July 2008

Grant Results

SUMMARY

The Center for Tobacco Research and Intervention at the University of Wisconsin served as the lead organization in a project to update the U.S. Public Health Service (PHS) clinical practice guideline, Treating Tobacco Use and Dependence. A panel of 24 experts in the field of tobacco cessation conducted the update during 2006 and 2007.

The Agency for Healthcare Research and Quality published the 2008 update to the U.S. Public Health Service clinical practice guideline, Treating Tobacco Use and Dependence in May 2008. (Available online.)

Key Findings

  • There was considerable progress made in tobacco research during the period separating the 2008 update and the previous (2000) guideline, according to the guideline panel. The 2008 guideline reports that:
    • Tobacco dependence is increasingly recognized as a chronic disease that typically requires ongoing assessment and repeated intervention.
    • Clinicians have many more effective treatment strategies than were previously identified, including seven different first-line effective medications approved by the FDA for treating tobacco use and dependence.
    • There is stronger evidence that counseling is an effective tobacco cessation treatment strategy, when used alone or in combination with medications and other treatments.
    • There is evidence that counseling increases abstinence rates for pregnant smokers — and, for the first time, that counseling is an effective treatment for adolescents.
    • "Quitlines," which provide tobacco cessation counseling via telephone, are an effective intervention with broad reach.
    • There is renewed evidence that effective counseling and medication treatments are of benefit to a wide range of populations, including smokers in low-income and diverse racial/ethnic minority populations.
    • Health care policies, such as providing insurance coverage for tobacco cessation treatment, significantly affect the likelihood that smokers will receive effective treatment for tobacco dependence and successfully stop tobacco use. Several studies on which these recommendations were based were funded by the Robert Wood Johnson Foundation (RWJF) programs Substance Abuse Policy Research and Addressing Tobacco in Managed Care.
    • There is a growing need for continued research to enhance not only the efficacy but also the reach, use and appeal of effective cessation treatments and services so they reach and benefit a broader population of those who want to quit. This recommendation reflects the findings and recommendations of the Consumer Demand Roundtable, co-funded by the American Cancer Society, Centers for Disease Control and Prevention, American Legacy Foundation, National Cancer Institute, National Institute on Drug Abuse and RWJF.
    • Specific interventions have been identified that motivate smokers not willing to quit to make a quit attempt.

Funding
RWJF supported this project through a grant of $97,754 to the University of Wisconsin School of Medicine and Public Health from January 2006 to June 2007.

Other funders included:

  • Agency for Healthcare Research and Quality ($475,000)
  • American Legacy Foundation ($100,000)
  • Center for Tobacco Research and Intervention at the University of Wisconsin ($52,300)

 See Grant Detail & Contact Information
 Back to the Table of Contents


THE PROBLEM

The U.S. Public Health Service clinical practice guideline, Treating Tobacco Use and Dependence, represents the gold standard for health care providers on how best to help patients quit tobacco use, according to project director Michael Fiore, M.D., M.P.H.

Fiore is founder of the Center for Tobacco Research and Intervention at the University of Wisconsin School of Medicine and Public Health, and director of RWJF's program, Addressing Tobacco in Managed Care (see Grant Results for more information) and Addressing Tobacco in Healthcare. More than 5 million copies of the 2000 guideline-related materials have been distributed in English, Spanish and other languages across the globe.

The original guideline, developed in 1996 by the federal Agency for Healthcare Research and Quality (AHRQ) was published after the National Committee for Quality Assurance (NCQA), an accrediting organization for managed care plans, issued a call for measures inviting public participation in revising its Healthcare Effectiveness Data and Information Set (HEDIS) to include tobacco use prevention and medical interventions to help smokers quit.

HEDIS is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance and quality of managed health care plans. As a result, a survey measure of smoking prevalence and intervention, which highlighted medical advice to quit smoking, was included in a modified form in HEDIS 3.0.

The guideline was updated in 2000 by a consortium of tobacco cessation researchers and clinicians. The U.S. Public Health Service issued it with a recommended structure for a brief intervention. This structure is known as the Five A's:

  • ASK: Ask every patient about smoking status at every visit.
  • ADVISE: Provide clear, strong and personalized advice for the patient to stop smoking.
  • ASSESS: Assess the willingness of the patient to make a quit attempt at this time.
  • ASSIST: For patients willing to make a quit attempt, provide evidence-based cessation counseling and medications. For patients unwilling to quit at this time, provide motivation counseling.
  • ARRANGE: Follow-up to assess progress with the quit plan.

