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Tobacco Use or Secondhand Exposure: Assessment and Interventions - Adult/Pediatric - Inpatient/Ambulatory

Tobacco Use or Secondhand Exposure: Assessment and Interventions - Adult/Pediatric - Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Alcohol and Tobacco, Related


1
Tobacco Use or Secondhand Exposure:
Assessment and Interventions –
Adult/Pediatric – Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ................................................................................................................................... 4
METHODOLOGY .................................................................................................................... 4
DEFINITIONS.......................................................................................................................... 5
INTRODUCTION ..................................................................................................................... 5
RECOMMENDATIONS ............................................................................................................ 5
Screening for Tobacco Use and Secondhand Exposure .............................................................. 6
Prevention and Anticipatory Guidance ....................................................................................... 7
Brief Advice and Assessment of Willingness to Quit .................................................................. 7
Care for Patients Willing to Quit ................................................................................................. 8
Counseling ............................................................................................................................... 8
Quit Line Referral ..................................................................................................................... 8
Pharmacotherapy .................................................................................................................. 10
Care for Patients Not Willing to Quit ........................................................................................ 16
Care for Patients Who Recently Quit ........................................................................................ 17
Relapse Prevention and Follow-up ........................................................................................... 18
UW HEALTH IMPLEMENTATION ........................................................................................... 19
APPENDIX A. EVIDENCE GRADING SCHEME(S) ...................................................................... 23
REFERENCES ........................................................................................................................ 24
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Contacts for Content:
Name: Michael Fiore, MD, MPH, MBA – Internal Medicine, UW-CTRI Director
Email Address: mcf@ctri.wisc.edu
Name: Robert Adsit, MEd – UW-CTRI Director of Education and Outreach
Phone Number: (608) 262-7557
Email Address: ra1@citri.wisc.edu
Contact for Changes:
Center for Clinical Knowledge Management (CCKM)
Email Address: CCKM@uwhealth.org
Coordinating Team Members:
Amy Skora, BS, CHES – UW-CTRI Outreach Specialist for Southern Wisconsin Richard
L. Brown, MD, MPH – Family Medicine
Alex Young, MD – Family Medicine/Urgent Care
Richard Deming, MD- Family Medicine (Swedish American Health System)
Paula Cody, MD – Pediatrics (Adolescent Medicine)
Kristin Berg, MD, MS – Internal Medicine
Kraig Kumfer, MD- Medicine- Hospitalists
Paula Cynkar, MPAS, PA-C – Medicine- Hospitalists
Susan Mindock- Center for Treatment of Addictive Disorders
Lisa Ziegler- Nursing- Coordinated Care
Lori Williams, RN- Pediatric Universal Care Unit
Alana Winchel, RN- Pediatrics- General
Cheryl DeVault, RN- Family Medicine – General
Laura LaCoursiere, RN – Medicine- Internal Medicine/General
Melanie Erskine, CMA- Family Medicine- General
Ashlie St. John, CMA- Medicine- Internal Medicine/General
James Stein, MD – Medicine- Preventive Cardiology
Jon Matsumura, MD- Surgery- Vascular Surgery
Kyla Bennett, MD- Surgery- Vascular Surgery
Christie Bartels, MD- Medicine- Rheumatology
Josh Vanderloo, PharmD, BCPS – Drug Policy Program
Rachelle Greller – UW Health Employee Wellness Program
Elaine Rosenblatt, MSN, FNP-BC – Unity Health Insurance
Deb Dunham, RPh, MS, CPHIMS – Center for Clinical Knowledge Management
(CCKM)
Review Individuals/Bodies:
Douglas Jorenby, PhD – Internal Medicine, UW-CTRI Clinical Services Director
Emmanuel Quarcoo, MSN, RN, ACNS-BC, CRRN- Family Medicine (D4/6)
Shelly VanDenBergh, MS, RN, GCNS-BC- D4/4
Brian Sharp, MD- Emergency Medicine
Jayne McGrath, RN- Emergency Medicine
Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 10/27/16)
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Executive Summary
Guideline Overview
This guideline is based primarily on the 2008 Department of Health and Human Services
guidelines for Treating Tobacco Use and Dependence1, with support provided by the 2013 and
2015 U.S. Preventive Services Task Force recommendations2,3 and the American Academy of
Pediatrics Policy Statement4 (reaffirmed in 2014).
Key Revisions (2016 Periodic Review)
1. Revised scope to exclude patients who are pregnant and include emergency and urgent care.
2. Added recommendations to support use of abbreviated versions of 5A’s model.
3. Added recommendations for screening of parents/caregivers during pediatric care/visit.
4. Revised suggested screening questions and assessment of willingness to quit.
5. Added recommendations for preoperative smoking cessation.
6. Added recommendation to quit smoking abruptly versus gradually.
7. Further defined first- and second-line pharmacotherapy options.
8. Added recommendations to prevent relapse and support patients who recently quit.
Key Practice Recommendations
1. Every adolescent and adult patient should be assessed for tobacco use at every clinical
encounter, preferably when vital signs are obtained or during inpatient admission.1,4-6 (UW
Health High quality evidence, strong recommendation) Parental smoking and tobacco use are
two of the strongest risk factors for smoking initiation in children.2,7 Therefore, it is important
to assess parental or caregiver use of tobacco during pediatric visits, and address
dependence as necessary.8,9 (UW Health Low quality evidence, strong recommendation)
2. Secondhand smoke exposure is harmful to all patients. Therefore, clinicians should ask
about tobacco smoke exposure from parents, caregivers, spouses, or environmental
conditions (e.g., multi-unit housing, public buildings where smoking is allowed).1,2,4,5,10 (UW
Health Moderate quality evidence, strong recommendation)
3. Every tobacco user should be offered at least minimal intervention, whether or not the
patient is referred to an intensive intervention.1,11 (HHS Strength of Evidence A) Once a
tobacco user is identified and advised to quit, the clinician should assess the patient’s
willingness to make a quit attempt at the current time.1 (HHS Strength of Evidence C)
4. The combination of counseling and medication is more effective for smoking cessation than
medication, brief advice, or usual care alone.1,12 Therefore, whenever feasible and
appropriate, both counseling and pharmacotherapy should be provided to patients trying to
quit.1,12 (UW Health High quality evidence, strong recommendation)
5. Counseling and NRT are recommended 4-8 weeks prior to surgery (UW Health Moderate
quality evidence, weak/conditional recommendation), as these interventions have been shown to
reduce surgical complication rates and increase long-term abstinence when compared to
less intensive support.13
6. Patients should be encouraged to quit smoking abruptly versus gradually.14 (UW Health
Moderate quality evidence, strong recommendation)
7. The choice of medication should be dependent upon patient preferences and prior
experiences identified via a discussion with the provider. (UW Health Moderate quality
evidence, weak/conditional recommendation)
8. Clinicians should use motivational techniques and health education to encourage smokers
not currently willing to quit to consider making a quit attempt in the future.1,15 (UW Health
Moderate quality evidence, strong recommendation)
Companion Documents
1. Tobacco Cessation Algorithm
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Scope
Disease/Condition(s): Tobacco use via smoking (e.g., cigarettes, cigars), smokeless delivery
(e.g., chewing tobacco, snuff), or electronic nicotine delivery systems (electronic cigarettes)
Clinical Specialty: Primary Care, Specialty Care, Inpatient, Emergency Medicine, Urgent Care
Intended Users: Physicians, Advanced Practice Providers, Registered Nurses, Licensed
Practice Nurses, Certified Medical Assistants, Case Managers, Social Workers, AODA
Counselors, Psychologists, Pharmacists
Objective(s): To provide a framework for the evaluation of patients for tobacco use or
secondhand smoke exposure, and to outline recommendations for treatment (or referral to
treatment) in tobacco users.
Target Population: Pediatric, adolescent (age 11-17 years), and adult (age 18 years or older)
patients who use or are exposed to tobacco/nicotine products. This guideline does not include
recommendations for patients who are pregnant or postpartum.
Interventions and Practices Considered:
ξ Screening for tobacco use or secondhand smoke exposure
