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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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3Clinical Interventions for Tobacco Use and Dependence

Background

This section of the Guideline presents specific strategies to guide clinicians providing brief interventions (less than 10 minutes). These brief interventions can be provided by all clinicians but are most relevant to clinicians who see a wide variety of patients and are bound by time constraints (e.g., physicians, nurses, physician assistants, nurse practitioners, medical assistants, dentists, hygienists, respiratory therapists, mental health counselors, pharmacists, etc.). The strategies in this chapter are based on the evidence described in Chapters 6 and 7, as well as on Panel opinion. Guideline analysis suggests that a wide variety of clinicians can implement these strategies effectively.

Why should members of a busy clinical team consider making the treatment of tobacco use a priority? The evidence is compelling: (1) clinicians can make a difference with even a minimal (less than 3 minutes) intervention (see Chapter 6); (2) a relation exists between the intensity of intervention and tobacco cessation outcome (see Chapter 6); (3) even when patients are not willing to make a quit attempt at this time, clinician-delivered brief interventions enhance motivation and increase the likelihood of future quit attempts122 (see Chapter 6); (4) tobacco users are being primed to consider quitting by a wide range of societal and environmental factors (e.g., public health messages, policy changes, cessation marketing messages, family members); (5) there is growing evidence that smokers who receive clinician advice and assistance with quitting report greater satisfaction with their health care than those who do not;23,87,88 (6) tobacco use interventions are highly cost effective (see Chapter 6); and (7) tobacco use has a high case fatality rate (up to 50% of long-term smokers will die of a smoking-caused disease123).

The goal of these strategies is clear: to change clinical culture and practice patterns to ensure that every patient who uses tobacco is identified, advised to quit, and offered scientifically sound treatments. The strategies underscore a central theme: it is essential to provide at least a brief intervention to every tobacco user at each health care visit. Responsibility lies with both the clinician and the health care system to ensure that this occurs. Several observations are relevant to this theme. First, although many smokers are reluctant to seek intensive treatments,124,125 they nevertheless can receive a brief intervention every time they visit a clinician.66,126 Second, institutional support is necessary to ensure that all patients who use tobacco are identified and offered appropriate treatment (see Chapter 5, Systems Interventions: Importance to Health Care Administrators, Insurers, and Purchasers). Third, the time limits on primary care physicians in the United States today (median visit = 12–16 minutes),127,128 as well as reimbursement restrictions, often limit providers to brief interventions, although more intensive interventions would produce greater success. Finally, given the growing use of electronic patient databases, smoker registries, and real-time clinical care prompts, brief interventions may be easier to fit into a busy practice and may be implemented in a variety of ways.

This chapter is divided into three sections to guide brief clinician interventions with three types of patients: (A) current tobacco users willing to make a quit attempt at this time; (B) current tobacco users unwilling to make a quit attempt at this time; and (C) former tobacco users who have recently quit. Patients who have never used tobacco or who have been abstinent for an extended period should be congratulated on their status and encouraged to maintain their tobacco-free lifestyle.

Given that more than 70 percent of tobacco users visit a physician and more than 50 percent visit a dentist each year,129 it is essential that these clinicians be prepared to intervene with all tobacco users. The five major components (the “5 A's”) of a brief intervention in the primary care setting are listed in Table 3.1. It is important for a clinician to ask the patient if he or she uses tobacco (Strategy A1), advise him or her to quit (Strategy A2), and assess willingness to make a quit attempt (Strategy A3). Strategies A1 to A3 need to be delivered to each tobacco user, regardless of his or her willingness to quit.

Table 3.1. The “5 A's” model for treating tobacco use and dependence.

Table 3.1

The “5 A's” model for treating tobacco use and dependence.

