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The 1996 Smoking Cessation Clinical Practice Guideline1 emphasized the dire health consequences of tobacco use and dependence, the existence of effective treatments, and the importance of inducing more smokers to use such treatments. It also called for newer, even more effective tobacco dependence treatments. All of these points still are germane. Nevertheless, heartening progress has been made in tobacco control since that time, and this progress is part of a larger pattern of change that stretches back over the past 40 years. This progress reflects the achievements of clinicians, the public health community, scientists, government agencies, health care organizations, insurers, purchasers, and smokers who have successfully quit. As a result, the current prevalence of tobacco use among adults in the United States (about 20.8%) is less than half the rate observed in the 1960s (about 44%).2,3
This Guideline concludes that tobacco use presents a rare confluence of circumstances: (1) a highly significant health threat;4 (2) a disinclination among clinicians to intervene consistently;5 and (3) the presence of effective interventions. This last point is buttressed by evidence that tobacco dependence interventions, if delivered in a timely and effective manner, significantly reduce the smoker's risk of suffering from smoking-related disease.6–13 Indeed, it is difficult to identify any other condition that presents such a mix of lethality, prevalence, and neglect, despite effective and readily available interventions.
Although tobacco use still is an enormous threat, the story of tobacco control efforts during the last half century is one of remarkable progress and promise. In 1965, current smokers outnumbered former smokers three to one.14 During the past 40 years, the rate of quitting has so outstripped the rate of initiation that, today, there are more former smokers than current smokers.15 Moreover, 40 years ago smoking was viewed as a habit rather than a chronic disease. No scientifically validated treatments were available for the treatment of tobacco use and dependence, and it had little place in health care delivery. Today, numerous effective treatments exist, and tobacco use assessment and intervention are considered to be requisite duties of clinicians and health care delivery entities. Finally, every state now has a telephone quitline, increasing access to effective treatment.
The scant dozen years following the publication of the first Guideline have ushered in similarly impressive changes. In 1997, only 25 percent of managed health care plans covered any tobacco dependence treatment; this figure approached 90 percent by 2003,16 although this increased coverage often includes barriers to use. Numerous states added Medicaid coverage for tobacco dependence treatment since the publication of the first Guideline so that, by 2005, 72 percent offered coverage for at least one Guideline-recommended treatment.16–18 In 2002, The Joint Commission (formerly JCAHO), which accredits some 15,000 hospitals and health care programs, instituted an accreditation requirement for the delivery of evidence-based tobacco dependence interventions for patients with diagnoses of acute myocardial infarction, congestive heart failure, or pneumonia (www.coreoptions.com/new_site/jcahocore.html; hospital-specific results: www.hospitalcompare.hhs.gov). Finally, Medicare, the Veterans Health Administration, and the United States Military now provide coverage for tobacco dependence treatment. Such policies and systems changes are paying off in terms of increased rates of assessment and treatment of tobacco use.
Data show that the rate at which smokers report being advised to quit smoking has approximately doubled since the early 1990s.19–22 Recent data also suggest a substantial increase in the proportion of smokers receiving more intensive cessation interventions.23,24 The National Committee for Quality Assurance (NCQA) reports steady increases for both commercial insurers and Medicaid in the discussion of both medications and strategies for smoking cessation.25 Finally, since the first Guideline was published in 1996, smoking prevalence among adults in the United States has declined from about 25 percent to about 21 percent.26
An inspection of the 2008 Guideline update shows that substantial progress also has been made in treatment development and delivery. Telephone quitlines have been shown to be effective in providing wide access to evidence-based cessation counseling.27,28 Seven U.S. Food and Drug Administration (FDA)-approved medications for treating tobacco dependence are now available, and new evidence has revealed that particular medications or combinations of medications are especially effective.
This Guideline update also casts into stark relief those areas in which more progress is needed. There is a need for innovative and more effective counseling strategies. In addition, although adolescents appear to benefit from counseling, more consistent and effective interventions and options for use with children, adolescents, and young adults clearly are needed. Smoking prevalence remains discouragingly high in certain populations, such as in those with low socioeconomic status (SES)/low educational attainment, some American Indian populations, and individuals with psychiatric disorders, including substance use disorders.3 New techniques and treatment delivery strategies may be required before the needs of these groups are adequately addressed. Moreover, although much of the available data come from randomized clinical trials occurring in research settings, it is imperative that new research examine implementation of effective treatments in real-world clinical settings. Finally, new strategies are needed to create consumer demand for effective treatments among tobacco users; there has been little increase in the proportion of smokers who make quit attempts, and too few smokers who do try to quit take advantage of evidence-based treatment that can double or triple their odds of success.29 New research and communication efforts must impart greater hope, confidence, and increased access to treatments so that tobacco users in ever greater numbers attempt tobacco cessation and achieve abstinence. To succeed, all of these areas require adequate funding.
