Treatment

Populations

General Resources

The CDC provides information on specific populations.

US Department of Health & Human Services' Office of Minority Health

The Policy Advocacy on Tobacco and Health: An Initiative to Build Capacity in Communities of Color for Tobacco Policy Change is an initiative to provide resources for community-based organizations and tribal groups interested in implementing effective tobacco prevention and cessation policy initiatives.

• Adults
• Adolescents
• Women
• Gay
• African Americans
• Hispanic
• Asians and Pacific Islanders
• American Indians and Alaska Natives
• Psychiatric Co-Morbidity and Chemical Dependance
• Co-Morbidity
• Pregnancy

Adults 

All clinicians are urged to actively deliver tobacco cessation interventions with adult smokers. Clinicians represent effective interventionists since they have contact with approximately 70% of smokers on an annual basis. Unfortunately, 50% of smokers report having NEVER been urged to quit by a clinician. It is estimated that 70% of all smokers are interested in quitting. As such, clinicians must identify those smokers who are willing to make a quit attempt. Once identified, these patients can be managed by the clinician or referred for more intensive treatment. Finally, clinicians must continue to discuss future cessation attempts with the unmotivated smoker. 

The "5 A's" for Brief Intervention

1. Ask - Systematically identify all tobacco users at EVERY visit. Implement an office-wide system for EVERY patient at EVERY clinic visit.
   ** Identification systems increase the rate of tobacco intervention from less than 50% to 65%**
2. Advise -strongly urge all smokers to quit. Convey a clear, strong and personalized message, such as: "I MUST advise you to quit smoking now! Quitting smoking represents the most important step you can take to improve your health".
3. Assess - the willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at this time?
4. Assist -Aid the patient in quitting.
   1. Set a quit date within the next few weeks
   2. Encourage nicotine replacement ( See nicotine replacement section)
   3. Provide key advice and encouragement
      1. Avoid other smokers
      2. Avoid alcohol consumption
      3. Reward yourself for staying smoke-free
      4. Stay busy
      5. Let others know you are quitting.
5. Arrange -Schedule follow-up contact (phone or face-to-face)
   1. Timing: one week and one month
   2. Actions:
      1. Congratulate success
      2. Identify problems
      3. Assess nicotine replacement
      4. Consider referral to intensive treatment (See Intensive Interventions)

Motivating Suggestions

To help your patient see the monetary value of cessation, have them think about what they could do with the money they save each year. A one-pack-a-day smoker spends around $1095 a year ($3 a pack) on cigarettes. That is the same as:

• 100 bottles of bath or massage oils
• 60 meals out (in a moderately priced restaurant)
• 150 60 minute long distance phone calls
• One membership to a gym, plus all new workout clothes
• two round-trip tickets from New York to Los Angeles, full-fare

Positive Reasons to Quit Now

• Within 24 hours, risk of sudden death from heart attack decreases
• Reduces risk of cancer
• Better senses of taste and smell and improved breathing
• Decreases risk of heart disease (down to the rates of non-smokers within a matter of years)
• More spending money
• Being a positive role model for your children
• Fewer health problems among your children, including fewer cases of asthma
• Increases physical ability and improved stamina
• Better appearance
• Personal satisfaction
• A sense of liberation

Older Adults

Services-funded initiative, the Medicare Stop Smoking Program (MSSP), will launch a quitline for Medicare beneficiaries age 65 and older in selected study areas of the following states:  Alabama, Florida, Missouri, Nebraska, Ohio, Oklahoma, and Wyoming.  The program will also provide coverage for nicotine replacement therapy through the proactive component of the quitline.  The goal of the MSSP is to test various benefit variations, one of which is a quitline, for effectiveness as a potential Medicare benefit.  (Initiation of a new benefit would of course require Congressional legislation).  The original kick-off had been planned for Sept. 1, 2001.

Smoking Among Older Adults is a Fact Sheet provided by the American Lung Association.

