Net Benefits of Tobacco Cessation Interventions Remain Well Established

The net benefits of tobacco cessation interventions in adults and pregnant women remain well established, based on new evidence in the US Public Health Service's 2008 clinical practice guideline reviewed by the US Preventive Services Task Force (USPSTF). This reaffirmation of the 2003 USPSTF recommendation on counseling to prevent tobacco use is reported in the April 21 issue of the Annals of Internal Medicine.

"Tobacco use, cigarette smoking in particular, is the leading preventable cause of death in the United States," write Ned Calonge, MD, MPH, from the Colorado Department of Public Health and Environment in Denver, and colleagues from the USPSTF. "Tobacco use results in more than 400,000 deaths annually from cardiovascular disease, respiratory disease, and cancer. Smoking during pregnancy results in the deaths of about 1000 infants annually and is associated with an increased risk for premature birth and intrauterine growth retardation."

The guidelines also note that environmental tobacco smoke is a factor contributing to death in approximately 38,000 people each year.

Specific recommendations of the USPSTF, both rated level of evidence A, regarding counseling to prevent tobacco use are as follows:

• Clinicians should ask all adults about tobacco use. For those who use tobacco, cessation interventions should be provided.

• Clinicians should ask all pregnant women about tobacco use. For those who smoke, augmented, pregnancy-tailored counseling should be provided.

This recommendation applies to adults 18 years or older and to all pregnant women regardless of age. USPSTF guidelines regarding counseling to prevent tobacco use in nonpregnant adolescents and children will be issued in a separate recommendation statement.

A useful mnemonic to help involve patients in discussions about smoking cessation is the "5-A" behavioral counseling framework: (1) Ask about tobacco use, (2) Advise to quit, using clear personalized messages, (3) Assess willingness to quit, (4) Assist in smoking cessation, and (5) Arrange follow-up and support.

The intensity of counseling is an important factor affecting success of tobacco cessation counseling. Brief (< 10 minutes), 1-time counseling often works, and even minimal interventions (< 3 minutes) appear to increase quit rates to a lesser degree.

However, longer sessions or multiple sessions are more effective in increasing the proportion of smokers who successfully quit and remain abstinent for 1 year. After 90 minutes of total counseling contact time, quit rates appear to plateau.

"Helpful components of counseling include problem-solving guidance for smokers (to help them develop a plan to quit and overcome common barriers to quitting) and the provision of social support as part of treatment," the guidelines authors write. "Complementary practices that improve cessation rates include motivational interviewing, assessing readiness to change, offering more intensive counseling or referrals, and using telephone 'quit lines.'"

Combination treatment using both counseling and pharmacotherapy is more effective than either component alone. Drugs approved by the US Food and Drug Administration (FDA) for treating tobacco dependence in nonpregnant adults include nicotine replacement therapy (gum, lozenge, transdermal patch, inhaler, and nasal spray), sustained-release bupropion, and varenicline. The USPSTF found that evidence was insufficient to assess the safety or efficacy of pharmacotherapy during pregnancy.

To successfully implement strategies for tobacco cessation interventions in primary care practice, the following should be considered:

• A tobacco user identification system should be established.

• Education, resources, and feedback should be optimized to facilitate clinician interventions.

• Staff should be designated to provide treatment and to evaluate the delivery of treatment in staff performance evaluations.

Evidence reviewed by the USPSTF was convincing that quitting smoking reduces the risk for heart disease, stroke, and lung disease in adults.

Compared with brief, generic counseling interventions alone, smoking cessation counseling sessions, supplemented by messages and self-help materials tailored for pregnant smokers, increase abstinence rates during pregnancy, based on evidence found by the USPSTF to be convincing.

At any point during pregnancy, quitting tobacco use is associated with marked health benefits both for the pregnant woman and her baby. However, evidence reviewed by the USPSTF was deemed to be inadequate to evaluate the safety or efficacy of pharmacotherapy given during pregnancy.

