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4 TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES Preventing tobacco use and helping those who use it to quit can have long-term benefits for individuals and for public health in general. State and federal government agencies, health-care organizations, and other groups that promote public health have developed and implemented tobacco control programs to help to prevent or reduce tobacco use. The programs use taxation, restrictions, mass-media campaigns, and effective and easily accessible behavioral counseling and tobacco-cessation medications. They provide services to varied target audiences, including young people, people with comorbid health problems, those of diverse ethnicities and socioeconomic status, and women. 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. Reducing tobacco use faces special challenges because tobacco products are legal and easy to acquire, highly addictive, and heavily promoted by a tobacco industry that spends billions of dollars a year to promote tobacco as part of the American culture (CDC, 2007a). Creating a tobacco-free culture will depend on developing an environment that encourages abstinence and makes many types of effective assistance and encouragement accessible to diverse populations. Maintaining a tobacco- free culture will require a sustainable infrastructure for comprehensive programs. The application of evidence-based best practices for tobacco control in military populations under the jurisdiction of the Department of Defense (DoD) is the subject of Chapter 5; Chapter 6 addresses the same issues for the population of veterans who use the Department of Veterans Affairs (VA) health-care system. The committee believes that well-designed tobacco-control programs can influence tobacco use by military personnel from the time they enter the military until they leave 115
116 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS the service and beyond. For military personnel who enter the VA health system, these practices can also influence their tobacco use as veterans. This chapter summarizes what is known about evidence-based best practices for tobacco-control programs in the general population with an emphasis on program components that are or could be most applicable to DoD and VA. The committee hopes that by implementing these practices, DoD will be able to prevent or reduce tobacco use by military personnel in all phases of their military serviceâfrom the time they enter the military until they leave the service or retire. Implementing these practices in VA may also reduce tobacco use in veterans. As discussed in the next two chapters, DoD and VA already have in place some of the components and practices, including the infrastructure and regulatory authority, for an effective tobacco-control program; in these instances the committee highlights how the departments can take advantage of current policies and procedures to increase their effectiveness and reach and also emphasizes where additional opportunities for tobacco control may reside. COMPREHENSIVE TOBACCO-CONTROL PROGRAMS Evidence supports the use of a comprehensive tobacco-control program to reduce tobacco consumption (Warner, 2007). A comprehensive approach to tobacco control results in changes that affect the entire population, from the individual to the societal level, by addressing the political, social, cultural, economic, and environmental factors that support the use or nonuse of tobacco. Tobacco-control programs reduce tobacco use at the population level by creating tobacco- free indoor and outdoor areas, restricting young peopleâs 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: â¢ Foster a tobacco-free culture and denormalize tobacco use in military personnel and veterans. â¢ Prevent the initiation of tobacco use by military personnel and their dependents during active duty and prevent relapse to tobacco use by military personnel and veterans who have quit. â¢ Eliminate exposure of military and veteran personnel, family, co-workers, and others to secondhand smoke and its health consequences.
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 117 â¢ Support and promote tobacco cessation in military personnel, veterans, and their dependents. â¢ Identify and eliminate disparities in tobacco treatment between the general population and military personnel or veterans in high-risk populations, including those with mental-health disorders. Numerous entities have developed and implemented successful tobacco-control programs. They include the federal government, specifically the National Cancer Institute (NCI) and the Centers for Disease Control and Prevention (CDC); various state governments; and commercial entities, such as Kaiser Permanente. California has been a leader in establishing a comprehensive tobacco-control program. Its program began in 1988 and adult tobacco use in California decreased from 22.7% to 13.3% by 2006 (CDC, 2007a). California served as the model for Massachusetts, which also developed a comprehensive program that resulted in a decrease in statewide tobacco consumption. California and Massachusetts were among the states that participated in the NCI American Stop Smoking Intervention Study (ASSIST) program and evaluation. See Appendix A for a detailed discussion of effective federal and state comprehensive tobacco-control programs. Comprehensive programs can provide the societal and organizational framework for reducing tobacco use in a population. 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. The process of creating tobacco-free environments should include educational campaigns to prepare the target communities and build support for the measures to be implemented. Once public support has been garnered, government and political support of tobacco-free policies must remain strong, including enforcement and sanctions for violations to ensure compliance (WHO, 2008). The comprehensive tobacco-control programs noted above and in Appendix A vary in target audience, size, funding sources, and bureaucratic oversight, but they share several key components that contribute to their success: the development and implementation of a strategic plan, dynamic leadership, effective and enforceable policies, communication interventions, adequate resources, appropriate
118 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS therapeutic interventions (including those for special populations), surveillance, evaluation of effectiveness with feedback, and management capability to bring about change. CDCâs (2007a) Best Practices for Comprehensive Tobacco Control Programs and its Tobacco: Guide to Community Preventive Services (CDC, 2009a) synthesize evidence-based practices into a multidimensional approach to public-health goals across the entire tobacco-use continuum from prevention to cessation. A combination of educational, clinical, and social strategies are recommended to denormalize tobacco use. In CDCâs Best Practices, the strategies are in five broad categories: (1) policies (for example, establishing tobacco-free facilities and increasing the price of tobacco products); (2) health promotion and education, including communication interventions (for example, mass-media antitobacco advertising campaigns and such innovative approaches as text messaging); (3) cessation interventions (for example, health-care-systemâbased cessation counseling and medications and population-based services, such as toll-free quitlines); (4) surveillance and evaluation; and (5) capacity-building, including administration and management procedures. Direct interventions for individuals, including health promotion and cessation, are important, but the other evidence-based strategiesâsuch as price increases, reduced access to tobacco products, tobacco-free environments, advertising bans, and changes in social perceptionsâall contribute to reducing tobacco use and ultimately encourage tobacco cessation (CDC, 2007a). Together, those key components can provide DoD and VA with the capacity to develop and implement a tobacco-control program that can achieve the five categories of strategies cited above. DoD and VA have established comprehensive programs for other public-health goals, such as weight management. In the following sections, the committee describes the key components of comprehensive tobacco-control programs. The committee believes that those key components, if implemented by DoD and VA, could help reduce and prevent tobacco use in their populations. The committee stresses that in addition to the components discussed in this chapter, a comprehensive program in either DoD or VA must begin with strong leadership that has the political and administrative will to effect changes in how the departments conduct their tobacco-control activities. An engaged leadership is also critical for implementing each of the program components presented in Table 4-1. Comprehensive tobacco- control programs with committed leadership and adequate resources are most effective in preventing tobacco use and helping tobacco users to quit. The sections below summarize the best evidence to support the use of the key program components and in the boxes provide a brief
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 119 TABLE 4-1 Key Components of Tobacco Control Programs Program Component Program Goals Eliminate Prevent Eliminate Disparities Tobacco- Tobacco- Exposure to Increase in Tobacco Free Use Secondhand Tobacco Use Culture Initiation Smoke Cessation Treatments Communication â¢ â¢ â¢ â¢ interventions Tobacco-use â¢ â¢ â¢ â¢ restrictions Tobacco retail â¢ â¢ â¢ â¢ environment Behavioral â¢ â¢ therapies and medications Special â¢ â¢ â¢ â¢ populations Surveillance and â¢ â¢ â¢ evaluation introduction to possible applications in military and veteran populations. The applications are discussed in greater detail in Chapters 5 (DoD) and 6 (VA) along with policy and program barriers to wider use of the key components. 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. COMMUNICATION INTERVENTIONS No tobacco-control intervention will be effective if it does not reach its target audience: tobacco users. Communication interventions must not only educate tobacco users and others about the hazards of
120 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS tobacco and provide information on how to access tobacco prevention and cessation services but, first and foremost, must focus on changing the social norm of tobacco use. CDC (2007a) states that âan effective state health communication should deliver strategic, culturally appropriate, and high-impact messages in a sustained, adequately funded campaign integrated into the overall state tobacco program effort.â There are many reasons why tobacco users do not seek assistance when quitting tobacco use, one of which may be a lack of knowledge that such assistance is available. Several approaches may be used to increase tobacco usersâ awareness of, and interest in, tobacco-cessation interventions. One communication approach is a mass-media campaign that alerts consumers about the hazards of tobacco use and informs them that assistance is available to help them quit. Product advertising can also alert consumers to tobacco-cessation medications or other programs, such as quitlines. In contrast, the advertising of tobacco products, particularly to young adults, has an enormous effect on increasing demand for tobacco products. Advertising and Promotions The tobacco industry has long understood that mass-media advertising and communication shape attitudes toward its brand images. As a result, cigarettes are one of the most heavily advertised US products, with advertising and promotion expenditures from 1940 to 2005 totaling $250 billion (in 2006 dollars) and reaching $13.5 billion in 2005 alone (in 2006 dollars) (NCI, 2008). Since the 1971 federal ban on television advertising of cigarettes and similar restrictions on the nature of advertising linked to the 1998 Master Settlement Agreement,1 the rate of smoking among people 18â24 years old has steadily declined (CDC, 2007b), but it continues to be a public-health problem as young people initiate tobacco use. Reports such as the Institute of Medicineâs (IOMâs) Ending the Tobacco Problem: Blueprint for the Nation (IOM, 2007), NCIâs The Role of the Media in Promoting and Reducing Tobacco Use (NCI, 2008), CDCâs Best Practices for Comprehensive Tobacco Control Programs (CDC, 2007a) and Tobacco: Guide to Community Preventive Services (CDC, 2009a), and other studies (Saffer and Chaloupka, 2000) have summarized a large body of literature on the effect of advertising on smoking behavior and concluded that the prevailing scientific opinion indicated a causal relationship between tobacco advertising and increased tobacco use. Because of the strong effect of visual advertising on tobacco 1 National Association of Attorneys General. http://www.naag.org/settle.htm (accessed February 2, 2009).
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 121 use, the IOM report recommended that all visual advertisements for tobacco products be limited to black-and-white, text-only formats. It also recommended prohibiting all advertising by tobacco companies to minors, regardless of purpose, inasmuch as even ostensibly discouraging advertisements and information-gathering campaigns, such as surveys, may encourage tobacco use. A recent study by Slater et al. (2007) found that advertising and price promotion contribute to the initiation of smoking (moving from one-time experimenters, or âpuffers,â to other, more established categories of smokers). The tobacco industry has also strategically targeted such populations as young men and women and racial and ethnic groups. It uses sophisticated advertising to appeal to the demographic and lifestyle characteristics of targeted audiences, such as social acceptance, athleticism, rewarded risk-taking, and masculinity or femininity (NCI, 2008). The committee notes that all of those characteristics are likely to appeal to a military audience that consists of young men and women being asked to undertake arduous duties and possibly risk their lives. Such conclusions have led the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) to call on nations to âundertake a comprehensive ban on all tobacco advertising, promotion and sponsorship . . . in accordance with its constitution or constitutional principles,â but the United States has yet to ratify the FCTC.2 Studies of comprehensive tobacco-advertising bans in several countries indicate that they have reduced consumption (Saffer and Chaloupka, 2000). The tobacco industry has changed its approach to tobacco promotion in response to changing regulatory environments. After implementation of the ban on television advertising, the tobacco industry used outdoor advertising, magazines, point-of-sale advertising, and direct mail to appeal to consumers (IOM, 2007). Point-of-sale advertising is associated with encouraging youth to try smoking (CDC, 2007a). With prices increasing as a result of higher state and federal taxes, the tobacco industry now spends $10 billion a year to provide price-discount promotions to merchants (Pierce, 2007). Price promotions play an important role in tobacco consumption because they counteract the effect of increased cigarette prices. The military services have enacted regulations that restrict or ban the advertising of tobacco products on military installations. VA does not have venues that advertise or sell tobacco products. 2 Current list of signatories can be viewed at: http://www.who.int/fctc/ signatories_parties/en/index.html (accessed May 19, 2009).