The National Center for Tobacco-Free Older Persons (NCTFOP) serves as a national advocate for and source of information on tobacco and its effects on older persons.

Centers for Medicare and Medicaid Services provides information about the elderly and smoking.

Case Studies

• Adult With Chronic Disease

Adolescents 

Tobacco use is truly a "pediatric epidemic", as the Surgeon General has described. The behavior begins during late childhood and adolescent years -- yet clinicians rarely deal with tobacco use during this period. All clinicians should discuss tobacco abstinence with parents, pediatric, and adolescent patients. Cessation interventions that have been shown to be effective with adults should be considered for use with children and adolescents.

Community and school-based behavioral interventions that are developmentally appropriate are effective ways to deliver cessation treatment. Peer involvement is recommended. Research has consistently identified a relationship between the smoking behavior of parents and adolescent smoking. Encouraging parents to quit increases adolescent quit rates. Little research has been conducted to determine the most effective mechanisms for treating adolescent tobacco use.

Clinicians are urged to openly discuss tobacco use with teenagers and to provide the following information :

• Most kids DON'T smoke or use smokeless tobacco.
• All forms of tobacco are addictive.
• Addiction takes away one's independence.
• Smoking gives you bad breath, stains your teeth, and decreases your athletic performance.
• Smoking does not make you cool , sexy or successful, as advertisements would make you believe.
• Tobacco is expensive.
• There are other ways to be different without causing severe, long-term health consequences.

Nicotine replacement should be considered only when there is strong evidence of nicotine dependence and a clear desire to quit tobacco use.

Teen-oriented tobacco cessation programs

The Youth Tobacco Cessation Collaborative (YTCC) was formed in 1998 to address the gap in knowledge about what cessation strategies are most effective in assisting youth to quit smoking.

The Campaign for Tobacco-Free Kids is the largest non-government initiative ever launched to protect children from tobacco addiction. This site provides recent news and information and links to sites with research data online.

The Surgeon General’s Report for Kids about Smoking

Thetruth.com is a website aimed at children to help educate them on tobacco use.

The Helping Young Smokers Quit initiative is a two-phase project that addresses the critical need to disseminate effective, developmentally appropriate cessation programs for adolescent smokers.

Case Studies

• Adolescent Cigarette Smoker

African Americans

National African American Tobacco Prevention Network

African Americans and Tobacco provided by the CDC

Americans for Nonsmokers Rights

California Black Health Network

Hispanic

National Latino Council on Alcohol & Tobacco Prevention

Hispanics and Tobacco provided by the CDC

Americans for Nonsmokers Rights

The California Hispanic/Latino Tobacco Education Partnership

USC Institute for Prevention Research - Hispanic/Latino Tobacco Education Network (H/LaTEN)

Asian American and Pacific Islanders

Asian Pacific Partners for Empowerment and Leadership

Asian Americans and Pacific Islanders and Tobacco provided by the CDC

Asian and Pacific Islander American Health Forum-Asian and Pacific Islander Tobacco Education Network (APITEN)

American Indians and Alaska Natives

The American Indian Tobacco Education Network (AITEN)

American Indians and Alaska Natives and Tobacco provided by the CDC

Women

National Women's Health Information Center

Women and Tobacco use provided by the CDC

Pattern of Tobacco Use Among Women and Girls — Fact Sheet provided by the CDC

Circle of Friends- Uniting to be smoke-free is dedicated to helping women quit smokng hrough the support of Family and Friends.

Save our Daughters provides information on women and smoking and ways to reduce tobacco's impact on women and girls.

Gay

The Gay American Smoke Out

Americans for Nonsmokers Rights

The National Coalition for LGBT Health

The Last Drag ( San Francisco)

Smoking Tobacco and the GLBT Community (PDF Brochure)

Smokers with Psychiatric Co-Morbidity/ or Chemical Dependency

Psychiatric Times provides articles on tobacco dependence and psychiatric disorders.