No published studies were identified addressing potential harms of counseling to prevent tobacco use in adults or pregnant women. However, the USPSTF judged that the magnitude of these harms is no greater than small. Although harms of pharmacotherapy used in tobacco cessation depend on the specific drug used, the USPSTF considers these harms to be small in nonpregnant adults.

"The USPSTF concludes that there is high certainty that the net benefit of tobacco cessation interventions in adults is substantial," the guidelines authors write. "The USPSTF also concludes that there is high certainty that the net benefit of augmented, pregnancy-tailored counseling in pregnant women is substantial."

The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF. Recommendations made by the USPSTF are independent of the US government and should not be construed as an official position of the AHRQ or the US Department of Health and Human Services. The guidelines authors have disclosed no relevant financial relationships.

Ann Intern Med. 2009;150:551-555.
Clinical Context

The 2003 USPSTF recommendations on counseling to prevent tobacco use recommended consistent documentation of smoking behavior by clinicians and counseling of all adults not to use tobacco.

This is a 2009 update of those recommendations with an examination of the current evidence based on the US Public Health Service's 2008 clinical practice guideline. The recommendations apply to adults 18 years and older and all pregnant women regardless of age. Separate guidelines will be issued for counseling to prevent tobacco use in nonpregnant adolescents and children.
Study Highlights

* Cigarette smoking is the leading preventable cause of death in the United States.
* Tobacco use results in more than 400,000 deaths annually from cardiovascular disease, respiratory disease, and cancer.
* Smoking during pregnancy results in the deaths of approximately 1000 infants annually and is associated with an increased risk for premature birth and intrauterine growth retardation.
* Environmental tobacco smoke contributes to an estimated 38,000 deaths annually.
* There is high certainty that the net benefit of tobacco cessation interventions in adults is substantial.
* All adults should be asked about tobacco use and tobacco cessation interventions offered to those who smoke.
* A tobacco user identification system should be in place in primary care offices.
* Education, resources, and feedback to providers should be provided, and clinician intervention should be encouraged and assessed as part of performance review.
* Brief counseling of less than 10 minutes and even less than 3 minutes is effective in improving quit rates at 1 year.
* There is a dose-response relationship between the intensity of counseling and quit rates, and quit rates plateau after 90 minutes of total counseling contact time.
* Helpful components of counseling include problem-solving guidance, provision of social support and complementary practices of motivational interviewing, assessing readiness to quit, and offering telephone "quit" lines.
* Telephone counseling "quit" lines also improve cessation rates.
* The 5 "A" behavioral counseling framework is an effective strategy to engage patients in discussion about tobacco use and cessation.
* They consist of the following: ask about tobacco use, advise to quit, assess willingness to quit, and arrange follow-up and support.
* There is good evidence that smoking cessation reduces the risk for heart disease, stroke, and lung disease.
* No studies describe harms of counseling to reduce tobacco use, and harms are considered small.
* Pharmacotherapy is effective and consists of nicotine replacement or medications.
* Nicotine replacement can be achieved with gum, lozenge, transdermal patch, inhaler, and nasal spray.
* Sustained-release bupropion and varenicline are other strategies.
* Combined treatment with both counseling and medications is more effective than either alone for reducing tobacco use.
* All pregnant women should be asked about tobacco use and use documented.
* In pregnant women, individual counseling with augmented messages and self-help materials vs generic brief counseling has been shown to increase quit rates.
* Smoking cessation at any stage during pregnancy yields substantial benefits for the mother and infant.
* There is inadequate evidence to evaluate the safety of pharmacotherapy during pregnancy.

Clinical Implications

* All adults and pregnant women should be asked about tobacco use and cessation interventions offered to smokers.
* Combination treatment with counseling and pharmacotherapy is more effective than either alone.

Source : http://cme.medscape.com/viewarticle/701721?src=cmemp