Mental Health Practice Guidelines

The below guidelines are meant for mental health professionals to use in their clinical practices. Please be aware that there are various authoring organizations. The NGC has summarized these guidelines. Links are provided to the original source within the guideline documents.

Guideline Title

Smoking cessation in HIV-infected patients.

Bibliographic Source(s)

New York State Department of Health. Smoking cessation in HIV-infected patients. New York (NY): New York State Department of Health; 2005 Jun. 8 p. [17 references]

Guideline Status

This is the current release of the guideline. This guideline updates a previous version: New York State Department of Health. Smoking cessation in HIV-infected patients. New York (NY): New York State Department of Health; 2004. 6 p.

Disease/Condition(s)

Human immunodeficiency virus (HIV) infection Nicotine dependence (smoking)

Guideline Category

CounselingEvaluationManagementPreventionScreeningTreatment

Clinical Specialty

Allergy and ImmunologyFamily PracticeInfectious DiseasesInternal MedicineObstetrics and GynecologyPsychology

Intended Users

PhysiciansPsychologists/Non-physician Behavioral Health CliniciansSubstance Use Disorders Treatment Providers

Guideline Objective(s)

To encourage clinicians to use evidence-based interventions to promote smoking cessation in HIV-infected patients

Target Population

Human immunodeficiency virus (HIV)-infected smokers

Interventions and Practices Considered

Screening Fagerstrom Test for Nicotine Dependence Evaluation/Counseling Assessment for Readiness to Quit Motivational interviewing techniques Identification of barriers to quitting Management/Treatment/Counseling/Prevention Smoking Cessation Assistance Setting a quit date Pharmacotherapy (nicotine replacement therapy or bupropion) Referral to a counseling program Relapse follow up

Major Outcomes Considered

Smoking cessation rates Risk and incidence of human immunodeficiency virus (HIV)-associated pulmonary infections and oropharyngeal lesions Incidence of antiretroviral (ARV)-associated complications Risk and incidence of acquired immunodeficiency syndrome (AIDS) defining and non-AIDS defining malignancies Incidence of coronary events in patients on protease inhibitor therapy Efficacy and cost-effectiveness of interventions designed to promote smoking cessation

Methods Used to Collect/Select Evidence

Hand-searches of Published Literature (Primary Sources) Hand-searches of Published Literature (Secondary Sources) Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

Not stated

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus (Committee)Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Quality of Evidence for Recommendation At least one randomized trial with clinical results Clinical trials with laboratory results Expert opinion

Methods Used to Analyze the Evidence

Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

The Human Immunodeficiency Virus (HIV) Guidelines Program works directly with committees composed of HIV Specialists to develop clinical practice guidelines. These specialists represent different disciplines associated with HIV care, including infectious diseases, family medicine, obstetrics and gynecology, among others. Generally, committees meet in person three to four times per year, and otherwise conduct business through monthly conference calls. Committees meet to determine priorities of content, review literature, and weigh evidence for a given topic. These discussions are followed by careful deliberation to craft recommendations that can guide HIV primary care practitioners in the delivery of HIV care. Decision making occurs by consensus. When sufficient evidence is unavailable to support a specific recommendation that addresses an important component of HIV care, the group relies on their collective best practice experience to develop the final statement. The text is then drafted by one member, reviewed and modified by the committee, edited by medical writers, and then submitted for peer review.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

Cost-effectiveness analyses were reviewed. Assistance with smoking cessation was found to be a cost-effective intervention that is underused by primary care providers and inadequately covered by health insurers.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

