Patient Population Under Consideration
This recommendation applies to adults aged 18 years or older,
including pregnant women. The USPSTF previously issued a separate
recommendation statement on primary care interventions for tobacco use
in children and adolescents (available online at www.uspreventiveservicestaskforce.org).
Although the USPSTF acknowledges that tobacco may be used in other
forms and that other substances aside from tobacco may be smoked, they
are not the focus of this recommendation.
Assessment of Risk
According to the 2012–2013 National Adult Tobacco Survey, smoking
prevalence is higher in the following groups: men; adults aged 25 to 44
years; persons with a race or ethnicity category of “other,
non-Hispanic”; persons with a GED (vs. graduate-level education);
persons with an annual household income of less than $20,000; and
persons who are lesbian, gay, bisexual, or transgender.6 Higher rates of smoking have been found in persons with mental health conditions.7
Implementation Considerations of Behavioral and Pharmacotherapy Interventions
The information that follows on the implementation of interventions
for smoking cessation draws from the USPSTF systematic evidence review8 and the 2008 Public Health Service guidelines.9
Assessment of Smoking Status
The 5 A’s framework (available at www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/5steps.htmlThis link goes offsite. Click to read the external link disclaimer)
is a useful strategy for engaging patients in discussions about smoking
cessation. This program includes the following: 1) Asking every patient
about tobacco use, 2) Advising all tobacco users to quit, 3) Assessing
their willingness to attempt to quit, 4) Assisting with attempts to
quit, and 5) Arranging follow-up.10
“Ask, Advise, Refer” is another approach and involves asking patients
about tobacco use, advising those who smoke to quit, and referring them
to evidence-based interventions. Treating smoking status as a vital sign
and recording smoking status at every health visit are also frequently
used to assess smoking status. Because many pregnant women who smoke do
not report it, using multiple-choice questions to assess smoking status
in this group may improve disclosure.9
Nonpregnant Adults
Both intervention types (pharmacotherapy and behavioral
interventions) are effective and recommended; combinations of
interventions are most effective, and all should be offered. The best
and most effective combinations are those that are acceptable to and
feasible for an individual patient; clinicians should consider the
patient’s specific medical history and preferences and offer and provide
the combination that works best for the patient.
Behavioral Interventions
Many behavioral interventions are available to encourage smoking
cessation in adults. These interventions can be delivered in the primary
care setting or can be referred to community settings with feedback to
the primary care provider. Effective behavioral interventions include
in-person behavioral support and counseling, telephone counseling, and
self-help materials (Table).
Behavioral interventions may increase rates of smoking abstinence from a
baseline range of approximately 5% to 11% in control groups to 7% to
13% in intervention groups.8
- Both minimal (<20 minutes in 1 visit) and intensive (≥20 minutes
plus >1 follow-up visit) physician-advice interventions effectively
increase the proportion of adults who successfully quit smoking and
remain abstinent for at least 6 months.8
- Brief, in-person behavioral counseling sessions (<10 minutes)
effectively increase the proportion of adults who successfully quit
smoking and remain abstinent for 1 year. Although less effective than
longer interventions, even minimal interventions (<3 minutes) have
increased cessation rates in some studies.9
- There is a dose–response relationship between the intensity of
counseling and cessation rates (that is, more or longer sessions improve
cessation rates).9
- Several sessions should be provided; according to the Public
Health Service guidelines, patients should receive at least 4 in-person
counseling sessions.9
- Cessation rates may plateau after 90 minutes of total counseling contact time.9
- Effective interventions can be delivered by various types of
primary care providers, including physicians, nurses, psychologists,
social workers, and cessation counselors.8, 9
- Both individual and group counseling are effective.9
- Effective counseling interventions provide social support and training in practical problem-solving skills.9
- Training in problem-solving skills includes helping persons who
smoke to recognize situations that increase their risk for smoking,
develop coping skills to overcome common barriers to quitting, and
develop a plan to quit.
- Basic information about smoking and successful quitting should be provided.
- Complementary practices that improve cessation rates include
motivational interviewing, assessing readiness to change, and offering
more intensive counseling or referrals.9
- Telephone counseling interventions are effective.8, 9
- Effective interventions provide at least 3 telephone calls.8
- Telephone counseling can be provided by professional counselors or
health care providers who are trained to offer advice over the
telephone.
