Upload
bernice-white
View
217
Download
0
Embed Size (px)
Citation preview
1
David B. Abrams, Ph.D
National Conference on Tobacco or Health Dec 10-12 2003 Boston
The Centers for Behavioral & Preventive Medicine
Brown Medical School, The Miriam Hospital
Interventions for Tobacco Dependence : An evidence-based, stepped-care, model
2
Change a Population ?Change a Population ?
o Population IMPACT to reduce Disease Burden.Population IMPACT to reduce Disease Burden.
o COMPREHENSIVE Intervention:COMPREHENSIVE Intervention: individual and “systems” individual and “systems”
o IMPACT =IMPACT = reach x effectiveness / unit cost reach x effectiveness / unit cost (EFFICIENCY)(EFFICIENCY)
o STEPPED-CARE:STEPPED-CARE: distributes a range of distributes a range of evidence-basedevidence-based interventions efficiently from least to most intensiveinterventions efficiently from least to most intensive
o LONG -TERM INVESTMENTLONG -TERM INVESTMENT - - sustained commitment sustained commitment Population change takes time can make a BIG difference Population change takes time can make a BIG difference
3
Never Smoked
Current Smoker
Ex Smoker
Initiation Rate
Cessation Rate
Source: Levy, D., Cummings & Hyland 2000 AJPH, 90 (8), 1311-1314
Relapse Rate
DISEASE BURDEN
Population Model of Tobacco Prevalence
Tobacco Industry PUSH
Public Health counter PUSH
- --
--
--
++
+
+
4
5000
4000
3000
1000
2000
0
Nu
mb
er
Great Depression
End of WW 2
1st Surgeon General’s Report
1st. World Conference on Smoking and Health
Broadcast Ad Ban
1st Great American Smoke-out
Nicotine Medications Available Over the Counter
Master Settlement Agreement
1st Smoking Cancer Concern
Federal Cigarette Tax Doubles
Surgeon General’s Report on Environmental Tobacco Smoke
1900 1910 1920 1930 1940 1950 19701960 199819901980
Year
Sources: United States Department of Agriculture; Surgeon General’s Reports.
Annual adult per capita cigarette consumption and major smoking and health events - United States, 1900-2000
Fairness Doctrine Messages on TV and Radio
A U.S. Public Health Service Clinical Practice GuidelineA U.S. Public Health Service Clinical Practice GuidelineJune 2000June 2000
Reviewed over 6,000 studies since 1970 and conducted meta analyses Reviewed over 6,000 studies since 1970 and conducted meta analyses on over 190 and clinical consensus on over 500 studies that met on over 190 and clinical consensus on over 500 studies that met rigorous research design and outcome measurement criteria,rigorous research design and outcome measurement criteria,
Fiore MC, Bailey WC, Cohen, SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline, USDHHS
Treating Tobacco Use andTreating Tobacco Use and DependenceDependence
PHSPHS
6
Major Findings and Major Findings and Panel Recommendations Panel Recommendations
1. Tobacco dependence is a chronic condition 1. Tobacco dependence is a chronic condition that often requires repeated intervention. that often requires repeated intervention. However, effective treatments exist that can However, effective treatments exist that can produce long-term or even permanent produce long-term or even permanent abstinence.abstinence.
7
Major Findings and Major Findings and Panel RecommendationsPanel Recommendations
2.2. Because effective tobacco dependence Because effective tobacco dependence treatments are available, every person who treatments are available, every person who uses tobacco should be offered one or more of uses tobacco should be offered one or more of these treatments.these treatments.
8
Major Findings andMajor Findings and Panel Recommendations Panel Recommendations
3. It is essential that clinicians and health 3. It is essential that clinicians and health care delivery systems (including care delivery systems (including administrators, insurers, and administrators, insurers, and purchasers) institutionalize the purchasers) institutionalize the consistent identification, documentation, consistent identification, documentation, and treatment of every tobacco user and treatment of every tobacco user seen in a health care setting.seen in a health care setting.
