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Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons: US Preventive Services Task Force Recommendat

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Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons: US Preventive Services Task Force Recommendat Clinical Review & Education JAMA | US Preventive Services Task Force | RECOMMENDATION STATEMENT Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons US Preventive Services Task Force Recommendation Statement US Preventive Services Task Force Editorial page 232 IMPORTANCE Tobacco use is the leading preventable cause of disease, disability, and death in Multimedia the US. In 2014, it was estimated that 480 000 deaths annually are attributed to cigarette smoking, including second hand smoke exposure. Smoking during pregnancy can increase Related articles pages 280 and 301 and JAMA Patient Page the risk of numerous adverse pregnancy outcomes (eg, miscarriage and congenital page 316 anomalies) and complications in the offspring (including sudden infant death syndrome and impaired lung function in childhood). In 2019, an estimated 50.6 million US adults (20.8% of Supplemental content the adult population) used tobacco; 14.0% of the US adult population currently smoked CME Quiz at cigarettes and 4.5% of the adult population used electronic cigarettes (e-cigarettes). jamacmelookup.com and CME Among pregnant US women who gave birth in 2016, 7.2% reported smoking cigarettes Questions page 303 while pregnant. OBJECTIVE To update its 2015 recommendation, the USPSTF commissioned a review to evaluate the benefits and harms of primary care interventions on tobacco use cessation in adults, including pregnant persons. POPULATION This recommendation statement applies to adults 18 years or older, including pregnant persons. EVIDENCE ASSESSMENT The USPSTF concludes with high certainty that the net benefit of behavioral interventions and US Food and Drug Associated (FDA)–approved pharmacotherapy for tobacco smoking cessation, alone or combined, in nonpregnant adults who smoke is substantial. The USPSTF concludes with high certainty that the net benefit of behavioral interventions for tobacco smoking cessation on perinatal outcomes and smoking cessation in pregnant persons is substantial. The USPSTF concludes that the evidence on pharmacotherapy interventions for tobacco smoking cessation in pregnant persons is insufficient because few studies are available, and the balance of benefits and harms cannot be determined. The USPSTF concludes that the evidence on the use of e-cigarettes for tobacco smoking cessation in adults, including pregnant persons, is insufficient, and the balance of benefits and harms cannot be determined. The USPSTF has identified the lack of well-designed, randomized clinical trials on e-cigarettes that report smoking abstinence or adverse events as a critical gap in the evidence. RECOMMENDATIONS The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and FDA-approved pharmacotherapy for cessation to nonpregnant adults who use tobacco. (A recommendation) The USPSTF recommends that clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant persons who use tobacco. (A recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant persons. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of e-cigarettes for tobacco cessation in adults, including pregnant persons. The USPSTF recommends that clinicians direct patients who use tobacco to other Author/Group Information: The US tobacco cessation interventions with proven effectiveness and established safety. (I statement) Preventive Services Task Force (USPSTF) members are listed at the end of this article. Corresponding Author: Alex H. Krist, MD, MPH, Virginia Commonwealth University, One Capitol Square, Sixth Floor, 830 E Main St, Richmond, VA 23219 JAMA. 2021;325(3):265-279. doi:10.1001/jama.2020.25019 ([email protected]). (Reprinted) 265 © 2021 American Medical Association. All rights reserved. Clinical Review & Education US Preventive Services Task Force USPSTF Recommendation: Interventions for Tobacco Smoking Cessation in Adults Summary of Recommendations The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and US Food and Drug Administration (FDA)–approved pharmacotherapy A for cessation to nonpregnant adults who use tobacco. The USPSTF recommends that clinicians ask all pregnant persons about tobacco use, advise them to stop A using tobacco, and provide behavioral interventions for cessation to pregnant persons who use tobacco. See the Figure for a more detailed summary of the recommendations The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms I for clinicians. See the Practice of pharmacotherapy interventions for tobacco cessation in pregnant persons. Considerations section for more information on recommended The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of behavioral interventions and electronic cigarettes (e-cigarettes) for tobacco cessation in adults, including pregnant persons. The USPSTF I recommends that clinicians direct patients who use tobacco to other tobacco cessation interventions with pharmacotherapy and for proven effectiveness and established safety. suggestions for practice regarding the I statements. USPSTF indicates US Preventive Services Task Force. obacco use is the leading preventable cause of disease, The USPSTF concludes that the evidence on pharmaco- disability, and death in the US. In 2014, it was estimated therapy interventions for tobacco smoking cessation in pregnant that 480 000 deaths annually are attributed to cigarette persons is insufficient because few studies are available, and the T 1 smoking, including second hand smoke. Smoking during preg- balance of benefits and harms cannot be determined. nancy can increase the risk for miscarriage, congenital anomalies, The USPSTF concludes that the evidence on the use of stillbirth, fetal growth restriction, preterm birth, placental abrup- e-cigarettes for tobacco smoking cessation in adults, including tion, and complications in the offspring, including sudden infant pregnant persons, is insufficient, and the balance of benefits and death syndrome and impaired lung function in childhood.1-4 In harms cannot be determined. The USPSTF has identified the lack 2019 (the most recent data currently available), an estimated 50.6 of well-designed, randomized clinical trials (RCTs) on e-cigarettes million US adults (20.8% of the adult population) used tobacco; that report smoking abstinence or adverse events as a critical gap 14.0% of the US adult population currently smoked cigarettes; and in the evidence. 4.5% of the US adult population used electronic cigarettes See the Figure, Table 1, and the eFigure in the Supple- (e-cigarettes).5 According to data from the National Vital Statistics ment for more information on the USPSTF recommendation ratio- System, in 2016, 7.2% of women who gave birth smoked ciga- nale and assessment. For more details on the methods the rettes during pregnancy.6 There are disparities in smoking behav- USPSTF uses to determine net benefit, see the USPSTF Proce- iors associated with certain sociodemographic factors: smoking dure Manual.8 rates are particularly high in non-Hispanic American Indian/Alaska Native persons; lesbian, gay, or bisexual adults; adults whose high- est level of educational attainment is a General Educational Devel- Practice Considerations opment certificate; persons who are uninsured and those with Medicaid; adults with a disability; and persons with mild, moder- Patient Population Under Consideration ate, or severe generalized anxiety symptoms.5 According to the This recommendation applies to adults 18 years or older, in- 2015 National Health Interview Survey, which reported responses cluding pregnant persons. The USPSTF has issued a separate from 33,672 adults, 68% of adults who smoked reported that they recommendation statement on primary care interventions wanted to stop smoking and 55% attempted quitting in the past for the prevention and cessation of tobacco use in children year7; only 7% reported having recently quit smoking and 31% and adolescents.9 reported having used cessation counseling, medication, or both when trying to quit.7 Definitions Key definitions related to tobacco use are reported in the Box. Although tobacco use refers broadly to the use of any USPSTF Assessment of Magnitude of Net Benefit tobacco product, cigarette smoking has historically been the most prevalent form of tobacco use in the US, and most of the evidence The USPSTF concludes with high certainty that the net benefit of be- surrounding cessation of tobacco products relates to quitting havioral interventions and US Food and Drug Administration (FDA)– combustible cigarette smoking. Thus, the current USPSTF recom- approved pharmacotherapy for tobacco smoking cessation, alone or mendations focus on interventions for tobacco smoking cessation. combined, in nonpregnant adults who smoke is substantial. Additionally, although e-cigarettes are considered a tobacco prod- The USPSTF concludes with high certainty that the net ben- uct that should also be the focus of tobacco prevention and cessa- efit of behavioral interventions for tobacco smoking cessation on tion efforts, for
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