122 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS The independent military newspaper, Stars and Stripes, does not carry tobacco advertising, but installation papers that are commercially owned may have such advertising. VA does not have advertising in its newsletters. Counteradvertising and Public Education Offsetting the tobacco industryâs mass-media influence through counteradvertising is critical for achieving a nonsmoking public norm, including the military or, indeed, any segment of society (CDC, 2007a, 2009a; IOM, 2007; NCI, 2008). Strategies to counter advertising by the tobacco industry include advertising bans and counteradvertising with the goal of preventing smoking initiation, promoting cessation, and changing social norms associated with tobacco use (CDC, 2007a). Strategies to change social norms include tailored, engaging messages for specific audiences. 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). Newer communication tools to disseminate counteradvertising information include Web-based advertising, text messaging to personal communication devices, and on-line Web logs (blogs) (CDC, 2007a). Media campaigns should have sufficient reach, frequency, and duration (at least 6 months and preferably 18â24 months) to influence behavior (CDC, 2007a). Many of the mass-media counteradvertising campaigns have focused on preventing or reducing tobacco use by youth and reducing exposure to secondhand smoke (CDC, 2009a). The American Legacy Foundationâs âtruthÂ©â antitobacco campaign and the Phillip Morris Companyâs âThink. Donât Smokeâ campaign are aimed at adolescents. The American Legacy Foundationâs campaign, particularly its negative advertising, was found to be effective in encouraging antitobacco sentiments in adolescents and in reducing tobacco-use initiation among youth (Farrelly et al., 2009), but the Phillip Morris campaign was not (Apollonio and Malone, 2009). NCI (2008) found that, in general, tobacco-industry youth smoking prevention campaigns have been ineffective and may even have resulted in increased smoking among some young people. CDC (2009a) found that the most effective mass- media education campaigns for decreasing the number of young people and adults who use tobacco, combined with other interventions, lasted at least 2 years. The committee notes that most people entering the military
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 123 are in their late teens, therefore, antitobacco messages should be directed at those young adults, particularly young men, who have the highest rates of tobacco use. There is strong evidence that public-education campaigns via broadcast and print media also increase tobacco cessation among both adults and youth (CDC, 2009a). Mass-media campaigns, when combined with such other interventions as the distribution of self-help materials, increased tobacco cessation by about 2 additional quitters per 100 people. Tobacco consumption was reduced by about 13%, and tobacco- use prevalence was reduced by about 3 people per 100 tobacco users (CDC, 2009a). Antitobacco messages that included information about accessing telephone quitlines significantly increased the number of people who called them. The evidence of the effectiveness of mass- media education cessation series (that is, broadcast instructional segments designed to recruit, inform, and motivate tobacco users to try quitting and to succeed) and for cessation contests is still insufficient (CDC, 2009a). The mass media, particularly the news media, have been underused by tobacco-control advocates; however, the use of counteradvertising is effective in reducing smoking among targeted adult and youth populations (CDC, 2007a; IOM, 2007; NCI, 2008). Wakefield et al. (2008) found that antitobacco mass-media campaigns were effective in reducing tobacco use if broadcast at regular intervals. Strong negative messages about the health risks posed by tobacco use are more effective than more neutral or humorous messages or negative messages about the tobacco industry (NCI, 2008). Although the evaluation of mass-media programs comes from heterogeneous studies of varied methodologic quality, meta-analyses demonstrate that mass-media counteradvertising campaigns can be effective in reducing smoking consumption and prevalence (Bala et al., 2008). DoD has a strong mass-media presence both in recruiting and in promoting healthy lifestyles among its military personnel. Such promotional activities can be adapted to promote antitobacco messages. VA can access mass-media outletsâsuch as newsletters, motivational materials for waiting rooms, and Web sitesâto encourage veterans to quit tobacco. DoD has initiated a militarywide antitobacco campaign with the slogan âQuit Tobacco. Make Everyone Proudâ that targets military personnel 18â25 years old and includes an interactive Web site.
124 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Finding: Counteradvertising programs are effective in preventing tobacco initiation and in increasing tobacco cessation in target audiences. TOBACCO-USE RESTRICTIONS Tobacco-free policies have been shown to increase tobacco cessation (CDC, 2009a; US Surgeon General, 2004). Policies and regulations restricting tobacco use adopted outside the DoD and VA systems are described below. They point to similar opportunities for DoD and VA to restrict tobacco use by their target audiences. Such policies and regulations have the potential to affect tobacco use by military personnel and their dependents, civilian employees on military installations, and veterans. Tobacco-use restrictions are most effective when they apply to a variety of public and private settings. Smoking prevalence and annual per-capita consumption are 4% and 14 packs higher, respectively, and quitting rates are 6% lower in states without comprehensive clean- indoor-air laws (Bonta, 2007; Emont et al., 1992). The effects on secondhand smoke, quitting rates, and consumption are maximized when smoking is banned as opposed to restricted to designated areas (Heironimus, 1992; Pizacani et al., 2003). It has been estimated that clean-air laws can reduce smoking prevalence by 10% (Levy and Friend, 2003). Smoking bans in public places and workplaces are generally supported by the public, including smokers (Fong et al., 2006; RTI International, 2005; WHO, 2008). Enforcement of tobacco-free laws and policies is critical for their effectiveness. 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). Those measures can be combined with penalties for tobacco users who break the rules. Community Settings Community settings for tobacco restrictions include private and public workplaces, restaurants and bars, and hospitals. By January 4, 2009, 23 states had laws calling for 100% smoke-free public and private workplaces, 23 states had laws calling for 100% smoke-free bars, and 28 states had laws calling for 100% smoke-free restaurants (ANRF, 2009a). As a result, over 70% of the US population is protected by some type of 100% smoke-free law, and nearly 40% by a law calling for 100% smoke- free workplaces, restaurants, or bars (ANRF, 2009b). Many states and
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 125 municipalities also have laws restricting smoking in prisons, lodgings, malls, and hospitals and health clinics. In 1997, Executive Order 13058 required that all federal buildings be smoke-free. Those measures have traditionally been framed as involving worker-safety issues, and this approach has helped to build public support for smoking bans (WHO, 2008). Research on the effects of workplace tobacco restrictions demonstrates that they are effective in reducing exposure of all workers to secondhand smoke and in promoting cessation by workers who smoke (Bonta, 2007; Brownson et al., 1995, 1997; Fichtenberg and Glantz, 2002; Fong et al., 2006; Glasgow et al., 1997; Moskowitz et al., 2000). Furthermore, results of several studies suggest that smoke-free legislation is associated with decreases in hospital admissions for acute coronary problems (Pell et al., 2008; Sargent et al., 2004). â¢ DoD Instruction 1010.15 states that DoD facilities must be smoke-free to protect civilian and military health, although there are areas that are exempt. â¢ Veterans Health Administration Directive 2008-052 establishes a smoke-free policy for VA health-care facilities; it has effectively eliminated indoor smoking areas for patients and staff, although designated outdoor smoking areas remain. In 1992, the Joint Commission on Accreditation of Healthcare Organizations (now the Joint Commission) issued a mandate that all accredited hospitals except psychiatric hospitals be smoke-free; a year later, 96% of hospitals in the United States were complying with the mandate (Fee and Brown, 2004). At least 2 national hospitals and 1,594 local and state hospitals, health-care systems, and clinics had adopted 100% smoke-free campus-grounds policies as of 2008 (ANRF, 2009c). Implementation of the Joint Commissionâs smoke-free standards, although initially aimed at protecting patients, has also had a favorable effect on the smoking behavior of hospital workers (Fee and Brown, 2004; Longo et al., 1996, 2001). There is some resistance to the adoption of tobacco-free restrictions in psychiatric health-care settings. 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;
126 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Prochaska et al., 2008; Ryabik et al., 1994; Smith et al., 1999; Ziedonis et al., 2008). Fears that smoking bans in restaurants and bars would translate into a loss of revenues have been contested by research showing that such policies have no negative economic effect on these establishments (Bartosch and Pope, 2002; Fong et al., 2006; Howell, 2005; Huang and McCusker, 2004; Rabius et al., 2007; RTI International, 2004; Scollo et al., 2003; Siegel, 1992; WHO, 2008). Some employers, including WHO, have adopted policies that prohibit any tobacco use by employees, including when they are not working. Those policies target the individual rather than a geographic location. Numerous police departments have implemented policies that prohibit smoking as a condition of employment (Holly Deal, National Fraternal Order of Police, personal communication, November 20, 2008). Both firefighters and police officers are required to be smoke-free as a condition of employment in Massachusetts. 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. They may also intensify stigma and its associated ill effects (Schroeder, 2008; Stuber et al., 2008). âNo-smokerâ policies are controversial because they raise concerns unrelated to health, including personal privacy and employment discrimination (ACLU, 1998; Chapman, 2005; Gray, 2005; Warner, 1994). More than half the states have statutes that prohibit employers from discriminating in hiring, firing, or conditions of employment on the basis of an employeeâs lawful behavior outside work, including some that specify tobacco use (Malouff et al., 1993). The committee acknowledges that such actions may have unintended consequences that need further exploration. Neither DoD nor VA requires that employees be tobacco-free. Both departments mandate smoke-free facilities in compliance with Executive Order 13058, which requires federal buildings to be smoke-free. Educational Settings In 2003, about half the public universities in the United States had banned smoking in all residence halls and dormitories and within a
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 127 specified distance from building entrances (Halperin and Rigotti, 2003). By January 2009, 260 colleges and universities had enacted 100% smoke-freeâcampus policies with no exemptions (ANRF, 2009d). 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). Smoking prevalence is lower among students living in smoke-free college housing than in housing without such bans (Wechsler et al., 2001). Furthermore, nonsmoking students living in smoke-free college housing are less likely to initiate smoking (Wechsler et al., 2001). DoD is in the unique position of already requiring that new recruits into all the services be tobacco-free during basic training; the Air Force also mandates that trainees be tobacco-free during some technical training. All military services require that recruits not use tobacco during basic military training. The military service academies do not require that students be tobacco-free. Private Residences and Vehicles There has been a marked increase in personal smoking bans in the home over the last few decades. Smoking bans in the home are associated with lower exposure of adult and child residents to secondhand smoke (Biener et al., 1997; Brownson et al., 1995; Martinez- Donate et al., 2003, 2007; Spencer et al., 2005; Wakefield et al., 2000a), and they encourage smoking cessation (Farkas et al., 2000; Longo et al., 2001; Siahpush et al., 2003; Wakefield et al., 2000b), reduce smoking levels, and increase the average time to the first cigarette of the day among continuing smokers (Borland et al., 2006; Pizacani et al., 2004). Home smoking bans are also effective in reducing smoking initiation, promoting cessation, and lowering cigarette consumption by adolescents and young adults (Borland et al., 2006; Clark et al., 2006a; Farkas et al., 2000; Hill et al., 2005; Lotrean et al., 2005; NIH, 2006; Thomson et al., 2005; Wakefield et al., 2000b). The potential effect of home smoking bans on smoking prevalence has been estimated to surpass that of smoke- free workplaces (Bonta, 2007). Some municipalities have taken steps toward promoting smoke-free housing (Older Americans Report, 2005; Smokefree Apartment House Registry, 2007). As noted above, the concept of smoke-free housing has already been implemented by the hospitality industry. Over 8,300 lodgings in the United States were
128 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS smoke-free in 2008, and 23 states and over 500 municipalities had laws specifying the minimum percentage of smoke-free rooms in hotels and motels (ANRF, 2009e; Stoller, 2008). There is evidence that the increasing prevalence of smoking restrictions in public places has translated into smokers and nonsmokers adopting smoking bans in their cars. A 2002â2003 survey indicated that 57.1% of US smokers do not smoke in their cars when nonsmokers are present (Borland et al., 2006). Several states and jurisdictions have adopted legislation to ban or limit smoking in private vehicles while children are present (American Lung Association, 2009; IOM, 2007; OTRU, 2006). In California, 85% of daily smokers support a ban on smoking in cars when children are present (Al-Delaimy et al., 2008). In a review of public attitudes toward laws for smoke-free private vehicles when children are present, more than 77% of smokers in California, New Zealand, and Australia supported such laws (Thomson and Wilson, 2009). DoD has no requirement for designated smoke-free housing for military personnel and their families. Outdoor Spaces An increasing number of outdoor venues (such as parks and beaches) are becoming smoke-free, especially in states with strong tobacco-control efforts, such as California. By January 2009, Hawaii and Iowa prohibited smoking in outdoor dining areas, and 149 municipalities had enacted laws for 100% smoke-free outdoor dining areas (ANRF, 2009f). Moreover, 76 municipalities and Puerto Rico had smoke-freeâ beach laws (ANRF, 2009g), and a total of 399 municipalities required all city parks or specifically named city parks to be smoke-free (ANRF, 2009h). 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. More important, there is evidence of strong public support in California for smoking bans in such outdoor public spaces as childrenâs playgrounds, parks, beaches, golf courses, and sports stadiums (Gilpin et al., 2004).