ξ Advise to quit and assessment of willingness to quit
ξ Assistance in quit attempt via counseling, motivational intervention, and/or pharmacotherapy
ξ Relapse prevention and follow-up
Major Outcomes Considered:
ξ Proportion of patients whose tobacco use status is identified and documented
ξ Proportion of tobacco users whose interest in quitting during the outpatient visit or
hospitalization is documented (interested in quitting at this time [within the next 30 days])
versus not interested in quitting at this time)
ξ Proportion of tobacco users who are provided recommended counseling (5 As versus
motivational counseling, based on interest in quitting at this time)
ξ Proportion of tobacco users who are provided medication to quit
ξ Tobacco use cessation (quit rates)
ξ Reduced secondhand exposure
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.
Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).
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Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.
Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).
Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.
Recognition of Potential Health Care Disparities: Health disparities exist in tobacco use,
morbidity, receipt of advice to quit, success of quit attempts, and rates of secondhand smoke
exposure across certain populations.16 Lower education and income, co-morbid mental health
and substance abuse diagnoses, poorer health status, and some racial/ethnic minorities (e.g.,
Native Americans) are also significantly associated with lower rates of advice to quit even after
adjustment for number of cigarettes smoked, time from last provider visit, income, comorbidities,
insurance coverage, gender, and age.17 Community and public policy changes (e.g., increasing
price of tobacco products, smoke-free public buildings) have been shown to reduce these
disparities, and targeted cessation programs could be implemented to support patients in
vulnerable populations.18
Definitions
Light smoker: any patient who smokes fewer than 10 cigarettes per day and includes patients
who may not smoke daily. This does not include patients who smoke low tar/low-nicotine
cigarettes.1
Introduction
Forty-two million American adults and about three million middle and high school students
smoke. In 2015, approximately 15% of all adults nationwide smoked with similar rates of
smoking among adults in Wisconsin. On average, compared to people who have never
smoked, smokers suffer more health problems and disability due to their smoking. Smoking
causes 87% of lung cancer deaths, 32% of coronary heart disease deaths, and 79% of all cases
of chronic obstructive pulmonary disease (COPD). It is estimated that the economic cost
attributed to smoking and exposure to tobacco smoke is $300 billion annually, with direct
medical costs of at least $130 billion and productivity losses of more than $150 billion per
year.19
Recommendations
Multiple care models exist to screen for tobacco use and provide pertinent interventions which
encourage cessation, including those based on brief advice, the principles of motivational
interviewing, or health education.1,15,20 The clinical situation or training of an individual clinician
may encourage delivering components of each model in an order or format relevant to the
individual clinical scenario.
The 5 A’s model is an endorsed model for tobacco screening and cessation.1 (UW Health High
quality evidence, strong recommendation) The 5 A’s model (Ask - Advise – Assess – Assist -
Arrange) is a brief intervention strategy endorsed by the U.S. Preventive Services Task Force,
American Academy of Pediatrics, and is described primarily within the 2008 Department of
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Health and Human Services (HHS) Public Health Service Clinical Practice Guideline for
Treating Tobacco Use and Dependence.1,3,8 This well established model may be particularly
useful when staff is not adequately trained in motivational interviewing techniques, or in patients
who express a low desire to quit.15,21 (UW Health Moderate quality evidence, strong recommendation)
Abbreviated versions of the 5 A’s model (e.g., Ask – Advise – Refer , Ask – Advise – Connect,
or Ask – Advise – Act) have been developed as a result of concerns for efficiency and physician
burden in clinical practice following implementation of the core model.22,23 In these abbreviated
models, staff routinely assess the smoking status of all patients, deliver brief advice to users to
quit smoking, and either: 1) distribute referral cards which includes the contact information to
evidence-based cessation treatments such as a quit line (AAR) or 2) directly connect tobacco
users interested in talking with a quit line via the electronic health record or fax (AAC).22,23 If an
abbreviated model is implemented, it is recommended to “connect” rather than “refer” patients to
evidence-based cessation treatments due to the greater number of patients enrolled in
treatment when connected rather than referred.9,22-24 (UW Health Moderate quality evidence, strong
recommendation)
Screening for Tobacco Use and Secondhand Exposure
Assessment of tobacco use is the first critical step in decreasing tobacco use. Tobacco use
status should be assessed and documented in adolescent and adult patients at every clinical
encounter (Table 1), preferably when vital signs are obtained or during inpatient admission.1,4-6
(UW Health High quality evidence, strong recommendation) Parental smoking and tobacco use are
two of the strongest risk factors for smoking initiation in children.2,7 Therefore, it is important to
assess parental or caregiver use of tobacco during pediatric visits, and address dependence as
necessary.8,9 (UW Health Low quality evidence, strong recommendation)
Secondhand smoke exposure is harmful to all patients. Therefore, clinicians should ask about
tobacco smoke exposure from parents, caregivers, spouses, or environmental conditions (e.g.,
multi-unit housing, public buildings where smoking is allowed).1,2,4,5,10 (UW Health Moderate quality
evidence, strong recommendation)
A national survey of adolescent and young adults demonstrated the recent transition from
electronic cigarette use to traditional cigarette smoking. Smokeless tobacco users (e.g.,
chewing tobacco, snuff) or users of nicotine products (e.g., electronic cigarettes) should be
identified, strongly urged to quit and provided counseling cessation interventions.1,25-30 (HHS
Strength of Evidence A) Users of cigars, pipes, and other non-cigarette forms of smoking tobacco
should be identified, strongly urged to quit, and offered the same counseling interventions
recommended for cigarette smokers.1 (HHS Strength of Evidence C) Provider should be aware
that cigar smokers are at an increased risk for coronary heart disease, COPD, periodontitis and
oral, esophageal, lung, and other cancers.31-34
Table 1. Screening Based Upon Patient Age
Suggested Question (Age 0-10 years)
Is this patient regularly exposed to tobacco smoke (e.g., at home, in a car, at work)?
Suggested Questions (Age 11-17 years)
Have you ever tried tobacco or nicotine products (including e-cigarettes, e-hookah, hookah, vape or chew)?
Are you regularly exposed to tobacco smoke (e.g., at home, in a car, at work)?
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Suggested Questions (Age 18 years or older)
Do you currently use or have you used tobacco or nicotine products within the last month?
Are you regularly exposed to tobacco smoke (e.g., at home, in a car, at work)?
Prevention and Anticipatory Guidance
Non-use should be reinforced by providers and other health care professionals in patients of
any age. (UW Health Low quality evidence, strong recommendation)
The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians provide
interventions, including education and brief counseling, to prevent initiation of tobacco use in
school-aged children and adolescents.2,4 (USPSTF Grade B) While screening for personal
tobacco use should begin at age 11, anticipatory guidance and education may be appropriate at
a much earlier age. The American Academy of Pediatrics (AAP) supports beginning anticipatory
guidance at the age of 5 years.4,8 Children and adolescents should be warned about the harmful
effects of tobacco and the ease with which experimentation progresses to addiction and regular
use.4,5 Messages for adolescents which have been shown to resonate include those related to
the effects of tobacco use on appearance, breath, sports performance, financial burdens, and
lack of benefit for weight loss.8
Brief Advice and Assessment of Willingness to Quit
When using the 5A’s model, patients who screen positive for tobacco use should receive brief
advice and be assessed for their willingness to quit.1 Minimal interventions lasting less than 3
minutes increase overall tobacco abstinence rates. Every tobacco user should be offered at
least minimal intervention, whether or not the patient is referred to an intensive intervention.1,11
(HHS Strength of Evidence A)
In a clear, strong, and personalized manner, urge every tobacco user to quit.1. All physicians
should strongly advise every patient who smokes to quit because evidence shows that
physician advice to quit smoking increases abstinence rates.1 (HHS Strength of Evidence A)
Advice should be1:
ξ Clear—“It is important that you quit smoking (or using chewing tobacco) now, and I can
