Recommendations for Tobacco Cessation Specialists and Programs Given that the specialist may assume diverse roles regarding smoking cessation-treatment, assessment, training of nonspecialists, and program development and evaluation—it is apparent that virtually all of the information in the guideline might be important to the specialist. However, highlighted in For the Specialist: Strategy 1 are guideline findings that seem particularly relevant to the specialist's implementation of intensive cessation programs. The above findings lead to the following recommendations regarding intensive smoking cessation programs (see For the Specialist: Strategy 2). Of course, implementation of these recommendations depends on factors such as resource availability, time constraints, and so on. Health Care Administrators, Insurers, and Purchasers Background Although clinical practice guidelines have traditionally focused on the role of the individual clinician, promoting smoking cessation in the United States requires a broader approach involving health care delivery administrators, insurers, and purchasers. Why broaden the scope of this document beyond the individual clinician? Smoking cessation efforts directed solely at the individual clinician have yielded disappointing results. National data suggest that, in a given visit with a clinician, most smokers are not advised and assisted with cessation (CDC, 1993b). Factors that contribute to this problem include failure to (a) include smoking assessment and cessation in the performance expectations of clinicians and (b) provide clinicians with an environment that supports systematic intervention with smokers. Without supportive systems, policies, and environmental prompts, the individual clinician cannot be counted on to assess and treat tobacco use reliably. In addition, an increasing number of Americans are receiving their health care in managed care settings. The structure of managed care environments provides new opportunities to identify and treat patients who smoke. These factors indicate that responsibility for smoking cessation treatment must be redistributed; just as every clinician has a professional responsibility to assess and treat tobacco users, health care administrators, insurers, and purchasers have a responsibility to craft policies, provide resources, and display leadership in fostering smoking cessation efforts. It is important to emphasize that smoking cessation treatments (both pharmacotherapy and counseling) are not consistently provided as paid services for subscribers of health insurance packages (Group Health Association of America, 1993), with one survey demonstrating that as few as 11 percent of health insurance carriers provided coverage for treatment of nicotine For the specialist: ■There is a strong dose-response relation between counseling intensity and cessation success. In general, the more intense the cessation intervention, the greater the rate of smoking cessation. Treatments may be made more intense by increasing (a) the length of individual treatment sessions and (b) the number of treatment sessions and number of weeks over which treatment is delivered. ■ Valid predictors of outcome are available. For instance, high levels of dependence, psychiatric comorbidity, and low levels of motivation to quit all predict greater likelihood of relapse. These measures might be used to adjust treatment intensity, to match patients with particular types of treatment, or for research purposes. Many different types of cessation providers (physicians, nurses, dentists, psychologists, pharmacists, etc.) are effective in increasing rates of smoking cessation, and involving multiple types of providers appears to enhance cessation rates. ■ Both individual and group counseling are effective smoking cessation formats. Particular counseling contents are especially effective. Problem-solving/skillstraining approaches and the provision of intratreatment support are associated with significant increases in cessation rates, as are aversive smoking techniques (e.g., rapid smoking). ■ Pharmacotherapy in the form of nicotine patch or nicotine gum therapy consistently increases smoking cessation rates regardless of the level of adjuvant behavioral or psychosocial interventions. Therefore, its use should be encouraged. Smoking cessation interventions are effective across diverse populations: across gender, racial, and ethnic groups; across age groups; in pregnant women; etc. addiction (Gelb, 1985). This lack of coverage is particularly surprising given that studies have shown that physician counseling against smoking is at least as cost-effective as several other preventive medical practices, including the treatment of mild or moderate hypertension or high cholesterol (Cummings, Rubins, and Oster, 1989). These and other findings resulted in the recent addition of a new objective to the national health promotion and disease prevention objectives for the year 2000. Increase to 100 percent the proportion of health plans that offer treatment of nicotine addiction (e.g., tobacco use cessation counseling by health care providers, tobacco use