Addiction Papers

Helping Smokers Before a Quit Attempt Increases Chances for Success, as Does Extended Medication

This research, funded by the National Cancer Institute, explored numerous smoking interventions that were delivered across the many phases of smoking treatment: i.e., motivating quitting, preparing to quit, quitting, and maintaining abstinence. Using highly efficient factorial designs, this series of 3 experiments identified the most promising interventions out of the many evaluated. For instance, smokers who got coaching and medications before a quit attempt—along with continued coaching after quitting—were more likely to quit smoking, according to new research published in the journal Addiction. Specifically, participants who received nicotine gum in preparation for a quit attempt plus intensive in-person counseling during the quit attempt were more likely to be smoke-free after 16 weeks (42.8%) than were participants who received only 1 of these components (31.1% or 29.1%) or neither (36%).

“What we found was that it helps to provide treatment to patients before they actually stop smoking,” said Dr. Tim Baker, a Principal Investigator and Director of Research at UW-CTRI. “It’s a bit like teaching a person how to parachute before the person jumps out of a plane. This study helped people quit and measured which treatments given before, during, and after a quit attempt show the most promise.”

Researchers also found that a particular counseling strategy, known as behavioral reduction counseling, helped smokers who were initially not interested in quitting. This type of counseling helped them decide to quit and succeed.

Twenty-six versus 8 Weeks of Nicotine Patch + Nicotine Gum increased abstinence rates from 34% to 43% at 6 months post-quit, and from 27% to 34% at 1 year. These success rates compare well with those of many intense, evidence-based treatments, which typically range from 15% to 35% abstinence at 6 months.

The findings resulted from a $9 million, 5-year grant from the National Cancer Institute that studied various quit-smoking treatments in 11 primary-care clinics in Wisconsin. In this study, known as the UW Partnership to Assist and Serve Smokers (UW-PASS), UW-CTRI delivered seamless, cutting-edge treatments for more than 1,500 smokers, including those who were ready to quit and those who weren’t.

This research relied on the Phase-Based Model of Smoking Treatment, which guided the selection of intervention components to be experimentally evaluated for the different phases of smoking treatment (e.g., Motivation, Preparation, Cessation, and Maintenance phases). For instance, based on this model, interventions designed to help motivate smokers to make a quit attempt (Motivation-phase interventions) were selected to be evaluated.

This research also used a cutting edge recruitment strategy to illustrate the translation potential for these findings. UW-CTRI collaborated with 2 health-care systems—Dean and Aurora Health Care—to modify the electronic health record in primary care clinics so that every patient was asked about smoking. Identified smokers were invited to participate in a program to help them quit or help them cut down on their smoking. If a patient were interested, an e-mail was generated from the electronic health record to UW-PASS staff, employed by UW-CTRI, who conducted screening, orientation, patient visits and follow up. Participant visits were conducted in their primary care clinic.

The study was also one of the first of its kind to use the Multiphase Optimization Strategy (MOST). MOST relies on engineering principles to systematically develop optimal treatment packages that include only effective components that work well together. This strategy uses factorial experimental designs to efficiently test multiple intervention components and identify the ones that are most promising. Factorial designs have the ability to evaluate an intervention component’s main effects (what it does by itself) and interaction effects (what it does when offered with other components). Once the most promising components are identified based on their main and interactive effects, MOST calls for their use in a combined treatment package and that the package be evaluated in a traditional randomized controlled trial.

UW-PASS comprised three projects.

Project 1 focused on increasing quit attempts and the ultimate success of those attempts amongst smokers who weren’t ready to quit but were willing to participate in treatment to cut down on their smoking (i.e., Motivation interventions). This experiment included 4 treatment factors that each compared 2 levels of treatment:

1. Behavioral Reduction Counseling vs. None. This counseling involved helping participants learn strategies, like delaying smoking or eliminating cigarettes in specific situations, with the intent of helping participants gain control of their smoking and cut down.
2. Motivational Interviewing vs. None. This counseling involved motivation-building exercises to reinforce intrinsic motivation and to help participants overcome ambivalence about quitting.
3. Nicotine Patches While Continuing to Smoke vs. None.
4. Nicotine Gum While Continuing to Smoke vs. None.

