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A direct comparison of the Public Health Service (PHS), University of Michigan Health System (UMHS), and Department of Veteran Affairs, Department of Defense (VA/DoD) recommendations for tobacco use cessation is provided in the tables below.
Following the tables and discussion of content comparison, the areas of agreement and areas of differences among the guidelines are identified.
Related Guideline
Listed below are common abbreviations used within the tables and discussions:
TABLE 3: RECOMMENDATIONS FOR TOBACCO USE CESSATION AND PREVENTION | |
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INITIAL INTERVENTIONS | |
Screening for Tobacco Use | |
PHS (2008) |
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) |
UMHS (2006) |
Key Points ASK all patients about smoking status and assess smoker's readiness to quit. Smoking status should be documented in the medical record. Rationale for Recommendations All patients should be asked about their smoking status and assessed for their willingness to quit (see Table 1 in the original guideline document). If a patient smokes, this should be documented in the medical record so that intervention can be offered. Techniques to remind the physician of a patient's smoking status include smoking status stickers, listing tobacco use on active problem list of tobacco status as part of vital signs. |
VA/DoD (2004) |
Ask About Tobacco Use Patients should be asked about tobacco use at most visits, as repeated screening increases rates of clinical intervention. [A]
Background. In order to assess tobacco use status, all patients should be asked about their use of tobacco (including the use of tobacco in any form) upon visiting any provider. This may be accomplished when the patient's vital signs are taken. The tobacco use status should be noted in the patient's record. If the medical record indicates that the patient has never used tobacco or has not used it for many years, repeated assessment is not necessary. |
Advise Tobacco Users to Quit | |
PHS (2008) |
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) |
UMHS (2006) |
Key Points ADVISE all smokers to seriously consider making a quit attempt using a clear, strong, and personalized message. Advice as brief as 3 minutes is effective in smoking cessation [A]. Rationale for Recommendations Brief clinician advice should be offered to the patient, including a personalized message as to why it is important to quit smoking now. Patients should then be asked about their willingness to quit smoking in the next month. |
VA/DoD (2004) |
Advise to Quit
Background. Every health care team member should urge every tobacco user to quit. Repeated messages on the importance of quitting made over time have an accumulated effect on encouraging patients to quit. This message should be delivered in the brief "advice" format such that it is clear, (e.g., "I think it is important for you to quit tobacco use now and I can help you."), concise, strong, (e.g., "As your clinician I want you to know that quitting tobacco use is the most important thing you could do to protect your health.") and personalized (e.g., "Quitting your tobacco use will help improve your [health symptom or specific disease]"). |
Assess Willingness to Quit and Provide Motivational Strategies | |
PHS (2008) |
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)
Tobacco dependence treatment is effective and should be delivered even if specialized assessments are not used or available. (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) |
UMHS (2006) |
ASSESS all smokers' willingness to make a quit attempt. If not yet ready to quit, offer motivational intervention using the 5 "R's":
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VA/DoD (2004) |
Assess Willingness to Quit Tobacco users should be assessed for willingness to quit at every visit. [C]
Background. Tobacco users should be given advice appropriate to their level of interest in quitting. Approximately 70 percent of tobacco users want to quit. The patient's level of interest will determine subsequent steps to be taken. By knowing the person's stage of willingness to quit tobacco use, the health care provider can decide whether to provide motivational material to quit tobacco use or, alternatively, specific instructions to help the person quit. Promote Motivation to Quit Tobacco users who are not willing to quit at this time should receive brief, non-judgmental motivational counseling designed to increase their motivation to quit, to include discussion about [Expert Consensus]:
Use of motivational intervention should be considered. This technique has been shown to be beneficial in motivating and changing behaviors of individuals with other substance use dependencies, including some evidence in cessation of smoking. [B] |
TREATMENT | |
Referral and/or Determination of Treatment Plan | |
PHS (2008) |
No specific recommendations offered. |
UMHS (2006) |
REFER patients interested in quitting within 30 days to a tobacco treatment specialist or other appropriate tobacco cessation program. Alternatively, health care providers can directly provide the following treatment: Treatment Options
