Smoking Cessation J DG 10, 10 CENTER DR

Clinical Practice Guideline Number 18 Smoking o Cessation 0o) o CO 0 E (f) ^ . U.S. Department of Health and Human Services Public Health Service Agency for Health Care Policy and Research Control and Prevention 1 Centers for Disease i The Agency for Health Care Policy and Research (AHCPR) was established in December 1989 under Public Law 101-239 (Omnibus Budget Reconciliation Act of 1989) to enhance the quality, appropriateness, and effectiveness of health care services and access to these services. AHCPR carries out its mission by conducting and supporting general health services research, including medical effectiveness research, facilitating development of clinical practice guidelines, and disseminating research findings and guide lines to health care providers, policymakers, and the public. The legislation also established within AHCPR the Office of the Forum for Quality and Effectiveness in Health Care (the Forum). The Forum has pri mary responsibility for facilitating the development, periodic review, and updating of clinical practice guidelines. The guidelines will assist practitioners in the prevention, diagnosis, treatment, and management of clinical conditions. The Centers for Disease Control and Prevention (CDC) promotes health and quality of life by preventing and controlling disease, injury, and disabil- ity. In acknowledgment of the important role clinical practice guidelines can play in reduction of tobacco use, CDC has collaborated with AHCPR as a partner in the development of this Clinical Practice Guideline. Guidelines are available in formats suitable for health care practitioners, the scientific community, educators, and consumers. AHCPR invites comments and suggestions from users for consideration in development and updating of future guidelines. Please send written comments to Director, Office of the Forum for Quality and Effectiveness in Health Care, AHCPR, Willco Building, Suite 310, 6000 Executive Boulevard, Rockville, MD 20852. NATIONAL INSTITUTE... *Vi Clinical Practice Guideline NiH LIBRARY Number 18 “I - SEP 3 1996 Smoking Cessation j DG 10, 10 CENTER DR. BETHESDA, MD 20892-1150 \ i Smoking Cessation Guideline Panel Michael C. Fiore, MD, MPH (Panel Chair) 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 U.S. Department of Health and Human Services Public Health Service Agency for Health Care Policy and Research Centers for Disease Control, and Prevention AHCPR Publication No. 96-0692 April 1996 ~ Guideline Development and Use S ip‘ Guidelines are systematically developed statements to assist practitioner - and patient decisions about appropriate health care for specific clinical condi- , ^ tions. This guideline was developed by a private-sector panel convened by the Agency for Health Care Policy and Research (AHCPR) and the Centers ^ I ' for Disease Control and Prevention (CDC). The panel employed an explicit science-based methodology and expert clinical judgment to develop specific statements on smoking cessation. Extensive literature searches were conducted, and critical reviews and syntheses were used to evaluate empirical evidence and significant outcomes. Peer review was undertaken to evaluate the reliability and utility of the guideline in clinical practice. The panel’s 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 guideline reflects the state of knowledge, current at the time of publication, on effective and appropriate care. Given the inevitable changes in the state of scientific information and technology, periodic review, updating, and revision will be done. We believe that this AHCPR and CDC-assisted clinical practice guideline will make positive contributions to the quality of care in the United States. We encourage practitioners and patients to use the information provided in the guideline. 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. Clifton R. Gaus, ScD David Satcher, MD, PhD Administrator Director Agency for Health Care Policy Centers for Disease Control and Research and Prevention Publication of this guideline does not necessarily represent endorsement by the U.S. Department of Health and Human Services. For sale by the U.S. Government Printing Office Superintendent of Documents, Mail Stop; SSOP, Washington, DC 20402-9328 ISBN 0-16-048610-6 ii Abstract This guideline contains strategies and recommendations designed to assist clinicians, smoking cessation specialists, and health care administrators/insurers/purchasers in identifying tobacco users and supporting and delivering effective smoking cessation interventions. These recommendations were made as a result of an exhaustive and systematic review and analysis of the scientific literature. The primary analytic technique used was meta-analysis. The strength of evidence that served as the basis for each recommendation is clearly indicated in the guideline. Public testimony and a peer review were also part of the guideline’s development process, as well as a notice in the Federal Register inviting review. The guideline’s principal findings are: Every person who smokes should be offered smoking cessation treatment at every office visit. Clinicians should ask and record the tobacco-use status of every patient. Cessation treatments even as brief as 3 minutes a visit are effective. More intense treatment is more effective in producing long-term abstinence from tobacco. Nicotine replacement therapy (nicotine patches or gum), clinician- delivered social support, and skills training are particularly effective components of smoking cessation treatment.^ Health care systems should make institutional changes that result in the systematic identification of, and intervention with, all tobacco users at every visit. The guideline proposes strategies for carrying out each of its specific recommendations. For clinicians, these recommendations are (1) systematically identify tobacco users and document their status; (2) strongly urge all smokers to quit; (3) identify smokers willing to make a quit attempt; (4) aid the patient in quitting by helping with a quit plan, offering nicotine replacement therapy, giving advice, and providing supplementary information; and (5) schedule followup contact. Recommendations for smoking cessation specialists are (1) assess the smoker who has entered an intervention program; (2) use a variety of clinical specialists; (3) ensure that the program is sufficiently intensive; (4) use a variety of program formats; (5) include effective counseling techniques; (6) target the smoker’s motivation to quit; (7) provide relapse prevention intervention; (8) offer nicotine replacement therapy; and (9) arrange followup contact. Recommendations for health insurance purchasers and health care As this guideline went to press, nicotine nasal spray was approved for use in the United States by the Food and Drug Administration, joining the nicotine patch and gum as effective available interventions. iii administrators are (1) consider making tobacco assessment, counseling, and treatment a contractual obligation of the insurers and providers that sell services; and (2) ensure that institutional changes to promote smoking cessation interventions are universally implemented. This document is in the public domain and may be used and reprinted without special permission, except for those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders. AHCPR appreciates citation as to source, and the suggested format is provided below: Fiore MC, Bailey WC, Cohen SJ, et al. Smoking Cessation. Clinical Practice Guideline No 18. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 96-0692. April 1996. Acknowledgments Many organizations and individuals made significant contributions during the development of this guideline. Although they are too numerous to mention here, the Contributors section lists individual consultants, peer reviewers, and support staff. This guideline would not have been possible without their collaborative efforts. All persons, organizations, and agencies with an interest in the smoking cessation guideline were invited to participate at a public meeting held in Bethesda, Maryland, on November 9, 1994. The panel gratefully acknowledges the valuable input received during that session. The panel gratefully acknowledges the extraordinarily supportive efforts of Ernestine W. Murray, RN, MAS, panel project officer from the Office of the Forum for Quality and Effectiveness in Health Care, Agency for Health Care Policy and Research (AHCPR). We also wish to thank Cheryl Campbell of Technical Resources International, Inc., and Sharon Sokoloff, PhD, of Mikalix and

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