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Am Fam Physician. 2001;63(8):1635-1636

The Public Health Service of the U.S. Department of Health and Human Services has released an update of the 1996 smoking cessation guideline that was developed by the Agency for Health Care Policy and Research (now called the Agency for Healthcare Research and Quality [AHRQ]). “Treating Tobacco Use and Dependence” was developed in response to the new data and the new treatments for tobacco dependence that have emerged since the mid-1990s. In addition to AHRQ, other sponsors of the guideline are the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), the National Heart, Lung, and Blood Institute, the National Institute on Drug Abuse, the Robert Wood Johnson Foundation and the University of Wisconsin Medical School Center for Tobacco Research and Intervention.

The guideline is available on the Surgeon General's Web site at It also may be obtained by calling AHRQ at 800-358-9295, the CDC at 800-CDC-1311 (800-232-1311) or the NCI at 800-4-CANCER (800-422-6237). The updated guideline contains eight chapters, which include information on assessment of tobacco use; effective brief interventions to encourage smoking cessation; treatment approaches; health care coverage; statistical evidence in support of the recommendations and special populations, such as women, pregnant smokers, hospitalized patients, racial and ethnic minorities, smokers with psychiatric conditions, children and adolescents, and the elderly. There is also a chapter on special topics, such as weight gain after smoking cessation, chewing tobacco, training of physicians and the economics of tobacco treatment.

Comparison with the 1996 Smoking Cessation Guideline

The guideline explains that the updated version includes data that attest to the progress made in tobacco research and treatment since the development of the 1996 clinical practice guideline. Tobacco dependence is now generally recognized as a chronic disease that requires repeated interventions. The guideline includes information on the use of any of the seven different agents now available to aid in smoking cessation. In addition, data now suggest that the combination of nicotine replacement therapy and drug therapy, with the use of medications such as bupropion or nortriptyline, may be more effective than nicotine replacement therapy alone. The guideline also notes that use of two different forms of nicotine replacement, such as the patch and gum, maybe helpful in patients who are unable to quit smoking when using a single type of nicotine replacement.

The updated guideline points to the strong association between the intensity of counseling and success at smoking abstinence. Research has identified telephone counseling as an effective strategy for providing social support during a patient's smoking cessation efforts. The guideline recognizes that the combination of pharmacotherapy and counseling may be optimal.

The updated guideline makes a case for insurance coverage for the treatment of smoking cessation. The guideline points out that treatments of smoking cessation are cost-effective relative to other routinely reimbursed medical interventions, such as treatment of hyperlipidemia and mammography screening.

Combination Nicotine Replacement Therapy

The U.S. Food and Drug Administration has not approved the use of two different forms of nicotine replacement. Because there is relatively little safety data on combination nicotine replacement therapies and they can increase the risk of nicotine overdoses, the guideline recommends such treatment only in patients who are unable to quit smoking with a single type of nicotine replacement. According to the guideline, combining the nicotine patch with a self-administered form of nicotine replacement, such as nicotine gum or nicotine nasal spray, is more effective than treatment with a single form of nicotine replacement.

This recommendation is based on a meta-analysis of three studies. All three studies used the nicotine patch in a 15-mg dosage. In two of the studies, nicotine gum was used to supplement the patch, and in the other study, nicotine nasal spray was used. With this approach, the nicotine patch provides a relatively steady level of nicotine while self-administered nicotine gum or nasal spray allows the patient to modify the nicotine dose as needed for symptoms of nicotine withdrawal. Combination nicotine replacement therapy was found to produce higher long-term abstinence rates than monotherapy. The combination of the nicotine patch and nicotine gum was found to suppress symptoms of nicotine withdrawal.

Key Recommendations

The following is an excerpt from the key recommendations outlined in the updated guideline:

  • 1. Tobacco dependence is a chronic condition that often requires repeated intervention. However, there are effective treatments that can produce long-term or even per manent abstinence.

  • 2. Because effective treatments of tobacco dependence are available, every patient who uses tobacco should be offered at least one of these treatments, as follows:

  • Patients who are willing to try to stop using tobacco should be provided treatments that have been identified as effective in this guideline.

  • Patients who are unwilling to quit using tobacco should be provided a brief intervention designed to increase their motivation to quit.

  • 3. It is essential that physicians and health care delivery systems (including administrators, insurers and purchasers) institutionalize the consistent identification, documentation and treatment of every tobacco user seen in a health care setting.

  • 4. Brief tobacco dependence treatment is effective, and every patient who uses tobacco should be offered at least brief treatment.

  • 5. There is a strong dose-response association between the intensity of tobacco dependence counseling and its effectiveness. Treatments that involve person-to-person contact (by means of individual, group or proactive telephone counseling) are consistently effective, and their effectiveness increases with the intensity of treatment (e.g., minutes of contact).

  • 6. Three types of counseling and behavioral therapies were shown to be especially effective and should be used with all patients who are attempting cessation of tobacco use:

  • Provision of practical counseling (problem solving and skills training).

  • Provision of social support as part of treatment.

  • Help in securing social support outside of treatment.

  • 7. Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking:

  • Five first-line pharmacotherapies that reliably increase long-term smoking abstinence rates were identified: bupropion sustained-release, nicotine gum, nicotine inhaler, nicotine nasal spray and nicotine patch.

  • Two second-line pharmacotherapies, clonidine and nortriptyline, were identified as efficacious and may be considered by physicians if first-line pharmacotherapies are not effective.

  • Over-the-counter nicotine patches are effective relative to placebo, and their use should be encouraged.

  • 8. Treatments of tobacco dependence are clinically effective and cost-effective relative to other medical and disease prevention interventions. As such, insurers and purchasers should ensure the following:

  • That all insurance plans include, as a reimbursed benefit, the counseling and pharmacotherapies identified as effective in this guideline.

  • That physicians are reimbursed for providing treatment of tobacco dependence just as they are reimbursed for the treatment of other chronic conditions.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, Assistant Medical Editor.

A collection of Practice Guidelines published in AFP is available at

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Copyright © 2001 by the American Academy of Family Physicians.

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