Clinical Practice Guidelines

New guideline challenges clinicians to help smokers quit

Clinicians should aggressively help their smoking patients quit, according to a new clinical practice guideline sponsored by the Agency for Health Care Policy and Research. The guideline, developed by a panel of smoking cessation experts, challenges all clinicians, including doctors, nurses, dentists, and others, to find out if their patients smoke, repeatedly encourage them to quit, and recommend treatments proven to work.

The 19-member panel was led by Michael C. Fiore, M.D., M.P.H., Director of the University of Wisconsin's Center for Tobacco Research and Intervention, and included physicians, nurses, mental health experts, a dentist, a pharmacist, psychologists, an epidemiologist, an educator, and a consumer representative.

The panel's recommendations include using the nicotine patch or nicotine gum—which doubles the chances of successfully quitting—combined with a clinician's encouragement and support and practical advice to smokers on how to cope with situations and behaviors that make them want to smoke.

According to Douglas B. Kamerow, M.D., M.P.H., AHCPR's director of clinical practice guideline development, there are about 46 million adult smokers in the United States, and more than 70 percent of them would like to stop smoking. Dr. Kamerow calls on clinicians to approach smoking as a chronic condition that is very difficult but not impossible to treat.

This is the first time the total body of information on smoking cessation has been analyzed systematically. In developing the guideline, the panel reviewed over 3,000 scientific articles that addressed the assessment and treatment of tobacco dependence, nicotine addiction, and clinical practice.

Only half the smokers who see a doctor have ever been urged to quit. If only 100,000 physicians helped 10 percent of their patients end their addiction each year, the number of smokers in the United States would drop by an additional 2 million people annually.

Smoking is the single greatest preventable cause of illness and death in the United States. People who smoke are at increased risk of heart disease, cancer, and other smoking-related illnesses that contribute to over 420,000 deaths a year. Medical costs for smokers are $50 billion annually, with an additional $47 billion for indirect expenses, such as time lost from work and disability.

The AHCPR-supported guideline recommends that clinicians:

• Ask every patient at every visit if he or she smokes.
• Write a patient's smoking status in the medical chart under vital signs.
• Ask patients about their desire to quit, and reinforce their intentions.
• Motivate patients who are reluctant to quit.
• Help motivated smokers set a quit date.
• Prescribe nicotine replacement therapy. (Editor's Note: The FDA has approved nicotine gum for over-the-counter use; the nicotine patch may be approved for OTC use by the end of 1996.)
• Help patients resolve problems that result from quitting. Counseling may be helpful to some patients to increase the likelihood of success.
• Encourage relapsed smokers to try quitting again.

Other recommendations to health care administrators, purchasers, and insurers include changing the health care delivery systems to make it a standard practice to identify and treat smokers and other tobacco users.

The consumer brochure released along with the guideline urges smokers to:

• Be committed. Be aware that breaking nicotine addiction isn't easy and takes a significant individual effort, but that half the people who have ever smoked have quit.
• Talk with their doctors and discuss nicotine replacement therapy and smoking cessation programs. Do everything possible to maximize the chance of success.
• Set a quit date; do not try to "taper off."
• Build on past mistakes. Think about what helped and what hurt.
• Create a support network of family and friends to be supportive and reinforce stop smoking efforts.
• Learn how to cope with situations that make a person want to resume smoking.
• Focus less on weight gain. Most people who stop smoking will gain less than 10 pounds, but the health benefits of quitting smoking outweigh the risks of weight gain.
• Avoid dieting while trying to give up smoking because it can undermine chances of quitting.

Whenever possible, smoking cessation treatments should be appropriately tailored to ethnic or racial groups. The guideline also offers recommendations for pregnant women, hospitalized patients, and persons with psychological problems. Recommendations also address tobacco prevention and cessation in children and adolescents and use of smokeless tobacco products (snuff and chewing tobacco).

No conclusions were drawn about the effectiveness of acupuncture, hypnosis, and drug therapies such as clonidine, antidepressants, and anxiolytics/benzodiazepines because of insufficient or inconclusive evidence.

The panel also made no recommendations regarding the use of nicotine nasal sprays and nicotine inhalers, since data on these products were limited. At the time of the panel's deliberations, the products were not licensed for prescription use in the United States. (Editor's Note: As the guideline went to press, the Food and Drug Administration approved the prescription use of nicotine nasal spray.)

AHCPR plans to disseminate the guideline, cosponsored by the Centers for Disease Control and Prevention, to a wide range of clinicians, smoking cessation specialists, health care administrators, purchasers, and insurers. A quick reference guide, pocket guide, and consumer version, in English and Spanish, also will be distributed.

The American Medical Association has received an educational grant from the Robert Wood Johnson Foundation to send copies of the guideline to 200,000 primary care doctors. AHCPR also will work with the American Association of Health Plans (formerly GHAA/AMCRA) to develop a practical guide, based on the guideline recommendations, targeted to meet the needs of health care systems.

The guideline publications Smoking Cessation: Quick Reference Guide for Primary Care Clinicians (AHCPR Publication No. 96-0693); Smoking Cessation: Quick Reference Guide for Smoking Cessation Specialists (AHCPR Publication No. 96-0694); and You Can Quit Smoking: Guide for Consumers (AHCPR Publication No. 96-0695) are available from AHCPR.

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