Both guidelines noted the need for a change in the health care delivery system that would make the delivery of these interventions a part of routine care for all tobacco users and the failure to provide it a sign of substandard care.

Since then, there has been a dramatic increase in published research about tobacco cessation counseling and other treatments, including the effectiveness of counseling through telephone quitlines and what works best to help specific groups of people to quit. Since the publication of the 2000 guideline the Food and Drug Administration approved two new medications — a nicotine lozenge and varenicline — to help people quit. And, through the foundation-supported, multifunded Youth Tobacco Cessation Collaborative, new youth-focused cessation research led to the identification of effective counseling strategies for teens and young adults, (i.e., smokers aged 12–24).

AHRQ, which publishes the guideline, mandates an assessment of the relevance of guidelines every five years. This assessment can typically result in a decision that the guideline is "current" as is, that a limited update is needed based on relevant new data or that a total rewrite is required. Based on this assessment, staff at the agency determined that an update of the 2000 tobacco guideline was necessary, rather than a complete revision.

 Back to the Table of Contents


RWJF STRATEGY

RWJF's commitment to smoking prevention and cessation dates back to the early 1990s and the beginning of the tenure of Steven Schroeder, M.D., as RWJF's third president. As a practicing physician, he had witnessed smoking's heavy toll firsthand and believed that RWJF could not fulfill its mission of improving the health of all Americans without addressing tobacco use.

Over the past 17 years, RWJF has invested in both tobacco prevention and treatment. Grant support included:

HEDIS

  • Funded the development of National Committee for Quality Assurance (NCQA) HEDIS 3.0 (Health Plan Employer Data and Information Set) performance measures for tobacco use and addiction. See Grant Results on ID# 028757.
  • Funded the development and field testing of additional HEDIS measures assessing the quality of health plan treatment for tobacco use and addiction. See Grant Results on ID# 037080.

AHRQ Guideline

  • Funded the production of the pocket guide. See Grant Results on ID# 029466.
  • Provided funding for a national conference on the guideline and dissemination of its proceedings. See Grant Results on ID# 030465.
  • Funded an array of medical societies to disseminate the guideline. See Grant Results on ID# 030525.
  • Funded two major unions to figure out how best to disseminate information about the guideline to leaders and members. See Grant Results on ID# 029471.
  • Along with other funders, supported the 2000 update of the guideline. See Grant Results on ID# 034068.

Other RWJF Cessation Programs and Initiatives

In addition, RWJF funded a number of major initiatives supporting research and advocacy to identify and disseminate effective cessation treatments. These include Addressing Tobacco in Managed Care, the Youth Tobacco Cessation Collaborative, Consumer Demand Roundtable, National Partnership to Help Pregnant Smokers Quit, the Campaign for Tobacco-Free Kids, SmokeLess States and Tobacco Policy Change.

 Back to the Table of Contents


THE PROJECT

The Center for Tobacco Research and Intervention at the University of Wisconsin served as the lead organization in a project to update the U.S. Public Health Service clinical practice guideline, Treating Tobacco Use and Dependence.

Project staff assembled a 24-member national guideline panel, which included tobacco cessation researchers and clinicians, representatives from professional societies, philanthropic institutions, government agencies and the business community. To ensure continuity, the panel included 15 of 18 members from the 2000 panel and nine new members. (See Appendix 1 for a list of guideline panel members.)

In addition, liaisons from five federal agencies participated in the guideline update. The agencies were:

  • Agency for Healthcare Research and Quality (AHRQ).
  • Centers for Disease Control and Prevention (CDC).
  • National Cancer Institute (NCI).
  • National Heart, Lung and Blood Institute (NHLBI).
  • National Institute on Drug Abuse (NIDA).

