This Tool Kit provides a practical approach to treating tobacco dependence effectively. The Tool Kit approaches tobacco dependence as a severe chronic illness, such as asthma, with exacerbations and remissions, and is based on the premise that chest physicians must be as actively and professionally engaged in treating tobacco dependence as they are with asthma. Effective tools, treatment algorithms, and strategies to obtain compensation for tobacco-dependence treatment services are provided.
Consensus recommendations in this Tool Kit are based both on the evidence in the literature and the extensive experience of the Committee members in tobacco-dependence treatment. Evidence on which we base our recommendations is described in the text and cited in the references. Because this product is a Tool Kit and not a guideline statement, we did not seek to formally grade evidence. For the interested reader, US guidelines, UK guidelines, and ERS guidelines are available. Treatment recommendations made in this Tool Kit are consistent with the recommendations in these guideline statements. However, the Tool Kit also includes practical information that is not part of the US Guideline due to the absence of studies in those areas, and useful tools to put your knowledge into practice. The tools in this Tool Kit include treatment algorithms, patient assessment tools, patient management tools, communication and patient education tools, resources for healthcare practitioners, and physician advocacy information. Thus, this Tool Kit is more than a guideline; it is a bridge that provides the additional, practical information and tools you need to connect the knowledge base provided in the guidelines with what you need for day-to-day medical practice to provide effective tobacco-dependence treatment.
Please be advised that in certain instances, this Tool Kit includes treatment recommendations that are not approved in the US (so-called off-label uses of pharmaceutical products). For prescribing information, please see package inserts for all pharmacotherapeutics mentioned in this Tool Kit.
The Tool Kit opens with Coding and Billing Principles, so that physicians can provide appropriate tobacco-dependence care to their patients and obtain fair compensation without undue financial hardship. The use of this Tool Kit places every chest physician at the forefront of preventive medicine and proactive treatment—a key component of every healthcare program.
Principles of therapy
Approaching tobacco dependence as a chronic disease acknowledges the altered central nervous system (CNS) neurobiology in tobacco-dependent patients. Therapy in asthma has the goal of achieving (near) normal airway function; similarly, the goal of therapy in tobacco dependence is to normalize brain function—so that the patient has minimal to no symptoms of nicotine withdrawal. Common nicotine withdrawal symptoms include:
- Dysphoric or depressed mood
- Irritability, frustration, or anger
- Difficulty concentrating
- Decreased heart rate
- Increased appetite or weight gain
The goal of tobacco-dependence therapy is to control and minimize these withdrawal symptoms through individualized treatment, thus allowing the patient to feel (near) normal while not using tobacco. The intensity of treatment should be based on the severity level of nicotine dependence. For highly nicotine-dependent patients, combination therapy is often needed.
In asthma, both long-acting Controllers and quick-acting Relievers are used; a similar approach can be used in tobacco-dependence treatment. Nicotine patches, bupropion, and varenicline can be thought of as Controllers. As in asthma, for those with moderate to severe disease, combination of Controller with Rescue or Reliever therapy is often needed to achieve therapeutic goals. Nicotine gum, lozenge, inhaler, and nasal spray can be thought of as Relievers, for as-needed use to relieve exacerbations (see Treatment Process and Approach and Stepwise Treatment Guide). A green-yellow-red zone Action Plan can be provided to the patient. Continuing the asthma analogy, medication is stepped down not according to a fixed time schedule, but as disease control permits. If the nicotine withdrawal symptoms are well-controlled, stepping down medication can be considered. If withdrawal symptoms are not well-controlled, consideration should be given to stepping up medications (see Pharmacologic Treatment and Quick Reference Guide to Pharmacotherapy).
Based on a chronic disease model, we propose that tobacco-dependence treatment follows a proactive approach model that we call ARMR: Assess and diagnose, Recommend a treatment plan, Monitor the treatment plan’s outcome, and Revise the treatment plan to improve effectiveness and minimize side effects.
- Assess and diagnose (see Patient Assessment Tools)
- The Fagerström Test for Nicotine Dependence (FTND) is used to assess level of nicotine dependence. Pediatric assessment can be done with the Modified Fagerström Tolerance Questionnaire (mFTQ) to assess nicotine dependence and/or the Hooked on Nicotine Checklist (HONC) to assess autonomy over smoking behaviors.
- Assess for previous history of or current psychiatric co-morbidities, such as depression, dysphoria, bipolar disorder, and post-traumatic stress disorder (PTSD) (see Depression, Mood, Dyspnea, and Quality of Life Scales).
- Recommend a treatment plan (see Pharmacologic Treatment)
- The treatment plan should be based on the level of nicotine dependence, with more dependent patients needing more aggressive therapy.
- Refer to the 2.2 Stepwise Tobacco-Dependence Treatment Guide, Tables #1 & #2.
- For moderate to severe tobacco dependence, the combination of a Controller and Reliever medication is most beneficial. Very severe dependence often requires more aggressive pharmacotherapy, often with combination Controller or high-dose nicotine patch and for longer-than-typical treatment durations (Tobacco-Dependence Treatment Process and Approach, Case Examples 1 & 2).
- Monitor the treatment plan’s outcome (see Patient Management Tools)
- The Nicotine Withdrawal Symptom (NWS) Scale is used to determine adequacy of control of withdrawal symptoms for patients already on treatment.
