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Contents:

• Work Group Members
• General Description of Guideline Format
• Population of Interest
• Priority Aims for Medical Groups When Using This Guideline
• Clinical Algorithms & Annotations
• Guideline Development History
• Evidence Grading System
• Other Guidelines Referenced Within This Guideline
• Instructions for Downloading the PDF Version of This Guideline

Population of Interest

Adults and mature adolescents.

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1. To increase the likelihood that tobacco-using patients who visit the clinic will quit.

Possible measure of accomplishing this aim:

• Although it is difficult to measure the quit rate accurately, this rate can be approximated by the percentage of users now or in the past 6 months who have quit at the time of an office visit.
2. To improve the proportion of patients whose current use of tobacco or exposure to tobacco smoke is obvious in the chart at any primary care clinic encounter.

Possible measure of accomplishing this aim:

• The percentage of patients' charts that either show that there is no tobacco use/exposure or (if a user) that the current use was documented at the most recent clinician visit
3. To improve the proportion of tobacco-users whose interest in quitting is assessed or who receive cessation advice at any clinic encounter.

Possible measure of accomplishing this aim:

• The percentage of patients with documented tobacco use or exposure at the latest visit who also have documentation that their cessation interest was assessed or that they received advice to quit.




4. To improve the proportion of clinic-visiting tobacco users interested in quitting who receive self-help materials and offers of support and follow-up after a quit date.

Possible measure of accomplishing this aim:

• The percentage of clinic-visiting tobacco users with documented interest in quitting at the latest visit whose charts also document that they received self-help materials and an offer of support and follow-up after a quit date.

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Clinical Algorithms & Annotations

• Algorithm Annotation List

1.   Community Intervention
2.   Establish Tobacco Use
3.   Documentation
5.   Reinforce Nonuse
6.   When Did the Patient Last Use Tobacco?
8.   Patient Wants Extra Help in Staying Quit?
9.   Congratulate on Quitting
10. Assistance in Staying Quit
11. Patients Who Last Used Tobacco Within the Last Month
12. Congratulate on Quitting/ Encourage a Follow-up
14. Assessing a User's Interest in Quitting
15. Patients not Ready to Consider Quitting
17. Patients Interested in Quitting in 1-6 Months
19. Discuss NRT; Give Self-Help Material; Counseling
20. Patients Interested in Quitting in 1 Month

• Discussion and References: Download PDF Version of This Guideline

1.      Community Intervention

The work group urges ICSI member medical groups, clinicians, HealthPartners, and employers to actively intervene within their community to reduce tobacco use. The establishment of smoke-free public spaces, limiting youth access to tobacco, restrictions on advertising, counteradvertising and increasing economic disincentives to tobacco use are among the most effective community actions to be supported.

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2.     Establish Tobacco Use

Adults who have not used tobacco for at least 6 months and who have an easily visible mark on their chart to that effect should have usage reassessed at every health supervision visit.

Everyone without a tobacco use mark on the chart or those with a mark indicating use within the past 6 months should be asked at nearly every visit about current use and the answer documented for the provider. This frequency of use assessment should be established as a clinic policy and should be done by a staff person, preferably the one who rooms the patient.

The two most common ways to indicate tobacco use status are with an appropriate label on the chart or with a vital sign in the progress notes.

Adolescents should have usage reassessed at nearly every visit, regardless of whether there is a chart notation of non-use, due to their risk of beginning tobacco use at any time.

Tobacco cessation is particularly important during pregnancy. For more information, see the ICSI Preterm Birth Prevention and Routine Prenatal Care guidelines. We recommend that clinics have a particularly consistent identification and cessation program for pregnant women and preconception visits.

Tobacco cessation is also very important in those individuals with heart disease or other risk factors for heart disease. (See also other ICSI guidelines such as the Stable Coronary Artery Disease, Treatment of Lipid Disorder in Adults, and Hypertension Diagnosis and Treatment guidelines.)

The rest of the algorithm is intended for the provider.

Strength of evidence for this recommendation: A.

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3.      Documentation

All conversations with tobacco-users should be documented, either in the progress note or on a special card or flow sheet if a clinic uses that approach. This documentation should include the user's attitude toward quitting and any quitting plans agreed upon. The documentation can be very brief.

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5.      Reinforce Nonuse

If time permits, it is helpful to compliment former tobacco-users. These former users are considered to be in the Maintenance stage once they have been quit for at least 6 months.

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6.      When Did the Patient Last Use Tobacco?

Although the usual definition of a user is one who uses tobacco daily, it would be ideal to classify any individual using tobacco with any frequency as a user.

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8.      Patient Wants Extra Help in Staying Quit?

A former user who is having some trouble staying quit may want or need more help than the provider can supply in the 2-3 minutes available to discuss this topic. Common difficulties include weight gain, stress, withdrawal symptoms, or social/habit/psychological needs.

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9.      Congratulate on Quitting

The first months after quitting are the transition between the Action and Maintenance stages. These months (especially the first 1-2 weeks), when one is at the highest risk for relapse, are the most challenging. Encourage the patient to avoid temptations to use tobacco again. Smoking cessation often takes 3-4 attempts before long-term success is achieved.

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10.     Assistance in Staying Quit

Counseling can be done by the provider or, preferably, by other staff, and should be designed to help quitters problem-solve any of the difficulties referred to in Annotation #8.

