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CDCshouldemployevidence-basedstrategiestohelppeoplequitusingtobaccothatsupporttheinitiationofquitattemptsandmaintaininglong-termabstinence,including:

socialmediainterventions,clinician-extenderorpoint-of-caretechnologytools,interactivevoiceresponsesystems,marketsegmentation,insurancecoverageforcessationtreatment,tobacco-free

policiesinsubstanceabusetreatment,mentalhealthandotherinstitutionalsettingsincludingprisonsandmilitarysettings.

JaniceTsohPhD,DorieApollonioPhD,NoahGubnerPhD,JosephGuydishPhD,SharonHallPhD,GaryHumfleetPhD,PamLingMD,DanielleRamoPhD,JasonSatterfieldPhD,MayaVijayraghavanMD,

LaurenLempertJD,MPH,andStantonGlantzPhD

CenterforTobaccoControlResearchandEducation,UniversityofCaliforniaSanFrancisco

DocketcontrolnumberCDC-2017-0103January2,2018

AlthoughtheCentersforDiseaseControlandPrevention’s(CDC)requestforinformationtoinformfutureactivitiesregardinghowtohelppeoplequitusingtobaccoidentifiestheimportanceofhelpingtobaccouserstoquitcompletely,itsfocuson“efficiency”and“cost-effectiveness”shouldemphasizetheeffectivenessofachievingoutcomesofbothquitattemptinitiationandlong-termsmokingabstinence.Inconsideringevidence-basedtreatment,theCDCshoulddiscourageprovisionofover-the-counternicotinereplacementtherapies(NRT)andothercessationmedicationsunlesstheyaretiedtocounselling.1Likewise,CDCshouldalsodiscourageuseofe-cigarettesandothernoveltobaccoproductsforquitattempts.Whilesomepeoplehavebeenabletoquitusingcigaretteswithe-cigarettes,formostpeople–especiallyadolescentsandyoungadults–e-cigarettesmakeithardertoquit,andtheyendupdual-orpoly-usersofcigarettes,e-cigarettes,andothertobaccoproducts,oftensubstitutingalternativetobaccoproductsinplaceswherecigarettesareprohibited.2,3,4CDCshouldalsopromotestrategiestohelpadolescentsandyoungadultsquit.Further,CDCshouldworktocountertheFDA’snewso-called“harmreduction”approachtonicotinewhichmayhavetheeffectofincreasinginitiationtotobaccoproducts,especiallyamongadolescentsandyoungadults,andsteeringsmokersto

1KotzD,BrownJ,WestR.Prospectivecohortstudyoftheeffectivenessofsmokingcessationtreatmentsusedinthe“realworld.”MayoClinProc.2014;89(10):1360–1367.KotzD,BrownJ,WestR.“Real-world”effectivenessofsmokingcessationtreatments:apopulationstudy.Addiction.2014;109(3):491–499.Leas,EC,etal,EffectivenessofPharmaceuticalSmokingCessationAidsinaNationallyRepresentativeCohortofAmericanSmokers.JNCI:JournaloftheNationalCancerInstitute,djx240,https://doi.org/10.1093/jnci/djx240.Published:21December2017.2KalkhoranS,GlantzSA.E-cigarettesandsmokingcessationinreal-worldandclinicalsettings:asystematicreviewandmeta-analysis.LancetRespirMed.2016Feb;4(2):116-28.doi:10.1016/S2213-2600(15)00521-4.Epub2016Jan14. 3 LeeS,GranaRA,GlantzSA.ElectroniccigaretteuseamongKoreanadolescents:across-sectionalstudyofmarketpenetration,dualuse,andrelationshiptoquitattemptsandformersmoking.JAdolescHealth.2014Jun;54(6):684-90.doi:10.1016/j.jadohealth.2013.11.003.Epub2013Nov22. 4 GlantzSA,BarehamD.E-cigarettes:Use,EffectsonSmoking,Risks,andPolicyImplications.AnnRevPubHealth2018(inpress).

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e-cigaretteswhichcoulddepresspopulation-levelsmokingcessation.Althoughithastheauthoritytodoso,FDAhasfailedtoprohibitflavorsinnewlydeemedtobaccoproducts(includinge-cigarettes),whichnotonlyencouragesinitiation,especiallyamongyouth,butalsodiscouragesquitting.Additionally,CDCshouldconsidersettingswherecigaretteshavetraditionallybeenusedasrewardsinmentalhealthhospitals,prisons,andmilitarysettings,5whichbothencouragessmokinginitiationanddiscouragesquitting.CDC’sfutureactivitiesshouldextendtothesesettings.Followingarerecommendationsforevidence-basedstrategiesthatcanhelpachievethesegoals.(1)HOWCANCDCLEVERAGEEMERGINGTECHNOLOGIESTODELIVEREVIDENCE-BASEDCESSATIONINTERVENTIONSTHROUGHNEWANDINNOVATIVEPLATFORMSTHATHAVEBROADREACH,ESPECIALLYAMONGYOUNGERADULTS,THOSEWITHLOWINCOME,ANDADULTSWITHCHRONICAND/ORBEHAVIORALHEALTHCONDITIONS?

CDCshouldpromoteemergingtechnologiesusingsocialmedia(e.g.Facebook,Twitter)andclinician-extendertechnologies(e.g.computertablets,websites,mobileappsthatworkinconjunctionwithhealthproviderinput).Thesechannelshaveshownbroadreachindeliveringevidence-basedcessationinterventionstounderservedpopulations,andareespeciallyeffectiveforyoungadults.Digitalplatformscanbeidealtodeliverevidence-basedextendedinterventionstoproducehighratesoflong-termabstinence.

