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Intensive tobacco dependence treatment can be provided by any suitably trained clinician. The evidence in Chapter 6 shows that intensive tobacco dependence treatment is more effective than brief treatment. Intensive interventions (i.e., more comprehensive treatments that may occur over multiple visits for longer periods of time and that may be provided by more than one clinician) are appropriate for any tobacco user willing to participate in them; neither their effectiveness nor cost-effectiveness is limited to a subpopulation of tobacco users (e.g., heavily dependent smokers).188–194 In addition, patients, even those not ready to quit, have reported increased satisfaction with their overall health care as tobacco counseling intensity increases.50,88
In many cases, intensive tobacco dependence interventions are provided by clinicians who specialize in the treatment of tobacco dependence. Such specialists are not defined by their certification, professional affiliation, or by the field in which they trained. Rather, specialists view tobacco dependence treatment as a primary professional role. Specialists possess the skills, knowledge, and training to provide effective interventions across a range of intensities. They often are affiliated with programs offering intensive treatment interventions or services (e.g., programs with staff dedicated to tobacco interventions in which treatment involves multiple counseling sessions, including quitlines). In addition to offering intensive treatments, specialists sometimes conduct research on tobacco dependence and its treatment.
As noted above, substantial evidence shows that intensive interventions produce higher success rates than do less intensive interventions. In addition, the tobacco dependence interventions offered by specialists represent an important treatment resource for patients even if they received tobacco dependence treatment from their own clinician.
The advent of state tobacco quitlines available through a national network at 1-800-QUIT-NOW (1-800-784-8669) means that intensive, specialist-delivered interventions are now available to smokers on an unprecedented basis. In addition to providing their own clinical tobacco dependence interventions, clinicians and health systems can take advantage of this availability by implementing systems that regularly refer patients to quitlines either directly or using fax referrals (e.g., via “fax-to-quit” referral procedures).195–199
Specialists also may contribute to tobacco control efforts through activities such as the following:
Serving as a resource to nonspecialists who offer tobacco dependence services as part of general health care delivery. This might include training nonspecialists in counseling strategies, providing consultation on difficult cases or for inpatients, and providing specialized assessment services for high-risk populations.
Developing, evaluating, and implementing changes in office/clinic procedures that increase the rates at which tobacco users are identified and treated.200
Conducting evaluation research to determine the effectiveness of ongoing tobacco dependence treatment activities in relevant institutional settings.
Developing and evaluating innovative treatment strategies that may increase the effectiveness and utilization of tobacco dependence treatments.
| Intensive counseling is especially effective. There is a strong dose-response relation between counseling intensity and quitting success. In general, the more intense the treatment intervention, the greater the rate of abstinence. Treatments may be made more intense by increasing (a) the length of individual treatment sessions and (b) the number of treatment sessions. |
| Many different types of providers (e.g., physicians, nurses, dentists, psychologists, social workers, cessation counselors, pharmacists) are effective at increasing quit rates; involving multiple types of providers can enhance abstinence rates. |
| Individual, group, and telephone counseling are effective tobacco use treatment formats. |
| Particular types of counseling strategies are especially effective. Practical counseling (problemsolving/skills-training approaches) and the provision of intratreatment social support are associated with significant increases in abstinence rates. |
| Medications such as bupropion SR, nicotine replacement therapies, and varenicline consistently increase abstinence rates. Therefore, their use should be encouraged for all smokers except in the presence of contraindications or for specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). In some instances, combinations of medications may be appropriate. In addition, combining counseling and medication increases abstinence rates. |
| Tobacco dependence treatments are effective across diverse populations (e.g., populations varying in gender, age, and race/ethnicity). |
| Assessment | Assessments should determine whether tobacco users are willing to make a quit attempt using an intensive treatment program. Other assessments can provide information useful in counseling (e.g., stress level, dependence; see Chapter 6A, Specialized Assessment). |
| Program clinicians | Multiple types of clinicians are effective and should be used. One counseling strategy would be to have a medical/health care clinician deliver a strong message to quit and information about health risks and benefits, and recommend and prescribe medications recommended in this Guideline update. Nonmedical clinicians could then deliver additional counseling interventions. |
| Program intensity | There is evidence of a strong dose-response relation; therefore, when possible, the intensity of the program should be: Session length - longer than 10 minutes Number of sessions - 4 or more |
| Program format | Either individual or group counseling may be used. Telephone counseling also is effective and can supplement treatments provided in the clinical setting. Use of self-help materials and cessation Web sites is optional. Followup interventions should be scheduled (see Chapter 6B). |
| Type of counseling and behavioral therapies | Counseling should include practical counseling (problemsolving/skills training) (see Table 6.19) and intratreatment social support (see Table 6.20). |
| Medication | Every smoker should be offered medications endorsed in this Guideline, except when contraindicated or for specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents; see Table 3.2 for clinical guidelines and Tables 3.3–3.11 for specific instructions and precautions). The clinician should explain how medications increase smoking cessation success and reduce withdrawal symptoms. The first-line medications include: bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline. Certain combinations of cessation medications also are effective. Combining counseling and medication increases abstinence rates. |
| Population | Intensive intervention programs may be used with all tobacco users willing to participate in such efforts. |
