This recommendation reaffirms the USPSTF's 2003 recommendation on Counseling to Prevent Tobacco Use and Tobacco-Caused Disease with respect to adults and pregnant women. Go to www.uspreventiveservicestaskforce.org/uspstf/uspstbac.htm to view the 2003 recommendation for children and adolescents. An updated recommendation on this topic for children and adolescents is being prepared.

This report was first published in Annals of Internal Medicine in April 2009 (Ann Intern Med 2009;150:551-55).

Importance

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.

Recognition of Behavior

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.

Effectiveness of Interventions to Change Behavior

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. Go to 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.

Harms of Interventions

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.

USPSTF Assessment

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.

Patient Population Under Consideration

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.

Counseling Interventions

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

Treatment

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

Useful Resources

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 https://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 https://www.thecommunityguide.org/tobacco/index.html. ²

Implementation

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 guideline¹ 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 statement⁴ and a link to the updated PHS guideline review can be found at https://www.uspreventiveservicestaskforce.org.

Policies of the American Academy of Family Physicians on tobacco use prevention and cessation⁵ are available at https://www.aafp.org/online/en/home/policy/policies/t/tobacco.html.

Clinical recommendations of the American College of Preventive Medicine on tobacco cessation counseling⁶ are available at https://www.acpm.org/page/tobacco.

Recommendations of the American College of Obstetricians and Gynecologists for assisting smoking cessation during pregnancy⁷ are available at http://www.acog.org/departments/dept_notice.cfm?recno=13&bulletin=1863.

Members of the USPSTF* 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).

*Members of the Task Force at the time this recommendation was finalized. For a list of current Task Force members, go to https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/current-members.

Disclaimer:Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

This document is in the public domain within the United States.

Requests for linking or to incorporate content in electronic resources should be sent via the USPSTF contact form.

Source: 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;150:551-55.