Counselling and Psychosocial Approaches ► Overview of Evidence
The following recommendations, and supporting evidence, have been extracted from existing clinical practice guidelines to inform the development of the CAN-ADAPTT Summary Statements.
CAN-ADAPTT worked with the Guidelines Advisory Committee (GAC) to conduct a literature search (years: 2002-2009) to identify existing clinical practice guidelines (CPGs). Five existing clinical practice guidelines were identified as meeting the high quality criteria set out in the AGREE Instrument. The recommendations contained in these high-quality CPGs have been used as the evidence base for the CAN-ADAPTT guideline development process. Click here to view CAN-ADAPTT’s guideline development process flowchart.
U.S. Department of Health and Human Services Public Health Service (2008)1
All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis. Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status or the use of other reminder systems such as chart stickers or computer prompts, significantly increases rates of clinician intervention. (Strength of Evidence = A)
Once a tobacco user is identified and advised to quit, the clinician should assess the patient’s willingness to quit at this time. (Strength of Evidence = C)
US: Tobacco dependence treatment is effective and should be delivered even if specialized assessments are not used or available. (Strength of Evidence = A) All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates. (Strength of Evidence = A)
Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates. Every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to an intensive intervention. (Strength of Evidence = A) There is a strong dose-response relation between the session length of person-to-person contact and successful treatment outcomes. Intensive interventions are more effective than less intensive interventions and should be used whenever possible (Strength of Evidence = A) Person-to-person treatment delivered for four or more sessions appears especially effective in increasing abstinence rates. Therefore, if feasible, clinicians should strive to meet four or more times with individuals quitting tobacco use. (Strength of Evidence = A)
Treatment delivered by a variety of clinician types increases abstinence rates. Therefore, all clinicians should provide smoking cessation interventions. (Strength of Evidence = A) Treatments delivered by multiple types of clinicians are more effective than interventions delivered by a single type of clinician. Therefore, the delivery of interventions by more than one type of clinician is encouraged (Strength of Evidence = C)
Proactive telephone counselling, group counselling, and individual counselling formats are effective and should be used in smoking cessation interventions. (Strength of Evidence = A) Smoking cessation interventions that are delivered in multiple formats increase abstinence rates and should be encouraged. (Strength of Evidence = A) Tailored materials, both print and Web-based, appear to be effective in helping people quit. Therefore, clinicians may choose to provide tailored self-help materials to their patients who want to quit. (Strength of Evidence = B)
All patients who receive a tobacco dependence intervention should be assessed for abstinence at the completion of treatment and during subsequent contacts. (1) Abstinent patients should have their quitting success acknowledged, and the clinician should offer to assist the patient with problems associated with quitting. (2) Patients who have relapsed should be assessed to determine whether they are willing to make another quit attempt. (Strength of Evidence = C)
Two types of counselling and behavioural therapies result in higher abstinence rates: (1) providing smokers with practical counselling (problem-solving skills/skills training), and (2) providing support and encouragement as part of treatment. These types of counselling elements should be included in smoking cessation interventions (Strength of Evidence = B)
The combination of counselling and medication is more effective for smoking cessation than either medication or counselling alone. Therefore, whenever feasible and appropriate, both counselling and medication should be provided to patients trying to quit smoking. (Strength of Evidence = A) There is a strong relation between the number of sessions of counselling, when it is combined with medication, and the likelihood of successful smoking cessation. Therefore, to the extent possible, clinicians should provide multiple counselling sessions, in addition to medication, to their patients who are trying to quit smoking. (Strength of Evidence = A)
Motivational intervention techniques appear to be effective in increasing a patient’s likelihood of making a future quit attempt. Therefore, clinicians should use motivational techniques to encourage smokers who are not currently willing to quit to consider making a quit attempt in the future. (Strength of Evidence = B)
New Zealand Ministry of Health (2007)2
