Current Evidence-Based Cessation Treatments: Efficacy and Critical Ingredients

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 dont last 24 h
• Sustained unaided quit rate lt3

3
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 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 woulddo
• Greater utilization, satisfaction
• Improved efficacy

14
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 EffectiveAbout 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 DisseminationOTC Marketing
Increased Utilization
Zyban intro
Nasal Spray
Patch mania
OTC switch
Estimated Assisted Quit Attempts(in thousands)
Burton et al, MMWR, 2000
19
Behavioral treatment
Pharmacologic treatment
20
Pharmacological Behavioral Treatments Additive
Effects
Pharm 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 Efficacy
Low High
Reach Low Present
Reach High
26
Barriers to Treatment Use

• Behavioral Tx
• Disconnect on mechanism
• Dont see a need
• Injury to esteem
• Doubt efficacy
• Cost
• Mostly non-cash

• Pharmacological Tx
• Disconnect on mechanism
• Dont 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
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!