An Updated Algorithm for Choosing Among Smoking

Cessation Treatments

John R. HughesUniversity of Vermont, USA

john.hughes@uvm.edu

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 AlgorithmNo 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

Combined treatment Heart attack (age 45)

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 OptionsFirst 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.