Treating Tobacco Use and Dependence

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Treating Tobacco Use and Dependence

• 2008 UPDATE

U.S. Public Health ServiceClinical Practice
Guideline
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2008 PHS Clinical Practice Guideline Update
Treating Tobacco Use and Dependence

• Brief history and developmental process
• Key findings of interest
• Getting more information

3
2008 PHS Clinical Practice Guideline Update
Treating Tobacco Use and Dependence

• Brief history and developmental process

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2008 PHS Clinical Practice Guideline Treating
Tobacco Use and Dependence Update

• History
• 1996Initial Guideline published
• literature from 19751995
• approximately 3,000 articles
• 2000Revised Guideline published
• literature from 19951999
• approximately 6,000 articles
• 2008Updated Guideline published
• literature from 19992007
• approximately 8,700 total articles
  

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2008 PHS Clinical Practice Guideline Treating
Tobacco Use and Dependence Update

• Update process started 7-1-06
• Scope remains the treatment of tobacco use and
  dependence
• Update rather than a full rewrite
• Used very similar development process

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Funded by

• Agency for Healthcare Research and Quality
• National Cancer Institute
• National Heart, Lung Blood Institute
• National Institute on Drug Abuse
• Centers for Disease Control and Prevention
• The Robert Wood Johnson Foundation
• American Legacy Foundation
• University of Wisconsin-Center for Tobacco
  Research and Intervention

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Panel Members

• Howard Koh, MD, MPH, FACP
• Thomas E. Kottke, MD, MSPH
• Harry A. Lando, PhD
• Robert Mecklenburg, DDS, MPH
• Robin Mermelstein, PhD
• Patricia Mullen, Dr PH
• C. Tracy Orleans, PhD
• Lawrence Robinson, MD, MPH
• Maxine Stitzer, PhD
• Anthony Tommasello, Pharm BS, PhD
• Louise Villejo, MPH, CHES
• Mary Ellen Wewers, PhD, RN, MPH

• Michael C. Fiore, MD, MPH, Chair
• Carlos Roberto Jaén, MD, PhD, FAAFP, Vice-Chair
• Timothy Baker, PhD, Senior Scientist
• William C. Bailey, MD, FACP, FCCP
• Neal Benowitz, MD
• Susan J. Curry, PhD
• Sally Faith Dorfman, MD, MSHSA
• Erika S. Froelicher, RN, MA, MPH, PhD
• Michael G. Goldstein, MD
• Cheryl Healton, DrPH
• Patricia Nez Henderson, MD, MPH
• Richard B. Heyman, MD

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PHS Liaisons

• Ernestine (Tina) Murray, AHRQ (Project Officer)
• Christine Williams, AHRQ
• Glen Bennett, NHLBI
• Stephen Heishman, NIDA
• Corrine Husten, CDC
• Glen Morgan, NCI

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Guideline Update Development Phases

• 1. Identify update topics
• 2. Meta-analysis of topics
• 3. Panel/liaisons workgroups
• 4. Establish recommendations and other
  content
• 5. Draft text
• 6. Peer review/public comment
• 7. Released May 7, 2008
• Full Guideline, including detailed financial
  disclosure information, available at
  www.surgeongeneral.gov/tobacco

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Final Selected Topics

• Proactive quitlines
• Combining counseling and medication relative to
  either counseling or medication alone
• Varenicline
• Various medication combinations
• Long-term medication use
• Tobacco use interventions for individuals with
  low socio-economic status/limited formal
  education
• Tobacco use interventions for adolescent smokers
• Tobacco use interventions for pregnant smokers
• Tobacco use interventions for individuals with
  psychiatric disorders, including substance abuse
  disorders
• Providing cessation interventions as a health
  benefit
• Systems interventions, including provider
  training and the combination of training and
  systems interventions

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Peer Review/Public Comment

• Over 90 independent tobacco treatment experts
  served as peer reviewers
• Federal Register notice announced availability of
  guideline for public comment

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2008 PHS Clinical Practice Guideline Update
Treating Tobacco Use and Dependence

• Brief history and developmental process
• Key findings of interest

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Combinations Medication and Counseling
Effectiveness of and estimated abstinence rates
for the combination of counseling and medication
versus medication alone (n 18 studies)
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Combinations Medication and Counseling
Effectiveness of and estimated abstinence rates
for the combination of counseling and medication
versus counseling alone (n 9 studies)
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• Treatment Recommendations
• Counseling