9
Major Findings andMajor Findings and Panel Recommendations Panel Recommendations
4. Brief tobacco dependence treatment is 4. Brief tobacco dependence treatment is effective, and every person who uses tobacco effective, and every person who uses tobacco should be offered at least brief treatment.should be offered at least brief treatment.
10
Major Findings and Major Findings and Panel RecommendationsPanel Recommendations
5. There is a strong 5. There is a strong dose-responsedose-response relation relation between the intensity of tobacco dependence between the intensity of tobacco dependence counseling and its effectiveness. Treatments counseling and its effectiveness. Treatments involving person-to-person contact (via involving person-to-person contact (via individual, group, or proactive telephone individual, group, or proactive telephone counseling) are consistently effective, counseling) are consistently effective, and their and their effectiveness increases with treatment effectiveness increases with treatment intensity (e.g., minutes of contact).intensity (e.g., minutes of contact).
11
Major Findings and Major Findings and Panel RecommendationsPanel Recommendations6. Three types of counseling and behavioral 6. Three types of counseling and behavioral
therapies were found to be especially effective therapies were found to be especially effective and should be used with all patients attempting and should be used with all patients attempting tobacco cessation:tobacco cessation: Provision of practical counseling Provision of practical counseling
(problem-solving/skills training)(problem-solving/skills training) Provision of social support as part of treatment (intra-Provision of social support as part of treatment (intra-
treatment social support)treatment social support) Help in securing social support outside of treatment Help in securing social support outside of treatment
(extra-treatment social support)(extra-treatment social support)
12
Major Findings andMajor Findings and Panel Recommendations Panel Recommendations7. Numerous effective pharmacotherapies for 7. Numerous effective pharmacotherapies for
smoking cessation now exist. Except in the smoking cessation now exist. Except in the presence of contraindications, these should be presence of contraindications, these should be used with all patients attempting to quit smoking.used with all patients attempting to quit smoking. Five Five first-linefirst-line pharmacotherapies were identified that pharmacotherapies were identified that
reliably increase long-term smoking abstinence rates:reliably increase long-term smoking abstinence rates:
Bupropion SRBupropion SR Nicotine gumNicotine gum Nicotine inhalerNicotine inhaler
Nicotine nasal sprayNicotine nasal spray Nicotine patchNicotine patch
13
Major Findings andMajor Findings and Panel Recommendations Panel Recommendations 8.8. Tobacco dependence treatments are Tobacco dependence treatments are
both clinically effective and cost-effective both clinically effective and cost-effective relative to other medical and disease relative to other medical and disease prevention interventions. prevention interventions.
14
Translating Findings into PracticeTranslating Findings into Practice
15
Reducing Population Disease BurdenReducing Population Disease Burden
--proactive, reach, access, --proactive, reach, access, --efficacy, --efficacy, --organizational infrastructure, --organizational infrastructure, --sustained societal commitment--sustained societal commitment Impact = Participation (reach) x EfficacyImpact = Participation (reach) x Efficacy
EFFICIENCY = Impact / Unit CostEFFICIENCY = Impact / Unit Cost
Source: Abrams et al ., Annals of Behavioral Medicine, 1996
16High
High
Low
Par
tici
pati
on (
Rea
ch)
Intervention Effectiveness
Intensive Counseling
clinic
Self-help
Brief
Counseling
Efficiency
Cost
Population IMPACT of Stepped-Care Model
17
Efficacy of Treatment Efficacy of Treatment ( (n n = 58 studies)= 58 studies)
FormatFormatEstimated Estimated
Abstinence RateAbstinence RateOdds RatioOdds Ratio(95%) CI(95%) CI
No format No format (reference group)(reference group) 10.8%10.8%1.01.0
13.9%13.9%1.31.3(1.1-1.6)(1.1-1.6)
Self-helpSelf-help
Proactive phoneProactive phonecounselingcounseling
Group counselingGroup counseling
12.3%12.3%
13.1%13.1%1.21.2(1.1-1.4)(1.1-1.4)
1.21.2(1.02-1.3)(1.02-1.3)
Individual counselingIndividual counseling 16.8%16.8%1.71.7(1.4-2.0)(1.4-2.0)
18
Tailored Behavioral CommunicationsTailored Behavioral Communications
o Credible information created especially for an individual based Credible information created especially for an individual based on unique information on unique information from from that person (and updated as they that person (and updated as they change over time)change over time)
o Advances in computers make it possible for real time interaction Advances in computers make it possible for real time interaction
o Can be combined with other interventions (e.g. brief counseling)Can be combined with other interventions (e.g. brief counseling)
o Everywhere we look, the concept of Everywhere we look, the concept of
mass customizationmass customization is being applied is being applied
Internet based intervention has potentially large Internet based intervention has potentially large reach, available 23/7/365 -- now being reach, available 23/7/365 -- now being evaluated with efficacy 12-23 % at 3 mo.evaluated with efficacy 12-23 % at 3 mo.