Thus, this 2008 Guideline update serves as a benchmark of the progress made. It should reassure clinicians, policymakers, funding agencies, and the public that tobacco use is amenable to both scientific analysis and clinical interventions. This history of remarkable progress should encourage renewed efforts by clinicians, policymakers, and researchers to help those who remain dependent on tobacco.
This Guideline, Treating Tobacco Use and Dependence: 2008 Update, a Public Health Service-sponsored Clinical Practice Guideline, is the product of the Treating Tobacco Use and Dependence Guideline Panel (“the Panel”), government liaisons, consultants, and staff. These individuals were charged with the responsibility of identifying effective, experimentally validated tobacco dependence clinical treatments and practices. This Guideline update is the third Public Health Service Clinical Practice Guideline published on tobacco use. The first Guideline, the 1996 Smoking Cessation Clinical Practice Guideline No. 18, was sponsored by the Agency for Healthcare Policy and Research (AHCPR, now the Agency for Healthcare Research and Quality [AHRQ]), U.S. Department of Health and Human Services (HHS). That Guideline reflected scientific literature published between 1975 and 1994. The second Guideline, published in 2000, Treating Tobacco Use and Dependence, was sponsored by a consortium of U. S. Public Health Service (PHS) agencies (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]) as well as the Robert Wood Johnson Foundation (RWJF) and the University of Wisconsin Center for Tobacco Research and Intervention (UW-CTRI). That Guideline reflected the scientific literature published from 1975 to 1999. The current 2008 update addresses literature published from 1975 to 2007.
The updated Guideline was written in response to new, effective clinical treatments for tobacco dependence that have been identified since 1999. These treatments promise to enhance the rates of successful tobacco cessation. The original 1996 Guideline was based on some 3,000 articles on tobacco treatment published between 1975 and 1994. The 2000 Guideline required 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. This body of research of course was further reviewed to identify a much smaller group of articles, based on rigorous inclusion criteria, which served as the basis for focused Guideline data analyses and review.
The 2008 updated Guideline was sponsored by a consortium of eight Federal Government and private nonprofit organizations: AHRQ, CDC, NCI, NHLBI, NIDA, American Legacy Foundation, RWJF, and UW-CTRI. All of these organizations have as their mission reducing the human costs of tobacco use. Given the importance of this issue to the health of all Americans, the updated Guideline is published by the PHS, HHS.
This Guideline update was written to be applicable to all tobacco users—those using cigarettes as well as other forms of tobacco. Therefore, the terms “tobacco user” and “tobacco dependence” will be used in preference to “smoker” and “cigarette dependence.” In some cases, however, the evidence for a particular recommendation consists entirely of studies using cigarette smokers as participants. In these instances, the recommendation and evidence refers to “smoking” to communicate the parochial nature of the evidence. In most cases, though, Guideline recommendations are relevant to all types of tobacco users. Finally, most data reviewed in this Guideline update are based on adult smokers, although data relevant to adolescent smokers are presented in Chapter 7.
The updated Guideline is divided into seven chapters that integrate prior and updated findings:
Chapter 1, Overview and Methods, provides the clinical practice and scientific context of the Guideline update project and describes the methodology used to generate the Guideline findings.
Chapter 2, Assessment of Tobacco Use, describes how each patient presenting at a health care setting should have his or her tobacco use status determined and how tobacco users should be assessed for willingness to make a quit attempt.
Chapter 3, Clinical Interventions for Tobacco Use and Dependence, summarizes effective brief interventions that can easily be delivered in a primary care setting. In this chapter, separate interventions are described for the patient who is willing to try to quit at this time, for the patient who is not yet willing to try to quit, and for the patient who has recently quit.
Chapter 4, Intensive Interventions for Tobacco Use and Dependence, outlines a prototype of an intensive tobacco cessation treatment that comprises strategies shown to be effective in this Guideline. Because intensive treatments produce the highest success rates, they are an important element in tobacco intervention strategies.
Chapter 5, Systems Interventions, targets health care administrators, insurers, and purchasers, and offers a blueprint to changes in health care delivery and coverage such that tobacco assessment and intervention become a standard of care in health care delivery.