help you.” “Cutting down while you are ill is not enough.” “Occasional or light smoking is
still dangerous.”
ξ Strong—“As your clinician, I need you to know that quitting smoking is the most
important thing you can do to protect your health now and in the future. The clinic staff
and I will help you.”
ξ Personalized—Tie tobacco use to current symptoms and health concerns, and/or its
social and economic costs, and/or the impact of tobacco use on children and others in
the household. “Continuing to smoke makes your asthma worse, and quitting may
dramatically improve your health.” “Quitting smoking may reduce the number of ear
infections your child has”.1
Once an adolescent or adult tobacco user is identified and advised to quit, the clinician should
assess the patient’s willingness to make a quit attempt at the current time (Table 2).1 (HHS
Strength of Evidence C) Hospitalized patients may be particularly motivated to make a quit
attempt due to their potentially heightened perception of the health risks of smoking based upon
the admitting illness, or due to their temporary housing in a smoke-free environment. The 2009
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Wisconsin Act 12 Smoking Ban35 prohibits smoking within inpatient health care facilities, and
The Joint Commission requires every accredited hospital to be smoke-free.1,6
Table 2. Assessment for Patient’s Willingness to Make a Quit Attempt
Are you willing to make a quit attempt at this time or in the next 30 days?
Care for Patients Willing to Quit
The combination of counseling and medication is more effective for smoking cessation than
medication, brief advice, or usual care alone.1,12 Therefore, whenever feasible and appropriate,
both counseling and pharmacotherapy should be provided to patients trying to quit.1,12 (UW
Health High quality evidence, strong recommendation)
In particular, preoperative smoking interventions which include brief or intensive behavioral
support and nicotine replacement therapy (NRT) have demonstrated effects on tobacco use
status at the time of surgery and longer term abstinence.13 Counseling and NRT are
recommended 4-8 weeks prior to surgery (UW Health Moderate quality evidence, weak/conditional
recommendation), as these interventions have been shown to reduce surgical complication rates
and increase long-term abstinence when compared to less intensive support.13
Counseling
Proactive telephone counseling, group counseling, and individual counseling formats are
effective and should be used in smoking cessation interventions.1,36 (HHS Strength of Evidence A)
During the individual counseling provided by a clinician, it is important to assist the patient is
developing a quit plan. (UW Health Low quality of evidence, strong recommendation) Conversations
surrounding quit plans should contain the following information (STARS).1,37
Quit Plan Components
ξ Set a quit date (ideally within 2-3 weeks).
ξ Tell others and ask for support (i.e., alert coworkers, family, and friends).
ξ Anticipate and plan for challenges and temptations (including withdrawal symptoms).
ξ Remove all tobacco products from home, car, and work environments.
ξ Stress total abstinence and sticking with treatment even if there is a slip or lapse.
In general, patients should be encouraged to quit smoking abruptly versus gradually.14 (UW
Health Moderate quality evidence, strong recommendation) In a recent randomized, controlled
noninferiority trial, a greater number of participants who quit smoking abruptly remained
abstinent at 4 weeks and 6 months following the quit date as compared to those who cut down
first.14
Quit Line Referral
Connection to a quit line service significantly increase abstinence rates compared to minimal
interventions or no counseling.1,38 Adult patients willing to make a quit attempt in the ambulatory
setting should be directly connected to a quit line to receive proactive telephone counseling
services (Table 3).22,23,36,38 (UW Health Moderate quality evidence, strong recommendation) While
connection to a quit line is also suggested in hospitalized adult patients willing to quit (UW Health
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9
Low quality evidence, weak/conditional recommendation), the strength of the evidence and benefits
of long-term abstinence are more established in the ambulatory setting than the inpatient
setting.39,40 Referral to a quit line also meets the counseling component of the Joint Commission
TOB-3 measure. For that measure, documentation of patient referral (or refusal to accept such
a referral) to evidence-based outpatient counseling at hospital discharge is required.
Tobacco-dependent adolescents should also be offered a quit line referral.8 (UW Health Low
quality evidence, strong recommendation) Telephone and text-based services are available and are
outlined in Table 3.
Table 3. Evidence-based Quit Line and Text-Based Tobacco Cessation Resources
National
ξ 1-800-QUIT-NOW (1-800-784-8669)
ξ SmokefreeTXT (to enroll, text QUIT to 47848 from a mobile phone)
ξ www.smokefree.gov (operated by the National Cancer Institute)
Wisconsin
ξ 1-800-QUIT-NOW (1-800-784-8669)
ξ Fax to Quit* 1-800-483-3114
ξ UW- Center for Tobacco Research and Intervention
Illinois ξ 1-866-QUIT-YES (1-866-784-8937)
ξ www.quityes.org (operated by the American Lung Association)
*The Fax to Quit program links the services of the Wisconsin Tobacco Quit Line directly to the potential quitter with
the help of health care providers. Rather than relying on the patient initiated contact, a quit coach proactively contacts
the tobacco user to provide an intervention after receiving a faxed consent form from a provider. The Quit Line faxes
a report back to the health care provider when the contact is made with the potential quitter.
Individual and Group Counseling in Adult Patients
Counseling provided by many different types of providers and other staff (e.g., physicians,
nurses, dentists, psychologists, pharmacists, etc.) as well as in different formats (practical
counseling/problem-solving treatment or support/encouragement- Table 4) is effective in
increasing tobacco cessation rates.1,37 (HHS Strength of Evidence B)
Both individual and group counseling are effective and are more effective than no counseling.
While the choice of format will depend on the provider and patient, a strong dose-response
relationship exists between counseling intensity and cessation success.1 (UW Health High quality
evidence, strong recommendation) Person- to-person treatment delivered for four or more sessions
appears especially effective in increasing abstinence rates, although even a single session of
counseling can be effective. Whenever feasible, physicians should strive to meet four or more
times with patients quitting tobacco use.1 (HHS Strength of Evidence A)
Hospitalized patients who are willing to quit demonstrate enhanced quit rates if they are
provided smoking cessation counseling and support post-discharge, with the typical
recommendation for post-discharge counseling to occur at least one month after discharge.40,41
(UW Health Moderate quality evidence, strong recommendation)
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Table 4. Mechanisms of Problem-solving Treatment
Problem-solving Treatment Component Examples
Recognition of danger situations –
Identification of events, internal states, or
activities that are thought to increase the risk
of smoking or relapse
ξ Being around other smokers
ξ Being under time pressure
ξ Getting into an argument
ξ Experiencing urges or negative moods
ξ Drinking alcohol
Coping skills -- Identification and practice of
coping or problem-solving skills. Typically,
these skills are intended to cope with danger
situations.
ξ Learning to anticipate and avoid danger
situations
ξ Learning cognitive strategies that will
reduce negative moods
ξ Accomplishing lifestyle changes that
reduce stress, improve quality of life, or
produce pleasure
ξ Learning cognitive and behavioral
activities that distract attention from
smoking urges
Basic information -- Provision of basic
information about smoking and successful
quitting.
ξ The nature/time course of withdrawal
ξ The addictive nature of smoking
ξ The fact that smoking (even a single puff)
increases the likelihood of full relapse
Individual and Group Counseling in Adolescent Patients
Counseling has been shown to be effective in adolescents, therefore adolescents who smoke
should be provided counseling interventions which aid them in quitting smoking.1,42 (HHS
Strength of Evidence B) The literature varies on counseling method (i.e., intensity, content,
format), however providers may provide the same 5 As approach to adolescent patients who
are willing to make a quit and attempt and use motivational interventions which are adapted for
the adolescent population for those not yet ready to quit.43 The counseling interventions for this
latter group should contain content related to enhancing motivation, establishing rapport, goal
setting, promotion of problem-solving and skills training, as well as relapse prevention.1,41,44,45
Here are a number of brief messages or talking points which may be used when talking to
teenage patients:
ξ Tobacco causes yellow teeth and fingers, bad breath, smelly clothes, and wrinkled skin.
ξ Cigarettes contain 4000 chemicals, 400 are toxic (arsenic & formaldehyde), and 40 cause
cancer.
ξ Eating healthy foods and exercising is a better way to lose weight than smoking.
