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An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA [email protected]

An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA [email protected]

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Page 1: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

An Updated Algorithm for Choosing Among Smoking

Cessation Treatments

John R. HughesUniversity of Vermont, USA

[email protected]

Page 2: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University 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.

Page 3: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

Benefits of An Algorithm

• Provides complete description of program

• Clarifies program elements and their integration

• Training Tool

• Encourages treatment quality

• Evidence-based

Page 4: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

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

Page 5: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

Types of Algorithms

• Optimal Care

• Stepped Care

• Treatment Matching

Page 6: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

Generic Optimal Care

• Varenicline, or nicotine patch + gum/lozenge/inhaler

• In-person, phone, or group counseling

• Written or internet materials

Page 7: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

Problems of Generic Optimal Care

• Overtreats?

• Assumes no prior history of treatment

• Assumes no mitigating factors

Page 8: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

Stepped Care AlgorithmNo treatment (age 25)

Pamphlet

OTC NRT

Group therapy

Internet

Combined treatment

Quits (age 50)

Page 9: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

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

Page 10: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

Treatment Matching: The Search for the Holy Grail

Page 11: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu
Page 12: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

Not Ready to Quit

• Brief advice

• Motivational interviewing (MI)

• 5 Rs (brief MI)

• Reduction

Page 13: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

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

Page 14: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

Assessments Not Included

• Motivation

• Level of dependence

• Withdrawal symptoms

• Craving

Page 15: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

Med OptionsFirst Line

•Combined NRT

•Varenicline

Second Line

•Single NRTs

•Bupropion (+NRT)

Third Line

•Clonidine

•Nortriptyline

•Nasal spray

Page 16: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

Behavioral Treatment Options

First Line

•Group treatment

•Individual treatment

•Phone treatment

•Internet

Second Line

•Mobile phone texts

•Written materials

Page 17: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

Action Points

• Abrupt vs gradual

• Abstain vs Lapse

• Lapse vs relapse

Page 18: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

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

Page 19: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu

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.