A. Any Person Encountering the VHA/DoD Health Care Delivery Systems
DEFINITION
Any person who is eligible for care in the Veterans Health Administration (VHA) or the Department of Defense (DoD) health care delivery system should be screened for tobacco use as defined in this guideline.
OBJECTIVE
To determine the person's current use of tobacco.
ANNOTATION
All persons should be asked about their use of tobacco upon visiting any provider. This is easily accomplished when the person's vital signs are taken. The tobacco use status should be noted in the person's record. Repeated assessment is not necessary in the case of the adult who has never used tobacco or has not used tobacco for many years and for whom this information is clearly documented in the medical record. The clinician can proceed further based on clinical relevance and appropriateness.
C. Is Person a Current Tobacco User?
OBJECTIVE
To identify persons who are "tobacco users" as specified in this guideline.
ANNOTATION
A "tobacco user" is a person who answers "yes" when asked whether he or she uses tobacco products.
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."
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.
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:
Chronic pain disorder (chronic pain will increase after stopping nicotine from tobacco or NRT).
2. Psychiatric risks:
OBJECTIVE
To provide an office-based approach for the tobacco user who is not referred to an intensive intervention program.
ANNOTATION
Every tobacco user should be offered at least brief or minimal support by the primary care manager (PCM)/ primary care provider (PCP). The success correlates directly with the length of time spent (3 to 10 minutes minimum) with the smoker over multiple visits for a variety of related and non-tobacco related conditions.
The essential elements of the brief visits will include eliciting the patient's interest in quitting, severity of tobacco dependence and withdrawal symptoms, length of previous quit attempts and reasons for relapse, appropriateness of behavioral and pharmacotherapy, the reasons why they use tobacco (stress control, habit, pleasure, etc.), and patients concerns about consequences of quitting such as weight gain.
The PCM/PCP can provide self-help reading material (see Appendix 4), prescribe the medications than are appropriate (see Appendix 2), establish a quit date, encourage use of behavioral techniques to disrupt the habits and rituals of tobacco use and schedule follow-up visits within 1 to 2 weeks of the quit date.
OBJECTIVE
To facilitate abstinence through provision of Pharmacological therapy to treat tobacco dependence.
ANNOTATION
Pharmacological therapy can be divided into nicotine replacement products and non-nicotine products. Every person who answers "no" should be offered pharmacotherapy except when medically contraindicated. Selection should be based on a review of the risks and benefits for each drug and the person's preference. Appendix 2, Pharmacology, includes a comprehensive review of these drugs. Appendix 3, Treatment/Cost, rates the relative cost of dosing.
OBJECTIVE
To assist the person in learning about the benefits of quitting.
ANNOTATION
Provide the person with self-help material. Provide Primary Care Managers (PCM)s and Primary Care Providers (PCP)s "How to" literature and a list of established "stop smoking" programs available. (See Appendix 4, Self-Help Material).
J. Initiate/reinforce Relapse Prevention
OBJECTIVE
To reinforce and motivate abstinence from tobacco and prevent future relapses (tertiary prevention).
ANNOTATION
Most tobacco relapses occur within the first three months after cessation, but some relapses occur years after quitting. Telephone calls, clinic visits, or any time the clinician encounters a former tobacco user can be appropriate times to accomplish intervention for relapse prevention. Minimal relapse prevention should be part of every primary care encounter with persons who have recently quit. Minimal reinforcement approaches can be expressed as:
- Offer congratulations on quitting.
- Encourage the person to continue tobacco free.
- Encourage active discussion of the benefits of quitting by asking the person open-ended questions designed to include the person's problem solving on:
- Anticipated health benefits derived from cessation.
- Success the person has had in quitting.
- The most notable tobacco withdrawal symptoms experienced.
- Problems or threats anticipated or encountered while maintaining abstinence (e.g., weight gain; negative mood, depression, or anxiety; prolonged withdrawal symptoms; and lack of social support for cessation.
K. Address Reasons for Unwillingness to Quit. Determine Medical/Psychological Risks of Continued Use
OBJECTIVE
To determine the existence of any medical or psychological conditions that may have predictable adverse outcomes if the person does not stop using tobacco products.
ANNOTATION
There are special target populations of smokers who need to be identified and referred for intervention because of the high likelihood of adverse outcomes that accompany continued tobacco use. These include:
- Pregnancy¾Due to increased risk to the mother and potential fetal prematurity, all pregnant patients should be encouraged to stop smoking as early in pregnancy as possible. (See the discussion about use of medications during pregnancy in Annotation H).
- Chronic tobacco related disease¾ Smokers who have developed a progressive, chronic tobacco related disease (Emphysema, coronary artery disease, peripheral vascular disease) that will continue to deteriorate should be urged to make an attempt to quit tobacco during routine primary care for those disorders.
- Complications of surgical anesthesia¾ Smoking cessation should be addressed with all pre-operative patients. If tobacco users will quit smoking 4 to 6 weeks prior to anesthesia, complications and post - operative recovery (infections, wound healing, cardiac procedures) can be reduced.
OBJECTIVE
To provide guidance and encouragement to heighten the motivation to quit tobacco use.
ANNOTATION
The PCM/PCP should use a motivational technique characterized by the "four Rs:" relevance, risks, rewards, and repetition.
- Relevance¾ Motivational information given to a person has the greatest impact if it is relevant to a person's disease status, family life or social situation.
- Risks¾ Ask the person to identify the potential negative consequences of smoking; then discuss the most relevant risks for the person in detail.
- Rewards¾ Ask the person to identify the potential benefits of quitting smoking. Highlight and elaborate on the benefits that are most relevant to the person.
- Repetition¾ The motivational intervention should be repeated when an unmotivated person visits the PCM/PCP in a primary care setting.
M. Assess Risk for Starting Tobacco Use
OBJECTIVE
To assess the potential for tobacco use in persons who have never used tobacco, based on existing risk factors.
ANNOTATION
The PCM/PCP can help identify the following information derived in the history and physical:
OBJECTIVE
To assess former tobacco user's risk of relapse and determine if relapse prevention counseling is advisable at this stage.
ANNOTATION
Tobacco use has been characterized as a chronic relapsing disorder due to the high frequency of relapse after a single quitting attempt. Indeed, relapse rates of up to 89 percent are expected among previous tobacco users who have achieved cessation after a single quitting attempt, cold turkey. However, cumulative success rates over multiple quitting attempts may improve the success rate.
OBJECTIVE
To educate potential tobacco users and prevent them from ever starting (primary prevention).
ANNOTATION
There are many reasons to address prevention in the early and middle school age groups. This group of children and young adults are very susceptible to adult role models and peer pressure. Tobacco use prevention pamphlets can be very informative and address age appropriate issues.