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AHCPR Guidelines

AHCPR Guidelines

Complete Summary

TITLE:
Smoking cessation.

SOURCE(S):
Rockville (MD): U. S. Department of Health and Human Services, Public Health Service, AHCPR; 1996 Apr. 124 (Clinical practice guideline; no. 18).[145 references]

ADAPTATION:
Not applicable: Guideline was not adapted from another source.

RELEASE DATE:
1996 Apr

DEVELOPER(S):
Agency for Health Care Policy and Research (AHCPR ) - Federal Government Agency [U.S.]

DEVELOPER COMMENT:
Not applicable

FUNDING SOURCE:
United States Government

FUNDING SOURCE ID:
Not applicable

COMMITTEE:
Smoking Cessation Guideline Panel

GROUP COMPOSITION:
A private-sector panel of 19 individuals convened by the Agency for Health Care Policy and Research and Centers for Disease Control and Prevention.

Names of Committee Members: Michael C. Fiore, MD, MPH; William C. Bailey, MD; Stuart J. Cohen, EdD; Sally Faith Dorfman, MD, MSHSA; Michael G. Goldstein, MD; Ellen R. Gritz, PhD; Richard B. Heyman, MD; John Holbrook, MD; Carlos Roberto Jaen, MD, PhD; Thomas E. Kottke, MD, MSPH; Harry A. Lando, PhD; Robert Mecklenburg, DDS, MPH; Patricia Dolan Mullen, DrPH; Louise M. Nett, RN, RRT; Lawrence Robinson, MD, MPH; Maxine L. Stitzer, PhD; Anthony C. Tommasello, MS; Louise Villejo, MPH, CHES; Mary Ellen Wewers, PhD, RN.

DISEASE/CONDITION:
Tobacco addiction

CATEGORY:
Treatment; Prevention; Screening

CLINICAL SPECIALTY:
Family Practice; Internal Medicine; Pediatrics; Geriatrics; Primary Care

INTENDED USERS:
Physicians; Nurses; Nurse Practitioners; Physician Assistants; Allied Health Care Practitioners; Respiratory Care Practitioners; Physical Therapists; Health Plans; Dentists; Pharmacists; Psychologists

OBJECTIVES:
To provide a simple and flexible set of strategies that ensure that all patients who use tobacco are offered motivational interventions and effective treatments to overcome tobacco addiction.

TARGET POPULATION:
Adults, adolescents, and children who use tobacco

INTERVENTIONS/PRACTICES:
Smoking Cessation Interventions including:

OUTCOMES CONSIDERED:

METHODS TO COLLECT EVIDENCE:
Searches of Electronic Databases; Hand-searches of Published Literature (Primary Sources); Hand-searches of Published Literature (Secondary Sources)

DESCRIPTION OF METHODS TO COLLECT EVIDENCE:
A comprehensive examination of literature published from 1976 through 1994 was performed. Articles were selected by computer searches and by scanning bibliographies. Approximately 3,000 articles were reviewed to identify the literature appropriate for evaluation. The appropriateness of an article was determined by applying the criteria for inclusion established a priori by the panel. The criteria were that the article (a) reported the results of a randomized, controlled trial of a tobacco-use cessation intervention, (b) provided followup results at a timepoint at least 5 months after the quit date, (c) were published in a peer-reviewed journal, (d) were published between 1975 and 1994 (e) were published in English. As a result of this review, more than 300 articles were included in our final database.

NUMBER OF SOURCE DOCUMENTS:
Approximately 3,000 articles were reviewed; more than 300 articles were included in the final database.

METHODS TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE:
Weighting According to a Rating Scheme (Scheme Given)

RATING SCHEME:
The quality and quantity of empirical support for the recommendation was rated by the following scheme:

  1. Multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielded a consistent pattern of findings.
  2. Some evidence from randomized clinical trials supported the recommendation, but the scientific support was not optimal. For instance, either few randomized trials existed, the trials that did exist were somewhat inconsistent, or the trials were not directly relevant to the recommendation. An example of the last point would be the case where trials were conducted using a study population that differed from the target population of the recommendation.
  3. Reserved for important clinical situations where the panel achieved consensus on the recommendation in the absence of relevant randomized controlled trials.

