What does a tobacco treatment clinic do?

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Most people who try to quit smoking do so on their own with little or no outside assistance. This doesn’t mean it’s the best way to do it. Nowadays most people also have access to a telephone quitline and over-the-counter nicotine replacement therapy. These treatment components have been proven to increase your chances of success. Some people are fortunate enough to live near a specialist face-to-face tobacco treatment service (e.g. there are such services in Minnesota, Massachusetts, New Jersey, Ohio and Mississippi), but many do not and may wonder about what kind of services are provided by a tobacco treatment clinic. So to give an idea of the kind of work carried out by such services, I’ve summarized below the work carried out at the service I work at.

The Tobacco Dependence Clinic, part of the Tobacco Dependence Program (TDP) at the University of Medicine and Dentistry of New Jersey (UMDNJ)-School of Public Health, opened in January 2001 to provide specialist assessment and treatment for people who want help with tobacco dependence. A multidisciplinary team of specialists in tobacco dependence treatment, including psychologists, clinical social workers, and physicians, work closely with other staff and faculty to provide tobacco dependence treatment based on the evidence-based assessment and treatment procedures outlined in the US Public Health Service Clinical Practice Guideline on Treating Tobacco Use and Dependence (1) and the New Jersey Guidelines for Tobacco Dependence Treatment (2). The clinical staff is also involved in training and consulting to the network of tobacco dependence treatment clinics throughout New Jersey, known as New Jersey Quitcenters, and to other providers of tobacco treatment. Furthermore, the Clinic is involved with several ongoing projects that target special populations, including Latinos, young smokers, medically-ill smokers, and smokers with co-occurring mental health and/or addiction problems.

All patients receive a comprehensive individual assessment, with core information from that assessment being coded into a database. Around 95% of patients assessed select a Target Quit Date (TQD), and these patients are then followed up either in person or by telephone 4 weeks and 6 months after their initial TQD. At the end of the assessment a treatment plan is developed that includes a recommendation on medications and whether or not the patient will attend group or individual appointments or both.

More than half of the patients who attend beyond the assessment are treated in group. The most common group model used is a closed 6 (weekly) session group format, with the group’s quit day on the second session. Patients attending group have significantly better outcomes than those only attending individual treatment, even after controlling for baseline characterisitics3. The clinic provides on-site tobacco treatment groups at local employers (including Pfizer Corp, Firmenich, Clinphone, and Rutgers University) which have proven very successful (http://www.tobaccoclinic.org/ ). An open (daytime) group for people with disabilities (primarily serious mental illness), and an open weekly relapse prevention group (in the evening) are also provided. In addition to counseling, over 90% of our patients use tobacco treatment medication and of these most use more than one form of pharmacotherapy. Initial quit rates appear to relate to how many medications patients use4. Overall, around 45% of patients report abstinence (no tobacco use in previous week) at one month follow-up and 31% are abstinent at 6 month follow-up (3). These data count all patients lost to follow-up (30-40%) as continuing smokers.

The treatment philosophy at the Tobacco Dependence Clinic is that tobacco dependence is a life threatening chronic illness that warrants as intensive a treatment for as long a period as is required to enable the patient to quit and stay quit. Patients are advised to continue on the full prescribed medication dose until they have experienced 14 consecutive days without any cravings, withdrawal symptoms or near lapses. Over a quarter of patients followed up at 6 months are still using medication (4). Interestingly, around 20% of new patients are now smokers who have attended the Clinic in a previous year. These repeat patients tend to be more dependent and more have a history of mental health treatment, but they have reasonable six-month quit rates on repeat treatment (23%, 22% and 20% at first, 2nd and 3rd treatment episode) (5). When including repeat treatment episodes, the proportion of patients who achieve abstinence at 6 months follow-up is 33%. (5) Other notable findings are (a) African American (AA) and Latino smokers of regular cigarettes have the same quit rates as whites, but AAs and Latinos who smoke menthols have about half the quit rate, even after controlling for other predictors of outcome (3,6) and (b) 50% of patients awaken to smoke at night and this is predictive of poor treatment outcome (7).