Socialmediaandmobileinterventions:In2017,thePewResearchCenterreportedthat95%ofAmericansownacellphone6and70%usesocialmedia.7Mobileinterventionsmaybeanidealmediumtoprovideextendedtreatments,whichhaveshowntoproduceunparalleledlong-termabstinencerates(45%to55%abstinenceratesat1yearorbeyond).8,9Despitethehighquitratesfromtheseextendedtreatments,therearemultiplebarriersinrecruitingandretainingpatientsintoface-to-faceextendedtreatments.Givenmobileinterventionsfortobaccousehaveabroadreach,theseinterventionscanimplementextendedtreatmentafteranintensiveface-to-faceintervention,toprovideintensiveelectroniccontactswithtailoredandextensivecontents,ortoprovidesupportforextendedprescriptiontoyieldhighabstinencerates.TheseideasarediscussedinarecentcommentarybyDr.Hall.10

5 Smith,ElizabethA,Poston,WalkerS.,Jahnke,SaraA.,Jitnarin,Nattinee,Haddock,ChristopherK.,Malone,RuthE.UnitedStatesMilitaryTobaccoPolicyResearch:AWhitePaper.2016.https://escholarship.org/uc/item/13v9c7pg6http://www.pewinternet.org/fact-sheet/mobile/7http://www.pewinternet.org/fact-sheet/social-media/8HallSM,HumfleetGL,MunozRF,ReusVI,RobbinsJA,ProchaskaJJ.Extendedtreatmentofoldercigarettesmokers.Addiction.2009;104(6):1043-52.doi:10.1111/j.1360-0443.2009.02548.x.PubMedPMID:19392908;PubMedCentralPMCID:PMC2718733.9HallSM,HumfleetGL,MunozRF,ReusVI,ProchaskaJJ,RobbinsJA.Usingextendedcognitivebehavioraltreatmentandmedicationtotreatdependentsmokers.AmJPublicHealth.2011;101(12):2349-56.doi:10.2105/AJPH.2010.300084.PubMedPMID:21653904;PMCID:PMC3222443.10Hall,S.M.CommentaryonLaude,et.al.:Extendedtreatmentofcigarettesmoking.Addiction.2017;112(8)1460-1461.doi:10.1111/add.13884.

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Socialmediahasabroadreachtoyoungadultsmokerswithhighengagementandretentionrates.11,12,13A2017reviewidentified7studiessupportingfeasibility,acceptability,andpreliminaryeffectivenessofsocialmediainterventionsforsmokingcessation.14AcounsellinginterventiondeliveredviaTwitterincombinationwithnicotinereplacementtherapy(NRT)yieldedsignificantlyhighershort-termquitrateswhencomparedtothosereceivingNRTalone.15Dr.DanielleRamoandcolleaguesattheUniversityofCaliforniaSanFranciscohavedevelopedtheTobaccoStatusProject(TSP)interventiondeliveredviaFacebooktargetingyoungadultsmokers.TSPhasdemonstratedhighengagementandpromisingefficacyat3-months.16,17Dr.Ramo’sresearchteamiscurrentlyconductingtworandomizedtrialstoextendTSPtoaddressbothtobaccoandalcoholuseamongyoungadults18andtotestaculturallytailoredTSPforsexualandgenderminoritysmokers.19Thesenewtrialswillhelpdeterminetheoptimallengthoftreatmentandtheextenttowhichtailoringishelpfulforyoungadultsandvulnerablegroups.Todate,socialmediainterventionshaveshownpositiveshorttermoutcomeswithhighengagementandbroadreach;CDCshouldencourageuseofthesechannels.ThesefindingsmayextendtootherplatformssuchasInstagramandSnapchat,whichisworthexploringdespitetherearenopublishedtrialstoourknowledge.

11RamoDE,LiuH,ProchaskaJJ.Amixed-methodsstudyofyoungadults'receptivitytousingFacebookforsmokingcessation:ifyoubuildit,willtheycome?AmJHealthPromot.2015Mar-Apr;29(4):e126-35.doi:10.4278/ajhp.130326-QUAL-128.Epub2014Feb27.12RamoDE,RodriguezTM,ChavezK,SommerMJ,ProchaskaJJ.FacebookRecruitmentofYoungAdultSmokersforaCessationTrial:Methods,Metrics,andLessonsLearned.InternetInterv.2014Apr;1(2):58-64.13RamoDE,ThrulJ,ChavezK,DelucchiKL,ProchaskaJJ.FeasibilityandQuitRatesoftheTobaccoStatusProject:AFacebookSmokingCessationInterventionforYoungAdults.JMedInternetRes.2015Dec31;17(12):e291.doi:10.2196/jmir.5209.14NaslundJA,KimSJ,AschbrennerKA,McCullochLJ,BrunetteMF,DalleryJ,etal.Systematicreviewofsocialmediainterventionsforsmokingcessation.AddictBehav.2017;73:81-93.15PechmannC,DelucchiK,LakonCM,ProchaskaJJ.RandomisedcontrolledtrialevaluationofTweet2Quit:asocialnetworkquit-smokingintervention.TobControl.2016.16RamoDE,ThrulJ,DelucchiKL,LingPM,HallSM,ProchaskaJJ.TheTobaccoStatusProject(TSP):StudyprotocolforarandomizedcontrolledtrialofaFacebooksmokingcessationinterventionforyoungadults.BMCPublicHealth.2015;15:897.17RamoDE,ThrulJ,DelucchiKL,HallSM,LingPM,BelohlavekA,ZhaoS,BeomyunH,ProchaskaJ.Thetobaccostatusproject:ThreemonthoutcomesforarandomizedcontrolledtrialofaFacebooksmokingcessationinterventionforyoungadults.DrugandAlcoholDependence,171,e173.DOI:http://dx.doi.org/10.1016/j.drugalcdep.2016.08.474.18https://clinicaltrials.gov/show/NCT0316330319https://clinicaltrials.gov/show/NCT03259360