19High
High
Low
Par
tici
pati
on (
Rea
ch)
Intervention Effectiveness
Intensive Counseling
NRT
Self-help
Brief
Counseling
+ NRT
Efficiency
Cost
Population IMPACT of Stepped-Care Model
20
Brief Clinical InterventionsBrief Clinical Interventionso The “5 A’s” for patients willing to make a quit The “5 A’s” for patients willing to make a quit
attemptattempto The “5 R’s” for patients unwilling to make a quit The “5 R’s” for patients unwilling to make a quit
attempt at this timeattempt at this timeo Relapse prevention for patients who have Relapse prevention for patients who have
recently quitrecently quito Health care administrators, insurers, and Health care administrators, insurers, and
purchasers should institutionalize guideline purchasers should institutionalize guideline findingsfindings
21
Opportunity for InterventionOpportunity for Intervention
o 70% of smokers have made at least one 70% of smokers have made at least one unsuccessful quit attemptunsuccessful quit attempt
o 46% try to quit each year46% try to quit each year
o More than 70% of smokers visit a health care More than 70% of smokers visit a health care setting each yearsetting each year
22
Efficacy of varying intervention intensity levels - total amount of contact time (n = 35 studies)
Total amount of contact time
No Minutes
1-3 Minutes
4-30 minutes
31-90 minutes
91 + minutes
Number of arms
16
12
20
16
16
Estimated odds ratio (95% C.I.)
1.0
1.4 (1.1, 1.8)
1.9(1.5, 2.3)
3.0 (2.3,3.8)
3.2 (2.3, 4.6)
Estimated abstinence rate (95% C.I.)
11.0
14.4 (11.3, 17.5)
18.8 (15.6, 22.0)
26.5 (21.5, 31.4)
28.4 (21.3, 35.5)
Source: Fiore MC, Bailey WC, Cohen, SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline, USDHHS,
23
6 Month Self ReportedSmoking Cessation Rates
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Advice Counseling Counseling + Gum
9%12%
17%
Physician Delivered InterventionFrom Ockene et al., 1991
PercentAbstinent
24
Pharmacological Intervention Effectiveness
• 1.5 - 3 X1.5 - 3 X more effective than placebomore effective than placebo
• Not Not related to level of Nicotine Dependencerelated to level of Nicotine Dependence
• Retains effectiveness when provided with Retains effectiveness when provided with minimal support minimal support
• Most effective when provided with Most effective when provided with behavioral treatmentbehavioral treatment
25
Efficacy of and estimated abstinence rates for the nicotine patch (n = 27 studies) and for nicotine patch therapy (n = 3)
Pharmocotherapy
Placebo
Nicotine Patch
Placebo
Over-the-counter nicotine patch therapy
Number of arms
28
32
3
3
Estimated odds ratio (95% C.I.)
1.0
1.9(1.7,2.2)
1.0
1.8(1.2,2.8)
Estimated abstinence rate
(95% C.I.)
