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Tobacco Use

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General Information

Description

  • use of tobacco in any form, frequently accompanied by addiction to nicotine

Definitions

  • interventions1
    • brief intervention is generally advice and counseling < 10 minutes in length
    • minimal intervention considered brief advice, usually < 3 minutes
    • motivational interviewing involves a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence
    • counseling encompasses multiple modalities such as behavioral therapy, relaxation, practical counseling (skills training), and aversion therapy
    • proactive telephone counseling includes quitlines with call-back counseling
    • reactive helplines require patient to initiate counseling and do not have call-back counseling
  • outcomes1
    • continuous abstinence, a measure of abstinence based on whether subjects are continuously abstinent from quit day to a specific point in time such as end of treatment or 6 months after the quit day
    • point prevalence, defined as measure of abstinence within set time period, usually 7 days before follow-up assessment

References

General references used

  1. Fiore MC, Jaen CR, Baker TB, et al; U.S. Department of Health and Human Services, Public Health Service. Clinical practice guideline: Treating tobacco use and dependence: 2008 update. DHHS 2008 May PDFPictureAsPdf, endorsed by American Academy of Pediatrics (Pediatrics 2008 Aug;122(2):471 PDFPictureAsPdf)
  2. Benowitz NL. Nicotine addiction. N Engl J Med. 2010 Jun 17;362(24):2295-303OpenInNewfull-textOpenInNew

Recommendation grading systems used

  • Public Health Service (PHS) guideline panel Strength of Evidence ratings
    • Strength of Evidence A - multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielded a consistent pattern of findings
    • Strength of Evidence B - some evidence from randomized clinical trials supported the recommendation, but the scientific support was not optimal
    • Strength of Evidence C - reserved for important clinical situations in which Panel achieved consensus on recommendation in the absence of relevant randomized controlled trials
    • Reference - United States Department of Health and Human Services/Public Health Service clinical practice guideline on treating tobacco use and dependence 2008 update (DHHS 2008 May PDFPictureAsPdf)
  • United States Preventive Services Task Force (USPSTF) grades of recommendation (June 2007 to June 2012)
    • Grade A - USPSTF recommends the service with high certainty of substantial net benefit
    • Grade B - USPSTF recommends the service with high certainty of moderate net benefit or moderate certainty of moderate-to-substantial net benefit
    • Grade C - clinicians may provide the service to select patients depending on individual circumstances; however, only small benefit is likely for most individuals without signs or symptoms
    • Grade D - USPSTF recommends against providing the service with moderate-to-high certainty of no net benefit or harms outweighing benefits
    • Grade I - insufficient evidence to assess balance of benefits and harms
    • Reference - USPSTF Grade DefinitionsOpenInNew
  • United States Preventive Services Task Force (USPSTF) grades of recommendation (prior to May 2007)
    • Grade A - USPSTF strongly recommends that clinicians provide the service to eligible patients, based on good evidence that the service improves important health outcomes and that benefits substantially outweigh harms
    • Grade B - USPSTF recommends that clinicians provide the service to eligible patients, based on at least fair evidence that the service improves important health outcomes and that benefits outweigh harms
    • Grade C - USPSTF makes no recommendation for or against routinely providing the service, based on at least fair evidence that the service can improve health outcomes but the balance of benefits and harms is too close to justify a general recommendation
    • Grade D - USPSTF recommends against routinely providing the service to asymptomatic patients, based on at least fair evidence that the service is ineffective or that harms outweigh benefits
    • Grade I - USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service
    • Reference - USPSTF Grade DefinitionsOpenInNew
  • National Heart, Lung, and Blood Institute (NHLBI) guideline grading system
    • definitions for evidence-based statements
      • Strong recommendation
        • benefits of recommended approach clearly exceed the harm, and quality of supporting evidence is excellent (Grade A or B)
        • in some clearly defined circumstances, strong recommendations may be made on basis of lesser evidence (Grade C or D) when high-quality evidence is impossible to obtain and anticipated benefits clearly outweigh harms
        • clinicians should follow strong recommendation unless clear and compelling rationale for alternative approach is present
      • Recommendation
        • benefits exceed harms but quality of evidence is not as strong (Grade B or C)
        • in some clearly defined circumstances, strong recommendations may be made on basis of lesser evidence (Grade D) when high-quality evidence is impossible to obtain and anticipated benefits clearly outweigh harms
        • clinicians should generally follow a recommendation but remain alert to new information and sensitive to patient preferences
      • Option
        • either quality of evidence that exists is suspect (Grade D) or well-performed studies (Grade A, B, or C) show little clear advantage to one approach versus another
        • clinicians should be flexible in their decision-making regarding appropriate practice, although they may set boundaries on alternatives; patient preference should have substantial influencing role
      • No recommendation
        • both lack of pertinent evidence (Grade D) and unclear balance between benefits and harms
        • clinicians should be minimally constrained in their decision-making and be alert to new published evidence that clarifies balance of benefit versus harm; patient preference should have substantial influencing role
    • grades of evidence
      • Grade A - well-designed randomized controlled trials or diagnostic studies performed on population similar to guidelines' target population
      • Grade B - randomized controlled trials or diagnostic studies with minor limitations; genetic natural history studies; overwhelmingly consistent evidence from observational studies
      • Grade C - observational studies (case-control and cohort design)
      • Grade D - expert opinion, case reports, or reasoning from first principles (bench research or animal studies)
    • Reference - NHLBI integrated guideline on cardiovascular health and risk reduction in children and adolescents (NHLBI Oct 2012OpenInNewPDFPictureAsPdf), summary can be found at NHLBI Oct 2012OpenInNewPDFPictureAsPdf