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 129 â¢ DoD has no requirement for smoke-free outdoor areas. The Air Force does not permit personnel to smoke while walking in uniform, and this ban includes outdoor areas. â¢ 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). Restrictions legitimize the right of nonsmokers not to be exposed to secondhand smoke and establish explicit economic, legal, and social penalties for people who violate them. Smoking bans also reduce the number of areas where smoking is possible, making smoking more inconvenient. By requiring smokers to leave other activities and go to designated smoking areas, smoking bans increase the cost of smoking and result in lower levels of smoking and more cessation attempts by those who continue to smoke. Furthermore, restrictions limiting smoking to fewer and more specific outside areas reduce exposure to smoking social models and can contribute to the prevention of smoking initiation by young people and the prevention of relapse by former smokers. Limits on where and when smoking takes place, decreased exposure to smoking models, and changes in the social function of smoking all work to denormalize tobacco use and reduce the glamour traditionally associated with it. In combination, the legal, economic, and social contingencies established by smoking restrictions change social sentiments regarding smoking and secondhand smoke, transform public perceptions of tobacco, and ultimately reduce smoking at the population level (Hovell et al., 2002). Finding: Tobacco-free policies have been effective in increasing tobacco cessation among youth and adults. Workplaces, including medical facilities, restaurants, and hotels; colleges and universities; parks and recreational areas; and even private residences and vehicles have implemented tobacco-free policies. TOBACCO RETAIL ENVIRONMENT The tobacco retail environment can affect the sale and use of tobacco products favorably or unfavorably. The retail environment encompasses the financial and nonfinancial costs of tobacco products, the accessibility of tobacco products (access restrictions based on age or
130 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS through physical barriers at the point of purchase), and the promotion of tobacco products at the point of sale and through advertising in periodicals, promotional events, coupons, and other means. Increased tobacco costs and restricted access to the products are associated with reduced consumption and increased cessation (CDC, 2009a). 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. As elaborated below, tobacco prices remain among the most effective public-policy levers available both to reduce tobacco use and to fund tobacco-control efforts, such as counteradvertising. Tobacco Prices and Taxes Higher prices reduce tobacco consumption by affecting initiation (Slater et al., 2007), cessation (IOM, 2007), and the intensity of smoking (IOM, 2007). Research has shown that the use of taxes to combat tobacco consumption is one of the most effective tobacco-control policies (Warner, 2007). Tobacco prices are usually raised through increases in state excise taxes; however, in 2009, the federal government increased the federal tax3 on cigarettes from $0.39 to $1.0066 per pack to pay for the expanded State Childrenâs Health Insurance Program (NCI, 2009). The most relevant evidence on tobacco prices and taxes that is applicable to DoD is summarized below. DoD sells tobacco products at its commissaries and exchanges, typically below the prices of the same products sold commercially outside military installations. VA no longer sells tobacco products in its canteens or at its facilities. Overwhelming evidence demonstrates that people are less likely to smoke and to smoke fewer cigarettes when cigarette prices are high (Chaloupka and Warner, 2000; Gallet and List, 2003; IOM, 2007; NIH, 2006). Econometric analyses show consistently that a 10% rise in cigarette prices reduces consumption by 3â5% (Chaloupka, 1999; Chaloupka and Warner, 2000; Gallet and List, 2003). Given high rates of smoking relapse and initiation in military personnel after basic training (Klesges et al., 2001, 2006), the evidence on the smoking behavior of young adults is particularly relevant. For example, one study suggests that older youths (17â20 years old) are more responsive to price than younger youths (Gruber and Zinman, 2001). A mounting body of rigorous evidence indicates that smoking behavior is more responsive to price among young adults than among older adults (Chaloupka and Warner, 2000; Chaloupka and Wechsler, 1997; Gruber and Zinman, 3 Childrenâs Health Insurance Program Reauthorization Act of 2009, Â§701. Public Law No.111-3 (February 4, 2009).
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 131 2001). In particular, Harris and Chan (1999) demonstrate declining responsiveness to price with age among people 15â29 years old. Recent research also demonstrates that the effect of price on youth and young- adult smoking occurs both directly in response to price and indirectly through response to the lower prevalence of smoking among peers (Powell et al., 2005). Smoking initiation and tobacco use are more common among junior enlisted military personnel. Those personnel tend to be young adults who are more susceptible to tobacco pricing than older adults. Thus, tobacco-price increases in DoD commissaries and exchanges could result in marked changes in tobacco use in the military populations that use the most tobacco. Results of several studies suggest that price increases facilitate smoking cessation. Adult smokers are more likely to attempt cessation when faced with increasing prices (Levy et al., 2005a; Reed et al., 2008), and higher prices facilitate successful smoking cessation among young adults (Tauras, 2004). However, some evidence shows that recent price increases may be less likely to affect smoking prevalence even though higher prices can lower the intensity of smoking (Sheu et al., 2004). That is true particularly in such populations as low-income people and pregnant women (Franks et al., 2007; Levy and Meara, 2006). The evidence on whether price affects smoking initiation is somewhat mixed: some studies show that price does not affect whether youths have âever smoked a cigarette,â and others show that price influences the initiation of smoking (Jha et al., 2006; Levy et al., 2005b; Thomas et al., 2008). The discrepancy can be reconciled when viewed in the context of research that distinguishes experimentation from established smoking. In a study of adolescents that distinguished isolated experimentation (moving from nonsmoker to having ever smoked âeven a puffâ) from more established smoking patterns, price had a significant effect on initiation (Emery et al., 2001). In the aggregate, the evidence is strong that higher prices lower the consumption of cigarettes along all dimensions: initiation, cessation, and intensity. One concern with raising local or state taxes is that people can evade higher prices by purchasing tobacco through the mail, through the Internet, or by using coupons (Hyland et al., 2004). Ribisl et al. (2007) note that the number of Internet vendors and sales of tobacco products are increasing, particularly in states with high excise taxes, possibly
132 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS offsetting some of the reduction in tobacco consumption associated with higher taxes (Ribisl et al., 2007). However, studies of tobacco smuggling, usually focused on interstate or cross-country smuggling, suggest that higher prices reduce the effect of smoking even in the presence of opportunities for smuggling (Chaloupka and Warner, 2000; IOM, 2007). â¢ Military exchanges and commissaries sell tobacco products at a discount compared with civilian retail outlets. â¢ VA no longer sells tobacco products at its facilities. Access to Tobacco Products The effectiveness of barriers to the purchase of cigarettes on adolescent smoking behavior is supported by reports from IOM (2007) and NCI (2005). The 2007 IOM report Ending the Tobacco Problem: Blueprint for the Nation called for licensing of retail sellers of tobacco. Such licensing prohibits self-service sales of cigarettes by unlicensed retailers. Although this licensing policy targets youth, such restrictions could apply to a broader population. 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). There are many reasons to believe that small measures, such as requiring clerk assistance or requiring people to make an extra effort to purchase cigarettes in commissaries and exchanges, may work to reduce smoking. As described in Chapter 3, a robust literature in behavioral economics suggests that people can change their behavior dramatically in response to relatively small changes in their environment. Conversely, the number of tobacco products or other nicotine- delivery products that can be used in tobacco-free areas is increasing. There are now several varieties of smokeless cigarettes that manufacturers advertise can be legally used in no-smoking areas because they do not emit smoke, but they still deliver a high dose of nicotine. Those products include snus (a moist tobacco powder for oral use), âdissolvingâ nicotine, and smokeless or electronic cigarettes, all of which allow smokers to maintain their nicotine concentrations in situations where they are unable to smoke. Surveys of military personnel indicate that the use of smokeless tobacco is on the rise, particularly among deployed personnel (DoD, 2006). Although some military installations restrict access to tobacco
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 133 products in commissaries and exchanges, others promote such products with large, prominent displaysâso-called power wallsânear checkout counters. Finding: Increasing the price of tobacco products is one of the most effective interventions to prevent tobacco use and promote tobacco cessation. The funds generated from increased prices could be used to expand other tobacco- control efforts. TOBACCO-CESSATION INTERVENTIONS The vast majority of smokers (80%) report that they want to quit, and over half of smokers will make a serious attempt to quit in any given year (Kaiser Family Foundation, 2009), but only about 4â7% succeed in quitting in any one try (Fiore et al., 2008). Studies show that the rate and duration of tobacco abstinence are increased, generally doubled, when cessation treatments are used (CDC, 2007a; Fiore and Jaen, 2008; Fiore et al., 2008). National surveys, however, indicate disappointingly low rates of use of tobacco-cessation treatment by the general public. For example, the 2005 National Health Interview Survey found that less than 5% of smokers who made a serious attempt to quit used both behavioral and pharmacologic treatment (Curry et al., 2007). A similar pattern is evident in the 2003 Current Population Survey (Shiffman et al., 2008). In addition to the evidence-based interventions discussed below, the committee considered harm reduction as a possible intervention for tobacco use by military and veteran populations. A previous IOM report (2001) found that there was insufficient evidence on the health effects of smokeless or modified tobacco products, although the International Agency for Research on Cancer has found that smokeless tobacco use causes cancer (IARC, 2007). The IOM report also recommended that âharm reduction be implemented as a component of a comprehensive national tobacco control program that emphasizes abstinence-oriented prevention and treatment.â A recent strategic dialogue reached the conclusion that âsignificant tobacco harm reduction can be achieved over the long term only in a world where virtually no one uses combustible tobacco productsâ (Zeller et al., 2009). The evidence base on smokeless- tobacco products is not sufficiently robust to determine what health hazards other than cancer and periodontal disease are associated with smokeless or modified tobacco products. Furthermore, the committee is concerned that such products may serve as starters or supplements for the use of smoked tobacco products. This dual use is a substantial concern as demonstrated by the number of military personnel who use both (see the
134 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS section on dual use in Chapter 5). The committee has insufficient evidence to make any recommendations with respect to the use of smokeless tobacco as an alternative to smoked tobacco. There is an evidence base that supports the use of nicotine-replacement therapies (NRTs) on an extended basis as a form of harm reduction if a person is trying to quit or has made a quit effort and is sustaining abstinence. The Public Health Service (PHS) Clinical Practice GuidelineâTreating Tobacco Use and Dependence: 2008 Update (Fiore et al., 2008) indicates that prolonged use of NRTs (for more than 14 weeks) is effective in increasing abstinence. In the sections below, the committee examines the evidence base on various tobacco-cessation interventions, including medications and behavioral therapies. It then identifies the most effective practices for providing those treatments to the targeted audiences. 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. For example, the 2008 PHS guideline (Fiore et al., 2008), the Task Force on Community Preventive Services Recommendations Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke (Hopkins, 2001), and the 2007 IOM report Ending the Tobacco Problem: A Blueprint for the Nation all conclude that the most effective way to achieve smoking cessation is to combine behavioral interventions that include person-to- person treatment with Food and Drug Administration (FDA)âapproved pharmacologic treatments. Effective behavioral interventions include brief advice and assistance from a health-care provider during routine health-care visits, multisession outreach telephone counseling, and face- to-face group and individual counseling. Although all those interventions are effective, there is a doseâresponse relationship in behavioral treatments: multisession intensive treatments achieve significantly higher quit rates than minimal-contact interventions. The use of FDA-approved tobacco-cessation medications, alone or in conjunction with behavioral interventions, is effective in maintaining long-term abstinence. Behavioral Interventions Behavioral interventions focus on providing tobacco users with specific skills and supports to modify their tobacco use. Building from
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 135 theoretical models of the determinants of tobacco use and cessation, the interventions typically have five key components: (1) self-monitoring, including systematic observation and recording of behavior; (2) cognitive restructuring, which involves identifying and altering thoughts and beliefs that may undermine quit efforts; (3) goal-setting focused on specific, quantifiable, and reasonable short-term (such as 1â2 weeks) and long-term (such as 6 months) goals; (4) problem-solving to identify and cope with high-risk situations that may lead to relapse; and (5) social support, seeking support from others and informing them of the types of support desired (NRC, 2003). Those interventions can be offered in different formats (such as face to face, over the telephone, and by computer) with different numbers and lengths of contact. Meta-analyses show that even a behavioral intervention contact as brief as 3 minutes improves the odds of quitting by as much as 40% compared with no treatment. 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 1â3 minutes to 91â300 minutes; however, contact time in excess of 300 minutes does not appear to increase abstinence rates (Fiore et al., 2008). Tobacco-Cessation Medications Seven medications have been approved by FDA for smoking cessation and are recommended by the 2008 PHS guideline alone or in combination as first-line medications (Fiore et al., 2008). The first-line medications include several forms of NRTsâgum, lozenges, and patches are available over the counter, and nasal sprays and inhalers are available by prescriptionâand bupropion sustained-release (SR) and varenicline, which are available by prescription. Each of these medications has been shown to increase the likelihood of smoking cessation significantly (Fiore et al., 2008). Nicotine gum, patches, and lozenges should be used for 6â14 weeks for both highly dependent and regular smokers. In addition to recommending the use of the nicotine patch as a single medication, the guideline recommends several medications in combination with it, including nicotine gum or spray, bupropion SR, and inhaled nicotine. Kornitzer et al. (1995) found a significant increase in abstinence rates in those who added gum use to patch use. In an effort to assess the comparative effectiveness of the FDA-approved medications, various cessation medications were compared to the nicotine patchâthe most commonly used cessation medication. The meta-analysis identified two medication regiments that were more effective than the nicotine patch: varenicline used alone and the combination of a long-term