Combining Counseling and Medication
Recommendation The combination of counseling
and medication is more effective for smoking
cessation than either medication or counseling
alone. Therefore, whenever feasible and
appropriate, both counseling and medication
should be provided to patients trying to quit
smoking. (Strength of Evidence
A). Recommendation There is a strong relation
between the number of sessions of counseling when
it is combined with medication, and the
likelihood of successful smoking cessation.
Therefore, to the extent possible, clinicians
should provide multiple counseling sessions, in
addition to medication, to their patients who are
trying to quit smoking. (Strength of Evidence
A).
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Strength of Evidence for Recommendations
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Pro-Active Quitlines
Effectiveness of and estimated abstinence rates
for quitline counseling compared to minimal
interventions, self-help or no counseling (n 9
studies)
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Pro-Active Quitlines
Effectiveness of and estimated abstinence rates
for quitline counseling and medication compared
to medication alone (n 6 studies)
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Medication

• Seven first-line medications shown to be
  effective and recommended for use by the
  Guideline Panel
• Bupropion SR
• Nicotine Gum
• Nicotine Inhaler
• Nicotine Lozenge
• Nicotine Nasal Spray
• Nicotine Patch
• Varenicline

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Varenicline
Effectiveness and abstinence rates for various
medications and medication combinations compared
to placebo at 6-months post-quit (n 86 studies)
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Nicotine Lozenge
Effectiveness of the nicotine lozenge Results
from the single randomized controlled trial.
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Relative Efficacy
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Medication Recommendation

• Recommendation Certain combinations of
  first-line medications have been shown to be
  effective smoking cessation treatments.
  Therefore, clinicians should consider using these
  combinations of medications with their patients
  who are willing to quit. Effective combination
  medications are
• Long-term (gt 14 weeks) nicotine patch
  other NRT (gum and spray)
• The nicotine patch the nicotine inhaler
• The nicotine patch bupropion SR.
• (Strength of Evidence A)

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Specific Populations

• Children and Adolescent Smokers
• Light Smokers
• Noncigarette Tobacco Users
• Pregnant Smokers

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Special Populations

• HIV-positive smokers
• Hospitalized smokers
• Lesbian/gay/bisexual/ transgender smokers
• Smokers with low SES/limited formal education
• Smokers with medical comorbidities

• Older smokers
• Smokers with psychiatric disorders including
  substance use disorders
• Racial and ethnic minority smokers
• Women smokers

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Low Socio-Economic Status/Limited Formal Education
Effectiveness of and estimated abstinence rates
for counseling interventions with low
socio-economic status/limited formal education (n
5 studies)
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Psychiatric Disorders Including Substance Use
Disorders
Effectiveness of and estimated abstinence rates
for treatment with bupropion and nortryptyline
for smokers with a history of depression (n 4
studies)
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• Specific Populations and Other Topics

Recommendation The interventions found to be
effective in this Guideline have been shown to be
effective in a variety of populations. In
addition, many of the studies supporting these
interventions comprised diverse samples of
tobacco users. Therefore, interventions
identified as effective in this Guideline are
recommended for all individuals who use tobacco
except when medication use is contraindicated or
with specific populations in which medication has
not been shown to be effective (pregnant women,
smokeless tobacco users, light smokers and
adolescents). (Strength of Evidence B).
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Adolescent Smokers
Effectiveness of and estimated abstinence rates
for counseling interventions with adolescent
smokers (n 7 studies)
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• Adolescent Smokers

Children and Adolescents Recommendation
Clinicians should ask pediatric and adolescent
patients about tobacco use and provide a strong
message regarding the importance of totally
abstaining from tobacco use. (Strength of
Evidence C) Recommendation Counseling has
been shown to be effective in treatment of
adolescent smokers. Therefore, adolescent
smokers should be provided with counseling
interventions to aid them in quitting smoking.
(Strength of Evidence B) Recommendation
Second-hand smoke is harmful to children.
Cessation counseling delivered in pediatric
settings has been shown to be effective in
increasing abstinence among parents who smoke.
Therefore, in order to protect children from
second-hand smoke, clinicians should ask parents
about tobacco use and offer them cessation advice
and assistance. (Strength of Evidence B)
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Pregnant Smokers
Effectiveness of and estimated pre-parturition
abstinence rates for psychosocial interventions
with pregnant smokers (n 8 studies)
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• Pregnant Smokers

Recommendation Because of the serious risks of
smoking to the pregnant smoker and the fetus,
whenever possible pregnant smokers should be
offered person-to-person 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 tobacco
dependence interventions to pregnant smokers at
the first prenatal visit as well as throughout
the course of pregnancy. (Strength of Evidence
B)
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System Recommendations

• Intervention as a covered health care benefit
• Clinician training and chart reminders
• Tobacco dependence treatment as a part of
  assessing health care quality
• Cost-effectiveness of tobacco dependence
  Interventions

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Intervention as a Covered Health Benefit
Estimated rates of quit attempts for individuals
who received tobacco use interventions as a
covered health insurance benefit (n 3 studies)
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Intervention as a Covered Health Benefit
Estimated abstinence rates for individuals who
received tobacco use interventions as a covered
benefit (n 3 studies)
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• Intervention as a Covered Health Benefit

