Treatment

The AHRQ

A Guideline Panel, comprised of tobacco treatment experts, consortium representatives from the National Institutes of Health, Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, Robert Wood Johnson Foundation and the Center for Tobacco Research and Intervention, University of Wisconsin Medical School, consultants and staff, produced the following Clinical Practice Guideline, Treating Tobacco Use and Dependence.

This guideline is an updated version of the 1996 Smoking Cessation Clinical Practice Guideline No. 18.  It is the product of a private-sector panel of experts, consortium representatives, and staff.  The update was written to include new, effective clinical treatments for tobacco dependence that have become available since the original guideline was developed.  Implementing the Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence will make an important contribution to the quality of care in the United States and the health of the American people.

• AHRQ reconvened a private-sector panel of experts to identify clinical practices and treatments that effectively help people quit tobacco use.
• The panel performed a systematic review of more than 6,000 scientific articles that addressed the assessment and treatment of tobacco dependence, nicotine addiction, and clinical practice, and based their recommendations on these findings.
• The 18-member panel included physicians, nurses, mental health experts, a dentist, a pharmacist, psychologists, an epidemiologist, and an educator.

The guideline challenges every clinician including, nurses, physicians, dentists, and others to:

• Find out if their patients smoke
• Repeatedly encourage them to quit
• Recommend treatments proven to work

The panel developed eight Findings and Recommendations:

1. Tobacco Dependence is a chronic condition that often requires repeated intervention.
2. Every patient who uses tobacco, whether willing or unwilling to quit, should be offered some sort of tobacco intervention.
3. It is essential that clinicians institutionalize the consistent identification, documentation, and treatment of every tobacco user seen in the health care setting.
4. Brief tobacco dependence treatment is effective and every patient who uses tobacco should be offered at least brief treatment.
5. There is a strong relationship between the intensity (e.g. minutes of counseling) of tobacco intervention counseling and its effectiveness.
6. Three types of counseling were found to be particularly effective: Problem solving and skills training; social support in treatment; and help finding social support outside of treatment.
7. Numerous pharmacotherapies for tobacco intervention exist and are effective.   Except where contraindicated, these should be used with all patients attempting to quit tobacco use.
8. Tobacco dependence treatments are both clinically effective and cost-effective relative to other medical and disease prevention interventions

• This Public Health Service- sponsored Clinical Practice Guideline gives hope to the 7 out of 10 smokers who try to quit each year.  I urge every clinician, health plan, and health care institution to make treating tobacco dependence a top priority.  Please ask your patients two key questions: "Do you smoke?" "Do you want to quit?" followed by the use of the recommendations in this guidelines. -- David Satcher, MD, PhD Former U.S. Surgeon General, Assistant Secretary for Health

  Proactive telephone counseling and individual and group counseling programs are effective. The panel found a direct relationship between the intensity of treatment and the likelihood for success. The guideline recommends that person-to-person treatment delivered for four or more sessions appears especially effective in increasing abstinence rates.

Facts About Smoking

• Only half the smokers who see a clinician have ever been urged to quit.
• Smoking is the single greatest preventable cause of illness and premature death in the United States(contributes to over 440,000 deaths a year).
• People who smoke are at increased risk of heart disease, cancer and other smoking-related illness.
• Medical costs for smokers are $75 billion annually to treat, and an additional $82 billion in indirect costs from lost time at work and disability.

The Guideline Recommends that Clinicians:

• Ask every patient at every visit if they smoke.
• Write a patient's smoking status in the medical chart under vital signs.
• Ask patients about their desire to quit, reinforcing their intentions.
• Motivate patients reluctant to quit.
• Help motivated smokers set a quit date. Prescribe pharmacotherapy, like nicotine gum, nicotine patch, or bupropion.
• Help patients resolve problems that result from quitting.
• Counseling may be helpful to some patients to increase the likelihood of success.
• Encourage relapsed smokers to try quitting again.

