Final Recommendation Statement

Tobacco Use Prevention: Counseling, 1996

January 01, 1996

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Recommendation Summary

Population Recommendation Grade
All patients who use tobacco products Tobacco cessation counseling is recommended on a regular basis for all patients who use tobacco products. A
Pregnant women and parents of children living at home Pregnant women and parents with children living at home also should be counseled on the potentially harmful effects of smoking on fetal and child health. A
Patients who are interested in tobacco cessation The prescription of nicotine patches or gum is recommended as an adjunct for selected patients. A
Children, adolescents, and young adults Anti-tobacco messages should be included in health promotion counseling of children, adolescents, and young adults based on the proven efficacy of risk reduction from avoiding tobacco use. A
Patients who are interested in tobacco cessation There is insufficient evidence to recommend for or against clonidine as an effective adjunct to tobacco cessation counseling. C
Children, adolescents and young adults The evidence for the effectiveness of clinical counseling to prevent the initiation of tobacco use is not clear. C

Full Recommendation:

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Expand All

Smoking accounts for one out of every five deaths in the U.S.1 It is the most important modifiable cause of premature death, responsible annually for an estimated 5 million years of potential life lost.1,2 About 420,000 Americans die each year as a result of smoking.1 Since early studies in the 1950s and 1960s, a large body of epidemiologic evidence has accumulated regarding the health effects of smoking. Major cohort studies, many case-control studies, and other data sources provide consistent, convincing evidence linking the use of tobacco with a variety of serious pulmonary, cardiovascular, and neoplastic diseases. The scope of this report does not permit an examination of each study of the health effects of smoking or the nature of the risk relationship (e.g., relative risk, dose-response relationship) between smoking and each disease. Detailed reviews of this extensive literature have been published elsewhere.1-6 number of consistent findings from this body of evidence are well established. First, tobacco is one of the most potent of human carcinogens, causing an estimated 148,000 deaths among smokers annually due to smoking-related cancers.1 The majority of all cancers of the lung, trachea, bronchus, larynx, pharynx, oral cavity, and esophagus are attributable to the use of smoked or smokeless tobacco.2,6 Smoking also accounts for a significant but smaller proportion of cancers of the pancreas,3,7-9 kidney,2 bladder,3,10 and cervix.3,11-13 Second, smoking promotes atherosclerosis and is a leading risk factor for myocardial infarction and coronary artery, cerebrovascular, and peripheral vascular disease.2,3 It is responsible for about 100,000 deaths from coronary heart disease and 23,000 deaths due to cerebrovascular disease each year.1 Third, smoking is an important risk factor for respiratory illnesses, causing 85,000 deaths per year from pulmonary diseases such as chronic obstructive pulmonary disease (COPD) and pneumonia.1,3 Children and adolescents who are active smokers have an increased prevalence and severity of respiratory symptoms and illnesses, decreased physical fitness, and potential retardation of lung growth.14 Fourth, the nicotine in tobacco is an addictive drug, and the pharmacologic and behavioral processes that determine nicotine addiction are similar to those that determine addiction to drugs such as heroin and cocaine.15,16 The initiation of tobacco use at an early age is associated with more severe addiction as an adult. Fifth, tobacco use may be associated with an increased risk of osteoporosis.17,18 Sixth, smoking affects the health of nonsmokers. Smoking during pregnancy causes about 5-6% of perinatal deaths, 17-26% of low-birth-weight births, and 7-10% of preterm deliveries,2,3 and it increases the risk of miscarriage and fetal growth retardation.3 It may also increase the risk for sudden infant death syndrome (SIDS).19,20 Passive smoking (or environmental tobacco smoke) increases the risk of lung cancer in nonsmokers,4,21 causing approximately 3,000 lung cancer deaths each year.4 It may also increase the risk of coronary heart disease in otherwise healthy nonsmokers.22-25 Environmental tobacco smoke exposure increases the frequency of middle ear effusions and lower respiratory infections in children, causing an estimated 150,000-300,000 cases of lower respiratory tract infections leading to 7,500-15,000 hospitalizations.4 In children, passive smoking is also associated with a small but measurable reduction in lung function4 and exacerbates asthma,4,26,27 causing symptoms in 200,000 to 1,000,000 asthmatics in addition to as many as 8,000-26,000 new cases of asthma a year.4 Passive smoking has also been associated with an increased risk of SIDS.19,20, 27a Finally, cigarettes are responsible for about 25% of deaths from residential fires, causing some 1,000 fire-related deaths and 3,300 injuries each year.28 Estimated smoking-attributable costs for medical care in 1993 were $50 billion,29 and excess lifetime medical expenditures for the current cohort of smokers may be as high as $500 billion.30

Although smoking has declined in the past three decades, 25% of adults in the U.S. continue to smoke.31 Among adults, cigarette smoking is more common among men, Native Americans and Alaska Natives, and persons of low socioeconomic status or with 9-11 years of education.31 Due to an increase in smoking by women during the period between 1940 and the early 1960s, lung cancer mortality in females has risen steadily since the mid-1960s lung cancer is now the leading cause of cancer death in women.32 Two thirds of female smokers continue to smoke during pregnancy.33 Most smokers begin tobacco use as teenagers.14 Currently, 19% of all high school seniors smoke on a regular basis among black high school seniors, however, only 4% smoke regularly.33a Of persons aged 18-24, 26% are current smokers.31 Smokeless tobacco is regularly used by 3% of adults (5.3 million persons)34 and by about 20% of male high school seniors.14

