1. Current Evidence-Based Cessation Treatments: Efficacy and Critical Ingredients
Saul Shiffman

2. 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%

3. Pharmacologic treatment
Behavioral treatment
Pharmacologic treatment

4. 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

5. 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

6. Effectiveness of Behavioral Treatment Components
Guess which treatment is no longer in current use
* Significantly better than nothing
Source: AHRQ analysis: 2000

7. More is Better
Source: AHRQ analysis: 2000

8. Developments in Behavioral Treatment
Little/no content innovation
Innovations in delivery modality & dissemination
Channels
Media
Providers
Packaging
Duration

9. The Old & New Models of Behavioral Treatment
Old way
New way
Approach
Cognitive-behavioral
Medium
Face-2-face
Phone, web
Delivery model
Central
De-centralized
Provider
Semi-Pro
Para-pro, computer
Scripting
Ad-lib
Scripted
Intensity
High
Low-Medium
Medication
Negative
Integrate

10. Some Low-Intensity, Convenient Forms Are Ineffective
Source: AHRQ analysis: 2000

11. Effectiveness Rises with Intensity
Source: AHRQ analysis: 2000

12. 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

13. Tailoring to Individuals
One size does not fit all
Assess user
Tailor content, emphasis, sequence to individual characteristics and needs
Model what a counselor would do
Greater utilization, satisfaction
Improved efficacy

14. Pharmacologic treatment
Behavioral treatment
Pharmacologic treatment

15. 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

16. All Medications Effective; About Equally Effective
Studies vary in populations, behavioral intervention, and length of follow-up
Source: AHRQ analysis: 2000

17. Combining Medications Enhances Efficacy
No combination approved by FDA
gum, puffer, nasal spray
Source: AHRQ analysis: 2000

18. Innovation in Dissemination: OTC Marketing Increased Utilization
Zyban intro
Nasal Spray
Patch mania
OTC switch
Estimated Assisted Quit Attempts (in thousands)
Burton et al, MMWR, 2000

19. Pharmacologic treatment
Behavioral treatment
Pharmacologic treatment

20. Pharmacological & Behavioral Treatments: Additive Effects
RR = 1.9
Pharm RR = 1.5
Beh
RR = 1.7
Beh
RR = 1.9
Silagy meta-analysis

21. Treatment Options: Approximate Effectiveness

22. Impact of Treatment Depends on Utilization
Impact (# of quits) =
Efficacy (% quit) X
Utilization (# using method)

23. Treatment Options: Most Effective are Least Used
Least effective methods most used 1% 8% 1%
11% 7%
72%

24. Even Among NRT Users Compliance is Poor – and it Matters
Average nicotine gum use ~ 4/day

25. Status of Cessation Treatment and Goals for Change
Efficacy
Low
High
Reach
Present

26. 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

27. We Are Reaching Only The Tip of the Iceberg
Actually trying to quit 5%
Not currently interested in quitting
56%
Interested in quitting, not ready to quit now
26%
Preparing to try quitting
13%
Our Church of Perpetual Abstinence
Sources: NHIS 2000, DiClemente et al, 1991

28. 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!

29. NOT!