Methodology

The guideline panel employed an explicit, science-based methodology and expert clinical judgment to develop its recommendations. The panel also subcontracted with Duke Clinical Research Institute for assistance in conducting statistical analyses. As part of the process, the panel:

  • Solicited suggestions from the wider tobacco treatment and control community (including members of the Society for Research on Nicotine and Tobacco) on topics to review as part of the guideline update. That resulted in 64 potential topics for review.
  • Scanned some 8,700 articles, including 2,700 published since January 1999, to identify articles that addressed these topics and for potential inclusion in meta-analysis — a statistical technique for combining information from different studies to derive an overall estimate of a treatment's effect. The primary criterion for inclusion in a meta-analysis was that the article reported the long-term (more than five months) results of a randomized controlled trial of a tobacco-use intervention.
  • Deliberated and selected 11 key topics to be updated, based on the evidence uncovered in the literature review and clinical importance. (For a list of the 11 topics, see Appendix 2.)
  • Performed a meta-analysis on each of the 11 topic areas using 184 randomized controlled trials.
  • Created seven workgroups composed of guideline panel members to create recommendations in the 11 topic areas.
  • Convened a two-day panel meeting held in June 2007, at which each workgroup chair reported to the panel as a whole, with an ensuing discussion about and voting on the proposed recommendations.
  • Drafted the guideline, a process that produced six drafts and a final version. Prior to completion of the final, more than 90 independent peer reviewers were asked to review and comment on the document. Public comment was also solicited through a notice in the Federal Register.

Other Funding

Other funders included:

  • Agency for Healthcare Research and Quality ($475,000)
  • American Legacy Foundation ($100,000)
  • Center for Tobacco Research and Intervention at the University of Wisconsin ($52,300)

 Back to the Table of Contents


RESULTS

  • The Agency for Healthcare Research and Quality published the 2008 update to the U.S. Public Health Service clinical practice guideline, Treating Tobacco Use and Dependence in May 2008. (Available online.) The guideline contains:
    • Detailed strategies and recommendations for delivering and supporting effective treatments for tobacco use and dependence. See Recommendations.
  • The agency also released two supplemental publications with the guideline:

In addition, the agency released a series of webcasts at the launch event for the guideline update, available online. Remarks at the event by RWJF Distinguished Fellow/Senior Scientist C. Tracy Orleans, Ph.D., are also available online.

Key Findings in the Guideline

There was considerable progress made in tobacco research over the period separating the 2008 guideline update and the previous (2000) guideline, according to the guideline panel. The 2008 guideline reports that:

  • Tobacco dependence is increasingly recognized as a chronic disease that typically requires ongoing assessment and repeated intervention.
  • Clinicians have many more effective treatment strategies than were previously identified.
  • There are seven different first-line effective medications approved by the FDA for treating tobacco use and dependence:
    • Multiple combinations of medications have been shown to be effective.
    • The 2008 guideline provides evidence regarding the effectiveness of medications relative to one another.
  • There is stronger evidence that counseling is an effective tobacco cessation treatment strategy, when used alone or in combination with other treatments:
    • Counseling adds significantly to the effectiveness of tobacco cessation medications.
    • Quitlines, which provide tobacco cessation counseling via telephone, are an effective intervention with broad reach.
    • Counseling increases abstinence among pregnant smokers and adolescent smokers.
  • Health care policies significantly affect the likelihood that smokers will receive effective tobacco dependence treatment and successfully stop tobacco use. For example, making tobacco dependence treatment a covered benefit of insurance plans increases the likelihood that a tobacco user will receive treatment and quit successfully.
  • There is a strong call for research to discover effective strategies for increasing the reach and use of effective therapies.

Recommendations

According to the clinical practice guideline, Treating Tobacco Use and Dependence, the overarching goal of these recommendations is that clinicians strongly recommend the use of effective tobacco dependence treatments to their patients who use tobacco, and that health systems, insurers and purchasers assist clinicians in making such effective treatments available.

  • Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments, however, exist that can significantly increase rates of long-term abstinence.
  • It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting.
  • Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use the counseling treatments and medications recommended in this guideline.
  • Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective in this guideline.
  • Individual, group and telephone counseling are effective and their effectiveness increases with treatment intensity. Two components of counseling are especially effective and clinicians should use these when counseling patients making a quit attempt:
    • Practical counseling (problem-solving/skills training).
    • Social support delivered as part of treatment.

