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Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville (MD): US Department of Health and Human Services; 2008 May.

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Treating Tobacco Use and Dependence: 2008 Update.

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Appendix DKey Recommendation Changes From the 2000 PHS-Sponsored Clinical Practice Guideline: Treating Tobacco Use and Dependence

Below is a summary of the substantive changes in recommendations from the 2000 Guideline to the 2008 Guideline Update. These changes include new 2008 update recommendations as well as recommendations that were deleted or changed substantially from the 2000 Guideline.

New Recommendations in the 2008 Update

Most, but not all, of the new recommendations appearing in the 2008 Treating Tobacco Use and Dependence Update resulted from new meta-analyses of the topics chosen by the Guideline Panel.

1. Formats of Psychosocial Treatments

Recommendation: Tailored materials, both print and Web-based, appear to be effective in helping people quit. Therefore, clinicians may choose to provide tailored self-help materials to their patients who want to quit. (Strength of Evidence = B)

2. Combining Counseling and Medication

Recommendation: The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore, whenever feasible and appropriate, both counseling and medication should be provided to patients trying to quit smoking. (Strength of Evidence = A)

Recommendation: There is a strong relation between the number of sessions of counseling when it is combined with medication, and the likelihood of successful smoking abstinence. Therefore, to the extent possible, clinicians should provide multiple counseling sessions, in addition to medication, to their patients who are trying to quit smoking. (Strength of Evidence = A)

3. For Smokers Not Willing To Make a Quit Attempt at This Time

Recommendation: Motivational intervention techniques appear to be effective in increasing a patient's likelihood of making a future quit attempt. Therefore, clinicians should use motivational techniques to encourage smokers who currently are not willing to quit to consider making a quit attempt in the future. (Strength of Evidence = B)

4. Nicotine Lozenge

Recommendation: The nicotine lozenge is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = B)

5. Varenicline

Recommendation: Varenicline is an effective smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A)

6. Specific Populations

Recommendation: The interventions found to be effective in this Guideline have been shown to be effective in a variety of populations. In addition, many of the studies supporting these interventions comprised diverse samples of tobacco users. Therefore, interventions identified as effective in this Guideline are recommended for all individuals who use tobacco, except when medically contraindicated or with specific populations in which medication has not been shown to be effective (pregnant women, smokeless tobacco users, light smokers, and adolescents). (Strength of Evidence = B)

7. Light Smokers

Recommendation: Light smokers should be identified, strongly urged to quit, and provided counseling cessation interventions. (Strength of Evidence = B)

Recommendations from the 2000 Guideline that were Deleted from the 2008 Update

All “C” level recommendations were reconsidered by the Panel, with the goal of limiting those that are based, in part, on Panel opinion. The 2008 Guideline Update has 8 “C” recommendations; the 2000 Guideline had 18. There were additional deletions of recommendations from the 2000 Guideline. Some of these other deletions reflect addressing specific populations differently in the 2008 Guideline update.

1. Advice To Quit Smoking

Recommendation: All clinicians should strongly advise their patients who use tobacco to quit. Although studies independently have not addressed the impact of advice to quit by all types of nonphysician clinicians, it is reasonable to believe that such advice is effective in increasing their patients' long-term quit rates. (Strength of Evidence = B)

2. Types of Counseling and Behavioral Therapies

Recommendation: Aversive smoking interventions (rapid smoking, rapid puffing, other aversive smoking techniques) increase abstinence rates and may be used with smokers who desire such treatment or who have been unsuccessful using other interventions. (Strength of Evidence = B)

3. Medications

Recommendation: Long-term smoking cessation medications should be considered as a strategy to reduce the likelihood of relapse. (Strength of Evidence = C)

4. Gender

Recommendation: The same smoking cessation treatments are effective for both men and women. Therefore, except in the case of the pregnant smoker, the same interventions can be used with both men and women. (Strength of Evidence = B)

5. Pregnancy

Recommendation: Medications should be considered when a pregnant woman otherwise is unable to quit, and when the likelihood of quitting, with its potential benefits, outweighs the risks of the medications and potential continued smoking. (Strength of Evidence = C)

6. Racial and Ethnic Minority Populations

Recommendation: Smoking cessation treatments have been shown to be effective across different racial and ethnic minorities. Therefore, members of racial and ethnic minorities should be provided treatments shown to be effective in this Guideline. (Strength of Evidence = A)

Recommendation: Whenever possible, tobacco dependence treatments should be modified or tailored to be appropriate for the ethnic or racial populations with which they are used. (Strength of Evidence = C)