Rationale for Recommendations Refer If patients are willing to make a quit attempt, the clinician has two options. The first option is to refer the patient to a Tobacco Treatment Specialist (TTS) or other appropriate tobacco cessation program. A TTS is a trained health professional who specializes in the treatment of tobacco dependence as part of his or her professional role. The TTS demonstrates the knowledge and skills to provide effective and evidence-based treatment for tobacco dependence. The TTS also serves as a resource and consultant to other healthcare professionals. The TTS can also provide the most effective and appropriate treatment to special populations (e.g. patients with a variety of co-morbidities, chemical dependency, or pregnancy). Many health care organizations have a TTS on staff. Local tobacco treatment specialists can be identified by state tobacco control agencies or through the Association for Treatment of Tobacco Use and Dependence (www.attud.org). Many national organizations such as the American Cancer Society and American Lung Association offer tobacco cessation programs. Listings of local programs can often be obtained through state and local health departments. The second option is to treat the patient. Several factors make health care settings ideal for delivery of smoking cessation interventions. As stated above, at least 70% of smokers see a physician each year. As many as 70% of these smokers report a desire to quit and have made at least one serious quit attempt. Smokers also report that advice from a clinician is an important motivator to quit. |
VA/DoD (2004) |
Educate about Treatment Options; Arrive at Shared Decision for Choice of Treatment; Determine and Document Treatment Plan Providers and patients should discuss the range of available treatment options and arrive at a mutually agreeable treatment plan. Discussion should address [Expert Consensus]:
Patient education and a treatment plan should be documented in the patient's record. [Expert Consensus] Assist Tobacco User to Quit All tobacco users who are willing to quit should be offered an effective tobacco cessation intervention, including:
All tobacco users must have reasonable access to minimal counseling and to either an intermediate or intensive cessation program. [A] Cessation treatment may include the following components:
Aversive smoking interventions (rapid smoking, rapid puffing, other aversive smoking techniques) increase abstinence rates and may be used with smokers who desire such treatment or who have been unsuccessful using other interventions. [B] Although aversive smoking has been demonstrated to be effective, it is rarely used due to the availability of medication. There is insufficient evidence to recommend for or against the use of the following interventions:
There is insufficient evidence to support the following strategies: relaxation/breathing, contingency contracting, weight/diet, cigarette fading, exercise, and negative effect. Exercise may be considered to help prevent the weight gain associated with tobacco cessation. [I] |
Counseling and Behavioral Therapies | |
PHS (2008) |
Treatment Structure and Intensity 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) 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) |
UMHS (2006) |
Refer patients interested in quitting within 30 days to a tobacco treatment specialist or other appropriate tobacco cessation program. Alternatively, health care providers can directly provide the following treatment:
Rationale for Recommendations Treatment — Counseling There is a strong dose response relationship between the intensity of person-to-person contact and successful outcomes [A]. When providing counseling, health care providers should be aware that barriers to smoking cessation include, but are not limited to, severe withdrawal during previous quit attempts, the presence of other smokers in the home or workplace, stressful life circumstances, psychiatric co-morbidities (i.e. depression, alcoholism), multiple quit attempts, and low motivation. Identifying these barriers during initial assessment will help to provide a tailored approach during counseling. In addition to clinician counseling in the office, intensive counseling (frequently defined as a minimum of weekly meeting for the first 4 to 7 weeks of cessation) significantly enhances cessation rates. However, participation in intensive counseling is based largely on patients' motivation to quit [C]. In some locations, if physicians formally refer patients to a tobacco cessation program, a third party may cover the fee with patients paying a reduced or no fee. |
VA/DoD (2004) |
Initiate Counseling Counseling in the Clinic Tobacco users who are willing to quit should receive some form of counseling. There is a dose-response relationship in counseling and rate of abstinence. [A]
Effective counseling can be delivered in multiple formats (e.g., group counseling, proactive telephone counseling, and individual counseling) and may be more effective when combined. [A] Counseling should be provided by a variety of clinician types (physicians or nonphysician clinicians, such as nurses, dentists, dental hygienists, psychologists, pharmacists, and health educators) to increase quit rates. [A] All patients who are willing to quit should have access to intensive counseling (Quitlines or intensive cessation program). Quitlines Tobacco users who are willing to quit may receive counseling via telephone Quitlines, as proactive telephone counseling has been demonstrated to be effective. Pharmacotherapy still needs to be coordinated by the primary care provider. [A] Background. There is strong evidence that behavioral interventions work. More intense interventions, as defined by face-to-face contact, using a multidisciplinary approach and multiple formats, result in better cessation outcomes. However, even brief counseling increases overall abstinence