Overview: Smoking Cessation

Smoking is a chronic condition that affects more than 46 million Americans. People who smoke are at risk of heart disease, cancer, and other smoking-related illnesses that cost more than $50 billion annually to treat, and an additional $47 billion in indirect costs from lost time at work and disability.

Smoking is the single greatest preventable cause of death and illness in the United States. An estimated 420,000 people die every year from smoking-related illnesses.

The only way people can prevent these smoking-related illnesses is to quit smoking. Studies show that over 70 percent of adult smokers would like to quit, but only half of them have ever been urged to quit by their health care provider.

The smoking cessation guideline challenges clinicians — physicians and other health care providers — to aggressively motivate and help their patients who smoke to quit. The guideline makes specific recommendations about how clinicians can identify smokers, repeatedly encourage them to quit, and offer treatments that have been proven to work.

The guideline found three treatment elements were particularly effective, used either alone or together, in helping smokers quit. They are:

• Nicotine replacement therapy — either the prescribed nicotine patch or nicotine gum, which doubles the rate of successfully quitting. [Nicotine gum has been approved for over-the-counter (OTC) use by the FDA. The nicotine patch may be approved for OTC use by the end of 1996.]
• Social support — encouragement and support from the clinician.
• Skills training/problem-solving — practical advice and techniques from the clinician that help people adapt to life as a non-smoker.

Individual or group counseling programs are also helpful. The guideline panel found a direct relationship between the intensity of treatment and the likelihood for success. The guideline recommends that counseling programs, if chosen, be delivered over 4 to 7 sessions (20 to 30 minutes in length), for at least 2 weeks, but preferably for 8 weeks.

No conclusions were drawn about the effectiveness of the following treatments:

• Acupuncture or hypnosis. There was insufficient evidence to support the effectiveness of either of these therapies.
• Clonidine, antidepressants, and anxiolytics/benzodiazepines. Lack of data and/or faulty studies offered little support for their use.

The guideline panel made no recommendations regarding the use of nicotine nasal sprays and nicotine inhalers. There were limited data on these products. At the time of the panel's deliberations, the products were not licensed for prescription in the United States. [As the guideline went to press, the FDA approved the prescription use of nicotine nasal spray.]

To develop the guideline, the Agency for Health Care Policy and Research (AHCPR) convened a private-sector panel of experts in the field of smoking cessation to identify clinical practices and treatments that effectively help people quit smoking. The panel performed a systematic review of more than 3,000 scientific articles that addressed the assessment and treatment of tobacco dependence, nicotine addiction, and clinical practice. The panel based their recommendations on these findings.

Recommendations for Clinicians

• Identify smokers. Ask every patient at every visit if they smoke.
• Implement a tobacco-user identification system in every clinic.
• Record smoking status as a vital sign.
• Encourage smokers to quit.
• Ask smokers about their desire to quit and reinforce their intentions.
• Give motivational messages to those who aren't ready to quit.
• Help motivated smokers set a quit date.
• Prescribe nicotine replacement therapy.
• Offer specific, practical advice about how to deal with life as a non-smoker, particularly how to handle situations or emotional states that may cause relapse.
• Encourage relapsed smokers to try to quit again.

Recommendations for Smokers Who Want To Quit

• Be committed. Make sure you're ready to work hard to quit.
• Talk with your doctor. Discuss nicotine replacement therapy and strategies to deal with wanting to smoke again. Do everything you can to maximize the chances for success.
• Set a quit date. Don't try to "taper off."
• Build on past mistakes. If you've tried to quit before, think about what helped and what hurt.
• Enlist support. Tell your family and friends you're quitting. Create a network you can turn to for help.
• Learn how to avoid or cope with situations and behavior that make you want to smoke.

For More Information

The guideline publications: Smoking Cessation: A Guide for Primary Care Clinicians; Smoking Cessation: Quick Reference Guide for Smoking Cessation Specialists; and You Can Quit Smoking, a consumer guide, and additional copies of this Overview are available free of charge from the AHCPR Publications Clearinghouse. Call toll-free 800-358-9295, or write to Smoking Cessation, AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907-8547.

Single and bulk copies of the full guideline, Smoking Cessation: Clinical Practice Guideline, may be purchased from the U.S. Government Printing Office by calling (202) 512-1800.

The clinical practice guideline, quick reference and consumer guides, and the articles used in the guideline meta-analyses will be available on the Internet through the AHCPR Home Page. Access the guideline products by using a Web browser, specifying URL http://www.ahrq.gov/clinic/ and clicking on "Clinical Practice Guidelines Online."

AHCPR, a part of the U.S. Public Health Service, is the lead agency charged with supporting research designed to improve the quality of health care, reduce its cost, and broaden access to essential services. AHCPR's broad programs of research, clinical guideline development, and technology assessment bring practical, science-based information to medical practitioners and to consumers and other health care purchasers.

April 1996

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