The Clinical Practice Guideline and related documents are available at www.surgeongeneral.gov/tobacco
Many new and effective treatment strategies are available to help patients quit tobacco use, according to an updated Clinical Practice Guideline released by the U.S. Public Health Service.
Expanding tobacco dependence literature and treatments available since 1999 led a consortium of eight federal agencies and nonprofit organizations to update the guideline for the first time since 2000. The new recognition of tobacco dependence as a chronic disease that generally requires ongoing assessment and repeated intervention is central to the update.
A 24-member panel screened more than 8,700 publications on tobacco dependence and treatment published since 1975 in preparation for the update. A total of 81 outside peer experts reviewed the findings.
The universal aim of the 276-page “Treating Tobacco Use and Dependence: 2008 Update” is to assist providers in strongly recommending effective tobacco dependence counseling and medications to patients who use tobacco. This includes consideration of seven first-line medications now approved by the Food and Drug Administration that “reliably increase long-term smoking abstinence rates.” Those medications are bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline (Chantix).
It is important to encourage use of effective medications alone or in combination for all patients attempting to quit smoking, except when medically contraindicated, according to the guideline. Also, evidence is insufficient for effectiveness in specific populations, including pregnant women, smokeless tobacco users, light smokers, and adolescents.
Increased evidence that counseling, alone and especially with medication, greatly increases a person's chances of quitting tobacco is recognized. There is a new consensus that counseling efforts can be effective in adolescent tobacco users, for example. Also, quitlines such as 1–800-QUIT-NOW are an effective intervention that can reach a large number of the 70% of 45 million smokers in the United States who indicate a desire to quit.
Individual and group counseling also are deemed effective, particularly with increasing treatment intensity. Practical counseling (problem-solving/skills training) and social support delivered as part of treatment were found especially effective.
The authors recognized that counseling and medication are effective when used by themselves for treating tobacco dependence. However, they suggest that providers encourage all patients to consider both, because the combination is more effective than either strategy alone.
The guideline also identifies areas where additional progress is needed. For example, although adolescents appear to benefit from counseling, more consistent and effective interventions and options for use with children, adolescents, and young adults are clearly needed. Future strategies should focus on populations where smoking prevalence “remains discouragingly high,” including people with a low socioeconomic status/low educational attainment, some American Indian populations, and individuals with psychiatric disorders, including substance use disorders.
The authors also call for additional research in real-world clinical settings and new strategies to increase consumer demand for effective cessation treatments. There has been little increase in the percentage of smokers who make quit attempts, they noted, and too few smokers who do try to quit take advantage of evidence-based treatments that can double or triple their odds of success.
The guideline was sponsored by the Agency for Healthcare Research and Quality; the Centers for Disease Control and Prevention; the National Cancer Institute; the National Heart, Lung, and Blood Institute; the National Institute on Drug Abuse; the American Legacy Foundation; the Robert Wood Johnson Foundation; and the University of Wisconsin School of Medicine and Public Health's Center for Tobacco Research and Intervention.
Twenty-one of 24 panel members had no significant financial interests. The other panel members were recused from deliberations relating to their areas of conflict.