rates. Effective counseling can also be provided by a wide variety of health care professionals, in addition to the patient's primary care physician. Tobacco use counseling and treatment can be provided in a variety of settings. It is crucial that the provider ensures that the tobacco user receives counseling and medication to assist him/her in quitting, regardless of the setting. Counseling tobacco users should start with having the patient set a quit date. Counseling and behavioral tobacco use cessation interventions should include: (1) providing practical counseling (problem-solving skills/skills training), (2) providing social support as part of treatment, and (3) helping tobacco users obtain social support outside of treatment. These three types of counseling and behavior therapies result in higher abstinence rates. Proactive telephone counseling, such as that provided by a Quitline, is another effective option for providing counseling to tobacco users. |
Pharmacotherapy | |
PHS (2008) |
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 Bupropion SR is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A) NRT 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:
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:
Medications Not Recommended by the Guideline Panel
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) Other Specific Populations and Topics 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) |
UMHS (2006) |
Treatment — Pharmacologic Therapies NRT, bupropion hydrochloride (Zyban), and varenicline (Chantix®) have been shown to significantly improve cessation rates [A]. Therefore, pharmacologic therapy should be recommended to all patients except in the presence of specific contraindications. Bupropion and varenicline are the two non-nicotine products with FDA approval for smoking cessation. Non-FDA approved agents with potential benefit in smoking cessation include nortriptyline and clonidine. These drugs may best be used as second-line agents when patients cannot take or do not wish to take either NRT, bupropion, or varenicline [D]. NRT The various NRTs significantly decrease symptoms of the withdrawal syndrome as smokers abruptly stop smoking [A]. In very highly dependent smokers, 4 mg gum is superior to 2 mg and most effective with counseling [A]. High dose patch therapy (i.e., 44 mg/24 hr = two patches) is safe and decreases withdrawal symptoms in highly dependent smokers, but does not increase long term cessation rates [A]. Those smoking 5 or fewer cigarettes per day have been shown to have few symptoms of nicotine withdrawal when they quit [C] and may not require NRT [D]. For those using nicotine gum, spray or inhaler, it is important that they are instructed in technique and dosing frequency so that underdosing does not occur. See Table 4 in the original guideline document for dosing and administration recommendations. The patient should also be provided with the educational handout, "How to Use Your Nicotine Product." Combining NRTs Given the additional cost of dual therapies (e.g., patch plus gum; patch plus inhaler; patch plus nasal spray) and limited benefit, combining NRT is best reserved for highly addicted smokers with several previous failed quit attempts [D]. Patients with Cardiovascular Disease The patch and nasal spray have demonstrated safety in patients with stable coronary artery disease [A]. While patients should be reminded not to smoke while using these products, studies have shown no increase in cardiac event rates when patients smoke while wearing the patch [C]. Choosing between Bupropion Hydrochloride or Nicotine Replacement A single trial sponsored by the manufacturer of Zyban suggests that bupropion may be superior to nicotine patch therapy [A]. Given this single study, it remains reasonable to consider patient preferences, previous quit attempt experiences and cost when choosing among pharmacologic therapies [D]. For smokers who have previously been unsuccessful, one randomized study showed higher success rates for both bupropion alone or in combination with the nicotine patch, compared to nicotine patch alone [A]. |
VA/DoD (2004) |
Initiate Pharmacotherapy to Assist Quit Tobacco users attempting to quit should be prescribed one or more effective first-line pharmacotherapies for tobacco use cessation. [A]
Tobacco users who do not respond to first-line therapies should:
Combination therapy may be effective for patients unable to quit with a single first-line agent. [B]
If patient has not responded after 2 courses of treatment, re-evaluate to assess the need of referral to intensive cessation program. Pharmacotherapies NOT recommended for tobacco cessation: antidepressants other than bupropion SR and nortriptyline; anxiolytics/benzodiazepines/beta-blockers; silver acetate; and mecamylamine. Special consideration should be given to the potential risks versus benefits in the presence of special circumstances (e.g., adolescents, pregnant women, mental health comorbidity, and populations with special military duties). [Expert Consensus] Patient who responded to therapy and successfully quit the use of tobacco and then relapsed should be treated in same manner as the initial therapy. Insufficient evidence exists to recommend the use of extended pharmacotherapy for relapse prevention. [I] First Line NRT Treatment of nicotine dependence with NRT should adhere to the three guiding principles of substance use disorder pharmacotherapy:
Five types of NRT products are available in the U.S. for pharmacological treatment of tobacco dependence.
