Specific Guideline Recommendations

Treating Tobacco Use and Dependence outlines specific strategies for clinicians, the steps necessary to effectively and efficiently identify smokers, to motivate them to make an attempt to quit, and to support them in quitting successfully through counseling, pharmacotherapy, and follow-up. The guideline panel provided key recommendations for all clinicians (Table 1). Select recommendations are discussed below.

Recommendation 1

Tobacco dependence is a chronic condition that often requires repeated intervention. However, effective treatments exist that can produce long-term or even permanent abstinence.

One of the central tenets of the 2000 guideline is the recognition of tobacco dependence as a chronic disease. Tobacco addiction carries a vulnerability to relapse that persists over time and often requires repeated intervention. This places responsibility on the chest clinician to provide ongoing counseling, support, and appropriate pharmacotherapy, just as for other chronic diseases such as hypertension or hypercholesterolemia. While not every smoker who presents to a clinic setting is willing to commit to an attempt to quit smoking during that visit, treatments should be offered at every visit to maximize the patient's chance of success.

Recommendation 2
Because effective tobacco-dependence treatments are available, every patient who uses tobacco should be offered at least one of the following treatments:
Patients willing to try to quit using tobacco should be provided with treatments that are identified as effective in the guideline; and

Patients unwilling to try to quit using tobacco should be provided with a brief intervention that is designed to increase their motivation to quit.

There are the following three types of patients with regard to tobacco use: (1) current tobacco users who are now willing to make an attempt to quit smoking; (2) current tobacco users who are unwilling to make an attempt to quit; and (3) former tobacco users who have recently quit.

For Patients Willing To Quit: The 5 As
The "5As" are designed to be a brief and effective intervention for tobacco users now willing to make an attempt to quit smoking (Table 2). It is important for the clinician to ask patients whether they use tobacco, to advise them to quit in a clear, strong, and personalized manner, and to assess their willingness to make an attempt to quit at that time. If the patient agrees to attempt cessation, the clinician should then assist in making a quit attempt and should arrange for follow-up contacts to prevent a relapse.

For Patients Unwilling to Quit: The 5 Rs
For patients not willing to make an attempt to quit at the time, clinicians should provide a brief intervention that is designed to promote the motivation to quit.

Patients may be unwilling to make an attempt to quit for a variety of reasons. They may lack information about the harmful effects of tobacco, they may not realize how these effects are relevant to their personal health history, they may lack the required financial resources, they may have fears or concerns about quitting, or they may be demoralized because of previous relapse experiences.[12] These patients may, however, respond to a motivational intervention that provides the clinician an opportunity to educate and reassure the patient by means of the following 5 Rs: relevance, risks, rewards, roadblocks, and repetition. This is most likely to be successful when the clinician is empathic, promotes patient autonomy, avoids arguments, and supports the patient's self-efficacy.[13,14]

For the Patient Who Has Recently Quit
Because of the chronic relapsing nature of tobacco dependence, clinicians should promote relapse prevention among their patients who have recently quit. Specifically, the clinician should reinforce the decision to quit, should review the benefits of quitting, and should assist in resolving any residual problems. This can be accomplished during scheduled clinic visits or proactive telephone calls.
Because most relapses occur within the first 3 months after quitting, particularly during the first 2 weeks, clinicians (or their staff) should arrange for follow-up visits and should provide relapse prevention during this critical time period. It should be noted that relapses may occur months or even years after quitting, however, so all former tobacco users may benefit from support and encouragement. Table 4 outlines components that should be part of all relapse-prevention contacts.

Recommendation 3
It is essential that clinicians and health-care delivery systems institutionalize the consistent identification, documentation, and treatment of every tobacco user who is seen in a health-care setting.
The first step in treating tobacco use and dependence is to identify tobacco users. The effective identification of tobacco use status not only opens the doors for successful interventions but also guides clinicians to identify appropriate interventions based on a patient's willingness to quit. The guideline panel recommended the implementation of an office-wide protocol that systematically solicits and documents the tobacco-use status of each patient at every visit. This can be done effectively by expanding the number of vital signs to include smoking status or by placing an appropriate tobacco-use sticker on all patient charts. In clinical settings where tobacco use has been universally documented, the rate at which physicians then asked their patients about smoking and provided specific advice on quitting approximately doubled.[11]

Recommendation 4
Brief tobacco-dependence treatment is effective, and every patient who uses tobacco should be offered at least brief treatment.
The 2000 guideline documents that clinical interventions as brief as 3 min can substantially increase cessation success. These findings support the idea that a personalized clinician message meaningfully enhances the likelihood that a smoker will make a successful attempt to quit smoking. Therefore, it is essential to provide at least a brief intervention for all tobacco users at each clinic visit.

Recommendation 5
There is a strong dose-response relationship between the intensity of tobacco dependence counseling and its effectiveness. Treatments involving person-to-person contact (ie, via individual, group, or proactive telephone counseling) are consistently effective, and their effectiveness increases with treatment intensity (eg, the number of minutes of contact).
While even a brief intervention is effective in increasing quitting rates, there is a dose-response relationship between treatment duration and its effectiveness. Because clinicians frequently have limited time with patients, adjuvant staff may be utilized to maximize the impact of treatment.

Guideline analysis suggests that a wide variety of health-care professionals can effectively implement these brief strategies. Adjuvant staff (eg, physician assistants, nurses, and medical assistants) reinforce the brief clinician cessation message and provide follow-up and support services to patients attempting to quit.

Recommendation 6
Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindication, these should be used with all patients who are attempting to quit smoking.
The treatment of tobacco dependence, like the treatment of other chronic diseases, requires the use of multiple modalities. Pharmacotherapy is an essential element of a multicomponent approach. The clinician should encourage all patients who are initiating an attempt to quit to use one or a combination of the recommended pharmacotherapies. Select patient groups (eg, those with medical contraindications, those smoking < 10 cigarettes a day, pregnant/ breastfeeding women, and adolescent smokers) require special consideration before the recommendation of pharmacotherapy. A more detailed discussion of pharmacotherapy use for select populations is available in the guideline.

The guideline panel identified five first-line medications with an established empirical record of efficacy in smoking cessation. These medications include the following: bupropion SR (Zyban; Glaxo SmithKline; Research Triangle Park, NC); the nicotine patch (various manufacturers); nicotine gum (various manufacturers); nicotine inhaler (Nicotrol Inhaler; Pharmacia; Helsingborg, Sweden); and nicotine nasal spray (Nicotrol NS; Pharmacia). These medications should be considered first as part of tobacco-dependence treatment (except in cases of contraindications). Each of these medications has been documented to increase significantly the rate of long-term smoking abstinence, and each has been approved as safe and efficacious by the US Food and Drug Administration. General guidelines for prescribing these pharmacotherapies are shown in Tables 5 and 6.

Combining the nicotine patch with a self-administered form of nicotine replacement therapy (NRT), utilizing the gum, the inhaler, or the nasal spray, is more efficacious than a single form of nicotine replacement. Patients should be encouraged to use such combined treatments if they are unable to quit using a single type of first-line pharmacotherapy. One study 15 has examined combining bupropion SR with NRT. There was a nonsignificant trend toward improved outcome. More research is needed in the realm of combination therapies.