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Am Fam Physician. 2022;106(5):513-522

Patient information: See related handout on smoking cessation

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

In the United States, 1 in 5 adults uses tobacco products. Cigarette smoking is the leading cause of preventable disease and death in the United States despite its known health effects. Although nearly one-half of people who smoke try to quit each year, only up to 1 in 20 who quit without support achieve abstinence for at least six months. All patients, including school-aged children and adolescents, should be asked if they smoke and offered evidence-based treatments for smoking cessation. Use of the 5 A’s framework (ask, advise, assess, assist, arrange) can help clinicians promote smoking cessation. Clinical studies have demonstrated that combining pharmacotherapy with effective behavior strategies is significantly more effective than either approach alone. Pharmacotherapies approved by the U.S. Food and Drug Administration for smoking cessation include nicotine replacement therapy, bupropion, and varenicline. Extended use (greater than 12 weeks) of a controller therapy (varenicline, bupropion, or nicotine patch) is associated with significantly higher sustained quit rates and lower relapse rates than standard use (six to 12 weeks). e-Cigarettes are not approved by the U.S. Food and Drug Administration for smoking cessation, and evidence supporting their benefit is inconclusive. Lung cancer screening is recommended for adults 50 to 80 years of age who have a 20-pack-year smoking history and currently smoke or have quit within the past 15 years. Lung cancer screening should be combined with smoking cessation tools and treatment.

In the United States, 1 in 5 adults uses tobacco products. Cigarettes and other forms of combustible tobacco products (cigars and pipes) account for 80.5% of tobacco use.1 Despite the known health effects of cigarettes, smoking is the leading cause of preventable disease and death in the United States.1

Clinical recommendation Evidence rating Comments
All patients should be asked about tobacco use and advised to quit.5,6 A U.S. Public Health Service report and USPSTF guideline
All nonpregnant adults who smoke cigarettes should be offered pharmacotherapy and behavior interventions to help cessation attempts.6 A USPSTF guideline and a systematic overview of 64 systematic reviews
Behavior interventions combined with pharmacotherapy improve smoking cessation rates.6,12,13 A Systematic reviews demonstrating that combined interventions are more effective than usual care or minimal intervention
Prescribe varenicline to patients willing to take varenicline even if they are not ready to quit smoking.9 B Systematic review of four RCTs showing that varenicline increases abstinence at six months, even in patients reluctant to quit, with few adverse effects; American Thoracic Society guideline reporting high certainty of benefits
All pregnant people should be screened for tobacco use, advised to quit, and provided behavior interventions to help with cessation.6,47 A USPSTF guideline with seven RCTs and five large observational studies; the benefits and risks of nicotine replacement therapy in pregnant people should be balanced against the risk of continued tobacco use
School-aged children and adolescents younger than 18 years should be asked about tobacco and e-cigarette use and provided with interventions to prevent initiation of tobacco use. There is insufficient evidence to recommend behavior interventions or pharmacotherapy to help cessation efforts in this population.51 B Strategies to prevent initiation of tobacco use include counseling and education; in school-aged children and adolescents, most smoking cessation studies were heterogenous and underpowered to determine the effectiveness of cessation interventions

Almost one-half of people who smoke try to quit each year; however, only up to 1 in 20 of those who quit without support achieve abstinence for at least six months. Brief discussions with clinicians can increase cessation rates by two-thirds, and more intensive treatment doubles the chances of quitting.2

Recommending Smoking Cessation

Including smoking status with the vital sign assessment has not resulted in increased smoking cessation rates. Despite doubling the documentation of patient smoking status from 38% to 78%, clinicians are not addressing smoking more often.3 Studies have shown that clinicians who are trained in smoking cessation and knowledgeable about local resources are more likely to provide smoking cessation interventions.4 Therefore, clinician training and engagement are important variables in smoking cessation interventions.

The American Academy of Family Physician’s (AAFP’s) Ask and Act Tobacco Cessation Program provides free resources and tools to aid physicians (https://www.aafp.org/family-physician/patient-care/care-resources/tobacco-and-nicotine/ask-act.html). All patients should be asked if they smoke, regardless of age, sex, or medical history. This includes school-aged children and adolescents because more than one-half of adult smokers start smoking daily before 18 years of age.5,6

The U.S. Public Health Service suggests using the 5 A’s framework (ask each patient about tobacco use, advise cessation, assess readiness to quit, assist tobacco users in quitting, arrange follow-up visits) in the outpatient setting5 (Table 159). Acknowledging that clinicians may not have adequate time and may not feel comfortable treating tobacco use disorders, simplified models such as AAR (ask, advise, refer to treatment resources) or AAC (ask, advise, connect patients to a quitline via fax, phone, or electronic referral) can be used.4