    Counseling but not medication is recommended for pregnant smokers and adolescent smokers. Several of the studies reviewed to support these recommendations include studies resulting from RWJF-funded Smoke-Free Families and Youth Tobacco Cessation Collaborative initiatives.
  • There are numerous effective medications for tobacco dependence and clinicians should encourage their use by all patients attempting to quit smoking, except when medically contraindicated or with specific populations for which there is insufficient evidence of safety and/or effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers and adolescents).
  • Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates:
    • Bupropion SR
    • Nicotine gum
    • Nicotine inhaler
    • Nicotine lozenge
    • Nicotine nasal spray
    • Nicotine patch
    • Varenicline
  • Clinicians should also consider the use of certain combinations of medications identified as effective in this guideline.
  • Counseling and medication are effective when used by themselves for treating tobacco dependence. However, the combination of counseling and medication is more effective than either alone. Clinicians should encourage all individuals making a quit attempt to use both counseling and medication.
  • Telephone quitline counseling is effective with diverse populations and has broad reach. Clinicians and health care delivery systems should both ensure patient access to quitlines and promote quitline use.
  • If a tobacco user is unwilling to make a quit attempt, clinicians should use the motivational treatments shown in this guideline to be effective in increasing future quit attempts.
  • Tobacco dependence treatments are both clinically effective and highly cost-effective relative to other clinical interventions. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in this guideline as covered benefits.

 Back to the Table of Contents


LESSONS LEARNED

  1. Working with as many experts as possible in the updating process is difficult but well worth the trouble in terms of the quality of the guideline produced. For example, although the panel rapidly reached consensus on many of the topics covered in this guideline, a few topics required very careful deliberation. This proved time consuming, and during the discussion, groups of panel members had divergent views on several topics. But the final conclusion reached at the end of the discussion was accepted as the appropriate conclusion, based on an exhaustive exploration of all scientific evidence. (Project Director/Fiore)
  2. Develop a clear understanding about the nature of the project and return to that understanding frequently during the process. For this project, that understanding was that the scope of the guideline was "the clinical treatment of tobacco use and dependence" and that treatment recommendations are based on analysis of the research literature. The panel returned to this understanding frequently as a way to refocus panel discussion away from tobacco control issues that, though important, did not belong in a guideline on clinical treatment. (Project Director/Fiore)
  3. Establish ways to manage "scope creep." In the original contract with the Agency for Healthcare Research and Quality, the number of topics to be analyzed was set at "three to five." However, many more topics than that deserved to be reviewed, and as expected panel members and the external tobacco community advocated for particular topics with no regard to available resources. The project team managed this expansion of scope in part by conceding some scope creep at the outset and resetting the number of topics to be analyzed at seven to 10 topics and hoping not to go past 10. (They ultimately ended up with 11 topics.) They also grouped topics whenever possible. (Project Director/Fiore)
  4. Establish methods to monitor, manage, detect and declare conflicts of interest. Conflicts of interest in producing guidelines are an increasing area of concern. To avoid any conflict of interests, the panel created procedures to increase transparency in the guideline process. These included:
    • Requiring panel members to fill out disclosure forms at the outset of the project.
    • Updating and reviewing the forms based on Public Health Service (PHS) criteria.
    • Asking members with potential conflicts of interest to recuse themselves from relevant portions of the meetings and from voting on relevant recommendations.
    • Expanding the group of people required to complete disclosure forms to include peer reviewers. (Project Director/Fiore)
  5. Responding to comments from 100 outside reviewers and the public adds considerably to the time needed to complete a guideline but is well worth the effort. The outside reviewers and public made more than 1,700 comments to the draft guideline. Considerable time and a high degree of organization was required for the thoughtful consideration of each. But a much clearer, more accurate guideline resulted. The public nature of the guideline development process, which included soliciting topics from the tobacco community at the beginning of the process, proved to be an important element in its transparency and credibility. It also led to the endorsement of this guideline by more than 50 professional organizations, far more than the previous Treating Tobacco Use and Dependence Guidelines and naturally led to dissemination activities by those endorsing organizations.
  6. Guidelines, even when based on thousands of articles, do not disseminate themselves. Both AHRQ and RWJF have supported previous efforts to publicize the guidelines and disseminate intervention tools to clinicians, health plans and the public.

