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Treating Tobacco Use and Dependence

Quick Reference Guide for Clinicians

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, and more complete information for health care decisionmaking. 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.

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To All Clinicians
Purpose
Key Findings
Tobacco Dependence as a Chronic Health Condition
     Tobacco Users Willing To Quit
     Tobacco Users Unwilling To Quit
     Tobacco Users Who Recently Quit
New Recommendations in the PHS-Sponsored Clinical Practice Guideline—Treating Tobacco Use and Dependence: 2008 Update
Conclusion
Guideline Availability

To All Clinicians

The Public Health Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and Dependence: 2008 Update , 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, Federal liaisons, and guideline staff were as follows:

Guideline Panel

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

Guideline Liaisons

Ernestine W. Murray, RN, BSN, MAS (Project Officer), Agency for
Healthcare Research and Quality
Glenn Bennett, MPH, CHES, National Heart, Lung, and Blood Institute
Stephen Heishman, PhD, National Institute on Drug Abuse
Corinne Husten, MD, MPH, Centers for Disease Control and Prevention
Glen Morgan, PhD, National Cancer Institute
Christine Williams, MEd, Agency for Healthcare Research and Quality

Guideline Staff

Bruce Christiansen, PhD (Project Director)
Megan E. Piper, PhD (Project Scientist)
Victor Hasselblad, PhD (Project Statistician)
David Fraser, MS (Project Coordinator)
Wendy Theobald, PhD (Editorial Associate)
Michael Connell, BS (Database Manager)
Cathlyn Leitzke, MSN, RN-C (Project Researcher)

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. Go to the complete Guideline (available at http://www.surgeongeneral.gov/tobacco/) for the methods, peer reviewers, references, and financial disclosure information.

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.

Abstract

This Quick Reference Guide for Clinicians contains strategies and recommendations from the Public Health Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and Dependence: 2008 Update. . The guideline was designed to assist clinicians; smoking cessation specialists; and healthcare 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 1975-2007 and uses the results of more than 50 meta-analyses.

This Quick Reference Guide for Clinicians 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:

Tobacco users who are willing to quit should receive intervention to help in their quit attempt.
Those who are unwilling to quit now should receive interventions to increase their motivation to quit.
Those who recently quit using tobacco should be provided relapse prevention treatment.

Suggested Citation

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, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. April 2009.

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Purpose

Tobacco is the single greatest cause of disease and premature death in America today, and is responsible for more than 435,000 deaths annually. About 20 percent of adult Americans currently smoke, and 4,000 children and adolescents smoke their first cigarette each day. The societal costs of tobacco-related death and disease approach $96 billion annually in medical expenses and $97 billion in lost productivity. However, more then 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 within the Clinical Practice Guideline Treating Tobacco Use and Dependence: 2008 Update demonstrated that efficacious treatments for tobacco users exist and should become a part of standard care giving. Research also shows that delivering such treatments is cost-effective. In summary, the treatment of tobacco use and dependence presents the best and most cost-effective opportunity for clinicians to improve the lives of millions of Americans nationwide.

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Key Findings

The guideline identified a number of key findings that clinicians should use:

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.
It is essential that clinicians and healthcare delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a healthcare setting.
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 recommended counseling treatments and medications in the Guideline.
Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective in the Guideline.
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.
There are numerous effective medications 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 should also consider the use of certain combinations of medications identified as effective in the Guideline.
Counseling and medication are effective when used by themselves for treating tobacco dependence. However, the combination of counseling and medication is more effective than either alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication.
Telephone quitline counseling is effective with diverse populations and has broad reach. Therefore, clinicians and healthcare delivery systems should both ensure patient access to quitlines and promote quitline use.
If a tobacco user is currently unwilling to make a quit attempt, clinicians should use the motivational treatments shown in the Guideline to be effective in increasing future quit attempts.
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 the Guideline as covered benefits.

