Research article
Randomized Trial of an Intervention to Facilitate Recycling for Relapsed Smokers

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Background

Tobacco dependence is a chronic condition requiring repeat treatment and long-term follow-up. However, current evidence regarding best approaches to providing these services is fairly limited. This study assessed the effectiveness of an intervention for increasing repeat tobacco-dependence treatment in a population of relapsed smokers.

Design

The study was a multicenter randomized controlled trial.

Setting/participants

Patients aged 19 and older receiving a prescription for nicotine replacement therapy or bupropion for smoking cessation in 2002 at one of five participating Veterans Affairs (VA) facilities were eligible.

Intervention

A total of 1900 eligible veterans were randomized to (1) patient phone call to assess smoking status, quit challenges, and treatment preferences, and computerized progress note to providers communicating this information (intervention); or (2) usual care (control).

Main outcome measures

Outcomes, assessed in 2003, included the proportion of patients receiving repeat pharmacologic or behavioral smoking-cessation treatment in the 6-month follow-up period (assessed from VA pharmacy and outpatient data), 7-day point prevalence abstinence, and satisfaction (assessed by patient survey).

Results

Thirty-four percent of intervention participants versus 22% of controls received treatment for tobacco dependence in the follow-up period (p =0.0001). Thirty-two percent of intervention participants versus 21% of controls received pharmacologic treatment (p =0.0001), and 12% of intervention subjects versus 8% of controls received behavioral treatment (p =0.005). Abstinence rates at follow-up were 25% for intervention subjects and 22% for controls (p =0.15). Intervention subjects were more likely than controls to report being satisfied with the general smoking-cessation help (87% vs 82%, p =0.01), as well as the pharmacologic help that they received from the VA (89 vs 84%, p =0.01).

Conclusions

The intervention significantly increased repeat treatment rates and satisfaction with services but did not have a significant effect on abstinence rates.

Introduction

Treating tobacco dependence is a national health priority with the potential to save millions of lives.1 Although many smokers try to quit every year,2 success rates are low for each attempt, and most smokers need to make multiple quit attempts before achieving long-term abstinence.3, 4, 5 These observations have lead to the recent assertion that tobacco dependence is a chronic condition requiring ongoing care and long-term follow-up.5 Offering repeat tobacco-dependence treatment is an essential component of this chronic disease model for tobacco-dependence treatment. Contrary to provider skepticism regarding patient interest in quitting,6 recent studies suggest that most smokers want to quit,7 and that there is considerable interest in repeat quit attempts (or “recycling”) among smokers who recently relapsed.8, 9 However, current evidence regarding best approaches to recycling is fairly limited. While the few studies that have evaluated the efficacy of repeat treatment found modest to no effect on cessation rates, most of these trials offered the same treatment used in the first attempt for use in the repeat attempt,10, 11, 12, 13 and all were efficacy trials conducted under highly controlled experimental conditions.10, 11, 12, 13, 14 Hence, additional studies evaluating alternative recycling approaches in real-world settings, including those that allow individuals to try a different pharmacologic or behavioral aid in the next quit attempt (or a combination of aids), are needed to inform implementation of the population-based approaches that will be required to support a chronic disease model for tobacco-dependence treatment.

The Recycling Smokers through Effective Treatment (or RESET) study implemented and evaluated an intervention that encouraged and facilitated recycling for relapsed smokers in a real-world setting. The intervention delivered information on patient smoking status and treatment preferences (elicited from a patient follow-up phone call) to providers (in the form of a computerized progress note), and encouraged providers to arrange the smoking-cessation assistance requested by the patient. This article summarizes the effects of this intervention on (1) receipt of repeat tobacco-dependence treatment, (2) number of quit attempts, (3) 7-day point prevalence abstinence, and (4) satisfaction with services in a population of smokers receiving care at Veterans Affairs (VA) medical facilities.

Section snippets

Objectives

The primary objective was to assess the intervention’s effectiveness for increasing repeat treatment for tobacco dependence. Secondary objectives included assessing the effect of the intervention on smoking behavior and satisfaction with services.

Population and setting

Veterans aged ≥19 years receiving a prescription for nicotine replacement therapy or bupropion for smoking cessation/Zyban (referred to hereafter as the index prescription) from one of the participating facilities were eligible for the study and were

Sample Characteristics

The average participant age was 55 years, 46% were married, 94% were male, 76% were Caucasian, and 85% of the sample had at least a high school education. Half of the sample reported fair to poor health and many had other documented chronic diseases. Most (66%) saw their primary care provider in the follow-up period. On average, patients reported smoking 27 cigarettes per day 2 years ago. Nicotine patch was the most common drug used in the index quit attempt (77% of the sample), followed by

Discussion and Conclusion

The RESET study used unique tools (pharmacy databases and electronic medical record functions) to identify smokers with a high probability of interest in quitting, and to facilitate recycling for them. The intervention facilitated recycling by (1) systematizing the follow-up of smokers making recent quit attempts, (2) collecting information on smoking status and treatment preferences, and (3) encouraging providers to ensure that treatment requested by patients was received. The results suggest

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