Strategy 1.1 - United States Public Health Service Guideline

    • May 25, 2010

The U.S. Public Health Service (USPHS) released the first-ever clinical practice guideline for tobacco cessation in 1996. RWJF helped support the dissemination of the guideline to a variety of health care providers (including physicians, nurses, dentists and others).

RWJF also helped support update of the guideline in 2000 and 2008.

What Is Known About Guidelines for Cessation Treatment

A simple intervention—the "5 A's"—can help smokers quit. USPHS guideline released in 1996 recommended health care providers use a brief intervention, known as the "5 A's," to help the smokers among their patients quit smoking. Taking as little as three to five minutes, health care professionals could significantly increase their patients' quit attempts and successes with the following five steps:

  1. Ask about tobacco use—Identify and document tobacco use status for every patient at every visit.
  2. Advise to quit—In a clear, strong and personalized manner, urge every tobacco user to quit.
  3. Assess willingness to make a cessation attempt—Is the tobacco user willing to make a cessation attempt at this time?
  4. Assist in cessation attempt—For patients willing to make a cessation attempt, use appropriate counseling and pharmacotherapy to help them quit. For others, provide motivational interviewing to boost quitting readiness.
  5. Arrange follow-up—Schedule follow-up contact, preferably within the first week after the cessation date and refer to additional follow-up care as needed.

The guideline included recommendations for the types of health care system and policy changes needed to support widespread adherence to this brief intervention.

Key RWJF-Sponsored Initiatives: Research

RWJF sponsored a number of independent research projects that tested the effectiveness of the 5-A model and the USPHS guideline. These projects included:

  • The impact of practice guidelines on physician behavior. A survey of physicians examined the impact of the practice guideline on physician smoking-cessation treatment performance. (See the RWJF abstract of an article in the American Journal of Preventive Medicine that reported these results.)
  • A study of the incremental costs of using the 5 A's. The incremental costs for using the 5 A's among pregnant smokers range between $24 and $34 for each pregnant smoker, according to the RWJF abstract of an article in Public Health Reports.
  • USPHS guideline and Medicaid recipients. A study found that only 10 states used the USPHS guideline to help design treatment programs or benefits packages for Medicaid recipients. (See the report.)
  • The National Commission on Prevention Priorities found the 5-A intervention to be the single most effective and cost-effective clinical preventive service for adults in the general population, saving an estimated $500 per smoker and generating a long-term quit rate of 22 percent for smokers getting this advice routinely over the course of their care. (See the RWJF abstract of an article in the American Journal of Preventive Medicine that reported these results.)

Key RWJF-Sponsored Initiatives: Action to Put Research Into Practice

  • Original guideline (1996)—When USPS developed the original guideline, RWJF helped support the dissemination of those guidelines to a variety of health care providers (physicians, nurses, dentists and others) with special efforts to reach those serving underserved low-income populations, those in racial or ethnic minority groups and those serving youth and pregnant women. For instance, dissemination grants were awarded to the American Medical Association, the National Medical Association (for Black physicians), the National Association of Black Nurses, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists. (See Program Results on ID# 029466, ID# 030028, ID# 030465 and ID# 030525.)
  • Updates (in 2000 and 2008)—RWJF supported the update of the guideline in 2000 (based on a review of more than 6,000 articles) and 2008 (based on a review of more than 9,000 articles). The 2008 version gives greater emphasis to reaching the guideline's ultimate audience—smokers and their families—and places special emphasis on smokers with limited income and formal education, and on pregnant women, youth and smokers with co-occurring psychiatric and substance use disorders. RWJF also supported communication efforts to widely publicize the new guideline. (See Program Results on ID# 034068, ID# 045383, ID# 055358 and a news release and on the 2008 guideline.)
  • (2001–03)—RWJF supported this Web-based database offering practical support for the treatment of tobacco dependence. The site—aimed primarily for practitioners—gives one-stop access to the latest research on tobacco-cessation treatment. (See Program Results.)

Key RWJF-Sponsored Initiatives: Advocacy & Communications Around What Works

  • The Smoking Cessation Leadership Center has provided resources and tools for health care professionals to help them implement evidence-based smoking cessation treatments in their everyday practices.

Other Related Resources Funded by RWJF

  • The Oregon Research Institute implemented and evaluated a five-step guideline similar to the 5 A's with a group of dentists and dental hygienists in Oregon. (See Program Results.)
  • A study to determine the most effective way of measuring whether providers follow smoking-cessation guidelines. (See the RWJF abstract.)
  • A study published in the Archives on Internal Medicine in March 2006 to determine the optimal dosage for nicotine replacement therapies. (See journal article.)