Administration (FDA). Combined interventions can result in long-term abstinence rates of more than 30%. Effectiveness has a dose-response relationship: multisession intensive interventions achieve significantly higher abstinence rates than brief interventions. FDA-approved tobacco-cessation medications are primarily nicotine-replacement therapies (such as nicotine gum or patch), bupropion, and varenicline. The Public Health Service (PHS) clinical-practice guideline Treating Tobacco Use and Dependence: 2008 Update provides an evidence base for tobacco-cessation treatments.

Treatment effectiveness is irrelevant if tobacco users are not aware of treatment options, cannot access them, cannot afford them, or do not use them when they are available. Tobacco-cessation interventions can be delivered in many settings and formats. Health-care providers can inform patients about the health effects of tobacco use and counsel them about treatment options during routine appointments, patients can be referred to proactive or reactive telephone quitlines for counseling and often medications, and patients can access computer-based programs that offer counseling, support, and medications. Evidence-based systems-level interventions that are particularly effective include tobacco-use identification systems, provider education, reminder systems with feedback, and dedicated staff. For patients who are willing to quit, an evidence-based algorithm known as the 5 A’s uses a decision tree to help health-care providers to do the following:

  1. Ask all patients about tobacco use.

  2. Advise all current users to quit.

  3. Assess all smokers’ willingness to quit.

  4. Assist smokers who are willing to quit by providing appropriate tobacco-dependence treatments.

  5. Arrange follow-up for smokers who are making a quit attempt.

That algorithm can be used by all health-care providers, including physicians, nurses, psychologists, health educators, dentists, and pharmacists. For patients who are unwilling to quit, health-care providers can use motivational interviewing to increase future cessation attempts. Motivational interviewing can follow the 5 R’s: (1) relevance (encourage patient to explain why quitting is relevant to them), (2) risks (ask patients to explain the adverse effects of tobacco use), (3) rewards (ask patients to identify the benefits of quitting), (4) roadblocks (ask patients about the barriers to their quitting), and (5) repetition (use a motivational intervention each time a patient is seen).



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