Clinical Practice Guidelines - Tobacco Cessation

• Guideline Title: Treating Tobacco Use and Dependence


• Major Recommendations
• Tobacco dependence is a chronic condition that often requires repeated intervention.
• The first step is to identify and assess the tobacco use status and separate patients into three treatment categories: Patients willing to quit, patients unwilling to quit, and patients who have recently quit.
• Effective treatments for tobacco dependence now exist, and every patient should receive at least minimal treatment everytime he or she visits a clinician.
• Treatment planning for patients who are attempting tobacco cessation should include both the counseling and behavioral therapies and the pharmacotherapies.
• Recommendations as Implemented in the Clinical Log software
CUSON has implemented the high-risk approach by using the following:
• All patients should be screened for tobacco use
• Tailored recommendations are displayed to the provider, depending on the tobacco use status and willingness to quit smoking
• Clinical Process

Step I. Identify patients for treatment by asking the two key questions:
• Do you smoke?
• Do you want to quit?
Step II. Separate patients into three treatment categories and make recommendations according to their treatment categories
• Patients who use tobacco and are willing to quit
• Patients who use tobacco but are unwilling to quit at this time
• Patients who have recently quit using tobacco

i) Patients who use tobacco and are willing to quit:
Use the “5 A’s”
• 1. Ask – Systematically identify all tobacco users at every visit and document the status
• 2. Advise – Strongly urge all tobacco users to quit in a clear strong and personalized manner
• 3. Assess – Determine willingness to make a quit attempt within the next 30 days
• 4. Assist – Aid the patient in quitting
• Help the patient with a quit plan that would start within two weeks
• Provide practical counseling
• Recognize dangerous situations that increase the risk of smoking or relapse
• Develop coping skills for problem solving
• Provide basic information about smoking and successful quitting
• Provide intra-treatment social support
• Encourage the patient in the quit attempt
• Communicate caring and concern
• Encourage the patient to talk about the quitting process
• Help patients obtain extra-treatment social support
• Train patient in support socialization skills
• Prompt support seeking
• Clinician arranges outside support
• Recommend the use of approved pharmacotherapy except in special circumstances
• Provide supplementary materials
• 5. Arrange – Schedule follow-up contact, either in person or through telephone
• The first follow-up contact should be soon after the quit date
• A second follow-up contact is recommended within the first month

ii) Patients who use tobacco but are unwilling to quit at this time:
Use the “5 R’s” motivational intervention
• Relevance – Encourage the patient to indicate why quitting is personally relevant, being as specific as possible
• Risks – Ask the patient to identify potential negative consequences of tobacco use
• Rewards – Ask the patient to identify potential benefits of stopping tobacco use
• Roadblocks – Ask the patient to identify barriers or impediments to quitting and note elements of treatment that could address barriers
• Repetition – the motivation intervention should be repeated every time an unmotivated patient visits the clinic setting

iii) Patients who have recently quit using tobacco:
Provide the relapse prevention treatment

• Minimal Practice relapse Prevention (brief)
• Should be part of every encounter with patient who has quit recently
• Encourage the patient’s active discussion of the topics below:
• The benefits, including the potential health benefits, that the patient may derive from cessation
• Any success the patient had in quitting (duration of abstinence, reduction in withdrawal, etc.)
• The problems encountered or anticipated threats to maintaining abstinence (e.g., depression, weight gain, alcohol. Other tobacco users in the household)
• Prescriptive Relapse Prevention (more intensive)
• Ask the patient to identify the problems encountered and discussed the solutions in details.
• Evidence Supporting the Recommendations
• Tobacco Use and Dependence: Quick Reference Guide for Clinicians
• US Department of Health and Human Services Tobacco Cessation Guideline
• Fiore, M. C., Bailey, W. C., Cohen, S. J., et al. (2000). Treating Tobacco Use and Dependence. Rockville , MD : U.S. Department of Health and Human Services. Public Health Services.