If the patient is willing to quit, the clinician should assist him or her in making a quit attempt by offering medication and providing or referring for counseling or additional treatment (Strategy A4), and arrange for followup contacts to prevent relapse (Strategy A5). If the patient is unwilling to make a quit attempt, the clinician should provide a motivational intervention (Strategies B1 and B2) and arrange to address tobacco dependence at the next clinic visit. The Strategy tables below (A1A5) comprise suggestions for the content and delivery of the 5 A's. The strategies are designed to be brief and require 3 minutes or less of direct clinician time. These intervention components constitute the core elements of a tobacco intervention, but they need not be applied in a rigid, invariant manner. For instance, the clinician need not deliver all elements personally. One clinician (e.g., a medical assistant) may ask about tobacco use status; and a prescribing clinician (e.g., physician, dentist, physician assistant, nurse practitioner) may deliver personal advice to quit, assess willingness to quit, and assist with medications, but then refer the patient to a tobacco intervention resource (e.g., a tobacco cessation quitline, health educator) that would deliver additional treatment to the patient. The clinician would remain responsible for the patient receiving appropriate care and subsequent followup, but, as with other sorts of health care, an individual clinician would not need to deliver all care personally.130 Evidence indicates that full implementation of the 5 A's in clinical settings may yield results that are superior to partial implementation.131

Table B1. Strategy. Motivational interviewing strategies.

Table B1

Strategy. Motivational interviewing strategies.

Table B2. Strategy. Enhancing motivation to quit tobacco—the “5 R's”.

Table B2

Strategy. Enhancing motivation to quit tobacco—the “5 R's”.

The effectiveness of tobacco intervention may reflect not only the contributions of the individual clinician, but also the systems and other clinical resources available to him or her. For instance, office systems that institutionalize tobacco use assessment and intervention will greatly foster the likelihood that the 5 A's will be delivered (see Chapter 5). The 5 A's, as described in Table 3.1, are consistent with those recommended by the NCI132,133 and the American Medical Association,77 as well as others.75,134137 The clinical situation may suggest delivering these intervention components in an order or format different from that presented, however. For example, clinical interventions such as: Ask/Assess, Advise, Agree on a goal, Assist, Arrange followup; Ask and Act; and Ask, Advise, and Refer have been proposed.116,130,138140

When “Assisting” smokers, in addition to counseling, all smokers making a quit attempt should be offered medication, except when contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). See Tables 3.2 to 3.11 for guidelines for prescribing medication for treating tobacco use and dependence.

Table 3.2. Clinical guidelines for prescribing medication for treating tobacco use and dependence.

Table 3.2

Clinical guidelines for prescribing medication for treating tobacco use and dependence.

Table 3.11. Clinical use of nortriptyline (See FDA package insert for more complete information.).

Table 3.11

Clinical use of nortriptyline (See FDA package insert for more complete information.).

A. For the Patient Willing To Quit

Table A1Strategy. Ask—Systematically identify all tobacco users at every visit

ActionStrategies for implementation
Implement an officewide system that ensures that, for every patient at every clinic visit, tobacco use status is queried and documented.aExpand the vital signs to include tobacco use, or use an alternative universal identification system.b
VITAL SIGNS
Blood Pressure: _______________________
Pulse: ________ Weight: ___________
Temperature: _________________________
Respiratory Rate: ______________________
Tobacco Use (circle one): Current Former Never
a

Repeated assessment is not necessary in the case of the adult who has never used tobacco or has not used tobacco for many years and for whom this information is clearly documented in the medical record.

b

Alternatives to expanding the vital signs include using tobacco use status stickers on all patient charts or indicating tobacco use status via electronic medical records or computerized reminder systems.

Table A2Strategy. Advise—Strongly urge all tobacco users to quit

ActionStrategies for implementation
In a clear, strong, and personalized manner, urge every tobacco user to quit.Advice should be:
  • Clear—“It is important that you quit smoking (or using chewing tobacco) now, and I can help you.” “Cutting down while you are ill is not enough.” “Occasional or light smoking is still dangerous.”
  • Strong—“As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you.”
  • Personalized—Tie tobacco use to current symptoms and health concerns, and/or its social and economic costs, and/or the impact of tobacco use on children and others in the household. “Continuing to smoke makes your asthma worse, and quitting may dramatically improve your health.” “Quitting smoking may reduce the number of ear infections your child has.”