7. Hospitalized Smokers

Recommendation: Smoking cessation treatments have been shown to be effective for hospitalized patients. Therefore, hospitalized patients should be provided smoking cessation treatments shown to be effective in this Guideline. (Strength of Evidence = B)

8. Psychiatric Illness and/or Nontobacco Chemical Dependency

Recommendation: Smokers with comorbid psychiatric conditions should be provided smoking cessation treatments identified as effective in this Guideline. (Strength of Evidence = C)

Recommendation: Bupropion SR and nortriptyline, efficacious treatments for smoking cessation in the general population, also are effective in treating depression. Therefore, bupropion SR and nortriptyline especially should be considered for the treatment of tobacco dependence in smokers with current or past history of depression. (Strength of Evidence = C)

Recommendation: Evidence indicates that smoking cessation interventions do not interfere with recovery from chemical dependency. Therefore, smokers receiving treatment for chemical dependency should be provided smoking cessation treatments shown to be effective in this Guideline, including both counseling and medications. (Strength of Evidence = C)

9. Children and Adolescents

Recommendation: When treating adolescents, clinicians may consider prescriptions for bupropion SR or NRT when there is evidence of nicotine dependence and desire to quit tobacco use. (Strength of Evidence = C)

10. Older Smokers

Recommendation: Smoking cessation treatments have been shown to be effective for older adults. Therefore, older smokers should be provided smoking cessation treatments shown to be effective in this Guideline. (Strength of Evidence = A)

11. Weight Gain After Stopping Smoking

Recommendation: The clinician should acknowledge that quitting smoking is often followed by weight gain. Additionally, the clinician should: (1) note that the health risks of weight gain are small when compared to the risks of continued smoking; (2) recommend physical activities and a healthy diet to control weight; and (3) recommend that patients concentrate primarily on smoking cessation, not weight control, until exsmokers are confident that they will not return to smoking. (Strength of Evidence = C)

12. Cost-Effectiveness of Tobacco Interventions

Recommendation: Intensive smoking cessation interventions are especially efficacious and cost-effective, and smokers should have ready access to these services as well as to less intensive interventions. (Strength of Evidence = B)

Note: The tobacco dependence treatments shown to be effective in this Guideline still are recommended as highly cost-effective with Strength of Evidence = A. The above recommendation, number 12, was deleted because it refers only to “intensive” smoking cessation interventions.

Recommendations from the 2000 Guideline that were Substantially Changed in the 2008 Update

The results of meta-analyses or consideration of literature not available for the 2000 Guideline led to substantive changes in some of the 2000 Guideline recommendations. Minor changes in wording are not listed here.

1. Screening and Assessment

2000 Guideline. Recommendation #1: All patients should be asked if they use tobacco and should have their tobacco-use status documented on a regular basis. Evidence has shown that this significantly increases rates of clinician intervention. (Strength of Evidence = A)

2000 Guideline. Recommendation #2: Clinic screening systems, such as expanding the vital signs to include tobacco use status, or the use of other reminder systems, such as chart stickers or computer prompts, are essential for the consistent assessment, documentation, and intervention with tobacco use. (Strength of Evidence = B)

2008 Guideline Update. Recommendation: All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis. Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status, or the use of other reminder systems, such as chart stickers or computer prompts, significantly increase rates of clinician intervention. (Strength of Evidence = A)

2. Types of Counseling and Behavioral Therapies

2000 Guideline. Recommendation: Three types of counseling and behavioral therapies result in higher abstinence rates: (1) providing smokers with practical counseling (problemsolving skills/skills training); (2) providing social support as part of treatment; and (3) helping smokers obtain social support outside the treatment environment. These types of counseling and behavioral therapies should be included in smoking cessation interventions. (Strength of Evidence = B)

2008 Guideline Update. Recommendation: Two types of counseling and behavioral therapies result in higher abstinence rates: (1) providing smokers with practical counseling (problemsolving skills/skills training); and (2) providing support and encouragement as part of treatment. These types of counseling elements should be included in smoking cessation interventions. (Strength of Evidence = B)

3. Medications

2000 Guideline. Recommendation: All patients attempting to quit should be encouraged to use effective medications for smoking cessation, except in the presence of special circumstances. (Strength of Evidence = A)

2008 Guideline Update. Recommendation: Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). (Strength of Evidence = A)

4. Combination Medications

2000 Guideline. Recommendation: Combining the nicotine patch with a self-administered form of nicotine replacement therapy (either the nicotine gum or nicotine nasal spray) is more efficacious than a single form of nicotine replacement, and patients should be encouraged to use such combined treatments if they are unable to quit using a single type of first-line medication. (Strength of Evidence = B)