- Depression, anxiety, suicidality, and other psychopathology are more common in smokers. Inadequate tobacco-dependence therapy may unmask these problems. Rarely, Controller medications (nicotine patch, bupropion, or varenicline) have been associated with depression and suicidality. Physicians treating tobacco dependence should routinely monitor for the development of psychiatric problems (see Depression, Mood, Dyspnea, and Quality of Life Scales) at each office visit, and, depending on the underlying cause, either increase nicotine replacement therapy, change control medications, or increase the doses of controller medications. In such cases, the treating physician should also consider psychiatric referral to determine whether these changes reflect an underlying or emergent psychiatric state or are merely nicotine withdrawal symptoms (see Tobacco-Dependence Treatment Process and Approach). Again, continuing the asthma analogy, this situation is very much like the controversy that revolves around the use of beta-agonists and increased mortality. Although over-use of beta agonists increases asthma mortality, so does poorly controlled asthma. Physician assessment and follow-up are key to better patient outcomes.
- Revise the treatment plan to improve its effectiveness and minimize side effects.
- Base effectiveness on achieving control of nicotine withdrawal (rather than treating for a fixed time limit like 6 weeks). The patient and physician should decide together whether treatment needs to be escalated, can be stepped down, or can be discontinued. Just like any chronic disease, including asthma, re-exposures or exacerbations may occur that require a temporary increase or re-institution of medication.
- If Reliever/Rescue medication is needed with high frequency (>10-15 times a day), consider escalation of the Controller medication regimen, such as by increasing the nicotine patch dose or by adding a second Controller medication.
Reduction toward cessation
Tobacco-dependent patients who are not yet ready to stop smoking may benefit from use of a nicotine patch or bupropion to help them reduce their smoking and prepare for stopping completely.
Relapse is common in tobacco-dependent patients, particularly those whose treatment plan is inadequate. Relapse prevention strategies (see Tobacco-Dependence Relapse-Prevention Checklist) are best discussed 4-6 weeks after stopping smoking and when nicotine withdrawal symptoms are well-controlled. Triggers for relapse (see Trigger Settings) can include:
- Stress (or other negative mood states)
- Particularly when that stress occurs in the presence of another smoker
- Especially if stress occurs in the presence of another smoker along with mild alcohol consumption
- Sudden or unexpected re-appearance of nicotine withdrawal symptoms
- Celebrating or at a party
- Particularly when consuming modest amounts of alcohol
- Plans to prevent relapse (see Tobacco-Dependence Relapse-Prevention Checklist and see Behavioral Homework Worksheet) in at-risk situations can include the following strategies:
- Think something different
- Do something different
- Use nicotine Rescue Medication to prevent exacerbations, relapse, or re-exposure
Tobacco dependence in pregnant women or women of childbearing age
Smoking is one of the most important modifiable causes of poor pregnancy outcomes in the United States.
- Ideally, women who smoke should be treated effectively for tobacco dependence BEFORE they become pregnant.
- Stopping smoking during pregnancy can still improve fetal outcomes.
- Behavioral counseling is advised as first-line therapy for tobacco-dependent pregnant women. If behavioral counseling alone is insufficient, pharmacotherapy for tobacco dependence, in most cases, poses less risk to the fetus than continued maternal smoking. As with any chronic disease, including asthma,working closely with the patient’s obstetrician is advised. An algorithm for treatment of tobacco dependence in pregnancy is described in Smoking and Tobacco-Dependence Treatment for Pregnant Women and Women of Childbearing Age.
Tobacco dependence in parents
Pediatric healthcare providers have an important role in tobacco-dependence treatment and prevention (see The Role of the Pediatric HealthCare Provider…). Tobacco dependence of parents can and should be addressed within the context of a child’s health care. We endorse the American Academy of Pediatrics statement, “Pediatric health care providers should be knowledgeable about tobacco-dependence treatment and ROUTINELY offer help and referral to those who are tobacco dependent”.
Most adolescents who smoke consider themselves to be addicted to nicotine, recall withdrawal symptoms during previous attempts to stop smoking, and find it difficult to stop smoking. They often continue smoking well into adulthood. The Hooked on Nicotine Checklist (HONC) can be used to assess loss of autonomy over smoking in adolescents and young adults. There has been a dearth of research into effective tobacco-dependence treatment programs for youth. Given the demonstrated effectiveness and safety of first-line tobacco-dependence treatments in adults and the grave harm of continued tobacco dependence, a trial of medically supervised pharmacotherapy plus close, ongoing follow-up is warranted in tobacco-dependent adolescents who are interested in stopping smoking (see Management of the Child/Adolescent at Risk for Smoking).
Intermittent, Non-Daily & Social Smoking
Intermittent, non-daily smoking—frequently escalating to daily smoking and tobacco dependence in adolescents—may represent a low-incidence, stable form of chronic low-level use in adults. (Intermittent, Non-Daily & Social Smoking). Although it may not be associated with substantial tobacco dependence, it still subjects the individual to the adverse health consequences of smoking. Many of the above-noted triggers for relapse are also triggers for intermittent tobacco users. For these patients, focus should be on assessment of smoking behavior; behavior modification centering around trigger avoidance or, when not possible, use of nicotine rescue medication; counseling about the dangers of their active smoking and the effect of their smoke on friends and loved ones; encouragement of a smoke-free home and car; and behavioral counseling to negotiate reduction and elimination of smoking.
In conclusion, the American College of Chest Physicians is committed to tobacco-dependence treatment and prevention. This Tool Kit will allow each of us to fully implement the College’s Fellowship Pledge that we take upon induction into Fellowship. This Tool Kit provides the treating physician and other health care providers with an effective program that can be instituted immediately for every patient in your practice, no matter age or gender. It builds on published tobacco-dependence treatment guidelines, lessons learned from prior versions of this Tool Kit, and the experience and expertise of the Tool Kit Committee members. It attempts to increase your comfort in providing treatment by using your experience in the stepwise treatment of asthma as a foundation for effective tobacco-dependence treatment. This Tool Kit will enable you to help your patients to stop smoking successfully and remain tobacco free.