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An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes

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

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An Updated Algorithm for Choosing Among Smoking Cessation Treatments John R. Hughes

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  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 Heart attack (age 45) Combined treatment Quits

  10. Treatment Matching: The Search for the Holy Grail

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

  12. 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

  13. Assessments Not Included • Motivation • Level of dependence • Withdrawal symptoms • Craving

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

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

  16. Action Points • Abrupt vs gradual • Abstain vs Lapse • Lapse vs relapse

  17. 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

  18. 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.

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