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Clinician-extendertechnologies:Over70%ofsmokershaveaclinicalencounterwithahealthcareproviderannually.20“Clinical-extendertechnologies”takeadvantageofthisfactand,workinginconjunctionwithhealthproviderinput,usemoderntechnologiestoextendtheclinicalsupportforsmokerstoenhancemotivationforquittingsmoking,initiatequitattempts,andmaintainabstinence.Theseinterventionscanbedeliveredviacomputertablets,websites,ormobileappsbefore(orafter)aclinicalvisitinawaitingroomorathomeoranylocationviamobiledevices.Theseinterventionshaveshownimportantpromiseinsavingcliniciantimewhileimprovingthefidelityofevidence-basedinterventionssuchasthe5A’s(Ask,Advise,Assess,AssistandArrange).These“blendedmodels”offertheefficiencyandscalabilityoftechnologicaltoolswhileretainingthesocialinfluenceandpersonalskillofhealthcareproviders.21ArecentstudyconductedbyDr.JasonSatterfieldandcolleaguesin3primarycareclinicsservingdiversepatientsshowedthata5-minutecomputertabletinterventiondeliveredinthewaitingroomcouldprepbothprovidersandpatientstohaveproductive5A’sdiscussionstopromotetobaccocessation.SurveysanddebriefinterviewsshowedthatthetechnologywasacceptableandtheblendedmodelpromotedadherenceandpositivebehavioralchangesamongEnglish-andSpanish-speakingpatients.22,23,24Theuseofaninteractive,tailoredvideoeducationprogramcalled“VideoDoctor”hasshownefficacyinfacilitatingpatient-providerdiscussionsamongpregnantsmokersandlimitedEnglishproficientAsianAmericansmokersinprimarycare.Thefirststudywasconductedin5communityprenatalclinics.25Pregnantsmokerswhoreportedtobaccouseinthepast30dayswererandomized.PregnantsmokersreceivingtheVideoDoctorinterventionweremorelikelytoreceiveprovideradviceontobaccouse(60.9vs.15.8%).

20USPublicHealthService.Treatingtobaccouseanddependence:2008update.Clinicalpracticeguideline.Rockville,MD:USDepartmentofHealthandHumanServices,USPublicHealthService;2008.https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/treating_tobacco_use08.pdf21SatterfieldJM.(2016).ThinkingOutsidetheVisit:DigitallyExtendingtheReachofBehavioralHealth.JGIM,31:982-984.DOI10.1007/s11606-016-3736-922KalkhoranS.,AppelleN.A.,NapolesA.M.,MunozR.F.,LumP.J.,AlvaradoN.,GregorichS.E.,SatterfieldJ.M.(2016).BeyondtheAskandAdvise:ImplementationofaComputerTabletInterventiontoEnhanceProviderAdherencetothe5AsforSmokingCessation.JSubstAbuseTreat,60:91-100.PubMedPMID26150093;PubMedCentralPMCID:PMC4670822.23NapolesAM,ApelleN,KalkhoranS,VijayaraghavanM,AlvaradoN,SatterfieldJM.(2016).Perceptionsofcliniciansandstaffregardingtheuseofdigitaltechnologyinprimarycare:qualitativeinterviewspriortoimplementationofacomputer-facilitated5Asintervention.BMCMedicalInformaticsandDecisionMaking,16:44-5724SatterfieldJ.M.,GregorichS,KalkhoranS,LumP,BloomeJ,AlavaradoN,MunozR,VijayaraghavanM.(InReview).Computer-Facilitated5A’sforSmokingCessation:ARandomizedTrialofTechnologytoPromoteProviderAdherence.AmJPrevMed.25TsohJY,KohnMA,GerbertB.PromotingsmokingcessationinpregnancywithVideoDoctorplusprovidercueing:arandomizedtrial.ActaObstetGynecolScand.2010;89(4):515-23.doi:10.3109/00016341003678419.PubMedPMID:20196678;PMCID:3312043.

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Anotherstudy,conductedbyDr.JaniceTsohandcolleagueswasasingle-groupfeasibilitypilotexaminingthefeasibility,acceptabilityandefficacyofaninteractive“MobileDoctor”intervention(iMD)withKorean-andVietnamese-speakingmalepatientswhosmokeddailyandpresentedforaprimarycarevisitinaFederallyQualifiedHealthCenter.26,27AsianAmericans,thefastestgrowingpopulationintheUnitedStates,reportedlyhavethelowestratesofreceivingphysicianadviseamongotherracialethnicgroups,34%28to41%.29TheiMDdelivers5As(Ask,Advise,Assess,AssistandArrange)viatailoredin-languagevideomessagesonamobiletablettopatientsrightbeforeahealthcarevisit.Participationratewashighwith>50%inprecontemplationwithnointenttoquitsmokingwithin6months.Thedeliveryofthevideointerventionaveraged13minutesinduration.AllpatientsreporteddiscussingtobaccousewiththeirprovideraftertheiMDsession.EHR-documented5AsweresignificantlyhigherattheiMDvisitforAssess,Assist,andArrange(36%to60%)whencomparedtoothervisitswithoutiMD(6%to13%).TheteamiscurrentlyconductingarandomizedtrialwithiMDinEnglish,Cantonese,KoreanandVietnameselanguages.30Integratingdigitaltechnologiesintoclinicalpracticecouldprovidesustainableandinexpensivesupporttosmokersoverextendedperiodswithoutgeographicallocationconstrains.CDCshouldencourageandsupporttheimplementationoftheseclinician-extenderorpoint-of-caretechnologiestoengagebothpatientsandproviderswithinandoutsideofclinicalsettingstosupportsmokingcessationefforts.(2)WHATARESOMEINNOVATIVEAPPROACHESTOREDUCETHECOST—INTIME,STAFFING,ANDFUNDING—OFPROVIDINGEFFECTIVECESSATIONSERVICESTOPEOPLEWHOWANTTOQUITUSINGTOBACCO?

