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An Updated Algorithm for
Choosing Among Smoking
Cessation Treatments
John R. Hughes
University of Vermont, USA
[email protected]
Disclosure
I have accepted honorarium or research
grants from almost all of the for-profit and
non-profit organizations that provide
products and services related to smoking
cessation.
Benefits of An Algorithm
• Provides complete description of program
• Clarifies program elements and their
integration
• Training Tool
• Encourages treatment quality
• Evidence-based
Problems of Algorithms
• Only focus on choosing among treatments
• Does not focus on improving quality of
provision of a given treatment
• Can never cover all possible situations
Types of Algorithms
• Optimal Care
• Stepped Care
• Treatment Matching
Generic Optimal Care
• Varenicline, or nicotine patch +
gum/lozenge/inhaler
• In-person, phone, or group
counseling
• Written or internet materials
Problems of
Generic Optimal Care
• Overtreats?
• Assumes no prior history of treatment
• Assumes no mitigating factors
Stepped Care Algorithm
No treatment (age 25)
Pamphlet
OTC NRT
Group therapy
Internet
Combined treatment
Quits (age 50)
Is Smoking Too Important to Use Stepped Care?
No treatment (age 22)
Pamphlet
OTC NRT
Group therapy
Internet
Heart attack (age 45)
Combined treatment
Quits
Treatment Matching:
The Search for the Holy Grail
Not Ready to Quit
•
•
•
•
Brief advice
Motivational interviewing (MI)
5 Rs (brief MI)
Reduction
Assessments for Those Who
Want to Quit
– Prior treatment and preference
– Daily vs nondaily smokers
– Pregnancy
– < 18 yrs old
– Alcohol/drug problem
– Non-drug psychiatric problem
– Weight gain concern
Assessments Not Included
• Motivation
• Level of dependence
• Withdrawal symptoms
• Craving
Med Options
First Line
• Combined NRT
• Varenicline
Second Line
• Single NRTs
• Bupropion (+NRT)
Third Line
• Clonidine
• Nortriptyline
• Nasal spray
Behavioral Treatment Options
First Line
• Group treatment
• Individual treatment
• Phone treatment
• Internet
Second Line
• Mobile phone texts
• Written materials
Action Points
• Abrupt vs gradual
• Abstain vs Lapse
• Lapse vs relapse
Summary
• Generic optimal and stepped care
algorithms should be avoided
• Treatment matching makes sense but not
empirically validated
• Only a few assessments needed
• Probably most important assessment is
prior treatments and current preferences
• Whether varencline should be prefered
over patch+gum/lozenge is unclear
Recent Algorithms
Abrams,D.B., Niaura,R., Brown,R.A., et al. The Tobacco Dependence
Treatment Handbook. A Guide to Best Practices. 2003; New
York, NY The Guilford Press
Bader P, McDonald P, Selby P. An algorithm for tailoring
pharmacotherapy for smoking cessation: Results from a Delphi
panel of international experts. Tobacco Control 2009 18:34-42
McEwen,A., Hajek,P., McRobbie,R. West,R. Manual of Smoking
Cessation. A Guide for Counselors and Publishers. 2006: Oxford
UK, Bladkwell Publishing.
Hughes JR. An updated algorithm for choosing among smoking cessation
treatments. J Substance Abuse Tx, in press.