136 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS nicotine patch with NRT gum or spray (Fiore et al., 2008). The guideline also recommends two second-line medications, defined as medications that FDA has not approved for tobacco-dependence treatment and about which there are more concerns for potential side effects than in the case of first-line medications: clonidine and nortriptyline. Interactions between tobacco smoke and various medications have been identified (Zevin and Benowitz, 1999), and clinicians should not only be aware of their patientsâ smoking status but also should monitor patients to ensure that their medications are acting as prescribed. 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 âthe combination of counseling and medication is more effective for smoking cessation than either intervention alone. Therefore, whenever feasible and appropriate, both counseling and medication should be provided to patients trying to quit smokingâ (Fiore et al., 2008). A meta-analysis of 9 studies showed a 70% increase in the likelihood of quitting when medication was added to counseling alone, and a meta-analysis of 18 studies showed a 40% increase in the likelihood of quitting when counseling was added to medication alone (Fiore et al., 2008). With behavioral counseling alone, there was a doseâresponse relationship between the number of counseling sessions and rates of cessation. Two or more sessions significantly increased cessation rates; the highest abstinence rates were observed with more than eight counseling sessions (32.5% abstinence rate at 6 months). Furthermore, among patients who used multiple tobacco-cessation medications in combination with individual or group counseling, the cessation rates at 6 months increased with the number of medications. Patients who continued to use medications at 6 months had a greater abstinence rate than those who quit using them in less than 6 months (82% vs. 52%) (Steinberg et al., 2006). Other Individual Interventions Although other tobacco-cessation interventions are availableâ such as self-help materials, rapid smoking, acupuncture, and hypnosisâ results are inconclusive with regard to their effectiveness in helping tobacco users achieve long-term abstinence. The 2008 PHS guideline states that rapid smoking (also called aversive smoking) was more
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 137 effective than no psychosocial counseling or therapy, but it is not a recommended treatment (Fiore et al., 2008). A Cochrane review on aversive smoking suggested that although it may be effective, more research was needed (Hajek and Stead, 2001). Self-help materials, such as brochures and videos, as either the only interventions or in combination with other interventions, do not significantly increase abstinence rates (Fiore et al., 2008). Acupuncture has also been assessed in both the guideline and a Cochrane review; the Cochran review found a slight positive effect (White et al., 2006), but the guideline did not. Neither the 2008 PHS guideline nor the Cochrane review found sufficient studies to assess the use of hypnosis for tobacco-use cessation. One study in veterans found that hypnosis increased abstinence at the 6- month and 12-month follow-ups (Carmody et al., 2008). The use of financial incentives for tobacco-use cessation has also been explored. 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). Volpp et al. (2006) studied the use of financial incentives in a group of veterans attending a VA medical center, paying some smokers to attend smoking-cessation classes and for remaining abstinent for 30 days. The financial incentives were useful for enrolling veterans in the program, but the 6-month quit rates between the incentive and no- incentive groups were not significantly different (p > 0.2). However, in a later study of employees at a large company, financial incentives for enrolling in and completing the smoking-cessation program and for maintaining abstinence for up to 12 months resulted in significantly higher abstinence rates compared with employees who did not receive such incentives (p < 0.001) (Volpp et al., 2009). Other interventions that have been studied include telling smokers about their decreased lung function, or lung âage,â as a result of smoking; the effectiveness of this intervention is uncertain (Kotz et al., 2008; Parkes et al., 2008; Wilt et al., 2007). Finding: Behavioral therapies are effective in increasing long-term tobacco cessation. Cognitive strategies and problem-solving are particularly effective when offered in a multisession format. Available over-the-counter and prescription medications, when used appropriately, also improve the likelihood of long-term tobacco cessation. A combination of the tobacco-cessation pharmacotherapies and behavioral therapies described above is most effective in achieving long-term tobacco cessation. Other
138 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS interventionsâsuch as hypnosis, acupuncture, and financial incentivesâhave been assessed in a few studies, but there is insufficient information on their effectiveness in achieving long-term tobacco cessation. DELIVERY OF INTERVENTIONS An integral aspect of tobacco control is generating a desire and willingness in people to quit using tobacco. Motivation to quit may spring from encouragement from family and friends, increased awareness of the hazards of tobacco use because of public-education campaigns, in response to increased prices for tobacco products or restrictions to areas where they may be used, or advice from a health- care provider. A comprehensive tobacco-control program ensures that many sources of encouragement and support are made available. 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. Inasmuch as most people who make a quit attempt relapse within 48 hours, removing barriers to treatment is paramount to maintaining abstinence. Provision of tobacco-cessation services can occur in many settings and formats. Health-care providers can inform patients about the health effects of tobacco use and counsel them about treatment options for quitting, patients can be referred to proactive or reactive telephone quitlines that provide cessation counseling and often medications, and patients can access computer-based cessation programs that offer counseling, support, and medicationsâalthough the evidence base on the latter is lacking. In this section, the committee considers the evidence base on those approaches for delivering tobacco-cessation services and the training needs of health-care professionals that provide them. The committee finds that a combination of in-person and other forms of program-delivery formats are likely to be the most effective in reaching the largest audience. A number of tobacco-cessation programs are used by health-care organizations (see Box 4-1), but they have not all been evaluated formally for their effectiveness.
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 139 BOX 4-1 Some Smoking-Cessation Programs â¢ BecomeAnEx, sponsored by the National Alliance for Tobacco Cessation (made up of the American Legacy Foundation and numerous other groups, government and nongovernment), is a three- step plan. It allows for personalizing a plan to relearn life without cigarettes. (http://www.becomeanex.org/#learn_overview) â¢ SmokeFree.gov provides an online step-by-step cessation guide with access to local and state telephone quitlines, the NCI national telephone quitline, NCIâs 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. (http://www.smokefree.gov) â¢ Freedom From SmokingÂ® Online, sponsored by the American Lung Association, is a free online smoking-cessation program that contains seven modules and has a telephone helpline. (http://www.ffsonline.org/) â¢ QuitNet, the self-proclaimed largest online quit program, is owned by Healthways Inc. It is free but has a commercial component. It includes stop-smoking resources, quitting tips and advice from expert counselors, quit support from the QuitNet community, and the ability to create an individualized quit-smoking plan. (http://www.quitnet.com/qnhomepage.aspx) â¢ Free and Clearâs Quit For LifeÂ® Program is the nationâs leading tobacco-cessation program and uses an evidence-based combination of physical, psychologic, and behavioral strategies to enable participants to take responsibility for, and overcome their addiction to, tobacco use. Free and Clearâs integrated mix of medication support, telephone-based cognitive behavioral coaching, and Web- based learning and support tools produces an average quit rate of 43%, making the Quit For Life Program at least 8 times as effective as quitting âcold turkey.â (http://www.freeclear.com/) â¢ Quit SmartÂ® is a commercial service that sells stop-smoking kits to smokers and offers fee-based classes and individual instruction in person or over the telephone. Quit Smart claims that its services have produced quit rates of 66%. The program and kit include a cigarette substitute, hypnosis, and medication recommendations. (http://www.quitsmart.com/) â¢ Other Web sites sponsored by commercial entities, including tobacco companies, provide some information on smoking cessation.
140 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Clinical Settings The PHS Clinical Practice GuidelineâTreating Tobacco Use and Dependence: 2008 Update outlines an evidence-based algorithm for addressing tobacco use and dependence as part of routine health-care delivery (Fiore et al., 2008). Known as the 5 Aâs, it begins with a patientâs presentation in a health-care setting and uses a decision tree to help the health-care provider to do the following: 1. Ask all patients about tobacco use. 2. Advise all current users to quit. 3. Assess smokersâ willingness to quit. 4. Assist smokers willing to quit by providing appropriate tobacco-dependence treatments. 5. Arrange follow-up for smokers who are making a quit attempt. Using the 5 Aâs should require only about 3 minutes of a clinicianâs time with a patient and other health professionals such as medical assistants can ask the patient about their tobacco-use status and include the information on the patientâs chart for the clinician. The guideline also includes specific recommendations for program intensity, the type of counseling, and the inclusion of medications. It states that in some clinical settings it may be more effective to deliver the 5 Aâs in a different format or order, such as Ask, Advise, and Refer (Fiore et al., 2008). Schroeder and Cooper (2005) found that many clinicians may not be aware of, or take the time to use, the 5 Aâs; therefore, the brief approach of Ask, Advise, and Refer patients to a quitline or other counseling service may be more acceptable to some clinicians. The guideline recognizes that not all patients are willing or able to quit and provides interventions for these patients. 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). The 5 Râs provide a framework for conducting motivational interviewing: 1. Relevanceâencourage patient to explain why quitting is relevant to them. 2. Risksâask patients to explain adverse effects of tobacco use. 3. Rewardsâask patients to identify the benefits of quitting. 4. Roadblocksâdetermine the barriers to a patientâs quitting.
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 141 5. Repetitionâuse a motivational intervention each time a patient is seen. 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) and a randomized trail (Burke et al., 2003; Butler et al., 1999) suggest that motivational interviewing does not increase long-term cessation rates, recent analyses have found it to be effective in promoting quit attempts and abstinence (Fiore et al., 2008; Soria et al., 2006; Van Schayck et al., 2008). DoD and VA have developed the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use, modeled on the PHS guideline; it provides evidence-based advice on many aspects of treatment of military personnel, their dependents, and veterans for tobacco use. A 1999â2000 survey of the use of the 5 Aâs by health-care providers in 9 health-maintenance organizations found that 90% of the 2,325 smokers were asked about their smoking status, 77% were advised to quit, 63% were assessed for willingness to quit, 35% were offered self-help materials (assist), 41% were offered or referred to classes or counseling (assist), 33% were offered pharmacotherapy (assist), and 13% had follow-up arranged. Thus, it seems that the health-care providers were more likely to advise smokers to quit than to assist in cessation, or especially, to arrange cessation treatments, in spite of the fact that all of the health plans in the study provided comprehensive coverage for tobacco-cessation counseling and medications. Those who were offered and used tobacco-cessation medications or counseling were significantly more likely be abstinent for 30 days at 12 months than those who did not (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.56â3.20, and OR, 1.82; 95% CI, 1.16â2.86). The use of self-help materials alone (OR, 0.71; 95% CI, 0.47â1.08) or having a health care provider only advise the patient to quit smoking were not effective (OR, 0.84; 95% CI, 0.56â 1.25) (Quinn et al., 2009). The 2002 National Ambulatory Medical Care Survey found that participating physicians were as likely to ask their male patients as their female patients, in all age categories, about tobacco use (65.1â73.2% of all patients). About 17â27% of the men and women who used tobacco
142 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS received counseling when visiting their physicians regardless of age, except for men over 75 years old, who were counseled only 5.6% of the time (Wallace et al., 2006). In some medical facilities, a variety of health-care providers (such as nurses, psychologists, counselors, and physicians) may be responsible for the delivery of tobacco-cessation interventions. In a meta- analysis examining the effectiveness of tobacco-cessation interventions by various health-care providers with or without NRTs, interventions without NRTs were most effective when delivered by a psychologist or physician. Counselors and nurses were also effective, but the difference compared with the placebo (usual care) was not statistically significant. When NRTs were combined with provider intervention, the effectiveness of most providers increased up to twofold (Mojica et al., 2004). Primary-Care Providers The 2008 PHS guideline found evidence that tobacco-cessation interventions offered by both physicians and nonphysicians (such as nurses, psychologists, dentists, and counselors) 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). Nurses In a Cochrane review of nursing interventions for smoking cessation, Rice and Stead (2008) conducted a meta-analysis of 31 studies and determined that nurse-provided interventions were more effective in reducing 6-month smoking rates than no intervention or usual care. High-intensity interventions, such as an initial counseling session of 10 minutes or more with additional materials and at least one follow-up contact, were more effective than low-intensity interventions. Nursing intervention was most effective for inpatients in a hospital and to a smaller extent for nonhospitalized patients. Interventions offered during a screening health check were less effective. The use of additional materials (such as leaflets) by a nurse did not appear to promote smoking cessation (Rice and Stead, 2008). Other Health-Care Providers Health-care providers other than primary-care clinicians and nurses have been considered as resources for tobacco-cessation counseling. Pharmacists are frequently associated with medical facilities,
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 143 particularly hospitals and large outpatient clinics. In addition to their obvious role in providing tobacco-cessation medications, including such over-the-counter medications as NRTs, some pharmacists have been trained to offer counseling and literature to their patients who use tobacco. In a Cochrane review of two studies conducted in the United Kingdom, only one study showed a significant association between pharmacist-provided counseling and record-keeping and self-reported 12-month abstinence rates (Sinclair et al., 2004). A more recent review by Dent et al. (2007) of 15 studies of tobacco-cessation services provided by pharmacists found a statistically significant difference in abstinence rates between the pharmacist-intervention groups and control groups (Dent et al., 2007). 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. 11.8%; p < 0.041) (Dent et al., 2009). Dentists are also well situated to counsel patients about tobacco use, particularly smokeless-tobacco use, which is associated with increased oral cancer and periodontal disease (see Chapter 2). At 12 months, smokeless-tobacco users who had received tobacco-cessation counseling from their oral-health professional (dentist or oral hygienist) had greater abstinence rates than those who did not receive such counseling (Carr and Ebbert, 2006). Finding: Multiple-session counseling in a health-care setting, preferably on an individual basis, is effective in achieving long-term tobacco cessation and may be provided by a variety of health-care providers in addition to physicians, such as nurses, dentists, and pharmacists. DoD and VA both have large, complex health-care systems that should strive to offer barrier-free access to tobacco-cessation services (both counseling and medications) that reflect current evidence on effective programs. Programs should be available to all members of the target populations regardless of place, time, and status (for example, active duty, deployed, reservist, at home) and be offered by a variety of health-care professionals.