Return to Table of Contents

There is a large body of evidence from prospective cohort and case-control studies showing that many of these health risks can be reduced by smoking cessation. Smokers who quit smoking before the age of 50 have up to half the risk of dying in the next 15 years that continuing smokers have evidence suggests that the risk of dying is reduced substantially even among persons who stop smoking after age 70.3 After 10 years of abstinence, the risk of lung cancer is 30-50% lower than that of continuing smokers the risk of oral and esophageal cancer is halved as soon as 5 years after cessation.3,7-9,35 Compared to current smokers, former smokers also have a lower risk of cervical and bladder cancer.3,13 One year after quitting, the risk of myocardial infarction and death from coronary heart disease is reduced by one half, and after 15 years it approaches that of nonsmokers.3 35a The risk and complications of peripheral artery disease decrease after smoking cessation.3 As early as 2 years after quitting, the risk of stroke starts to decrease, and within 5-15 years it returns to (or near to) that of persons who have never smoked.3,36 36a Relative to continuing smokers, smokers who quit have decreased COPD mortality rates respiratory symptoms such as cough, sputum production, and wheezing and infections such as bronchitis and pneumonia.3 Pregnant women who stop smoking by the 30th week of gestation have infants with higher birth weights than infants born to women who smoke throughout pregnancy.3

Return to Table of Contents

Clinicians have both the opportunity and the means to modify smoking behavior and address nicotine dependency in their patients. It has been estimated that about 70% of the 46 million adult smokers in the U.S. could be counseled by clinicians during the course of ongoing medical care.31,37 The effectiveness of tobacco cessation counseling in improving clinical outcomes has been demonstrated in several studies in pregnant women. In two randomized controlled trials, smoking cessation counseling with self-help materials significantly increased mean birth weight and decreased the incidence of intrauterine growth retardation.38,39 For nonpregnant individuals, evidence of improved clinical outcomes is more limited. Among otherwise healthy middle-aged smokers with spirometric evidence of early COPD, an intensive smoking cessation program combining behavior modification and nicotine gum significantly reduced the age-related decline in forced expiratory volume in 1 second (FEV1).39a In middle-aged men, smoking cessation counseling alone40 or in combination with dietary advice and/or hypertension management41,42 decreased coronary heart disease morbidity and mortality, although results were statistically significant in only one trial.41

A number of clinical trials have demonstrated the effectiveness of certain forms of clinician43-48 and group47,49,50 counseling in changing the smoking behavior of patients. In pregnant women, randomized controlled trials have reported improvements in abstinence rates of 5-23% between intervention and control groups.38,39,51-53 The intervention groups received individual counseling sessions at the time of the first prenatal visit, self-help manuals that targeted pregnant women, and mail or phone follow-up, while control groups received advice alone. A meta-analysis of 39 clinical trials in nonpregnant adults examined different types of clinical smoking cessation techniques involving various combinations of counseling, distribution of literature, and nicotine replacement therapy. It found higher cessation rates in the intervention compared to the control groups, with the differences in cessation rates averaging 6% after 1 year.47 Subsequent published trials have demonstrated increases in abstinence rates of 3-7% in patients receiving clinician counseling43-46,48 and of 8-25% with group counseling, compared to controls.49,50 The key elements of effective counseling seem to be providing reinforcement through consistent and repeated advice from a team of providers to stop smoking, setting a specific "quit date," and scheduling follow-up contacts or visits. Using additional modalities, such as self-help materials, referral to group counseling, advice from more than one clinician, or chart reminders identifying patients who smoke, seems to further enhance effectiveness.47,48,54-56

One controlled trial that evaluated the effectiveness of counseling in changing smokeless tobacco use found significantly higher abstinence rates at 12-month follow-up in patients receiving personalized advice and explanation of oral lesions by dental hygienists, self-help materials, and encouragement to set a quit date, compared to those receiving usual care.57 57a Another controlled trial in professional baseball team players found that compared to those receiving usual care, patients who received counseling (similar to that in the trial cited above) plus nicotine gum, and who were shown photographs of oral cancer-associated facial disfigurement had significantly higher smokeless tobacco cessation rates.58

As adjuncts to counseling, the prescription of nicotine products can facilitate smoking cessation.59-71 71a Randomized controlled trials have found that 12-month cessation rates after brief clinician counseling and multiple follow-up visits double from 4-9% with placebo to 9-25% with the nicotine patch.64,65,69,71 When used correctly and in combination with clinician advice to stop smoking, nicotine gum increases long-term smoking cessation rates by about one third.72,73 The higher dose nicotine gum (4 mg) has proven to be more effective than the 2 mg dose in highly nicotine-dependent subjects.73 (Nicotine dependence is commonly measured by the number of cigarettes smoked daily or by the Fagerström Test for Nicotine Dependence.74) Nicotine inhalers and nasal sprays are new modalities that have been found to be effective in clinical trials, but studies in primary care settings are needed before widespread use can be recommended.75-76 76a No trials have directly compared the effectiveness of the various adjuncts. Two meta-analyses of controlled trials of nicotine replacement therapies found a significant benefit for all modalities with no modality being significantly better than another.73,77 Nicotine gum, however, was found to be effective in patients with high but not low nicotine dependence, while there was no difference in the efficacy of the nicotine patch by severity of nicotine dependence.73 The evidence suggests that nicotine products are most effective as adjuncts to ongoing smoking cessation counseling.77,78 Furthermore, patients need proper instruction on how to use the nicotine replacement therapies. Patients have been reported to use nicotine patches and gum without discontinuing smoking, thus increasing the risk of nicotine toxicity.79,80 The most common adverse effects of nicotine gum include hiccups, flatulence, nausea, and indigestion, while the nicotine patch commonly causes local skin reactions and insomnia.73,78 The nicotine inhaler and nasal spray are associated with irritation of the throat and coughing, and with nasal soreness, respectively.75,76