The panel declined to make recommendations when there was no relevant evidence or the evidence considered was too weak or inconsistent.

METHODS TO ANALYZE EVIDENCE:
Systematic Review
Meta-Analysis of Randomized Controlled Trials

DESCRIPTION OF METHODS TO ANALYZE EVIDENCE:
The literature was reviewed systematically by (a) establishing a priori criteria for relevant studies, (b) reviewing abstracts and articles selected by computer searches and by scanning bibliographies, (c) compiling and reviewing the full articles, (d) compiling evidence tables summarizing these articles, and (e) conducting meta-analyses where possible.

The primary meta-analytic model used in the guideline was logistic regression using random effects modeling. The panel methodologists chose to employ random effects modeling, assuming that both the subject populations and the treatment elements analyzed would vary from study to study. Random effects modeling is well suited to accommodate such variation among studies.

The meta-analyses yielded logistic regression coefficients that were converted to odds ratios. Once odds ratios were obtained from meta-analyses, the statistical methodologist estimated 95 percent confidence intervals around the odds ratios. After computing the odds ratios and their confidence intervals, the statistical methodologist then converted the odds ratios to cessation percentages and their 95 percent confidence intervals. (Cessation percentages indicate the estimated long-term smoking cessation rate achieved under the tested treatment or treatment characteristic.)

The cessation percentage results duplicate the odds ratio results, but are presented because their meaning may be clearer for some readers.

REVIEW METHODS:
External Peer Review

DESCRIPTION OF REVIEW METHODS:
The panel and AHCPR invited 155 outside reviewers to peer review the guideline draft. In addition, AHCPR placed a notice in the Federal Register inviting individuals to review and comment on the draft guideline. A total of 71 reviewers provided comments. Peer reviewers included clinicians, health care program directors, social workers, counselors, health educators, researchers with clinical experience, consumers and key personnel at selected Federal agencies (CC, National Institute on Drug Abuse, NCI, Food and Drug Administration [FDA]) among others. Reviewers were asked to evaluate the guideline based on five criteria: validity, reliability, clarity, clinical applicability, and utility. The reviewers were encouraged to provide additional comments. Comments of the peer reviewers were evaluated by the panel and panel staff and were incorporated into the guideline, when appropriate.

ENDORSER(S):
Not stated

IMPLEMENTATION STRATEGY:
Not applicable

MAJOR RECOMMENDATIONS:
Summary:

  1. Effective smoking cessation treatments are available, and every patient who smokes should be offered one or more of these treatments.
  2. It is essential that clinicians determine and document the tobacco-use status of every patient treated in a health care setting.
  3. Brief cessation treatments are effective, and at least a minimal intervention should be provided to every patient who uses tobacco.
  4. A dose-response relation exists between the intensity and duration of a treatment and its effectiveness. In general, the more intense the treatment, the more effective it is in producing long-term abstinence from tobacco.
  5. Three treatment elements, in particular, are effective, and one or more of these elements should be included in smoking cessation treatment: nicotine replacement therapy, social support, skills training/problem solving.
  6. Effective reduction of tobacco use requires that health care systems make institutional changes that result in systematic identification of, and intervention with, all tobacco users at every visit.

