Review and special articleA Clinical Practice Guideline for Treating Tobacco Use and Dependence: 2008 Update: A U.S. Public Health Service Report
Introduction
This report summarizes the 2008 U.S. Public Health Service (PHS) Clinical Practice Guideline, Treating Tobacco Use and Dependence (“2008 Update”) and provides an evidence-based blueprint for clinicians and healthcare systems to treat the deadly chronic disease of tobacco addiction effectively. The importance of such a blueprint is clear—clinicians and healthcare delivery systems have unparalleled access to American smokers; over 70% of smokers visit a clinician each year and most of them report wanting to quit. Half of all smokers alive today—more than 20 million Americans—will be killed prematurely by a disease directly caused by their tobacco use, making the treatment of tobacco dependence the chief medical and public health challenge of our time.
This guideline concludes that tobacco use presents a rare confluence of circumstances: (1) a highly significant health threat,1 (2) a disinclination among clinicians to intervene consistently,2 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.3, 4, 5, 6, 7, 8, 9, 10 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 is still an enormous threat, the story of tobacco control efforts over the last half century is one of remarkable progress and promise. In 1965, current smokers outnumbered former smokers three-to-one.11 Over 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.12 Moreover, 40 years ago, smoking was viewed as a habit rather than a chronic disease. No scientifically validated interventions were available for the treatment of tobacco use and dependence and it had little place in healthcare delivery. Today, numerous effective treatments exist, and tobacco-use assessment and intervention are considered to be requisite duties of clinicians and healthcare delivery entities. Finally, every state now has a telephone quitline, increasing access to effective treatment.
This 2008 Update builds substantially on prior findings published in the 1996 and 2000 guidelines.13 The scant dozen years since the first guideline was released yielded impressive improvements in the treatment of tobacco addiction. In 1997, only 25% of managed healthcare plans covered any tobacco-dependence treatment; this figure approached 90% by 2003,14 although coverage often includes provisions that serve as barriers to its use (e.g., large co-pays). Numerous states added Medicaid coverage for tobacco-dependence treatment since the publication of the first guideline so that by 2005, 72% offered coverage for at least one guideline-recommended treatment.14, 15, 16 In 2002, the Joint Commission (formerly, JCAHO), which accredits some 15,000 hospitals and healthcare programs, instituted an accreditation requirement for the delivery of evidence-based tobacco-dependence interventions for patients with diagnoses of acute myocardial infarction, congestive heart failure, or pneumonia. Finally, Medicare, the Veteran's Health Administration, and the U.S. military now provide coverage for tobacco-dependence treatment. Such policies and systems changes are paying off in terms of increased rates of clinical assessment and treatment of tobacco use.
This 2008 Update serves as a benchmark of the progress made and the challenges that remain. It should reassure clinicians, policymakers, funding agencies, and the public that tobacco use is amenable to both scientific analysis and to clinical interventions. This history of remarkable progress should encourage renewed efforts by clinicians, policymakers, and researchers to help those who remain dependent on tobacco. Adherence to the recommendations in this 2008 Update will provide such help, ensuring that every smoker who visits a healthcare setting in America can receive an effective treatment for tobacco dependence.
Section snippets
Background
The Clinical Practice Guideline for Treating Tobacco Use and Dependence: 2008 Update (2008 Update) is the result of a collaboration among eight governmental and nonprofit organizations: Agency for Healthcare Research and Quality (AHRQ); CDC; National Cancer Institute (NCI); National Heart, Lung, and Blood Institute; National Institute on Drug Abuse; Robert Wood Johnson Foundation; the Legacy Foundation; and the Center for Tobacco Research and Intervention at the University of Wisconsin School
Evidence Synthesis: Overview of the Guideline Development Procedures
Figure 1 provides an overview of the guideline development process. Since the panel was asked to update, rather than completely revise, the 2000 Treating Tobacco Use and Dependence Guideline, the panel's first task was to identify those topics that merited specific meta-analyses based on their importance and the availability of relevant literature, ideally, with some published since 1999. Consultations with panel members and outside experts generated a list of 64 topics from which the panel
Key Guideline Recommendations
Figure 2 presents a model for treating tobacco use and dependence. It underscores the chronic and often relapsing nature of tobacco dependence emphasizing the message that clinicians need to persist in efforts to provide evidence-based treatments.