144 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Tobacco Quitlines There is ample evidence that tobacco quitlines are efficacious (Borland et al., 2001; Stead et al., 2006; Zhu and Anderson, 2004), particularly when combined with other interventions (CDC, 2009b). Quitlines offer the advantage of generally being available when needed and free of charge for counseling. No appointments are necessary to access them, and patients can call them for individual counseling in privacy. Quitlines also help patients to overcome barriers to treatment, such as living at a considerable distance from a clinic or other treatment locations, being unable to attend counseling sessions because of work or social commitments, and waiting for the next tobacco-cessation program to begin. The statewide use of a quitline as part of a comprehensive tobacco-use cessation program began in California in the early 1990s and was followed in Massachusetts. Now all 50 states and the District of Columbia have tobacco quitlines (http://www.smokefree.gov/). Any adult in need of tobacco-use cessation services can call a national telephone number (1-800-QUIT-NOW), which will route the caller to his or her state tobacco quitline; this referral service is sponsored by NCI. NCI also has a toll-free quitline at 1-877-44U-QUIT that has a smoking- cessation counselor available during the day for help in quitting and to provide answers to smoking-related questions in English or Spanish. Although quitline access is available to all adults across a broad demographic spectrum, quitlines vary greatly in quality, intensity, and duration. Three factors increase their efficacy: proactive quitlines (participant may initiate call with proactive follow-up by quitline or a telephone counselor may initiate the call to the participant) rather than reactive quitlines (the participant initiates all calls to the quitline) (Stead et al., 2006); counseling that lasts longer (for example, at least four sessions) and that includes booster sessions (Hollis et al., 2007; Stead et al., 2006); and quitlines that provide NRTs (Fiore et al., 2008; Rabius et al., 2007). Cummins et al. (2007) surveyed 62 publicly available quitlines in North America (all 50 states, the District of Columbia, Puerto Rico, and 10 Canadian provinces) in 2004â2005. Most of the US quitlines had trained counselors available for a mean of 85 hours/week, many of them offering counseling in 2 languages, and a few offering as many as 8 languages. 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. In addition to their telephone counseling services, about 50% of the quitlines offered Internet-based services, including
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 145 general quitline information, cessation information, self-directed quit plans, automated e-mail messages, chat rooms, and interactive counseling. About one-third of the quitlines mailed free medications to callers, and 23% provided vouchers for medications. Although many of the quitlines had specialized protocols for pregnant women, smokeless- tobacco users, ethnic populations, and people 12â17 years old, far fewer offered protocols for multiple addictions, people 18â24 years old, those with mental illness, or older adults. Most of the quitlines had some criteria for receiving free medications, such as lack of insurance coverage. The North American Quitline Consortium (NAQC) was established to help federal and state health departments, quitline service providers, researchers, and service providers, such as the American Cancer Society, to improve quitline services. In addition to the state quitlines and the service providers, NAQC members include CDC, the Robert Wood Johnson Foundation, the American Legacy Foundation, ClearWay Minnesota, and several Canadian organizations. NAQC is one resource for information about current quitline services, improving quitline quality, and assessing quitline efficacy and research. Although quitlines are acknowledged to be effective in reaching a large number of tobacco users and can be tailored to reach specific audiences, they do have limitations. Quitlines typically reach only a small proportion of their target populations and are chronically underfunded. The 2003 National Action Plan for Tobacco Cessation (Fiore, 2003) recommended that state quitlines use at least four person- to-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. The plan also called for states to receive earmarked grants to maintain their quitlines and for quitlines to meet national performance standards. Zhu and Anderson (2004) noted that the promotion of a quitline may prompt tobacco users to attempt to quit on their own even if they did not contact the quitline (Zhu and Anderson, 2004). Quitlines therefore may reach a broader audience than only tobacco users who are seeking counseling, including their friends and family who may call to request information on how to support or initiate quit attempts by tobacco users.
146 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS The national action plan specifically states that military personnel and their families should be eligible to use the national quitline and that a toll-free number should be available for military personnel and their families stationed overseas. DoD and VA populations live in a variety of locations including small and remote communities and overseas, where in-person tobacco-cessation services may be scarce or nonexistent. 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. Evidence indicates that a quitline should be proactive (counselor-initiated) and should provide four to six sessions and follow-up sessions as necessary. Computer-Based Programs Several studies have assessed the effectiveness of computer- based tobacco-cessation interventions, but there is insufficient information on their effectiveness. Nevertheless, the committee considered these programs as more people, both civilian and military, turn to computers for a variety of health information, assistance, and support. Many computer-based interventions have the advantage of being tailored to individual participants on the basis of their responses to questions, and they can be used to reach a large audience, including people who may not be contemplating quitting. Counseling may be conducted by telephone or e-mail with additional individualized resources, such as chat rooms, videos, graphics, journals, and action plans (Etter, 2002); computer-based programs can also be combined with medication. The efficacy of tailored computer-based tobacco-cessation programs is varied (Strecher and Velicer, 2003). Etter (2006) surveyed current and former smokers about the quality and helpfulness of 133 tobacco-cessation Web sites. Two of the most frequently visited sites were run by tobacco companies and were not considered helpful by participants. Two sites were ranked above average for quality and were nonprofit (Anti-smoking.com and Smokefree.gov), and the one ranked highest for helpfulness (Quitsmoking.About.com) was a for-profit
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 147 Website. Strecher et al. (2008) found that a Web-based behavioral smoking-cessation program was less effective for participants who were younger, male, and had less formal education (Strecher et al., 2008). Feil et al. (2003) designed a Web-based cessation site and studied recruitment approaches, use patterns, retention incentives, satisfaction, and cessation rate. The program included social support and cognitiveâbehavioral coping skills. Of the 370 subjects followed for 3 months, the 7-day point- prevalence abstinence rate was 18% on the basis of intent-to-treat analysis (Feil et al., 2003). One example of a computer-based service is QuitNetÂ® that includes personalized interactive materials for members, provides proactive telephone counselors, and hosts an online support community of other smokers and ex-smokers (Cobb et al., 2005). One version of the program is available free to the public, and the other is an enhanced version available to commercial organizations. Other computer-based tobacco-use cessation programs include Quit For Life, offered by Free and Clear, Inc.; Freedom From SmokingÂ®, developed by the American Lung Association; and BecomeAnEX, sponsored by the National Alliance for Tobacco Cessation. SmokeFree.gov offers an online smoking-cessation program that includes text messaging with an NCI tobacco-cessation counselor. The SmokeFree.gov site also contains a referral for military personnel to DoDâs âQuit Tobacco. Make Everyone Proudâ program. According to the National Institutes of Health Web site (www.clinicaltrials.gov), formal assessments of QuitNet and other online smoking-cessations programs are under way. Finding: Computer-based tobacco-use cessation programs may be able to reach a large audience of tobacco users, but there is insufficient evidence of their effectiveness. Provider Education Many people see a health-care professional (such as a primary- care physician or dentist) at least once a year. Each visit can be an opportunity to ask patients about their tobacco use and educate them about adverse health effects and available interventions. But first, health- care 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 Aâs to increase the rate of asking, advising, and assisting patients with tobacco cessation. The National Ambulatory Medical Care Survey of office-based physicians in the United States
148 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS conducted by the National Center for Health Statistics in 2001â2003 found that physicians identified smoking status during 68% of office visits and counseled about 20% of smokers during their visits. Pregnant women were most frequently asked about their smoking status but were the least likely to receive smoking counseling. The use of tobacco- cessation medication, primarily prescription bupropion, was recorded in only 1.7% of visits (Thorndike et al., 2007). A Cochrane review found that training of health-care providers increased the likelihood that they would offer evidence-based cessation interventions during patient visits (Lancaster et al., 2000). Numerous training programs are available for health-care providers, some of them free of charge. For example, the University of California, San Francisco, has a program, Rx for Change: Clinician- Assisted Tobacco Cessation, that trains health-professionals, students, and licensed clinicians in the 5 Aâs or the Ask-Advise-Refer model (accessible at http://www.rxforchange.ucsf.edu). The 2AandR online program, sponsored by the Washington State Department of Health and run by Free and Clear, Inc., also offers training and resources to health- care providers based on the 2008 PHS guideline. The American Lung Associationâs 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?id=9). There is a lack of training among mental-health professionals, primary-care providers, and tobacco-cessation specialists with regard to tobacco-cessation interventions for patients with psychiatric disorders (Williams and Ziedonis, 2006). Training psychiatrists to provide cognitive-behavior therapy to mental-health patients for tobacco cessation within the psychodynamic therapeutic model taught in most psychiatric residencies may be challenging inasmuch as only about half the psychiatry residencies require cognitive-behavior therapy training (Prochaska et al., 2007). Provider-level strategies for increasing patient use of cessation interventions include electronic or written prompts and reminders on medical charts or records such as the assessment and documentation of tobacco-use status as a vital sign at every health-care visit (Fiore et al., 2008). For example, primary-care physicians who used a computer report of their patientsâ smoking status that included tailored recommendations for discussing smoking cessation were more likely to have abstinent patients at a 6-month follow-up than those who supplied standard care (Smith et al., 2007; Unrod et al., 2007). Provider reminder systems have been shown to be effective in increasing tobacco cessation, particularly when combined with provider education (CDC, 2009a).