This research found that 2 Motivation-phase intervention components appear to be relatively effective with smokers who are willing to reduce their smoking but not quit: nicotine gum and behavioral reduction counseling. Relatively large smoking reductions were caused by 2 component combinations: Nicotine gum combined with behavioral reduction counseling, and behavioral reduction counseling combined with motivational interviewing. Further, behavioral reduction counseling improved 12-week abstinence rates, and nicotine gum, when used without motivational interviewing, increased abstinence after a subsequent aided quit attempt.

In sum, main and interactive effects showed that Motivation-phase nicotine gum and behavioral reduction counseling appear to be effective intervention components amongst smokers who are initially unwilling to quit.

Project 2 of UW-PASS examined the effects of intervention components amongst patients who were already motivated to quit smoking. It evaluated interventions that were delivered both before (Preparation interventions) and after (Cessation and Maintenance interventions) a quit attempt. Specifically, it examined whether use of nicotine-replacement medication and behavioral coaching before quitting smoking helped the patient remain smoke-free. Project 2 also tested intervention components delivered after the quit attempt: type of delivery (in-person coaching vs. telephone), intensity of coaching, and length of medication. This experiment included 6 treatment factors that each compared 2 levels of treatment:

1. Preparation Nicotine Patch vs. None.
2. Preparation Nicotine Gum vs. None.
3. Preparation Counseling vs. None. This counseling helped smokers to change their smoking patterns (e.g., delay the first cigarette of the morning, not smoke in the car, reduce their smoking).
4. Intensive Cessation In-Person Counseling vs. Minimal. This counseling focused on providing intra-treatment social support and developing skills for dealing with cravings and other withdrawal symptoms.
5. Intensive Cessation Phone Counseling vs. Minimal. This counseling was similar to the In-Person Counseling, but delivered over the phone.
6. 16 vs. 8 Weeks of Maintenance Combination Nicotine Replacement Therapy (Nicotine Patch + Nicotine Gum).

Preparation Counseling significantly improved Week 16 abstinence rates, while both forms of Preparation Nicotine Replacement Therapy interacted synergistically with Intensive Cessation In-Person Counseling. In other words, it was especially beneficial for participants to receive both Preparation NRT and Intensive Cessation In-Person Counseling. Conversely, Intensive Cessation Phone Counseling and Intensive Cessation In-Person Counseling were redundant; i.e., adding one to the other did not boost quit rates.

Interventions showing promise to help smokers quit included:

• Preparation Nicotine Gum or Patch.
• Preparation Counseling.
• Intensive Cessation In-Person Counseling.

Extended Maintenance Medication (16-versus 8-weeks of Combination Nicotine Replacement Therapy) and Intensive Cessation Phone Counseling were less promising.

Project 3 studied ways to increase long-term abstinence rates: i.e., Maintenance phase interventions. In particular, it focused on long-term medication use, extended counseling, and ways to enhance long-term medication adherence. Most smokers don’t use enough medication or use it the right way. The goal was to see what happened if a patient took medication as prescribed vs. skipping doses or ceasing treatment prematurely. Adherence treatments included automated medication adherence calls, electronic medication monitoring with feedback and counseling, and medication adherence counseling. Project 3 also examined the outcomes of long-term coaching and medication. This experiment included 5 treatment factors that each compared 2 levels of treatment:

1. Extended Maintenance Medication (26 vs. 8 Weeks of Nicotine Patch + Nicotine Gum).
2. Maintenance (phone) Counseling versus None.
3. Medication Adherence Counseling versus None. This treatment attempted to educate participants about the myths and facts regarding NRT use.
4. Automated (medication) Adherence Calls versus None. These automated calls reinforced the use of medication and problem-solving to try and use the medication at the recommended rate.
5. Electronic Medication Monitoring with Feedback and Counseling versus Electronic Medication Monitoring Alone. All participants carried electronic monitoring devices that tracked when they used the nicotine gum. Those in the feedback condition were given feedback and counseling on whether they were able to meet the goal of at least 5 pieces of gum per day.

There were 4 interaction effects at 1 year, showing that an intervention component’s effectiveness depended upon the components with which it was combined. Two types of treatment were found to be especially promising in helping smokers quit and remain so:

• Extending medication to 26 weeks, versus 8 weeks, helped people to be smoke-free a year after the quit date.
• Extended phone counseling could help smokers stay quit.