Combating Tobacco Use in Military and Veteran Populations (2009) / Chapter Skim
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4 TOBACCO-CONTROL PROGRAMS:EVIDENCE-BASED PRACTICES
4 TOBACCO-CONTROL PROGRAMS:EVIDENCE-BASED PRACTICES
Pages 115-196
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From page 115... ...
Evidence-based best practices for tobacco control have been widely promoted and have succeeded in reducing tobacco use in the United States. The committee recognizes, however, that identifying the best practices for specific and diverse populations can be challenging.
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From page 116... ...
Tobacco-control programs reduce tobacco use at the population level by creating tobaccofree indoor and outdoor areas, restricting young people's access to tobacco products, limiting tobacco advertising, having sustained counteradvertising campaigns, increasing the cost of tobacco products, and providing easily accessible tobacco-cessation products and services. Comprehensive tobacco-control programs for military and veteran populations could help to do the following: • Foster a tobacco-free culture and denormalize tobacco use in military personnel and veterans.
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From page 117... ...
Although such programs and policies may prevent young people from initiating tobacco use and reduce the exposure of the general population to secondhand smoke, a comprehensive program must also be applicable to people who are already using tobacco regularly. Interventions are needed to assist individual tobacco users, each of whom has a particular level of addiction, particular reasons for smoking and for trying to stop, and possibly concurrent health problems that affect their interest in and ability to quit.
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From page 118... ...
capacity-building, including administration and management procedures. Direct interventions for individuals, including health promotion and cessation, are important, but the other evidence-based strategies -- such as price increases, reduced access to tobacco products, tobacco-free environments, advertising bans, and changes in social perceptions -- all contribute to reducing tobacco use and ultimately encourage tobacco cessation (CDC, 2007a)
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From page 119... ...
DoD and VA already have some of the policy and infrastructure capabilities, similar to those of states, that would allow them to develop and implement comprehensive tobacco-control programs. The capabilities include leadership, the ability to develop and enforce policies that affect all their constituents, and resources that may be dedicated for specific purposes such as tobacco control.
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, CDC's Best Practices for Comprehensive Tobacco Control Programs (CDC, 2007a) and Tobacco: Guide to Community Preventive Services (CDC, 2009a)
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Such conclusions have led the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC)
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From page 122... ...
Mass-media campaigns involving television, radio, newspapers, billboards, posters, leaflets, and booklets that deglamorize and denormalize tobacco use have been used successfully as tobacco-control interventions alone and in combination with other program components, such as increased prices for tobacco products and community-based education programs (CDC, 2007a; IOM, 2007; NCI, 2008)
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Tobacco consumption was reduced by about 13%, and tobaccouse prevalence was reduced by about 3 people per 100 tobacco users (CDC, 2009a)
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Comprehensive legislation establishing clear penalties for violations needs to be paired with effective enforcement policies for smoking restrictions to advance tobacco control. Fining the owners of establishments where violations occur is the most effective way to enforce the law (WHO, 2008)
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Although it has been argued that smoking helps patients to manage their symptoms and that banning smoking may exacerbate mental illness (Stage et al., 1996) , evidence indicates that smoking restrictions can be implemented in psychiatric health-care settings without adverse effects (Alam, 2007;
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From page 126... ...
The effectiveness of policies that prohibit employment of smokers has not been evaluated, and Houle and Siegel (2009) note that although such policies may help tobacco users to quit, they may also exacerbate economic disadvantages for people who smoke and are unable to find employment, their families, the surrounding community, and the larger society.
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From page 127... ...
. Moreover, 68% of the public universities do not sell tobacco products, and about half have written policies banning tobacco advertising on campus (Halperin and Rigotti, 2003)
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. Aside from potential protective effects for nonsmokers, smoking bans in outdoor spaces contribute to the denormalization of tobacco use, reduce smoking rates, and prevent future initiation of smoking by children and adolescents.