First Line Non-NRT There are a number of factors to be considered when determining whether a person desiring help in tobacco cessation would be a candidate for bupropion SR, including:
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Combined Psychosocial and Pharmacological Interventions | |
PHS (2008) |
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) |
UMHS (2006) |
The efficacy of all forms of NRT is improved with concomitant counseling, but there is evidence for the effectiveness of NRT, even in the absence of counseling. In very highly dependent smokers, 4 mg gum is superior to 2 mg and most effective with counseling [A]. |
VA/DoD (2004) |
Pharmacotherapy should be combined with minimal counseling (less than 3 minutes). [A] |
CONSIDERATIONS IN SPECIAL POPULATIONS |
Pregnant Women | |
PHS (2008) |
Other Specific Populations and Topics 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. |
UMHS (2006) |
Pregnant Patients Intensive counseling interventions increase quit rates during pregnancy [A]. If intensive counseling is not possible, brief in-office counseling still has a beneficial effect and should be offered. Few studies have addressed the safety of NRT or bupropion in pregnancy directly; however, studies show that less nicotine and fewer metabolites cross the placenta with the use of NRT than with smoking itself. Therefore cautious use of bupropion with NRT (especially nicotine gum) may be considered after reviewing risks and benefits with the patient. Breastfeeding Women Smoking leads to a significant reduction in breast milk volume and increases the likelihood of early discontinuation [A]. Data support the use of bupropion plus NRT in nursing mothers, with increased cessation rates. The safety profile is favorable, as less nicotine and fewer metabolites are found in breast milk with NRT, compared to smoking more than a half a pack per day. Additionally, eliminating environmental exposure to the infant is a favorable outcome. It is not known whether varenicline is excreted in human milk. |
VA/DoD (2004) |
The guideline refers to recommendations offered in DoD/VA Clinical Practice Guideline for Management of Uncomplicated Pregnancy regarding smoking cessation and pregnancy. Specific recommendations from this guideline include:
Background. Smoking in pregnancy presents risks for both the woman and the fetus. Tobacco use by pregnant women has been shown to cause adverse fetal outcomes, including stillbirths, spontaneous abortions, decreased fetal growth, premature births, low birth weight, placental abruption, sudden infant death syndrome (SIDS), cleft palates and cleft lips, and childhood cancers. Many women are motivated to quit during pregnancy, and health care professionals can take advantage of this motivation by reinforcing the knowledge that cessation will reduce health risks to the fetus and that there are postpartum benefits for both the mother and child. Even women who have maintained total abstinence from tobacco for 6 or more months during pregnancy have a high rate of relapse in the postpartum period. Postpartum relapse may be decreased by continued emphasis on the relationship between maternal smoking and poor health outcomes in infants and children (i.e., SIDS, respiratory infections, asthma, and middle ear disease). |
Children and Adolescents | |
PHS (2008) |
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) |
UMHS (2006) |
Treatment — Counseling The evidence for the effectiveness of counseling in adolescent smokers is less robust. However, some studies demonstrate that smoking cessation counseling in the primary care setting can improve adolescent smokers' quit rates [A]. There is little difference between the well infant, child respiratory illness, and other child illness settings as contexts for parental smoking cessation interventions [B]. Treatment — Pharmacologic Therapies The utility of pharmacologic therapy for adolescents has been examined in a number of small studies. While the evidence indicates that these therapies are safe, they seem to be more effective when coupled with counseling. Additional, larger trials are ongoing to evaluate this issue. In the meantime, NRT or bupropion may be considered for use in adolescent smokers [D]. |
VA/DoD (2004) |