Chapter 6, Evidence and Recommendations, presents the results of Guideline literature reviews and statistical analyses and the recommendations that emanate from them. Guideline analyses address topics such as the effectiveness of different counseling strategies and medications; the relation between treatment intensities and treatment success; whether screening for tobacco use in the clinic setting enhances tobacco user identification; and whether systems changes can increase provision of effective interventions, quit attempts, and actual cessation rates. The Guideline Panel also made specific recommendations regarding future research needs.
Chapter 7, Specific Populations and Other Topics, evaluates evidence on tobacco intervention strategies and effectiveness with specific populations (e.g., HIV-positive smokers; hospitalized smokers; lesbian/gay/bisexual/transgender smokers; smokers with low SES/limited educational attainment; smokers with medical comorbidities; older smokers; smokers with psychiatric disorders, including substance use disorders; racial and ethnic minorities; women smokers; children and adolescents; light smokers; pregnant smokers; and noncigarette tobacco users). The Guideline Panel made specific recommendations for future research on topics relevant to these populations. This chapter also presents information and recommendations relevant to weight gain after smoking cessation, with specific recommendations regarding future research on this topic.
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:
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 care systems, insurers, and purchasers assist clinicians in making such effective treatments available.
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.
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.
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.
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.
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
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.
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.
Telephone quitline counseling is effective with diverse populations and has broad reach. Therefore, clinicians and health care delivery systems should both ensure patient access to quitlines and promote quitline use.
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.
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.
A comparison of the findings of the 2008 Guideline update with the 2000 Guideline reveals the considerable progress made in tobacco research over the brief period separating these two works. Among many important differences between the two documents, the following deserve special note:
The updated Guideline has produced even stronger evidence that counseling is an effective tobacco use treatment strategy. Of particular note are findings that counseling adds significantly to the effectiveness of tobacco cessation medications, quitline counseling is an effective intervention with a broad reach, and counseling increases abstinence among adolescent smokers.
The updated Guideline offers the clinician a greater number of effective medications than were identified in the previous Guideline. Seven different effective first-line smoking cessation medications are now approved by the FDA for treating tobacco use and dependence. In addition, multiple combinations of medications have been shown to be effective. Thus, the clinician and patient have many more medication options than in the past. The Guideline also now provides evidence regarding the effectiveness of medications relative to one another.
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 a benefit covered by insurance plans increases the likelihood that a tobacco user will receive treatment and quit successfully.
The research reviewed for this 2008 Guideline update suggests a bright future for treating tobacco use and dependence. Since the first AHCPR Clinical Practice Guideline was published in 1996, encouraging progress has been made in tobacco dependence treatment. An expanding body of research has produced a marked increase in the number and types of effective treatments and has led to multiple new treatment delivery strategies. These new strategies are enhancing the delivery of tobacco interventions both inside and outside health care delivery systems. This means that an unprecedented number of smokers have access to an unprecedented number of effective treatments.
Although the data reviewed in this Guideline update are encouraging and portend even greater advances through future research, for many smokers, the progress has been an undelivered promissory note. Most smokers attempting to quit today still make unaided quit attempts,29–32 although the proportion using evidence-based treatments has increased since the publication of the 1996 AHCPR Guideline.33–35 Because of the prevalence of such unaided attempts (those that occur without evidence-based counseling or medication), many smokers have successfully quit through this approach.6,36 It is clear from the data presented in this Guideline, however, that smokers are significantly more likely to quit successfully if they use an evidence-based counseling or medication treatment than if they try to quit without such aids. Thus, a future challenge for the field is to ensure that smokers, clinicians, and health systems have accurate information on the effectiveness of clinical interventions for tobacco use, and that the 70 percent of smokers who visit a primary care setting each year have greater access to effective treatments. This is of vital public health importance because the costs of failure are so high. Relapse results in continuing lifetime exposure to tobacco, which leads to increased risk of death and disease. Additional progress must be made in educating clinicians and the public about the effectiveness of clinical treatments for tobacco dependence and in making such treatments available and attractive to smokers.
Continued progress is needed in the treatment of tobacco use and dependence. Treatments should be even more effective and available, new counseling strategies should be developed, and research should focus on the development of effective interventions and delivery strategies for populations that carry a disproportionate burden from tobacco (e.g., adolescents; pregnant smokers; American Indians and Alaska Natives; individuals with low SES/limited educational attainment; individuals with psychiatric disorders, including substance use disorders). The decrease in the prevalence of tobacco use in the United States during the past 40 years, however, has been a seminal public health achievement. Treatment of tobacco use and dependence has played an important role in realizing that outcome.
