E. Educate About Treatment Options; Arrive At Shared Decision For Choice Of Treatment; Determine And Document Treatment Plan

OBJECTIVES

Provide the tobacco user who desires to quit choices and a variety of treatment modalities.

BACKGROUND

Once the tobacco user has stated a willingness to quit, the provider and patient should discuss the available treatment options. It should be noted that the same modality of tobacco use treatment will not be appropriate or desirable for every patient – one size does not fit all. This is an important step, combining the provider’s knowledge of the treatment options and their characteristics with the patient’s preferences and individual needs. When ever possible, a more intensive treatment option should be available, as it has shown a higher success rate for patients who are willing to attend.

The provider should outline the different available treatment choices (treatment within primary care, telephone counseling, and referral to an intensive cessation program). The provider and patient may also want to take into account the patient’s available social support and other psychosocial factors that may affect cessation success/relapse (e.g., major life changes or stressors or depression), as well as possible barriers to various treatment options/combinations (e.g., concerns about time commitment or travel to a group or lack of access to the internet). In some cases, the provider may need to help the patient select program(s) that pertain(s) to their comorbid condition. Depending on the desires of the patient, level of training of the provider, the local resources of the health care setting, and the level of administrative support, the patient should be able to select from a variety of tobacco treatment options.

RECOMMENDATIONS

1. Providers and patients should discuss the range of available treatment options and arrive at a mutually agreeable treatment plan. Discussion should address [Expert Consensus]:
   • Individually relevant information regarding effectiveness, availability, suitability, and contraindications of different treatment options
   • Patient’s individual preferences and concerns about the treatment options/combinations
   • Tailoring treatment for patients with special needs (pregnancy, adolescents, co-morbid conditions) should have access to programs tailored to their needs (see Annotations Q1-6 - Special Populations).
   • Choosing the most intensive treatment option that the patient is willing to use or attend.
2. Patient education and a treatment plan should be documented in the patient's record. [Expert Consensus]

DISCUSSION

Describing the treatment options and evidence of efficacy to the patient allows them to choose the most appropriate treatment option to meet their needs and preferences. For example, pharmacologic treatment appears more effective at preventing weight gain than counseling (Leischow & Stitzer, 1991). Research suggests differences exist between females and males regarding concerns about post-cessation weight gain.

While there has been considerable literature supporting a shared approach to decision-making (Edwards et al., 2003; O’Connor et al., 2001), there have been no studies examining this approach to choosing treatment for tobacco use cessation.

The selected strategy must be individualized for each patient based on the provider’s appraisal of the patient’s comorbidity, current tobacco use, level of dependence, daily schedule, relapse risk factors, concern about weight gain, available support, and willingness to quit. Following counseling, the patient’s own preferences should be factored into the decision-making. The provider and the patient must mutually determine the goal of the proposed therapeutic regimen and patient preferences. The provider and patient should select the most intensive strategy that the patient is willing to use to maximize the likelihood for a successful quit. More contact time generally lead to increase likelihood for a successful quit.