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Treating Tobacco Use and Dependence: 2008 Update

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Abstract

Treating Tobacco Use and Dependence: 2008 Update, a Public Health Service-sponsored Clinical Practice Guideline, is a product of the Tobacco Use and Dependence Guideline Panel (“the Panel”), consortium representatives, consultants, and staff. These 37 individuals were charged with the responsibility of identifying effective, experimentally validated tobacco dependence treatments and practices. The updated Guideline was sponsored by a consortium of eight Federal Government and nonprofit organizations: the Agency for Healthcare Research and Quality (AHRQ); Centers for Disease Control and Prevention (CDC); National Cancer Institute (NCI); National Heart, Lung, and Blood Institute (NHLBI); National Institute on Drug Abuse (NIDA); American Legacy Foundation; Robert Wood Johnson Foundation (RWJF); and University of Wisconsin School of Medicine and Public Health's Center for Tobacco Research and Intervention (UW-CTRI). This Guideline is an updated version of the 2000 Treating Tobacco Use and Dependence: Clinical Practice Guideline that was sponsored by the U.S. Public Health Service, U. S. Department of Health and Human Services.

An impetus for this Guideline update was the expanding literature on tobacco dependence and its treatment. The original 1996 Guideline was based on some 3,000 articles on tobacco treatment published between 1975 and 1994. The 2000 Guideline entailed the collection and screening of an additional 3,000 articles published between 1995 and 1999. The 2008 Guideline update screened an additional 2,700 articles; thus, the present Guideline update reflects the distillation of a literature base of more than 8,700 research articles. Of course, this body of research was further reviewed to identify a much smaller group of articles that served as the basis for focused Guideline data analyses and review.

This Guideline contains strategies and recommendations designed to assist clinicians; tobacco dependence treatment specialists; and health care administrators, insurers, and purchasers in delivering and supporting effective treatments for tobacco use and dependence. The recommendations were made as a result of a systematic review and meta-analysis of 11 specific topics identified by the Panel (proactive quitlines; combining counseling and medication relative to either counseling or medication alone; varenicline; various medication combinations; long-term medications; cessation interventions for individuals with low socioeconomic status/limited formal education; cessation interventions for adolescent smokers; cessation interventions for pregnant smokers; cessation interventions for individuals with psychiatric disorders, including substance use disorders; providing cessation interventions as a health benefit; and systems interventions, including provider training and the combination of training and systems interventions). The strength of evidence that served as the basis for each recommendation is indicated clearly in the Guideline update. A draft of the Guideline update was peer reviewed prior to publication, and the input of 81 external reviewers was considered by the Panel prior to preparing the final document. In addition, the public had an opportunity to comment through a Federal Register review process. The key recommendations of the updated Guideline, Treating Tobacco Use and Dependence: 2008 Update, based on the literature review and expert Panel opinion, are as follows:

Ten Key Guideline Recommendations:

The overarching goal of these recommendations is that clinicians strongly recommend the use of effective tobacco dependence counseling and medication treatments to their patients who use tobacco, and that health systems, insurers, and purchasers assist clinicians in making such effective treatments available.

1.

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.

2.

It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting.

3.

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 counseling treatments and medications recommended in this Guideline.

4.

Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective in this Guideline.

5.

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 (problemsolving/skills training)
  • Social support delivered as part of treatment

6.

Numerous effective medications are available 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 also should consider the use of certain combinations of medications identified as effective in this Guideline.
7.

Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication.

8.

Telephone quitline counseling is effective with diverse populations and has broad reach. Therefore, both clinicians and health care delivery systems should ensure patient access to quitlines and promote quitline use.

9.

If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments shown in this Guideline to be effective in increasing future quit attempts.

10.

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 this Guideline as covered benefits.

The updated Guideline is divided into seven chapters that provide an overview, including methods (Chapter 1); information on the assessment of tobacco use (Chapter 2); clinical interventions, both for patients willing and unwilling to make a quit attempt at this time (Chapter 3); intensive interventions (Chapter 4); systems interventions for health care administrators, insurers, and purchasers (Chapter 5); the scientific evidence supporting the Guideline recommendations (Chapter 6); and information relevant to specific populations and other topics (Chapter 7).

A comparison of the findings of the updated Guideline with the 2000 Guideline reveals the considerable progress made in tobacco research over the brief period separating these two publications. Tobacco dependence increasingly is recognized as a chronic disease, one that typically requires ongoing assessment and repeated intervention. In addition, the updated Guideline offers the clinician many more effective treatment strategies than were identified in the original Guideline. There now are seven different first-line effective agents in the smoking cessation pharmacopoeia, allowing the clinician and patient many different medication options. In addition, recent evidence provides even stronger support for counseling (both when used alone and with other treatments) as an effective tobacco cessation strategy; counseling adds to the effectiveness of tobacco cessation medications, quitline counseling is an effective intervention with a broad reach, and counseling increases tobacco cessation among adolescent smokers.

Finally, there is increasing evidence that the success of any tobacco dependence treatment strategy cannot be divorced from the health care system in which it is embedded. The updated Guideline contains new evidence that health care policies significantly affect the likelihood that smokers will receive effective tobacco dependence treatment and successfully stop tobacco use. For instance, making tobacco dependence treatment a covered benefit of insurance plans increases the likelihood that a tobacco user will receive treatment and quit successfully. Data strongly indicate that effective tobacco interventions require coordinated interventions. Just as the clinician must intervene with his or her patient, so must the health care administrator, insurer, and purchaser foster and support tobacco intervention as an integral element of health care delivery. Health care administrators and insurers should ensure that clinicians have the training and support to deliver consistent, effective intervention to tobacco users.

One important conclusion of this Guideline update is that the most effective way to move clinicians to intervene is to provide them with information regarding multiple effective treatment options and to ensure that they have ample institutional support to use these options. Joint actions by clinicians, administrators, insurers, and purchasers can encourage a culture of health care in which failure to intervene with a tobacco user is inconsistent with standards of care.

Contents

Suggested citation:

Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

Bookshelf ID: NBK63952
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