U.S. Preventive Services Task Force
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Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Reprints are available from the USPSTF Web site (http://www.preventiveservices.ahrq.gov).
For a list of the members of the USPSTF, see the Appendix.
U.S. Preventive Services Task Force. Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults and Pregnant Women: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement. Ann Intern Med. 2009;150:551-555. doi: 10.7326/0003-4819-150-8-200904210-00009
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Published: Ann Intern Med. 2009;150(8):551-555.
Appendix: U.S. Preventive Services Task Force
Reaffirmation of the 2003 U.S. Preventive Services Task Force (USPSTF) recommendation on counseling to prevent tobacco use.
The USPSTF reviewed new evidence in the U.S. Public Health Service's 2008 clinical practice guideline and determined that the net benefits of tobacco cessation interventions in adults and pregnant women remain well established.
Ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. (Grade A recommendation)
Ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke. (Grade A recommendation)
The U.S. Preventive Services Task Force (USPSTF) makes recommendations about preventive care services for patients without recognized signs or symptoms of the target condition.
It bases its recommendations on a systematic review of the evidence of the benefits and harms and an assessment of the net benefit of the service.
The USPSTF recognizes that clinical or policy decisions involve more considerations than this body of evidence alone. Clinicians and policymakers should understand the evidence but individualize decision making to the specific patient or situation.
The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. This is a grade A recommendation.
The USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke. This is a grade A recommendation.
See the Figure for a summary of this recommendation and suggestions for clinical practice.
FDA = U.S. Food and Drug Administration; USPSTF = U.S. Preventive Services Task Force.
See Table 1 for a description of the USPSTF grades and Table 2 for a description of the USPSTF classification of levels of certainty about net benefit.
Tobacco use, cigarette smoking in particular, is the leading preventable cause of death in the United States. Tobacco use results in more than 400 000 deaths annually from cardiovascular disease, respiratory disease, and cancer. Smoking during pregnancy results in the deaths of about 1000 infants annually and is associated with an increased risk for premature birth and intrauterine growth retardation. Environmental tobacco smoke contributes to death in an estimated 38 000 people annually.
The “5-A” behavioral counseling framework provides a useful strategy for engaging patients in smoking cessation discussions: 1) Ask about tobacco use; 2) Advise to quit through clear personalized messages; 3) Assess willingness to quit; 4) Assist to quit; and 5) Arrange follow-up and support.
In nonpregnant adults, the USPSTF found convincing evidence that smoking cessation interventions, including brief behavioral counseling sessions (<10 minutes) and pharmacotherapy delivered in primary care settings, are effective in increasing the proportion of smokers who successfully quit and remain abstinent for 1 year. Although less effective than longer interventions, even minimal interventions (<3 minutes) have been found to increase quit rates. See the Clinical Considerations section for a discussion of complementary services to which primary care clinicians may refer patients.
The USPSTF found convincing evidence that smoking cessation decreases the risk for heart disease, stroke, and lung disease.
In pregnant women, the USPSTF found convincing evidence that smoking cessation counseling sessions, augmented with messages and self-help materials tailored for pregnant smokers, increases abstinence rates during pregnancy compared with brief, generic counseling interventions alone. Tobacco cessation at any point during pregnancy yields substantial health benefits for the expectant mother and baby. The USPSTF found inadequate evidence to evaluate the safety or efficacy of pharmacotherapy during pregnancy.
Finding no published studies that describe harms of counseling to prevent tobacco use in adults or pregnant women, the USPSTF judged the magnitude of these harms to be no greater than small. Harms of pharmacotherapy are dependent on the specific medication used. In nonpregnant adults, the USPSTF judged these harms to be small.
The USPSTF concludes that there is high certainty that the net benefit of tobacco cessation interventions in adults is substantial.
The USPSTF also concludes that there is high certainty that the net benefit of augmented, pregnancy-tailored counseling in pregnant women is substantial.
This recommendation applies to adults 18 years or older and all pregnant women regardless of age. The USPSTF plans to issue a separate recommendation statement about counseling to prevent tobacco use in nonpregnant adolescents and children.
Various primary care clinicians may deliver effective interventions. There is a dose–response relationship between quit rates and the intensity of counseling (that is, more or longer sessions improve quit rates). Quit rates seem to plateau after 90 minutes of total counseling contact time (1). Helpful components of counseling include problem-solving guidance for smokers (to help them develop a plan to quit and overcome common barriers to quitting) and the provision of social support as part of treatment. Complementary practices that improve cessation rates include motivational interviewing, assessing readiness to change, offering more intensive counseling or referrals, and using telephone “quit lines” (1).