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Tobacco Dependence as a Chronic Health Condition

Tobacco dependence is a chronic health condition that often requires multiple, discrete interventions by a clinician or team of clinicians. The "5 A's" of treating tobacco dependence (Ask, Advise, Assess, Assist, and Arrange follow-up) is a useful way to understand tobacco dependence treatment and organize the clinical team to deliver that treatment. While a single clinician can provide all 5 A's, it is often more clinically and cost-effective to have the 5 A's implemented by a team of clinicians and ancillary staff. However when a team is used, coordination of efforts is essential with a single clinician retaining overall responsibility for the interventions. Clinician extenders such as quit lines, Web-based interventions, local quit programs and tailored, self-help materials can often be, and should be, incorporated into the 5 A's approach. These treatment extenders can make clinical interventions more efficient.

This Quick Reference Guide for Clinicians is organized around the 5 A's. However, the clinical situation may suggest delivering these components in a different order or format. The following sections address the three main groups of tobacco users:

Those who are willing to quit.
Those who are unwilling to quit now.
Those who recently quit.

This Quick Reference Guide for Clinicians is based on Guideline findings and includes many tables directly from the Guideline.

Table 1. The "5 A's" model for treating tobacco use and dependence

Ask about tobacco use	Identify and document tobacco use status of every patient at every visit.
Advise to quit	In a clear, strong and personalized manner urge every tobacco user to quit.
Assess	For current tobacco user, is the tobacco user willing to make a quit attempt at this time? For the ex-tobacco user, how recent did you quit and are there any challenges to remaining abstinent?
Assist	For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional behavioral treatment to help the patient quit. For patients unwilling to quit at this time, provide motivational interventions designed to increase future quit attempts. For the recent quitter and any with remaining challenges, provide relapse prevention.
Arrange	All those receiving the previous A's should receive followup.

Select for Figure 1: The "5 A's": Treating Tobacco Dependence as a Chronic Disease.

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Tobacco Users Willing To Quit

The "5 A's," Ask, Advise, Assess, Assist, and Arrange, are designed to be used with the smoker who is willing to quit.

Table 2. Ask—Systematically identify all tobacco users at every visit

Action

Strategies for Implementation

Implement an office-wide 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 include using tobacco use status stickers on all patient charts or indicating tobacco use status via electronic medical records or computerized reminder systems.

Table 3. Advise—Strongly urge all tobacco users to quit

Action

Strategies for Implementation

In a clear, strong, and personalized manner, urge every tobacco user to quit.

Advice should be:

Clear—"I think it is important for you to quit smoking (or using chewing tobacco) now and I can help you."
"Cutting down while you are ill is not enough."
“Occasional or light smoking is still dangerous.”
Strong—"As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you."
Personalized—Tie tobacco use to current symptoms and health concerns, and/or its social and economic costs, and/or the impact of tobacco use on children and others in the household. “Continuing to smoke makes your asthma worse, and quitting may dramatically improve your health. Quitting smoking may reduce the number of ear infections your child has.”

Table 4. Assess—Determine willingness to make a quit attempt

Action

Strategies for Implementation

Assess every tobacco user's willingness to make a quit attempt at this time

Assess patient's willingness to quit: "Are you willing to give quitting a try?"

If the patient is willing to make a quit attempt at this time, provide assistance.
- If the patient will participate in an intensive treatment, deliver such a treatment or link/refer to an intensive intervention.
- If the patient is a member of a special population (e.g., adolescent, pregnant smoker, racial/ethnic minority), consider providing additional information.
If the patient clearly states he or she is unwilling to make a quit attempt at this time, provide an intervention shown to increase future quit attempts.

