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New guideline challenges clinicians to help smokers quit
Clinicians should aggressively help their smoking patients quit,
according to a new clinical practice guideline sponsored by the
Agency for Health Care Policy and Research. The guideline,
developed by a panel of smoking cessation experts, challenges all
clinicians, including doctors, nurses, dentists, and others, to
find out if their patients smoke, repeatedly encourage them to
quit, and recommend treatments proven to work.
The 19-member panel was led by Michael C. Fiore, M.D., M.P.H.,
Director of the University of Wisconsin's Center for Tobacco
Research and Intervention, and included physicians, nurses,
mental health experts, a dentist, a pharmacist, psychologists, an
epidemiologist, an educator, and a consumer representative.
The panel's recommendations include using the nicotine patch or
nicotine gum—which doubles the chances of successfully
quitting—combined with a clinician's encouragement and
support and practical advice to smokers on how to cope with
situations and behaviors that make them want to smoke.
According to Douglas B. Kamerow, M.D., M.P.H., AHCPR's director
of clinical practice guideline development, there are about 46
million adult smokers in the United States, and more than 70
percent of them would like to stop smoking. Dr. Kamerow calls on
clinicians to approach smoking as a chronic condition that is
very difficult but not impossible to treat.
This is the first time the total body of information on smoking
cessation has been analyzed systematically. In developing the
guideline, the panel reviewed over 3,000 scientific articles that
addressed the assessment and treatment of tobacco dependence,
nicotine addiction, and clinical practice.
Only half the smokers who see a doctor have ever been urged to
quit. If only 100,000 physicians helped 10 percent of their
patients end their addiction each year, the number of smokers in
the United States would drop by an additional 2 million people
Smoking is the single greatest preventable cause of illness and
death in the United States. People who smoke are at increased
risk of heart disease, cancer, and other smoking-related
illnesses that contribute to over 420,000 deaths a year. Medical
costs for smokers are $50 billion annually, with an additional
$47 billion for indirect expenses, such as time lost from work
The AHCPR-supported guideline recommends that clinicians:
- Ask every patient at every visit if he or she smokes.
- Write a patient's smoking status in the medical chart under
- Ask patients about their desire to quit, and reinforce their
- Motivate patients who are reluctant to quit.
- Help motivated smokers set a quit date.
- Prescribe nicotine replacement therapy. (Editor's Note: The
FDA has approved nicotine gum for over-the-counter use; the
nicotine patch may be approved for OTC use by the end of
- Help patients resolve problems that result from quitting.
Counseling may be helpful to some patients to increase the
likelihood of success.
- Encourage relapsed smokers to try quitting again.
Other recommendations to health care administrators,
purchasers, and insurers include changing the health care
delivery systems to make it a standard practice to identify
and treat smokers and other tobacco users.
The consumer brochure released along with the guideline urges
- Be committed. Be aware that breaking nicotine addiction
isn't easy and takes a significant individual effort, but
that half the people who have ever smoked have quit.
- Talk with their doctors and discuss nicotine replacement
therapy and smoking cessation programs. Do everything
possible to maximize the chance of success.
- Set a quit date; do not try to "taper off."
- Build on past mistakes. Think about what helped and what
- Create a support network of family and friends to be
supportive and reinforce stop smoking efforts.
- Learn how to cope with situations that make a person want to
- Focus less on weight gain. Most people who stop smoking will
gain less than 10 pounds, but the health benefits of quitting smoking
outweigh the risks of weight gain.
- Avoid dieting while trying to give up smoking because it can
undermine chances of quitting.
Whenever possible, smoking cessation treatments should be
appropriately tailored to ethnic or racial groups. The guideline
also offers recommendations for pregnant women, hospitalized
patients, and persons with psychological problems.
Recommendations also address tobacco prevention and cessation in
children and adolescents and use of smokeless tobacco products
(snuff and chewing tobacco).
No conclusions were drawn about the effectiveness of acupuncture,
hypnosis, and drug therapies such as clonidine, antidepressants,
and anxiolytics/benzodiazepines because of insufficient or
The panel also made no recommendations regarding the use of
nicotine nasal sprays and nicotine inhalers, since data on these
products were limited. At the time of the panel's deliberations,
the products were not licensed for prescription use in the United
States. (Editor's Note: As the guideline went to press, the
Food and Drug Administration approved the prescription use of
nicotine nasal spray.)
AHCPR plans to disseminate the guideline, cosponsored by the
Centers for Disease Control and Prevention, to a wide range of
clinicians, smoking cessation specialists, health care
administrators, purchasers, and insurers. A quick reference
guide, pocket guide, and consumer version, in English and
Spanish, also will be distributed.
The American Medical Association has received an educational
grant from the Robert Wood Johnson Foundation to send copies of
the guideline to 200,000 primary care doctors. AHCPR also will
work with the American Association of Health Plans (formerly
GHAA/AMCRA) to develop a practical guide, based on the guideline
recommendations, targeted to meet the needs of health care
The guideline publications Smoking Cessation: Quick Reference
Guide for Primary Care Clinicians (AHCPR Publication No.
96-0693); Smoking Cessation: Quick Reference Guide for Smoking
Cessation Specialists (AHCPR Publication No. 96-0694); and
You Can Quit Smoking: Guide for Consumers (AHCPR
Publication No. 96-0695) are available from AHCPR.
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