Interactivevoiceresponsesystemsprovidecost-effectivecessationservicestosmokersduringhospitalizationandpost-discharge.Otherinnovativeapproachesincludingtheuseofsocialmediaandclinician-extendertechnologieshaveshownbroadreachtodeliverevidence-basedtreatmenttosmokersincommunityandpractice-basedsettings.WhileNRTisaprovencessationintervention,theevidenceconsistentlyshowsthatNRTusedwithoutcounsellingis

26TsohJ,QuachT,DuongT,ParkE,WongC,LamH,HuangS,NguyenT.AddressingtobaccouseinKoreanandVietnamesesmokingpatientsincommunityhealthprimarycaresettinginCalifornia,UnitedStates.SymposiumpresentationattheSocietyforResearchonNicotineandTobacco23rdAnnualMeeting;Florence,Italy2017.Available:http://c.ymcdn.com/sites/www.srnt.org/resource/resmgr/conferences/2017_annual_meeting/SRNT_2017_Abstract_Book__Web.pdf27TsohJ,QuachT,DuongT,ParkE,WongC,HuangS,NguyenT.InteractiveMobileDoctor(iMD)toPromotePatient-ProviderDiscussiononTobaccoUseamongKoreanandVietnamesePatientsinPrimaryCare:APilotStudy.Nicotine&TobaccoResearch.UnderReview.28BabbS,MalarcherA,SchauerG,AsmanK,JamalA.QuittingSmokingAmongAdults—UnitedStates,2000-2015.MMWRMorbMortalWklyRep2017;65:1457-1464.29NugentC,SchoenbornC,VahratianA.Discussionsbetweenhealthcareprovidersandtheirpatientswhosmokecigarettes.Hyattsville,MD:NationalCenterforHealthStatistics;2014.Availablefrom:http://www.cdc.gov/nchs/data/databriefs/db174.pdf.30https://clinicaltrials.gov/show/NCT02966132

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ineffectiveorevenharmfulintermsofpromotingcessation.Thus,inordertoprovideeffectivesmokingcessationservices,theCDCshoulddiscourageprovisionofNRTwithoutcounseling.

Smoking-induceddiseasesareamongtheleadingetiologiesforhospitaladmissionsandasignificantcontributortohealthcarecostsinsafetynethealthsettings.Smokingcessationwouldsignificantlyimprovehealthoutcomesandreducecosts.Providingtobaccocessationtreatmentduringahospitalizationisaneffectiveinterventionbecausesmokersmaybemotivatedtoquit,especiallyiftheyareadmittedforasmoking-relatedillness,31andareforcedtobetemporarilyabstinentbecauseofhospitalsmoke-freepolicies.32However,theefficacyofhospital-basedcounselingislimitedifthecounselingisnotcontinuedintheoutpatientsettingafterdischarge.Thus,providingaccesstosustainedcessationsupportafterhospitaldischargeiscriticalinordertoincreasecessationrates.

Theinteractivevoiceresponsesystem(IVR)isapromisingtechnologythatoffershospitalizedsmokerscontinuedcessationcounselingafterdischarge,therebyincreasingtheirchancesofsuccessfulsmokingcessation.33TheIVRisatelephone-basedtechnologythatallowsacomputertodetectvoiceandtouchtonesduringaphoneconversationandrespondwithprerecordedaudio.AnIVRsystemhasbeenusedtoautomaticallyinitiatephonecallsafterdischarge,screenandassesssmokingstatus,domedicationmanagement,andconnectappropriatepatientstoalivecounselor.ThisincombinationwithFDA-approvedmedicationsforcessationfor3monthshasbeenshowntoincrease6-monthabstinenceamonghospitalizedpatients.Arecentreviewfoundthatofferingsmokingcessationcounselingpost-dischargeformorethanamonthafterdischargeincreasedsmokingcessation,whereasinterventionsthatofferedlesspost-dischargecontactwerenoteffective.34

TheIVRsystemhasbeenusedsuccessfullyinseveralhospitalsintheU.S.(e.g.MassachusettsGeneralHospital,MedicalUniversityofSouthCarolinaHealthSystems)andCanada(“OttawaModel”)withimprovementincessationrates.35,36InarecentrandomizedcontrolledtrialofanIVRinterventionforhospitalizedsmokers,thoseintheinterventionarmhadbiochemically-confirmed6-monthpointprevalenceabstinencerateof26%comparedto15%intheusualcarearm.Self-reportedpast7-dayabstinencerateswere52%forsustainedcareversus39%forusualcareat1month,and41%versus28%at6months.

31RigottiNA,MunafoMR,SteadLF,SmokingCessationInterventionsforHospitalizedSmokers.ASystematicReview.ArchInternMed.2008;168(18):1950-1960.32LongoDR,BrownsonRC,KruseRL.SmokingbansinUShospitals:resultsofanationalsurvey.JAMA.1995;274(6):488-491.33ReganS,ReyenM,LockhartAC,RichardsAE,RigottiNA.Aninteractive34RigottiNA,MunafoMR,SteadLF,SmokingCessationInterventionsforHospitalizedSmokers.ASystematicReview.ArchInternMed.2008;168(18):1950-1960.35RigottiNA,ReganS,LevyDSetal.,SustainedCareInterventionandPostdischargeSmokingCessationAmongHospitalizedAdults:ARandomizedClinicalTrial.JAMA.2014;312(7):719-728.36MullenKA,ManuelDG,HawkenSJetal.,Effectivenessofahospital-initiatedsmokingcessationprogramme:2-yearhealthandhealthcareoutcomes.TobControl.2016;0:1-7.

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Thesametrialfoundanestimatedfirst-yearincrementalcosts-per-quitattemptof$7,220-$3,062,asthenumberofsmokersrangedfrom50to500,respectively.37Forsubsequentyears,theestimatedcost-per-patientreducedto$302-$288andthecostperquitattemptto$2741-$2641.Ifinsurerspaidformedications,thecost-per-patientinthefirstyearrangedbetweento$608-$151asthenumberofsmokersrangedfrom50to500,respectively,and$115-$101forsubsequentyears.Thecost-per-quit,assuminginsurerspaidformedications,forthefirstyearwas$5,527-$1,369and$1,048-$921insubsequentyears.ThelargestcostburdenforahospitalsystemtosetuptheIVRsystemisduringthefirstyear,withanestimatedone-time-infrastructurecostofapproximately$27,000,assumingthatinsurerspaidformediations.ThesecostsreducedsignificantlyinsubsequentyearsafterestablishingtheIVRsystem.