Intensive Clinical Interventions
Intensive tobacco-dependence treatment can be provided by any suitably trained clinician. The evidence presented in the 2008 Update shows that intensive tobacco-dependence treatment is more effective than brief treatment. Intensive interventions (i.e., more-comprehensive treatments that may occur over multiple visits for longer periods of time and may be provided by more than one clinician) are appropriate for any tobacco user willing to participate in them; neither their effectiveness nor cost
Clinician Training
Training in tobacco-use interventions should not only transmit essential treatment skills but also inculcate the belief that tobacco-dependence treatment is a standard of good clinical practice.48, 115, 116 Such training has been shown to be cost effective.117 For clinicians-in-training, most clinical disciplines currently neither provide training, nor require competency, in tobacco-use interventions,118 although this is slowly improving.119, 120 One survey of U.S. medical schools found that
Economic Aspects of Tobacco and Health Systems Interventions
Smoking exacts a substantial financial burden on the U.S. A recent report of the U.S. CDC estimated that tobacco dependence costs the nation more than $96 billion per year in direct medical expenses and $97 billion in lost productivity.126 Given these substantial costs, research has focused on the economic impact and cost effectiveness of tobacco-cessation interventions.
Cost effectiveness can be measured in a variety of ways, including cost per quality-adjusted-life-year saved (QALY); cost per
Guideline Recommendations Regarding Special Populations and Special Topics
Because specific populations have higher tobacco-use prevalence rates, reaching these populations is a key challenge for effectively treating tobacco dependence. The 2008 Update panel concluded that the interventions found to be effective in this guideline are effective in a variety of populations including those with health disparities. In addition, many of the studies supporting these interventions comprised diverse samples of tobacco users. As a result, the panel concluded that the
Conclusions
In summary, the 2008 tobacco guideline update panel's major conclusions and recommendations are:
- 1
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.
- 2
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.
- 3
Tobacco
References (147)
- et al.
Effects of smoking cessation on health care use: is elevated risk of hospitalization among former smokers attributable to smoking-related morbidity?
Drug Alcohol Depend
(2007) The economics of smoking and cardiovascular disease
Prog Cardiovasc Dis
(2003)- et al.
Evaluating primary care behavioral counseling interventions: an evidence-based approach
Am J Prev Med
(2002) - et al.
Smokers ages 50+: who gets physician advice to quit?
Prev Med
(2000) - et al.
The clinician's role in promoting smoking cessation among clinic patients
Med Clin North Am
(1992) - et al.
Beyond efficacy testing redux
Am J Prev Med
(2004) - et al.
Multiple behavioral risk factor interventions in primary careSummary of research evidence
Am J Prev Med
(2004) - et al.
The top priority: building a better system for tobacco-cessation counseling
Am J Prev Med
(2006) - et al.
Effects of high dose transdermal nicotine replacement in cigarette smokers
Pharmacol Biochem Behav
(2007) - et al.
Nicotine gum, 2 and 4 mg, for nicotine dependenceA double-blind placebo-controlled trial within a behavior modification support program
Chest
(1995)
Women's Initiative for Nonsmoking (WINS V): under-use of nicotine replacement therapy
Heart Lung
Motivation for smoking cessation among the Norwegian public
Addict Behav
Weight gain as an impediment to cigarette smoking cessation: a lingering problem in need of solutions
Prev Med
A randomized controlled trial of an individualized motivational intervention on smoking cessation for parents of sick children: a pilot study
Appl Nurs Res
Late relapse/sustained abstinence among former smokers: a longitudinal study
Prev Med
The health consequences of smoking: a report of the Surgeon General
Effect on cessation counseling of documenting smoking status as a routine vital sign: an ACORN study
Ann Fam Med
Reducing tobacco use: a report of the Surgeon General
Short-term economic and health benefits of smoking cessation: myocardial infarction and stroke
Circulation
The total lifetime health cost savings of smoking cessation to society
Eur J Public Health
Short-term impact of smoking cessation on myocardial infarction and stroke hospitalisations and costs in Australia
Med J Aust
Smoking cessation for the secondary prevention of coronary heart disease
Cochrane Database Syst Rev
Explaining the decrease in U.S. deaths from coronary disease, 1980–2000
N Engl J Med
Cigarette smoking among adults—United States, 2004
MMWR
Cigarette smoking among adults—United States, 2004
MMWR
A clinical practice guideline for treating tobacco use and dependence: a U.S. Public Health Service report
JAMA
State Medicaid coverage for tobacco-dependence treatments—United States, 2005
MMWR
Adoption of system strategies for tobacco cessation by state Medicaid programs
Med Care
Treating tobacco use and dependence: 2008 update
Practice guideline for the treatment of patients with nicotine dependence
Am J Psychiatry
Treatment of patients with substance use disorders, second editionAmerican Psychiatric Association
Am J Psychiatry
American Medical Association guidelines for the diagnosis and treatment of nicotine dependence: how to help patients stop smoking
Ending the tobacco problem: a blueprint for the nation
Smoking cessation guidelines for health professionals: an updateHealth Education Authority
Thorax
Cigarette smoking among adults—United States, 2006
MMWR
Impact of nicotine replacement therapy on smoking behavior
Annu Rev Public Health
Healthy people 2000: national health promotion and disease prevention objectives
How important are comprehensive literature searches and the assessment of trial quality in systematic reviews?Empirical study
Health Technol Assess
Adjusting for publication bias in the presence of heterogeneity
Stat Med
Physician and other health-care professional counseling of smokers to quit—United States, 1991
MMWR
Dental visits among smoking and nonsmoking U.S. adults in 2000
Am J Health Behav
Cigarette smoking among adults—United States, 2000
MMWR
Promoting repeat tobacco-dependence treatment: are relapsed smokers interested?
