Summary

USPSTF 2021 recommends clinicians ask all adults, including pregnant persons, about tobacco use, advise cessation, and provide interventions (Grade A). Nonpregnant adults should receive both behavioral counseling and FDA-approved pharmacotherapy (NRT, bupropion SR, varenicline); pregnant persons should receive behavioral counseling. Evidence is insufficient (I statement) for pharmacotherapy in pregnancy and for e-cigarettes as a cessation aid in any adult. Recommendations are consistent with the 2015 statement, with new commentary on e-cigarettes and the 2019 EVALI outbreak.

Key Recommendations

Ask all adults ≥18 years, including pregnant persons, about tobacco use at every visit using frameworks such as the 5 A’s (Ask, Advise, Assess, Assist, Arrange), Ask-Advise-Refer, or smoking status as a vital sign.
For nonpregnant adults who use tobacco, provide both behavioral counseling and FDA-approved pharmacotherapy (Grade A).
FDA-approved cessation pharmacotherapy is limited to nicotine replacement therapy (NRT), bupropion SR, and varenicline; varenicline appears more effective than NRT or bupropion SR.
Combination NRT (long-acting patch plus a short-acting form such as gum, lozenge, inhaler, or nasal spray) is more effective than single-form NRT.
For pregnant persons who use tobacco, provide behavioral counseling (cognitive behavioral, motivational, supportive therapy, feedback, incentives, social support); health education alone is not effective (Grade A).
Do not recommend e-cigarettes for tobacco cessation in any adult (I statement); direct patients to interventions with proven effectiveness and established safety.
Evidence is insufficient to recommend for or against pharmacotherapy (NRT, bupropion SR, varenicline) for cessation in pregnancy; use shared decision-making weighing severity of dependence (I statement).
Effective behavioral modalities include physician advice, nurse advice, individual counseling, group therapy, telephone quitlines, and mobile/text-message interventions.
Quitting smoking at any point in pregnancy benefits mother and infant, but quitting early in pregnancy provides the greatest fetal benefit.
Use multiple-choice questions to assess smoking status in pregnancy, as many pregnant patients underreport tobacco use.

Thresholds & Doses

Applies to adults ≥18 years, including pregnant persons.
Combined behavioral + pharmacotherapy interventions typically include ≥4 counseling sessions with 90–300 minutes total contact time; largest effect seen with ≥8 sessions.
Minimal physician advice defined as a single session <20 minutes with ≤1 follow-up; intensive advice = ≥20 minutes or >1 follow-up.
Physician advice increases cessation at ≥6 months: 8.0% vs 4.8% (RR 1.76).
Nurse advice: 14.2% vs 12.2% cessation (RR 1.29).
Individual counseling: 11.4% vs 7.7% (RR 1.48); group therapy: 10.4% vs 5.8% (RR 1.88).
Mobile phone/text-based: 9.5% vs 5.6% cessation (RR 1.54).
Any NRT: 16.9% vs 10.5% cessation at ≥6 months (RR 1.55); combination NRT: 16.9% vs 13.9% single-form (RR 1.25).
Bupropion SR: 19.0% vs 11.0% cessation (RR 1.64).
Varenicline: 25.6% vs 11.1% cessation (RR 2.24).
Combined pharmacotherapy + intensive behavioral counseling: 15.2% vs 8.6% cessation (RR 1.83).
Behavioral counseling in pregnancy: 16.4% vs 12.2% cessation in late pregnancy (RR 1.35); lowers low-birth-weight rate (RR 0.83) and increases mean birth weight by ~55.6 g.

Citations

Recommendation Summary table — Grade A for ask/advise/behavioral counseling + pharmacotherapy in nonpregnant adults; Grade A behavioral counseling in pregnant persons; I statements for pharmacotherapy in pregnancy and e-cigarettes.
Clinician Summary — implementation via 5 A’s, Ask-Advise-Refer, vital sign approach; FDA-approved options (NRT, bupropion SR, varenicline); ≥4 sessions, 90–300 min total contact.
Practice Considerations: Interventions for Tobacco Cessation — combined behavioral + pharmacotherapy, varenicline > NRT/bupropion, combination NRT > single NRT.
Practice Considerations: Pregnant Persons — behavioral counseling effective; health education alone ineffective; early-pregnancy cessation maximizes fetal benefit.
Suggestions for Practice Regarding I Statements — shared decision-making for pharmacotherapy in pregnancy; do not recommend e-cigarettes for cessation.
Supporting Evidence: Benefits of Tobacco Cessation Interventions — effect sizes (RRs) for physician/nurse/individual/group/telephone/mobile counseling and for NRT, bupropion SR, varenicline.
Table 2 — behavioral counseling intervention types, intensity, and demonstrated benefit by modality.
Update of Previous USPSTF Recommendation — consistent with 2015 statement; adds e-cigarette/EVALI context.