Help Starts Here provides information about Chemical Dependence, Psychiatric Disorders and Tobacco Addiction

Co-Morbidity

The National Cancer Institute offers a patient summary on smoking cessation and continued risk in cancer patients is adapted from a summary written for health professionals by cancer experts.

Memorial Sloan-Kettering Cancer Center was one of the first centers in the country to have a service devoted specifically to managing nicotine dependence in cancer patients. The website provides information about the program that is offered.

The Association of Cancer Online Resources provides information about smoking cessation for cancer patients.

American Diabetes Association provides information the effect smoking has on Diabetes.

Diabetes Australia offers a look at how smoking effects every part of your body and your life.

The Cleveland Clinic provides a Fact sheet about Diabetes and Smoking.

American Heart Association provides information about cigarette smoking and cardiovascular diseases.

The CDC provides a fact sheet about smoking and cardiovascular disease and strokes among women.

Action on Smoking and Health provides information about environmental tobacco smoke and asthma.

The CDC provides information about environmental tobacco smoke, asthma and children.

The Mayo Clinic provides information about Chronic Obstructive Pulmonary Disease and Smoking cessation.

The Cancer Council Western Australia provides a fact sheet about Chronic Obstructive Pulmonary Disease and smoking.

Pregnancy

All pregnant smokers should be strongly encouraged to stop smoking throughout the entire length of their pregnancy. Cutting down the amount smoked is NOT sufficient. All pregnant smokers should be offered, at the very least, a minimal intervention (See below). Whenever possible, intensive counseling is recommended. It's never too late to quit smoking during pregnancy. Health benefits, for both the mother and fetus, can be obtained throughout the entire 9 months.

The same behavioral interventions that have been shown to be effective with all smokers should be applied to the pregnant smoker. Remember the Four A's:

1. Ask every pregnant women about smoking -- some pregnant women may try to hide their smoking status or try to minimize their use.
2. Advise every pregnant women to quit early since this benefits the mother and fetus most. Quitting anytime (even late in pregnancy) will benefit both the mother and fetus.
3. Assist every pregnant woman by providing motivational messages, such as:
   "This is the most important gift you, as a new mother, can give to your baby. It will be important to stay quit after your baby is born. Remaining smoke-free will keep your baby healthy. I would like to help you stop smoking today".
4. Arrange for follow-up to assess progress. Congratulate successes -- remind the woman that she is truly helping herself and her baby. Incorporate relapse prevention strategies since postpartum relapse rates are high even if a women maintains abstinence during pregnancy.

To date, nicotine replacement, as a form of treatment, has not been systematically evaluated among pregnant smokers. According to the 1996 AHCPR [now Agency for Healthcare Research and Quality (AHRQ)] Smoking Cessation Clinical Practice Guideline, nicotine replacement should be used during pregnancy only if the increased likelihood of smoking cessation, with its potential benefits, outweighs the risk of nicotine replacement and potential concomitant smoking.

Smoke-Free Families is a national program supported by The Robert Wood Johnson Foundation working to discover the best ways to help pregnant smokers quit, and spread the word about effective, evidence-based treatments.

National Healthy Mothers, Health Babies Coalition is a recognized leader and resource in maternal and child health. HMHB reaches an estimated ten million health care professionals, parents and policymakers through its membership of over 100 local, state and national organizations.

Maternal and Infant Health: Smoking During Pregnancy is information provided by the Centers for Disease Control and Prevention.

Smoking Cessation for Pregnancy and Beyond: Learn Proven Strategies to Help Your Patients Quit

Great Start (Pregnant Smokers)- The American Legacy Foundation is dedicated to building a world where young people reject tobacco and anyone can quit.

The National Partnership to Help Pregnant smokers Quit is a coalition of diverse organizations that have joined forces to improve the health of this and future generations by increasing the number of pregnant smokers who quit smoking.