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Promoting Repeat Tobacco Dependence Treatment: Are Relapsed Smokers Interested?
Steven S. Fu, MD; Melissa R. Partin, PhD; Annamay Snyder, MPH; Lawrence C. An, MD; David B. Nelson, PhD; Barbara Clothier, MS, MA;Sean Nugent, BA; Mark L. Willenbring, MD; and Anne M. Joseph, MD, MPH
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Promoting Repeat Tobacco Dependence Treatment: Are Relapsed Smokers Interested?

Steven S. Fu, MD; Melissa R. Partin, PhD; Annamay Snyder, MPH; Lawrence C. An, MD; David B. Nelson, PhD; Barbara Clothier, MS, MA;Sean Nugent, BA; Mark L. Willenbring, MD; and Anne M. Joseph, MD, MPH

Background: Promotion of repeat tobacco dependence treatment among relapsed smokers interested in "recycling" (repeat quit attempt) may be a promising approach to increase quit rates.

Objective: To report relapsed smokers' interest in recycling and their treatment preferences.

Study Design: Descriptive analysis of a population of relapsed smokers who were randomized to receive a recycling intervention strategy to increase tobacco dependence treatment rates, as part of a randomized controlled trial at 5 Veterans Affairs medical centers.

Methods: Individuals prescribed a tobacco dependence medication in 2002 were eligible and were identified from the Department of Veterans Affairs Pharmacy Benefits Management database. Intervention group participants (n = 951) were contacted for a standardized telephone interview approximately 6 months after the prescription fill date to assess smoking status, interest in recycling, and treatment preferences. Bivariate analyses and generalized linear mixed-model regressions were used to describe outcomes.

Results: The response rate to the intervention telephone call was 62% (586/951), at which 61% (357/586) of respondents had relapsed. Almost two thirds of relapsed smokers were interested in recycling within 30 days. Of these, 91% wanted behavioral or pharmacologic smoking cessation treatment, and 64% wanted behavioral and pharmacologic treatment. In multivariate analyses, independent predictors of interest in recycling within 30 days included black race, lower smoking level, and greater number of smoking-related medical conditions.

Conclusion: Most smokers who attempt to quit but relapse want to quit again right away, and most are interested in receiving behavioral and pharmacologic treatment.

(Am J Manag Care. 2006;12:235-243)

The prevalence of tobacco use in the United States cannot be reduced dramatically without helping smokers quit smoking.1 Successful cessation has immediate health benefits for all smokers and has a major effect on the economic burden of tobacco-related diseases.2 On the one hand, interest in quitting is high, and 70% of the 46 million smokers in the United States want to quit completely.3,4 On the other hand, smoking cessation rates for the past 10 to 15 years have remained stable, despite the increased availability of effective behavioral and pharmacologic treatment to help smokers quit smoking. For example, the quit ratio (proportion of ever smokers who have quit), a "dipstick" measure of successful quitting, has remained roughly 50% since 1990.5 In addition, most quit attempts, including those with treatment, do not result in long-term cessation. Depending on the population and intensity of treatment, 65% to 95% of quit attempts end in failure.6,7 This high rate of relapse illustrates the difficulty and challenges of achieving and sustaining successful smoking cessation.8-10

Promoting repeat tobacco dependence treatment among relapsed smokers interested in "recycling" (repeat quit attempt) may be a promising approach to re-engage smokers in the quitting process and to increase cessation rates. Recycling and promotion of repeat treatment recognizes that tobacco dependence is a chronic relapsing disorder and that most smokers will make multiple attempts to quit before successfully achieving long-term abstinence. Because quit attempts aided by behavioral or pharmacologic treatment for tobacco dependence are more likely to be successful than untreated quit attempts,11 it is important that recycling strategies involve delivery of additional treatment. However, clinicians may fail to make tobacco cessation a high priority because they believe that their patients are uninterested in treatment.12 Indeed, there is limited information about relapsed smokers' interest in recycling after a failed quit attempt or about their preferences for various treatment methods.

The Recycling Smokers Through Effective Treatment (RESET) study is a multicenter randomized controlled trial to test the effectiveness of a recycling intervention strategy designed to increase rates of tobacco dependence treatment. The analyses presented herein describe the prevalence and predictors of interest in recycling and smoking cessation treatment preferences among participants in the intervention arm of the RESET study.


Study Design, Setting, and Participants

Eligible participants were identified from the Department of Veterans Affairs (VA) comprehensive database on VA-issued pharmaceutical prescriptions (Pharmacy Benefits Management database), which includes medication utilization information for every VA patient who has activity at a VA pharmacy. Individuals 19 years or older who received a prescription for nicotine replacement therapy (NRT) (nicotine inhaler, spray, patch, or gum) or for bupropion sustained release (SR) for smoking cessation between February and October 2002 from 1 of 5 participating VA medical centers (Denver, Colo; Salt Lake City, Utah; New Orleans, La; Providence, RI; and Puget Sound, Wash) were eligible for the study. The selected facilities were chosen to represent variation in size, region, and tobacco-dependence prescription protocols (restricted vs unrestricted prescribing privileges for primary care providers). Individuals who did not have a primary care appointment at a participating facility in 2001 or 2002 were excluded, as the intervention was directed in part toward participants' primary care providers. Individuals who did not have complete telephone numbers and addresses in local computerized patient records systems were also excluded because participants in the intervention and control groups were contacted by letter and telephone. The institutional review board at each participating site approved this study.

