Review and special article
A Clinical Practice Guideline for Treating Tobacco Use and Dependence: 2008 Update: A U.S. Public Health Service Report

https://doi.org/10.1016/j.amepre.2008.04.009Get rights and content

Objective

To summarize the U.S. Public Health Service guideline Treating Tobacco Use and Dependence: 2008 Update, which provides recommendations for clinical interventions and system changes to promote the treatment of tobacco dependence.

Participants

An independent panel of 24 scientists and clinicians selected by the U.S. Agency for Healthcare Research and Quality on behalf of the U.S. Public Health Service. A consortium of eight governmental and nonprofit organizations sponsored the update.

Evidence

Approximately 8700 English-language, peer-reviewed articles and abstracts, published between 1975 and 2007, were reviewed for data that addressed assessment and treatment of tobacco dependence. This literature served as the basis for more than 35 meta-analyses.

Consensus process

Two panel meetings and numerous conference calls and staff meetings were held to evaluate meta-analyses and relevant literature, to synthesize the results, and to develop recommendations. The updated guideline was then externally reviewed by more than 90 experts, made available for public comment, and revised.

Conclusions

This evidence-based, updated guideline provides specific recommendations regarding brief and intensive tobacco-cessation interventions as well as system-level changes designed to promote the assessment and treatment of tobacco use. Brief clinical approaches for patients willing and unwilling to quit are described.

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

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