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Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2000 Update. Rockville (MD): US Department of Health and Human Services; 2000 Jun.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Treating Tobacco Use and Dependence: 2000 Update.

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7Special Populations

Background

Many factors could potentially affect the choice, delivery, and efficacy of tobacco dependence treatments. For instance, should interventions be tailored or modified on the basis of gender, race/ethnicity, age, comorbidity, or hospitalization status? Should pregnant smokers receive pharmacotherapy? Do tobacco dependence interventions interfere with other chemical dependency treatments? These and other special issues and populations are considered in this chapter.

A variety of health care specialties can play a key role in addressing issues related to special populations (e.g., obstetricians and family practitioners for pregnant smokers; gynecologists and family practitioners for preconception counseling and general health maintenance; pediatricians, family practitioners, and dentists for children and adolescents; internists, including cardiologists, pulmonologists, oncologists, and general internists, and family practitioners for hospitalized patients; geriatricians for older smokers; and dentists and dental hygienists for smokeless tobacco users).

One over-riding issue relevant to all tobacco users considering a quit attempt is to ensure that all textual materials used (e.g., self-help brochures) are at an appropriate reading level. This is particularly important given epidemiological data showing that tobacco use rates are markedly higher among individuals of lower educational attainment.149

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)

One important question regarding quitting smoking is whether men and women should receive different cessation interventions. Smoking cessation clinical trials reveal that the same treatments benefit both men and women;140, 150 however, research suggests that some treatments are less efficacious in women than in men (e.g., NRTs).151, 152

Although research suggests that women benefit from the same interventions as do men, women may face different stressors and barriers to quitting that may be addressed in treatment. These include greater likelihood of depression, greater weight control concerns, hormonal cycles, and others.153 This suggests that women may benefit from tobacco dependence treatments that address these topics, although few studies have examined programs targeted to one gender. Finally, women who are considering becoming pregnant may be especially receptive to tobacco dependence treatment.

Future Research

The following topics regarding gender require additional research:

  • The efficacy of interventions that are targeted to specific genders.
  • The impact of gender-specific motives that may increase quit attempts and success (e.g., quitting to improve fertility and reproductive health, erectile dysfunction, pregnancy outcomes, physical appearance, and osteoporosis).
  • Gender differences in efficacy of tobacco dependence treatments found to be effective in this guideline.

Pregnancy

Recommendation: Because of the serious risks of smoking to the pregnant smoker and the fetus, whenever possible pregnant smokers should be offered extended or augmented psychosocial interventions that exceed minimal advice to quit. (Strength of Evidence = A)

Recommendation: Although abstinence early in pregnancy will produce the greatest benefits to the fetus and expectant mother, quitting at any point in pregnancy can yield benefits. Therefore, clinicians should offer effective smoking cessation interventions to pregnant smokers at the first prenatal visit as well as throughout the course of pregnancy. (Strength of Evidence = B)

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

The selection criteria for the pregnancy meta-analysis were adjusted to reflect this unique population. Abstinence data were included only if they were biochemically confirmed, due to reports of high levels of deception regarding smoking status found in pregnant women.35, 36, 37 Studies that had followup time points of less than 5 months were included because of the desire for preparturition data. For the meta-analysis, either minimal interventions (<3 minutes) or interventions labeled as "usual care" constituted the reference condition. Seven studies met the criteria and were included in the analysis comparing augmented smoking cessation interventions with usual care in pregnant women. A "usual care" intervention with pregnant smokers typically consists of a recommendation to stop smoking, often supplemented by provision of self-help material or referral to a stop-smoking program. Extended or augmented psychosocial interventions typically involve these treatment components as well as more intensive counseling than minimal advice. As can be seen from the data in Table 41, extended or augmented interventions are significantly more efficacious than usual care in pregnant women.

Table 41. Meta-analysis: Efficacy of and estimated abstinence rates for augmented interventions with pregnant smokers (n = 7 studies).

Table

Table 41. Meta-analysis: Efficacy of and estimated abstinence rates for augmented interventions with pregnant smokers (n = 7 studies).

Components of some extended or augmented psychosocial interventions are listed in Table 42. These interventions were selected from articles included in the Table 41 meta-analysis and should guide the clinician treating the pregnant smoker.

Table 42. Examples of effective interventions with pregnant patients.

Table

Table 42. Examples of effective interventions with pregnant patients.