cessation classes, prescriptions for nicotine replacement therapies, and/or other cessation services) (DHHS, 1995). Cost-Effectiveness of Smoking Cessation Interventions Smoking cessation treatments are not only clinically effective, they have economic benefits as well. It is vital that all three audiences targeted in this For the specialist: Strategy 2. Recommendations regarding intensive smoking cessation programs Assessment Program clinicians Program intensity Program format Counseling content Pharmacotherapy Population Assessments should determine whether smokers are motivated to quit smoking via an intensive cessation program. Other assessments can provide information useful in counseling (e.g., stress level, presence of comorbidity; see Chapter 3, Specialized Assessment). Multiple types of clinicians should be used. One strategy would be to have a medical/health care clinician deliver messages about health risks and benefits, and nonmedical clinicians deliver psychosocial or behavioral interventions. Because of evidence of a strong dose-response relation, the intensity of the program should be: Session length at least 20-30 min in lengtha Length in weeks at least 2 w, preferably more than 8 w Either individual or group counseling may be used. Use of adjuvant self-help material is optional. Followup assessment procedures should be used (see Chapter 3). Counseling should involve either or both problem-solving/ skills-training content as well as social support delivered during treatment sessions (see Chapter 3, subsection on Content of Smoking Cessation Interventions). In addition, content should target motivation to quit and relapse prevention (see Chapter 4). Except in special circumstances, every smoker should be offered nicotine replacement. Encourage the use of nicotine patch or nicotine gum Intensive intervention programs may be used with all a Session length of 20-30 min was recommended because most trials of effective smoking cessation counseling used sessions of at least this length. guideline recognize that smoking cessation treatments ranging from brief clinician advice to specialist-delivered intensive programs are cost-effective in relation to other sorts of medical interventions. Cost-effectiveness analyses (Cummings, Rubin, and Oster, 1989; Eddy, 1981, 1986; Oster, Huse, Delea, et al., 1986) have shown that smoking cessation treatment compares quite favorably with routine medical interventions such as the treatment of hypertension and hypercholesterolemia and preventive interventions such as periodic mammography. In fact, Eddy referred to smoking cessation treatment as the "gold standard" of preventive interventions (Eddy, 1992). Although only a minority of smokers will achieve success in response to a single application of treatment, clinicians, specialists, and administrators should not forget or ignore the significant health and economic benefits of cessation treatments relative to their costs. The cost-effectiveness of guideline recommendations for smoking cessation will be addressed in detail in an ancillary document sponsored by AHCPR. Recommendations for Health Care Administrators, Health care delivery administrators, insurers, and purchasers can promote tobacco cessation through a systems approach. Purchasers (usually corporations, companies, or other consortia that purchase health care benefits for a group of individuals) should consider making tobacco assessment, counseling, and treatment a contractual obligation of the health care insurers and/or providers that sell them services. In addition, health care administrators and insurers must provide clinicians with assistance to ensure that institutional changes promoting smoking cessation interventions are universally and systematically implemented. A number of institutional policies would facilitate these interventions: Implement a tobacco-user identification system in every clinic (see For Dedicate staff to provide smoking cessation treatment identified as effective in this document and assess the delivery of this treatment in staff performance evaluations (see For Health Care Administrators, Insurers, and Purchasers: Strategy 3). Promote hospital policies that support and provide smoking cessation services (see For Health Care Administrators, Insurers, and Purchasers: Strategy 4). Include smoking cessation treatment (both pharmacotherapy and counseling), identified as effective in this guideline, as paid services for all subscribers of health insurance packages (see For Health Care Administrators, Insurers, and Purchasers: Strategy 5). Reimburse fee-for-service clinicians for delivery of effective smoking cessation treatments and include these interventions among the defined duties of salaried clinicians (see For Health Care Administrators, Insurers, and Purchasers: Strategy 6). For health care administrators, insurers, and purchasers: Strategy 1. Implement a tobacco-user identification system in every clinic a Repeated assessment is not necessary in the case of the adult who has never smoked or not smoked for many years, and for whom this information is clearly documented in the medical record. |