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 149 NCI has developed a Handheld Computer Smoking Intervention Tool (HCSIT), which assists clinicians with smoking-cessation counseling during patient visits. The software was developed in accordance with the current PHS guideline and includes a handheld version of the Fagerstrom Test for Nicotine Dependence. The tool guides clinicians through the appropriate questions and makes intervention recommendations, including prescription information, on the basis of the level of dependence. The HCSIT contains medication information, brief motivational interventions for tobacco users, and evidence-based recommendations from the PHS guideline. The easy-to-use program can be used with PalmÂ®, SmartPhone, and MicrosoftTM Pocket PC handheld computers. For more information, see http://www.smokefree.gov/hp- hcsit.html. VA initiated a preceptor training program to improve delivery of tobacco-cessation treatment for veterans with mental disorders. The program uses a train-the-trainer format to educate more than 160 VA mental-health and substance-use disorder providers from every Veteran Integrated Service Network about evidence-based clinical practices and mentors their progress in integrating smoking cessation into routine psychiatric care. Finding: The training of health-care providers in tobacco- cessation interventions is effective in increasing the likelihood that a patient will be asked about tobacco-use status, be advised to quit, and be assisted with tobacco- cessation services. 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. Many populations of tobacco users may be reluctant to quit, find it hard to do so, or be at risk for adverse health outcomes; these special populations include âhard-coreâ smokers who have smoked for many years, people with psychiatric and medical comorbidities, and people who have other complicating conditions, such as homelessness. Those populations have not traditionally been the focus
150 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS of tobacco-control and cessation programs, and they may require modified or innovative approaches to help them quit. This may have particular relevance for DoD and VA: both treat tobacco users who have mental illness and other comorbidities, and VA treats a homeless population. Other populations served by the VA and military health systems that may require different approaches for effective tobacco- cessation 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. Tobacco Users with Mental-Health Disorders Disproportionately higher rates of smoking (see Chapter 3 for specifics) are related to an increased risk of tobacco-related illness among those with psychiatric or mental disorders. For example, persons with chronic mental illness die about 25 years earlier compared to those withoutâmortality is primarily due to lung cancer and cardiovascular disease (Colton and Manderscheid, 2006), and half of premature deaths in alcoholics are attributable to cigarette smoking (Hurt et al., 1996). These statistics underscore the importance of developing effective treatments for patients with psychiatric comorbidities. Tobacco-cessation interventions in people with psychiatric disorders have been the subject of much research and several reviews (Fagerstrom and Aubin, 2009; Hagman et al., 2008; Ranney et al., 2006; Schroeder, 2009; Ziedonis et al., 2008). Barriers impede the application of cessation treatments in mental-health populations, contributing to the high rates of tobacco use and low rates of cessation in this population (Williams and Ziedonis, 2004). Foremost among these barriers is a seeming reluctance on the part of mental-health professionals to provide concurrent treatment for mental-health disorders and tobacco use. For example, in mental health- care settings, smoking-cessation treatment seems neglected as psychiatric patients only receive cessation counseling during 38% of their visits with physicians and 12% of their visits with psychiatrists (Ziedonis et al., 2008). In the past, cigarettes have even been used as tokens to reinforce positive behavior (Gustafson, 1992). Possible reasons for this reluctance include the belief that nicotine withdrawal may exacerbate a patientâs psychiatric symptoms, lack of training in tobacco-cessation treatment and counseling, possible interactions between cessation medications and medications prescribed for other psychiatric disorders, and the attitude that tobacco use is a long-term problem and thus a lower priority than more immediate psychiatric concerns (Ziedonis et al., 2006, 2007).
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 151 In spite of the 1996 publication of the American Psychiatric Association guideline recommending that psychiatric patients receive routine treatment for tobacco use (American Psychiatric Association, 1996), the proportion of mental-health patients counseled about smoking by their primary-care physicians (23%) or their psychiatrists (18%) is low (Thorndike et al., 2001). The National Ambulatory Medical Care Survey found that psychiatrists offered tobacco-cessation counseling to only 12.4% of their patients who smoked (Himelhoch and Daumit, 2003). More counseling was offered to patients who were over 50 years old, had diabetes, had hypertension, had obesity, lived in a rural location, or were in their initial visit. A study of 250 hospitalized psychiatric smokers found that only 105 were actually identified as current smokers in their medical records and none had received a diagnosis of nicotine dependence or withdrawal (the facility was smoke-free) or had cessation services as part of their hospital treatment; however, NRT was prescribed for 56% of the smokers, almost all of whom used it (Prochaska et al., 2004a). Ziedonis et al. (2008) noted that mental-health providers may be ideal for delivering tobacco-cessation treatment because there is a therapeutic alliance between patient and provider; patients will return for treatment for their psychiatric symptoms regardless of their cessation status, and the provider can use these opportunities to encourage repeated attempts to quit; and it is relatively cost-efficient in that tobacco- cessation treatment can be delivered during planned visits to the provider (Ziedonis et al., 2008). Although people with psychiatric disorders have higher rates of tobacco use than people without these disorders, many of them are interested in quitting and will attempt to quit. The National Comorbidity Survey found that smokers with history of mental illness in the past month had a self-reported quit rate of 30.5% compared with a quit rate of 42.5% for those without any mental illness (Lasser et al., 2000). Patients with psychiatric disorders may use tobacco as a self-medication for their symptoms (Fagerstrom and Aubin, 2009; Khantzian, 1997; Lerman et al., 1998) because nicotine has been associated with improved psychomotor function in people with depression (Malpass and Higgs, 2007) and has been associated with enhanced attention, sensory gating, and working memory in those with schizophrenia (Dalack and Meador-Woodruff, 1996; Strasser et al., 2002; Ziedonis et al., 2007). However, as discussed in Chapter 3, nicotine withdrawal may exacerbate some psychiatric symptoms if not properly controlled (Fagerstrom and Aubin, 2009). 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
152 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS with alcohol dependence (Fiore et al., 2008). Although quit rates and relapse rates are higher in populations with psychiatric disorders, long- term abstinence can be achieved. In treating psychiatric patients for tobacco use, it must be remembered that traditional tobacco-cessation therapies may need modification to address issues specific to a psychiatric population such as self-medication, the particular psychiatric diagnoses, medications that the patients are already taking for their psychiatric symptoms, and the need for modified psychotherapy. Furthermore, in treating nicotine addiction, as in treating such other addictions as heroin addiction, it may be necessary to provide treatment for longer periods than the typical 12 weeks (Schroeder, 2009). The committee notes that treatment of tobacco dependence in people who have psychiatric disorders requires a tailored approach to meet individual needs, treatment can be enhanced through a combination of medication and psychosocial therapy, and tobacco use can alter the effectiveness of a variety of medications. 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), and substance-use disorders (Gulliver et al., 2006; Kodl et al., 2006). The 2008 PHS guideline (Fiore et al., 2008) indicates that current evidence is insufficient to determine whether smokers with mental-health disorders are more likely to quit if they receive interventions tailored to their disorders or symptoms or whether standard treatments are equally effective. Ziedonis (2004) found that cessation interventions for psychiatric patients may include telephone-based counseling, Internet- based approaches, and face-to-face counseling, but more research is needed. They caution, however, that the interventions may be most effective in those with less severe mental illnesses, including addictions, because the interventions tend to be brief or time-limited and are not tailored to a particular mental illness. Tobacco-Cessation Medications In general, the FDA-approved tobacco-cessation medications that have been shown to be effective for the general populationâNRTs (gum, patch, spray, lozenge, and inhaler), bupropion, and vareniclineâ have also been shown to be effective in people with psychiatric disorders (Fiore et al., 2008; Stapleton et al., 2008). However, as with patients with any comorbidity, treating tobacco dependence in psychiatric patients
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 153 requires an understanding of the specific condition, the medications that are being used to treat the condition, and the severity of the dependence. Clinicians and tobacco-cessation counselors may need to adjust or combine tobacco-cessation medications to treat both the psychiatric symptoms and the nicotine dependence most effectively (VA/DoD, 2004). For example, Richmond and Zwar (2003) found that bupropion reduced withdrawal symptoms and was effective for smoking cessation in people with and without a history of depression or alcoholism. Heavier smokers may need higher doses of the cessation medications and additional NRTs (Richmond and Zwar, 2003). Extra emphasis on the use of NRTs or bupropion for treating nicotine dependence may be necessary in those with more severe tobacco dependence (VA/DoD, 2004). 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); therefore, patients should be monitored closely for side effects, including depression and suicidal ideation, while on the drug. More research on the association between varenicline and suicide is needed (see the FDA website, www.fda.gov, for updates on the status of varenicline). A number of studies have found that the combination of medication and psychosocial treatments may be more effective than either alone for patients with mental illness (Fiore et al., 2008). For example, Evins et al. (2001) studied the effect of bupropion SR and cognitive behavioral therapy on smoking behavior in patients with schizophrenia. The authors found that bupropion SR combined with cognitive behavioral therapy facilitated smoking reduction in some schizophrenic patients and stabilized psychiatric symptoms during attempts to quit (Evins et al., 2001). McFall et al. (2006) found that integrated tobacco-cessation treatment consisting of cessation medication with behavioral counseling and psychotherapy was effective in veterans with posttraumatic stress disorder (PTSD). Similarly, preliminary studies of tobacco-dependence treatment in PTSD patients indicated that behavioral treatments combined with medication when offered by a patientâs mental-health provider were more effective than referral to a tobacco-cessation clinic. Furthermore, repeat treatment delivered in the context of a continuing therapeutic relationship was more effective than brief, episodic treatment delivered by a specialist (Fu et al., 2007). Similar results were seen in patients with diagnosed psychotic disorders: a combination of NRT, motivational interviewing, and 8 sessions of individual cognitive-behavior therapy resulted in point-prevalence abstinence rates at 3, 6, and 12 months that were 3 times higher in the treatment group than in the group receiving routine care (Baker et al.,
154 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS 2006). There was a doseâresponse relationship between abstinence and attendance at the treatment sessions. An additional, potentially unexpected benefit of reducing or eliminating tobacco use by patients with mental illness is lowering of psychotropic medication dosages. Patients with serious mental illness, such as schizophrenia or bipolar disorder, are commonly given antipsychotic medications, such as olanzapine or clozapine. Smokers who receive those medications may need about twice the dosage of nonsmokers, because of the effect of the polycyclic aromatic hydrocarbons in tobacco smoke on medication metabolism (Desai et al., 2001). Other medications that are affected similarly include haloperidol and fluphenazine (Desai et al., 2001; Workgroup on Substance Use Disorders, 2006). Cigarette smoking may also increase the clearance of benzodiazepines (Smith et al., 1983). Careful monitoring of the side effects of psychiatric medications during changes in tobacco use is necessary, particularly during the early abstinence period (VA/DoD, 2004). Health-care providers should be actively involved in working with patients to adjust medications and to inquire about side effects. Tobacco users with mental illness may need to be treated for a longer period and with more intensive treatments than nonusers (Collie et al. 2006). In the section below, the committee assesses the evidence on tobacco-cessation interventions for specific psychiatric disorders that may be seen in military personnel returning from Iraq and Afghanistan and in veterans from those and earlier conflicts: PTSD, major depressive disorder (MDD), alcohol abuse and dependence, and schizophrenia. Posttraumatic Stress Disorder In a review by Fu et al. (2007), PTSD was strongly associated with tobacco use and nicotine dependence; many studies reported smoking rates of over 50% in those with the disorder. Although several observational studies have shown that smokers with PTSD are less inclined to quit smoking than smokers without PTSD or with other psychiatric disorders, several clinical studies have indicated that smokers with PTSD or other mental disorders respond to tobacco-cessation treatment at levels nearly equivalent to those in smokers without mental disorders (Fu et al., 2007). For tobacco users with PTSD, there appears to be greater abstinence from tobacco use when cessation interventions are integrated into standard mental health care. In one study, 107 veterans with PTSD who smoked were encouraged to make multiple attempts to quit (that is, repeated treatment) during a 6-month treatment period. The 9-month, 7- day point-prevalence abstinence rate was 18% in the integrated-care
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 155 group and 3% in the standard smoking-cessation group (difference not significant) (McFall et al., 2005, 2006). The sample was small, but, given the effect size, the committee considers that this intervention merits further study. Collie et al. (2006) reported that cue-reactivity and coping-skills training may be beneficial in cessation efforts in smokers who have PTSD, extrapolating from the literature on preventing alcohol abuse. Other approaches that have been found effective in increasing tobacco- cessation rates in people with PTSD include supportive counseling and mood management, particularly before the quit attempt begins. Unaided quit attempts result in higher relapse rates in the first week after quitting in smokers with PTSD than in smokers without a mental disorder (Zvolensky et al., 2008). One small trial of bupropion SR in PTSD patients found it to be effective compared with placebo (Hertzberg et al., 2001). Depression Research indicates that smokers with depression can be motivated to attempt to quit smoking and, with formal assistance, accept and use tobacco-cessation treatment (Acton et al., 2001; Haug et al., 2005; Prochaska et al., 2004a). Acceptance was not correlated with chronicity of depression history, severity of current depressive symptoms, severity of nicotine dependence, sex, age, or education (Haug et al., 2005). Recent research has shown that people in treatment for chronic depression can be treated for tobacco dependence with no adverse effects on their mental-health functioning or compensation with other substance use (Prochaska et al., 2008). Meta-analyses of smoking-cessation trials published in 1988â 2000 found that smokers with a history of depression were as likely as those without such a history to achieve short-term (up to 3 months) or long-term abstinence (at least 6 months) (Covey et al., 2006; Hitsman et al., 2003). 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; MuÃ±oz et al., 1997; Thorsteinsson et al., 2001). Several studies have compared standard smoking-cessation treatment (ST) with the combination of ST and cognitive-behavioral therapy for depression (CBT-D) in smokers with past MDD and recurrent MDD (Brown et al., 2001; Haas et al., 2004; Hall et al., 1994, 1996, 1998). Contrary to expectation, CBT-D with ST did not produce significantly higher abstinence rates than ST alone in smokers with past MDD, perhaps because these smokers already fared well in nonpharmacologic standard