10.0
17.7 (16.0,19.5)
6.7
11.8(7.5,16.0)
Source: Fiore MC, Bailey WC, Cohen, SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline, USDHHS, June 2000, Rockville, MD
26
1
1.5
2
2.5
3
3.5
bupropionbupropion2.62.6
nicotine patchnicotine patch3.03.0
2.42.42.32.32.12.1
1.71.7
nicotine gumnicotine gum1.61.6
nicotine nasal spray
nicotine nasal spray
2.32.3nicotine inhaler
nicotine inhaler
2.42.4
Odds Ratios for Meta-analysesOdds Ratios for Meta-analyses
27
Eventually From Pharmacogenomics to...Eventually From Pharmacogenomics to...
ContextCultureCommunityBehaviorCognitive Schema Neuroscience
pharmacogenomic - biobehavioral - socio - cultural
tailoring
+ x x
=
28
Systems InterventionsSystems Interventions
o Health care administrators, insurers, and Health care administrators, insurers, and purchasers should implement systems purchasers should implement systems interventions to promote the consistent interventions to promote the consistent identification and treatment of tobacco identification and treatment of tobacco users:users: Implement a tobacco-user identification Implement a tobacco-user identification
system in every clinic (screening)system in every clinic (screening) Provide education, resources, and Provide education, resources, and
feedback to promote provider interventionfeedback to promote provider intervention
29
Vital Signs StampVital Signs Stamp
VITAL SIGNSVITAL SIGNS
Pulse:Pulse:
TemperatureTemperature::
Respiratory Rate:Respiratory Rate:
(circle one)(circle one)
CurrentCurrent FormerFormer NeverNeverTobacco Use:Tobacco Use:
Blood Pressure:Blood Pressure:
WeightWeight::
30
Impact of having a tobacco use status identification system in place on rates of clinician intervention with their patients who
smoke (n = 9 studies)
Screening System
No Screening system in place to identify smoking status (ref. group)
Screening system in place to identify smoking status
Number of arms
9
9
Estimated odds ratio (95% C.I.)
1.0
3.1 (2.2-4.2)
Estimated intervention rate
(95% C.I.)
38.5
65.6 (58.3-72.6)
Source: Fiore MC, Bailey WC, Cohen, SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline, USDHHS, June 2000, Rockville, MD
31High
High
Low
Rea
ch
Effectiveness
Individual Counseling
CLINIC
Group Program
Self-change
Educational
Pamphlets
Self-help guides
Brief Counseling
EfficiencyPopulation IMPACT of Stepped-Care Model
Behavioral Stepped Care
PLUS PHARMACO
THERAPY
Plus Tailored Mass Custom
ization
Cost
32
Estimated Efficacy and Utilization of Estimated Efficacy and Utilization of Approaches to Smoking CessationApproaches to Smoking Cessation
EFFICACY REACH IMPACT (% quit at (# using method (total # Intervention 6 months) annually) quitters)
None (unaided) 3 22,800,000 684,000
Internet 12 6,000,000 720,000
Rx NRT (1995) 14 2,500,000 350,000
OTC NRT (1996) 14 6,300,000 882,000
Behavioral counseling 24 395,000 94,800
Inpatient treatment 32 500 160
Adapted from Shiffman et al. (1998). Annual Review of Public Health.
33
Change a Population ?Change a Population ?
o Population IMPACT to reduce Disease Burden.Population IMPACT to reduce Disease Burden.
o COMPREHENSIVE Intervention:COMPREHENSIVE Intervention: individual and “systems” individual and “systems”
o IMPACT =IMPACT = reach x effectiveness / unit cost reach x effectiveness / unit cost (EFFICIENCY)(EFFICIENCY)
o STEPPED-CARE:STEPPED-CARE: distributes a range of distributes a range of evidence-basedevidence-based interventions efficiently from least to most intensiveinterventions efficiently from least to most intensive
o LONG -TERM INVESTMENTLONG -TERM INVESTMENT - - sustained commitment sustained commitment Population change takes time can make a BIG difference Population change takes time can make a BIG difference