Tobacco use disorder: Screening and referral​

Key points

• People should be screened for tobacco use at least once per year. The primary care setting is the ideal place to do this.
• Tobacco use disorder is a chronic, relapsing condition. The U.S. Centers for Disease Control and Prevention suggests screening at every visit because smoking status can change.
• Adolescents should be screened for tobacco use because the toxic effects of tobacco on the nervous system may be greater during this period when significant neurodevelopment around inhibitory control occurs.

Why screen?

• Tobacco is the leading cause of preventable death in the world.
• There is no safe or low-risk level of tobacco use.
• 17% of Canadians smoke. The rate is higher among young adults (22% for ages 20–24 and 24% for ages 25–34).
• Smoking is responsible for 90% of chronic obstructive pulmonary disease and 30% of all cancers. It is a risk factor for diabetes and hypertension.
• 50% of people who smoke will die prematurely.
• Second-hand smoke is more lethal than other indoor contaminants such as asbestos, radon or wood fires.
• Adolescents should be screened for tobacco use because the toxic effects of tobacco on the nervous system may be greater during this period when significant neurodevelopment around inhibitory control occurs.
• Smoking during adolescence predicts tobacco use disorder in adulthood.

Screening in primary care

• People should be screened for tobacco use at least once per year. The primary care setting is the ideal place to do this. Screening involves asking about all forms of tobacco use, including smoked products and smokeless products.
• Tobacco use disorder is a chronic, relapsing condition. The U.S. Centers for Disease Control and Prevention suggests screening at every visit because smoking status can change.
• Health care providers should screen for tobacco use in people who have mental illness or other addiction issues.

Screening protocols

• A systematic approach to asking about tobacco use is best. Documenting tobacco status can involve medical questionnaires, stickers on charts, electronic health records, chart reminders or computer-reminder systems.
• Ask about all forms of tobacco use, including smoked products (cigarettes, cigarillos, cigars, blunts, pipe, shisha, hookah, electronic cigarette) and smokeless products (chewing tobacco, dipping tobacco, dissolvable tobacco, snus, snuff). Ask: "Have you used any form of tobacco in the past six months?"
• Another common screener is the Calculation of Pack Year History. This tool provides a numerical value of the person's lifetime tobacco exposure. This information should be highly visible on the client's chart. Use this formula: number of cigarettes per day multiplied by the number of years smoked divided by 20 equals pack years.
• An indirect screening tool is the breath carbon monoxide monitor. People who smoke have carbon monoxide levels greater than three parts per million.
• Use the five A's:

Ask: Identify in their charts all clients who smoke.

Advise: Find a kind but clear and forceful way to recommend that the client quit.

Assess: Check out the client's readiness to quit.

Assist: Offer assistance whether the client is ready or not.

Arrange: Schedule follow-up with you or with a smoking cessation clinic.

Diagnostic questionnaires

• Use the Fagerström Test for Nicotine Dependence, which is a common self-report measure.

Specialist referral

Consider referring the person for specialist treatment in the following situations:

• there are barriers to counselling, such as limited time, resources or staff
• the person has multiple problems that could benefit from multidisciplinary case management
• the person is not responding to interventions.

Evidence summary

Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT). (2011). Canadian Smoking Cessation Clinical Practice Guideline. Toronto, ON: Centre for Addiction and Mental Health.

Herie, M., Dragonetti, R. & Selby, P. (2012). Alcohol and tobacco use problems. In A. Khenti, J. Sapag, S. Mohamound & A. Ravindran (Eds.), Collaborative Mental Health: An Advanced Manual for Primary Care Professionals (pp. 195–214). Toronto, ON: Centre for Addiction and Mental Health.

Kwasnicka, A. & Selby, P. (2011). The patient with a substance use problem. In D. Goldbloom & J. Davine (Eds.), Psychiatry in Primary Care: A Concise Canadian Pocket Guide (pp. 85–112). Toronto, ON: Centre for Addiction and Mental Health.