A Clinical Blueprint to Accelerate the Elimination of Tobacco Use

On May 7, 2008, the US Public Health Service (PHS) released the Clinical Practice Guideline Treating Tobacco Use and Dependence: 2008 Update.¹ This guideline describes how clinicians and health care systems can significantly reduce tobacco use prevalence by delivering evidence-based treatments to their patients who smoke.

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 3 to 1. During 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.² Since tobacco use rates peaked in the 1960s, smoking prevalence among adults has decreased by half, to about 20% today.² Moreover, 40 years ago smoking was viewed as a habit rather than as a chronic disease, and smokers had no access to scientifically validated treatments.

Today numerous effective treatments exist and progress in the war against tobacco is accelerating. For instance, remarkable advances have been made in the scant dozen years since the publication of the first guideline. In 1997, only 25% of managed health care plans covered any tobacco dependence treatment; this figure approached 90% by 2003.³ Numerous states added Medicaid coverage for tobacco dependence treatment since the publication of the first guideline so that by 2005, 75% offered coverage for at least 1 guideline-recommended treatment,⁴ although this increased coverage often includes barriers to use. In 2002, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations), which accredits some 15 000 hospitals and health care 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. Medicare, the Veteran's Health Administration, and the US military now provide coverage for tobacco dependence treatment, and every state has a telephone tobacco quitline. Such policies and systems changes are paying off in terms of increased rates of tobacco intervention and cessation.^{5 - 7}

While this progress has been impressive, tobacco use remains an enormous health threat, as 45 million US adults continue to smoke.⁸ Given that more than 70% of these smokers visit a health care setting each year, clinicians are ideally situated to increase the rate of tobacco cessation among these smokers and reduce their risk of tobacco-caused disease. The promise of the clinical visit is enhanced because, as shown in the 2008 guideline update, numerous effective tobacco dependence treatments exist—treatments that significantly increase the likelihood of tobacco users both making quit attempts and successfully quitting.

A major obstacle to greater reductions in tobacco use prevalence is that clinicians do not consistently provide these effective smoking cessation treatments.⁹ This produces a rare confluence of circumstances: (1) a highly significant health threat; (2) a disinclination among clinicians to intervene consistently; and (3) the presence of clinically effective, and cost-effective, interventions. 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.¹⁰ The 2008 guideline update directly addresses these circumstances by identifying effective interventions as well as treatment delivery systems that have the potential to increase tobacco users' exposure to effective treatment.¹

This 2008 guideline update builds substantially on evidence and conclusions published in the 1996 and 2000 guidelines.^{11 - 12} The update contains findings and recommendations that are based on a systematic review of almost 9000 publications, more than 50 meta-analyses, and expert summaries of relevant literature. The guideline provides a blueprint for clinicians and health care systems, describing how smokers can access effective treatments, how clinicians can provide such treatments quickly and effectively, and how health care systems can support both smokers and clinicians in smoking cessation efforts.

Brief Interventions. Interventions exemplified by the 5 A's (Ask, Advise, Assess, Assist, Arrange) and its variants are effective and can be provided in a cost-effective manner throughout health care systems to all smokers regardless of their intention to quit. It is appropriate to apply brief interventions repeatedly given the chronic nature of tobacco dependence. The guideline sets a clinical standard that clinicians and health care systems consistently identify and document tobacco use status and provide evidence-based treatments to every tobacco user seen in a health care setting.

Counseling. There is stronger evidence than was previously available that counseling is a critical part of tobacco cessation. Individual, group, and telephone counseling are documented as effective, and their effectiveness increases with treatment intensity. Counseling adds significantly to the effectiveness of tobacco cessation medications and both counseling and medications should be provided whenever possible. New findings regarding counseling include (1) telephone counseling, which has broad reach and is now available nationwide through 1-800-QUIT NOW; and (2) interventions for patients not willing to quit at the present time. These interventions can lead to increased quit attempts among smokers who expressed little motivation to quit. Clinicians are provided clear directions on how to respond when smokers say they do not want to quit.

Medication. Seven different smoking cessation medications are now approved by the US Food and Drug Administration for treating tobacco use and dependence: 2 nonnicotine medications—bupropion and varenicline—and 5 nicotine replacement medications—gum, patch, nasal spray, inhaler, and lozenge. All of these medications were found to be effective first-line medications in the guideline meta-analyses. In addition, multiple combinations of medications have been shown to be effective. For the first time, the 2008 guideline update has assessed the relative effectiveness of cessation medications.¹ These comparisons showed that 2 forms of pharmacotherapy, varenicline (2 mg) and the combination of long-term nicotine patch + ad lib nicotine nasal spray or gum, produced significantly higher long-term abstinence rates than did the nicotine patch by itself.

Policy. Increasing evidence shows that the success of any tobacco dependence treatment strategy cannot be separated from the health care system in which it is embedded. Coordinated interventions involving the patient, clinician, health care administrator, insurer, and purchaser are essential for success. Health care policies can significantly increase the likelihood that smokers will receive effective tobacco dependence treatment and quit. Policy-related findings include (1) Providing tobacco dependence treatment as a covered insurance benefit results in more treatment being provided, increased quit attempts, and higher quit rates. (2) Offering clinician training, especially coupled with other system changes (ie, chart reminders), increases rates of clinician intervention (eg, asking about smoking, setting a quit date, providing counseling and medication, arranging for follow-up). (3) Issues of documentation and reimbursement can hinder provision of treatment. Information about diagnostic and billing codes is included to help clinicians with this process. (4) Tobacco dependence treatment is highly cost-effective relative to interventions for other clinical conditions and provides excellent return on investment to both employers and health plans.

Tobacco use occurs across multiple populations. The 2008 guideline documents the effectiveness of tobacco dependence counseling and medication treatments among broad populations of smokers (eg, human immunodeficiency virus–positive and hospitalized patients, lesbian/gay/bisexual/transgender individuals, individuals with low socioeconomic status and limited formal education, those with medical or psychiatric comorbidities, older individuals, racial and ethnic minorities, and women). The evidence suggests that, with few exceptions, members of diverse populations can benefit from the tobacco interventions shown to be effective in general populations of tobacco users. However, evidence is not available to endorse the use of medications with adolescents, pregnant smokers, light smokers (those smoking <10 cigarettes per day), or smokeless tobacco users.

In conclusion, half of all US smokers alive today—more than 20 million—will die prematurely from a disease directly caused by their tobacco use if they are unable to quit, making treatment of tobacco dependence a chief medical and public health challenge. The 2008 guideline update serves as a benchmark of the progress made and the challenges that remain to eliminate tobacco dependence from society. Thus, the update should reassure clinicians, policy makers, funding agencies, and the public that tobacco use is amenable to both scientific analysis and clinical interventions. This history of remarkable progress in treating tobacco dependence should encourage renewed efforts by clinicians, policy makers, and researchers to help the 45 million US individuals who continue to smoke. Adherence to the recommendations in the 2008 PHS guideline update will provide such help, ensuring that every smoker who visits a US health care setting can receive effective treatment for tobacco dependence.