Recommendation Providing tobacco dependence
treatments (both medication and counseling) as a
paid or covered benefit by health insurance plans
has been shown to increase the proportion of
smokers who use cessation treatment, attempt to
quit, and successfully quit. Therefore,
treatments shown to be effective in the Guideline
should be included as covered services in public
and private health benefit plans. (Strength of
Evidence A).
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Systems InterventionsClinician Training and
Chart Reminders
Effectiveness of clinician training combined with
charting on asking about smoking status
(Ask) (n 3 studies)
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Systems InterventionsClinician Training and
Chart Reminders
Effectiveness of training combined with charting
on setting a quit date (Assist) (n 2 studies)
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Systems InterventionsClinician Training and
Chart Reminders
Effectiveness of training combined with charting
on arranging for follow-up (Arrange) (n 2
studies)
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• Systems InterventionsClinician Training and
  Chart Reminders

Clinician Training and Reminder
Systems Recommendation All clinicians and
clinicians-in-training should be trained in
effective strategies to assist tobacco users
willing to make a quit attempt and to motivate
those unwilling to quit. Training appears to be
more effective when coupled with systems changes.
(Strength of Evidence B).
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For Smokers Not Willing To Make a Quit Attempt at
This Time
Recommendation Motivational intervention
techniques appear to be effective in increasing a
patients likelihood of making a future quit
attempt. Therefore, clinicians should use
motivational techniques to encourage smokers who
are not currently willing to quit to consider
making a quit attempt in the future. (Strength
of Evidence B).
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The "5 A's" Model for Treating Tobacco Use and
Dependence - 2000

• Ask about tobacco use. Identify and document
  tobacco use status for every patient at every
  visit.
• Advise to quit. In a clear, strong and
  personalized manner urge every tobacco user to
  quit.
• Assess willingness to make a quit attempt. Is the
  tobacco user willing to make a quit attempt at
  this time?
• Assist in quit attempt. For the patient willing
  to make a quit attempt, use counseling or
  pharmacotherapy to help him or her quit.
• Arrange followup. Schedule followup contact,
  preferably within the first week after the quit
  date.

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The "5 A's" Model for Treating Tobacco Use and
Dependence - 2008

• Ask about tobacco use. Identify and document
  tobacco use status for every patient at every
  visit.
• Advise to quit. In a clear, strong and
  personalized manner urge every tobacco user to
  quit.
• Assess willingness to make a quit attempt. Is the
  tobacco user willing to make a quit attempt at
  this time?
• Assist in quit attempt. For the patient willing
  to make a quit attempt, offer medication and
  provide or refer for counseling or additional
  treatment to help the patient quit. For patients
  unwilling to quit at the time, provide
  interventions designed to increase future quit
  attempts.
• Arrange followup. For the patient willing to make
  a quit attempt, arrange for follow-up contacts,
  beginning within the first week after the quit
  date.
• For patients unwilling to make a quit attempt at
  the time, address tobacco dependence and
  willingness to quit at next clinic visit.

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The "5 A's" Model for Treating Tobacco Use and
Dependence - 2008
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10 Key Guideline Recommendations
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10 Key Guideline Recommendations

• Tobacco dependence is a chronic disease that
  often requires repeated intervention and multiple
  attempts to quit. However, effective treatments
  exist that can significantly increase rates of
  long-term abstinence.
• It is essential that clinicians and healthcare
  delivery systems consistently identify and
  document tobacco use status and treat every
  tobacco user seen in a healthcare setting.

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10 Key Guideline Recommendations

• 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.

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10 Key Guideline Recommendations

• 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

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10 Key Guideline Recommendations

• 6. There are numerous effective medications 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

? Clinicians should also consider the use of
certain combinations of medications identified
as effective in this Guideline.
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10 Key Guideline Recommendations

• 7. Counseling and medication are effective when
  used by themselves for treating tobacco
  dependence. However, the combination of
  counseling and medication 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 healthcare delivery
  systems should both ensure patient access to
  quitlines and promote quitline use.

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10 Key Guideline Recommendations

• 9. If a tobacco user is currently 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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2008 PHS Clinical Practice Guideline Update
Treating Tobacco Use and Dependence

• Brief history and developmental process
• Key findings of interest
• Getting more information

53
Key Guideline Web Links

• Guideline Materials
• http//www.surgeongeneral.gov/tobacco/
• List of over 55 endorsing organizations at
• http//www.ctri.wisc.edu/Researchers/researchers_C
  PGupdate2008_endorse.htm
• May 7th Webcast
• http//www.ctri.wisc.edu/
• then click on View the Webcast
• UW-CTRI
• www.ctri.wisc.edu