ξ Smoking a pack a day costs more than $200 per month – more than the cost of an X-Box
game, a monthly cell phone bill, or a box set of DVDs.
ξ Ask the teen: “Do you feel that cigarettes control your life in any way?”
Pharmacotherapy
Seven medications (varenicline, bupropion, and the five nicotine agents – gum, patch, lozenge,
inhaler, and nasal spray) have been approved by the FDA as safe and effective agents to
promote tobacco dependence. All of these medications have been endorsed and
recommended by the 2008 United States Public Health Service Clinical Practice Guideline and
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the 2015 United States Preventive Services Task Force.1,3 These bodies recommend that
clinicians provide at least one cessation medication to every patient making a quit attempt.
Barriers to a successful quit attempt, such as medication cost and availability of agents over-
the-counter, should be minimized as much as possible. Patients should be encouraged to
contact their insurance provider to determine specific coverage. Insurance coverage can be
variable, but many provide coverage under the Affordable Care Act. However, reimbursement
(particularly for nicotine replacement therapy) may depend on provider prescription.
Adult Patients
Pharmacologic support is recommended to all smokers who are motivated to make a quit
attempt, in the absence of specific contraindications (e.g., bupropion and seizure history) and in
specific populations for whom there is insufficient evidence or safety concerns (i.e., pregnant
women, smokeless tobacco users, light smokers and adolescents).1 (HHS Strength of Evidence A)
The efficacy of tobacco-cessation counseling interventions is enhanced by the use of
pharmacologic therapy. Pharmacologic support is be most successful when one or more of the
following criteria are met1:
ξ The patient is motivated to quit within the month.
ξ The patient agrees to quit using tobacco products with the start of nicotine replacement
therapy (or 1-2 weeks after the start of bupropion or varenicline).
ξ The patient agrees to participate in a follow-up program.
ξ Previous quit attempts have failed because of withdrawal symptoms
Although abrupt cessation is preferred14 (UW Health Moderate quality evidence, strong
recommendation), nicotine replacement therapy (NRT) may also be used in conjunction with
physician encouragement and instruction to reduce daily smoking as much as possible in
patients unwilling to quit.37,46-48 (UW Health Low quality evidence, weak/conditional recommendation)
A third indication for the use of pharmacotherapy may be to minimize withdrawal symptoms in
hospitalized patients who are unwilling to make a quit attempt.1,6,49(UW Health Low quality
evidence, weak/conditional recommendation)
A recent randomized comparison of varenicline, combination NRT, and the nicotine patch alone
did not demonstrate significant differences in abstinence rates at 26 weeks.50 The choice of
medication should be dependent upon any contraindications identified by the provider as well as
patient preferences identified via a discussion with the provider. (UW Health Moderate quality
evidence, weak/conditional recommendation) Information on the contraindications, adverse effects,
considerations, and recommended doses for FDA-approved medications is listed in Table 5.
Single first-line agents include varenicline, bupropion, or NRT (gum, inhaler, lozenge, nasal
spray, patch) (see Table 5).1 Certain combinations of first-line medications have also been
shown to be effective smoking cessation treatments; in particular using two types of NRT (patch
+ rapid-delivery form [e.g., the nicotine lozenge or gum]) has been found to be more effective
than using a single type.1,3 Clinicians should consider using these combinations of medications
in patients who are willing to quit.1 Effective combination medications include the following1,37,51
(UW Health High quality evidence, strong recommendation):
ξ Nicotine patch + other rapid-delivery form of NRT (gum, lozenge, or nasal spray);
ξ Nicotine patch + nicotine inhaler; or
ξ Nicotine patch + bupropion.
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Precautions in patients using non-nicotine pharmacotherapy
The U.S. FDA added Boxed Warnings for the two non-nicotine smoking cessation
pharmacotherapies, bupropion (Zyban™ and generics) and varenicline (Chantix™), highlighting
the risk of serious neuropsychiatric symptoms. The boxed warning for these pharmacotherapies
directs clinicians to monitor patients for the emergence of such symptoms, and if they emerge,
to continue monitoring until they resolve. The EAGLES trial recently challenged the warning, as
a comparison of varenicline and bupropion to the nicotine patch or placebo did not demonstrate
a significant increase in neuropsychiatric adverse events attributable to the medications in
patients with and without pre-existing psychiatric conditions.52
Cardiovascular diseases
Nicotine replacement therapy (NRT) is not an independent risk factor for acute myocardial
events.1 NRT should be used with caution among particular cardiovascular patient groups,
including those in the immediate (within 2 weeks) post myocardial infarction period, those with
serious arrhythmias, and those with unstable angina pectoris. NRT can safely be used in most
hospitalized patients, both for cessation and to manage tobacco withdrawal symptoms.
Skin reactions
Up to 50% of patients using the nicotine patch will have a mild and self-limiting local skin
reaction that can worsen over the course of therapy. Skin reactions may be prevented or
minimized by rotating application sites with each new patch and applying each new patch to
non-hairy, clean, dry skin on the upper body or upper outer arm. Hydrocortisone (0.5 or 1%;
both OTC preparations) may reduce local reactions. Fewer than 5% of patients require
discontinuation of patch treatment.
Nicotine Toxicity
Used and unused nicotine delivery systems should be kept out of the reach of children and pets.
Adolescent Patients
No medications are currently approved by the U.S. Food and Drug Administration for tobacco
cessation in children and adolescents.2 Although nicotine replacement has been shown to be
safe in adolescents, there is little evidence that these medications and bupropion SR are
effective in promoting long-term smoking abstinence among adolescent smokers.53-58 As a
result, pharmacotherapy is not broadly recommended but may be considered on an individual
basis in adolescent patients following a discussion with their provider.8 (UW Health Very low
quality evidence, weak/conditional recommendation)
Other Tobacco Use
The current evidence is insufficient to suggest that the use of pharmacotherapy increases long-
term abstinence among users of smokeless tobacco.28,59,60 However, pharmacotherapy may be
considered on an individual basis in smokeless tobacco users following a discussion with their
provider, particularly among smokeless tobacco users who report significant withdrawal
symptoms upon attempting cessation. (UW Health Very low quality evidence, weak/conditional
recommendation)
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13
Table 5. Pharmacotherapy Options for Tobacco Cessation in Nonpregnant Patients1,61-64
Medication Contraindications/ Precautions Adverse Effects Dosage Initiation, Use, & Monitoring
Varenicline
(Chantix)
Prescription only
(HHS Strength of
Evidence A)
Avoid use in patients with:
- Unstable psychiatric status
- History of suicidal ideation
FDA Boxed Warning: Serious
neuropsychiatric events including but
not limited to depression, suicidal
ideation, suicide attempt, and
completed suicide have been reported
Use with caution in patients:
- With serious psychiatric illness
- With significant renal impairment
- Nausea
- Insomnia
- Abnormal,
strange dreams
0.5 mg every morning (Days 1-3)
0.5 mg twice daily (Days 4-7)
1 mg twice daily (Days 8-end)
Start 1 week before quit date and
use 3-6 months OR
Begin and then quit smoking
between day 8 and 36
Monitor for neuropsychiatric
symptoms including changes in
behavior, hostility, agitation,
depressed mood, and suicide-
related events, including ideation,
behavior, and attempted suicide
Combination
Therapy:
Nicotine Patch +
short-acting
nicotine products
(e.g., lozenge, gum)
(HHS Strength of
Evidence A)
Only patch + bupropion is currently
FDA-approved Reference individual medications
Follow instructions for individual
medications
Follow instructions for individual
medications
Bupropion
SR 150
(Generic, Zyban,
Wellbutrin SR)
Prescription only
(HHS Strength of
Evidence A)
Avoid use in patients with:
- History of seizures or risk for
seizures
- Use of monoamine oxidase inhibitor
(MAOI)
- Use of bupropion in any other form
- History of eating disorders
FDA Boxed Warning: Serious
neuropsychiatric events have occurred
in patients taking bupropion for
smoking cessation
- Insomnia
- Agitation
- Dry mouth
150 mg each morning (Days 1-3)
150 mg twice daily (at least 8 hours
apart) (Days 4-end)
Start 1-2 weeks before quit date;
use 2-6 months
Monitor for neuropsychiatric
symptoms including changes in
behavior, hostility, agitation,
depressed mood, and suicide-
related events, including ideation,
behavior, and attempted suicide
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14
Medication Contraindications/ Precautions Adverse Effects Dosage Initiation, Use, & Monitoring
Nicotine Patch
(Generic,
Nicoderm CQ)