Clonidine has also been investigated as an adjunct to smoking cessation counseling. Four of five randomized trials with follow-ups of 3-12 months have reported improved abstinence rates of 8-21%.81-85 Only one result was statistically significant,83 but sample sizes may have been inadequate in the other three trials that showed nonsignificant benefits.82,84,85 Side effects, including drowsiness and dry mouth, occurred in 5-25% of those receiving clonidine, resulting in significantly higher rates of discontinuation of clonidine compared to placebo.81,83,84

The prevention of initiation of tobacco use by children and adolescents is an important role for the clinician. Nearly all current initiation of tobacco use occurs before high school graduation.14 Approximately 25% of 12-13-year-old children report having experimented with cigarettes, and 4% are regular smokers.86 There have been no published trials that have adequately evaluated interventions by clinicians in preventing tobacco use initiation. Since the mid-1970s, however, over 90 controlled trials of school-based tobacco use prevention interventions have been published.14 School-based programs reduce the incidence87,88 and prevalence89-91 of tobacco use in adolescents at 2-4-year follow-up. Longer follow-up has shown little long-term benefit, however, suggesting that program effects need to be reinforced.92,93 The most successful of these programs involve teaching the skills to resist social pressures to use tobacco, along with the short- and long-term consequences of using tobacco (see Clinical Intervention).94 

Return to Table of Contents

All major health care organizations and authorities recommend routine clinician counseling of adults, pregnant women, parents, and adolescents to avoid or discontinue smoking and use of smokeless tobacco.95-108

Return to Table of Contents

Although the significant health hazards of tobacco use and the benefits of cessation are well established, studies suggest that many clinicians fail to counsel patients (or their parents) who smoke to stop tobacco use.37,109,110 This reluctance to intervene may be the result of a number of variables, including lack of confidence in the ability to provide adequate counseling, lack of patient interest, lack of financial reimbursement or personal reward, insufficient time, and inadequate staff support.111 As described above, however, a number of studies have shown that clinician counseling can change behavior, even when the intervention is relatively brief. Nearly 50% of all living individuals who have ever smoked have stopped,31 and 30% of quitters report being urged to quit by a physician.113 Approximately 90% of successful quitters have quit without intensive counseling but by stopping abruptly or with the help of quitting manuals.113 Moreover, even a modest decrease in smoking rates can have significant public health implications when multiplied by the more than 30 million smokers seen annually by U.S. clinicians.37 A cost-effectiveness study supports the clinical value of offering smoking cessation counseling during the routine office visit of patients who smoke.114

Although there are no data on the effectiveness of clinician counseling in preventing the initiation of tobacco use by children, school-based programs are effective in reducing the prevalence of smoking among children for up to 4 years. Clinicians can provide leadership and support that may enhance both school-based programs and community-based efforts such as restrictions on tobacco advertising, enforcement of laws that prevent minors' access to tobacco, and tax increases on tobacco products to decrease the demand among children.14 

Return to Table of Contents

A complete history of tobacco use, and an assessment of nicotine dependence among tobacco users, should be obtained from all adolescent and adult patients. Tobacco cessation counseling is recommended on a regular basis for all patients who use tobacco products ("A" recommendation). Pregnant women and parents with children living at home also should be counseled on the potentially harmful effects of smoking on fetal and child health ("A" recommendation). The optimal frequency for performing counseling to prevent tobacco use has not been determined with certainty, but repeated messages over long periods of time are associated with the greatest success in helping patients achieve abstinence.47 The prescription of nicotine patches or gum is recommended as an adjunct for selected patients ("A" recommendation). There is insufficient evidence to recommend for or against clonidine as an effective adjunct to tobacco cessation counseling ("C" recommendation).

Certain strategies can increase the effectiveness of counseling against tobacco use (also see published guidelines104,105,107,115-118):

