MAY/JUNE 2008
Volume 14 - No. 2

SRNT Newsletter

Advancing Science & Health

MAY/JUNE 2008, Volume 14, Number 2

Treating Tobacco Use and Dependence: Clinical Practice Guidelines Update

by Michael Fiore

On May 7, the U.S. Public Health Service released the 2008 Clinical Practice Guideline Update: Treating Tobacco Use and Dependence at the American Medical Association (AMA) national headquarters in Chicago. At the event, the energy and enthusiasm were palpable.

Highlights included:

- The recommendations themselves, which offer a national blueprint for clinicians and health systems. They describe how clinicians can provide effective treatments quickly and effectively, how smokers can access these treatments, and how health-care systems can support both clinicians and smokers in utilizing evidence-based tobacco dependence treatments.

- The charge to carry the recommendations forward from speakers like Society for Research on Nicotine and Tobacco (SRNT) President Scott Leischow, former U.S. Surgeon General C. Everett Koop and SRNT President-Elect Sue Curry.

Scott Leischow

Leischow said, "While SRNT's primary focus is on encouraging and disseminating new research discoveries, we recognize that to be most useful those discoveries, which are not always consistent, must be interpreted and translated into recommendations for policy, as well as clinical and community practice."

"When implemented, the Guideline will save lives not only in the United States, but around the world. Its impact cannot be underestimated," he concluded.

- The support of 58 organizations, including SRNT. Literally tens of thousands of clinicians and those who are part of health-care systems will be unleashed to implement the recommendations. A full list of the endorsing organizations can be found at http://www.ctri.wisc.edu/Researchers /researchers_CPGupdate2008_endorse.htm.

Scott Leischow, ernestine "Tina" Murray from the Agency on Health Research and Quality, and assistant Surgeon General James Galloway.

- The more than 110 people in the audience who had ample opportunity to talk and strategize with each other during pre- and post-event receptions.

A webcast of the event is available at http://www.rwjf.org. There, speakers such as Dr. Tom Freiden, New York City commissioner of health offer comments such as: "What you have here is the best of the best in the release of a clinical practice guideline. In the process, content, practicality and the rigor of its work, I really salute all the people who worked on the program, for what really should be a model for any clinic or medical practice." A highlight of the day was the final speaker, AMA President and former director of the United States Office on Smoking and Health, Ron Davis, who issued a call to arms to American clinicians to address tobacco dependence with their patients who smoke.

Guideline recommendations were based on a systematic review of almost 9,000 publications, and included more than 50 meta-analyses and expert summaries of relevant literature.

Here's a taste of what's new or different in the 2008 Update.

New Recommendations:

Quit line counseling is effective with diverse populations and has broad reach. Quit line callers on average are four times more likely to quit tobacco use than those who attempt to quit without treatment. Anyone who calls 1-800-QUIT-NOW (784-8669) can get free counseling services.
C. Everett Koop

The combination of counseling and medication is significantly more effective than either alone. When at all practical, both should be provided. However, medication should not be used when contraindicated—and are not recommended for pregnant women, light smokers, adolescent smokers or smokeless tobacco users.
- This Guideline includes information on two mediations approved by the FDA since the release of the 2002 Guideline _ the nicotine lozenge and varenicline. Seven medications are now approved by the FDA for tobacco-dependence treatment.

New Emphasis:

Tobacco dependence is a chronic condition that often requires repeated intervention to achieve long-term abstinence. Many patients relapse several times before quitting for good. Clinicians should intervene using the recommended treatments in the Guideline, regardless of the smoker's past success.
Recommendation for tobacco dependence counseling is strengthened for:
- Pregnant smokers
- Adolescents
- Spit tobacco users
- Light smokers
For smokers with a history of depression, bupropion SR and nortriptyline are significantly more effective than placebo.
Tobacco dependence counseling and medication are effective with diverse populations, including racial and ethnic minorities, those of limited education or finances, patients with medical or psychiatric co-morbidities and LGBT patients.
Healthcare policies and systems changes can significantly reduce barriers to treatment:
- Tobacco-dependence treatment as a covered health-insurance benefit results in significantly more quit attempts and higher quit rates.
- Clinician training combined with a charting/documentation system, significantly increases rates of clinician intervention, and also dramatically improves patient quit rates.
- Documentation and reimbursement issues must be addressed by the healthcare system or these become a hindrance to provision of treatment.
New motivational strategies have now been shown to increase interest in quitting among patients not willing to quit at the present time. Clinician counseling can lead to increased future quit attempts among these smokers.

The Guideline represents nearly two years of work by a 24-member panel informed by the input of many SRNT members. More than 90 independent peer reviewers offered feedback on Guideline drafts, as did members of the public.

As impressive as all the findings were, SRNT's President-elect and panel member Sue Curry emphasized that there is still much to learn. She highlighted 100 topics mentioned in the Guideline Update as future research candidates, challenging the SRNT's membership to future expand the evidence-base for treating tobacco dependence.

To order copies of the Guideline and its related material, visit http://www.ahrq.gov/clinic/tobacco/order.htm

About the Author: Michael Fiore is the founder and director of the 16-year-old University of Wisconsin Center for Tobacco Research and Intervention. The Center is focused on understanding tobacco dependence _ and translating that understanding into clinical practices that help more smokers quit.