Prescription or OTC

(HHS Strength of
Evidence A)
Do not use in patients with severe
eczema or psoriasis
- Local skin
reaction
- Insomnia
- Vivid dreams
One patch per day
If > 10 cigarettes/day: 21 mg for 4
weeks, 14 mg for 2-4 weeks, 7 mg
for 2-4 weeks
Pre-quit: Up to 6 months prior to
quit date
Post-quit: 12 weeks

Rotate sites of application with
each new patch to minimize skin
irritation

If removed, takes 0.5-3 hrs. after
reapplication to reach effective
levels

If cigarette cravings occur upon
awakening, wear for 24 hours; if
vivid dreams or other sleep
disturbances occur, remove the
patch at bedtime and apply a new
patch in the morning
Nicotine Gum
(Generic, Nicorette)

Prescription or OTC

(HHS Strength of
Evidence A)
- Caution with dentures
- Can worsen dental problems
- Do not eat or drink 15 minutes
before or during use
- Mouth soreness
- Stomach ache
- Heartburn
- Unpleasant taste
2 mg (smoking > 30 min. after
waking)
4 mg (smoking < 30 min. after
waking)

Maximum 24 pieces/day

(HHS Strength of Evidence B)
1 piece every 1-2 hrs.
(6-15 pieces/day) for the first 6
weeks, every 2-4 hours for the
next 3 weeks, every 4-8 hours for
the final 2 weeks; use for 3 months