  • Direct, face-to-face advice and suggestions. The most effective clinician message is a brief, unambiguous, and informative statement on the need to stop using tobacco. If possible, the clinician should also review the short- and long-term health, social, and economic benefits of quitting and foster the tobacco user's belief in his or her ability to stop. The message should address the patient's concerns and any barriers presented by age, social environment, nicotine dependence, and general health. If the patient is not contemplating cessation, then the clinician should try to motivate the patient again at the next visit. If the patient is contemplating stopping, then the clinician should try to get agreement on a specific "quit date" and should prepare the patient for withdrawal symptoms. Patients who have experienced a relapse after previous quit attempts should be reassured that most smokers achieve long-term cessation only after several unsuccessful attempts.
  • Reinforcement. Schedule "support visits" or follow-up telephone calls, especially during the first 2 weeks when relapse is common.119
  • Office reminders. Use a register system or chart stickers for tobacco users to increase the probability that an anti-tobacco message is delivered at each visit.
  • Self-help materials. Dispense a variety of effective self-help packages to motivate and aid the majority of tobacco users who quit on their own. These materials are listed in reference works 120 and are available from voluntary organizations in most communities.
  • Community programs for additional help in quitting. Local hospitals, health departments, community health centers, work sites, commercial services, and voluntary organizations frequently offer smoking cessation programs to which patients can be referred. Clinicians should not, however, refer patients to programs providing treatment of unproven efficacy (e.g., electric shock therapy).121
  • Drug therapy. The prescription of nicotine products as adjuncts to counseling may facilitate cessation by relieving withdrawal symptoms. Persons using the nicotine patch or gum should be advised to stop all tobacco use completely before starting the medication and to carefully store and dispose of products to prevent accidental ingestion by children or pets. The patch should be used on clean, dry, non-hairy skin sites that are alternated daily. A skin site should not be used more frequently than once a week.122 The patch is generally prescribed for 6-8 weeks over which time the dosage of nicotine is weaned.78 Those using nicotine gum should be instructed to chew the gum slowly and intermittently to allow proper absorption by the buccal mucosa. While using nicotine gum, patients should not drink or eat acidic substances such as coffee, colas, or citrus juices, which impair nicotine absorption.123 Nicotine gum is used as needed for up to 3 months, when the risk of relapse is greatest, and then tapered over the next 3 months.122 In pregnant or nursing patients or patients with a recent myocardial infarction, severe or worsening angina, serious arrhythmias, or vasospastic or endocrine disorders, the potential risks of nicotine adjuncts must be weighed carefully against the known adverse effects of tobacco. Nicotine adjuncts should also be used with caution in persons with peptic ulcer disease, claudication, renal or hepatic insufficiency, or accelerated hypertension. Nicotine gum is contraindicated in patients with active temporomandibular joint disease.122 

Anti-tobacco messages should be included in health promotion counseling of children, adolescents, and young adults based on the proven efficacy of risk reduction from avoiding tobacco use ("A" recommendation), although the evidence for the effectiveness of clinical counseling to prevent the initiation of tobacco use is less clear ("C" recommendation).

Because school-based programs have been shown to delay initiation of tobacco use, clinicians should support such programs in their communities. Effective school-based programs teach children skills to recognize and resist social pressure to smoke, dip, or chew tobacco as well as to understand the short-term (e.g., bad breath, cost, decreased athletic ability, cough, phlegm production, and shortness of breath) and long-term adverse consequences of tobacco use. Examples of support that clinicians can provide include: becoming aware of programs already in place in local schools and reinforcing their messages with patients and their parents, alerting parents to the existence of such programs, and encouraging parental participation and involvement serving as a consultant to local schools that implement such programs developing a list of referrals for tobacco cessation programs for youths and serving as a community advocate to keep effective programs in place (L.A. Maiman and D. Haynie, National Institutes of Health, personal communication, March 1994). 

Return to Table of Contents

The draft update of this chapter was prepared for the U.S. Preventive Services Task Force by Mary Jo Trepka, MD, MPH, and Carolyn DiGuiseppi, MD, MPH, based in part on a background paper on smoking and pregnancy prepared for the Canadian Task Force on the Periodic Health Examination by Susan E. Moner, MD.

