Putting Prevention into Practice

An Evidence-Based Approach

Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults and Pregnant Women



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Am Fam Physician. 2010 Nov 15;82(10):1269-1270.

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This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See CME Quiz on page 1201.

Case Study

A young married couple visits your office for their initial prenatal visit. They each smoke one pack of cigarettes daily.

Case Study Questions

  1. Which one of the following approaches to addressing tobacco use is consistent with the recommendations of the U.S. Preventive Services Task Force (USPSTF)?

    • A. Address smoking status only if the couple's physical examinations and initial screening tests are abnormal.

    • B. Provide identical tobacco cessation counseling to the husband and the wife.

    • C. Provide tobacco cessation counseling to the husband and the wife, including augmented pregnancy-tailored counseling for the wife.

    • D. Offer pharmacotherapy to assist with smoking cessation for the wife only.

    • E. Offer pharmacotherapy to the husband and the wife.

  2. Which of the following statements about counseling and interventions to prevent tobacco use are correct?

    • A. The “5-A” framework (Ask, Advise, Assess, Assist, Arrange) provides a useful counseling strategy for tobacco cessation.

    • B. To be effective, counseling regarding tobacco use must last at least 30 minutes or include multiple sessions.

    • C. Combination therapy with counseling and medication is more effective than either component alone.

    • D. There is insufficient evidence that smoking cessation in pregnancy yields health benefits for the infant.

  3. Which of the following strategies have been shown to improve rates of tobacco cessation counseling and interventions in primary care settings?

    • A. Implementing a tobacco user identification system.

    • B. Dedicating staff to provide tobacco dependence treatment.

    • C. Providing feedback to promote clinician intervention.

    • D. Recommending consultation with a mental health professional.

Answers

1. The correct answer is C. Tobacco use, and cigarette smoking in particular, 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 about 1,000 infants annually and is associated with an increased risk of premature birth and intrauterine growth retardation.

The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. In addition, the USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke.

The USPSTF has found convincing evidence that smoking cessation interventions delivered in the primary care setting are effective in increasing the proportion of smokers who successfully quit and remain abstinent for one year. Pharmacotherapy has been shown to be effective in increasing smoking cessation rates in nonpregnant adult patients. The USPSTF found inadequate evidence to evaluate the safety or efficacy of pharmacotherapy during pregnancy.

2. The correct answers are A and C. The “5-A” framework provides a useful tobacco cessation counseling strategy: 1) Ask about tobacco use; 2) Advise to quit through clear personalized messages; 3) Assess willingness to quit; 4) Assist to quit; and 5) Arrange follow-up and support. Although there is a dose-response relationship between quit rates and intensity of counseling, even brief counseling sessions (less than 10 minutes) improve tobacco cessation rates. In nonpregnant adults, combination therapy, including counseling and medication, is more effective than either component alone.

The USPSTF found convincing evidence that tobacco cessation at any point during pregnancy yields substantial health benefits for the expectant mother and baby.

3. The correct answers are A, B, and C. According to the USPSTF, strategies that have been shown to improve rates of tobacco cessation counseling and interventions in primary care settings include implementing a tobacco user identification system; providing education, resources, and feedback to promote clinician intervention; and dedicating staff to provide tobacco dependence treatment and assessing the delivery of this treatment in staff performance evaluations.

SOURCES

U. S. Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. 2009;150(8):551–555.

Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville, Md.: U.S. Department of Health and Human Services. Public Health Service; May 2008. http://www.surgeongeneral.gov/tobacco/. Accessed March 31, 2009.

The case study and answers to the following questions on counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women are based on the recommendations of the U.S. Preventive Services Task Force (USPSTF), an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. More detailed information on this subject is available in the USPSTF Recommendation Statement on the USPSTF Web site (http://www.uspreventiveservicestaskforce.org). The practice recommendations in this activity are available at http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm.



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