Requires proper chewing
technique (chew and park)

GI side effects are usually due to
overly vigorous chewing

Oral substitute for cigarettes

Nicotine Inhaler
(Nicotrol inhaler)

Prescription only

(HHS Strength of
Evidence A)
- May irritate mouth/throat at first
(improves with use)
- Use with caution in patients with
bronchospastic disease
- Local irritation of
mouth & throat
6-16 cartridges/day
Inhale 80 times/cartridge
May save partially-used cartridge
for next day

Maximum 16 cartridges/day
Pre-quit: Up to 6 months before
quit date
Post-quit: Up to 6 months; taper at
end

Requires frequent puffing

Oral substitute for cigarettes

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Medication Contraindications/ Precautions Adverse Effects Dosage Initiation, Use, & Monitoring
Nicotine
Lozenge
(Generic, Commit)
Prescription or OTC
(HHS Strength of
Evidence B)
- Do not eat or drink 15 minutes
before or during use
- One lozenge at a time
- Limit 20 in 24 hrs.
- Unpleasant taste
- Hiccups
- Cough
- Heartburn
- Mouth irritation
2 mg (smoking > 30 min. after
waking)
4 mg (smoking < 30 min. after
waking)
Maximum 20 lozenges/day
Use 3-6 months
Weeks 1-6: 1 every 1-2 hrs.
Weeks 7-9: 1 every 2-4 hrs.
Weeks 10-12: 1 every 4-8 hrs.
Oral substitute for cigarettes
Can be used in patients with poor
dentition
Nicotine Nasal
Spray
(Nicotrol NS)
Prescription only
(HHS Strength of
Evidence A)
- Do not use in patients with severe
reactive airway disease
- Avoid use in patients with chronic
allergic rhinitis, nasal polyps, or
sinusitis
- May irritate nose (improves with
use)
- May cause dependence
- Nasal and throat
irritation
- Rhinitis
- Sneezing,
coughing
0.5 mg/spray
1 “dose” = 2 sprays (1 in each nostril)
1-2 doses/hour (2-4 sprays/hour)
8-40 doses/day (16-80 sprays/day)
Maximum 5 doses/hr (10 sprays/hr)
and 40 doses/day (80 sprays/day)
Use 3-6 months; taper at end
DO NOT inhale
Local irritation to nasal mucosa is
difficult for many patients to
tolerate
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16


Care for Patients Not Willing to Quit

Motivational Intervention/Health Education
Clinicians should use motivational techniques and health education to encourage smokers not
currently willing to quit to consider making a quit attempt in the future.1,15 (UW Health Moderate
quality evidence, strong recommendation) Motivational intervention may include counseling
strategies such as motivational interviewing41,65-67 or discussions which identify or touch on
content related to the “5 Rs” (relevance, risks, rewards, roadblocks, and repetition).41,68,69
Motivational intervention does support an increase in quit attempts in individuals not already
willing to quit.41,70

Understanding what motivates patients to want to quit is critical to understanding why a patient
succeeds or fails. It is important to emphasize learning from prior quit attempts in achieving
success, and reinforcing the role of social supports such as a spouse, children, or
grandchildren. A patient unwilling to quit may respond to motivational interventions following the
“5 Rs” (Table 6), especially when physician time or training does not permit motivational
interviewing.1,15,37 (UW Health Moderate quality evidence, strong recommendation)

Table 6. The "5 Rs" of Motivational Interventions
Relevance
Encourage the patient to indicate why quitting is personally relevant, being as specific
as possible. Motivational information has the greatest impact if it is relevant to a
patient's disease status or risk, family or social situation (e.g., having children in the
home), health concerns, age, gender, and other important patient characteristics (e.g.,
prior quitting experience, personal barriers to cessation).
Risk
Ask the patient to identify the potential negative consequences of tobacco use and
highlight those that seem most relevant to the patient. Examples of consequences
include:
ξ Acute risks: shortness of breath, exacerbation of asthma, impotence, infertility,
increased risk of respiratory infections, harm to pregnancy
ξ Long-term risks: heart attacks, strokes, lung and other cancers, COPD (chronic
bronchitis and emphysema), osteoporosis, long-term disability, the need for
extended care.
ξ Environmental risks: increased risk of lung cancer and heart disease in spouse,
increased risk for low birth-weight, sudden infant death syndrome (SIDS), middle
ear diseases, and respiratory infections in children of smokers.
Reward
Ask the patient to identify the potential benefits of quitting tobacco use; highlight those
that seem most relevant to the patient. Examples of rewards include:
ξ Food will taste better
ξ Save money
ξ Home, car, breath will smell better
ξ Have healthy babies and children
ξ Perform better in physical activities
ξ Improved sense of smell
ξ Feel better about yourself
ξ Improved health
ξ Feel better physically
ξ Setting a good example for children and decreasing the likelihood they will smoke
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17
Road-
blocks
Ask the patient to identify barriers to quitting and note elements of treatment (problem
solving, pharmacotherapy) that could address the barriers. Common barriers include:
ξWithdrawal symptoms
ξFear of failure
ξWeight gain
ξLack of support
ξDepression
ξEnjoyment of tobacco
ξBeing around tobacco users
ξLimited knowledge of effective treatment options
Repetition
The motivational intervention should be repeated every time an unmotivated patient
visits the clinic setting. Tobacco users who have failed in previous quit attempts should
be told that most people make repeated quit attempts before they are successful.
Motivational Interviewing
Motivational interviewing is a patient-centered style of counseling which is designed to help
patients explore ambivalence about behavior change, encourage empathy, and self-efficacy. It
is a specialized technique which requires intensive training, as well as ongoing practice. When
compared to brief advice and usual care, motivational interviewing (conducted in 1-6 sessions
for 10-60 minutes per session) demonstrated a modest increase in cessation rates in adult
tobacco users at six months.20 Motivational interviewing by physicians is recommended as an
intervention for tobacco users who are not willing to quit, and can also be used as a method of
providing secondhand smoke exposure education.20,21,67,71 (UW Health Moderate quality evidence,
weak/conditional recommendation) Insufficient evidence exists to recommend an optimal number of
sessions or follow-up contacts, however it is suggested that shorter sessions (less than 20
minutes) appear to result in a greater benefit than longer sessions.20 (UW Health Moderate quality
evidence, weak/conditional recommendation)
For additional information or training, refer to motivationalinterviewing.org for more information.
Care for Patients Who Recently Quit
Abstinent patients should have their quitting success acknowledged, and the clinician should
offer to assist the patient with problems associated with quitting.1 (HHS Strength of Evidence C)
In particular, the clinician should confirm that the patient has filled his/her cessation medication
prescription, that they are adherent with that medication, and that any side effects are
manageable.
If a patient has recently quit (e.g., within the last 6-12 months), it is important to assess
challenges, need for support, and risk of relapse. A provider may use open-ended questions to
identify any success or barriers the patient is experiencing. These may include the following1:
Successes:
ξ The benefits, including health benefits, which the patient may derive from cessation.
ξ Any success the patient has had in quitting (duration of abstinence, reduction on
withdrawal).
Disadvantages or Barriers to Abstinence:
ξ Anticipated problems or threats to maintaining abstinence.
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ξ Weight gain – the clinician might make dietary, exercise, or lifestyle recommendations, or
might refer the patient to a specialist or program. The patient can be reassured that some
weight gain after quitting is common, is usually temporary, and that significant dietary
restrictions soon after quitting may be counterproductive.
ξ Negative mood or depression – if significant, the clinician might prescribe appropriate
medications or refer the patient to a specialist.
ξ Prolonged withdrawal symptoms – if the patient reports prolonged craving or other
withdrawal symptoms, the clinician might consider extending therapy.
ξ Lack of support for cessation – the clinician might schedule follow-up phone calls with the
patient, help the patient identify sources of support within his/her environment, or refer the
patient to an appropriate organization that offers cessation counseling or support.
Relapse Prevention and Follow-up
All quitters are at risk of relapse but several groups of patients are at higher risk of relapse and
should have more intensive phone or office visit follow up. Predictors of a greater risk of relapse
include:
ξ High levels of nicotine dependence
ξ Psychiatric comorbidity
ξ Low levels of motivation to quit
For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within
the first week after the quit date or discharge.72,73 (UW Health Low quality evidence, weak/conditional
recommendation) Follow-up contacts may include a scheduled cessation counseling session with
the attending physician, a follow-up telephone call by designated hospital staff, referral to group,
community, or health plan cessation counseling (e.g., UW-CTRI), or education and information
regarding quit lines (1-800-QUIT NOW). Insufficient evidence exists to support the use of any
specific behavioral intervention, frequency of contact or duration which would help recent
quitters avoid relapse.1,74
Patients who have relapsed should be assessed to determine whether they are wiling to make
another quit attempt.1 (HHS Strength of Evidence C)
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19


