Background

This section of the Guideline presents specific strategies to guide clinicians providing brief interventions (less than 10 minutes). These brief interventions can be provided by all clinicians but are most relevant to clinicians who see a wide variety of patients and are bound by time constraints (e.g., physicians, nurses, physician assistants, nurse practitioners, medical assistants, dentists, hygienists, respiratory therapists, mental health counselors, pharmacists, etc.). The strategies in this chapter are based on the evidence described in Chapters 6 and 7, as well as on Panel opinion. Guideline analysis suggests that a wide variety of clinicians can implement these strategies effectively.

Why should members of a busy clinical team consider making the treatment of tobacco use a priority? The evidence is compelling: (1) clinicians can make a difference with even a minimal (less than 3 minutes) intervention (see Chapter 6); (2) a relation exists between the intensity of intervention and tobacco cessation outcome (see Chapter 6); (3) even when patients are not willing to make a quit attempt at this time, clinician-delivered brief interventions enhance motivation and increase the likelihood of future quit attempts¹²² (see Chapter 6); (4) tobacco users are being primed to consider quitting by a wide range of societal and environmental factors (e.g., public health messages, policy changes, cessation marketing messages, family members); (5) there is growing evidence that smokers who receive clinician advice and assistance with quitting report greater satisfaction with their health care than those who do not;^23,87,88 (6) tobacco use interventions are highly cost effective (see Chapter 6); and (7) tobacco use has a high case fatality rate (up to 50% of long-term smokers will die of a smoking-caused disease¹²³).

The goal of these strategies is clear: to change clinical culture and practice patterns to ensure that every patient who uses tobacco is identified, advised to quit, and offered scientifically sound treatments. The strategies underscore a central theme: it is essential to provide at least a brief intervention to every tobacco user at each health care visit. Responsibility lies with both the clinician and the health care system to ensure that this occurs. Several observations are relevant to this theme. First, although many smokers are reluctant to seek intensive treatments,^124,125 they nevertheless can receive a brief intervention every time they visit a clinician.^66,126 Second, institutional support is necessary to ensure that all patients who use tobacco are identified and offered appropriate treatment (see Chapter 5, Systems Interventions: Importance to Health Care Administrators, Insurers, and Purchasers). Third, the time limits on primary care physicians in the United States today (median visit = 12–16 minutes),^127,128 as well as reimbursement restrictions, often limit providers to brief interventions, although more intensive interventions would produce greater success. Finally, given the growing use of electronic patient databases, smoker registries, and real-time clinical care prompts, brief interventions may be easier to fit into a busy practice and may be implemented in a variety of ways.

This chapter is divided into three sections to guide brief clinician interventions with three types of patients: (A) current tobacco users willing to make a quit attempt at this time; (B) current tobacco users unwilling to make a quit attempt at this time; and (C) former tobacco users who have recently quit. Patients who have never used tobacco or who have been abstinent for an extended period should be congratulated on their status and encouraged to maintain their tobacco-free lifestyle.

Given that more than 70 percent of tobacco users visit a physician and more than 50 percent visit a dentist each year,¹²⁹ it is essential that these clinicians be prepared to intervene with all tobacco users. The five major components (the “5 A's”) of a brief intervention in the primary care setting are listed in Table 3.1. It is important for a clinician to ask the patient if he or she uses tobacco (Strategy A1), advise him or her to quit (Strategy A2), and assess willingness to make a quit attempt (Strategy A3). Strategies A1 to A3 need to be delivered to each tobacco user, regardless of his or her willingness to quit.

Table 3.1

The “5 A's” model for treating tobacco use and dependence.

