Introduction

Negative health consequences of nicotine use disorder (NUD) are one of the greatest public health threats, with more than 20 million Americans having died as a result of NUD, particularly cigarette smoking, in the past 50 years.¹ and 16 million Americans experiencing smoking-related disease.²  It is estimated that over 47 million U.S. adults currently use tobacco products, with over 34 million smoking cigarettes.³  These numbers may not well account for vaping of nicotine products that has recently been increasing in prevalence, thus underestimating the number of Americans affected by NUD. In the United States, tobacco use is the leading cause of preventable death and multiple serious health conditions, including smoking-related cancers; cardiovascular, pulmonary, and metabolic diseases; worsened pregnancy and birth outcomes; residential fires; and harms related to secondhand smoke exposure.⁴ It is estimated that, from 1965 through 2014, cigarette smoking prematurely claimed lives of more than 20,000,000 Americans—10 times more than the wars fought by the United States.¹

Evidence-Based Brief Interventions for NUD

There is strong evidence for Screening and Brief Intervention (SBI) as an effective screening and therapeutic approach to address NUD. Tobacco SBIs are recommended by the U.S. Preventive Services Task Force (USPSTF) as a routine component of primary care for all adults; with the recent emergence and rapid increase in e-cigarette use and vaping, recommendations to apply SBI toward non-combustible nicotine use are also emerging.^5,6 The National Institute on Drug Abuse provides a clinical resource for SBI screening tools for nicotine, alcohol, and other drug misuse and use disorders.⁷ (This is included in the Resources section below).

SBI approaches, often based on Motivational Interviewing, have been shown to be effective for nicotine use reduction and cessation, including when delivered by primary care clinicians.^5,6  For best effects, clinicians should schedule follow-up visits and reassess the patient’s progress with smoking reduction/cessation efforts. The SBIs often include strategies such as the “5 As” (Ask, Assess, Advise, Assist, Arrange) or the FRAMES (Feedback, Responsibility, Advice, Menu of Strategies, Empathy, Self-Efficacy) methods^8-10.  The 5 As is a recommended method to assess readiness to quit smoking.^11,12  For those unwilling to quit, Motivational Interviewing-based strategies (e.g., express empathy, develop discrepancy, roll with resistance, and support self-efficacy), can be useful to help increase patient motivation to reduce or quit nicotine use.^9,13  This includes the “5 Rs” approach (Relevance, Risks, Rewards, Roadblocks, Repetition)