ThesecostestimatessuggestthatanIVR-basedinterventioncouldbemosteffectiveinhospitalsystemsthattreatalargevolumeofsmokersandthathaveacentralizedtobaccotreatmentprogram.TheIVR-basedinterventioncouldbeparticularlycost-effectiveinsafetynethospitalsthatservealargevolumeoflow-incomepatients,wheretobaccouseisconcentrated.Suchprogramswouldbemostviableifgovernmentandprivateinsurancepoliciescontinuetocoverevidence-basedsmokingcessationtreatments.

IntheCanadiansystem,currentsmokerswhowererecruitedfromoneof14hospitalsandwhoparticipatedinthe‘OttawaModel’forsmokingcessation(anIVR-basedinterventionfor6months)experiencedlowerratesofall-causereadmission,smoking-relatedreadmission,andall-causeemergencydepartmentvisits.38Reductionsinmortalitywerenotobservedat1months,buttheyweresignificantlyreducedat1-and2-yearsfollow-up.Suchinterventionscouldpotentiallyreducesubsequenthealthcareutilization,therebyfurtherreducinghealth-carecosts.Consideringtheoveralllow-costsofprovidinghospital-basedcessationprograms,thesetypesofinterventionsshouldbeimplementedinallhospitals.

Asdiscussedabove,othertechnology-basedapproachessuchassocialmedia(includingFacebookandTwitter)andclinician-extendertechnologiesviabriefinteractiveassessmentandfeedbackviacomputertabletsoronlineathealthcaresettingshaveshownpromiseindeliveringtobaccocessationtreatment.Moreover,thesetechnologieshaveabroadreachextendingtodisadvantagedpopulationsincommunityandpractice-basedsettings,andshowhighengagementandacceptabilityforbothsmokersandtheirhealthcareproviders.Althoughthesetechnologiesmayrequireanupfrontinvestmentandcarefulattentiontoimplementationchallenges,theyprovideanimportantopportunitytosavecliniciantimewhileimprovingfidelity,improveoutcomes,andsavemoney.39

WhileNRTisaprovencessationinterventionwhencombinedwithcounselling,theevidenceconsistentlyshowsthatNRTusedwithoutcounsellingisineffectiveorevenharmfulintermsofpromoting

37RigottiNA,ReganS,LevyDSetal.,SustainedCareInterventionandPostdischargeSmokingCessationAmongHospitalizedAdults:ARandomizedClinicalTrial.JAMA.2014;312(7):719-728.38MullenKA,ManuelDG,HawkenSJetal.,Effectivenessofahospital-initiatedsmokingcessationprogramme:2-yearhealthandhealthcareoutcomes.TobControl.2016;0:1-7.39SatterfieldJM.(2016).ThinkingOutsidetheVisit:DigitallyExtendingtheReachofBehavioralHealth.JGIM,31:982-984.DOI10.1007/s11606-016-3736-9

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cessation.40ManystatesandmedicalsystemsprovideNRTalone;thispracticeshouldbediscouragedasawaste–andpossiblycounterproductive–useofresources.

ThisissueisofparticularconcernbecausethetobaccoindustryisnowenteringtheNRTbusinessaspartofaplantoholdontocustomersinformedbytheunderstandingthatNRTwithoutcounsellinglikelydepressescessation.AsApollonioandGlantz41noted:

MajortobaccocompaniesintheUnitedStatesandtheUnitedKingdomviewedNRT,evenwhenitwasonlyavailablebyprescription,asarecreationalproductthatcouldmaintainandpossiblyexpandtheuseofnicotineassmokingbecamelesssociallyacceptable.AlthoughNRTwasapprovedforcessation,tobaccoindustryresearchfoundintheearly1990sthatmanysmokersuseditincombinationwithcigarettesandthatsmokerswhousedNRTforcessationwouldotherwisehavequitoutright.49–51,53,54

Inthe21stcentury,medicalresearchbegantofindsimilarresults.ThemajorityofsmokerswhoreceiveprescriptionNRTreceivecounselingonhowtousethemedication.59InitialclinicaltrialssuggestingcomparableeffectivenessforOTCNRTreliedonsimulatedOTCuseratherthanreal-worldOTCuse.11–16Follow-uppopulationstudiesofOTCNRTshoweditdidnotimprove—andcouldimpede—cessation,withoutanorganizedcessationprogram.8,9,17,18Outsideofmonitoredsettings,NRTisoftenusedforshorterperiodsthanrecommendedandnotcombinedwithbehavioralcounseling.10Thesefindingsareconsistentevenamongindividualsmotivatedtoquit:afollow-upstudyofparticipantsenrolledinaclinicaltrialofnicotinepatchusersfoundthatafter8years,therewasnostatisticallysignificantdifferenceinabstinenceforpatchusersthannonusers.60Moreover,smokerswhousedover-the-counterNRTweresignificantlylesslikelytoquitthanweresmokerswhodidnotuseanycessationaids.8,9

Tobaccocompaniesexpressedinterestindevelopingandmarketingalternativeproductscontainingnicotineasearlyasthe1950s,buttheywereconcernedaboutmarketingthembecausedoingsocouldleadtoFDAregulation.In2009,followingnewFDAregulationofcigarettes,tobaccocompaniesbegansellingthealternativenicotineproductstheyhadfirstproposeddecadesearlier.61In2014,RJReynoldsTobaccobegansellingitsnicotinegum,Zonnic,throughouttheUnitedStates.Internally,RJRclassifiedZonnicwithitse-cigarettebrandVuse,consideringbothproductstobepartofits“questtowardbecominga‘totaltobaccocompany.’”4

Reflectingthisambition,marketingin2015forZonnicsuggestedthatsmokerscoulduseitwithcigarettes:“Quittingdoesn’thavetofeellikeallornothing.”61ThismarketingisconsistentwithtobaccoindustryresearchthatfoundmanysmokersusedNRTincombinationwithcigarettes

40KotzD,BrownJ,WestR.Prospectivecohortstudyoftheeffectivenessofsmokingcessationtreatmentsusedinthe“realworld.”MayoClinProc.2014;89(10):1360–1367.KotzD,BrownJ,WestR.“Real-world”effectivenessofsmokingcessationtreatments:apopulationstudy.Addiction.2014;109(3):491–499.Leas,EC,etal,EffectivenessofPharmaceuticalSmokingCessationAidsinaNationallyRepresentativeCohortofAmericanSmokers.JNCI:JournaloftheNationalCancerInstitute,djx240,https://doi.org/10.1093/jnci/djx240.Published:21December2017.41ApollonioD,GlantzSA.TobaccoIndustryResearchonNicotineReplacementTherapy:"IfAnyoneIsGoingtoTakeAwayOurBusinessItShouldBeUs".AmJPublicHealth.2017Oct;107(10):1636-1642.doi:10.2105/AJPH.2017.303935.Epub2017Aug17.