Smoking in pregnancy imparts risks to both the woman and the fetus. Cigarette smoking by pregnant women has been shown to cause adverse fetal outcomes, including stillbirths, spontaneous abortions, decreased fetal growth, premature births, low birth weight, placental abruption, sudden infant death syndrome (SIDS), cleft palates and cleft lips, and childhood cancers. Many women are motivated to quit during pregnancy, and health care professionals can take advantage of this motivation by reinforcing the knowledge that cessation will reduce health risks to the fetus and that there are postpartum benefits for both the mother and child.157

The first step in intervention is assessment of tobacco use status. This is especially important in a population with reported high rates of deception. Research has shown that the use of multiple choice questions (see Table 43), as opposed to a simple yes/no question can increase disclosure among pregnant women by as much as 40 percent.158

Table 43. Clinical practice when assisting a pregnant patient in smoking cessation.

Table

Table 43. Clinical practice when assisting a pregnant patient in smoking cessation.

Quitting smoking prior to conception or early in the pregnancy is most beneficial, but health benefits result from abstinence at any time. Therefore, a pregnant smoker should receive encouragement and assistance in quitting throughout her pregnancy.

Even women who have maintained total abstinence from tobacco for 6 or more months during pregnancy have a high rate of relapse in the postpartum period.159, 160 Postpartum relapse may be decreased by continued emphasis on the relationship between maternal smoking and poor health outcomes in infants and children (SIDS, respiratory infections, asthma, and middle ear disease).159, 160, 161, 162 Preventing postpartum relapse is, however, an area that would benefit from future research. Table 43 outlines clinical factors to address when counseling pregnant women about smoking.

For pregnant smokers who are unable to quit with the help of an augmented intervention (see Table 42), clinicians may consider additional or alternative psychosocial treatments such as those described in Chapter 4. The exception to this would be the use of rapid smoking, which can result in extremely high blood nicotine levels.

Clinicians may choose to consider pharmacotherapy for pregnant smokers who have been unable to quit using psychosocial interventions. In such cases, the clinician and pregnant smoker must contrast the risks and unknown efficacy of pharmacotherapy in pregnant women with the substantial risks of continued smoking. Although smoking during pregnancy clearly leads to substantial risks for both the pregnant smoker and the fetus, the clinician and patient also must be aware of potential risks of different pharmacotherapies. For example, a number of studies have shown that nicotine itself presents risks to the fetus, including neurotoxicity,163 and bupropion SR has been shown to cause seizures in 1 out of 1,000 patients.164

If the clinician and pregnant or lactating patient decide to use NRT pharmacotherapy, the clinician should consider monitoring blood nicotine levels to assess level of drug delivery. In addition, the clinician should consider using medication doses that are at the low end of the effective dose range, and consider choosing delivery systems that yield intermittent, rather than continuous, drug exposure (e.g., nicotine gum rather than the nicotine patch). Because none of these medications has been tested in pregnant women for efficacy in treating tobacco dependence, the relative ratio of risks to benefits is unclear. Additionally, since small amounts of these medications are passed through breast milk, they may pose some risks for nursing infants.

Future Research

The following topics regarding smoking and pregnancy require additional research:

  • Relapse prevention with pregnant women and women who have recently given birth.
  • The efficacy of relapse prevention programs for spontaneous "self-quitters."
  • The most efficacious amount of contact time, number of sessions, and duration for smoking cessation interventions with pregnant women.
  • The efficacy of various counseling and behavioral therapies and motivational interventions (e.g., physiological feedback of adverse impacts, quitting benefits).
  • Efficacious treatments for highly dependent smokers.
  • The safety and efficacy of tobacco dependence pharmacotherapy during pregnancy to the woman and the fetus, including: the relative risks and benefits of pharmacotherapy use as a function of dependence, and the appropriate formulation and timing of pharmacotherapy.
  • The safety and efficacy of tobacco dependence pharmacotherapy to the woman and child during nursing.
  • The efficacy of targeted or individualized interventions in pregnancy.
  • Strategies for linking preconception, pregnancy, and postpartum (including pediatric) interventions.

Racial and Ethnic Minorities

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)

Ethnic and racial minority groups in the United States—African Americans, American Indians/ Alaska Natives, Asians and Pacific Islanders, Hispanics -- experience higher mortality in a number of disease categories compared with others. For example, African Americans experience substantial excess mortality from cancer, cardiovascular disease, and infant death, all of which are directly affected by tobacco use.165, 166 American Indian/Alaska Native subgroups have some of the highest documented rates of infant mortality caused by SIDS,167 which also is affected by tobacco use. Therefore, there is a critical need to deliver effective tobacco dependence interventions to ethnic and racial minorities. Unfortunately, there is evidence that large proportions of some racial/ethnic groups lack adequate access to primary care providers.166 This suggests that special efforts and resources should be provided to meet the treatment needs of these populations.

