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• Treating Tobacco Use and Dependence: 2008 Update (PDF) 

Treating Tobacco Use and Dependence: 2008 Update, a Public Health Service- sponsored Clinical Practice Guideline, is a product of the Tobacco Use and Dependence Guideline Panel (“the Panel”), consortium representatives, consultants, and staff. These 37 individuals were charged with the responsibility of identifying effective, experimentally validated tobacco dependence treatments and practices. The updated Guideline was sponsored by a consortium of eight Federal Government and nonprofit organizations: the Agency for Healthcare Research and Quality (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); American Legacy Foundation; Robert Wood Johnson Foundation (RWJF); and University of Wisconsin School of Medicine and Public Health’s Center for Tobacco Research and Intervention (UW-CTRI). This Guideline is an updated version of the 2000 Treating Tobacco Use and Dependence: Clinical Practice Guideline that was sponsored by the U.S. Public Health Service, U. S. Department of Health and Human Services. An impetus for this Guideline update was the expanding literature on tobacco dependence and its treatment. The original 1996 Guideline was based on some 3,000 articles on tobacco treatment published between 1975 and 1994. The 2000 Guideline entailed 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. Of course, this body of research was further reviewed to identify a much smaller group of articles that served as the basis for focused Guideline data analyses and review. This Guideline contains strategies and recommendations designed to assist clinicians; tobacco dependence treatment specialists; and health care administrators, insurers, and purchasers in delivering and supporting effective treatments for tobacco use and dependence. . . .

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. . . .

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. 1. 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.

2. 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. 3. 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. 4. 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. 5. 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 6. 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

8 • Clinicians also should consider the use of certain combinations of medications identified as effective in this Guideline. 7. 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. 8. 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. 9. 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. 10. 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.

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