Table A3Strategy. Assess—Determine willingness to make a quit attempt

ActionStrategies for implementation
Assess every tobacco user's willingness to make a quit attempt at the time.Assess patient's willingness to quit: “Are you willing to give quitting a try?”
  • If the patient is willing to make a quit attempt at the time, provide assistance (see Chapter 3A, Strategy A4).
    • If the patient will participate in an intensive treatment, deliver such a treatment or link/refer to an intensive intervention (see Chapter 4).
    • If the patient is a member of a special population (e.g., adolescent, pregnant smoker, racial/ethnic minority), consider providing additional information (see Chapter 7).
  • If the patient clearly states that he or she is unwilling to make a quit attempt at the time, provide an intervention shown to increase future quit attempts (see Chapter 3B).

Table A4Strategy. Assist—Aid the patient in quitting (provide counseling and medication)

ActionStrategies for implementation
Help the patient with a quit plan. A patient's preparations for quitting:
  • Set a quit date. Ideally, the quit date should be within 2 weeks.
  • Tell family, friends, and coworkers about quitting, and request understanding and support.
  • Anticipate challenges to the upcoming quit attempt, particularly during the critical first few weeks. These include nicotine withdrawal symptoms.
  • Remove tobacco products from your environment. Prior to quitting, avoid smoking in places where you spend a lot of time (e.g., work, home, car). Make your home smoke-free.
Recommend the use of approved medication, except when contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents).Recommend the use of medications found to be effective in this Guideline (see Table 3.2 for clinical guidelines and Tables 3.33.11 for specific instructions and precautions). Explain how these medications increase quitting 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; second-line medications include: clonidine and nortriptyline. There is insufficient evidence to recommend medications for certain populations (e.g., pregnant women, smokeless tobacco users, light smokers, adolescents).
Provide practical counseling (problemsolving/skills training).Abstinence. Striving for total abstinence is essential. Not even a single puff after the quit date.141

Past quit experience. Identify what helped and what hurt in previous quit attempts. Build on past success.

Anticipate triggers or challenges in the upcoming attempt. Discuss challenges/triggers and how the patient will successfully overcome them (e.g., avoid triggers, alter routines).

Alcohol. Because alcohol is associated with relapse, the patient should consider limiting/abstaining from alcohol while quitting. (Note that reducing alcohol intake could precipitate withdrawal in alcohol-dependent persons.)

Other smokers in the household. Quitting is more difficult when there is another smoker in the household. Patients should encourage housemates to quit with them or to not smoke in their presence.

For further description of practical counseling, see Table 6.19.
Provide intratreatment social support.Provide a supportive clinical environment while encouraging the patient in his or her quit attempt. “My office staff and I are available to assist you.”“I'm recommending treatment that can provide ongoing support.”

For further description of intratreatment social support, see Table 6.20.
Provide supplementary materials, including information on quitlines.Sources: Federal agencies, nonprofit agencies, national quitline network (1-800-QUIT-NOW), or local/state/tribal health departments/quitlines (see Appendix B for Web site addresses).

Type: Culturally/racially/educationally/age-appropriate for the patient.

Location: Readily available at every clinician's workstation.
For the smoker unwilling to quit at the timeSee Section 3B.

Table A5Strategy. Arrange—Ensure followup contact

ActionStrategies for implementation
Arrange for followup contacts, either in person or via telephone.Timing: Followup contact should begin soon after the quit date, preferably during the first week. A second followup contact is recommended within the first month. Schedule further followup contacts as indicated.

Action during followup contact: For all patients, identify problems already encountered and anticipate challenges in the immediate future. Assess medication use and problems. Remind patients of quitline support (1-800-QUIT-NOW). Address tobacco use at next clinical visit (treat tobacco use as a chronic disease).

For patients who are abstinent, congratulate them on their success.

If tobacco use has occurred, review circumstances and elicit recommitment to total abstinence. Consider use of or link to more intensive treatment (see Chapter 4).
For smokers unwilling to quit at the timeSee Section 3B.

