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Progress in Prevention: New Guideline for Tobacco Use and Dependence Provides Arsenal of Effective Interventions

Dennison, Cheryl R. PhD, RN, ANP, FAHA; Hughes, Suzanne MSN, RN, FAHA

The Journal of Cardiovascular Nursing: September-October 2008 - Volume 23 - Issue 5 - p 383-385
doi: 10.1097/01.JCN.0000317454.10521.95

Cheryl R. Dennison, PhD, RN, ANP, FAHA Assistant Professor, School of Nursing, Johns Hopkins University, Baltimore, Maryland.

Suzanne Hughes, MSN, RN, FAHA Director, Patient and Community Education and Research, Robinson Memorial Hospital, Ravenna, Ohio.

Corresponding author Cheryl R. Dennison, PhD, RN, ANP, FAHA, School of Nursing, Johns Hopkins University, Rm 419, 525 N Wolfe St, Baltimore, MD 21205-2110 (

Tobacco use remains the chief avoidable cause of illness and death in our society and accounts for more than 435,000 deaths each year in the United States.1 Smoking causes heart disease, stroke, multiple cancers, complications of pregnancy, chronic obstructive pulmonary disease, and many other diseases.2 Moreover, substantial health dangers of involuntary exposure to tobacco smoke have been documented.2 Despite the public's awareness of these health dangers, tobacco use remains surprisingly prevalent. Recent estimates show that about 21% of adult Americans smoke, representing approximately 45 million current adult smokers.3,4 In addition, tobacco use is a pediatric disease, with about 4,000 youth aged 12 to 17 years smoking their first cigarette each day, and about 1,200 children and adolescents become daily cigarette smokers.5,6 Although tobacco smoking rates have decreased over the past several decades, new generations of Americans are at risk of the extraordinarily harmful consequences of tobacco use.

The 2008 update to Treating Tobacco Use and Dependence provides strategies and recommendations designed to assist clinicians; tobacco dependence treatment specialists; and healthcare administrators, insurers, and purchasers in delivering and supporting effective treatments for tobacco use and dependence.7 The Ten Key Guideline Recommendations are as follows:

  1. Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long-term abstinence.
  2. It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting.
  3. Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use the counseling treatments and medications recommended in this guideline.
  4. Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective in this guideline.
  5. Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. Two components of counseling are especially effective, and clinicians should use these when counseling patients making a quit attempt: (a) practical counseling (ie, problem solving and skills training) and (b) social support delivered as part of treatment.
  6. Numerous effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempting to quit smoking-except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (ie, pregnant women, smokeless tobacco users, light smokers, and adolescents).
    1. Seven first-line medications, 5 nicotine containing (ie, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, and nicotine patch) and 2 non-nicotine (ie, bupropion SR and varenicline), reliably increase long-term smoking abstinence rates.
    2. Clinicians also should consider the use of certain combinations of medications identified as effective in this guideline.
  7. Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication.
  8. Telephone quit line counseling is effective with diverse populations and has broad reach. Therefore, both clinicians and health care delivery systems should ensure patient access to quit lines and promote quit line use.
  9. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments shown in this guideline to be effective in increasing future quit attempts.
  10. Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in this guideline as covered benefits (Table 1).


The updated guideline contains new evidence that health care policies and system-level approaches significantly affect the likelihood that smokers will receive effective tobacco dependence treatment and successfully stop tobacco use.7 System-level strategies for treating tobacco use and dependence include the following:

  1. Implement a tobacco user identification system in every clinic.
  2. Provide education, resources, and feedback to promote provider intervention.
  3. Dedicate staff to provide tobacco dependence treatment and assess the delivery of this treatment in staff performance evaluations.
  4. Promote hospital policies that support and provide inpatient tobacco dependence services.
  5. Include tobacco dependence treatments (both counseling and medication) identified as effective in this guideline as paid or covered services for all subscribers or members of health insurance packages.

In addition to the full text of the guideline, clinician and consumer materials are available by visiting the Surgeon General's Web site at Additional tools are available at

Although tobacco control efforts during the last half century have led to remarkable progress, tobacco use remains an enormous threat. However, further progress is likely to be attained through joint actions by clinicians, administrators, insurers, and purchasers to encourage a culture of health care in which failure to use evidence-based interventions with a tobacco user is inconsistent with standards of care.

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1. Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and productivity losses-United States, 1997-2001. MMWR Morb Mortal Wkly Rep. 2005;54:625-628.
2. US Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004.
3. Centers for Disease Control and Prevention. Cigarette smoking among adults-United States, 2006. MMWR Morb Mortal Wkly Rep. 2007;56:1157-1161.
4. Centers for Disease Control and Prevention. Tobacco use among adults-United States, 2005. MMWR Morb Mortal Wkly Rep. 2006;55:1145-1148.
5. Substance Abuse and Mental Health Services Administration. Results from the 2006 National Survey on Drug Use and Health: national findings. Rockville, MD: Department of Health and Human Services; 2007. Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293.
6. Substance Abuse and Mental Health Services Administration. Results from the 2005 National Survey on Drug Use and Health. Rockville, MD: Department of Health and Human Services; 2005. Office of Applied Studies, NSDUH Series H-27, DHHS Publication No. SMA -5-4061.
7. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence:2008 Update. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service; 2008.
8. Tobacco cessation-you can quit smoking now! Accessed May 20, 2008.
9. Treating tobacco use and dependence: 2008 update. Accessed May 20, 2008.
© 2008 Lippincott Williams & Wilkins, Inc.