Boosting Population Quits Through Evidence-Based Cessation Treatment and Policy
Introduction
The greatest declines in smoking-caused death in the U.S. over the next 30 years will come from increasing adult cessation.1 While about 70% of U.S. smokers want to quit2 and almost 45% make serious quit attempts annually,3 fewer than 10% quit successfully.4, 5 Behavioral and pharmacologic treatments generally double unassisted quit rates across a range of populations,6 hold enormous potential to increase cessation nationwide, and are among the most cost effective of all prevention programs.7, 8 However, evidence-based cessation treatments currently are used by only a small fraction of U.S. smokers who try to quit.9, 10 Treatment use is particularly limited among smokers with the highest smoking prevalence, including those with comorbid psychiatric and substance abuse problems, and lower levels of income and education, thereby contributing even more strongly to poor outcomes and to disparities in disease burden and mortality.11, 12
National panels have focused on the need to expand treatment use by aligning cessation treatments and the policies that support their use and delivery among all levels of medicine and public health. The 2007 NIH State-of-the-Science Conference13 and the National Tobacco Cessation Collaborative Consumer Demand Roundtable14 highlighted the need to maximize the reach, use, and population impact of treatments. The 2008 IOM report Ending the Tobacco Problem: A Blueprint for the Nation15 called for a coordinated, comprehensive, national strategy to dramatically increase the number of smokers who quit each year and concluded that “systems integration is arguably the single most critical missing ingredient needed to maximize the as yet unrealized potential to significantly increase population cessation rates.”16
It should be noted for this series of papers that the “systems integration” concept referred to herein is much broader than the usual call for the integration of cessation services into the healthcare delivery system. Systems integration involves multilevel integration of at least three overlapping domains: (1) better consumer awareness of, access to, and use of the full range of evidence-based cessation interventions; (2) improved reach to smokers at the individual, group, neighborhood, organizational, community, state, and national levels, and across different modes of delivery; and (3) better alignment of cessation treatment and policy across cessation episodes to support smokers through multiple quit attempts and to ensure sustained maintenance of cessation (for details, see the 2008 IOM report16).
This paper and the two that follow17, 18 take a fresh look at ways to markedly increase smoking cessation at the population level by modeling the implementation of a defined set of policies to improve the reach, use, and impact of smoking-cessation treatments. The paper begins with an analytic framework to map the impact of cessation treatments and policies on the core components of the population quit rate: (1) quit attempts; (2) treatment use; and (3) long-term treatment effectiveness. Next the evidence is selectively reviewed regarding the impact of each of the cessation treatments on each element of the population quit rate. Finally, five treatment-related policies were reviewed, that if implemented in a coordinated fashion could increase reach, access, use, and long-term effectiveness (i.e., reduce relapse rates) of treatment, and ultimately accelerate reductions in the population prevalence of smoking. Three of the policies have a strong evidence base: (1) expanded cessation treatment coverage and provider reimbursement; (2) adequate funding for the use and promotion of evidence-based, state-sponsored telephone quitlines; and (3) incentives for the adoption of healthcare system supports proven to increase the delivery of evidence-based brief provider interventions. Two promising approaches are considered that could play a role in enhancing the effectiveness of evidence-based treatments: (4) promoting effective Internet-based cessation programs, and (5) providing a more coordinated national treatment strategy (i.e., systems integration, referred to above and in the recent IOM Report16) that includes tailoring of treatment, stepped-care approaches, and more comprehensive care management and continuity of care.16 A more speculative examination is made of the potential synergies and interactions that are likely to occur when these policies are implemented in tandem. In areas where the evidence is less robust or nonexistent, this series of papers identifies gaps in our knowledge base that will need to be addressed.
Using the framework and findings in this paper, the second paper17 in this series models the impact of individual and combined cessation treatment policies on population quit rates. The third paper18 uses the SimSmoke model19, 20 to expand the analyses in the second paper to include the effects of three public health policies: tax increases, clean indoor air laws, and health communication interventions such as antismoking media campaigns. Together the series describes how multiple cessation-related policies can be combined to create a comprehensive population cessation strategy (i.e., systems integration16), making use of simulation modeling to paint a vision of “plausible futures” with respect to impact on quit rates and national prevalence. The models serve as heuristic guideposts for policymakers, stakeholders, and healthcare, public health and other agencies, identifying promising policy “levers” to promote adult cessation.