B. For the Patient Unwilling To Quit

Promoting the Motivation To Quit

All patients entering a health care setting should have their tobacco use status assessed routinely. Clinicians should advise all tobacco users to quit and then assess a patient's willingness to make a quit attempt. For patients not ready to make a quit attempt at the time, clinicians should use a brief intervention designed to promote the motivation to quit.

Patients unwilling to make a quit attempt during a visit may lack information about the harmful effects of tobacco use and the benefits of quitting, may lack the required financial resources, may have fears or concerns about quitting, or may be demoralized because of previous relapse.164167 Such patients may respond to brief motivational interventions that are based on principles of Motivational Interviewing (MI),168 a directive, patient-centered counseling intervention.169 There is evidence that MI is effective in increasing future quit attempts;170174 however, it is unclear that MI is successful in boosting abstinence among individuals motivated to quit smoking.173,175,176

Clinicians employing MI techniques focus on exploring a tobacco user's feelings, beliefs, ideas, and values regarding tobacco use in an effort to uncover any ambivalence about using tobacco.169,177,178 Once ambivalence is uncovered, the clinician selectively elicits, supports, and strengthens the patient's “change talk” (e.g., reasons, ideas, needs for eliminating tobacco use) and “commitment language” (e.g., intentions to take action to change smoking behavior, such as not smoking in the home). MI researchers have found that having patients use their own words to commit to change is more effective than clinician exhortations, lectures, or arguments for quitting, which tend to increase rather than lessen patient resistance to change.177

The four general principles that underlie MI are: (1) express empathy, (2) develop discrepancy, (3) roll with resistance, and (4) support self-efficacy.168,179 Specific MI counseling strategies that are based on these principles are listed in Strategy B1. Because this is a specialized technique, it may be beneficial to have a member of the clinical staff receive training in motivational interviewing. The content areas that should be addressed in a motivational counseling intervention can be captured by the “5 R's”: relevance, risks, rewards, roadblocks, and repetition (Strategy B2). Research suggests that the “5 R's” enhance future quit attempts.169,180

C. For the Patient Who Has Recently Quit

Treatments for the Recent Quitter

Smokers who have recently quit face a high risk of relapse. Although most relapse occurs early in the quitting process,96,101,181 some relapse occurs months or even years after the quit date.181184 Numerous studies have been conducted to identify treatments that can reduce the likelihood of future relapse. These studies attempt to reduce relapse either by including special counseling or therapy in the cessation treatment, or by providing additional treatment to smokers who have previously quit. In general, such studies have failed to identify either counseling or medication treatments that are effective in lessening the likelihood of relapse,185 although there is some evidence that special mailings can reduce the likelihood of relapse.186,187 Thus, at present, the best strategy for producing high long-term abstinence rates appears to be use of the most effective cessation treatments available; that is, the use of evidence-based cessation medication during the quit attempt and relatively intense cessation counseling (e.g., four or more sessions that are 10 minutes or more in length).

Ex-smokers often report problems that have been worsened by smoking withdrawal or that coexisted with their smoking. If a clinician encounters a tobacco user who recently quit, the clinician might reinforce the patient's success at quitting, review the benefits of quitting, and assist the patient in resolving any residual problems arising from quitting (Strategy C1). Such expressions of interest and involvement on the part of the clinician might encourage the patient to seek additional help with cessation should she or he ultimately relapse. When the clinician encounters a patient who is abstinent from tobacco and is no longer engaged in cessation treatment, the clinician may wish to acknowledge a patient's success in quitting. The abstinent former smoker also may experience problems related to cessation that deserve treatment in their own right (see Strategy C2).

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Table C1

Strategy. Intervening with the patient who has recently quit. The former tobacco user should receive congratulations on any success and strong encouragement to remain abstinent. When encountering a recent quitter, use open-ended questions relevant (more...)

Table C2. Strategy. Addressing problems encountered by former smokers.

Table C2

Strategy. Addressing problems encountered by former smokers.

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