ATTUD Journal Club Postings

Do We Need Tobacco Treatment Specialists?

In the past blogs I have reviewed the evidence whether treatment from a trained TTS produces higher quit rates than from a less-intensive non-TTS therapy. The Cochrane review of this question examined 5 RCTs and stated “We failed to detect a greater effect of intensive counselling compared to brief counselling (5 trials, RR 0.96, 95% CI 0.74 to 1.25).” However, my earlier journal club article pointed out several observational trials that found trained TTS achieves a higher quit rate (see 11/3/14; Does specialist, in-person treatment improve quit rates?).

Another large observational trial that is quite externally valid has just been published (Song F, et al “Differences in Longer-Term Smoking…” NTR, advanced access). This study examined the effect of self-help booklets and recruited about 1500 smokers who were abstinent at 4 months. Those who had been recruited from a clinic where they had been seen by a TTS were 1.5 times more likely to be abstinent at 12 month follow up than those recruited from primary care offices, pharmacies or health trainers and had not seen a TTS. So, here we are in the conundrum that the more internally-valid RCTs did not find efficacy but the more externally-valid observational trials did find effectiveness. The difference may be that the Cochrane review did not examined TTS vs non-TTS, rather looked at studies with more contact time vs less contact time. Thus, it may be training and experience of TTS’s that is important, not the amount of time they spend with the smoker.

None of the studies have addressed cost-effectiveness, which presents another conundrum. If we ask is the cost/quitter more for TTS than non-TTS treatments, – the answer is clearly yes. So if I am a medical organization, I might conclude better to put my money in less expensive non-TTS treatments. But this really depends on two things. First, if we hypothesize that TTS treatments are especially needed for those smokers who have failed less-intensive treatments (a plausible notion) and, if such smokers have greater potential health care expenditures than those who respond to non-TTS treatments, one might conclude it is as reasonable to choose TTS treatment. On the other hand, it may be that it is mostly younger, less-addicted smokers who are responding to less intensive treatment (a plausible notion). Since we know the greatest benefit of smoking cessation comes from quitting at an early age, this could mean it really is better to spend more money on less-intensive treatments. Finally, one could argue that simply showing more intensive treatment is less cost-effective does not mean we should not provide treatment for the more addicted (e.g. we still lots of money on tertiary care for many illnesses that could be treated less expensively if treated early on.) In fact, treating smoking (even in older, more addicted smokers) is one of the most cost-effective treatments in medicine. In addition, to ignore more addicted smokers because it costs more to get them to quit is, to me, antithetical to medical practice.