Children and Adolescents Pediatric and adolescent patients and their parents should be screened by health care providers for tobacco use and provided a strong message regarding the importance of total abstinence from tobacco use. [Expert Consensus] Health care providers in a pediatric setting should advise parents to quit smoking to limit their children's exposure to second-hand smoke. [A] Health care providers in a pediatric setting should offer smoking cessation advice and interventions to parents to improve the parent's chance of quitting use of tobacco. [C] Adolescents who use tobacco and are interested in quitting should be offered counseling and behavioral interventions that were developed for adolescents. [A] Counseling and behavioral interventions shown to be effective with adults may be considered for use with adolescents. [Expert Consensus] When treating adolescents, providers may consider prescriptions for bupropion SR or NRT when there is evidence of nicotine dependence and desire to quit tobacco use. [Expert Consensus] |
Other Special Populations | |
PHS (2008) |
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 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 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) |
UMHS (2006) |
Racial and Ethnic Minorities Smoking cessation treatment has been shown to be effective across both racial and ethnic minorities [A]. Little research has examined intervention specifically designed for a particular ethnic or racial group; however, it is recommended that, when possible, smoking cessation treatment should be tailored to the specific ethnic or racial population with which they are used [C]. It is essential that counseling or self-help materials be conveyed in a language understood by the smoker. Psychiatric Cofactors If presence of psychiatric cofactors, such as depression, eating disorder, anxiety disorder, attention deficit disorder, or alcohol abuse, strongly consider referral to intensive counseling [B]. Treatment of cofactors must be undertaken in preparation for smoking cessation. Non-cigarette Tobacco Users Spit tobacco users should be identified and strongly urged to quit tobacco use, using the same counseling interventions recommended for smokers [A]. The clinicians should provide a clear message that the use of spit tobacco is not a safe alternative to smoking. Use of cigars, pipes, and other non-cigarette combustible forms of tobacco should be identified, strongly urged to quit, and offered the same counseling interventions recommended for smokers [C]. Gender Concerns Smoking cessation treatments are shown to benefit both women and men [B]. Two studies suggest that some treatments are less efficacious in women than in men. Women may face different stressors and barriers to quitting (e.g., greater likelihood of depression, greater weight control concerns, and hormonal cycles). This research suggests cessation programs that address these issues would be more effective in treating women [D]. Older Smokers Smoking cessation treatment has been shown to be effective for older adults and should be provided, as cessation improves pulmonary function and cerebral circulation [A]. Several studies have found cessation rates among motivated older adults similar to those for younger adults; however, supportive counseling and social support may be of more value to prevent relapse than education or skills training [A]. Hospitalized Smokers Providing hospitalized patients with high-intensity behavioral counseling and follow-up of at least 30 days has been shown to increase cessation rates [A]. NRT supplementation can also be useful in this population. Briefer interventions (<20 minutes, delivered only during the hospitalization) have not yet been shown to be helpful. Additional treatment can include self-help brochures or audio/video tapes, chart prompts reminding physicians to advise for cessation, pharmacologic therapy, hospital counseling, and post-discharge counseling telephone calls. Hospitalization should be used as a springboard to promote smoking cessation. |
VA/DoD (2004) |
Military Recruits and Trainees Prevent relapse of basic trainees who quit using tobacco as a result of their participation in basic military training.
Hospitalized Patients Encourage all health care team members to advise hospitalized tobacco users to quit and provide tobacco cessation treatment.
Older Patients Encourage all health care team members to advise older tobacco users to quit and provide tobacco cessation treatment.