2008 Guideline Update. Recommendation: Certain combinations of first-line medications have been shown to be effective smoking cessation treatments. Therefore, clinicians should consider using these combinations of medications with their patients who are willing to quit. Effective combination medications are long-term (> 14 weeks) nicotine patch + other NRT (gum and spray), the nicotine patch + the nicotine inhaler, and the nicotine patch + bupropion SR. (Strength of Evidence = A)

5. Children and Adolescents

2000 Guideline. Recommendation #1: Counseling and behavioral interventions shown to be effective with adults should be considered for use with children and adolescents. The content of these interventions should be modified to be developmentally appropriate. (Strength of Evidence = C)

2008 Guideline Update. Recommendation #1: Counseling has been shown to be effective in treatment of adolescent smokers. Therefore, adolescent smokers should be provided with counseling interventions to aid them in quitting smoking. (Strength of Evidence = B)

2000 Guideline. Recommendation #2: Clinicians in a pediatric setting should offer smoking cessation advice and interventions to parents to limit children's exposure to secondhand smoke. (Strength of Evidence = B)

2008 Guideline Update. Recommendation #2: Secondhand smoke is harmful to children. Cessation counseling delivered in pediatric settings has been shown to be effective in increasing cessation among parents who smoke. Therefore, to protect children from secondhand smoke, clinicians should ask parents about tobacco use and offer them cessation advice and assistance. (Strength of Evidence = B)

6. Noncigarette Tobacco Users

2000 Guideline. Recommendation: Smokeless/spit tobacco users should be identified, strongly urged to quit, and treated with the same counseling cessation interventions recommended for smokers. (Strength of Evidence = B)

2008 Guideline Update. Recommendation: Smokeless tobacco users should be identified, strongly urged to quit, and provided counseling cessation interventions. (Strength of Evidence = A)

7. Cost-Effectiveness of Tobacco Dependence Interventions

2000 Guideline. Recommendation: Sufficient resources should be allocated for clinician reimbursement and systems support to ensure the delivery of efficacious tobacco use treatments. (Strength of Evidence = C)

2008 Guideline Update. Recommendation: Sufficient resources should be allocated for systems support to ensure the delivery of effective tobacco use treatments. (Strength of Evidence = C)

8. Tobacco Dependence Treatment as a Part of Assessing Health Care Quality

2000 Guideline. Recommendation: Provision of Guideline-based interventions to treat tobacco use and addiction should be included in standard ratings and measures of overall health care quality (e.g., NCQA HEDIS, the Foundation for Accountability [FACCT]). (Strength of Evidence = C)

2008 Guideline Update. Recommendation: Provision of Guideline-based interventions to treat tobacco use and dependence should remain in standard ratings and measures of overall health care quality (e.g., NCQA, HEDIS). These standard measures also should include measures of outcomes (e.g., use of cessation treatment, short- and long-term abstinence rates) that result from providing tobacco dependence interventions. (Strength of Evidence = C)

9. Providing Smoking Cessation Treatments as a Covered Benefit

2000 Guideline. Recommendation: Smoking cessation treatments (both medication and counseling) should be included as a paid or covered benefit by health benefit plans, because doing so improves utilization and overall abstinence rates. (Strength of Evidence = B)

2008 Guideline Update. Recommendation: Providing tobacco dependence treatments (both medication and counseling) as a paid or covered benefit by health insurance plans has been shown to increase the proportion of smokers who use cessation treatment, attempt to quit, and successfully quit. Therefore, treatments shown to be effective in the Guideline should be included as covered services in public and private health benefit plans. (Strength of Evidence = A)

Guideline Availability

This Guideline is available in several formats suitable for health care practitioners, the scientific community, educators, and consumers.

The Clinical Practice Guideline presents recommendations for health care providers, with brief supporting information, tables and figures, and pertinent references.

The Quick Reference Guide is a distilled version of the clinical practice Guideline, with summary points for ready reference on a day-to-day basis.

The Consumer Version is an information booklet for the general public to increase consumer knowledge and involvement in health care decisionmaking.

The full text of the Guideline, with and without the text references and the meta-analyses references (listed by evidence table), is available by visiting the Surgeon General's Web site at: www.ahrq.gov/path/tobacco.htm#Clinic.

Single copies of these Guideline products and further information on the availability of other derivative products can be obtained by calling any of the following Public Health Service organizations' toll-free numbers:

Agency for Healthcare Research and Quality (AHRQ)

800-358-9295

Centers for Disease Control and Prevention (CDC)

800-311-3435

National Cancer Institute (NCI)

800-4-CANCER

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