In January, 2007 the TDP opened a new clinic in Newark, New Jersey, and by December 2007 over 3500 patients have been treated at the Clinics, which aim to treat over 500 new patients per year. Both clinics are fully integrated into the local healthcare systems, receiving referrals from community providers and hospitals via a Fax-to-Quit system, as well as linkages with the University and Hospitals’ electronic medical records system. The New Brunswick clinic serves Middlesex and adjacent New Jersey counties, and more than twice as many Middlesex county residents attend the clinic for tobacco treatment than engage in counseling on New Jersey’s excellent free Quitline (8). Also, with support from a grant from the Robert Wood Johnson Foundation, the proportion of Latino patients has increased from 3% in 2001 to 15% in 2006.

The major challenge faced by the clinics is in the area of billing and reimbursement from health insurance. 53% of the patients have private health insurance, 13% Medicaid, 12% Medicare and 22% have no health insurance. Even for those with private health insurance most plans do not cover the counseling provided by the clinic and in many cases medications (e.g. NRT, Zyban, or Chantix) are not covered either. Lack of systematic and comprehensive insurance coverage for high quality tobacco dependence treatment is a major barrier to helping smokers quit.

The success of the Tobacco Dependence Clinic at UMDNJ-School of Public Health shows that there is a demand for high quality tobacco dependence treatment among smokers, even in a state that already provides free high-quality telephone and internet support for smoking cessation. The smoking cessation outcomes show that quit-rates comparable to or greater than those achieved in research studies can be achieved by a clinical service implementing the Guideline on Treating Tobacco Use and Dependence (1). Full details of all patient characteristics and outcomes are provided in Clinic Annual Reports (9) . Further details of this work and publications can be found at www.tobaccoprogram.org .


Acknowledgements:
The clinic is part of the Tobacco Dependence Program at UMDNJ-School of Public Health which is funded by New Jersey Department of Health and Senior Services, as part of New Jersey’s Comprehensive Tobacco Control Program (NJ CTCP). The Tobacco Dependence Program also receives funding from NJ CTCP for youth cessation in schools, training health professionals, and community education and outreach. The TDP is also supported by grants from Robert Wood Johnson Foundation, Rutgers Community Health Foundation, and the Cancer Institute of New Jersey.

References.
pdfs of many of these are available at: http://www.tobaccoprogram.org/staffarticles.htm

1. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, MD US Department of Health and Human Services. Public Health Service 2000.
2. Slade J, Zeidonis D, Foulds J, Lindberg D and Order-Conners B. New Jersey Guidelines for Tobacco Dependence Treatment. New Jersey Department of Health and Senior Services, 2001. http://www.tobaccoprogram.org/pdf/njguidelines.pdf
3. Foulds J, Gandhi KK, Steinberg MB, Richardson D, Williams J, Burke M, Rhoads GG. Factors associated with quitting smoking at a tobacco dependence treatment clinic. American Journal of Health Behavior 2006; 30:400-412
4. Steinberg MB, Foulds J, Richardson DL, Burke MV, Shah P. Pharmacotherapy and smoking cessation at a tobacco dependence clinic. Preventive Medicine 2006; 42:114-119.
5. Han ES, Foulds J, Steinberg MB, Gandhi KK, West B, Richardson D, Zelenetz S, Dasika J. Characteristics and smoking cessation outcomes of patients returning for repeat tobacco dependence treatment. International Journal of Clinical Practice 2006 September; 60(9): 1068-1074.
6. Gandhi KK, Foulds J, Steinberg MB, Lou SE, Williams J. Lower quit rates among menthol cigarette smokers at a tobacco treatment clinic. (Internal report submitted for publication).
7. Bover MT, Foulds J, Steinberg MB, Richardson D, Marcella SW. Waking at night to smoke as a marker for tobacco dependence: patient characteristics and relationship to treatment outcome. International Journal of Clinical Practice Feb 2008; 62(2): 182-190..
8. Foulds J, Steinberg MB, Williams JM, Ziedonis DM. Pharmacotherapy for tobacco dependence: past , present and future. Drug and Alcohol Review Jan 2006; 25:57-69
9. Tobacco Dependence Clinic Annual Reports available at: http://www.tobaccoprogram.org/clinic.htm
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About the Author


MA, MAppSci, PhD

Dr. Jonathan Foulds is an expert in the field of tobacco addiction.

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