There are well-documented differences between racial and ethnic minorities and whites in smoking prevalence, smoking patterns, and quitting behavior in the United States.166, 168, 169 In addition, smoking prevalence and patterns vary substantially among minority subgroups.166, 167 Racial and ethnic minority groups also differ from whites in awareness of the health effects of smoking170 and report a sense of fatalism that may affect disease prevention efforts. On the other hand, both tobacco dependence and desire to quit appear to be prevalent across all racial and ethnic groups.166, 168, 169, 171

Studies have demonstrated the efficacy of a variety of smoking cessation interventions in minority populations. Nicotine patch,172 clinician advice,173, 174 counseling,175 tailored self-help manuals and materials, and telephone counseling173, 176 have been shown to be effective with African Americans. Nicotine patch177 and self-help materials, including a mood management component,178 have been shown to be effective with Hispanic smokers. Screening for tobacco use, clinician advice, clinic staff reinforcement, and followup materials have been shown to be effective for American Indian populations.179

Few studies have examined interventions specifically designed for particular ethnic or racial groups, and there is no consistent evidence that targeted cessation programs result in higher quit rates in these groups than do generic interventions of comparable intensity.176 Moreover, smoking cessation interventions developed for the general population have been effective with racial and ethnic minority participants. Therefore, clinicians should offer treatments identified as effective in this guideline to their patients from all racial and ethnic groups. It is essential, however, that cessation counseling or self-help materials be conveyed in a language understood by the smoker. Additionally, culturally appropriate models or examples may increase the smoker's acceptance of treatment. Clinicians should remain sensitive to individual differences and health beliefs that may affect treatment acceptance and success in all populations (see section in Chapter 6A, Specialized Assessment).

Future Research

The following topics regarding racial and ethnic minorities require additional research:

  • The efficacy of targeted versus generic interventions for different racial and ethnic minority populations.
  • The identification of the specific barriers or impediments to treatment or treatment success (e.g., socioeconomic status, inadequate access to medical care), and the differential health effects related to smoking patterns for racial and ethnic minorities.
  • Motivators of cessation that are especially effective with members of racial and ethnic minorities (e.g., fear of illness requiring long-term care and disability).

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)

Four studies met the selection criteria and were relevant to the analysis comparing augmented smoking cessation treatment with usual care for hospitalized patients. Because the analysis was limited to four studies, no attempt was made to categorize the augmented treatment with respect to intensity or type for the purpose of the meta-analysis. For reference only, the augmented interventions in the analyzed studies included elements such as self-help via brochure or audio/videotape, chart prompt reminding physician to advise smoking cessation, pharmacotherapy, hospital counseling, and postdischarge counseling telephone calls. As can be seen from the data in Table 44, augmented smoking cessation interventions among hospitalized patients increase rates of smoking abstinence.

Table 44. Meta-analysis: Efficacy of and estimated abstinence rates for augmented interventions with hospitalized smokers (n = 4 studies).

Table

Table 44. Meta-analysis: Efficacy of and estimated abstinence rates for augmented interventions with hospitalized smokers (n = 4 studies).

It is vital that hospitalized patients attempt to quit smoking, because smoking may interfere with their recovery. Among cardiac patients, second heart attacks are more common in those who continue to smoke.16, 180 Lung, head, and neck cancer patients who are successfully treated, but who continue to smoke, are at elevated risk for a second cancer.181, 182, 183, 184, 185 Additionally, smoking negatively affects bone and wound healing.186, 187, 188

Hospitalized patients may be particularly motivated to make a quit attempt for two reasons. First, the illness resulting in hospitalization may have been caused or exacerbated by smoking, highlighting the patient's personal vulnerability to the health risks of smoking. Second, every hospital in the United States must now be smoke free if it is to be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). As a result, every hospitalized smoker is temporarily housed in a smoke-free environment. For these reasons, clinicians should use hospitalization as an opportunity to promote smoking cessation in their patients who smoke.189, 190 Patients in long-term care facilities also should receive tobacco dependence interventions identified as efficacious in this guideline. Suggested interventions for hospitalized patients can be found in Table 45.