Specific recommendations:

I. Screen for Tobacco Use

All patients should be asked if they use tobacco and should have their tobacco-use status documented on a regular basis. (Strength of Evidence = A)

Clinic screening systems such as expanding the vital signs to include smoking status, or the use of smoking status chart stickers, are essential for consistent assessment and documentation of smoking. (Strength of Evidence = B)

II. Advice to Quit Smoking

All physicians should strongly advise every patient who smokes to quit. (Strength of Evidence = A)

All clinicians should strongly advise their patients who smoke to quit. Although studies have not independently addressed the impact of advice to quit by all types of nonphysican clinicians, it is reasonable to believe that such advice is effective. (Strength of Evidence = C)

III. Specialized Assessment

Clinicians should routinely assess both the smoking status of all of their patients and the appropriateness of cessation interventions such as nicotine replacement therapy. (Strength of Evidence = A)

Cessation treatment is effective without specialized assessments. Clinicians, therefore, should intervene with every patient who smokes even if specialized assessments are not available. (Strength of Evidence = A)

Clinicians may engage in specialized assessments in order to gauge potential for successful quitting. (Strength of Evidence = C)

IV. Interventions

Smoking cessation interventions delivered by a variety of clinicians and health care personnel increase cessation rates. Clinician involvement in smoking cessation interventions should be based on factors such as access to smokers, level of training, and interest rather than on membership in a specific professional discipline. (Strength of Evidence = A)

All health care personnel and clinicians should repeatedly and consistently deliver smoking cessation interventions to their patients. Smoking cessation interventions should be delivered by as many clinicians and types of clinicians as is feasible given available resources. (Strength of Evidence = A)

V. Treatment Formats

To be most effective, smoking cessation interventions should include either individual or group counseling/contact. (Strength of Evidence = A)

Vl. Efficacy of Self-Help Treatment Alone

Where feasible, smokers should be provided with access to support through a telephone hotline/helpline as a self-help intervention. (Strength of Evidence = B)

VIl. Intensity of Person-to-Person Clinical Intervention

There is a strong dose-response relationship between the intensity of person-to-person contact and successful cessation outcome. Intensive interventions are more effective and should be used when resources permit. (Strength of Evidence = A)

Every smoker should be offered at least a minimal or brief intervention whether or not the smoker is referred to an intensive intervention. (Strength of Evidence = B)

VIIl. Content of Smoking Cessation Interventions

Smoking cessation interventions should help smokers recognize and cope with problems encountered in quitting (problem solving/skills training) and should provide social support as part of treatment. (Strength of Evidence = B)

Smoking cessation interventions that use some type of aversive smoking procedure (rapid smoking, rapid puffing, other aversive smoking) increase cessation rates and may be used with smokers who desire such treatment or who have been unsuccessful using other interventions. (Strength of Evidence = B)

lX. Person-to-Person Treatment: Duration and Number of Sessions

In general, the greater the number of weeks over which person-to-person counseling or treatment is delivered, the more effective it is. Therefore, the duration of smoking cessation interventions should last as many weeks as is feasible given available resources. (Strength of Evidence = A)

Person-to-person treatment delivered over four to seven sessions appears especially effective in increasing cessation rates. Therefore, if available resources permit, clinicians should strive to meet at least four times with quitting smokers. (Strength of Evidence = A)

X. Smoking Cessation Pharmacotherapy

Patients should be encouraged to use nicotine replacement therapy (patch or gum) for smoking cessation except in the presence of special circumstances. (Strength of Evidence = A)

Transdermal nicotine (the nicotine patch) is an efficacious smoking cessation treatment that patients should be encouraged to use. The nicotine patch is effective across diverse settings and populations and when used with a variety of psychosocial interventions. (Strength of Evidence = A)

Nicotine gum is an efficacious smoking cessation treatment that patients should be encouraged to use. (Strength of Evidence = A)

Xl. Followup Assessment and Procedures

All patients who receive an intervention should be assessed for abstinence at the completion of treatment or during subsequent clinic visits. (1)For abstinent patients, all should receive relapse prevention treatment. (2)For patients who have relapsed, assess their willingness to quit (Strength of Evidence = C):

XIl. Reimbursement for Smoking Cessation Treatment

Smoking cessation treatments (both pharmacotherapy and counseling) should be provided as paid services for subscribers of health insurance/managed care. (Strength of Evidence = C)