156 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS treatment. However, in smokers with recurrent MDD (two or more past episodes), CBT-D with ST resulted in significantly higher abstinence rates than ST alone (p = 0.02). In sum, adding CBT-D to usual smoking- cessation treatment is efficacious in smokers with a history of recurrent depression. Cognitive-behavioral therapy with an emphasis on group cohesion and social support (Ait-Daoud et al., 2006) and mood management combined with tobacco-cessation treatment and increased therapist time (Brown et al., 2001; Collie et al., 2006) also appear to be effective in smokers with recurrent depression. Hall et al. (2006) conducted a comparison of a stepped-care intervention with a brief-contact intervention in smokers with current depression recruited from four mental-health outpatient clinics. The stepped-care intervention consisted of a computerized expert system based on the stage-of-change model and the option of receiving six 30- minute psychotherapy sessions that included mood-management training and medication (nicotine patch and/or bupropion). The brief-contact intervention included a smoking-treatment referral list and a packet of educational materials at the first visit. Abstinence rates at 12 and 18 months were higher in depressed smokers who received the stepped-care intervention than in the brief-contact controls (Hall et al., 2006). An etiologic connection may exist between smoking and depression (Aubin, 2009; Kotov et al., 2008). The variation in symptoms of MDD may affect smoking-cessation outcomes (Burgess et al., 2002) in such a way that increasing depressive symptoms are associated with poorer cessation outcomes. Smokers with a history of MDD who were currently free from depression and not on antidepressant medication and who stopped smoking were at a significantly increased risk for a new episode of depression (OR, 7.17; 95% CI, 1.5â34.5) compared with those who were not abstinent. The risk persisted during the 6-month follow-up period (Glassman et al., 2001). Alcohol Abuse and Dependence It has been estimated that 80% of people who abuse or are dependent on alcohol are smokers (Sussman, 2002), and rates of tobacco use and nicotine dependence increase with alcohol consumption (Falk et al., 2006). Of importance for DoD is that the 2001â2002 National Epidemiologic Survey on Alcohol and Related Conditions found that the co-use of alcohol and tobacco was highest in men and women 18â24 years old (Falk et al., 2006). However, although most alcoholics are interested in quitting tobacco at some point and some are concerned that doing so will make them drink more (Joseph et al., 2003), treatment for tobacco cessation is not routinely included in alcohol-treatment programs
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 157 in spite of evidence that tobacco-cessation treatment does not impede alcohol-use outcomes (Burling et al., 2001; Gulliver et al., 2006). Concurrent treatment for tobacco use and alcohol dependence or abuse has been studied, but results are mixed. Some studies have shown that cessation rates tend to increase with length of sobriety if the two treatments are delivered concurrently (Heffner et al., 2007). Tobacco- cessation rates were about 3 times as great in people with 3 months of sobriety or more as in people with shorter sobriety, although both groups relapsed at about the same rate. At 3â6 months of sobriety, tobacco- cessation rates resembled those of alcohol nonusers, and 1-year cessation rates were as high as 46% in people who had been sober for several years (Sussman, 2002). Other studies of concurrent treatment found greater participation rates in tobacco-cessation treatment; however, long-term cessation rates did not differ significantly from those seen when smoking intervention was delayed for 6 months after alcohol treatment indicating that optimal timing has yet to be determined (Joseph et al., 2002). Sequential treatments may be preferred for some people (Kodl et al., 2006). Ellingstad et al. (1999) suggested that tobacco cessation may improve alcohol-treatment outcomes because it removes a cue for alcohol use (Ellingstad et al., 1999). In a study of outpatients in alcohol treatment, the longer the period of alcohol abstinence, the more receptive to quitting smoking were those with low scores on the Center for Epidemiologic Studies Depression Scale (Hitsman et al., 2002). Patten et al. (2002) assessed the use of behavioral therapy alone or behavioral therapy with cognitive- behavioral mood-management training for tobacco abstinence in depressive smokers with a history of alcohol dependence. Behavioral therapy alone was more effective in helping smokers with low scores on the Hamilton Rating Scale for Depression to achieve short-term tobacco abstinence, whereas the mood-management training was more effective in increasing abstinence in smokers with high depression scores (Patten et al., 2002). Those studies suggest that treating people who have both depression and alcohol dependence for tobacco use requires assessing both disorders in addition to nicotine addiction. Ait-Daoud et al. (2006) found that the preponderance of evidence suggests that concurrent treatment for depression and tobacco use is preferable to treating either disorder alone, even in people who have alcohol dependence, and that a combination of pharmacotherapies and cognitive-behavioral therapy was most advantageous (Ait-Daoud et al., 2006).
158 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Schizophrenia Patients with schizophrenia are treated in a variety of intensive- treatment settings (such as psychiatric hospitals, residential facilities, and day-treatment programs), and these settings provide an opportunity to deliver an intensive smoking-cessation treatment integrated with mental health care. However, only recently have some psychiatric treatment settings begun to address tobacco use. As with other psychiatric disorders, the percentage of people with schizophrenia who are smokers is more than twice the percentage of smokers in the general population (Kotov et al., 2008). People with schizophrenia appear to be able to quit tobacco with the support of psychosocial treatment, nicotine-dependence treatment medications, and social support (Workgroup on Substance Use Disorders, 2006). Although many experience difficulties and can relapse, some people with schizophrenia are interested in reducing their tobacco consumption (Forchuk et al., 2002). Patients with schizophrenia who smoke appear to be more severely ill than patients who do not smoke, although the severity of specific symptoms does not appear to differ between smokers and nonsmokers (Kotov et al., 2008). Clinical studies show that psychologic treatment interventions of different intensity have been effective, including one-to-one and group-based counseling using modified American Lung Association interventions, cognitive-behavioral therapy, social-skills training, and contingency monetary reinforcement. Much of the relevant literature on people with psychotic disorders, such as schizophrenia, has focused on interactions between antipsychotic medications and bupropion rather than on the efficacy of psychologic treatments. Most of the studies in this population using NRT or bupropion have included a psychologic-treatment component (Addington et al., 1998; Goldberg et al., 1996; Ziedonis and George, 1997). 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), chronic obstructive pulmonary disease (COPD), and cardiovascular disease (CVD) (see Chapter 2). Smoking is also known to have an adverse effect on people who have those diseases and other illnesses, such as diabetes, that are not commonly linked to smoking. The 2006 National Health Interview Survey (NHIS) found that 36.9% of smokers with any smoking-related chronic disease continued to smoke, including almost 49% with emphysema, 41% with chronic bronchitis, 21% with lung cancer, 39% with other cancers, 29% with coronary heart disease, and 30% with stroke; only 19% of those with no chronic disease smoked (CDC, 2007a). A significant portion of veteran
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 159 patients suffer from chronic diseases: in 2008, over 2 million veterans had a diagnosis of hypertension, over 175,000 had a diagnosis of heart failure, over 150,000 had peripheral vascular disease, over 400,000 had a diagnosis of COPD, over 65,000 had a stroke, and over 28,000 had a diagnosis of lung cancer (James Schaeffer, VA, personal communication, February 26, 2009). Thus, this issue is of particular importance to DoD and VA with regard to both the medical consequences of continued smoking and also smoking-cessation treatment as they each treat large populations with comorbid illnesses. The prognosis of CVD in smokers can improve markedly with smoking cessation (Burns, 2003). Continued smoking is associated with earlier age of disease onset, disease progression, recurrent events, and higher mortality (Van Spall et al., 2007). For example, the risk of myocardial infarction decreases within 1 year after smoking cessation, and 10-year survival after coronary-artery bypass surgery increases from 68% to 84% (Cavender et al., 1992). Most studies of tobacco-cessation intervention in patients with CVD have been conducted in hospitalized male patients and compared usual care with more intensive programs. The more intensive interventions included behavior therapy, telephone support, and self-help materials, often in combination. Behavioral therapy and telephone support were slightly more effective than self-help materials, but better 6- and 12-month abstinence rates were obtained with more intensive treatments of at least 1-month duration; brief interventions were not effective (Barth et al., 2008). When 12-week intensive behavior-modification therapy was combined with individualized medication, long-term abstinence was significantly increased in patients with CVD (33% vs. 9%; p < 0.0001), and patients had fewer hospitalizations later and had reduced all-causes mortality (Mohiuddin et al., 2007). Intervention intensity is related to increased treatment efficacy in the 2008 PHS guideline (Fiore et al., 2008). Medicationsâsuch as NRTs, bupropion SR, and vareniclineâfor 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). Peripheral arterial disease is also associated with smoking, and current management of peripheral arterial disease includes smoking-cessation interventions (Aronow, 2008). The Lung Health Study demonstrated that permanent abstinence from smoking can reduce the progression from early COPDâmild to moderate airway obstructionâto clinically serious lung disease (Anthonisen, 2004). Evidence indicates that smoking cessation improves lung function and long-term survival in people with COPD regardless of disease severity (Godtfredsen et al., 2008), and the risk of COPD exacerbation diminishes as the length of abstinence increases (Au et al.,
160 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS 2009). Nevertheless, the risk of death from COPD may remain increased even after 20 years of smoking abstinence; once lung disease is disabling, continued abstinence may slow the decline, but symptom- related benefits may be fewer (Burns, 2003). Sherman et al. (2003) reported that smokers attending a VA hospital for COPD were more likely to receive smoking-cessation therapy than smokers without COPD (Sherman et al., 2003). Smoking-cessation interventions in those with COPD that combine behavioral and pharmacologic interventions were more effective than behavioral interventions alone or no treatment (Fiore et al., 2008; Hilberink et al., 2005; Wagena et al., 2004). A long-term cessation program that included 2-week hospitalization, NRT, physical exercise, and group counseling with a year of telephone follow-up by trained staff was found to be significantly more effective in maintaining abstinence at 3 years than usual care for patients with COPD (38% vs. 10%) (Sundblad et al., 2008). Other programs with combined therapy have been effective in achieving long-term smoking cessation (Jonsdottir et al., 2004). Bupropion has been shown to be both safe and efficacious as a smoking-cessation medication for patients with COPD (Tashkin et al., 2001; Wagena et al., 2004). Cancer patients who smoke are at increased risk for recurrence of cancer, second primary cancers, reduced cancer-treatment efficacy, increased medication toxicity, and reduced survival and quality of life (Gritz et al., 2005, 2006, 2007). Smokers undergoing surgery for cancer or other health conditions experience increased postsurgical complications of anesthesia, respiratory infections, and wound healing (including healing after reconstructive plastic surgery). Continued smoking can also compromise radiation-therapy outcomes, increase toxicity, and exacerbate side effects. Although chemotherapy has not been specifically studied with regard to continued smoking, compromised immune function, weight loss, fatigue, and susceptibility to infection may all be exacerbated by continued smoking. The efficacy of cancer-chemotherapy agents and molecular treatments (such as tyrosine kinase inhibitors of epidermal growth-factor receptors) may be reduced by induction of drug-metabolizing enzymes due to tobacco smoke (Gritz et al., 2007; Toschi and Cappuzzo, 2007). Up to 60% of patients with smoking-related tumors are current smokers at diagnosis (McBride and Ostroff, 2003); although many patients may quit in preparation for surgery or other treatments, the relapse rate is high (Gritz et al., 2007; Walker et al., 2006). Duffy et al. (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
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 161 who received usual care (Duffy et al., 2006). As in patients with CVD and COPD, smoking-cessation interventions for cancer patients must factor in the medications that the patients are taking for the cancer (and other possible comorbidities) and their psychologic status. Smoking- cessation intervention studies of cancer patients have not shown a consistent effect, and more research is needed. Future studies should use the evidence-based treatments set forth in the 2008 PHS guideline (Fiore et al., 2008), combine behavioral counseling and pharmacologic treatments, involve the provider treatment team, and validate outcomes. Two chronic diseases exacerbated by smoking are diabetes and asthma. Smoking puts diabetic patients at higher risk for vascular disease, stroke, nephropathy, neuropathy, lower-extremity morbidity, and premature death from CVD (Haire-Joshu et al., 1999; Phisitkul et al., 2008). Smoking-cessation intervention trials have had mixed findings, but in large trials, nurse-delivered interventions and motivational interviewing have shown favorable results (Canga et al., 2000; Davies et al., 2008; Persson and Hjalmarson, 2006). Further research on motivational interviewing by a primary-care nurse is under way (Jansink et al., 2009). In people with asthma, symptoms may be triggered and aggravated by active smoking and by secondhand smoke. Other adverse effects among asthmatic smokers include increased frequency of attacks, increased symptom severity, higher hospitalization rates, and rapid decline in lung function (Althuis et al., 1999; Sippel et al., 1999; Siroux et al., 2000; Yun et al., 2006). Cigarette smoking may reduce the effectiveness of steroid treatment for asthma (Tyc and Throckmorton- Belzer, 2006). Smoking prevalence in adult asthmatics is similar to that in the general population (Thomson et al., 2004), and intervention studies in adults have not been reported. Adolescents with asthma are more likely than nonasthmatic adolescents to have parents that smoke (Otten et al., 2005). 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 DoDâs TRICARE health system and VA. The populations include hospitalized smokers, older smokers, racial and ethnic minority populations, women, pregnant smokers, and smokeless-tobacco users. In general, the literature on tobacco-cessation treatments for those populations is sparse.