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insteadofasameanstoquitsmoking.PhilipMorrisbeganmarketingnicotinelozengesin2016.5,6

…

Tobaccoindustryresearchfromthe1970sforwardtreatedallproductscontainingnicotine—includingcigarettes,e-cigarettesandtheirprecursors,andothers(e.g.,gums,patches,andcandy)—aspartofasinglemarket:thenicotinedelivery,orCravingReliefmarket.Industrymarketinganticipatesthatnoncigarettenicotinedeliveryproductswillbeusedbysmokersforwhomsmokingisunacceptable,thusfacilitatingandnormalizinglifelongnicotineaddiction.Thesefindingssuggestthattheleastharmfulwaytosellnicotinedeliveryproductsistorestrictthemtosmokerswhosequitattemptsaremedicallysupervised,consistentwiththeoriginalstudiesofNRTforsmokingcessation.7[CitationsinthisquotationarecitationsinApollonioD,GlantzSA.TobaccoIndustryResearchonNicotineReplacementTherapy:"IfAnyoneIsGoingtoTakeAwayOurBusinessItShouldBeUs".AmJPublicHealth.2017Oct;107(10):1636-1642.doi:10.2105/AJPH.2017.303935.Epub2017Aug17.]

TheCDCshoulddiscourageprovisionofover-the-counterNRTandothercessationmedicationsunlesstheyaretiedtocounselling.

(3)HOWMIGHTSTANDARDIZATIONOFQUITLINESERVICESACHIEVEGREATEREFFICIENCYWHILEALSOPRESERVINGSTATEQUITLINES'“BRANDS,”FLEXIBILITY,ANDCAPACITYFORINNOVATION?

CDCshouldestablishastandardizedquitlinetreatmentprotocolwithidentifiedbasiccoretreatmentcomponentsofquitlineservicethatareconsistenttotheinterventionprotocolusedtoestablishtheeffectivenessofquitline.42Thestandardizedquitlinetreatmentprotocolamendabletoadd-oncomponentssuchasinteractiveweb-sites,NRTcombinedwithcounsellingasselectedbystatesaccordingtoresources.43

(4)WHATCOMMUNICATIONCHANNELSANDCOMMUNICATIONSTRATEGIESSHOULDCDCCONSIDEREMPLOYINGTOENSURETHATBOTHTOBACCOUSERS,INCLUDINGTHOSEBELONGINGTOHIGH-RISKANDDISADVANTAGEDPOPULATIONS,ANDHEALTHCAREPROVIDERSAREAWAREOFANDHAVEACCESSTOEVIDENCE-BASEDCESSATIONRESOURCES?

Inadditiontoconventionalmediacommunicationchannels,CDCshouldemploymarketsegmentationstrategies,andpeer-outreachstrategiessuchascommunityorlayhealthworkeroutreachforunderserved,hard-to-reachpopulationsegments.

42ZhuSH,AndersonCM,TedeschiGJ,RosbrookB,JohnsonCE,ByrdM,Gutierrez-TerrellE.Evidenceofreal-worldeffectivenessofatelephonequitlineforsmokers.NEnglJMed.2002;347(14):1087-93.doi:10.1056/NEJMsa020660.PubMedPMID:12362011.43LichtensteinE,ZhuS-H,TedeschiGJ.SmokingCessationQuitlines:AnUnderrecognizedInterventionSuccessStory.TheAmericanpsychologist.2010;65(4):252-261.doi:10.1037/a0018598.

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Smartphonesandmobiledevicesareusedwidelybyyoungadults(96%liveinhouseholdswithsmartphones)44andintheUS,whileBlackandHispanicpeoplearelesslikelytohavehomebroadbandinternetaccess,theyownmobiledevicesatratessharessimilartowhites.45MediapromotionhasshowneffectivenessinincreasingquitlineutilizationamongEnglishandnon-Englishspeakers.Inadditiontomediacommunicationchannels,marketsegmentationstrategiesmaybeusedtodefinecommunicationaudiencesandreachhighriskanddisadvantagedpopulationsmoreeffectively.Ourresearchhasshownhowtobaccomarketingencouragesuseamongvulnerablegroupssuchaspoorwomen,46ruralmales,47,48,49,50andyoungpeople.51,52,53,54OthershaveshownhowtobaccocompaniestargetAfricanAmericans,55,56,57Hispanics,58Asians,59workingpoor,60theLGBTcommunity,61,62homeless