UW Health Implementation
Potential Benefits:
ξ Tobacco cessation and improved health
ξ Reduced secondhand smoke exposure to family members, coworkers, etc.

Potential Harms:
ξ Nicotine dependent patients attempting to quit tobacco use may experience a range of
unpleasant withdrawal symptoms, both physical and psychological. Use of pharmacologic
therapy may reduce withdrawal symptoms, while introducing potential side effects of the
medication.

Pertinent UW Health Policies & Procedures
1. UWMF Policy- Smoke and Tobacco Free Policy
2. UWHC Policy 1.41- Smoke Free/Tobacco Free Workplace
3. UWHC Policy 8.47- Screening, Assessment and Reassessment of Patients
4. UWHC Policy 8.02- Assessment and Reassessment of Patients and Documentation in
Clinics

Patient Resources

Quit Smoking
1. Health Facts For You #2022: Quit Smoking Fact Sheet
2. Health Facts For You #2028: You Can Quit Smoking (Spanish)
3. Health Facts For You #3096: Quit Smoking (English)
4. Health Facts For You #3200: Quit Smoking Packet (Spanish)
5. Health Facts For You #6763: Quit Smoking (Spanish)
6. Health Facts For You #7515: Why You Should Quit Smoking
7. Health Information: Smoking Cessation
8. Health Information: Smoking Cessation Readiness Calculator
9. Health Information: Smoking Cessation: Getting support
10. Health Information: Smoking Cessation: Helping someone quit
11. Health Information: Smoking Cost Calculator
12. Health Information: Smoking Fewer Cigarettes
13. Health Information: Smoking Triggers
14. Health Information: Smoking: Choosing a Good Time to Quit
15. Healthwise: Smoking: Stopping
16. Kids Health: Kids and Smoking
17. Kids Health: Nicotine: What Parents Need to Know
18. Lexicomp: Quitting Smoking
19. Lexicomp: Quitting Smoking for Older Adults

Forms of Tobacco Use and Secondhand Exposure
1. Healthwise: Smokeless Tobacco: Quitting
2. Kids Health: E-Cigarettes
3. Kids Health: Smokeless Tobacco
4. Kids Health: What is a Hookah?
5. Lexicomp: Electronic Cigarettes
6. Kids Health: Secondhand Smoke
7. Lexicomp: Dangers of Secondhand Smoke

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20


For Adolescents
1. Health Facts For You #5624: Quit Tobacco Program Workbook for Teens
2. Health Information: Tobacco Use in Teens
3. Healthwise: Teens Thinking About Quitting Smoking: After Your Visit
4. Kids Health: How Can I Quit Smoking?
5. Kids Health: Is It Safe to Vape Around Children?
6. Kids Health: Smoking
7. Kids Health: Stop Smoking: Your Personal Plan
8. Lexicomp: Quitting Smoking for Teens and Young Adults

Medications
1. Health Decision Handouts used in Preventive Cardiology
a. Using Bupropion To Help You Stop Smoking
b. Using the Nicotine Patch and Lozenge to Help You Stop Smoking
c. Varenicline (Chantix)
2. Health Facts For You #5328: Bupropion ER (ZYBAN®) for Smoking Cessation
3. Health Facts For You #6141: Using a Nicotine Patch
4. Health Information: Nicotine Gum
5. Health Information: Nicotine Inhaler
6. Health Information: Nicotine Patches
7. Health Information: Smoking Cessation, Deciding About Medication
8. Healthwise: Anti-Smoking Medication: Deciding About
9. Lexicomp: Nicotine
10. Lexicomp: Nicotine Patch
11. Lexicomp: Nicotine Step 1 [OTC]
12. Lexicomp: Nicotine Step 2 [OTC]
13. Lexicomp: Nicotine Step 3 [OTC]
14. Lexicomp: Varenicline

Relapse Prevention
1. Health Facts For You #7008: Tobacco Use- How to Avoid Once You’ve Quit
2. Health Information: Smoking Cessation: Coping with craving and withdrawal
3. Health Information: Smoking Cessation: Dealing with weight gain
4. Health Information: Smoking Cessation: Preventing slips or relapses
5. Health Information: Smoking Cessation: What to do when you crave nicotine

Tobacco and Comorbid Conditions
1. Health Facts For You #6150: Smoking and Wound Healing (Burn Patients)
2. Health Information: Smoking and Coronary Artery Disease
3. Health Information: Smoking and Heart Attack Risk Calculator
4. Health Information: Smoking and Life Span Calculator
5. Health Information: Smoking And Stroke Risk
6. Health Information: Smoking in Cancer Care: Supportive Care- Health Professional
7. Health Information: Smoking in Cancer Care: Supportive Care- Patient Information
8. Health Information: Smoking: Health Risk for Family Members
9. Health Information: Smoking: Heart Attack and Stroke Risks
10. Health Information: Smoking: Sexual and Reproductive Problems
11. Kids Health: Smoking and Asthma
12. Lexicomp: Smoking: Not Just Harmful to Your Lungs and Heart