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• VA cannot have smoke-free campuses because of the congressional requirement that there be outdoor smoking areas for patients. Several interactive mechanisms might explain the effectiveness of smoking restrictions to achieve tobacco control (Hovell et al., 2002)
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. As tobacco restrictions have increased along some dimensions, such as cigarette taxes and smoke-free legislation, manufacturers have responded with increasingly innovative tobacco products, particularly varieties of smokeless tobacco.
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(2007) note that the number of Internet vendors and sales of tobacco products are increasing, particularly in states with high excise taxes, possibly
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However, a recent study examining stores that required clerk assistance to obtain tobacco products showed no significant effect of licensing on smoking behavior among youth (Slater et al., 2007)
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From page 133... ...
. The IOM report also recommended that "harm reduction be implemented as a component of a comprehensive national tobacco control program that emphasizes abstinence-oriented prevention and treatment." A recent strategic dialogue reached the conclusion that "significant tobacco harm reduction can be achieved over the long term only in a world where virtually no one uses combustible tobacco products" (Zeller et al., 2009)
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From page 134... ...
Evidence-Based Interventions Tobacco users today have access to a variety of evidence-based interventions that, if used appropriately, can significantly increase the likelihood that they will achieve long-term abstinence. There is abundant evidence on effective tobacco-cessation interventions, and numerous groups have provided detailed and consistent recommendations for individual-level interventions.
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From page 135... ...
Abstinence rates increase as the length of counseling sessions increases from minimal (under 3 minutes) to longer than 10 minutes, as the number of sessions increases, and as the total contact time increases from 1–3 minutes to 91–300 minutes; however, contact time in excess of 300 minutes does not appear to increase abstinence rates (Fiore et al., 2008)
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From page 136... ...
Because former smokers may relapse and current smokers may decide to quit smoking, it is important to ascertain smoking status at each office visit and to inform patients of the need to be aware of possible changes in their response to any medication, whether prescription or over the counter and whether used for tobacco cessation or for other conditions. Combined Behavioral Interventions and Medications The guideline concludes that "the combination of counseling and medication is more effective for smoking cessation than either intervention alone.
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A Cochrane review found that the use of financial incentives increased the rate of participation in smoking-cessation programs but did not increase long-term abstinence rates (Cahill and Perera, 2008)
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From page 138... ...
Individual interventions to promote tobacco-use cessation are effective and can help many people achieve and maintain abstinence, but if tobacco users are not aware of the treatments, cannot easily access them, cannot afford them, or do not use them when they are available, the effectiveness of the treatment is irrelevant. All of these barriers may prevent tobacco users from seeking or receiving treatment when they are motivated to quit.
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From page 139... ...
• SmokeFree.gov provides an online step-by-step cessation guide with access to local and state telephone quitlines, the NCI national telephone quitline, NCI's instant-messaging service, and various publications, which may be downloaded, printed, or ordered. The Web site was created by the Tobacco Control Research Branch of NCI.
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From page 140... ...
Health-care providers can use motivational interviewing for patients unwilling to quit and to encourage future quit attempts, (Fiore et al., 2008; Rubak et al., 2005)
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From page 141... ...
Feedback loops help providers to motivate tobacco users who are unwilling to quit and encourage former users or newly quitting users to prevent relapse. Although a meta-analysis (Burke et al., 2003; Butler et al., 1999)
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From page 142... ...
were more effective in increasing abstinence rates than no intervention. Compared with no advice, brief advice from a primary-care physician was effective in increasing 6-month quit rates, and intensive interventions were slightly more effective than brief counseling (Stead et al., 2007)
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From page 143... ...
. A later randomized controlled study of pharmacist intervention for tobacco cessation in a VA community-based outpatient clinic showed that patients who received three face-to-face group counseling sessions from the pharmacist in addition to tobacco-cessation medication had a biochemically confirmed 6-month abstinence rate that was greater than that in patients who received one 5- to 10-minute call from the pharmacist in addition to medication (28% vs.
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From page 144... ...
All the quitlines offered multisession (generally 5 sessions) proactive telephone counseling, and some offered follow-up reactive sessions; the first session was usually 30 minutes long, and the follow-up sessions were shorter.
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From page 145... ...