Not stated

Major Recommendations

The Quality of Evidence ratings (I-III) are defined at the end of the "Major Recommendations" field. Prevalence and Impact Clinicians should use evidence-based interventions to promote smoking cessation in human-immunodeficiency virus (HIV)-infected patients. (III) Key Point: Cigarette smoking is highly prevalent among both human immunodeficiency virus (HIV)-infected patients and substance users. Assessment for Readiness to Quit Clinicians should routinely assess HIV-infected patients' smoking status and readiness to quit. (III) Clinicians should identify and discuss barriers to quitting smoking for HIV-infected smokers who are not interested in stopping in the immediate future, but may consider it at a later time. (III) Smoking Cessation Assistance Clinicians should advise all smokers to quit and should offer smoking cessation assistance including pharmacotherapy to smokers who are interested in quitting. (I) (See Appendix B in the original guideline document for information on drugs used for smoking cessation.) Key Point: Clinicians should follow up attempts to quit with discussions of relapse prevention. Relapses should be followed up with discussions of new strategies for the next attempt to quit. Quality of Evidence for Recommendation At least one randomized trial with clinical results Clinical trials with laboratory results Expert opinion

Clinical Algorithm(s)

None provided

Type of Evidence supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Potential Benefits

Overall Benefits For human immunodeficiency virus (HIV) infected substance users, quitting smoking could decrease the risk of HIV-associated infections and malignancies and reduce the incidence of antiretroviral (ARV)-associated complications. Adding pharmacotherapy to in-person or telephone behavioral counseling doubles the cessation rate. Counseling is also effective by itself. See Appendix B in the original guideline document for information on specific advantages of the various drugs used for smoking cessation.

Potential Harms

Side Effects of Pharmacotherapy Nicotine Replacement Therapy Transdermal patches (Nicoderm CQ and Nicotrol): skin irritation, insomnia Nicotine polacrilex gum (Nicorette): mouth irritation, sore jaw, dyspepsia, hiccups Nicotine polacrilex lozenge: headache, heartburn, hiccups, nausea, cough Vapor inhaler (Nicotrol inhaler): mouth and throat irritation, cough Nasal spray (Nicotrol NS):nasal irritation, sneezing, coughing, teary eyes Non-Nicotine Therapy Sustained release bupropion (Zyban or Wellbutrin SR): insomnia, dry mouth, agitation, increases risk of seizure (<0.1%) Nortriptyline (recommended as second line therapy, although not approved by the Food and Drug Administration [FDA] as a smoking cessation aid): dry mouth, sedation, dizziness, should be used with caution in patients with coronary heart disease Clonidine (recommended as second line therapy, although not approved by the FDA as a smoking cessation aid): dry mouth, sedation, dizziness

Description of Implementation Strategy

Following the development and dissemination of guidelines, the next crucial steps are adoption and implementation. Once practitioners become familiar with the content of guidelines, they can then consider how to change the ways in which they take care of their patients. This may involve changing systems that are part of the office or clinic in which they practice. Changes may be implemented rapidly, especially when clear outcomes have been demonstrated to result from the new practice such as prescribing new medication regimens. In other cases, such as diagnostic screening or oral health delivery, however, barriers emerge which prevent effective implementation. Strategies to promote implementation, such as through quality of care monitoring or dissemination of best practices, are listed and illustrated in the companion document to the original guideline (HIV clinical practice guidelines, New York State Department of Health; 2003), which portrays New York's HIV Guidelines Program. The general implementation strategy is outlined below. Statement of purpose and goal to encourage adoption and implementation of guidelines into clinical practice by target audience Define target audience (providers, consumers, support service providers). Are there groups within this audience that need to be identified and approached with different strategies (e.g., HIV Specialists, family practitioners, minority providers, professional groups, rural-based providers)? Define implementation methods. What are the best methods to reach these specific groups (e.g., performance measurement consumer materials, media, conferences)? Determine appropriate implementation processes. What steps need to be taken to make these activities happen? What necessary processes are internal to the organization (e.g., coordination with colleagues, monitoring of activities)? What necessary processes are external to the organization (e.g., meetings with external groups, conferences)? Are there opinion leaders that can be identified from the target audience that can champion the topic and influence opinion? Monitor progress. What is the flow of activities associated with the implementation process and which can be tracked to monitor the process? Evaluate. Did the processes and strategies work? Were the guidelines implemented? What could be improved in future endeavors?

