Where: Minneapolis-St. Paul.
The Issue: To devise a smoking cessation program based on chronic disease management principles rather than a one-time quit attempt.
In the traditional model for smoking cessation therapy, smokers who want to quit undergo a time-limited program that involves six to 12 weeks of medication therapy and four to six counseling sessions. Usually, these attempts are viewed as discrete, stand-alone episodes.
“People either make it or they don't,” said Anne M. Joseph, MD, MPH, a professor in the department of medicine at the University of Minnesota in Minneapolis.
Most don't. Even when the intervention is robust and well designed, she said, long-term quit rates usually only hover around a disappointing 15% to 20%. One reason for this, some researchers feel, is that the traditional model doesn't incorporate the possibility that people will backslide or relapse.
“[The traditional model] doesn't really match smokers' behavior, their mindset, very well,” Dr. Joseph said. “It didn't make a lot of sense to me as a clinician to basically deliver something and not have a plan for it not working.”
Dr. Joseph and her colleagues decided to test a smoking cessation treatment that would address smoking as a chronic disease, similar to diabetes or high blood pressure.
“The approach we took was when somebody says they want to quit, it should basically continuously be on the table until they accomplish that,” she said.
Although the idea is not new in the smoking cessation field, testing it has so far been challenging, she noted. “It's not a rocket science intervention, but actually implementing it into a treatment protocol was unique,” she said.
How it worked
From June 1, 2004 through May 31, 2009, Dr. Joseph and her colleagues performed a randomized, controlled trial comparing a combination of counseling and nicotine replacement therapy with usual care.
Four hundred forty-three smokers from the community received five counseling phone calls and nicotine replacement therapy for four weeks. After that, they were randomly assigned to receive usual care, defined as two additional counseling phone calls, or longitudinal care, defined as telephone counseling and nicotine replacement therapy for another 48 weeks.
One important feature of the study, according to Dr. Joseph, was the way it addressed slips or relapses. For example, people who had been smoking 20 cigarettes a day but had cut down to 10 a day were encouraged to remain at that lower level of smoking and to continue nicotine replacement therapy until they were ready to try to quit again. That helped keep people engaged in the process, Dr. Joseph noted.
“When people are smoking less they tend to feel better and they're kind of proud about it,” she said. “It meant you could kind of reframe those lapses as ‘Well, you've made some progress, you're going in the right direction, not quite there yet’ ... and not couch that whole episode as a failure.”
Another interesting finding, according to Dr. Joseph, was the point at which participants actually quit. More participants in the longitudinal care group reported prolonged abstinence or quitting every month as the study went on. The numbers did not plateau, she said.
“That would suggest that the intervention should have been longer. Clinically, we know that some people don't quit in a year, but I actually see that as a good thing, because it again suggests that we should just work with people over a longer period of time.”
Dr. Joseph also noted that participants in the longitudinal care group usually talked with the same counselor, which allowed the extra benefit of establishing a relationship.
“A number of people talked about that being an important component of the intervention in that they had some sense of accountability to that person because they talked to them over a long period of time,” she said.
Dr. Joseph stressed that her study was an experimental intervention that deviated substantially from the typical model of care. A physician trying this approach in clinical practice would need to develop staff and patient resources to support it, she said.
For example, national and statewide quit lines are currently available to smokers, but they are based on the traditional system where people who want to quit smoking are expected to need a finite number of calls, Dr. Joseph said. A physician's office would need to enlist a trained professional, such as a pharmacist or a nurse, who would be available to provide ongoing counseling, or give patients access to a long-term quit line.
“Right now we don't typically have infrastructure for doing that,” Dr. Joseph said. “You would have to develop it on a local level.”
Words of wisdom
Physicians considering implementing this approach should keep in mind that the counselors in Dr. Joseph's study were proactive in contacting participants, she noted.
“It's not like we sat back and waited for people to call our counselors. We were basically quite persistent, and that takes resources,” she said.
Dr. Joseph and her colleagues are working on a cost-effectiveness analysis of the longitudinal care intervention. She also noted that ideally, the results of the current study would be replicated in other populations and in different settings.
“Wearing my scientific hat, of course you'd like to see [that],” she said. “But I think with limited additional data from another trial or two, we could strongly advocate for adding a longitudinal care option to existing telephone care systems.”