Clinicians should be reimbursed for delivering effective smoking cessation treatments. (Strength of Evidence = C)

XIIl. Promoting the Motivation to Quit

For patients not willing to initiate a quit attempt at the time of their health care visit, clinicians should engage in a brief intervention designed to promote motivation to quit. (Strength of Evidence = C)

XIV. Relapse Prevention

When clinicians encounter a recent quitter, they should reinforce the patient's decision to quit, review the benefits of quitting, and assist the patient in resolving any residual problems arising from quitting. (Strength of Evidence = C)

XV. Gender

The same smoking cessation treatments are effective for both men and women. Therefore, the same interventions can be used with both sexes. (Strength of Evidence = B)

XVl. Racial and Ethnic Minorities

Members of racial and ethnic minorities should be provided smoking cessation treatments shown to be effective in this guideline. (Strength of Evidence = B)

Whenever possible, smoking cessation treatments should be modified or tailored to be appropriate for the ethnic or racial populations with which they are used. (Strength of Evidence = C)

XVIl. Pregnancy

Pregnant smokers should be strongly encouraged to quit throughout pregnancy. Because of the serious risks of smoking to the pregnant smoker and fetus, pregnant smokers should be offered intensive counseling treatment. (Strength of Evidence = A)

Minimal interventions should be used if more intensive interventions are not feasible. (Strength of Evidence = C)

Motivational messages regarding the impact of smoking on both the pregnant smoker and fetus should be given. (Strength of Evidence = C)

Nicotine replacement should be used during pregnancy only if the increased likelihood of smoking cessation, with its potential benefits, outweighs the risk of nicotine replacement and potential concomitant smoking. (Strength of Evidence = C)

XVIIl. Hospitalized Smokers

For every hospitalized patient, the following steps should be taken: (a) ask each patient on admission if he/she smokes and document smoking status; (b) for current smokers, list smoking status on the admission problem list and as a discharge diagnosis; (c) assist all smokers with quitting during the hospitalization, using treatments identified as effective in this guideline, including nicotine replacement therapy if appropriate; and (d) provide advice and assistance on how to remain abstinent after discharge. (Strength of Recommendation = C)

XlX. Smokers with Psychiatric Comorbidity

Smokers with comorbid psychiatric conditions should be offered smoking cessation treatments identified as effective in this guideline. (Strength of Evidence = C)

Although it is not necessary to assess for psychiatric comorbidity prior to initiating smoking treatment, such assessment may be helpful in that it allows the clinician to prepare for an increased likelihood of smoking relapse or for exacerbation of the comorbid condition in response to nicotine withdrawal. (Strength of Evidence = C)

XX. Weight Gain After Smoking Cessation

The clinician should inform smokers that they are likely to gain weight when they stop smoking. The clinician should recommend that smokers not take strong measures (e.g. strict dieting) to counteract weight gain during a quit attempt. Moreover, ex-smokers should wait until they are confident that they will not return to smoking before trying to reduce their weight. (Strength of Evidence = C)

For smokers who are greatly concerned about weight gain, the clinician may prescribe or recommend nicotine gum, which has been shown to delay weight gain after quitting. (Strength of Evidence = A)

XXl. Smokeless Tobacco Use

Smokeless tobacco (chewing tobacco and snuff) users should be identified and strongly encouraged to quit. (Strength of Evidence = C)

Smokeless tobacco users should be treated with the same psychosocial cessation interventions recommended for smokers. (Strength of Evidence = B)

XXIl. Children and Adolescents: Primary Prevention of Tobacco Addiction

Clinicians should provide their pediatric and adolescent patients, and the parents of these patients, with a strong message regarding the importance of totally abstaining from tobacco use. (Strength of Evidence = C)

Cessation interventions shown to be effective with adults should be considered for use with children and adolescents. The content of these interventions should be modified to be developmentally appropriate. Nicotine replacement should be considered only when there is clear evidence of nicotine dependence and a clear desire to quit tobacco use. (Strength of Evidence = C)

CLINICAL ALGORITHM(S):
A clinical algorithm is provided for a tobacco cessation evidence model.

