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Am Fam Physician. 2021;103(12):online

Related Putting Prevention into Practice: Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons

As published by the USPSTF.

Summary of Recommendations

The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)–approved pharmacotherapy for cessation to nonpregnant adults who use tobacco (Table 1). A recommendation.

What does the USPSTF recommend?Nonpregnant adults:
  • Ask about tobacco use.

  • Provide behavioral interventions and pharmacotherapy for cessation to those who use tobacco.


Grade A
Pregnant persons:
  • Ask about tobacco use.

  • Provide behavioral interventions for cessation to those who use tobacco.


Grade A
Pregnant persons who use tobacco:
  • The evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy for tobacco cessation.


I statement
Adults and pregnant persons who use tobacco:
  • The evidence is insufficient to assess the balance of benefits and harms of using e-cigarettes for tobacco cessation. Clinicians should direct patients to other cessation interventions with proven effectiveness and established safety.


I statement
To whom does this recommendation apply?Adults 18 years or older, including pregnant persons
What's new?This recommendation is consistent with the 2015 USPSTF recommendation. This recommendation incorporates newer evidence and language in the field of tobacco cessation, including new evidence on the harms of e-cigarettes (i.e., vaping).
How to implement this recommendation?
  1. Ask all adults, including pregnant persons, about tobacco use, using methods such as:

    5 A's: Ask, Advise, Assess, Assist, Arrange follow-up

    Ask, Advise, Refer

    Vital sign: treat smoking status as a vital sign

  2. Provide cessation interventions to persons who use tobacco

    For nonpregnant adults who use tobacco, provide behavioral counseling and pharmacotherapy for cessation

    ○ Effective behavioral counseling interventions include physician advice, nurse advice, individual counseling, group behavioral interventions, telephone counseling, and mobile phone–based interventions

    ○ FDA-approved pharmacotherapy for cessation includes nicotine replacement therapy, bupropion sustained-release, and varenicline

    ○ Combined behavioral counseling and pharmacotherapy includes at least 4 or more behavioral counseling sessions with 90 to 300 minutes of total contact time

    For pregnant persons who use tobacco, provide behavioral counseling for cessation

    ○ Effective behavioral counseling includes cognitive behavioral, motivational, and supportive therapies such as counseling, health education, feedback, financial incentives, and social support

What are other relevant USPSTF recommendations?The USPSTF has made a recommendation on primary care interventions for prevention and cessation of tobacco use in children and adolescents. This recommendation is available at https://www.uspreventiveservicestaskforce.org.
Where to read the full recommendation statement?Visit the USPSTF website to read the full recommendation statement. This includes more details on the rationale of the recommendation, including benefits and harms, supporting evidence, and recommendations of others.

The USPSTF recommends that clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant persons who use tobacco (Table 1). A recommendation.

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant persons(Table 1). I statement.

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of electronic cigarettes (e-cigarettes) for tobacco cessation in adults, including pregnant persons. The USPSTF recommends that clinicians direct patients who use tobacco to other tobacco cessation interventions with proven effectiveness and established safety(Table 1). I statement.

See the Practice Considerations section for more information on recommended behavioral interventions and pharmacotherapy and for suggestions for practice regarding the I statements.

Introduction

Tobacco use is the leading preventable cause of disease, disability, and death in the United States. In 2014, it was estimated that 480,000 deaths annually are attributed to cigarette smoking, including secondhand smoke.1 Smoking during pregnancy can increase the risk for miscarriage, congenital anomalies, stillbirth, fetal growth restriction, preterm birth, placental abruption, and complications in the offspring, including sudden infant death syndrome and impaired lung function in childhood.14 In 2019 (the most recent data currently available), an estimated 50.6 million U.S. adults (20.8% of the adult population) used tobacco; 14.0% of the U.S. adult population currently smoked cigarettes; and 4.5% of the U.S. adult population used e-cigarettes.5 According to data from the National Vital Statistics System, in 2016, 7.2% of women who gave birth smoked cigarettes during pregnancy.6 There are disparities in smoking behaviors associated with certain sociodemographic factors: Smoking rates are particularly high in non-Hispanic American Indian/Alaska Native persons; lesbian, gay, or bisexual adults; adults whose highest level of educational attainment is a General Educational Development certificate; persons who are uninsured and those with Medicaid; adults with a disability; and persons with mild, moderate, or severe generalized anxiety symptoms.5 According to the 2015 National Health Interview Survey, which reported responses from 33,672 adults, 68% of adults who smoked reported that they wanted to stop smoking, and 55% attempted quitting in the past year7; only 7% reported having recently quit smoking, and 31% reported having used cessation counseling, medication, or both when trying to quit.7

USPSTF Assessment of Magnitude of Net Benefit

The USPSTF concludes with high certainty that the net benefit of behavioral interventions and FDA-approved pharmacotherapy for tobacco smoking cessation, alone or combined, in nonpregnant adults who smoke is substantial.

The USPSTF concludes with high certainty that the net benefit of behavioral interventions for tobacco smoking cessation on perinatal outcomes and smoking cessation in pregnant persons is substantial.

The USPSTF concludes that the evidence on pharmacotherapy interventions for tobacco smoking cessation in pregnant persons is insufficient because few studies are available, and the balance of benefits and harms cannot be determined.

The USPSTF concludes that the evidence on the use of e-cigarettes for tobacco smoking cessation in adults, including pregnant persons, is insufficient, and the balance of benefits and harms cannot be determined. The USPSTF has identified the lack of well-designed, randomized clinical trials on e-cigarettes that report smoking abstinence or adverse events as a critical gap in the evidence.

See Table 2 for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine net benefit, see the USPSTF Procedure Manual.8

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