Many new and effective treatment strategies are available that clinicians can employ to help patients quit tobacco use, according to an updated Clinical Practice Guideline released recently by the U.S. Public Health Service.
Use of multiple interventions, individual and group counseling, integration of effective therapies into routine health care delivery, and insurance reimbursement increase the likelihood a patient with tobacco dependence can quit, according to the guideline.
Expanding tobacco dependence literature and new treatments available since 1999 led a consortium of eight federal agencies and nonprofit organizations to update the guideline for the first time since 2000. The new recognition of tobacco dependence as a chronic disease that generally requires ongoing assessment and repeated intervention is central to the update.
A 24-member panel screened more than 8,700 publications on tobacco dependence and treatment published since 1975 in preparation for the update. A total of 81 outside peer experts reviewed the panel's findings.
The universal aim of the 276-page “Treating Tobacco Use and Dependence: 2008 Update” is assist clinicians in strongly recommending effective tobacco dependence counseling and medications to patients who use tobacco. This includes consideration of seven first-line medications now approved by the Food and Drug Administration that “reliably increase long-term smoking abstinence rates.” Those medications are bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline (Chantix).
It is important to encourage use of effective medications alone or in combination for all patients attempting to quit smoking, except when medically contraindicated, according to the guideline. Also, evidence is insufficient for effectiveness in specific populations, including pregnant women, smokeless tobacco users, light smokers, and adolescents.
However, it is not enough for clinicians to recommend these medications. Health systems, insurers, and purchasers need to increase availability and facilitate use of these therapies to help physicians help their patients. “Making tobacco dependence treatment a covered benefit of insurance plans increases the likelihood that a tobacco user will receive treatment and quit successfully,” the authors wrote.
Increased evidence that counseling, alone and especially with medication, greatly increases a person's chances of quitting tobacco is recognized. There is a new consensus that counseling efforts can be effective in adolescent tobacco users, for example. Also, quitlines such as 1–800-QUIT-NOW are an effective intervention that can reach a large number of the 70% of 45 million smokers in the United States who indicate a desire to quit, according to the guideline.
Individual and group counseling also are deemed effective, particularly with increasing treatment intensity. Practical counseling (problem-solving/skills training) and social support delivered as part of treatment were found especially effective. Use these interventions when counseling patients making a quit attempt, the authors suggested.
Clinical interventions both for patients who are willing or unwilling to make a quit attempt at the time are outlined. Interventions for individuals with psychiatric disorders, including substance use disorders, are also recommended.
The guideline was sponsored by the Agency for Healthcare Research and Quality; the Centers for Disease Control and Prevention; the National Cancer Institute; the National Heart, Lung, and Blood Institute; the National Institute on Drug Abuse; the American Legacy Foundation; the Robert Wood Johnson Foundation; and the University of Wisconsin School of Medicine and Public Health's Center for Tobacco Research and Intervention.
Of the 24 panel members, 21 had no significant financial interests. The three other panel members were recused from panel deliberations relating to their areas of conflict.
The Clinical Practice Guideline and related documents are available at www.surgeongeneral.gov/tobacco