TYPE OF EVIDENCE:
The recommendations are primarily based on the published scientific literature. When the scientific literature was incomplete or inconsistent in a particular area, the recommendations reflect the professional judgment of panel members and consultants. The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

QUALIFYING STATEMENTS:

  1. The recommendations may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the practitioner in light of available resources and circumstances presented by individual patients.
  2. An absence of studies should not be confused with a proof of lack of efficacy. In certain situations, there was little direct evidence regarding the efficacy of various treatments, and in these cases the panel usually rendered no opinion.
  3. The panel chose not to emphasize comparisons among efficacious interventions for several reasons. First, the most important goal of the analytic process was to identify all of those interventions that are efficacious. Second, selection or use of particular intervention techniques or strategies is usually a function of practical influences (e.g. time available, training of the clinician, patient preference, cost). And finally, data were often inadequate or unavailable to make adequate statistical comparisons of different types of interventions. For example, although numerous studies have investigated the efficacy of both the nicotine patch and nicotine gum relative to placebo treatments, no published randomized trials directly compared the efficacy of these two pharmacotherapies.
  4. Despite a lack of emphasis on the rank-ordering of interventions, some interventions were so superior to control or no-treatment conditions that the panel clearly identified them as superior to other intervention.

COST ANALYSIS:
Not applicable

POTENTIAL BENEFITS:

  1. Decreased incidence of medical illnesses related to tobacco use.
  2. Decreased number of deaths related to tobacco use.

SUBGROUP(S) MOST LIKELY TO BENEFIT:
Not stated

POTENTIAL HARMS:

SUBGROUP(S) MOST LIKELY TO BE HARMED:

TITLE:
Smoking cessation.

SOURCE(S):
Rockville (MD): U. S. Department of Health and Human Services, Public Health Service, AHCPR; 1996 Apr. 124 (Clinical practice guideline; no. 18).[145 references]

GUIDELINE STATUS:
This is the original release of the guideline.

GUIDELINE AVAILABILITY:
Electronic copies: AHCPR's guidelines are available from the National Library of Medicine's HSTAT database.

Print copies: Available from the AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907; (800) 358-9295.

COMPANION DOCUMENTS:
The following documents are available:

  1. Helping smokers quit: a guide for primary care clinicians. Rockville, MD: AHCPR, 1996 Apr. (Quick reference guide; no. 18). AHCPR Pub. No. 96-0693
  2. Smoking cessation: information for specialists. Rockville, MD: AHCPR, 1996 Apr. 12 p. (Quick reference guide: no. 18). AHCPR Pub. No. 96-0694
  3. Smoking cessation: a systems approach. A guide for health care administrators, insurers, managed care organizations and purchasers. Rockville, MD: AHCPR, 1997 Apr. 6 p. AHCPR Pub. No. 97-0698
  4. You can quick smoking: patient guide. Rockville, MD: AHCPR, 1996 Apr. (Consumer guide; no. 18). AHCPR Pub. No. 96-0695
  5. Si quiere, puede dejar de fumar. Rockville, MD: AHCPR, 1996 Apr. (Consumer guide - Spanish language; no. 18)
  6. Fiore MC, et al. Smoking cessation. Rockville, MD: AHCPR, 1996 Oct. 601 p. (Guideline technical report; no. 18). AHCPR Publication No. 97-N004

Electronic copies: Items 1 through 5 are available from the National Library of Medicine's HSTAT database.

Print copies: Items 1 through 4 are available from the AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907; (800) 358-9295.

NGC STATUS:
This summary was completed by ECRI on June 30, 1998. The information was verified by the guideline developer on December 1, 1998.

COPYRIGHT STATEMENT:
No copyright restrictions apply.

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