Psychiatric/Mental Health Patient Provide effective tobacco cessation services to patients with psychiatric comorbidities
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Follow-up and Prevention of Relapse | |
PHS (2008) |
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):
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UMHS (2006) |
Arrange follow-up either with phone call or office visit. Follow-up contact should occur soon after the quit date, preferably during the first week [C]. Extending treatment contacts over a number of weeks appears to increase cessation rates [D]. Further follow-up as needed. For abstinent patients, prevent relapse by
For smoking patients:
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VA/DoD (2004) |
Arrange Follow-up Tobacco users who receive a tobacco cessation intervention should be scheduled for ongoing follow-up for abstinence. [B] Follow-up should be documented and should:
Tobacco users who relapse should be assessed for willingness to make another quit attempt and offered repeated interventions. [B] Tobacco users should be tracked to increase the systematic delivery of interventions for tobacco cessation and increase the likelihood of long-term abstinence. [B] Initiate/Reinforce Relapse Prevention
Background. Tobacco use is characterized as a chronic relapsing disorder due to the high number of relapses after a single quit attempt. Studies have documented that smokers may make between 3 and 7 serious quit attempts before successfully quitting. Relapse frequently occurs within a few hours or up to 3 months after quitting, and may even occur after a year or more of abstinence. Addressing the issue of relapse before it occurs and identifying risk factors has been helpful in devising coping strategies to help the tobacco user to quit and prepare them to accept relapse as a learning experience and not a failure. Assess Risk for Relapse
Relapse
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Follow-up and Prevention of Relapse | |
PHS (2008) |
Treatment Structure and Intensity Formats of Psychosocial Treatments 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) |
UMHS (2006) |
Information the Patient Needs to Know Supplementary materials. The UMHS produces two useful patient education handouts:
Additionally, the National Cancer Institute produces the pamphlet "Clearing the Air" (NIH Pub. 03-1647). You may obtain 20 free copies at a time by calling 1-800-4-CANCER (1-800-422-6237). It is also available online at http://www.smokefree.gov/pubs/clearing_the_air.pdf. Preparation and effects. Review with patients the following additional information about preparing for quitting and related factors.
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VA/DoD (2004) |
Offer Self-Help Material Consider offering a variety of effective self-help educational materials to motivate and aid in the quitting process (e.g., pamphlets/booklets/mailings/manuals, videotapes, audiotapes, Internet Web pages, and computer programs). [Expert Consensus] |
TABLE 5. EVIDENCE RATING SCHEMES AND REFERENCES | |
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PHS (2008) |
Strength of Evidence Grades
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UMHS (2006) |
Levels of evidence reflect the best available literature in support of an intervention or test:
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VA/DoD (2004) |
Quality of Evidence (QE) I: Evidence obtained from at least one properly randomized controlled trial II-1: Evidence obtained from well-designed controlled trails without randomization II-2: Evidence obtained from well-designed cohort or case-control analytic studies II-3: Evidence obtained from multiple time series, dramatic results in uncontrolled experiments III: Opinions of respected authorities; case reports, and reports of expert committees Overall Quality Good: High grade evidence (I or II-1) directly linked to health outcome Fair: High grade evidence (I or II-1) linked to intermediate outcome or Moderate grade evidence (II-2 or II-3) directly linked to health outcome Poor: Level III evidence or no linkage of evidence to health outcome Net Effect of Intervention Substantial:
Moderate:
Small:
Zero or Negative:
Grade of Recommendation A: A strong recommendation that the intervention is always indicated and acceptable B: A recommendation that the intervention may be useful/effective C: A recommendation that the intervention be considered D: A recommendation that a procedure may be considered not useful/effective, or may be harmful I: Insufficient evidence to recommend for or against; the clinician will use clinical judgment |
The Public Health Service (PHS), University of Michigan Health System (UMHS), and the Department of Veterans Affairs, Department of Defense (VA/DoD) present recommendations for tobacco use cessation. The organizations provide explicit reasoning behind their judgments and rate the evidence upon which their recommendations are based.
