstinent for 5 years.
- Everyone without a tobacco use mark on the chart or those with a mark indicating use within the past 6 months should be asked at nearly every visit.
- Adolescents should have usage reassessed at nearly every visit, regardless of whether there is a chart notation of nonuse.
Everyone without a tobacco use mark on the chart or those with a mark indicating use within the past 6 months should be asked at nearly every visit about current use and the answer documented for the provider. This frequency of use assessment should be established as a clinic policy and should be done by a staff person, preferably the one who rooms the patient.
The two most common ways to indicate tobacco use status are with an appropriate label on the chart or with a vital sign in the progress notes.
Adolescents should have usage reassessed at nearly every visit, regardless of whether there is a chart notation of non-use, due to the risk of beginning tobacco use at any time.
Tobacco cessation is particularly important during pregnancy. For more information, see the related National Guideline Clearinghouse (NGC) summaries of the Institute for Clinical Systems Improvement's (ICSI's) guidelines: Management of Labor and Routine Prenatal Care. The guideline developers recommend that clinics have a particularly consistent identification and cessation program for pregnant women and preconception visits.
Tobacco cessation is also very important in those individuals with heart disease or other risk factors for heart disease. (See the related NGC summaries of the ICSI guidelines: Stable Coronary Artery Disease, Hypertension Diagnosis and Treatment).
Evidence supporting this recommendation is of classes: A, C, D, M, R
2a. Establish Secondhand Smoke Exposure for All Patients and Encourage a Smoke-Free Environment
Key Points:
- Inform patients of their increased risk of disease due to second-hand smoke exposure. Encourage a smoke-free living and working environment.
Inform patients of their increased risk of disease due to second-hand smoke exposure. Encourage a smoke-free living and working environment for patients, and assist the exposed patient to communicate with other household members about decreasing smoking in the house. Encourage the patient to support smoking cessation efforts among other household members who use tobacco.
Evidence supporting this recommendation is of classes: M, R
- Document the Tobacco Use Discussion
Key Point:
- All discussions with tobacco users should be documented.
All discussions with tobacco-users should be documented, either in the progress note or on a special card or flow sheet if a clinic uses that approach. This documentation should include the user's attitude toward treatment and any quitting plans agreed upon. The documentation can be very brief. Documentation is necessary to facilitate coordination between various providers and support staff, to permit follow-up and referral arrangements, and to allow subsequent visits to build on discussions started earlier.
- Reinforce Nonuse
Key Point:
- Compliment and reinforce nonuse in former tobacco users.
If time permits, it is helpful to compliment former tobacco-users. These former users are considered to be in the Maintenance stage once they have quit for at least 12 months. Although a former user can return to tobacco use after years of abstinence, the recidivism rate reaches a low level by 12 months. The guideline developers suggest monitoring the patient for 12 months.
Evidence supporting this recommendation is of class: R
- When Did the Patient Last Use Tobacco?
Although the usual definition of a user is one who uses tobacco daily, it would be ideal to classify any individual using tobacco with any frequency as a user.
- 0 – 12 Months Ago
Those who have quit using tobacco within the last month (particularly within the past week) are at a very high risk for resuming usage. Reinforcement and follow-up can be crucial for these individuals.
Evidence supporting this recommendation is of class: M
- Wants Extra Help in Remaining Tobacco-Free?
A former user who is having some trouble remaining tobacco-free may want or need more help than the provider can supply in the 2 to 3 minutes available to discuss this topic. Common difficulties include weight gain, stress, withdrawal symptoms, or social/habit/psychological needs.
- Congratulate on Quitting/Encourage In-Office or Referral Counseling
Key Points:
- The first 12 months after quitting (especially the first 2 weeks) is when one is at the highest risk for relapse.
- Follow-up options include a face-to-face, telephoned or mailed (postal or electronic) expression of support and willingness to help.
Those who have quit using tobacco within the last month (particularly within the past week) are at a very high risk for resuming use. Reinforcement and follow-up can be crucial during this period.
The first 12 months after quitting are the transition between the Action and Maintenance stages. These months (especially the first 2 weeks), when one is at the highest risk for relapse, are the most challenging. Encourage the patient to avoid temptations to use tobacco again. Smoking cessation often takes 3 to 4 attempts before long-term success is achieved.
Counseling can be done by the provider or, preferably, by other staff, and should be designed to help patients problem-solve any of the difficulties referred to in Annotation #8.
Counseling can also be achieved by referring a user to groups, a non-office counselor, or an external tobacco cessation specialist. It should be recognized, though, that most patients are unwilling to attend such groups, especially if they are separate from the clinic. However, any such referrals should not replace clinician advice and assistance.
If a practice does not have a way for providers to easily and efficiently refer to staff or others when a complex quitting problem is brought up, it becomes impossible for the provider to complete the tobacco discussion within 1 to 3 minutes. The result will be that providers will be understandably reluctant to bring up the topic with every user as is needed for success.