The equivalent of counseling can also be achieved by referring a user to groups or other resources. It should be recognized, though, that most quitters are unwilling to attend such groups, especially if they are separate from the clinic.

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11.     Patients Who Last Used Tobacco Within the Last Month

Those who have quit using tobacco within the last month (particularly within the past week) are at a very high risk for returning to the habit. Reinforcement and follow-up can be crucial during this period.

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12.     Congratulate on Quitting/ Encourage a Follow-up

A follow-up means a mailed or (preferably) telephoned expression of support and willingness to help. The timing of follow-ups should be discussed with the patient; generally, the follow-up should come at the time when it will be most needed or wanted. Follow-ups can be handled by office staff.

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14.     Assessing a User's Interest in Quitting

Assessment of interest in quitting and timing of that interest should be done after the main reasons for the visit have been addressed, and should precede any advice about quitting. This allows a 1-3 minute tobacco discussion accommodating both the user's needs and the provider's time limits.

It is recognized that this discussion may not be possible or appropriate at each visit. The goal should be to discuss tobacco cessation at nearly every visit.

Remember that progress from one stage of readiness to quit to the next is as valuable as a quit attempt.

Strength of evidence for this recommendation: B.

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15.     Patients not Ready to Consider Quitting

A user not ready to consider quitting within the next 6 months is called a precontemplator, and is helped most when a provider avoids confrontation while conveying both the message that quitting is important and the desire to be helpful when the user is ready to consider quitting. A simple informational pamphlet about the problems attending tobacco use and an expression of the provider's desire to be helpful are far more productive than an attempt to scare or argue unwilling users into quitting.

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17.     Patients Interested in Quitting in 1-6 Months

The contemplator is considering quitting within the next 1-6 months. Contemplators are accepting of supportive and respectful urging to quit and encouragement to start thinking about a serious plan for doing so. Persuasive written, audio, or video information about the pros and cons of quitting may be appropriate for contemplators.

Strength of evidence for this recommendation: B.

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19.     Discuss NRT; Give Self-Help Material; Counseling

Nicotine Reduction Therapy (NRT) can be very helpful to selected patients. It is most effective if certain conditions are true; see the NRT box on the algorithm page for those conditions.

If NRT is utilized, it will be most effective when accompanied by a follow-up program which consists of behavior change counseling before the quit attempt. Behavior counseling should continue at least monthly after the quit date. Both individual and group follow-up programs are effective. Although both pregnancy and cardiovascular disease are described as contraindications for use of NRT, there is preliminary evidence of safety in these conditions and it is clearly more safe than the continued smoking which is a major preventable risk.

Strength of evidence for this recommendation: A.

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20.     Patients Interested in Quitting in 1 Month

Users in the preparation stage are ready to attempt to quit in the next month. They will want to quit on their own, but will be pleased to receive some specific support from their provider. That support can be highly effective for these users.

It is always appropriate to request the user to set a quit date within the next 1-3 weeks, to provide self-help information or suggestions, and (most importantly) to encourage the patient to accept some form of follow-up soon after the quit date. (See Annotation #10.)

Strength of evidence for this recommendation: A.

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Work Group Leader
Leif I. Solberg, MD, HealthPartners

Cardiology
Thomas E. Kottke, MD, Mayo Clinic

Family Practice
Donald A. Pine, MD, HealthSystem Minnesota
Michael Schoenleber, MD, HealthPartners

Health Education
Jane A. Norstrom, Institute for Research & Education

Internal Medicine
David Klevan, MD, HealthPartners
Leif I. Solberg, MD, HealthPartners

Nursing
Joanne Kellan, RN, HealthPartners

Ob/Gyn Nurse Practitioner
Renee Compo, RN, CNP, HealthPartners

Pediatrics
Susan Asch, MD, Stillwater Medical Group

Measurement Advisor
Leif I. Solberg, MD, HealthPartners

BHCAG Representative
Sandra Dahl, Honeywell, Inc.

Facilitator
Chris Schroeder, RN, ICSI

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Guideline Development History

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Evidence Grading System

Grade A: Conclusion based on a randomized, controlled trial that has been published in a peer-reviewed journal.

Grade B: Conclusion based on one of the following study types published in a peer-reviewed journal
                 (but not on a randomized, controlled trial):

• a trial using historical or other non-randomized controls;
• a prospective cohort study;
• a case-control study; or
• a meta-analytic study.

Grade C: Conclusion based on one of the following (but not on any studies of the types mentioned above):

• an uncontrolled case series; or
• expert opinion.

Guidelines obtained from the Agency for Health Care Policy and Research (AHCPR) or other sources, position statements, panel consensus statements from the National Institutes of Health (NIH) or elsewhere, review articles, and textbook chapters that cite primary evidence are not assigned a grade because they are not primary evidence. The individual studies cited in such secondary sources can be graded according to the categories presented above.

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Other Guidelines Referenced Within This Guideline

• Preterm Birth Prevention
• Routine Prenatal Care
• Stable Coronary Artery Disease
• Treatment of Lipid Disorder in Adults
• Hypertension Diagnosis and Treatments
  

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Instructions for Downloading PDF Version of This Guideline

Click here to download the full version of this Guideline in PDF format. You will need ADOBE Acrobat reader to view the file. The reader may be found here.

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