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For every hospitalized patient, the following steps should be taken: Ask each patient on admission if he or she uses tobacco and document tobacco use status. For current tobacco users, list tobacco use status on the admission problem list (more...)

Future Research

The following topics regarding hospitalized patients require additional research:

  • The efficacy of interventions provided by different hospital personnel, including nurses.
  • The efficacy of pharmacotherapy with hospitalized patients.
  • Relapse prevention once the patient leaves the hospital.

Smokers With Psychiatric Comorbidity and/or 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 should be especially 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 pharmacotherapy. (Strength of Evidence = C)

The term "psychiatric comorbidity" refers to the co-occurrence of smoking with another psychiatric disorder. Although it is not necessary to assess for psychiatric comorbidity prior to initiating tobacco dependence treatment, psychiatric comorbidity is important to the assessment and treatment of smokers for several reasons:

  • Psychiatric disorders are more common among smokers than in the general population. For instance, as many as 30 percent of patients seeking smoking cessation services may have a history of depression,121 and 20 percent or more may have a history of alcohol abuse or dependence.191, 192, 193, 194, 195 Among abusers of alcohol and drugs, smoking occurs at rates well above population average (e.g., greater than 70%).196, 197, 198 These individuals may infrequently present themselves for tobacco dependence treatment. However, such treatments could be conveniently delivered within the context of chemical dependence clinics.
  • Smoking cessation or nicotine withdrawal may exacerbate a patient's comorbid condition. For instance, smoking cessation may elicit or exacerbate depression among patients with a prior history of affective disorder.199, 200, 201, 202
  • As noted in the Specialized Assessment section in Chapter 6A, smokers with psychiatric comorbidities have heightened risk for relapse to smoking after a cessation attempt.88, 191, 195, 202

Although psychiatric comorbidity places smokers at increased risk for relapse, such smokers can be helped by smoking cessation treatments.195, 203, 204, 205, 206, 207 Currently, there is insufficient evidence to determine whether smokers with psychiatric comorbidity benefit more from specialized or tailored cessation treatments than from standard treatments.102, 208 Even though some smokers may experience exacerbation of a comorbid condition upon quitting smoking, most evidence suggests that abstinence entails little adverse impact. For instance, patients in inpatient psychiatric units are able to stop smoking with few adverse effects (e.g., little increase in aggression).209, 210, 211 Finally, stopping smoking may affect the pharmacokinetics of certain psychiatric medications.212 Therefore, clinicians may wish to monitor closely the actions or side effects of psychiatric medications in smokers making a quit attempt.

Evidence shows that bupropion SR is efficacious for both depression and smoking cessation. Therefore, it appears to be an appropriate medication to use with depressed smokers trying to quit. Nortriptyline is also efficacious for both depression and smoking cessation, but its side-effect profile renders it a second-line medication.

The treatment of tobacco dependence can be provided concurrent to treating patients for other chemical dependencies (alcohol and other drugs). With patients in treatment for chemical dependency, there is little evidence that patients with other chemical dependencies relapse to other drug use when they stop smoking.209, 213, 214 However, such patients should be followed closely after they stop smoking.

Future Research

The following topics regarding psychiatric comorbidity and/or chemical dependency require additional research:

  • The relative efficacy of bupropion SR and nortriptyline versus NRT in patients with psychiatric comorbidity, including depression.
  • The efficacy and impact of tobacco dependence treatments within the context of other chemical dependency treatments.
  • The importance and efficacy of specialized assessment and tailored interventions in these populations.

Children and Adolescents

Recommendation: Clinicians should screen pediatric and adolescent patients, and their parents, for tobacco use and provide a strong message regarding the importance of totally abstaining from tobacco use. (Strength of Evidence = C)

Recommendation: 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)

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)

Recommendation: Clinicians in a pediatric setting should offer smoking cessation advice and interventions to parents to limit children=s exposure to second-hand smoke. (Strength of Evidence = B)

