Section II: Guidelines for the Development of Effective Agency Tobacco Cessation Programs

• Background
• Program Development Recommendations
• Checklist for Assessing a Group Cessation Program

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BACKGROUND

The Public Health Service (PHS), of the U.S. Department of Health and Human Services is a leading entity addressing tobacco cessation. In 2000, the PHS released Treating Tobacco Use and Dependence , a PHS-sponsored Clinical Practice Guideline, an update of the 1996 Smoking Cessation Clinical Practice Guideline . A comparison of the findings of the year 2000 guideline with the earlier 1996 guideline indicates that considerable progress was made in tobacco research over the brief period separating these two publications. Among the myriad of important differences between the two documents, the following deserve special note:

The PHS Guideline has produced even stronger evidence of the association between counseling intensity and successful treatment outcomes, as well as identified additional evidence-based counseling strategies such as telephone quit lines.

The PHS Guideline offers the clinician many more efficacious pharmacological treatment strategies than its predecessor.

The PHS Guideline includes strong evidence that smoking cessation treatments shown to be efficacious (both pharmacotherapy and counseling) are relatively cost-effective.

Like its predecessor, the PHS Guideline includes a rigorous systematic review of the evidence performed by a private-sector panel of experts who employed an explicit, science-based methodology and expert clinical judgment to develop recommendations on the treatment of tobacco use and dependence.

The PHS Guideline was developed by a consortium of Federal Government and nonprofit organizations comprised of the Agency for Healthcare Research and Quality; Centers for Disease Control and Prevention; National Cancer Institute; National Heart, Lung, and Blood Institute; National Institute on Drug Abuse; Robert Wood Johnson Foundation; and University of Wisconsin Medical School's Center for Tobacco Research and Intervention.

Much of the following information can be found in the Clinician's Packet, a comprehensive PHS Guideline spin-off tool, featuring a wide array of evidence-based materials designed to encourage clinicians to help their patients quit using tobacco and adopt healthier lifestyles. The Clinician's Packet can be accessed at www.ahrq.gov/path/tobacco.htm.

Whether agency-developed programs are administered internally (e.g., by a coordinated effort involving the agency's Health Unit and the Employee Assistance Program counselors) or externally (by contracting with tobacco cessation program providers), agencies are urged to follow these PHS Guideline recommendations in the development of their programs.

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Program Development Recommendations

Assess the Smoker who has Entered a Program

Assess whether participants in tobacco cessation programs are motivated to quit using an intensive program. Specialists may also conduct other assessments that can provide information useful in counseling. For example, such assessments may reveal the presence of high stress levels caused by other issues in a tobacco user's life or may reveal the presence of other psychological or medical conditions that will affect success in quitting.

Use a Variety of Clinicians

Many different types of providers (physicians, nurses, dentists, psychologists, pharmacists, etc.) are effective in increasing rates of tobacco cessation, and involving multiple types of providers may enhance abstinence rates. Given that so many tobacco users visit a health care setting at some point, it is important that clinicians be prepared to intervene with tobacco users who are willing to quit.

The five major interventional steps (the "5As" ) to be used by providers in the health care setting are Ask, Advise, Assess, Assist , and Arrange . One strategy would be to have a medical/health care clinician deliver messages about health risks and benefits, and nonmedical clinicians deliver psychological or behavioral interventions.

Ensure that the Program is Intensive Enough

Individual or group counseling programs are helpful. The PHS guidelines expert panel found a strong dose-response relationship between counseling intensity and cessation success. The following elements are recommended:

Session length – longer than 10 minutes

Number of sessions – 4 or more sessions

Total contact time – longer than 30 minutes

Use a Variety of Program Formats

While individual or group counseling is effective, proactive telephone counseling is also effective and tobacco users are more likely to use this format. Use of educational or self-help materials is an option for employees who don't wish to participate in counseling but this intervention may not be as effective as counseling. Follow-up assessment procedures should be used in any intervention.

Include Effective Counseling Techniques

Interventions should include problem solving/skill training content as well as clinician-delivered social support for quitting. For example, common elements of problem solving/skills-training treatments would be:

1. recognition of danger situations (e.g., being around other smokers, being under time pressure, getting into an argument, experiencing urges or negative moods, or drinking alcohol);
2. development of coping skills (e.g., learning to anticipate and avoid danger situations, learning cognitive strategies that will reduce negative moods, accomplishing lifestyle changes that reduce stress, improve quality of life, or produce pleasure); and
3. understanding basic information about quitting (e.g., the nature/timeframe of withdrawal, the addictive nature of smoking, or the fact that any smoking, even a single puff, increases the likelihood of full relapse).

Common elements of supportive smoking cessation treatments would be:

1. encourage the participant in the quit attempt;
2. communicate caring and concern;
3. encourage the participant to talk about the quitting process; and
4. provide basic information about smoking and successful quitting. Social support during treatment can also be effective.

Provide Relapse Prevention Intervention

Most relapses occur soon after a person quits, although some people relapse months or years after the quit date. Therefore, specialists should work to prevent long-term risks of relapse. These interventions can occur during treatment sessions or during follow-up contacts and should:

1. reinforce the employee's decision to quit;
2. review the benefits of quitting; and
3. assist in resolving any problems related to quitting.

Include Pharmacotherapy (Medications)

The use of pharmacotherapy is a key part of a multicomponent approach to assisting patients with their tobacco dependence.

All tobacco users trying to quit should receive pharmacotherapy, except in the presence of special medical circumstances. The guideline panel identified six first-line medications, including the five nicotine replacement therapies: the nicotine patch, nicotine gum, nicotine lozenge, nicotine nasal spray, and the nicotine inhaler; and one non-nicotine medication: bupropion SR. Each has been shown to significantly increase the rates of long-term abstinence.

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A Checklist for Assessing a Group Cessation Program

NOTE: Providers should be carefully screened before contracting for their services or referring employees. The following checklist, provided by the Office on Smoking and Health of the U.S. Department of Health and Human Services, can be used for screening such services.

• How long has the organization been in existence? How long has it been providing tobacco cessation programs?
• How many people have gone through the program?
• Will the approach be appropriate for the employee?
• What methods are used to help tobacco users quit?
• How is maintaining abstinence addressed?
• What resources are provided to help promote the program among agency employees and stimulate participation?
• Have others been satisfied with the program?
• Will they provide a list of clients, especially other Federal agencies?
• Will they provide references so that satisfaction and success rates can be checked?
• What are the qualifications of the instructors? What training have they received? What is their cessation counseling experience?
• Are printed materials appropriate for the educational level of the employees? Are they attractive and motivational?
• Will the structure of the program accommodate the needs of employees? That is, can they:
• accommodate all shifts?
• provide on-site and off-site programs?
• structure flexible program formats?
• provide audio or visual equipment?
• Is the program provider willing to provide ongoing assistance and follow-up once the formal program ends?
• Does the program incorporate participants' support systems? For example, peers and family members?
• Does the program offer any form of guarantee? For example, can employees repeat the program for free or at a lower cost?
• Can the program provider provide evidence of six-month and one-year success rates of previous clients? (A range of 20-40% success rate is realistic.) Remember: if it sounds too good to be true, it probably is.
• How much does the program cost per employee? Are group discounts available?