ComponentDescriptionComments
AskAll tobacco users should be identified on patient intakeClinicians must then initiate a conversation about smoking during the visit
Promoting smoking cessation increases patient satisfaction even if they are not yet ready to quit
AdviseOffer unambiguous support for smoking cessationAdvice should be direct and clear
Use the patient’s medical history, family history, and goals to help shape the advice
AssessAssess the patient’s willingness to quit, previous quit attempts, and current level of nicotine dependence*Smoking within five minutes of waking is considered severe dependence, and smoking within 30 minutes is considered moderate dependence; behaviors around smoking should also be assessed (i.e., other substance use, mental health, and stress)
AssistOffer support and resources
Explain the adverse effects that may occur when the patient quits
Counsel patients about medications that may need titration with smoking cessation
Clinics should have updated local resources on hand for clinicians to reference
Common adverse effects are irritability, anxiety, restlessness (peaks within one week and lasts two to four weeks); patients with depression may experience depressive symptoms (without significant increase in depressive episodes or suicidality); weight gain (although most smokers gain less than 10 lb [4.54 kg] when quitting, it is a common patient concern)
Medications such as beta blockers, antipsychotics, insulin, and benzodiazepines often need titration
ArrangeSet a quit date or a check-in date
Discuss future situations that may make cessation difficult, including how to handle possible smoking triggers
Schedule a follow-up to discuss pharmacotherapy
Abstinence by quit date is highly predictive of long-term success
Many patients have triggers that are behaviorally linked to smoking; understanding these can help with cessation

For record keeping and revenue purposes, it is important to correctly code smoking screening and counseling services (Table 210). In electronic health records, these codes can also be linked to patient resources or clinician tools for local, up-to-date treatments and referrals.

CodeDescription (with nicotine dependence)
F17 codes
F17.210Cigarettes, uncomplicated
F17.211Cigarettes, in remission
F17.213Cigarettes, with withdrawal
F17.218Cigarettes, with other nicotine-induced disorders
F17.219Cigarettes, with unspecified nicotine-induced disorders
F17.290Other tobacco product, uncomplicated
F17.291Other tobacco product, in remission
F17.293Other tobacco product, with withdrawal
F17.298Other tobacco product, with other nicotine-induced disorders
F17.299Other tobacco product, with unspecified nicotine-induced disorders
Z code
Z71.6Counseling and medical advice: tobacco abuse counseling
CPT codes
1000FTobacco use assessed (CAD, CAP, COPD, peripheral vascular disease, diabetes mellitus)
1031FSmoking status and exposure to secondhand smoke in the home assessed (asthma)
1032FCurrent tobacco smoker and currently exposed to secondhand smoke (asthma)
1034FCurrent tobacco smoker (CAD, CAP, COPD, peripheral vascular disease, diabetes)
4000FTobacco use cessation intervention, counseling (CAD, CAP, COPD, asthma, diabetes, peripheral vascular disease)
4001FTobacco use cessation intervention, pharmacologic therapy (CAD, CAP, COPD, peripheral vascular disease, asthma, diabetes)
4004FPatient screened for tobacco use and received cessation intervention (counseling and/or pharmacotherapy), if identified as a tobacco user (peripheral vascular disease, CAD)
HCPCS/CPT codes
99406Intermediate counseling cessation treatment: cessation counseling visit greater than three minutes but not more than 10 minutes
99407Intensive counseling: cessation counseling visit greater than 10 minutes

Pharmacotherapy

All nonpregnant adults who smoke cigarettes should be offered pharmacotherapy for smoking cessation, especially patients who meet the criteria for nicotine dependence.2 The U.S. Preventive Services Task Force (USPSTF) recommends pharmacotherapy, alone or combined with behavior strategies, for smoking cessation, and the AAFP supports this recommendation.6,11 Clinical studies have demonstrated that combining pharmacotherapy with behavior strategies significantly improves quit success compared with usual care or minimal intervention.6,12 Adding behavior support to pharmacotherapy is more effective than pharmacotherapy alone.6,13

There are seven pharmacotherapies approved by the U.S. Food and Drug Administration (FDA) for smoking cessation: nicotine replacement therapy (NRT) in the form of a transdermal patch, gum, lozenge, inhaler, and nasal spray; bupropion; and varenicline (Chantix). These therapies are identified as controllers or relievers based on their duration of action. Controllers (i.e., bupropion, varenicline, and nicotine patch) help reduce the impulse to smoke, whereas relievers (short-acting NRTs) aid in managing acute cravings. Table 3 summarizes FDA-approved therapies for smoking cessation.8,14,15

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