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

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 1^5–9). 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

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.

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