Guideline Update: Combination of Counseling, Medications Most Effective for Combating Tobacco Dependence

Evidence from the U.S. Public Health Service's 2008 update of the Clinical Practice Guideline: Treating Tobacco Use and Dependence indicates that both counseling and medication for tobacco dependence in adults are effective, especially when combined.

Moreover, suggests the AAFP-endorsed guideline update, health systems, insurers and purchasers should help clinicians make such treatments available.

Originally released in 1996, the guideline was last updated in 2000.

"The 2008 update provides an excellent summary of evidence that has been accumulating about effective tobacco dependence treatment," says family physician Carlos Jaén, M.D., Ph.D., vice chair of the guideline update panel. Jaén is chair of the department of family and community medicine at the University of Texas Health Science Center in San Antonio. He's also a member of the AAFP Tobacco Cessation Advisory Committee.

The management concepts set forth in the guideline update stand to benefit family physicians and their patients in particular, Jaén says. "At no other time in history have we had such a large number of effective treatments and interventions that can be delivered in the context of the family medicine office."

The update makes it clear that tobacco dependence is a chronic disease that often requires repeated interventions and multiple attempts to quit, Jaén says. "We wouldn't think of counseling a diabetic patient for diet and exercise once and then be done with it. The same applies to tobacco dependence."

It shouldn't be just the doctor who intervenes, adds Jaén. "The people who work in our family medicine offices are very motivated to help patients. This guideline update provides tools to help all of us help our patients. It should be a team effort -- which fits into the concept of the patient-centered medical home."

Another member of the AAFP Tobacco Cessation Advisory Committee, Tom Weida, M.D., represented the Academy at the May 7 release of the guideline update in Chicago. He also is speaker of the AAFP Congress of Delegates and professor of family and community medicine at Penn State College of Medicine in Hershey, Pa.

Weida says the 2008 guideline update is consistent with the Academy's position on treating tobacco dependence. Like Jaén, Weida is pleased with the guideline's approach to tobacco dependence as a chronic condition. "Because of that, caring for tobacco dependence fits in with the patient-centered medical home and the chronic disease management process," Weida says. "If Medicare accepts tobacco dependence as a chronic disease, then we can provide effective treatment and get paid appropriately for it. Currently, we have to show that we're treating another disease, such as bronchitis, in order to get paid for treating tobacco dependence."

The guideline update provides evidence-based, step-by-step strategies for conducting a brief tobacco use intervention in the primary care setting, noting that time and reimbursement restrictions often limit primary care providers to such brief interventions. The strategies are based on the "five A's":

The update notes that the clinical situation may suggest delivering these intervention components in an order or format different from that shown above. It lists the Academy's Ask and Act program as one clinical intervention framework that has been proposed.

After tobacco use has been identified, the clinician has advised the patient to quit and the patient has expressed a willingness to do so, the clinician should encourage use of both counseling and medication for adults, the guideline update says. Because there is little evidence showing that medications are effective in achieving long-term abstinence in adolescents, counseling should be encouraged in these patients.

Individual, group and telephone counseling are all effective, according to the update, and their effectiveness increases with treatment intensity. "I was pleasantly surprised by the strength of evidence for counseling provided by telephone quitlines," Jaén says. "It's a powerful way to augment anything we do in the office." Quitlines are available in all states and from national organizations. For example, tobacco users throughout the United States can call (800) QUIT-NOW [784-8669] for free tobacco cessation counseling.

The update also specifies seven first-line medications that reliably increase long-term smoking abstinence rates, and it provides information on their clinical use. The medications are

Clinicians should encourage use of these medications by all tobacco users who want to quit except those in whom it is medically contraindicated, pregnant women, smokeless tobacco users, light smokers and adolescents. For those groups, there's insufficient evidence of effectiveness, the update says.

Evidence also shows that careful use of certain combinations of medications -- such as the nicotine patch and nicotine gum -- is effective, says Jaén.

If a tobacco user is unwilling to make a quit attempt, clinicians should use motivational interventions described in the update, which have been shown to increase future quit attempts.

The guideline update also calls on health care administrators, insurers and purchasers to use a systems approach to help clinicians assess and treat tobacco use consistently. Such an approach should include these steps:

"We family physicians have a responsibility as patient advocates to encourage payers and purchasers to include effective tobacco dependence treatments in their benefit packages," Jaén says, "and it's not enough just to include it -- they have to promote it. Many people have no idea that their insurance covers tobacco cessation."