44http://www.pewresearch.org/fact-tank/2017/05/25/a-third-of-americans-live-in-a-household-with-three-or-more-smartphones/45http://www.pewresearch.org/fact-tank/2017/08/31/smartphones-help-blacks-hispanics-bridge-some-but-not-all-digital-gaps-with-whites/46Brown-JohnsonCG,EnglandLJ,GlantzSA,LingPM.TobaccoindustrymarketingtolowsocioeconomicstatuswomenintheU.S.A.TobControl.2014;23(e2):e139-46.47LingPM,HaberLA,WedlS.Brandingtherodeo:acasestudyoftobaccosportssponsorship.AmJPublicHealth.2010;100(1):32-41.48MejiaAB,LingPM.Tobaccoindustryconsumerresearchonsmokelesstobaccousersandproductdevelopment.AmJPublicHealth.2010;100(1):78-87.49KostyginaG,LingPM.Tobaccoindustryuseofflavouringstopromotesmokelesstobaccoproducts.TobControl.2016Nov;25(Suppl2):ii40-ii49.50CorteseDK,LingPM.EnticingtheNewLad:MasculinityasaProductofConsumptioninTobaccoIndustry-DevelopedLifestyleMagazines.MenMasc.2011;14(1):4-30.51HafezN,LingPM.FindingtheKoolMixx:howBrown&Williamsonusedmusicmarketingtosellcigarettes.TobControl.2006;15(5):359-66.52LingPM,GlantzSA.Whyandhowthetobaccoindustrysellscigarettestoyoungadults:evidencefromindustrydocuments.AmJPublicHealth.2002.Jun;92(6):908-16.53LingPM,GlantzSA.Usingtobacco-industrymarketingresearchtodesignmoreeffectivetobacco-controlcampaigns.JAMA.2002Jun12;287(22):2983-9.54LingPM,GlantzSA.Tobaccoindustryresearchonsmokingcessation.Recapturingyoungadultsandotherrecentquitters.JGenInternMed.2004.May;19(5Pt1):419-26.55BalbachED,GasiorRJ,BarbeauEM.R.J.Reynolds'targetingofAfricanAmericans:1988-2000.AmJPublicHealth.2003;93(5):822-7.56YergerVB,MaloneRE.AfricanAmericanleadershipgroups:smokingwiththeenemy.TobControl.2002;11(4):336-45.57YergerVB,PrzewoznikJ,MaloneRE.Racializedgeography,corporateactivity,andhealthdisparities:tobaccoindustrytargetingofinnercities.Journalofhealthcareforthepoorandunderserved.2007;18(4Suppl):10-38.58Iglesias-RiosL,ParascandolaM.AhistoricalreviewofR.J.Reynolds'strategiesformarketingtobaccotoHispanicsintheUnitedStates.AmJPublicHealth.2013;103(5):e15-27.59MuggliME,PollayRW,LewR,JosephAM.TargetingofAsianAmericansandPacificIslandersbythetobaccoindustry:resultsfromtheMinnesotaTobaccoDocumentDepository.TobControl.2002;11(3):201-9.

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andpersonswithmentalillness63andothers.Inparticular,tobaccocompaniestargetyoungadultsbymakingsmokingappeartobeanaturalpartofyoungadultsocialculturesandeventailoredtheircigarettepackdesignstotheculture.64Themarketingstrategiesusedbytobaccocompaniestosellcigarettescanbeusedtoimprovetobaccocontrolprograms.Previouslysecrettobaccoindustrydocumentsrevealhowtobaccocompaniestargetandmarkettobaccoproductstoencourageyoungadultsmokingandunderminesmokingcessation.65,66,67Thesecommercialmarketsegmentationstrategiescanalsobeusedtoreachyoungadulttargetsfortobaccocontrol,learningfromdecadesoftobaccoindustrymarketresearch.68,69,70Dr.PamelaLinghasusedthisknowledgetodevelopsophisticatedstrategiestoimprovethereach,relevance,andpersuasivenessofanti-tobaccomessages.Commercialmarketsegmentationstrategiescanbeusedtodefine“psychographic”targetsbasedonlifestyle,values,aspirations,activities,self-image,andsocialaffiliation,ratherthandemographiccharacteristicsalone.Onenovelandefficientwaytodeterminethepsychographicsofyoungadultsisutilizing“peercrowds”foranti-tobaccointerventions.71,72,73Incontrasttoone’sfriendswhichmakeupapeergroup,thepeer

60BarbeauEM,Leavy-SperounisA,BalbachED.Smoking,socialclass,andgender:whatcanpublichealthlearnfromthetobaccoindustryaboutdisparitiesinsmoking?TobControl.2004;13(2):115-20.61StevensP,CarlsonLM,HinmanJM.Ananalysisoftobaccoindustrymarketingtolesbian,gay,bisexual,andtransgender(LGBT)populations:strategiesformainstreamtobaccocontrolandprevention.HealthPromotPract.2004;5(3Suppl):129s-134s.62SmithEA,ThomsonK,OffenN,MaloneRE."Ifyouknowyouexist,it'sjustmarketingpoison":meaningsoftobaccoindustrytargetinginthelesbian,gay,bisexual,andtransgendercommunity.AmJPublicHealth.2008;98(6):996-100363ApollonioDE,MaloneRE.Marketingtothemarginalised:tobaccoindustrytargetingofthehomelessandmentallyill.TobControl.2005;14(6):409-15.64HendlinY,AndersonSJ,GlantzSA.'Acceptablerebellion':marketinghipsteraestheticstosellCamelcigarettesintheUS.TobControl.2010;19(3):213-22.65CorteseDK,LewisMJ,LingPM.Tobaccoindustrylifestylemagazinestargetedtoyoungadults.JAdolescHealth.2009;45(3):268-80.66AndersonSJ,PollayRW,LingPM.Takingad-VantageoflaxadvertisingregulationintheUSAandCanada:reassuringanddistractinghealth-concernedsmokers.SocSciMed.2006;63(8):1973-85.67AndersonSJ,GlantzSA,LingPM.Emotionsforsale:cigaretteadvertisingandwomen'spsychosocialneeds.TobControl.2005;14(2):127-35.68FallinA,NeilandsTB,JordanJW,LingPM.SocialBrandingtoDecreaseLesbian,Gay,Bisexual,andTransgenderYoungAdultSmoking.NicotineTobRes.2015;17(8):983-9.69FallinA,NeilandsTB,JordanJW,HongJS,LingPM.Wreaking"havoc"onsmoking:socialbrandingtoreachyoungadult"partiers"inOklahoma.AmJPrevMed.2015;48(1Suppl1):S78-85.70LingPM,LeeYO,HongJ,NeilandsTB,JordanJW,GlantzSA.Socialbrandingtodecreasesmokingamongyoungadultsinbars.AmJPublicHealth.2014;104(4):751-60.71LeeYO,JordanJW,DjakariaM,LingPM.UsingpeercrowdstosegmentBlackyouthforsmokingintervention.HealthPromotPract.2014;15(4):530-7.72LishaNE,JordanJW,LingPM.Peercrowdaffiliationasasegmentationtoolforyoungadulttobaccouse.TobControl.2016;25(Suppl1):i83-i89.