Section snippets
Analytic Framework for Modeling the Population Impact of Interventions
The primary outcome for evaluating the impact of cessation is the adult population quit rate, defined as the proportion of the U.S. smoking population that, on an annual basis, quits smoking and maintains abstinence for 6 months.21, 22, 23Figure 1 depicts the framework of annual population quit rates as a function of three components: (1) the proportion of all current smokers who make a serious quit attempt each year; (2) the proportion of serious quitters who make use of one or more
Evidence-Based Cessation Treatments
The 2008 U.S. Public Health Service clinical practice guideline6 (hereafter referred to as “the 2008 Guideline”) recommends behavioral and pharmacologic cessation treatments as outlined in Table 1. The behavioral treatments include counseling, social support, problem solving, and cessation skills training offered in face-to-face, individual, or group formats, or via proactive telephone quitlines. Pharmacologic treatments include seven FDA-approved, first-line medications (i.e., bupropion SR,
Evidence-Based Cessation Treatment Policies
This review of cessation treatment policy research is selective in extracting how current and future treatment policy levers could be used and integrated to increase quit attempts, cessation treatment use, long-term treatment effectiveness, and ultimately the population quit rate. It is designed to provide a range of plausible parameter estimates that are used in the two modeling papers that follow. Three public health policies and healthcare systems changes are reviewed that are intended to
Cessation Treatment Coverage and Provider Reimbursement
There is strong evidence that policies that reduce smokers' out-of-pocket treatment costs and reimburse their providers for cessation services increase treatment use and successful long-term quitting. The 2008 Guideline6 recommends that all insurers provide tobacco-cessation benefits that include: (1) payment for evidence-based counseling and medications (both prescription and over-the-counter); (2) coverage of at least four counseling sessions of at least 30 minutes each delivered via
Funding for the Use and Promotion of Evidence-Based State-Sponsored Telephone Quitlines
In 2004, the establishment of a national network of tobacco quitlines (1-800-QUIT-NOW) greatly expanded smokers' access to evidence-based behavioral and pharmacologic treatment. State quitlines now have the potential to reduce access barriers to counseling and medication and to enhance long-term quit rates by better coordinating and tailoring proven counseling and pharmacologic treatments over time. However, financial support for state quitlines and their promotion is limited and uncertain,
Healthcare System Changes to Prompt, Guide, and Incentivize Tobacco Treatment
In this section, studies were reviewed that have evaluated changes in healthcare systems and policies to improve the consistent delivery of evidence-based brief healthcare provider interventions recommended as the “5A's” intervention. As evidence is lacking on the specific effect when all components of the 5A's are delivered, studies were reviewed of brief clinician interventions lasting 3–10 minutes, and consider opportunities for improved follow-up. Whereas many of the estimates in the
Policies to Improve Individually Tailored, Stepped-Care Approaches and the Long-Term Effectiveness of Evidence-Based Treatments
Improving treatment efficacy requires reducing the very high rate of relapse through development of more effective and efficient interventions, improvement of continuity of care, and delivery of repeated treatments geared toward re-cycling smokers who relapse. Reducing relapse is a powerful yet largely unexplored lever in the pathway toward boosting population-level cessation rates.77, 78 Smokers try multiple times to quit and make as many as 5–8 quit attempts before they successfully maintain
Conclusion
An analytic framework for understanding the population impacts of a defined set of tobacco-cessation treatments and related policies is introduced. Recognizing that population cessation is determined by (1) the number of smokers who make a serious quit attempt; (2) the proportion of serious quitters who make use of evidence-based treatments; and (3) the long-term effectiveness of those treatments, this paper selectively reviewed the evidence for the independent effects of treatments and related
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Tailored text message and web intervention for smoking cessation in U.S. socioeconomically-disadvantaged young adults: A randomized controlled trial
2022, Preventive MedicineCitation Excerpt :This study demonstrates strong effects of a brief, low-touch tailored text message smoking-cessation intervention on self-reported smoking abstinence, reduction in days smoked, and confidence to quit at 12 weeks. Even if abstinence is not sustained, boosting quit attempts in this group may improve quit success in the future, as well as overall population quit rates (Abrams et al., 2010). Future studies are needed to assess the effect of dual use of e-cigarettes and cigarettes on cessation in this age group (Klemperer and Villanti, 2021), the durability of intervention effects over time, and whether intervention tailoring is needed to produce smoking abstinence in SDYA.
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