1 current evidence-based cessation treatments: efficacy and critical ingredients saul shiffman
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Current Evidence-Based Cessation Treatments:
Efficacy and Critical Ingredients
Saul Shiffman
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Outcome of Smoking Cessation without Treatment
47% report trying to quit annually
13% of unaided quit efforts don’t last 24 h
Sustained unaided quit rate <3%
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Behavioral treatment
Pharmacologic treatment
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Behavioral Treatment
Aimed at assisting behavior change Practical psycho-educational approach Based on cognitive-behavioral treatment
principles “Multi-component” mix dominates
Few/no “brand-name” differentiated treatment approaches
Little/no content innovation in 20 years
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Active Ingredients in Behavioral Programs
Information
Motivation enhancement
Encouragement
Support
Planning & problem-solving
Tips & techniques
Medication support
Process orientation
Structure Conceptual
Temporal
A specific, step-by-step, pathway to quitting
Contact, engagement, caring
Lifestyle change
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Effectiveness of Behavioral Treatment Components
0
5
10
15
20
25
Est
. q
uit
rat
e
No contact
Aversive smoking*
Problem solving*
External support*
Support in trtmt*
Mood/stress mgmt
Weight/diet
Contracting
Relaxation
Source: AHRQ analysis: 2000
* Significantly better than nothing
Guess which treatment is no longer in current use
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More is Better
0
5
10
15
20
25
30
Est
. q
uit
rat
e
< 2 wks
2-4 wks
4-8 wks
> 8 wks
Source: AHRQ analysis: 2000
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Developments in Behavioral Treatment
Little/no content innovation Innovations in delivery modality &
disseminationChannelsMediaProvidersPackagingDuration
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The Old & New Models of Behavioral Treatment
Old way New way
ApproachApproach Cognitive-behavioral
Cognitive-behavioral
MediumMedium Face-2-face Phone, web
Delivery modelDelivery model Central De-centralized
ProviderProvider Semi-Pro Para-pro, computer
ScriptingScripting Ad-lib Scripted
IntensityIntensity High Low-Medium
MedicationMedication Negative Integrate
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Some Low-Intensity, Convenient Forms Are Ineffective
0
2
4
6
8
10
12
Est
. q
uit
rat
e No self-help
Hotline*
Tapes
Referal
Booklets
Source: AHRQ analysis: 2000
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Effectiveness Rises with Intensity
0
2
4
6
8
10
12
14
16
18
Est
. q
uit
rat
e No Tx
Self-help
Proactive phone*
Group Counseling*
Indiv. Counseling*
Source: AHRQ analysis: 2000
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Targeting to Groups
By gender, ethnicity, age, disease, etc, etc
No evidence they require different approaches
Targeted materials may be more appealing
Situations that affect the challenge & need may need different approach e.g., pregnancy, acute abstinence in hospital
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Tailoring to Individuals
One size does not fit all Assess user Tailor content, emphasis,
sequence to individual characteristics and needs
Model what a counselor woulddo
Greater utilization, satisfaction Improved efficacy
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Behavioral treatment
Pharmacologic treatment
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Pharmacological Treatment
Meant to address dependence-related symptoms
Nicotine Replacement Therapy (NRT) Patch Gum Lozenge Puffer Nasal spray
Bupropion New compounds, approaches coming
(Frank Vocci)
OTC
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All Medications Effective;About Equally Effective
0 5 10 15 20 25 30 35
Nicotine gum
Nicotine patch
Nicotine puffer
Nicotine nasal spray
Bupropion
Est. quit rate
Placebo
Active
Source: AHRQ analysis: 2000
Studies vary in populations, behavioral intervention, and length of follow-up
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Combining Medications Enhances Efficacy
0
5
10
15
20
25
30
35
Est
. q
uit
rat
e
Patch
Patch +
Source: AHRQ analysis: 2000
No combination approved by FDA
gum, puffer, nasal spray
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Est
ima
ted
Ass
iste
d Q
uit
Att
emp
ts(i
n t
ho
usa
nd
s)
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Year
Zyban
Inhaler
Nasal Spray
Patch
Gum
Innovation in Dissemination:OTC Marketing Increased Utilization
Burton et al, MMWR, 2000
Patch mania
OTC switch
Zyban intro
Nasal Spray
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Behavioral treatment
Pharmacologic treatment
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0
5
10
15
20
25
Low High
Intervention intensity
% A
bst
inen
t
Active
Placebo
Silagy meta-analysis
Pharmacological & Behavioral Treatments: Additive Effects
PharmRR = 1.9
Pharm RR = 1.5
BehRR = 1.7
BehRR = 1.9
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Treatment Options: Approximate Effectiveness
0%
5%
10%
15%
20%
25%
30%
No Tx Brief Intensive
Behavioral Treatment
Qu
it r
ate
(%)
No meds
Medication
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Impact of Treatment Depends on Utilization
Impact (# of quits)
=
Efficacy (% quit)
X
Utilization (# using method)
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Treatment Options: Most Effective are Least Used
0%
5%
10%
15%
20%
25%
30%
No Tx Brief Intensive
Behavioral Treatment
Qu
it r
ate
(%)
No meds
Medication
72%
11%7%
8% 1%
1%Least effective methods most used
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Even Among NRT Users Compliance is Poor – and it Matters
0%
10%
20%
30%
40%
50%
60%
70%
Low (4.7) High (10.5)
Number of Lozenges Per Day
% Q
uit
(6
wee
ks)
Active
Placebo
Average nicotine gum use ~ 4/day
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Status of Cessation Treatment and Goals for Change
Efficacy
Low High
Reach
Low Present
High
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Barriers to Treatment Use
Behavioral Tx Disconnect on
mechanism Don’t see a need Injury to esteem Doubt efficacy
Cost Mostly non-cash
Pharmacological Tx Disconnect on
mechanism Don’t see a need Injury to esteem Doubt efficacy Doubt safety Cost
Mixed empirical support
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We Are Reaching Only The Tip of the Iceberg
Not currently interested in quitting
56%
Interested in quitting, not ready to quit now
26%
Preparing to try quitting
13%
Actually trying to quit
5%
Sources: NHIS 2000, DiClemente et al, 1991
Our Church of Perpetual Abstinence
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Building Demand
“Build it, they will come” Marketing: product, positioning, packaging, promotion
Figure out what people want Explain what it is Explain why they need it Make it pleasant, palatable, effective Make it cool Different strokes for different folks Make it, attractive, accessible, & convenient Promote it (repeatedly) Maintain a continuing relationship & system of care
– not!
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NOT!