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • Alan Drabkin, MD (Section Editor of Family Medicine; Assistant Professor of Population Medicine, Harvard Medical School; Massachusetts, United States)
  • Allen Shaughnessy, PharmD, M Med Ed, FCCP (Professor of Family Medicine and Director of Master Teacher Fellowship, Tufts University Family Medicine Residency; Cambridge Health Alliance; Massachusetts, United States)
  • Dr. Shaughnessy declares no relevant financial conflicts of interest.
  • Alan Ehrlich, MD (Executive Editor; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States)
  • Dr. Ehrlich declares no relevant financial conflicts of interest.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T114788, Tobacco Use; [updated 2018 Dec 04, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T114788. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

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    General Information

    • Description

    • Definitions

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    Epidemiology

    • Incidence/Prevalence

    • Likely risk factors

    • Possible risk factors

    • Factors not associated with increased risk

    • Associated conditions

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    Etiology and Pathogenesis

    • Pathogenesis

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    History and Physical

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      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Past medical history (PMH)

      • Social history (SH)

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      Physical

      • HEENT

      • Lungs

      • Extremities

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    Diagnosis

    • Making the diagnosis

    • Testing overview

    • Blood tests

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    Management

    • Management overview

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    Complications and Prognosis

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      Complications

      • Complications of tobacco use

      • Complications from environmental tobacco smoke exposure

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      Prognosis

      • Mortality

      • Smoking cessation and relapse

      • Prognosis after tobacco cessation

      • Risks associated with smoking cessation

      • Additional information

  • KeyboardArrowRight

    Prevention and Screening

    • KeyboardArrowRight

      Prevention

      • Behavior-based approaches

      • Family-based approaches

      • Community-based approaches

      • School-based approaches

    • Screening

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    Quality Improvement

    • Medicare/Joint Commission National Hospital Inpatient Quality Measures

    • Physician Quality Reporting System Quality Measures

    • Quality and Outcomes Framework Indicators

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

      • Asian guidelines

      • Australian and New Zealand guidelines

      • Central and South American guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

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    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Alan Drabkin MD
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Affiliations

Section Editor of Family Medicine, DynaMed; Massachusetts, United States; Assistant Professor of Population Medicine, Harvard Medical School; Massachusetts, United States

Recommendations Editor
Allen Shaughnessy PharmD, M Med Ed, FCCP
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Affiliations

Professor of Family Medicine and Director of Master Teacher Fellowship, Tufts University; Massachusetts, United States

Conflicts of Interest

Dr. Shaughnessy declares no relevant financial conflicts of interest.

Deputy Editor
Alan Ehrlich MD
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Affiliations

Executive Editor, DynaMed; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Ehrlich declares no relevant financial conflicts of interest.

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