162 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS Women In 2001, the US Surgeon General released a second major report on women and smoking (US Surgeon General, 2001). The surgeon general emphasized that although smoking is not the norm among women, those who use tobacco are at risk for adverse health effects. If they are pregnant and smoke there is also an increased risk to the fetus. The Department of Health and Human Services offers a Web site with health information for women that contains information on tobacco use and cessation, including information for pregnant smokers (http://www.4woman.gov/QuitSmoking/index.cfm). The 2008 PHS guideline indicates that women are responsive to the same smoking- cessation treatments as men, specifically medication (bupropion SR, NRTs, and varenicline) and counseling intervention, such as active telephone counseling, individually tailored follow-up, and advice to quit aimed at childrenâs health (Fiore et al., 2008). Croghan et al. (2009) found that among smokers who participated in an individualized tobacco-cessation program in a large hospital, there was no difference between men and women in outcomes although women were more likely to receive a prescription for tobacco-cessation medication. Female veterans with PTSD are twice as likely to smoke as those without PTSD (Dobie et al., 2004). Female and male veteran smokers receiving care at VA medical centers were equally likely to be advised to quit smoking and to be referred to tobacco-cessation services, but women were less likely to be given cessation medications and to have quit at the 1-year follow-up. When asked about what would constitute an ideal smoking-cessation program for women, female veterans indicated that support, particularly emotional support from peers, would be an important component of any such program and that options for individual and group support would be helpful (Katzburg et al., 2008). 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); therefore, treatment for smokeless- tobacco use is an important consideration for military health advisers. In addition, many military personnel who use smokeless tobacco also smoke cigarettes, and this may increase the complexity of cessation interventions for either form of tobacco use. Evidence summarized in a Cochrane review of two randomized trials of pharmacotherapies for smokeless-tobacco use with 6-month follow-up found that neither nicotine replacement nor bupropion were effective (Ebbert et al., 2007a). Behavioral interventions, such as counseling by a dentist or telephone
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 163 counseling, might be effective, but more study is needed (Carr and Ebbert, 2006; Ebbert et al., 2007a; Klesges et al., 2006). The 2008 PHS guideline also indicates that counseling is effective for smokeless- tobacco cessation, although the evidence for cessation medications is insufficient (Fiore et al., 2008). A review of behavioral and pharmacologic interventions for smokeless-tobacco use found similar results (Severson, 2003). Cessation counseling during a dental visit was more effective in increasing 12-month abstinence than group support sessions in a tobacco-cessation clinic or self-help materials with brief counseling. The use of NRT gum, NRT patch, or bupropion did not improve cessation in smokeless-tobacco users. Hospitalized Tobacco Users Several studies of tobacco cessation in hospitalized smokers are included in the above discussion of tobacco users with comorbidities (Barth et al., 2008; Prochaska et al., 2004b; Sundblad et al., 2008). In addition, a Cochrane review assessed smoking-cessation treatments for hospitalized patients (Rigotti et al., 2007). Hospitalized tobacco users benefit from tobacco-cessation treatments, particularly intensive cognitive-behavioral therapy combined with NRT (Simon et al., 2003). Smokers who received a multicomponent cessation intervention consisting of face-to-face in-hospital counseling, a videotape, self-help literature, NRT, and 3 months of telephone follow-up after noncardiac surgery had higher biochemically confirmed abstinence rates at 12 months than those who received only self-help literature and brief counseling (relative risk, 2.0; p = 0.04) (Simon et al., 1997). A meta- analysis of treatment of hospitalized patients shows that intensive therapy begun in the hospital and continuing with at least 1 month of follow-up after discharge appears to result in the best cessation rate; the addition of cessation medications does not increase the rate (Rigotti et al., 2007). Other Tobacco Users The 2008 PHS guideline assesses tobacco cessation in several special populations, including those with low socioeconomic status (SES) and little formal education, older smokers, and racial and ethnic minorities (Fiore et al., 2008). There is a paucity of studies on the effectiveness of tobacco-cessation treatments in each of those populations. Tobacco users with low SES and little formal education benefit from the use of nicotine patches in combination with counseling, including proactive telephone counseling and motivational messages with or without telephone counseling (Fiore et al. 2008). Older smokers
164 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS typically do not receive adequate treatment for tobacco use (Doolan and Froelicher, 2008), but they too benefit from a variety of tobacco- cessation treatments, including those used for low-SES tobacco users. Buddy support, tailored self-help materials, and physician advice are also effective (Fiore et al., 2008). Effective interventions for racial and ethnic minorities include medications (bupropion SR and nicotine patches), motivational counseling, clinician advice, tailored self-help materials, telephone counseling, and biomedical feedback (Fiore et al., 2008). Heavy smokers are those who smoke more than 1 pack of cigarettes a day (20 cigarettes in a pack), typically 25â30 cigarettes/day. The number of cigarettes smoked per day can be predictive of withdrawal symptoms. For people with severe tobacco dependence, it may be necessary to increase the dose of cessation medications to alleviate symptoms or to use combinations of treatments (Dale et al., 1995)âperhaps three or more medications simultaneously (Ebbert et al., 2007b). The committee recommends that health-care providers consider tailoring the dose of NRT and the use of multiple NRTs or other combination medications in these patients. Finding: Although most studies have focused on treating tobacco users in the general public, evidence suggests that special populationsâsuch as those with mental illness, women, and those with medical comorbiditiesâwill 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. RELAPSE-PREVENTION INTERVENTIONS The issue of relapse from tobacco abstinence is well known but not well studied. As many as 75â80% of smokers who quit tobacco use will relapse within 6 months (Carmody, 1992). Most people who quit without assistance relapse within the first 8 days after quitting (Hughes et al., 2004). Studies of people who used nicotine medications to quit suggest that long-term (1-year) abstinence rates are about 10% and that the rate of relapse after 1 year is not significant (Hughes et al., 2008). Several factors may be at play in relapse, including the biologic nature of nicotine addiction, conditioned activities (such as smoking when drinking alcohol or coffee), and cognitive-social learning factors. Men and women may be concerned about gaining weight if they stop smoking (Carmody, 1992; Clark et al., 2004, 2005, 2006b). A Cochrane review of
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 165 relapse-prevention interventions found that behavioral interventions were not effective although therapy that helps smokers to avoid smoking cues had the best results; long-term use of varenicline was most effective for prolonged prevention of relapse whereas long-term use of bupropion did not appear to be effective (Hajek et al., 2005). A study of 1,700 smokers randomized to receive a nicotine inhaler, bupropion, or both for 3 months found that the combination therapy increased abstinence rates but did not prevent relapse (Croghan et al., 2007). A variety of tobacco-cessation treatmentsâincluding cognitive-behavioral therapy, social support, pharmacotherapies, and cue avoidanceâmay be required to prevent relapse and maintain long-term abstinence (Carmody, 1992). SURVEILLANCE AND EVALUATION The comprehensive tobacco-control programs described in this chapter have features in common that increase their effectiveness. An important feature is surveillance mechanisms to assess whether tobacco- use 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 âis the process of monitoring tobacco-related attitudes, behaviors, and health outcomes at regular intervalsâ (CDC, 2007a). Mechanisms to monitor the effectiveness of interventions may require surveys of populations to assess specific health behaviors, analysis of medical records, inventories, or financial tracking. CDC recommends that states spend specific dollar amounts per user on tobacco control. Surveillance must be continuous; a snapshot of a program is not sufficient to indicate its effectiveness. Scheduled periodic evaluations are the best surveillance tools, but ad hoc information may also be useful in identifying trouble spots or anomalies. Surveillance information helps program leaders modify programs to meet changing needs or to address disparities. Surveillance can indicate whether policies are being enforced, whether medications are being correctly prescribed and taken, whether quitlines are being used, whether mass-media campaigns are reaching target audiences, and whether funds are being spent appropriately. Feedback information obtained through surveillance is critical for ensuring that a tobacco-control program is effective. Tobacco-control surveillance includes prevalence of tobacco use, its health and economic consequences, its sociocultural determinants and tobacco-control policy responses, and tobacco-industry activities. There is evidence that performance measures work well and it is possible to relate them to program improvements (IOM, 2005; Perrin, 1998, 1999). Performance measures may take the form of metrics, such as the number of people who enroll in a smoking-cessation program, the
166 COMBATING TOBACCO USE IN MILITARY AND VETERAN POPULATIONS number of people who are counseled to quit using tobacco by their health-care providers, the number of people who quit at some time after using an intervention, or the number and types of policies aimed at achieving tobacco control. Progress in tobacco-use cessation treatment at the population level can be known because of metrics that are tied to resources (Curry et al., 2006, 2008). Some metrics consist of straightforward information about investment in state and national mass-media campaigns to promote smoking cessation and use of evidence-based treatments, such as state quitlines. Other metrics are indicators of the coverage of tobacco- cessation interventions in federal insurance plans (such as Medicare and Medicaid) and employer-sponsored insurance (Bondi et al., 2006). With support from the Robert Wood Johnson Foundation, several national surveys of managed-care coverage for tobacco-cessation services have been conducted (McPhillips-Tangum et al., 2006), but funding for those surveys has ended. The National Committee for Quality Assurance (NCQA, 2008) report The State of Health Care Quality 2007 states that counseling smokers to quit increases the likelihood that they will do so and is a cost-effective intervention. Interventions such as discussing tobacco-cessation strategies and the use of NRTs increase the potential for smoking cessation. 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). Those measures allow tracking of patientsâ reports of whether their physicians have advised them quit and offered behavioral and pharmacologic treatments. Inpatient metrics derive from the Joint Commission accreditation measures of the number of inpatients that receive advice or counseling for smoking cessation during their hospital stays. These metrics are a core measure for assessing the treatment of acute myocardial infarction, congestive heart failure, and pneumonia. The National Quality Forum nursing-sensitive care measures include nursing-centered interventions for smoking cessation (Robert Wood Johnson Foundation, 2008). The Agency for Healthcare Research and Qualityâs annual National Healthcare Quality Report includes measures related to primary-care provider advice to quit for all smokers over 18 years old during routine office visits and postâmyocardial infarction counseling to quit smoking (HHS, 2007). Health-care system metrics related to front-line clinical practice are complemented by individual-level data from national surveys, such
TOBACCO-CONTROL PROGRAMS: EVIDENCE-BASED PRACTICES 167 4 as the NHIS. Although not part of the core items, information on health- care provider advice on, and assistance with, quitting and information on the use of evidence-based treatments are available as part of the cancer- control supplement to the NHIS. However, the NHIS surveys include only the civilian, noninstitutionalized US population and exclude the military population, although dependents of active-duty service members may be included. With regard to the availability of effective behavioral treatment through a national quitline network, the North American Quitline Consortium tracks the number of services and types of telephone counseling available through state quitlines. Members of the consortium also contribute information about quitline use and the characteristics of quitline callers through their minimal dataset (NAQC, 2008). In addition to collecting specific information about tobacco- cessation services offered by health-care providers, evaluation of comprehensive tobacco programs has been undertaken and can serve as a model for future program evaluations. The NCI reviewed the effectiveness of the state tobacco-control programs that had participated in the federal ASSIST program described in Appendix A (Gilpin et al., 2006). The Robert Wood Johnson Foundation has also assessed state tobacco-control programs (http://www.rwjf.org/pr/product.jsp?id= 21098). 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. Program evaluations also help to identify needed policy changes and can support leadership initiatives for program enhancements. CDC has developed a set of key outcome indicators for evaluating comprehensive tobacco-control programs that may be used by DoD and VA to monitor progress and determine the success of their programs. Outcome indicators are presented for achieving three program goals that are applicable to both DoD and VA populations: preventing tobacco-use initiation, eliminating nonsmokersâ exposure to secondhand smoke, and promoting quitting (CDC, 2009b). Finding: Periodic and public evaluation of tobacco-control programs, based on performance metrics and other surveillance tools help provide the necessary information to 4 The NHIS is conducted annually, but detailed tobacco questions are asked only as part of the cancer supplement; the supplement was last administered in 2005. It is available online at http://www.cdc.gov/nchs/nhis.htm (accessed on March 10, 2009).
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