D. Assess Readiness to Quit. Advise Quitting

OBJECTIVE

To ascertain the person's willingness to quit using tobacco.

ANNOTATION

The medical record of tobacco users who regularly visit a clinic should document at least three assessments for willingness to quit per year. Those visiting a clinic on fewer than three occasions should be assessed at every visit. Although tobacco status is to be assessed periodically throughout the year, there is no requirement that counseling about tobacco cessation should be offered at every visit. Helpful approaches in determining the person's position on the use of tobacco and/or readiness to change include:

1. State that the person's health would improve if he or she were to quit smoking.
   
   
2. Deal with the subject of addiction to tobacco in a nonjudgmental way.
   
   
3. Link health concerns to tobacco use by giving advice linking the person's chief complaint to smoking, e.g., "If you would quit smoking you wouldn't be so short of breath."

DISCUSSION

By knowing the person's stage of readiness to quit using tobacco, the primary care manager can decide whether to provide motivational material to quit using tobacco or specific instructions to help the person quit.²

Michael C. Fiore, M.D., M.P.H., chaired the AHCPR Smoking Cessation Guideline Panel, which reviewed 3,000 articles and selected 300 as a database for meta-analysis to provide a valid synthesis of smoking cessation treatment outcome data. The Panel made numerous recommendations based upon these data, each of which carries a strength of evidence rating indicating the quality and quantity of empirical support. Throughout this VHA/DoD Guideline, references to Fiore reflect ratings assigned by the AHCPR panel for the specific meta-analysis cited. The meta-analysis was graded by this Tobacco Use Cessation Working Group as Level of evidence (LE) = A and Strength of Recommendation (SR) = I. This grade is applied to all evidence attributed to Fiore in this guideline. When the LE or SR diverged on a particular aspect of diagnosis or treatment, pertinent articles were reviewed and graded in this guideline.

EVIDENCE

Providing motivational resources to quit using tobacco products increases the success of the person quitting. LE = A, SR = I Fiore et al. 1996

REFERENCES

² Fiore et al. 1996

E. Is Tobacco Cessation Program Available and Is Person Willing to Attend?

OBJECTIVE

To refer the tobacco user to a tobacco cessation program, if available.

ANNOTATION

To be most effective, the treatment of tobacco dependence should include either individual or group counseling. There is a strong relationship between the intensity of counseling and successful recovery from tobacco dependence. Intensive interventions are most effective and should be used when resources permit.

EVIDENCE

The intensity and frequency of counseling directly correlate to the success of quitting tobacco use.

LE= A, SR = I Fiore et al. 1996

F. Address Comorbid Conditions

OBJECTIVE

To determine whether the person has other clinical conditions that need prioritized intervention before instituting a tobacco cessation program.

ANNOTATION

Persons must be assessed for any medical and/or psychiatric problems that may adversely affect the intervention. In the person's plan of treatment the following conditions need to be identified and treated before referral to a tobacco use cessation program.

1. Medical conditions:

1. Chronic pain disorder (chronic pain will increase after stopping nicotine from tobacco or NRT).

2. Psychiatric risks:

1. Substance use disorder.
2. Depression.
3. Psychosis.
4. Post-traumatic stress disorder (PTSD).
5. Eating disorders.
6. Anxiety.

DISCUSSION

When these person's conditions are clinically stable, tobacco cessation treatment may begin.^3,4

EVIDENCE

Tobacco cessation treatment should not be initiated until the person is clinically stable.

LE = A, SR = I Cromwell et al.; LE = C, SR = I Fiore 1996

REFERENCES

³ Fiore et al. 1996 Page 43; ⁴ Cromwell et al. 1997