Ask about and document smoking status for all patients. For people who smoke or have recently stopped smoking, the smoking status should be checked and updated on a regular basis. Systems should be in place in all health care settings (medical centres, clinics, hospitals, etc.) to ensure that smoking status is accurately documented on a regular basis. (Grade = A)
All doctors should provide brief advice to quit smoking at least once a year to all patients who smoke. (Grade = A) All other health care workers should also provide brief advice to quit smoking at least once a year to all patients who smoke. (Grade = B) Record the provision of brief advice in patient records. (Grade = C)
All doctors should provide brief advice to quit smoking at least once a year to all patients who smoke. (Grade = A) All other health care workers should also provide brief advice to quit smoking at least once a year to all patients who smoke. (Grade = B) Record the provision of brief advice in patient records. (Grade = C) Aim to see people for at least four cessation support sessions. (Grade = A)
Health care workers providing evidence-based cessation support (that is, more than just brief advice) should seek appropriate training. (Grade = C) Health care workers trained as smoking cessation providers require dedicated time to provide cessation support. (Grade = C)
Offer telephone counselling as an effective method of stopping smoking. People who smoke can be directed to Quitline (tollfree: 0800 778 778). (Grade = A) Providing face-to-face smoking cessation support either to individual patients or to groups of smokers is an effective method of stopping smoking. (Grade = A) Make self-help materials available, particularly those that are tailored to individuals, but such materials should not be the main focus of efforts to help people stop smoking. (Grade = √)
Institute for Clinical Systems Improvement (ICSI) (2004)3
Adults who have not used tobacco for at least 12 months and who have an easily visible mark on their chart to that effect should be asked about their tobacco use status yearly until abstinent for five years. Everyone without a tobacco use mark on the chart or those with a mark indicating use within the past six months should be asked at nearly every visit. (Class = A, C, D, M, R)
Ask a tobacco user who is ready to quit to set his/her own quit date. (Class = C, R)
All discussions with tobacco users should be documented. (No Grade)
Consideration may also be given to making a referral to a tobacco cessation consultant or a center with programs in tobacco cessation. Other resources include local tobacco cessation classes, community support systems, and self-help brochures and materials from drug companies. (Class=A)
Compliment and reinforce non-use in former tobacco users. (Class = R)
The first 12 months after quitting (especially the first two weeks) is when one is at the highest risk for relapse. Follow-up options include a face-to-face, telephone, or mailed (postal or electronic) expression of support and willingness to help. (Class = M)
A pre-contemplator (a user not ready to consider quitting within the next six months) benefits from non-confrontational messages about the importance of quitting and the awareness that provider help is available when ready. (No Class).
A contemplator (who will consider quitting within the next 1-6 months) is accepting of supportive urging to quit and encouragement of a plan. (Class = C, R)
Registered Nurses Association of Ontario (RNAO) (2007)4
Nurses implement minimal tobacco use intervention using the “Ask, Advise, Assist, Arrange” protocol with all clients. (Strength of Evidence =A)
Nurses introduce intensive smoking cessation intervention (more than 10 minutes duration) when their knowledge and time enables them to engage in more intensive counselling. (Strength of Evidence =A)
Nurses recognize that tobacco users may relapse several times before achieving abstinence and need to re-engage clients in the smoking cessation process.
(Strength of Evidence = B)
Nurses should be knowledgeable about community smoking cessation resources, for referral and follow-up. (Strength of Evidence = C)
Nurses encourage persons who smoke, as well as those who do not, to make their homes smoke-free, to protect children, families and themselves from exposure to second-hand smoke. (Strength of evidence = A)
1. U.S. Department of Health and Human Services Public Health Service. (2008, May). Clinical practice guideline: Treating tobacco use and dependence: 2008 update.
Ministry of Health. (2007, August). New Zealand smoking cessation guidelines. Wellington: Ministry of Health.
Institute for Clinical Systems Improvement (ICSI). (2004, June). Health care guideline: Tobacco use
prevention and cessation for adults and mature adolescents. Retrieved October 24, 2007 from:
Registered Nurses Association of Ontario (RNAO). (2007, March). Integrating smoking cessation into daily nursing practice.; Registered Nurses Association of Ontario (RNAO). (2003, October). Integrating smoking cessation into daily nursing practice. Retrieved October 26, 2007 from: http://www.rnao.org/bestpractices/PDF/BPG_smoking_cessation.pdf
Couselling and Psychosocial Approaches