    RWJF in concert with the co-funded National Tobacco Cessation Collaborative (NTCC) will focus its new dissemination efforts on consumers, addressing common misconceptions about effective treatments and promoting their wider use.

    Optimizing the use and impact of guideline-based treatments requires aligning cessation policies and programs with broader public health tobacco control efforts. For instance, in 2003, at the time it raised tobacco taxes and implemented a comprehensive smoke-free law, New York City's Department of Public Health and Mental Hygiene promoted the state quitline and provided free supplies of nicotine replacement therapy to the first 3,500 callers. Resulting, citywide one-year quit rates were the highest ever recorded in the United States. The Campaign for Tobacco-Free Kids is working to achieve this kind of alignment in its ongoing technical assistance and advocacy efforts. (Program Officer/Orleans)

 Back to the Table of Contents


AFTER THE GRANT

Project staff developed other supplemental publications for the guideline:

  • A fact sheet describing "what's new" in the guideline (distributed in the packet handed out at the launch meeting at the American Medical Association (AMA) Headquarters in Chicago).
  • An article for a peer-reviewed journal summarizing guideline findings. This is available online and will be published in the American Journal of Preventive Medicine, in the fall of 2008.
  • A commentary on the guideline by Michael Fiore, M.D., M.P.H., and Carlos Jaen, M.D., Ph.D., was published in the May 7, 2008 issue of the Journal of the American Medical Association.

Staff may also develop an abstract of the guideline.

 Back to the Table of Contents


GRANT DETAILS & CONTACT INFORMATION

Project

Co-Funding an Update of the National Clinical Guideline for Treating Tobacco Use and Dependence

Grantee

University of Wisconsin School of Medicine and Public Health (Madison,  WI)

  • Amount: $ 97,754
    Dates: January 2006 to June 2007
    ID#:  055358

Contact

Michael C. Fiore, M.D., M.P.H.
(608) 262-8673
mcf@ctri.medicine.wisc.edu

Web Site

http://www.ahrq.gov/path/tobacco.htm

 Back to the Table of Contents


APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Panelists for 2008 Update of Treating Tobacco Use and Dependence

Michael Fiore, M.D., P.P.H., Chair
Professor
University of Wisconsin School of Medicine and Public Health
Department of Medicine
Director
Center for Tobacco Research and Intervention
Madison, Wis.

Carlos Roberto Jaén, M.D., Ph.D., F.A.A.F.P., Vice Chair
Professor and Chair
Department of Family and Community Medicine
University of Texas Health Science Center at San Antonio
San Antonio, Texas

Timothy Baker, Ph.D.
Professor
University of Wisconsin School of Medicine and Public Health
Department of Medicine
Associate Director
Center for Tobacco Research and Intervention
Madison, Wis.

William C. Bailey, M.D., F.A.C.P., F.C.C.P.
Director
Lung Health Center
University of Alabama at Birmingham
Birmingham, Ala.

Neal L. Benowitz, M.D.
Chief
Division of Clinical Pharmacology and Experimental Therapeutics
University of California, San Francisco
San Francisco, Calif.

Susan J. Curry, Ph.D.
Director
Institute for Health Research and Policy
University of Illinois at Chicago
Chicago, Ill.

Sally Faith Dorfman, M.D., M.S.H.S.A.
Associate Director
Medical Affairs, Infertility
Ferring Pharmaceuticals, Inc.
Parsippany, N.J.

Erika S. Froelicher, R.N., M.A., M.P.H., Ph.D.
Professor
Department of Physiological Nursing
Department of Epidemiology and Biostatistics
University of California, San Francisco
San Francisco, Calif.

Michael G. Goldstein, M.D.
Associate Director
Clinical Education and Research
Institute for Healthcare Communication
New Haven, Conn.

Cheryl Healton, Dr.P.H.
President and Chief Executive Officer
American Legacy Foundation
Washington, D.C.

Patricia Nez Henderson, M.D., M.P.H.
Vice President
Black Hills Center for American Indian Health
Rapid City, S.D.

Richard B. Heyman, M.D.
Former Chair
Committee on Substance Abuse
American Academy of Pediatrics
Cincinnati, Ohio

Howard K. Koh, M.D., M.P.H., F.A.C.P.
Harvey V. Fineberg Professor of the Practice of Public Health
Associate Dean for Public Health Practice
Director of the Division of Public Health Practice
Department of Health Policy and Management
Harvard School of Public Health
Boston, Mass.