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21
External Resources for Patients
1. Unity Health Insurance Tobacco Cessation Programs & Resources
2. Smokefree Teen (SfT) Resources
3. UW-Center for Tobacco Research and Intervention (UW-CTRI) Fact Sheets
a. Plan to Quit
b. Quit Chewing Tobacco Fact Sheet
c. Electronic Cigarettes (E-cigs) Fact Sheet
4. UW-Center for Tobacco Research and Intervention (UW-CTRI) Smoker Website
Guideline Metrics
TOB Measures (Inpatient Psych Unit only)
TOB-1: Tobacco Use Screening
TOB-2/2A: Tobacco Use Treatment
TOB-3/3A: Tobacco Use Treatment at Discharge
ACO
1. ACO-17: Tobacco Use- Screening and Cessation Intervention
WCHQ
1. Diabetes Care- Tobacco Free: % of patients with diabetes age 18-75 yrs. whose most
recent tobacco documentation status with any provider within the last 12 months is tobacco
free.
2. Diabetes Care- All or None Outcome Measure: Optimal Control
3. Ischemic Vascular Disease Care- Tobacco Free: %
Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect and uwhealth.org in a dedicated location for Clinical
Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.
Best Practice Alerts (BPA)
UWOP Tobacco Cessation
UWOP Tobacco Quit Line
UWOP Followup on Tobacco Quit Line
Delegation Protocols
Referral to Wisconsin Tobacco Quit Line – Adult – Ambulatory [130]
Related UW Health Clinical Practice Guidelines
1. Standard Primary Care Rooming Criteria – Adult/Pediatric – Ambulatory Guideline
2. Preventive Health Care – Pediatric/Adult – Ambulatory Guideline
3. Hypertension – Adult – Inpatient/Ambulatory Guideline
4. Mechanical Circulatory Device – Adult – Inpatient/Ambulatory Guideline
5. Standards of Medical Care in Diabetes – Pediatric/Adult – Inpatient/Ambulatory Guideline
6. Asthma – Pediatric/Adult – Inpatient/Ambulatory Guideline
7. Chronic Obstructive Pulmonary Disease – Adult – Inpatient/Ambulatory Guideline
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22


Order Sets & Smart Sets
Tobacco Cessation [5088]
Passive Smoke Exposure [5326]
Quit Connect - Tobacco Cessation [6023]
IP – Tobacco Abstinence – Adult – Supplemental [682]
IP – Psychiatry – Adult – Discharge [5059]
IP – Vascular Surgery – Adult – Discharge [4824]

Reporting Workbench Reports
IP Heart Failure Core Measure (HF-4) Adult smoking cessation counseling: admitted patients/
discharged patients
IP PN Core Measure (PN-4) Adult smoking cessation counseling: discharged patients
Audit- Smoking Cessation (24hrs/48hrs/72hrs/96hrs)

Inpatient Documentation Flowsheets
The following are some tobacco use-related flowsheets used in inpatient Health Link, including
the Adult and Peds Health Assessment completed on admission.
FLO 314603 Have you ever used tobacco?
FLO 314643 Tobacco Use Status
Currently using - interested in quitting
Currently using - not interested in quitting
Quit in last year
Quit over a year ago
FLO 212074 Smokeless Tobacco Status
FLO 330648 Are you interested in quitting tobacco use?
FLO 330646 Do you or have you ever smoked or chewed tobacco?
FLO 451545 Tobacco Use Disorder UW R WISH

Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.

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23
Appendix A. Evidence Grading Scheme(s)
Figure 1. GRADE Methodology adapted by UW Health
GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.
GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.
Figure 2. U.S. Department of Health and Human Services (HHS)1
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24


References
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2. Moyer VA, Force USPST. Primary care interventions to prevent tobacco use in children
and adolescents: U.S. preventive services task force recommendation statement.
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3. Siu AL, Force USPST. Behavioral and Pharmacotherapy Interventions for Tobacco
Smoking Cessation in Adults, Including Pregnant Women: U.S. Preventive Services
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4. HealthHealth CoE, Abuse CoS, Adolescence Co, Child CoNA. From the American
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5. Sims TH, Abuse CoS. From the American Academy of Pediatrics: Technical report--
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for Tobacco Research & Intervention; 2012:
http://www.ctri.wisc.edu/HC.Providers/h0spit8ls/hospitalmanual2013.pdf.
7. Baxi R, Sharma M, Roseby R, et al. Family and carer smoking control programmes for
reducing children's exposure to environmental tobacco smoke. Cochrane Database Syst
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8. Farber HJ, Walley SC, Groner JA, Nelson KE, Control SoT. Clinical Practice Policy to
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2015;136(5):1008-1017.
9. Drehmer JE, Hipple B, Nabi-Burza E, et al. Proactive enrollment of parents to tobacco
quitlines in pediatric practices is associated with greater quitline use: a cross-sectional
study. BMC Public Health. 2016;16:520.
10. Best D, Health CoE, Health CoNAC, Adolescence Co. From the American Academy of
Pediatrics: Technical report--Secondhand and prenatal tobacco smoke exposure.
Pediatrics. 2009;124(5):e1017-1044.
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2016CCKM@uwhealth.org

Patient Presentation
Screen for tobacco use or secondhand
exposure at every encounter (Table 1)
Current
user?
Advise to quit Yes
Is patient willing
to make a quit attempt
at this time or in the
next 30 days?
Provide motivational
intervention/health
education (5 Rs) or
motivational
interviewing**
No
** Hospitalized patients may also be
interested in pharmacotherapy to
minimize withdrawal symptoms.
Connect to or provide
treatment interventions:
1) Connection to quit line
2) Group/individual counseling
3) Pharmacotherapy
Yes
Complete follow-up contacts
beginning within the first
week after quit date or 30
days after discharge
Abstinence?
Quit
recently?
No
Secondhand
exposure?
No
Patients age > 18 years:
Reinforce tobacco-free lifestyle.
Patients age 5-17 years:
Provide education and anticipatory
guidance to prevent initiation.
No
Provide education
on health risks associated with
secondhand smoke exposure.
Provide referral to parent/
caregivers as appropriate.
Yes
Reinforce
tobacco-free
lifestyle and assess
challenges, need for
support and risk of
relapse.
Yes
Yes
No
Tobacco Use Assessment and Interventions in
Nonpregnant Adolescent and Adult Patients
Reference: UW Health Tobacco Use Assessment and
Cessation Clinical Practice Guideline
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2016CCKM@uwhealth.org