- Providing self-help materials (primarily print-based) that are
tailored to the individual patient (that is, beyond a brochure that
simply describes the health effects of smoking) is also effective in
improving smoking abstinence.8
Evidence on nontailored, print-based, self-help materials;
computer-based programs; and mobile phone–based interventions (such as
mHEALTH) is mixed, although several trials show promise.8
Pharmacotherapy
Combinations of Pharmacotherapy
- Using 2 types of NRT has been found to be more effective than using
a single type. In particular, there was evidence that combining a
nicotine patch with a rapid-delivery form of NRT is more effective than
using a single type.
- Some studies suggest that NRT in combination with bupropion SR may
be more efficacious than bupropion SR alone but not necessarily NRT
alone.8
Combinations of Behavioral and Pharmacotherapy Interventions
- Combining behavioral and pharmacotherapy interventions may increase cessation rates from approximately 8% to 14%8 compared with usual care or minimal behavioral interventions (such as self-help materials or brief advice on quitting).
- These combination interventions often have behavioral components
delivered by specialized cessation counselors or trained staff and often
use NRT.
- Combination interventions often involve several sessions (≥4) and tend to be more successful with more sessions.
- The largest effect was found in interventions that provided 8 or
more sessions, although the difference in effect among the number of
sessions was not significant.
- Contact time ranged from 0 to greater than 300 minutes; interventions lasting 91 to 300 minutes were most common.
- The addition of behavioral support to pharmacotherapy also
significantly increased cessation rates from approximately 18% in
persons using pharmacotherapy alone to 21% in those using a combination
of pharmacotherapy and behavioral support.8
- Intensity of behavioral support ranged from 0 to greater than 300
minutes of contact; interventions most often involved greater than 91
minutes of contact (roughly 40% were 91 to 300 minutes, and 60% were
>300 minutes).8
Pregnant Women
Behavioral Interventions
- Effective behavioral interventions in pregnant women who smoke
include counseling, feedback, health education, incentives, and social
support. Compared with usual care or controls, behavioral interventions
can increase rates of smoking abstinence from approximately 11% to 15%
in pregnant women.8
- Effective behavioral interventions provided more intensive
counseling than minimal advice and other standard components of usual
care.9
- Counseling sessions augmented with messages and self-help materials
tailored for pregnant women who smoke increased abstinence rates during
pregnancy compared with brief, generic counseling interventions alone.9
- Counseling specific to pregnant women should include messages
about the effects of smoking on both maternal and fetal health and
clear, strong advice to quit as soon as possible. Although smoking
cessation at any point during pregnancy yields substantial health
benefits for the expectant mother and baby, quitting early in pregnancy
provides the greatest benefit to the fetus.9
Other Interventions
Health care system–based strategies that have been shown to improve
rates of clinical interventions for smoking cessation in primary care
settings include implementing an identification system for tobacco
users; providing education, resources, and feedback to promote clinician
intervention; and dedicating staff to provide treatment for tobacco
dependence and assessing the delivery of this treatment in staff
performance evaluations.9
Useful Resources
Primary care clinicians may find the following resources useful in
talking with adults and pregnant women about smoking cessation: Centers
for Disease Control and Prevention fact sheets on quitting smoking (www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htmThis link goes offsite. Click to read the external link disclaimer), the U.S. Department of Health and Human Services’ BeTobaccoFree (http://betobaccofree.hhs.gov/quit-now/index.html#professionalsThis link goes offsite. Click to read the external link disclaimer), the U.S. Department of Health and Human Services’ SmokeFreeWomen (http://women.smokefree.gov/pregnancy-motherhood.aspxThis link goes offsite. Click to read the external link disclaimer), and the Public Health Service’s 2008 clinical practice guidelines.9
In addition, the following resources may be useful to primary care
clinicians and practices trying to implement interventions for smoking
cessation: the Substance Abuse and Mental Health Services
Administration–Health Resources and Services Administration Center for
Integrated Health Solutions’ resources for smoking cessation (www.integration.samhsa.gov/health-wellness/wellness-strategies/tobacco-cessation-2This link goes offsite. Click to read the external link disclaimer), Centers for Disease Control and Prevention state and community resources for tobacco-control programs (www.cdc.gov/tobacco/stateandcommunity/index.htmThis link goes offsite. Click to read the external link disclaimer), and the World Health Organization’s toolkit for delivering brief smoking interventions in primary care (www.who.int/tobacco/publications/smoking_cessation/9789241506953/enThis link goes offsite. Click to read the external link disclaimer).