If the patient is willing to quit, the clinician should assist him or her in making a quit attempt by offering medication and providing or referring for counseling or additional treatment (Strategy A4), and arrange for followup contacts to prevent relapse (Strategy A5). If the patient is unwilling to make a quit attempt, the clinician should provide a motivational intervention (Strategies B1 and B2) and arrange to address tobacco dependence at the next clinic visit. The Strategy tables below (A1–A5) comprise suggestions for the content and delivery of the 5 A's. The strategies are designed to be brief and require 3 minutes or less of direct clinician time. These intervention components constitute the core elements of a tobacco intervention, but they need not be applied in a rigid, invariant manner. For instance, the clinician need not deliver all elements personally. One clinician (e.g., a medical assistant) may ask about tobacco use status; and a prescribing clinician (e.g., physician, dentist, physician assistant, nurse practitioner) may deliver personal advice to quit, assess willingness to quit, and assist with medications, but then refer the patient to a tobacco intervention resource (e.g., a tobacco cessation quitline, health educator) that would deliver additional treatment to the patient. The clinician would remain responsible for the patient receiving appropriate care and subsequent followup, but, as with other sorts of health care, an individual clinician would not need to deliver all care personally.¹³⁰ Evidence indicates that full implementation of the 5 A's in clinical settings may yield results that are superior to partial implementation.¹³¹

Table B1

Strategy. Motivational interviewing strategies.

Table B2

Strategy. Enhancing motivation to quit tobacco—the “5 R's”.

The effectiveness of tobacco intervention may reflect not only the contributions of the individual clinician, but also the systems and other clinical resources available to him or her. For instance, office systems that institutionalize tobacco use assessment and intervention will greatly foster the likelihood that the 5 A's will be delivered (see Chapter 5). The 5 A's, as described in Table 3.1, are consistent with those recommended by the NCI^132,133 and the American Medical Association,⁷⁷ as well as others.^75,134–137 The clinical situation may suggest delivering these intervention components in an order or format different from that presented, however. For example, clinical interventions such as: Ask/Assess, Advise, Agree on a goal, Assist, Arrange followup; Ask and Act; and Ask, Advise, and Refer have been proposed.^{116,130,138–140}

When “Assisting” smokers, in addition to counseling, all smokers making a quit attempt should be offered medication, except when contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). See Tables 3.2 to 3.11 for guidelines for prescribing medication for treating tobacco use and dependence.

Table 3.2

Clinical guidelines for prescribing medication for treating tobacco use and dependence.

Table 3.11

Clinical use of nortriptyline (See FDA package insert for more complete information.).

A. For the Patient Willing To Quit

B. For the Patient Unwilling To Quit

C. For the Patient Who Has Recently Quit

Treatments for the Recent Quitter

Smokers who have recently quit face a high risk of relapse. Although most relapse occurs early in the quitting process,^96,101,181 some relapse occurs months or even years after the quit date.^181–184 Numerous studies have been conducted to identify treatments that can reduce the likelihood of future relapse. These studies attempt to reduce relapse either by including special counseling or therapy in the cessation treatment, or by providing additional treatment to smokers who have previously quit. In general, such studies have failed to identify either counseling or medication treatments that are effective in lessening the likelihood of relapse,¹⁸⁵ although there is some evidence that special mailings can reduce the likelihood of relapse.^186,187 Thus, at present, the best strategy for producing high long-term abstinence rates appears to be use of the most effective cessation treatments available; that is, the use of evidence-based cessation medication during the quit attempt and relatively intense cessation counseling (e.g., four or more sessions that are 10 minutes or more in length).

Ex-smokers often report problems that have been worsened by smoking withdrawal or that coexisted with their smoking. If a clinician encounters a tobacco user who recently quit, the clinician might reinforce the patient's success at quitting, review the benefits of quitting, and assist the patient in resolving any residual problems arising from quitting (Strategy C1). Such expressions of interest and involvement on the part of the clinician might encourage the patient to seek additional help with cessation should she or he ultimately relapse. When the clinician encounters a patient who is abstinent from tobacco and is no longer engaged in cessation treatment, the clinician may wish to acknowledge a patient's success in quitting. The abstinent former smoker also may experience problems related to cessation that deserve treatment in their own right (see Strategy C2).

Table C1

Strategy. Intervening with the patient who has recently quit. The former tobacco user should receive congratulations on any success and strong encouragement to remain abstinent. When encountering a recent quitter, use open-ended questions relevant (more...)

Table C2

Strategy. Addressing problems encountered by former smokers.