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

2. 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.

3. Benefits of An Algorithm Provides complete description of program Clarifies program elements and their integration Training Tool Encourages treatment quality Evidence-based

4. 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

5. Types of Algorithms Optimal Care Stepped Care Treatment Matching

6. Generic Optimal Care Varenicline, or nicotine patch + gum/lozenge/inhaler In-person, phone, or group counseling Written or internet materials

7. Problems of Generic Optimal Care Overtreats? Assumes no prior history of treatment Assumes no mitigating factors

8. Stepped Care Algorithm No treatment (age 25) Pamphlet OTC NRT Group therapy Internet Combined treatment Quits (age 50)

9. 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

10. Treatment Matching: The Search for the Holy Grail

12. Not Ready to Quit Brief advice Motivational interviewing (MI) 5 Rs (brief MI) Reduction

13. 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

14. Assessments Not Included Motivation Level of dependence Withdrawal symptoms Craving

15. Med Options First Line Combined NRT Varenicline Second Line Single NRTs Bupropion (+NRT) Third Line Clonidine Nortriptyline Nasal spray

16. Behavioral Treatment Options First Line Group treatment Individual treatment Phone treatment Internet Second Line Mobile phone texts Written materials

17. Action Points Abrupt vs gradual Abstain vs Lapse Lapse vs relapse

18. 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

19. 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.