An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of...
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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.](https://reader035.fdocuments.in/reader035/viewer/2022072014/56649e7d5503460f94b7f8d0/html5/thumbnails/1.jpg)
An Updated Algorithm for Choosing Among Smoking
Cessation Treatments
John R. HughesUniversity of Vermont, USA
![Page 2: An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes University of Vermont, USA john.hughes@uvm.edu.](https://reader035.fdocuments.in/reader035/viewer/2022072014/56649e7d5503460f94b7f8d0/html5/thumbnails/2.jpg)
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.
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Benefits of An Algorithm
• Provides complete description of program
• Clarifies program elements and their integration
• Training Tool
• Encourages treatment quality
• Evidence-based
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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
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Types of Algorithms
• Optimal Care
• Stepped Care
• Treatment Matching
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Generic Optimal Care
• Varenicline, or nicotine patch + gum/lozenge/inhaler
• In-person, phone, or group counseling
• Written or internet materials
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Problems of Generic Optimal Care
• Overtreats?
• Assumes no prior history of treatment
• Assumes no mitigating factors
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Stepped Care AlgorithmNo treatment (age 25)
Pamphlet
OTC NRT
Group therapy
Internet
Combined treatment
Quits (age 50)
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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
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Treatment Matching: The Search for the Holy Grail
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Not Ready to Quit
• Brief advice
• Motivational interviewing (MI)
• 5 Rs (brief MI)
• Reduction
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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
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Assessments Not Included
• Motivation
• Level of dependence
• Withdrawal symptoms
• Craving
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Med OptionsFirst Line
•Combined NRT
•Varenicline
Second Line
•Single NRTs
•Bupropion (+NRT)
Third Line
•Clonidine
•Nortriptyline
•Nasal spray
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Behavioral Treatment Options
First Line
•Group treatment
•Individual treatment
•Phone treatment
•Internet
Second Line
•Mobile phone texts
•Written materials
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Action Points
• Abrupt vs gradual
• Abstain vs Lapse
• Lapse vs relapse
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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
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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.