Return to Table of Contents

1. Centers for Disease Control and Prevention. Cigarette smoking—attributable mortality and years of potential life lost — United States, 1990. MMWR. 1993;42:645–649. [PubMed]
2. Department of Health and Human Services. Rockville, MD; 1989. Reducing the health consequences of smoking: 25 years of progress. A report of the Surgeon General.
3. Department of Health and Human Services. Rockville, MD; 1990. The health benefits of smoking cessation: a report of the Surgeon General.
4. U.S. Environmental Protection Agency. Washington, DC; 1992. Respiratory health effects of passive smoking: lung cancer and other disorders.
5. National Cancer Institute. Smokeless tobacco or health: an international perspective. Bethesda: National Institutes of Health. 1993;(Publication no. DHHS (NIH) 93-3461.)
6. Department of Health and Human Services. Washington, DC; 1986. The health consequences of smokeless tobacco: a report of the advisory committee to the Surgeon General.
7. Ghadirian P, Simard A, Baillargeon J. Tobacco, alcohol and coffee and cancer of the pancreas: a population-based, case-control study in Quebec, Canada. Cancer. 1991;67:2664–2670. [PubMed]
8. Howe GR, Jain M, Burch JD, et al. Cigarette smoking and cancer of the pancreas: evidence from a population-based case-control study in Toronto, Canada. Int J Cancer. 1991;47:323–328. [PubMed]
9. Bueno de Mesquita HB, Maisonneuve P, Moerman CJ, et al. Life-time history of smoking and exocrine carcinoma of the pancreas: a population-based case-control study in the Netherlands. Int J Cancer. 1991;49:816–822. [PubMed]
10. Hartge P, Silverman DT, Schairer C, et al. Smoking and bladder cancer risk in blacks and whites in the United States. Cancer Causes Control. 1993;4:391–394. [PubMed]
11. Coker AL, Rosenberg AJ, McCann MF, et al. Active and passive cigarette smoke exposure and cervical intraepithelial neoplasia. Cancer Epidemiol Biomarkers Prev. 1992;1:349–356. [PubMed]
12. Sood AK. Cigarette smoking and cervical cancer: meta-analysis and critical review of recent studies. Am J Prev Med. 1991;7:208–213. [PubMed]
13. Gram IT, Austin H, Stalsberg H. Cigarette smoking and the incidence of cervical intraepithelial neoplasia, grade III, and cancer of the cervix uteri. Am J Epidemiol. 1992;135:341–346. [PubMed]
14. Department of Health and Human Services. Washington, DC; 1994. Preventing tobacco use among young people: a report of the Surgeon General.
15. Department of Health and Human Services. Rockville, MD; 1988. The health consequences of smoking: nicotine addiction. A report of the Surgeon General, 1988.
16. Henningfield JE, Cohen C, Pickworth WB. Psychopharmacology of nicotine. In: Orleans CT, Slade J, eds. Nicotine addiction. New York: Oxford University Press, 1994:24–45.
17. Hopper JL, Seeman E .The bone density of female twins discordant for tobacco use. N Engl J Med. 1994;330:387–392. [PubMed]
18. Seeman E, Melton LJ, O'Fallon WM, et al. Risk factors for spinal osteoporosis in men. Am J Med. 1983;75:977–983. [PubMed]
19. Mitchell EA, Ford RPK, Steward AW, et al. Smoking and the sudden infant death syndrome. Pediatrics. 1993;91:893–896. [PubMed]
20. Schoendorf KC, Kiely JL. Relationship of sudden infant death syndrome to maternal smoking during and after pregnancy. Pediatrics. 1992;90:905–908. [PubMed]
21. Stockwell HG, Goldman AL, Lyman GH, et al. Environmental tobacco smoke and lung cancer risk in nonsmoking women. J Natl Cancer Inst. 1992;84:1417–1422. [PubMed]
22. Hole DJ, Gillis CR, Chopra C, et al. Passive smoking and cardiorespiratory health in a general population in the west of Scotland. BMJ. 1989;299:423–427. [PMC free article] [PubMed]
23. Helsing KJ, Sandler DP, Comstock GW, et al. Heart disease mortality in nonsmokers living with smokers. Am J Epidemiol. 1988;127:915–922. [PubMed]
24. Humble C, Croft J, Gerber A, et al. Passive smoking and 20-year cardiovascular disease mortality among nonsmoking wives, Evans County, Georgia. Am J Public Health. 1990;80:599–601. [PMC free article] [PubMed]
25. Svendsen KH, Kuller LH, Martin MJ, et al. Effects of passive smoking in the Multiple Risk Factor Intervention Trial. Am J Epidemiol. 1987;126:783–795. [PubMed]
26. Chilmonczyk BA, Salmun LM, Megathlin KN, et al. Association between exposure to environmental tobacco smoke and exacerbations of asthma in children. N Engl J Med. 1993;328:1665–1669. [PubMed]
27. Sherrill DL, Martinez FD, Lebowitz MD, et al. Longitudinal effects of passive smoking on pulmonary function in New Zealand children. Am Rev Respir Dis. 1992;145:1136–1141. [PubMed]
27A. Klonoff-Cohen HS, Edelstein SL, Lefkowitz ES, et al. The effect of passive smoking and tobacco exposure through breast milk on sudden infant death syndrome. JAMA. 1995;273:795–798. [PubMed]
28. Miller AL. Quincy, MA; 1993. The U.S. smoking-material fire problem through 1991: the role of lighted tobacco products in fire.
29. Centers for Disease Control and Prevention. Medical-care expenditures attributable to cigarette smoking—United States, 1993. MMWR. 1994;43:469–472. [PubMed]
30. Hodgson TA. Cigarette smoking and lifetime medical expenditures. Milbank Q. 1992;70:81–125. [PubMed]
31. Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 1993. MMWR. 1994;43:925–930. [PubMed]
32. Centers for Disease Control and Prevention. Mortality trends for selected smoking-related cancers and breast cancer—United States, 1950-90. MMWR. 1993;42:857–866. [PubMed]