Suggestions for Practice Regarding the I Statements
Pharmacotherapy for Pregnant Women
Although smoking prevalence is lower in pregnant women than
nonpregnant women of the same age, approximately 1 in 6 pregnant women
aged 15 to 44 years smoke.7
Smoking during pregnancy slows fetal growth, doubles the risk for
delivering a baby with low birthweight, and increases the risk for fetal
death by 25% to 50%. For women in whom behavioral counseling does not
work, other options to promote smoking cessation may be beneficial.
A few studies have evaluated the benefit of NRT on perinatal and
child health outcomes. Although results generally suggest a potential
benefit, the overall evidence is too limited to draw clear conclusions.
Nicotine replacement therapy is a pregnancy category D medication, which
means that there is positive evidence of fetal risk based on adverse
reaction data from investigational or marketing experience or studies in
humans. However, it has been suggested that NRT may be safer than
smoking during pregnancy.4, 11
Potential adverse events reported include increased rates of cesarean
delivery, slightly increased diastolic blood pressure, and skin
reactions to the patch. Potential adverse events reported in nonpregnant
adults include higher rates of low-risk cardiovascular events, such as
tachycardia. There is no evidence of perinatal harms from NRT, although
few trials reported consistently on these adverse events.
The USPSTF identified no studies on bupropion SR or varenicline
pharmacotherapy during pregnancy. These drugs are both pregnancy
category C, which means that animal reproduction studies have shown an
adverse effect on the fetus but there are no adequate well-controlled
studies in humans.
In the absence of clear evidence on the balance of benefits and harms
of pharmacotherapy in pregnant women, clinicians are encouraged to
consider the severity of smoking behavior in each patient and engage in
shared decision making to determine the best individual treatment
course.
ENDS
Approximately 69% of adults who smoke daily report interest in quitting, and roughly 43% attempted to quit in the previous year.1
To date, no ENDS manufacturer has applied for or received FDA approval
to market its product for smoking cessation purposes. According to a
small 2013 study, approximately two thirds of physicians reported that
they believed that electronic cigarettes (e-cigarettes) were a helpful
aid for smoking cessation, and 35% recommended them to patients.12
A recent small survey of e-cigarette users found that 56% reported
using them to quit or reduce cigarette use, and 26% reported using them
to smoke in places where conventional cigarettes were banned.13
Because of the perception by the public and clinicians that ENDS may be
used for quitting conventional smoking, the USPSTF reviewed the
evidence in this area. No studies evaluated the use of ENDS for smoking
cessation in pregnant women or adolescents. The USPSTF identified only 2
RCTs that evaluated the effect of e-cigarettes on smoking abstinence in
adults and found mixed results. Neither study reported any serious
adverse events related to ENDS use; however, potential concerns raised
in other literature include the unknown safety and toxicity of their
components and aerosols,14, 15 and poisoning in children who mishandle nicotine cartridges.16
How the ingredients in ENDS may affect a fetus is also unknown.
Overall, the USPSTF found the evidence on the use of ENDS as a smoking
cessation tool in adults, including pregnant women, and adolescents to
be insufficient.
Additional Approaches to Prevention
Given the public health significance of the consequences of tobacco
use, numerous public health interventions aim to prevent tobacco use and
promote smoking cessation. The Community Preventive Services Task Force
offers several recommendations on interventions that can be used in
community settings (available at www.thecommunityguide.org/tobacco/index.htmlThis link goes offsite. Click to read the external link disclaimer).
The Surgeon General’s report, “The Health Consequences of Smoking—50
Years of Progress,” discusses initiatives to end the tobacco use
epidemic in the United States.1
In addition, the USPSTF recommends that primary care clinicians provide
interventions, including education or brief counseling, to prevent the
initiation of tobacco use among school-aged children and adolescents
(available at www.uspreventiveservicestaskforce.org).