In the RESET study, randomization occurred at the level of the participant. The number of participants recruited from each site was proportional to its tobacco dependence prescription volume during the recruitment period. Between 245 and 500 participants were recruited from each site; the combined sample size for all facilities was 1900. Using a computer-generated algorithm, the 1900 eligible veterans, stratified by facility, were randomly assigned to (1) a patient telephone call and computerized provider prompt (intervention group) or (2) usual care (control group). The intervention strategy included a telephone call to collect information about smoking status, interest in recycling, and treatment preferences. The information collected was communicated through an electronic progress note to the primary care provider and, if requested by the VA facility, to a representative of the facility's smoking cessation clinic. Progress notes were sent for abstinent patients and for patients interested in quitting but not for patients who wanted to quit later or not at all. The following 4 types of progress notes were generated for use in the intervention: (1) the patient wanted to quit using NRT, (2) the patient wanted to quit using bupropion SR and reported potential contraindications to its use, (3) the patient wanted to quit using bupropion SR and reported no potential contraindications to its use, or (4) the patient successfully quit.

Data Collection

Participants randomized to the intervention group were contacted by telephone approximately 6 months after they received a prescription for NRT or for bupropion SR for smoking cessation. Trained telephone interviewers at the coordinating site (Minneapolis VA Medical Center) made 6 attempts to reach each participant. During the intervention telephone call (5-10 minutes), interviewers determined participants' smoking status, interest in making a repeat quit attempt, and treatment preferences (eg, specific behavioral and pharmacologic treatment options). Participants in the control group were not contacted by the study team during the intervention period. All RESET study participants (intervention and control) were contacted 12 months after they received their index prescription for a brief follow-up telephone survey to assess demographic characteristics, which are used as covariates in the analyses herein and as outcome measures for the larger trial.

The objective of the intervention telephone call was to gather information and to assess interest in quitting. We did not attempt to persuade participants to quit smoking. Smoking status was assessed, and for those who were smoking, we assessed the mean number of cigarettes they smoked per day and their interest in making another quit attempt. For those participants interested in trying to quit again, we assessed their preferences for behavioral counseling or for pharmacologic treatment for a repeat quit attempt. For smokers interested in quitting, we also collected information about the medications used in their last quit attempt, adverse effects associated with the last medications used, and quit challenges. When participants were asked about their interest in quitting again, they received no encouragement to quit. For participants who were not interested in quitting, no attempt was made to change their minds. For participants who expressed interest in quitting but stated that they were not interested in the available behavioral or pharmacologic treatment options, we reminded them that their chances of success were much greater if they used counseling and medication therapy and gave them another opportunity to choose a treatment option. For patients who refused this second opportunity, no additional attempts were made to encourage them to choose a treatment option.


Intervention participants were asked if they were using medications for smoking cessation. Participants who were using a smoking cessation medication were considered still in treatment, and their smoking status was not assessed. To assess smoking status, all other participants were asked whether they had smoked any cigarettes within the past 7 days. If they reported that they had not smoked any cigarettes, including even a puff, they were considered abstinent. If they reported any smoking in the past 7 days, they were considered to have relapsed to smoking.

The intervention telephone call collected self-reported information about quitting history, use of smoking cessation medications, experience with adverse effects, quit challenges, and current number of cigarettes smoked per day (measure of nicotine dependence). To assess the presence of smoking-related or mental health comorbid conditions, we used participants' clinical diagnosis information in the 2 years before study enrollment from VA outpatient medical records.13-15 We obtained information about age and sex from VA outpatient medical records and information about race, education, and marital status from the 12-month follow-up survey. In addition, information about the characteristics and practices of the smoking cessation programs (eg, medications available, prescribing policy, and behavioral counseling options) available at each participating facility was provided by the facility's smoking cessation coordinator during a brief telephone survey.


The primary outcomes for this analysis were participants' interest in recycling within 30 days and their treatment preferences. To assess interest in recycling, participants were asked if they were seriously thinking about quitting smoking within 30 days. To assess treatment preferences, participants were read a brief description of each of the smoking cessation medication options available at their site. The nicotine patch and bupropion SR were available at all 5 sites; 4 of the sites also offered nicotine gum. Because the nicotine inhaler and the nicotine nasal spray were not available at most of the participating sites, they were not offered as treatment options. Participants interested in recycling were asked to choose which option they would be most interested in trying during their next quit attempt. They were allowed to pick more than 1 option if they preferred. Participants were also read a brief description of the behavioral counseling options available at their site and could choose an option if they wished. Three of the 5 sites offered group and individual counseling. One site only offered participants the option of developing a quit plan with their primary care provider. At another site, participants did not have the option of attending individual counseling sessions (although group sessions were available).

Statistical Analysis

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