Follow-up options include a face-to-face, telephoned, or mailed (postal or electronic) expression of support and willingness to help. The timing of follow-ups should be discussed with the patient; generally, the follow-up should come at the time when it will be most needed or wanted. Follow-ups can be expertly performed by office staff.
Regardless of the desirability of return visits, the guideline developers believe that there is neither time nor likelihood of return visits happening very frequently, so other arrangements should be made.
- Intending to Quit in Next 6 Months?
Key Points:
- The goal should be to discuss tobacco cessation at nearly every visit.
- Progress from one stage of readiness to quit to the next is valuable.
Assessment of interest in quitting and timing of that interest should be done after the main reasons for the visit have been addressed, and should precede any advice about quitting. This allows a 1 to 3 minute tobacco discussion accommodating both the user's needs and the provider's time limits.
It is recognized that this discussion may not be possible or appropriate at each visit. The goal should be to discuss tobacco cessation at nearly every visit.
Remember that progress from one stage of readiness to quit to the next is valuable.
The guideline developers have incorporated the exciting and scientifically-based concept of readiness stages for behavior change developed by Prochaska and DiClemente, which have been particularly tested in tobacco cessation, into this guideline. The guideline developers believe that these stages (see Annotations #9-12) can focus the physician message and make it more effective and feasible. However, it is necessary for the provider to first assess readiness to quit by asking if a user would consider quitting and then asking when (> 6, 1-6, or 0-1 months). The strategy taken should then be tailored to the individual user's readiness stage.
Evidence supporting this recommendation is of classes: C, R
- Patients Not Intending to Quit in Next 6 Months
Key Point:
- A "precontemplator" benefits from nonconfrontational messages about importance of quitting and the awareness that provider help is available when ready.
A user not ready to consider quitting within the next 6 months is called a precontemplator and is helped most when a provider avoids confrontation while conveying both the message that quitting is important and the desire to be helpful when the user is ready to consider quitting. A simple informational pamphlet about the problems attending tobacco use and an expression of the provider's desire to be helpful are far more productive than an attempt to scare or argue unwilling users into quitting.
- Intending to Quit in Next Month?
See Annotation #12, "Intending to Quit in Next 6 Months?"
- Patient Not Intending to Quit in Next Month
Key Points:
- A "contemplator" is accepting of supportive urging to quit and encouragement of a plan.
- Ask a tobacco user who is ready to quit to set his/her own date.
The contemplator is considering quitting within the next 1 to 6 months. Contemplators are accepting of supportive and respectful urging to quit and encouragement to start thinking about a serious plan for doing so. Persuasive written, audio, or video information about the pros and cons of quitting may be appropriate for contemplators.
Virtually every tobacco-cessation expert and program, including the National Cancer Institute program, recommends asking a tobacco user who is ready to quit to set his/her own quit date. They also recommend some type of follow-up, often a return visit. Because users are unlikely to keep the appointment, alternatives such as phone calls are usually substituted.
Evidence supporting this recommendation is of classes: C, R
- Assist the Patient to Quit
Key Points:
- Ask a tobacco user who is ready to quit to set his/her own quit date.
- Three treatment elements are effective for smoking cessation intervention: pharmacotherapy, social support for cessation, and skills training/problem-solving.
- On average, nicotine replacement therapy (NRT) and Zyban (bupropion SR) double the probability of success.
- Combining nicotine patches with other self-administered forms of NRT (gum, spray) is more effective than a single form of NRT.
- Minnesotans have high-quality free telephone line counseling for smoking cessation.
- Other resources include local tobacco cessation classes, community support systems, and self-help brochures and materials from drug companies.
Negotiate the Quit Date
The National Cancer Institute program recommends asking a tobacco-user who is ready to quit to set his/her own quit date.
Counsel to Support Cessation and Build Abstinence Skills
The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline emphasizes that three treatment elements in particular are effective for smoking cessation intervention: pharmacotherapy, social support for cessation, and skills training/problem-solving. The guideline emphasizes the dose-response relationship between the intensity and duration of treatment and its effectiveness. In general, the more intense the treatment, the more effective it is in producing long-term abstinence from tobacco. These principles should be kept in mind when counseling and assisting the patient to stop using tobacco.
Evidence supporting this recommendation is of classes: A, C, M, R
Discuss Pharmacotherapy
On average, nicotine replacement therapy (NRT) and Zyban (bupropion SR) double the probability of success. It is most effective if the patient agrees to completely stop tobacco use with the start of NRT or 1 week after starting Zyban (bupropion), and the patient agrees to participate in a follow-up program of some type. NRT includes nicotine gum, nicotine lozenges, nicotine transdermal patches, nicotine inhalers, and nicotine nasal spray.
The nicotine lozenge has proven to be effective in helping patients quit smoking. [Conclusion Grade I: See Conclusion Grading Worksheet – Appendix A – Annotation #16 (Nicotine Lozenge) in the original guideline document].