The 2003 National Action Plan for Tobacco Cessation (Fiore, 2003) recommended that state quitlines use at least four personto-person proactive calls, that there be no cost to insurers for the use of the quitline by eligible tobacco users, and that all NRTs be made available to quitline users free of charge or that users receive vouchers for prescription medications.
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From page 146... ...
Veterans, in particular, may find it difficult to access VA tobacco-cessation services if they are disabled or otherwise disadvantaged. Finding: Quitlines, particularly proactive quitlines, are effective in reaching a large number of tobacco users and increasing abstinence rates over those achieved with usual care.
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From page 147... ...
But first, healthcare providers must themselves be aware of tobacco-cessation interventions and be comfortable in providing advice on these matters to their patients. The use of evidence-based interventions may be enhanced by educating providers on the 5 A's to increase the rate of asking, advising, and assisting patients with tobacco cessation.
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From page 148... ...
The American Lung Association's Tobacco Cessation Resource Center has electronic resources for health-care providers to use in their clinics and organizations; providers are able to request additional assistance as needed (accessible at http://www.tobaccoprc.org/page.cfm?
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From page 149... ...
Computer-aided training and reminder systems help health providers to discuss tobacco cessation with their patients. TOBACCO CESSATION IN SPECIAL POPULATIONS The 2007 IOM report Ending the Tobacco Problem: A Blueprint for the Nation acknowledges that some tobacco users will have a more difficult time in quitting than others.
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Other populations served by the VA and military health systems that may require different approaches for effective tobaccocessation services include women, pregnant women, minority-group members, hospitalized tobacco users, older tobacco users, and smokeless-tobacco users. In the sections below, the committee considers the evidence on tobacco-cessation interventions for special populations with an emphasis on treating those with mental-health disorders.
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From page 151... ...
. The best time to start tobacco-cessation treatment is not clear; some studies indicate that it can be concurrent with treatment for psychiatric disorders, but some evidence suggests that it is more effective if given when psychiatric symptoms are less severe, particularly in those
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From page 152... ...
Behavioral Interventions Behavioral interventions have been applied for tobacco users with several mental-health disorders, including schizophrenia (McChargue et al., 2002; Ziedonis, 2004; Ziedonis et al., 2007) , depression (Brown et al., 2001; Hitsman et al., 2003)
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From page 153... ...
. Varenicline has been associated anecdotally with changes in behavior, agitation, depressed mood, suicidal ideation, and attempted and completed suicide in some tobacco users (FDA, 2008)
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. For tobacco users with PTSD, there appears to be greater abstinence from tobacco use when cessation interventions are integrated into standard mental health care.
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From page 155... ...
. Three randomized, controlled trials indicate that smokers with MDD are capable of achieving abstinence rates comparable with those of nondepressed smokers after similar interventions (Hall et al., 2006; Muñoz et al., 1997; Thorsteinsson et al., 2001)
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, treatment for tobacco cessation is not routinely included in alcohol-treatment programs
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From page 157... ...
(1999) suggested that tobacco cessation may improve alcohol-treatment outcomes because it removes a cue for alcohol use (Ellingstad et al., 1999)
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From page 158... ...
. Tobacco Users with Medical Comorbidities Smoking is the leading cause of morbidity in the general population and is causally linked to the development of many cancers (particularly lung cancer)
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From page 159... ...
. Medications -- such as NRTs, bupropion SR, and varenicline -- for tobacco cessation in patients with CVD appear to be both safe and effective (Fiore et al., 2008; Joseph and Fu, 2003; Tonstad et al., 2003)
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From page 160... ...
(2006) showed that patients with head and neck cancers who smoked and had alcohol abuse or depression had higher 6-month abstinence rates after a nurse-administered smoking-cessation intervention consisting of cognitive-behavioral therapy combined with medication than patients
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From page 161... ...
. Other Special Populations of Tobacco Users The 2008 PHS guideline and some Cochrane reviews have assessed the efficacy of tobacco-cessation treatments for several specific groups; some of the results have particular relevance for the populations served by DoD's TRICARE health system and VA.