The Guideline panel is optimistic that this updated guideline is a harbinger of a new and very promising era in the treatment of tobacco use and dependence.  The guideline codifies an evolving culture of health care - one in which every tobacco user has access to effective treatments for tobacco dependence.  This new standard of care provides clinicians and health care delivery systems with their greatest opportunity to improve the current and future health of their patients by assisting those addicted to tobacco.  Tobacco users and their families deserve no less.

*Whenever possible, tobacco dependence treatments should be modified or tailored to be appropriate for the ethnic or racial populations in which they are used.  The guideline also provides recommendations for pregnant woman, hospitalized patients, persons with psychological problems, children and adolescents, and users of  non-cigarette tobacco products (cigars, pipes, snuff and chewing tobacco).

The "5 A's" for Brief Intervention

• Ask about tobacco use

  Identify and document tobacco use status for every patient at every visit .

• Advise the quit

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

• Assess willingness to make a quit attempt

  Is the tobacco user willing to make a quit attempt at this time?

• Assist in quit attempt

  For the patient willing to make a quit attempt, use counseling and pharmacotherapy to help him or her quit.

• Arrange follow-up

  Schedule follow-up contact, preferably within the first week after the quit date.

The Guideline Consumer Guide Urges Tobacco Users to Use the Five Keys For Quitting:

• Get Ready. Set a quit date. Get rid of all tobacco and tobacco paraphernalia in your environment. Don't let people smoke around you. Review past quit attempts for what works and what didn't.
• Get Support and Encouragement. You have a better chance of being successful if you have help.  Tell your family, friend, and coworkers that you are going to quit. Talk to your health care provider. Get individual, group, or telephone counseling. The more counseling you have, the better your chances of quitting. Call your local health department for information about programs in your area.
• Learn New Skills and Behaviors.  Try to distract yourself from urges to smoke; talk to someone, take a walk, or make yourself busy with a task. When you first quit, change your routine: Use a different route to work, drink tea instead of coffee, eat breakfast in a different place. Do something to reduce your stress. Plan something enjoyable to do everyday. Drink lots of water and other fluids.
• Get medication and use it correctly. Medications can help you stop smoking and lessen the urge to smoke. The FDA has approved five medications: Bupropion SR (by prescription), Nicotine gum, Nicotine inhaler (by prescription), Nicotine nasal spray (by prescription), and Nicotine patch (by prescriptoin or OTC).  Ask your health care provider for advice.
• Be prepared for relapse or difficult situtations. Most relapses occur within the first three months of qitting, ad most people try several times before they finally quit. Some difficult situations to watch for are: drinking alcohol, being around other smokers, gaining weight, and being in a bad mood or depression.

Tobacco Use Treatment: A Systems Approach

1. Recommendations for Health Care Administrators, Insurers, and Purchasers provides helpful strategies in implementing standard procedures for assessment and treatment of tobacco in health care settings. These recommendations include:
2. Implementations of a tobacco-user identification system in every clinic
3. Provision of education, resources and feedback to promote provider intervention
4. Dedication of staff to provide tobacco dependence treatment and assessment of delivery of treatment in staff performance evaluations
5. Promotion of hospital policies that support/provide tobacco dependence services
6. Inclusion of tobacco dependence treatment (counseling AND pharmacotherapy) as paid or covered services
7. Reimbursement of clinicians and specialists for delivery of effective tobacco dependence treatments and including these interventions among the defined duties of clinicians.

For More Information:

Call toll-free 800-358-9295, or write to:

AHRQ Publications Clearinghouse
P.O. Box 8547
Silver Spring, MD 20907-9295

Agency for Healthcare Research and Quality

540 Gaither Road
Rockville, MD 20850
301-427-1364

The full guideline, quick reference and consumer guides, and the meta-analysis reference are available on the Internet through the AHRQ Home Page (www.ahrq.gov/clinic/) under  "Clinical Practice Guidelines Online"