Tobacco use is a pediatric concern. In the United States, more than 6,000 children and adolescents try their first cigarette each day.7 More than 3,000 children and adolescents become daily smokers every day,8 resulting in approximately 1.23 million new smokers under the age of 18 each year.7 Among adults who had ever smoked daily, 89 percent tried their first cigarette and 71 percent were daily users at or before age 18.63 Among high school seniors who had used smokeless tobacco, 79 percent had first done so by the ninth grade.63, 215 By the time they are high school seniors, 22 percent of adolescents smoke daily.216, 217, 218 Young people experiment with or begin regular use of tobacco for a variety of reasons related to social and parental norms, advertising, peer influence, parental smoking, weight control, and curiosity.63, 219 Nicotine dependence, however, is established rapidly even among adolescents.220 Because of the importance of primary prevention in this population, clinicians should pay particular attention to delivering these messages to their patients. Specifically, because tobacco use often begins during preadolescence221 clinicians should routinely assess and intervene with this population. Prevention strategies useful in more general settings can be found in the Institute of Medicine report Growing Up Tobacco Free.222

Young people vastly underestimate the addictiveness of nicotine. Of daily adolescent smokers who think that they will not smoke in 5 years, nearly 75 percent are still smoking 5-6 years later.63 Of the nearly three-fourths of adolescents (70.2 percent) who have ever tried smoking, more than one-third (35.8 percent) became daily smokers during high school. Seventy percent of adolescent smokers wish they had never started smoking in the first place.223 About three out of every four adolescent smokers have made at least one serious attempt to quit smoking and have failed.224

Tobacco Use Treatments in Children and Adolescents

A recent study has shown that adolescents' smoking status was identified in 72.4 percent of office visits, but smoking cessation counseling was provided at only 16.9 percent of clinic visits of adolescent smokers.20 Therefore, clinicians both need to assess adolescent tobacco use and offer cessation counseling. Clinicians also should make an effort to prepare adolescents to quit smoking. For instance, clinicians may use motivational interventions such as those listed in Chapter 3B or consider techniques adapted for use with children.56 Also, children and adolescents may benefit from community- and school-based intervention activities. The messages delivered by these programs should be reinforced by the clinician.63

A recent comprehensive review of adolescent cessation programs in a variety of settings has concluded that such programs produce quit rates that exceed naturally occurring quit rates, but that more and higher quality research needs to be done.225

Children and adolescents also benefit from the delivery to parents of information regarding second-hand smoke exposure. A review of the studies conducted by the expert panel showed that the delivery of information to parents regarding the harms of exposing children to second-hand smoke reduces childhood exposure to second-hand smoke and may reduce parental smoking rates.162, 226, 227

Because there is no evidence that bupropion SR or nicotine replacement is harmful for children and adolescents, clinicians may consider their use when tobacco dependence is obvious. However, because of the psychosocial and behavioral aspects of smoking in adolescents, clinicians should be confident of the patient's tobacco dependence and intention to quit before instituting pharmacotherapy. Factors such as degree of dependence, number of cigarettes per day, and body weight should be considered (see Table 4 for adult clinical recommendations).228

Future Research

The following topics regarding adolescents and children require additional research:

  • The efficacy of advice and counseling.
  • The efficacy of pharmacotherapy.
  • The efficacy of interventions designed specifically to motivate youth to stop using tobacco.
  • The efficacy of interventions designed to treat tobacco dependence in youth.
  • The efficacy of child-focused versus family-focused interventions.
  • The efficacy of treating parents' tobacco use in the context of pediatric visits.

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)

It is estimated that 13 million Americans ages 50 and older and 4.5 million adults over age 65 smoke cigarettes.229 Smokers over the age of 65 can both quit smoking and benefit from abstinence.16, 230 Smoking cessation in older smokers can reduce the risk of myocardial infarction, death from coronary heart disease, and lung cancer. Moreover, abstinence can promote more rapid recovery from illnesses that are exacerbated by smoking and can improve cerebral circulation.231, 232 In fact, age does not appear to diminish the benefits of quitting smoking.231

The smoking cessation interventions that have been shown to be effective in the general population also have been shown to be effective with older smokers. Research has demonstrated the efficacy of the "4 A's" (ask, advise, assist, and arrange followup) in patients ages 50 and older.233 Counseling interventions,234, 235, 236 physician advice,235 buddy support programs,237 age-tailored self-help materials,229, 235, 238 telephone counseling,229, 238 and the nicotine patch239 have all been shown to be effective in treating tobacco use in adults ages 50 and older.

Due to particular concerns of this population (e.g., mobility issues) the use of proactive telephone counseling appears particularly promising with older smokers.

Future Research

The following topics regarding older smokers require additional research:

  • The efficacy of general tobacco use and dependence interventions, as well as those designed particularly for older smokers in promoting tobacco abstinence.
  • The efficacy of pharmacotherapy.
  • Effective methods to motivate older smokers to make a quit attempt.

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