Table 5. Assist—Aid the patient in quitting (provide counseling and medication)

Action	Strategies for Implementation
Help the patient with a quit plan.	A patient's preparations for quitting: Set a quit date. Ideally, the quit date should be within 2 weeks. Tell family, friends, and coworkers about quitting and request understanding and support. Anticipate challenges to planned quit attempt, particularly during the critical first few weeks. These include nicotine withdrawal symptoms. Remove tobacco products from your environment. Prior to quitting, avoid smoking in places where you spend a lot of time (e.g., work, home, car). Make your home smoke-free.
Recommend the use of approved medication, except when contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents).	Explain how these medications increase quitting success and reduce withdrawal symptoms. FDA-approved medications include: bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline. There is insufficient evidence to recommend medication for pregnant women, adolescents, smokeless tobacco users, and light smokers (< 10 cigarettes/day).
Provide practical counseling (problem solving/skill training).	Abstinence—Striving for total abstinence is essential."Not even a single puff after the quit date. Past quit experience. Identify what helped and what hurt in previous quit attempts. Build on past success. Anticipate triggers or challenges in the upcoming attempt. Discuss challenges/triggers and how the patient will successfully overcome them (e.g., avoid triggers, alter routines).. Alcohol. Because alcohol is associated with relapse, the patient should consider limiting/abstaining from alcohol while quitting. (Note that reducing alcohol intake could precipitate withdrawal in alcohol-dependent persons.) Other smokers in the household. Quitting is more difficult when there is another smoker in the household. Patients should encourage housemates to quit with them or to not smoke in their presence.
Provide intratreatment social support.	Provide a supportive clinical environment while encouraging the patient in his or her quit attempt. "My office staff and I are available to assist you." "I'm recommending treatment that can provide ongoing support."
Help patient obtain extra-treatment social support.	Help patient develop social support for his or her quit attempt in his or her environments outside of treatment. "Ask your spouse/partner, friends, and coworkers to support you in your quit attempt."
Provide supplementary materials, including information on quitlines.	Sources: Federal agencies, nonprofit agencies, national quitline network (1-800-QUIT-NOW), or local/state/tribal health departments/quitlines. Type: Culturally/racially/educationally/age-appropriate for the patient. Location: Readily available at every clinician's workstation.

Assist Component—Three Types of Counseling

Counseling should include teaching practical problem solving skills and providing support and encouragement.

Table 6. Common elements of practical counseling

Practical counseling (problem-solving/skills training) treatment component	Examples
Recognize danger situations—Identify events, internal states, or activities that increase the risk of smoking or relapse.	Negative affect and stress. Being around other tobacco users Drinking alcohol. Experiencing urges. Smoking cues and availability of cigarettes.
Develop coping skills—Identify and practice coping or problem-solving skills. Typically, these skills are intended to cope with danger situations.	Learning to anticipate and avoid temptation and trigger situations. Learning cognitive strategies that will reduce negative moods. Accomplishing lifestyle changes that reduce stress, improve quality of life, and reduce exposure to smoking cues. Learning cognitive and behavioral activities to cope with smoking urges (e.g., distracting attention; changing routines).
Provide basic information—Provide basic information about smoking and successful quitting.	The fact that any smoking (even a single puff) increases the likelihood of a full relapse. Withdrawal symptoms typically peak within 1-2 weeks after quitting but may persist for months. These symptoms include negative mood, urges to smoke, and difficulty concentrating. The addictive nature of smoking.

Table 7. Common elements of supportive counseling

Supportive treatment component	Strategies for implementation
Encourage the patient in the quit attempt.	Note that effective tobacco dependence treatments are now available. Note that one-half of all people who have ever smoked have now quit. Communicate belief in patient's ability to quit. Encourage patient self-efficacy.
Communicate caring and concern.	Ask how patient feels about quitting. Directly express concern and willingness to help as often as needed.. Ask about the patient's fears and ambivalence regarding quitting.
Encourage the patient to talk about the quitting process.	Ask about: Reasons the patient wants to quit. Concerns or worries about quitting. Success the patient has achieved. Difficulties encountered while quitting.

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