33. National Center for Health Statistics. Hyattsville, MD; 1993. Health United States 1992 and Healthy People 2000 Review.
33A. Giovino GA, Schooley MW, Zhu B-P, et al. Surveillance for selected tobacco-use behaviors, United States, 1900-1994. In: CDC surveillance summaries, November 18, 1994. MMWR. 1994;43(SS-3)1–43. [PubMed]
34. Centers for Disease Control and Prevention. Use of smokeless tobacco among adults—United States, 1991. MMWR. 1993;42:263–266. [PubMed]
35. Yu MC, Garabrant DH, Peters JM, et al. Tobacco, alcohol, diet, occupation, and carcinoma of the esophagus. Cancer Res. 1988;48:3843–3848. [PubMed]
35A. Negri E, La Vecchia C, D'Avanzo B, et al. Acute myocardial infarction: association with time since stopping smoking in Italy. GISSI-EFRIM Investigators. J Epidemiol Community Health. 1994;48:129–133. [PMC free article] [PubMed]
36. Kawachi I, Colditz GA, Stampfer MJ, et al. Smoking cessation and decreased risk of stroke in women. JAMA. 1993;269:232–236. [PubMed]
36A. Wannamethee SG, Shaper AG, Whincup PH, et al. Smoking cessation and the risk of stroke in middle-aged men. JAMA. 1995;274:155–160. [PubMed]
37. Centers for Disease Control and Prevention. Physician and other health-care professional counseling of smokers to quit—United States, 1991. MMWR. 1993;42:854–857. [PubMed]
38. Ershoff DH, Quinn VP, Mullen PD, et al. Pregnancy and medical cost outcomes of a self-help prenatal smoking cessation program in an HMO. Public Health Rep. 1990;105:340–347. [PMC free article] [PubMed]
39. Sexton M, Hebel JR A clinical trial of change in maternal smoking and its effect on birth weight. JAMA. 1984;251:911–915. [PubMed]
39A. Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA. 1994;272:1497–1505. [PubMed]
40. Rose G, Hamilton PJS, Colwell L, et al. A randomised controlled trial of anti-smoking advice: 10-year results. J Epidemiol Community Health. 1982;36:102–108. [PMC free article] [PubMed]
41. Hjermann I, Velve Byre K, Holme I, et al. Effect of diet and smoking intervention on the incidence of coronary heart disease. Report from the Oslo Study Group of a randomised trial in healthy men. Lancet. 1981;2:1303–1310. [PubMed]
42. Multiple Risk Factor Intervention Trial Research Group. Mortality rates after 10. 5 years for participants in the Multiple Risk Factor Intervention Trial: findings related to a priori hypotheses of the trial [published erratum in JAMA 1990;263:3151]. JAMA. 1990;263:1795–1801. [PubMed]
43. Wilson DM, Taylor DW, Gilbert JR, et al. A randomized trial of a family physician intervention for smoking cessation. JAMA. 1988;260:1570–1574. [PubMed]
44. Ockene JK, Kristeller J, Goldberg R, et al. Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial. J Gen Intern Med. 1991;6:1–8. [PubMed]
45. Bronson DL, Flynn BS, Solomon LJ, et al. Smoking cessation counseling during periodic health examinations. Arch Intern Med. 1989;149:1653–1656. [PubMed]
46. Hollis JF, Lichtenstein E, Vogt TM, et al. Nurse-assisted counseling for smokers in primary care. Ann Intern Med. 1993;118:521–525. [PubMed]
47. Kottke TE, Battista RN, DeFriese GH, et al. Attributes of successful smoking cessation interventions in medical practice: a meta-analysis of 39 controlled trials. JAMA. 1988;259:2882–2889. [PubMed]
48. Cohen SJ, Stookey GK, Katz BP, et al. Encouraging primary care physicians to help smokers quit: a randomized, controlled trial. Ann Intern Med. 1989;110:648–652. [PubMed]
49. Curry SJ, Marlatt GA, Gordon J, et al. A comparison of alternative theoretical approaches to smoking cessation and relapse. Health Psychol. 1988;7:545–556. [PubMed]
50. Stevens VJ, Hollis JF. Preventing smoking relapse, using an individually tailored skills-training technique. J Consult Clin Psychol. 1989;57:420–424. [PubMed]
51. Hjalmarson AIM, Hahn L, Svanberg B. Stopping smoking in pregnancy: effect of a self-help manual in controlled trial. Br J Obstet Gynaecol. 1991;98:260–264. [PubMed]
52. Windsor RA, Lowe JB, Perkins LL, et al. Health education for pregnant smokers: its behavioral impact and cost benefit. Am J Public Health. 1993;83:201–206. [PMC free article] [PubMed]
53. Mayer JKP, Hawkins B, Todd R. A randomized evaluation of smoking cessation interventions for pregnant women at a WIC clinic Am J Public Health. 1990;80:76–78. [PMC free article] [PubMed]
54. Russell MAH, Wilson C, Taylor C, et al. Effect of general practitioners' advice against smoking. BMJ. 1979;2:231–235. [PMC free article] [PubMed]
55. Janz NK, Becker MH, Kirscht MK, et al. Evaluation of a minimal contact smoking cessation intervention in an outpatient setting. Am J Public Health. 1987;77:805–808. [PMC free article] [PubMed]
56. Sanders D, Fowler G, Mant D, et al. Randomized controlled trial of anti-smoking advice by nurses in general practice. J R Coll Gen Pract. 1989;39:273–276. [PMC free article] [PubMed]
57. Little SJ, Stevens VJ, Severson HH, et al. An effective smokeless tobacco intervention for dental hygiene patients. J Dent Hyg. 1992;66:185–190. [PubMed]
57A. Stevens VJ, Severson H, Lichtenstein E, et al. Making the most of a teachable moment: a smokeless-tobacco cessation intervention in the dental office. Am J Public Health 199585231–235. [PMC free article] [PubMed]
58. Greene JC, Walsh MM, Masouredis C. A program to help major league baseball players quit using spit tobacco: report of a pilot study. J Am Dent Assoc. 1994;124:559–568. [PubMed]
59. Lam W, Sze PC, Sacks HS, et al. Meta-analysis of randomised controlled trials of nicotine chewing-gum. Lancet. 1987;2:27–30. [PubMed]