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. Smokeless-Tobacco Users Numerous forms of smokeless tobacco are available, and its use is on the rise in military populations, particularly those deployed to Iraq and Afghanistan (Smith et al., 2008)
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. Other Tobacco Users The 2008 PHS guideline assesses tobacco cessation in several special populations, including those with low socioeconomic status (SES)
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From page 164... ...
Finding: Although most studies have focused on treating tobacco users in the general public, evidence suggests that special populations -- such as those with mental illness, women, and those with medical comorbidities -- will benefit from the same tobacco-cessation treatments, although some modifications may be necessary to avoid medical complications. A combination of tailored behavioral therapy and medication is effective for tobacco cessation in these populations.
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From page 165... ...
An important feature is surveillance mechanisms to assess whether tobaccouse restrictions and modifications of the retail environment are being enforced and are reducing tobacco consumption and also to determine whether the various tobacco-cessation interventions are assisting tobacco users to quit. CDC states that surveillance "is the process of monitoring tobacco-related attitudes, behaviors, and health outcomes at regular intervals" (CDC, 2007a)
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From page 166... ...
NCQA has a quality measure for medical assistance with smoking cessation that consists of three components: advising smokers to quit, discussing smoking-cessation medications, and discussing smoking-cessation strategies. NCQA has recently proposed revising the Health Plan Employer Data and Information Set measure for 2010 to include other tobacco products, such as pipes, snuff, and chew (NCQA, 2008)
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From page 167... ...
. Public dissemination of these evaluations can help to engage outside participants in program improvement, encourage transparency in program processes, and permit cross-program comparisons to determine best practices for tobacco control.
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2008. The California Tobacco Control Program: Can We Maintain the Progress?
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From page 169... ...
American Journal of Cardiovascular Drugs 8(6)
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2006. Determinants and consequences of smoke-free homes: Findings from the International Tobacco Control (ITC)
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2006. Interventions for tobacco cessation in the dental setting.
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From page 172... ...
2007a. Best Practices for Comprehensive Tobacco Control Programs -- 2007.
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Tobacco Control 16(Suppl 1)
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2008. The role of health care systems in increased tobacco cessation.
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Tobacco Control 2:13-17. Etter, J
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Tobacco Control 15(Suppl 3)
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2006. What contributed to the major decline in per capita cigarette consumption during California's comprehensive tobacco control programme?
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A critical component of medical management in chronic disease populations. American Journal of Preventive Medicine 33(Suppl 6)
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American Journal of Public Health 96(10)
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From page 180... ...
Tobacco Control 14(2)
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2007. Smokeless Tobacco and Some Tobacco-Specific N-Nitrosamines.
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From page 182... ...
2006. Efficacy of a tailored tobacco control program on long-term use in a population of US military troops.
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From page 183... ...
2005b. The Healthy People 2010 smoking prevalence and tobacco control objectives: Results from the SimSmoke tobacco control policy simulation model (United States)
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2001. A prospective investigation of the impact of smoking bans on tobacco cessation and relapse.
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From page 185... ...
NCI Tobacco Control Monograph Series, Number 16. Bethesda, MD: NCI.
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2007. Tobacco industry marketing, population-based tobacco control, and smoking behavior.
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2005. The importance of peer effects, cigarette prices and tobacco control policies for youth smoking behavior.
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From page 188... ...
2004. First Annual Independent Evaluation of New York's Tobacco Control Program: Final Report.
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From page 189... ...
In Smoking and Restaurants: A Guide for Policy Makers. Berkeley: University of California, Berkeley/University of California, San Francisco Preventative Medicine Residency Program; American Heart Association, California Affiliate; Alameda County Health Care Services Agency, Tobacco Control Program.
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American Journal of Preventive Medicine 35(6)
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Cochrane Database of Systematic Reviews 4:CD000146. Steinberg, M
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2008. Population tobacco control interventions and their effects on social inequalities in smoking: Systematic review.
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American Journal of Preventive Medicine 19(3)
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2008. Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence.
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Tobacco Control 18(4)
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2008. Impact of posttraumatic stress disorder on early smoking lapse and relapse during a self-guided quit attempt among community-recruited daily smokers.
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