Boosting Population Quits Through Evidence-Based Cessation Treatment and Policy

Abstract

Only large increases in adult cessation will rapidly reduce population smoking prevalence. Evidence-based smoking-cessation treatments and treatment policies exist but are underutilized. More needs to be done to coordinate the widespread, efficient dissemination and implementation of effective treatments and policies. This paper is the first in a series of three to demonstrate the impact of an integrated, comprehensive systems approach to cessation treatment and policy. This paper provides an analytic framework and selected literature review that guide the two subsequent computer simulation modeling papers to show how critical leverage points may have an impact on reductions in smoking prevalence. Evidence is reviewed from the U.S. Public Health Service 2008 clinical practice guideline and other sources regarding the impact of five cessation treatment policies on quit attempts, use of evidence-based treatment, and quit rates. Cessation treatment policies would: (1) expand cessation treatment coverage and provider reimbursement; (2) mandate adequate funding for the use and promotion of evidence-based state-sponsored telephone quitlines; (3) support healthcare systems changes to prompt, guide, and incentivize tobacco treatment; (4) support and promote evidence-based treatment via the Internet; and (5) improve individually tailored, stepped-care approaches and the long-term effectiveness of evidence-based treatments. This series of papers provides an analytic framework to inform heuristic simulation models in order to take a new look at ways to markedly increase population smoking cessation by implementing a defined set of treatments and treatment-related policies with the potential to improve motivation to quit, evidence-based treatment use, and long-term effectiveness.

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.