60. Jarvis MJ, Raw M, Russell MAH, et al. Randomised controlled trial of nicotine chewing gum. BMJ. 1982;285:537–540. [PMC free article] [PubMed]
61. Jackson PH, Stapleton JA, Russell MAH, et al. Predictors of outcome in a general practitioner intervention against smoking. Prev Med. 1986;15:244–253. [PubMed]
62. Tonnesen P, Fryd V, Hansen M, et al. Effect of nicotine chewing gum in combination with group counseling on the cessation of smoking. N Engl J Med. 1988;318:15–18. [PubMed]
63. Hughes JR, Gust SW, Kennan RM, et al. Nicotine vs placebo gum in general medical practice. JAMA. 1989;261:1300–1305. [PubMed]
64. Tonnesen P, Norregaard J, Simonsen K, et al. A double-blind trial of a 16-hour transdermal nicotine patch in smoking cessation. N Engl J Med. 1991;325:311–315. [PubMed]
65. Stapleton JA, Russell MA, Feyerabend C, et al. Dose effects and predictors of outcome in a randomized trial of transdermal nicotine patches in general practice. Addiction. 1995;90:31–42. [PubMed]
66. Transdermal Nicotine Study Group. Transdermal nicotine for smoking cessation: six-month results from two multicenter controlled clinical trials. JAMA. 1991;266:3133–3138. [PubMed]
67. Daughton DM, Heatley SA, Prendergast JJ, et al. Effect of transdermal nicotine delivery as an adjunct to low-intervention smoking cessation therapy: a randomized, placebo-controlled, double-blind study. Arch Intern Med. 1991;151:749–752. [PubMed]
68. Muller P, Abelin T, Ehrsam R, et al. The use of transdermal nicotine in smoking cessation. Lung. 1990;168(suppl):445–453. [PubMed]
69. Sachs DPL, Sawe U, Leischow SJ. Effectiveness of a 16-hour transdermal nicotine patch in a medical practice setting, without intensive group counseling. Arch Intern Med. 1993;153:1881–1890. [PubMed]
70. Fiore MC, Kenford SL, Jorenby DE, et al. Two studies of the clinical effectiveness of the nicotine patch with different counseling treatments. Chest. 1994;105:524–533. [PubMed]
71. Hurt RD, Dale LC, Fredrickson PA, et al. Nicotine patch therapy for smoking cessation combined with physician advice and nurse follow-up: one-year outcome and percentage of nicotine replacement. JAMA. 1994;271:595–600. [PubMed]
71A. Fiore MC, Smith SS, Jorenby DE, et al. The effectiveness of the nicotine patch for smoking cessation. A meta-analysis. JAMA. 1994;271:1940–1947. [PubMed]
72. Oster G, Huse DM, Delea TE, et al. Cost-effectiveness of nicotine gum as an adjunct to physician's advice against cigarette smoking. JAMA. 1986;256:1315–1318. [PubMed]
73. Tang JL, Law M, Wald N. How effective is nicotine replacement therapy in helping people to stop smoking? BMJ. 1994;308:21–26. [PMC free article] [PubMed]
74. Fagerström KO, Heatherton TF, Kozlowski LT. Nicotine addiction and its assessment. Ear Nose Throat J. 1992 1990;69:763–767. [PubMed]
75. Tonnesen P, Norregaard J, Mikkelsen K, et al. A double-blind trial of a nicotine inhaler for smoking cessation. JAMA. 1993;269:1268–1271. [PubMed]
76. Sutherland G, Stapleton JA, Russell MA, et al. Randomised controlled trial of nasal nicotine spray in smoking cessation. Lancet. 1992;340:324–329. [PubMed]
76A. Hjalmarson A, Franzon M, Westin A, et al. Effect of nicotine nasal spray on smoking cessation. A randomized, placebo-controlled, double-blind study. Arch Intern Med. 1994;154:2567–2572. [PubMed]
77. Silagy C, Mant D, Fowler G, et al. Meta-analysis on efficacy of nicotine replacement therapies in smoking cessation. Lancet. 1994;343:139–142. [PubMed]
78. Fiore MC, Jorenby DE, Baker TB, et al. Tobacco dependence and the nicotine patch: clinical guidelines for effective use. JAMA. 1992;268:2687–2694. [PubMed]
79. Johnson RE, Steven Stevens VJ, Hollis JF, et al. Nicotine chewing gum use in the outpatient care setting. J Fam Pract. 1992;34:61–65. [PubMed]
80. Orleans CT, Resch N, Noll E, et al. Use of transdermal nicotine in a state-level prescription plan for the elderly: a first look at "real-world" patch users. JAMA. 1994;271:601–607. [PubMed]
81. Prochazka AV, Petty TL, Nett L, et al. Transdermal clonidine reduced some withdrawal symptoms but did not increase smoking cessation. Arch Intern Med. 1992;152:2065–2069. [PubMed]
82. Wei H, Hao W, Young D. Effect of clonidine on cigarette cessation and in the alleviation of withdrawal symptoms. Br J Addict. 1988;83:1221–1226. [PubMed]
83. Glassman AH, Stetner F, Walsh T, et al. Heavy smokers, smoking cessation, and clonidine: results of a double-blind, randomized trial. JAMA. 1988;259:2863–2866. [PubMed]
84. Davison R, Kaplan K, Fintel D, et al. The effect of clonidine on the cessation of cigarette smoking. Clin Pharmacol Ther. 1988;44:265–267. [PubMed]
85. Hilleman DE, Mohiuddin SM, Delcore MG, et al. Randomized, controlled trial of transdermal clonidine for smoking cessation. Ann Pharmacother. 1993;27:1025–1028. [PubMed]
86. Moss AJ, Allen KF, Giovino GA, et al. Hyattsville, MD; 1992. Recent trends in adolescent smoking, smoking-update correlates, and expectations about the future. Advance data from vital and health statistics, no. 221. [PubMed]
87. Hansen WB, Johnson CA, Flay BR, et al. Affective and social influences approaches to the prevention of multiple substance abuse among seventh-grade students: results from Project SMART. Prev Med. 1988;17:135–154. [PubMed]
88. Abernathy TJ, Bertrand LD. Preventing cigarette smoking among children: results of a four-year evaluation of the PAL program. Can J Public Health. 1992;83:226–229. [PubMed]