Combination therapy with counseling and medications is more effective at increasing cessation rates than either component alone. Pharmacotherapy approved by the U.S. Food and Drug Administration and identified as effective for treating tobacco dependence in nonpregnant adults includes several forms of nicotine replacement therapy (gum, lozenge, transdermal patch, inhaler, and nasal spray), sustained-release bupropion, and varenicline (1).
Detailed reviews and recommendations about clinical interventions for tobacco cessation are available in the U.S. Public Health Service Clinical Practice Guideline “Treating Tobacco Use and Dependence: 2008 Update” (available at http://www.surgeongeneral.gov/tobacco) (1).
Tobacco-related recommendations from the Centers for Disease Control and Prevention's Guide to Community Preventive Services are available at http://www.thecommunity_guide.org/tobacco(2).
Strategies that have been shown to improve rates of tobacco cessation counseling and interventions in primary care settings include implementing a tobacco user identification system; providing education, resources, and feedback to promote clinician intervention; and dedicating staff to provide tobacco dependence treatment and assessing the delivery of this treatment in staff performance evaluations (1).
In 2003, the USPSTF reviewed the evidence for tobacco cessation interventions in adults and pregnant women contained in the 2000 U.S. Public Health Service (PHS) clinical practice guideline “Treating Tobacco Use and Dependence” (3) and found that the benefits of these interventions substantially outweighed the harms (4). In 2008, the USPSTF reviewed new evidence in the updated PHS guideline (1) and determined that the net benefits of screening and tobacco cessation interventions in adults and pregnant women remain well established. The USPSTF found no new substantial evidence that could change its recommendations and, therefore, reaffirms its previous recommendations. The previous recommendation statement (4) and a link to the updated PHS guideline review can be found at http://www.preventiveservices.ahrq.gov.
Policies of the American Academy of Family Physicians on tobacco use prevention and cessation (5) are available at http://www.aafp.org/online/en/home/policy/policies/t/tobacco.html.
Clinical recommendations of the American College of Preventive Medicine on tobacco cessation counseling (6) are available at http://www.acpm.org/pol_practice.htm.
Recommendations of the American College of Obstetricians and Gynecologists for assisting smoking cessation during pregnancy (7) are available at http://www.acog.org/departments/dept_notice.cfm?recno=13&bulletin=1863.
Members of the U.S. Preventive Services Task Force† are Ned Calonge, MD, MPH, Chair (Colorado Department of Public Health and Environment, Denver, Colorado); Diana B. Petitti, MD, MPH, Vice-Chair (Arizona State University, Phoenix, Arizona); Thomas G. DeWitt, MD (Children's Hospital Medical Center, Cincinnati, Ohio); Allen J. Dietrich, MD (Dartmouth Medical School, Hanover, New Hampshire); Kimberly D. Gregory, MD, MPH (Cedars-Sinai Medical Center, Los Angeles, California); David Grossman, MD (Group Health Cooperative, Seattle, Washington); George Isham, MD, MS (HealthPartners Inc., Minneapolis, Minnesota); Michael L. LeFevre, MD, MSPH (University of Missouri School of Medicine, Columbia, Missouri); Rosanne M. Leipzig, MD, PhD (Mount Sinai School of Medicine, New York, New York): Lucy N. Marion, PhD, RN (School of Nursing, Medical College of Georgia, Augusta, Georgia); Bernadette Melnyk, PhD, RN (Arizona State University College of Nursing & Healthcare Innovation, Phoenix, Arizona); Virginia A. Moyer, MD, MPH (Baylor College of Medicine, Houston, Texas); Judith K. Ockene, PhD (University of Massachusetts Medical School, Worcester, Massachusetts); George F. Sawaya, MD (University of California, San Francisco, San Francisco, California); J. Sanford Schwartz, MD (University of Pennsylvania Medical School and the Wharton School, Philadelphia, Pennsylvania); and Timothy Wilt, MD, MPH (University of Minnesota Department of Medicine and Minneapolis Veteran Affairs Medical Center, Minneapolis, Minnesota).
†This list includes members of the Task Force at the time this recommendation was finalized. For a list of current Task Force members, go to http://www.ahrq.gov/clinic/uspstfab.htm.
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