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1. Treating Tobacco Use and Dependence. Clinical Practice Guideline.

Fiore, Michael C (panel chair), Guideline panel members. (University of Wisconsin Medical School, Center for Tobacco Research and Intervention (Madison, WI))

This guideline was written to be relevant to all tobacco users -- those using cigarettes as well as other forms of tobacco. Tobacco dependence is a chronic condition that often requires repeated intervention. However, effective treatments exist that can produce long-term or even permanent abstinence.

Guidelines relevant to three different types of patients are included in this manual. These types are:

  • The Patient Willing to Quit: For patients who want to quit tobacco, the recommended strategy is to begin with the Brief Intervention (the "5 A's": ask, advise, assess, assist, arrange), followed by more intensive clinical intervention. Three types of counseling and behavioral therapies were found to be especially effective with all patients attempting tobacco cessation. These are: provision of practical counseling (problem solving/skills training); provision of social support as part of treatment (intra-treatment social support); and help in securing social support outside of treatment (extra-treatment social support). Additionally, numerous pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking.

  • The Patient Unwilling to Quit: For patients not ready to make a quit attempt, clinicians should use the Brief Intervention as a tool to promote the motivation to quit. Patients unwilling to quit may lack information about the harmful effects of tobacco, may lack the financial resources, may have fears or concerns about quitting, or may be demoralized because of previous relapse.

  • The Patient Who Has Recently Quit: Because of the chronic relapsing nature of tobacco dependence, clinicians should provide a brief effective relapse prevention treatment. They should reinforce the patient's decision to quit, review the benefits of quitting, and assist the patient in resolving any residual problems arising from quitting.

Significant barriers exist that interfere with clinicians' assessment and treatment of smokers. Many clinicians lack knowledge about how to identify smokers quickly and easily, which treatments are efficacious, how such treatments can be delivered, and the relative efficacies of different treatments. Additionally, they may fail to intervene because of inadequate clinic or institutional support for routine assessment and treatment of tobacco use and for other reasons such as time restraints. Some clinicians may also be reluctant to recommend and prescribe pharmacotherapy for their patients who smoke.

Treating Tobacco Use and Dependence: 2008 Update.

Fiore MC, Bailey WC, Cohen SJ ; et al. Rockville, MD : U.S. Department of Health and Human Services, Public Health Service, 2008 (original manual published in 2000).

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Intervention Details:

Population studied:Adults; Adolescents; Children; Pregnant women; Smokers with co-occurring mental illness and/or chemical dependency; Men; Women
Drug studied:Tobacco
Therapy format:Individual; Group
Therapy type:Behavioral; Pharmacotherapy; Brief intervention
Delivery mode:Telephone
Setting:Outpatient; Primary care


  • This guideline was developed by a multidisciplinary, non-Federal panel of experts, in collaboration with a consortium of tobacco cessation representatives, consultants, and staff. An explicit, science-based methodology was employed along with expert clinical judgment to develop recommendations on treating tobacco use and dependence. Extensive literature searches were conducted and critical reviews and syntheses were used to evaluate empirical evidence and significant outcomes. Peer review was undertaken to evaluate the validity, reliability, and utility of the guideline in clinical practices. The guideline was sponsored by seven Federal Government and nonprofit organizations: the Agency for Healthcare Research and Quality (AHRQ); Centers for Disease Control and Prevention (CDC); National Cancer Institute (NCI); National Heart, Lung, and Blood Institute Foundation (NHLBI); National Institute on Drug Abuse (NIDA); Robert Wood Johnson Foundation (RWJF); and University of Wisconsin Medical School's Center for Tobacco Research and Intervention (CTRI).

Supporting References:

  1. American Psychiatric Association. Practice guideline for the treatment of patients with nicotine dependence. American Journal of Psychiatry 1996;153(10 suppl):S1-S31.
  2. Woller SC, Smith SS, Piasecki TM, Jorenby DE, Helberg CP, Love RR, et al. Are clinicians intervening with their patients who smoke? A "real-world" assessment of 45 clinics in the upper Midwest. Wisconsin Medical Journal 1995;94(5):266-272.
  3. American Medical Association. American Medical Association guidelines for the diagnosis and treatment of nicotine dependence : How to help patients stop smoking. Washington DC : American Medical Association, 1994.
  4. Glynn TJ, Manley MW. How to help your patients stop smoking : a National Cancer Institute manual for physicians. Bethesda, MD : NIH Publication No. 89-3064, 1989.
  5. Prochaska J, Goldstein MG. Process of smoking cessation. Implications for clinicians. Clinics in Chest Medicine, 1991;12(4):727-35.
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