89. Elder JP, Wildey M, de Moor C, et al. The long-term prevention of tobacco use among junior high school students: classroom and telephone interventions. Am J Public Health. 1993;83:1239–1244. [PMC free article] [PubMed]
90. Schinke SP, Gilchrist LD, Snow WH. Skills intervention to prevent cigarette smoking among adolescents Am J Public Health 198575665–667.View this and related citations using . [PMC free article] [PubMed]
91. Botvin GJ, Dusenbury L, Tortu S, et al. Preventing adolescent drug abuse through a multimodal cognitive-behavioral approach: results of a three-year study. J Consult Clin Psychol. 1990;58:437–446. [PubMed]
92. Flay BR, Koepke D, Thomson SJ, et al. Six-year follow-up of the first Waterloo School Smoking Prevention Trial Am J Public Health 1989791371–1376.View this and related citations using . [PMC free article] [PubMed]
93. Murray DM, Pirie P, Luepker RV, et al. Five- and six-year follow-up results from four seventh-grade smoking prevention strategies. J Behav Med. 1989;12:207–218. [PubMed]
94. Bruvold WH. A meta-analysis of adolescent smoking prevention programs. Am J Public Health. 1993;83:872–880. [PMC free article] [PubMed]
95. American College of Physicians, Health and Public Policy Committee. Methods for stopping cigarette smoking. Ann Intern Med. 1986;105:281–295. [PubMed]
96. American Academy of Family Physicians. Kansas City, MO; 1994. Age charts for periodic health examination. (Reprint no. 510.)
97. American Academy of Pediatrics. Tobacco-free environment: an imperative for the health of children and adolescents. Pediatrics. 1994;93:866–868. [PubMed]
98. American Academy of Pediatrics. Elk Grove Village, IL; 1988. Guidelines for health supervision II.
99. American College of Obstetricians and Gynecologists. Smoking and reproductive health. Washington, DC; Technical Bulletin no. 180. 1993:1–6.
100. Manley M, Epps RP, Husten C, et al. Clinical interventions in tobacco control: a National Cancer Institute training program for physicians. JAMA. 1991;266:3172–3173. [PubMed]
101. American Medical Association. Policy compendium. Chicago: American Medical Association. 1993:432–435.
102. American Dental Association. Transaction. 1992.
103. Canadian Task Force on the Periodic Health Examination. Canadian guide to clinical preventive health care. Ottawa: Canada Communication Group. 1994:26–36, 500-513.
104. National Institutes of Health. Clinical interventions to prevent tobacco use by children and adolescents: a supplement to: How to help your patients stop smoking: a National Cancer Institute manual for physicians. Bethesda: National Institutes of Health. 1989;(Publication no. DHHS (NIH) 89-3064.)
105. American Medical Association. Guidelines for adolescent preventive services (GAPS): recommendations and rationale. Chicago: American Medical Association. 1994:107–116.
106. American Academy of Otolaryngology-Head and Neck Surgery Washington, DC: Washington, DC; 1992. Smokeless tobacco.
107. National Institutes of Health. Tobacco and the clinician: interventions for medical and dental practice. Bethesda: National Institutes of Health. 1994;(Publication no. DHHS (NIH) 94-3693.)
108. Green M, ed. Arlington, VA; 1994. Bright Futures: guidelines for health supervision of infants, children, and adolescents.
109. Anda RF, Remington PL, Sienko DG, et al. Are physicians advising smokers to quit? The patient's perspective. JAMA. 1987;257:1916–1919. [PubMed]
110. Frankowski BL, Secker-Walker RH. Advising parents to stop smoking: opportunities and barriers in pediatric practice. Am J Dis Child. 1989;143:1091–1094. [PubMed]
111. Kottke TE, Willms DG, Solberg LI, et al. Physician-delivered smoking cessation advice: issues identified during ethnographic interviews. Tobacco Control. 1994;3:46–49.
112. Deleted in proof
113. Fiore MC, Novotny TE, Pierce JP, et al. Methods used to quit smoking in the United States. Do cessation programs help? [published erratum appears in JAMA 1991;265:358] JAMA. 1990;263:2760–2765. [PubMed]
114. Cummings SR, Rubin SM, Oster G. The cost-effectiveness of counseling smokers to quit. JAMA. 1989;261:75–79. [PubMed]
115. National Institutes of Health. Clinical opportunities for smoking intervention: a guide for the busy physician. Bethesda: National Institutes of Health. 1986;(Publication no. DHHS (NIH) 86-2178.)
116. National Institutes of Health. How to help your patients stop smoking: a National Cancer Institute manual for physicians. Bethesda: National Institutes of Health. 1989;(Publication no. DHHS (NIH) 89-3064.)
117. American Academy of Family Physicians. Kansas City, MO; 1987. AAFP stop smoking program.
118. American Medical Association. How to help patients stop smoking: guidelines for diagnosis and treatment of nicotine dependence. Chicago: American Medical Association, 1994.
119. Kenford SL, Fiore MC, Jorenby DE. Predicting smoking cessation: who will quit with and without the nicotine patch. JAMA. 1994;271:589–594. [PubMed]
120. U.S. Public Health Service. Washington, DC; 1994. Clinician's handbook of preventive services. pp. 117, 333–336.
121. Orleans CT. Understanding and promoting smoking cessation: overview and guidelines for physician intervention. Annu Rev Med. 1985;36:51–61. [PubMed]
122. Physicians' desk reference. Montvale, NJ; 1993. 47th ed; pp. 1264–1267, 1380-1387, 6765-6769. [PMC free article]
123. Henningfield JE, Radzius A, Cooper TM, et al. Drinking coffee and carbonated beverages blocks absorption of nicotine from nicotine polacrilex gum. JAMA. 1990;264:1560–1564. [PubMed]

Return to Table of Contents