The 2008 PHS guideline included in this synthesis updates a previous version, published in 2000. The UMHS and the VA/DoD guidelines included in this synthesis utilized to some degree, evidence and recommendations released in 2000 by the U.S PHS. For instance, UMHS utilized evidence derived from literature searches of both the 1996 Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality [AHRQ]) guideline and the 2000 PHS guideline (both of which are now considered out of date). UMHS also supplemented the supporting evidence for their recommendations with subsequently published information. The VA/DoD guideline refers often to the 2000 PHS guideline, but also based its recommendations on an extensive review of more recent literature.
All three guidelines recommend a variation of the "Five A" behavioral counseling framework of asking (identifying users), advising (urging users to quit), assessing (determining users' willingness to quit), assisting (through counseling or drug therapy), and arranging for follow-up. UMHS recommends an updated variation of this framework known as the "3-A's and Refer" model. This model recommends that if, during assessment, it is determined that the patient is interested in quitting within 30 days, he or she should be referred to a Tobacco Treatment Specialist or other tobacco cessation program. They do, however, also provide treatment recommendations for physicians who choose to treat the patient rather than refer him or her.
The guidelines agree that all patients should be asked if they use tobacco and should have their tobacco-use status documented on a regular basis. The groups recommend that physicians advise all tobacco users identified during screening to seriously consider making a quit attempt and that advice should be "clear," "strong," and "personalized" and should include a discussion of the health benefits of quitting, self-help materials, and referral to community groups, if necessary. After being assessed for willingness to quit, each of the guidelines also agrees that patients who do not wish to quit should receive motivational interventions (e.g., the 5 R's: relevance, risks, rewards, roadblocks, and repetition).
There is overall agreement that tobacco users who are willing to quit should have access to some form of counseling, including intensive counseling if desired. PHS and VA/DoD agree that counseling is most effective when delivered by a variety of clinician types and in multiple formats, and that proactive telephone counseling (quitlines), group counseling, and individual counseling are effective. They are also in agreement that specific types of counseling and behavioral therapies should be included in smoking cessation interventions. The two types recommended by both groups are practical counseling (problem solving/skills training) and the provision of support and encouragement as part of treatment. VA/DoD also recommends a third type of counseling, which is helping tobacco users obtain social support outside of treatment.
The dose-response relationship between treatment intensity and abstinence from tobacco use is emphasized by all three groups. They agree that counseling as brief as three minutes can be effective in smoking cessation, but that intensive interventions are more effective than less intensive interventions and should be used whenever possible. With regard to frequency, there is overall agreement that multiple counseling sessions increase abstinence rates. PHS notes that, if possible, clinicians should strive to meet four or more times with individuals quitting tobacco use. UMHS similarly notes that intensive counseling (frequently defined as a minimum of weekly meeting for the first 4 to 7 weeks of cessation) significantly enhances cessation rates.
Recommendations regarding pharmacologic therapy are similar. NRT (nicotine gum, patch, inhaler, nasal spray, and lozenge) and bupropion, are first-line pharmacologic therapies recommended by all three groups. The two most recently published guidelines, PHS (2008) and UMHS (2006) also cite varenicline (approved by the FDA in 2006) as an appropriate first-line agent. Nortriptyline and clonidine are recommended as second-line treatments by all three guideline groups.
All three groups also address combining NRTs for improved efficacy. PHS and VA/DoD agree that combining the nicotine patch (PHS specifies long-term [>14 weeks] patch) with a self-administered form of NRT (gum or nasal spray) is more efficacious than a single form of NRT. The combination of the nicotine patch and the nicotine inhaler is also cited as effective by PHS. UMHS, however, notes that, given the additional cost of dual therapies and limited benefit, combining NRT is best reserved for highly addicted smokers with several previous failed quit attempts.
With regard to combining NRT and non-nicotine medications, PHS recommends the combination of the nicotine patch and bupropion SR, noting that it is the only combination approved by the FDA for smoking cessation. VA/DoD in contrast notes that there is some suggestive evidence for combining these two agents, but it is inconclusive. The divergence between the two groups may be due to research studies published since the publication of the VA/DoD guideline (2004). UMHS does not provide a formal recommendation, but notes that for smokers who have previously been unsuccessful, one randomized study showed higher success rates for both bupropion alone or in combination with the nicotine patch, compared to nicotine patch alone.