Thomas E. Kottke, M.D., M.S.P.H.
Senior Clinical Investigator
HealthPartners Research Foundation
Minneapolis, Minn.
Professor of Medicine
University of Minnesota
St. Paul, Minn.

Harry A. Lando, Ph.D.
Professor
Division of Epidemiology and Community Health
University of Minnesota
Minneapolis, Minn.

Robert E. Mecklenburg, D.D.S., M.P.H.
Consultant, Tobacco and Public Health
Potomac, Md.

Robin Mermelstein, Ph.D.
Deputy Director
Institute for Health Research and Policy
Director
Center for Health Behavior Research
Professor
Psychology Department
University of Illinois at Chicago
Chicago, Ill.

Patricia Dolan Mullen, Dr.P.H.
Professor of Health Promotion and Behavioral Sciences
University of Texas School of Public Health
Houston, Texas

C. Tracy Orleans, Ph.D.
Robert Wood Johnson Distinguished Fellow/Senior Scientist
Robert Wood Johnson Foundation
Princeton, N.J.

Lawrence Robinson, M.D., M.P.H.
Deputy Commissioner
Philadelphia Department of Public Health
Health Promotion/Disease Prevention
Philadelphia, Pa.

Maxine L. Stitzer, Ph.D.
Professor
Department of Psychiatry and Behavioral Sciences
Behavioral Biology Research Center
Johns Hopkins/Bayview Medical Center
Baltimore, Md.

Anthony C. Tommasello, B.S., M.S., Ph.D.
Director
Office of Substance Abuse Studies
University of Maryland School of Pharmacy
Baltimore, Md.

Louise Villejo, M.P.H., C.H.E.S.
Executive Director
Patient Education Office
Office of Public Affairs
University of Texas M.D. Anderson Cancer Center
Houston, Texas

Mary Ellen Wewers, Ph.D., M.P.H., R.N.
Professor
Division of Health Behavior and Health Promotion
College of Public Health
Associate Dean for Research and Faculty Development
Ohio State University
Columbus, Ohio


Appendix 2

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Eleven Topics Updated in Treating Tobacco Use and Dependence

  • Effectiveness of proactive quitlines.
  • Effectiveness of combining counseling and medication relative to either counseling or medication alone.
  • Effectiveness of varenicline (a new FDA-approved smoking cessation medication).
  • Effectiveness of various medication combinations.
  • Effectiveness of long-term medication use.
  • Effectiveness of tobacco use interventions for individuals of low socioeconomic status and/or limited formal education.
  • Effectiveness of tobacco use interventions for adolescent smokers.
  • Effectiveness of tobacco use interventions for pregnant smokers.
  • Effectiveness of tobacco use interventions for individuals with psychiatric disorders including substance use disorders.
  • Effectiveness of providing tobacco use interventions as a health benefit in insurance plans.
  • Effectiveness of systems interventions, including provider training and the combination of training and systems interventions.

 Back to the Table of Contents


BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Reports

Helping Smokers Quit: A Guide for Clinicians, a handy pocket reference to the guideline for clinicians. Rockville, Md.: Agency for Healthcare Research and Quality, 2008. Available online.

Help for Smokers and Other Tobacco Users, an easy-to-read consumer booklet. Rockville, Md.: Agency for Healthcare Research and Quality, 2008. Available online.

Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, Md.: Agency for Healthcare Research and Quality, 2008. Available online.

World Wide Web Sites

www.ahrq.gov/path/tobacco.htm#Clinic. "Treating Tobacco Use and Dependence: 2008 Update," on the Agency for Healthcare Research and Quality Web site includes the guideline update and supplemental materials. Rockville, Md: Agency for Healthcare Research and Quality. Updated May 2008.

www.rwjf.org/pr/product.jsp?id=29591. Webcast presentation of the launch event for the guideline update.

Presentations and Testimony

C. Tracy Orleans, Remarks at the Launch Event for PHS Tobacco Cessation Guidelines in Chicago. Available online.

 Back to the Table of Contents


Report prepared by: Robert Crum
Reviewed by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: C. Tracy Orleans

Most Requested