Implementation Tools

Chart Documentation/Checklists/FormsFor information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

IOM Care Need

Living with IllnessStaying Healthy

IOM Domain

EffectivenessPatient-centeredness

Bibliographic Source(s)

New York State Department of Health. Smoking cessation in HIV-infected patients. New York (NY): New York State Department of Health; 2005 Jun. 8 p. [17 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2004 (revised 2005 Jun)

Guideline Developer(s)

New York State Department of Health - State/Local Government Agency [U.S.]

Source(s) of Funding

New York State Department of Health

Guideline Committee

Substance Use Committee

Composition of Group that Authored the Guideline

Committee Chair: Marc N. Gourevitch, MD, MPH, Director, Division of General Internal Medicine, New York University School of Medicine Committee Members: Bruce Agins, MD, MPH, Medical Director, AIDS Institute, New York State Department of Health; Julia H. Arnsten, MD, MPH, Associate Professor Medicine, Epidemiology and Population Health, and Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center; Steven L. Batki, MD, Director, Addiction Psychiatry Clinic, Crouse Chemical Dependency Treatment Services, Interim Associate Chief of Staff for Research, Syracuse VA Medical Center, Professor and Director of Research, Department of Psychiatry, SUNY Upstate Medical University; Lawrence S. Brown, Jr., MD, MPH, Clinical Associate Professor of Public Health, Weill Medical College, Cornell University, President, American Society of Addiction Medicine, Senior Vice President, Division of Medical Services, Evaluation and Research, Addiction Research and Treatment Corporation; Brenda Chabon, PhD, Assistant Professor, Dept. of Psychiatry and Behavioral Sciences, Montefiore Medical Center/Albert Einstein College of Medicine; Barbara Chaffee, MD, MPH, Clinical Associate Professor of Medicine, Upstate Medical Center Clinical Campus at Binghamton, Binghamton, New York, Medical Director, Internal Medicine, Binghamton Family Care Center, United Health Services Hospitals; Steven Kipnis, MD, FACP, FASAM, Medical Director, New York State Office of Alcoholism & Substance Abuse Services; Nancy Murphy, NP, HIV Primary Care Provider, Center for Comprehensive Care, Room 14A36, St Luke's Roosevelt Hospital Center; David C. Perlman, MD, Chief, Infectious Diseases, Beth Israel Medical Center - Singer Division, Professor of Medicine, Albert Einstein College of Medicine, Director, AIDS Inpatient Unit, Beth Israel Medical Center; Benny Primm, MD, Executive Director, Division of Medical Services, Evaluation and Research, Addiction Research and Treatment Corporation; Sharon Stancliff, MD, Medical Director, Harlem East Life Plan, Medical Consultant, NYSDOH, AIDS Institute; Robert Whitney, MD, Erie County Medical Center AIDS Institute: Diane Rudnick, Director, Substance Abuse Section, New York State Department of Health

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

Guideline Availability

Electronic copies: Available from the New York State Department of Health AIDS Institute Web site. Print copies: Available from Office of the Medical Director, AIDS Institute, New York State Department of Health, 5 Penn Plaza, New York, NY 10001; Telephone: (212) 268-6108

Availability of Companion Documents

The following is available: HIV clinical practice guidelines. New York (NY): New York State Department of Health; 2003. 36 p. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site. Print copies: Available from Office of the Medical Director, AIDS Institute, New York State Department of Health, 5 Penn Plaza, New York, NY 10001; Telephone: (212) 268-6108 Additionally, the Fagerstrom Test for Nicotine Dependence is available in Appendix A in the original guideline document.

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI on February 2, 2005. This NGC summary was updated by ECRI on August 16, 2005.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is copyrighted by the guideline developer. See the New York State Department of Health AIDS Institute Web site for terms of use.

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx.NGC, AHRQ, and its contractor ECRI make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.Readers with questions regarding guideline content are directed to contact the guideline developer.