Based on the available evidence, the task force recommended that that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and FDA-approved pharmacotherapy for cessation to nonpregnant adults who use tobacco. This is an “A” recommendation.
The task force also gave an “A” recommendation that clinicians ask all pregnant patients about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant patients who use tobacco.
At the same time, the USPSTF issued an “I” recommendation regarding the use of pharmacotherapy interventions in pregnant patients. The task force concluded that the current evidence is insufficient to assess the balance of benefits and harms associated with pharmacotherapy interventions in this population.
Finally, the task force issued an “I” recommendation on e-cigarettes, and concluded that the current evidence is insufficient to assess the benefits and harms of using these devices for tobacco cessation in all adults, including those who are pregnant. The USPSTF instead recommends that clinicians direct patients who use tobacco to other interventions that have demonstrated proven effectiveness and have established safety records.
“Quitting is the most important step a smoker can take to lead a stronger and healthier life,” said Michael Silverstein, M.D., M.P.H., a member of the task force, in a press release. “The good news is there are multiple safe and proven ways to help adults quit tobacco, including counseling, medications or a combination of both.”
Tobacco use is the leading cause of preventable disease, disability and death in the United States. According to the CDC, about 14% of all adults, or roughly 34 million people, smoked cigarettes in 2019, the last year for which data are available. Use of smokeless tobacco products, while less common than combustible tobacco, is also associated with a number of health problems and may increase the risk for heart disease and stroke, as well as for early delivery and stillbirth when used during pregnancy.
The final recommendation is consistent with a draft recommendation statement posted on the USPSTF website in June 2020, and updates the task force’s 2015 final recommendation statement on behavioral and pharmacotherapeutic interventions for tobacco smoking cessation in adults, including those who are pregnant. The AAFP supported the 2015 recommendation.
In its evidence review, which included 67 systematic reviews, the task force found that, compared with usual care or minimal support control groups that did not use medications, combined pharmacotherapy and behavioral interventions increased smoking abstinence in adults by 83%. The task force also found that all seven medications approved by the FDA for smoking cessation (transdermal nicotine patches, nicotine lozenges, nicotine gum, nicotine inhalers, nicotine nasal spray, varenicline tartrate and bupropion hydrochloride sustained release) were found to be more effective in increasing quit rates compared with placebo or nondrug therapies at six months followup.
Despite considerable evidence on the effectiveness of various tobacco cessation methods, the investigators noted research gaps in two areas.
First, they stated that further research is needed to determine the efficacy of e-cigarettes for tobacco cessation, calling for trials that compare e-cigarettes with no intervention and with the most effective known combination of pharmacotherapy and behavioral support. They also called for more research to help standardize and quantify e-cigarette use and nicotine levels, and studies that use the latest versions of e-cigarettes and heated tobacco products.
Second, they called for further research on the safety and effectiveness of tobacco cessation medications in pregnant individuals. They stated that while some studies have shown that behavioral counseling alone is an effective intervention for some patients, few studies of nicotine replacement therapy have been conducted during pregnancy, and that it would be valuable to obtain data on adverse events and levels of nicotine exposure from NRT compared to what occurs with smoking.
“We know that behavioral counseling helps pregnant people quit tobacco use and leads to healthier pregnancies,” explained Chien-Wen Tseng, M.D., M.P.H., M.S.E.E., associate research director in the Department of Family Medicine and Community Health at the University of Hawaii John A. Burns School of Medicine and a member of the task force. “However, we need more research to know whether medicines to help quit tobacco are a safe option during pregnancy.”
A draft recommendation statement was posted for public comment on the USPSTF website from June 2 to June 29, 2020.
In response to comments about the “I” recommendation on the use of e-cigarettes, the task force stated that it could not determine whether e-cigarettes are effective in helping people to quit smoking or what potential long-term harms were associated with e-cigarette use, and thus could not recommend for or against using them.
In response to several requests that the USPSTF recommend nicotine replacement therapy during pregnancy, the task force explained that too few trials were identified to determine whether nicotine replacement therapy provided more benefits or harms, which resulted in the call for more research on this topic.
Finally, in response to other comments, the task force clarified some language and provided additional information from the 2020 surgeon general’s report on smoking cessation.
The final recommendation statement also includes links to several resources for clinicians and patients, including
The AAFP's Commission on Health of the Public and Science plans to review the USPSTF's final recommendation statement, evidence review and evidence summary, and will then determine the Academy's stance on the recommendation.