FROM ANNALS of INTERNAL MEDICINE
The U.S. Preventive Services Task Force has issued a final grade A recommendation urging clinicians to ask all adults whether they smoke, advise them to quit if they do, and provide cessation aids to adults who use tobacco.
The guideline also includes Grade I statements, which say “the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant women and electronic nicotine delivery systems for tobacco cessation in all adults (Ann Intern Med. 2015 Sep 22. doi: 10.7326/M15-2023 ).
The guideline reaffirms the 2009 USPSTF recommendation , which recommends clinicians ask all adults about tobacco use and provides tobacco cessation interventions to help them quit. The new guideline differs from the 2009 recommendation in that it calls for more evidence on the use of e-cigarettes for smoking cessation in adults and the use of medications to help pregnant women stop smoking.
“A large body of evidence on interventions for smoking cessation already exists, and the overall benefit of pharmacotherapy and behavioral counseling to promote smoking is well established,” says the new USPSTF guideline.
“Tobacco is the leading preventable cause of disease, disability, and death in the United States,” with cigarette smoking, specifically, causing more than 480,000 premature deaths annually and accounting for one in every five deaths, according to the guideline.
“In pregnant women, smoking increases the risk of congenital anomalies; perinatal complications, such as preterm birth, fetal growth restriction, and placental abruption; miscarriage and stillbirth; and neonatal or pediatric complications, such as sudden infant death syndrome and impaired lung function in childhood,” the guideline says.
According to a 2013 systematic review of 28 studies, rates of smoking abstinence at 6 months or more were 8% in groups that received physician advice, compared with 5% in groups that received no advice or usual care (risk ratio, 1.76; 95% confidence interval, 1.56-1.96).
Pharmacotherapy was effective at stopping nonpregnant smokers from continuing to smoke; a 2012 systematic review of 117 nicotine replacement therapy (NRT) studies found that 17% of participants who took any form of an NRT drug abstained from smoking for 6 months or more, compared with 10% of participants who received placebo or did not take an NRT drug (RR, 0.60; 95% CI, 1.53-1.68), the review says.
Combinations of behavioral counseling and pharmacotherapy for smoking cessation also were effective; “a 2012 good-quality systematic review” found the abstinence rate of participants who received combination pharmacotherapy and intensive behavioral counseling was 14.5%, at 6 months or more, compared with 8% among control participants who received “usual care, self-help materials, or brief advice on quitting (which was less intensive than the counseling or support given to the intervention groups)” (RR, 1.82; 95% CI, 1.66-2.00).
For pregnant women, “a good-quality systematic review of 86 studies done in 2013” found that behavioral interventions were effective at improving rates of smoking cessation. Compared with control participants, pregnant women who received any type of behavioral intervention before the third trimester had higher cessation rates late in pregnancy (15% vs. 11%; RR, 1.45; 95% CI, 1.27-1.64), the review says.
Responding to pubic comments, USPSTF said that “both intervention types (pharmacotherapy and behavioral intervention) are effective and recommended,” with combinations of interventions being the most effective at getting patients to stop smoking.
“Further research is still needed to elucidate specific features of complex behavioral counseling interventions, benefits of pharmacotherapy in specific populations [such as pregnant women and adults with mental health conditions], and the efficacy of newer technology-based interventions … such as Internet-based programs, mobile or smartphone applications, and text-messaging programs.” The document also called for investigations into the safety, benefits, and harms of electronic nicotine delivery systems.
The authors of the guidelines stated they had nothing to disclose.