Am J Manag Care
Tobacco and the clinician: interventions for medical and dental practice
How does physician advice influence patient behavior?Evidence for a priming effect
Arch Fam Med
Physicians can make a difference with smokers: evidence-based clinical approachesPresentation given during the Symposium on Smoking Cessation at the 29th World Conference of the IUATLD/UICTMR and Global Congress on Lung Health, Bangkok, Thailand, 23–26 November 1998. International Union Against Tuberculosis and Lung Disease
Int J Tuberc Lung Dis
Cited by (948)
Assessing efficacy of a web-based smoking cessation tool - QuitAdvisorMD: Protocol for a practice-based, clustered, randomized control trial
2024, Contemporary Clinical Trials CommunicationsAccess to effective smoking cessation medications in patients with medicare, medicaid and private insurance
2023, Public Health in PracticeEnhancing Tobacco Quitline Outcomes for African American Adults: An RCT of a Culturally Specific Intervention
2023, American Journal of Preventive MedicinePredictors of Cessation in Men Using a Tobacco Quitline: A Follow-Up Study
2023, American Journal of Preventive Medicine
Carlos Roberto Jaén, MD, PhD, FAAFP, University of Texas Health Science Center at San Antonio
Timothy B. Baker, PhD, University of Wisconsin School of Medicine and Public Health
William C. Bailey, MD, FACP, FCCP, University of Alabama at Birmingham
Glenn Bennett, MPH, CHES, National Heart, Lung, and Blood Institute
Neal L. Benowitz, MD, University of California San Francisco
Bruce A. Christiansen, PhD, University of Wisconsin School of Medicine and Public Health
Michael Connell, BS, University of Wisconsin School of Medicine and Public Health
Susan J. Curry, PhD, University of Illinois-Chicago
Sally Faith Dorfman, MD, MSHSA, Ferring Pharmaceuticals, Inc, Parsippany NJ
David Fraser, MS, University of Wisconsin School of Medicine and Public Health
Erika S. Froelicher, RN, MA, MPH, PhD, University of California San Francisco
Michael G. Goldstein, MD, Institute for Healthcare Communication, New Haven CT
Victor Hasselblad, PhD, Duke University, Durham NC
Cheryl G. Healton, DrPH, American Legacy Foundation, Washington DC
Stephen Heishman, PhD, National Institute for Drug Abuse
Patricia Nez Henderson, MD, MPH, Black Hills Center for American Indian Health, Rapid City SD
Richard B. Heyman, MD, American Academy of Pediatrics, Cincinnati OH
Corinne Husten, MD, MPH, Partnership for Prevention (formerly with CDC)
Howard K. Koh, MD, MPH, FACP, Harvard School of Public Health
Thomas E. Kottke, MD, MSPH, University of Minnesota, St Paul MN
Harry A. Lando, PhD, University of Minnesota, Minneapolis MN
Cathlyn Leitzke, MSN, RN-C, University of Wisconsin School of Medicine and Public Health
Robert E. Mecklenburg, DDS, MPH, Consultant, Tobacco and Public Health, Potomac MD
Robin J. Mermelstein, PhD, University of Illinois-Chicago
Glen Morgan, PhD, National Cancer Institute
Patricia Dolan Mullen, DrPH, University of Texas School of Public Health
Ernestine W. Murray, RN, BSN, MAS, Agency for Health Care Research and Quality
C. Tracy Orleans, PhD, Robert Wood Johnson Foundation
Megan E. Piper, PhD, University of Wisconsin School of Medicine and Public Health
Lawrence Robinson, MD, MPH, Philadelphia Department of Public Health
Maxine L. Stitzer, PhD, Johns Hopkins/Bayview Medical Center, Baltimore MD
Wendy Theobald, PhD, University of Wisconsin School of Medicine and Public Health
Anthony C. Tommasello, PharmBS, PhD, University of Maryland School of Pharmacy, Baltimore MD
Louise Villejo, MPH, CHES, University of Texas M.D. Anderson Cancer Center, Houston TX
Mary Ellen Wewers, PhD, RN, MPH, Ohio State University, Columbus OH
Christine Williams, MEd, Agency for Health Care Research and Quality
- ⁎
Michael C. Fiore, MD, MPH, University of Wisconsin School of Medicine and Public Health