Nicotine nasal spray has been shown to be effective. It is, however, the most addictive of the products and is probably best reserved for patients who have failed other forms of NRT, who still desire to use a product to become completely tobacco-free.
Bupropion (Zyban) has been found to be efficacious in smoking cessation and can be offered to patients who have no history of seizures, no history of eating disorders, or who are not taking any other form of bupropion (i.e., Wellbutrin) or monoamine oxidase (MAO) inhibitors.
Suggestions on the clinical use of nicotine patches can be found in the Annotation Appendix A of the original guideline document; nicotine gum in Annotation Appendix B; nicotine lozenges in Annotation Appendix C; bupropion SR in Annotation Appendix D; nicotine inhalers in Annotation Appendix E; and nicotine nasal spray in Annotation Appendix F.
Evidence supporting this recommendation is of classes: A, R
Combination Therapy
Combining nicotine patches with other self-administered forms of NRT (gum, lozenge or spray) may be more effective than a single form of NRT. [Conclusion Grade I: See Conclusion Grading Worksheet – Appendix B – Annotation #16 (Combination Therapy) in the original guideline document]
If patients use NRT or Zyban, it is important for them to become completely tobacco-free. Ongoing use of tobacco predicts failure long-term. One strategy is to encourage patients to make their tobacco-free program more intense with each use of tobacco after their quit date. They can add an exercise program, call a help line, ask for a friend's help, read a pamphlet, etc.
Although both pregnancy and cardiovascular disease are described as contraindications for the use of NRT, there is evidence of safety in these conditions, and NRT is more safe than smoking.
Clinicians should encourage their patients to check with their insurance plans, as coverage is sometimes available for NRT.
Evidence supporting this recommendation is of classes: A, C, D, M
Offer Phone Line
Minnesotans have high quality free telephone line counseling for smoking cessation. Clinicians are advised to refer patients to their respective health plan quitlines. If a patient does not belong to one of the health plans listed in the original guideline document, s/he should refer to the QUITPLAN Helpline: 1-888-354-PLAN. They are also planning to offer face-to-face counseling soon. It is helpful to provide a handout with tobacco quitline numbers when referring to a quitline. These handouts are available from Blue Cross Blue Shield of Minnesota.
An important message to convey to smokers is that quitline counselors provide expert advice in a friendly and supportive manner.
- Smokers can consult quitlines for assistance about any issue related to tobacco cessation.
- Quitline counselors can answer brief questions or provide counseling, depending on the needs of the smoker.
- Quitlines can help smokers who are not quite ready to quit as well as those who have set a quit date.
- Smokers who are not quite ready to quit can receive assistance in figuring out the next steps.
- Quitlines can also help smokers who have quit but are having difficulty maintaining cessation.
- Quitlines can send written self-help materials and may provide free NRT.
- The quitlines also can help those who want to know how to support someone who is trying to quit.
Evidence supporting this recommendation is of class: A
Other Resources
Consideration may also be given to making a referral to a tobacco cessation consultant or a center with programs in tobacco cessation. Other resources include local tobacco cessation classes, community support systems, and self help brochures and materials from drug companies.
Evidence supporting this recommendation is of class: A
Encourage Follow-up
Encourage the patient to arrange for a follow-up soon after the quit date.
Evidence supporting this recommendation is of class: R
Definitions:
Classes of Research Reports:
- Primary Reports of New Data Collection:
Class A:
- Randomized, controlled trial
Class B:
Class C:
- Nonrandomized trial with concurrent or historical controls
- Case-control study
- Study of sensitivity and specificity of a diagnostic test
- Population-based descriptive study
Class D:
- Cross-sectional study
- Case series
- Case report
- Reports that Synthesize or Reflect upon Collections of Primary Reports:
Class M:
- Meta-analysis
- Systematic review
- Decision analysis
- Cost-effectiveness analysis
Class R:
- Consensus statement
- Consensus report
- Narrative review
Class X:
Conclusion Grades:
Grade I: The evidence consists of results from studies of strong design for answering the question addressed. The results are both clinically important and consistent with minor exceptions at most. The results are free of any significant doubts about generalizability, bias, and flaws in research design. Studies with negative results have sufficiently large samples to have adequate statistical power.
Grade II: The evidence consists of results from studies of strong design for answering the question addressed, but there is some uncertainty attached to the conclusion because of inconsistencies among the results from the studies or because of minor doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from weaker designs for the question addressed, but the results have been confirmed in separate studies and are consistent with minor exceptions at most.
Grade III: The evidence consists of results from studies of strong design for answering the question addressed, but there is substantial uncertainty attached to the conclusion because of inconsistencies among the results from different studies or because of serious doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from a limited number of studies of weak design for answering the question addressed.
Grade Not Assignable: There is no evidence available that directly supports or refutes the conclusion.