There are some disagreements on the use of drug therapy in pregnant women and in children and adolescents, and these differences are also discussed below.
The guideline groups agree that pregnant women who smoke should be strongly urged to quit. UMHS and PHS recommend intensive counseling be offered to pregnant smokers, but note that brief counseling still has a beneficial effect and should be offered if intensive counseling is not possible.
All three guidelines address special populations and agree that these special populations can benefit from many of the same treatments as the general population, but that treatment can be improved by recognizing the problems or concerns of the individual.
There is overall agreement that all patients who receive a tobacco dependence intervention should be assessed for abstinence at the completion of treatment and during subsequent clinic contacts. The groups agree that abstinent patients should have their quitting success acknowledged, be offered assistance with problems associated with quitting, and be educated regarding relapse prevention. All three groups recommend that patients who have relapsed should be assessed to determine whether they are willing to make another quit attempt and if so, offered repeated interventions.
All three groups agree that there is evidence to support the effectiveness of counseling interventions to promote smoking cessation in adolescents. VA/DoD states that adolescents who use tobacco and are interested in quitting should be offered counseling and behavioral interventions that were developed for adolescents. They add, however, that interventions shown to be effective with adults may also be considered for use with adolescents. UMHS states that the evidence for the effectiveness of counseling in adolescent smokers is less robust than for adults, but that some studies do demonstrate that smoking cessation counseling in the primary care setting can improve adolescent smokers' quit rates.
Recommendations regarding pharmacological interventions in adolescents differ. Refer to Areas of Differences below.
The groups differ in their recommendations concerning use of pharmacologic therapy for pregnant women. VA/DoD (through DoD/VA Clinical Practice Guideline for Management of Uncomplicated Pregnancy) makes no recommendations either for or against drug therapy during pregnancy. PHS states that there is insufficient evidence to recommend medications for pregnant women. UMHS, in contrast, notes that cautious use of bupropion with NRT (especially nicotine gum) may be considered after reviewing risks and benefits with the patient.
While all three groups agree that ETS is harmful to children, there is disagreement regarding the effectiveness of counseling interventions aimed at parents who smoke to limit children's exposure to ETS. PHS and VA/DoD agree that in order to limit their children's exposure to secondhand smoke, clinicians should ask parents about tobacco use and offer them cessation advice and assistance. UMHS, in contrast, states that there is mixed evidence to support counseling to reduce ETS exposure in the home. They resume by noting that there is little difference between the well infant, child respiratory illness, and other child illness settings as contexts for parental smoking cessation interventions.
Recommendations regarding pharmacological treatment of tobacco dependence in adolescents differ. VA/DoD states that physicians may consider prescribing bupropion SR or NRT to adolescents when there is evidence of nicotine dependence and desire to quit. UMHS similarly notes that until ongoing larger studies addressing this topic are published, NRT or bupropion may be considered for use in adolescent smokers. PHS, in contrast to VA/DoD and UMHS, states that there is insufficient evidence to recommend medications for tobacco dependence treatment to adolescents.
This Synthesis was prepared by ECRI on January 22, 2001 and reviewed by the guideline developers as of June 11, 2001. It was modified by ECRI on January 25, 2005 and reviewed by the guideline developers as of March 14, 2005. It was updated in March 2005 to include the 2004 VA/DoD guideline and was reviewed by the developer as of March 17, 2005. This Synthesis was updated on November 9, 2005 following the withdrawal of the PHS guideline from the NGC Web site. This synthesis was updated in December 2006 to update the UMHS recommendations. This synthesis was updated most recently on December 6, 2007 to remove recommendations from SMOH and NZGG. This Synthesis was updated most recently in October 2008 to remove USPSTF recommendations and update PHS recommendations.
Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Tobacco use cessation and prevention. In: National Guideline Clearinghouse (NGC) [website]. Rockville (MD): 2001 Jul 29 (revised 2008 Oct). [cited YYYY Mon DD]. Available: http://www.guideline.gov.