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crowdreflectsaculturalgroupwithsharedvalues,interestsandactivitiesthatextendsbeyondone’simmediatecircleoffriends.74Peercrowdaffiliationindependentlypredictstobaccouse,controllingfordemographics.Experimentalstudieshaveshownthatmessagestailoredtopeercrowdresultedinstrongerantismokingattitudesandlowerlevelsofsmokingsusceptibilityamongadolescentswhoidentifiedwiththatcrowd.75In2014Dr.Lingcompletedthefirstpopulation-basedstudyofBayAreaYoungAdultHeath(BAYAHS)usingpsychographicsegmentationtoassesstobaccouse.Incontrolledanalyses,affiliationwith“HipHop”(AOR=4.32,95%CI=1.48,12.67)and“Country”(AOR=3.13,95%CI=1.21,8.09)peercrowdswassignificantlyassociatedwithsmoking.MultivariablemodelscontrollingfordemographicsestimatedahighprobabilityofsmokingamongbarpatronsaffiliatingwithHipHop(47%)andCountry(52%)peercrowds.76Targetinghigh-riskpeercrowdscanreachhalfoftheyoungadultsmokersinSanFranciscowithgreaterefficiency.Targetinghigh-riskpeercrowdsalsopreferentiallyreachesdisproportionatelyaffectedgroupsofyoungadultsmokersandmaybeavaluabletooltoaddressdisparitiesintobacco-relatedcancerriskandmorbidity.TargetinglimitedEnglishproficientpopulationsegmentswhereusageofevidence-basecessationresourcesislowispossible.Usingpeer-to-peer/layhealthworkeroutreachinvolvingbothsmokersandtheirfamilymemberswithAsianAmericanimmigrantshasdemonstratedsignificantincreasesinutilizationofquitlineandNRTat3and6monthsfollow-up.Dr.JaniceTsohandcolleaguesconductedasinglegrouppilotwith96pairsofdailysmoker(with42%inprecontemplation)andafamilymember.Thisstudydemonstratedincreaseinutilizationofquitline(from0%to39%)andFDA-approvedNRTorprescribedsmokingcessationmedications(from2%to16%)at3-month.77Inasecondstudy,aRCTwith107smoker-familypairs,thefamily-basedinterventionyieldedsignificantlyhigherratesofquitlineuse(39%vs2%)andNRTuse(33%vs4%)whencomparedtothecontrolgroupreceivingeducationonnutritionwithin3to6monthspost-treatmentinitiation.78

73MoranMB,SussmanS.Changingattitudestowardsmokingandsmokingsusceptibilitythroughpeercrowdtargeting:moreevidencefromacontrolledstudy.HealthCommun.2015;30(5):521-4.74LishaNE,JordanJW,LingPM.Peercrowdaffiliationasasegmentationtoolforyoungadulttobaccouse.TobControl.2016;25(Suppl1):i83-i89.75MoranMB,SussmanS.Changingattitudestowardsmokingandsmokingsusceptibilitythroughpeercrowdtargeting:moreevidencefromacontrolledstudy.HealthCommun.2015;30(5):521-4.76Ling,PamelaM.etal.Bars,Nightclubs,andCancerPrevention:NewApproachestoReduceYoungAdultCigaretteSmoking.AmericanJournalofPreventiveMedicine,Volume53,Issue3,S78-S85 77TsohJY,BurkeNJ,GildengorinG,WongC,LeK,NguyenA,ChanJL,SunA,McPheeSJ,NguyenTT.ASocialNetworkFamily-FocusedInterventiontoPromoteSmokingCessationinChineseandVietnameseAmericanMaleSmokers:AFeasibilityStudy.NicotineTobRes.2015;17(8):1029-38.doi:10.1093/ntr/ntv088.PubMedPMID:26180229;PubMedCentralPMCID:PMCPMC4542845.78TsohJ,BurkeN,GildengorinG,LeK,WongC,KimJ,McPheeS,NguyenT.PromotingSmokingCessationamongVietnameseAmericansusingaFamily-BasedLayHealthWorkerIntervention:AClusterRandomizedControlledTrial.PaperpresentedattheSocietyforResearchonNicotineandTobacco23rdAnnualMeeting;Florence,Italy2017,March.

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(5)WHATROLESHOULDCDC,STATEANDLOCALHEALTHDEPARTMENTS,NOTFORPROFITINSTITUTIONS,TRADITIONALHEALTHCAREPROVIDERS,AND/ORPROFESSIONALHEALTHCAREPARTNERORGANIZATIONS,PLAYINENSURINGTHATHIGH-RISKPOPULATIONS(SUCHASSMOKERSLIVINGBELOWTHEPOVERTYLEVELORTHOSEWITHBEHAVIORALHEALTHCONDITIONS)HAVEACCESSTOTAILOREDCESSATIONSERVICESOFAPPROPRIATEINTENSITYTOHELPTHEMSUCCESSFULLYQUIT?

TheCDCshouldrecommendinsurancecoverageofsmokingcessationtreatmentandadvocateforstatehealthdepartmentcoverageofsmokingtreatment.Inaddition,theCDCshouldlead,coordinate,andsupportinitiativestoimplementtobacco-freegroundspoliciesinalldrugabusetreatmentandmentalhealthsettings,aswellasinprisonsandthemilitary.

CDCshouldworkwithdepartmentsofpublichealth,tobaccocontrolauthorities,andsubstanceabuseandmentalhealthagenciesatbothstateandcountylevels.ItshouldcoordinateeffortswiththeSAMHSACenterforSubstanceTreatment,andwithNIHagenciesconcernedwithsmokingandcancer(NCI)andwithNIHagenciesconcernedwithaddiction(NIDA,NIAAA).(Whilethecommentbelowfocusesondrugabusetreatmentsettings,thesubstantiverecommendationextendstomentalhealthsettingsandothertreatmentsystemsaswell.)Additionally,CDCshouldworkwithcorrectionsofficialsandmilitarypersonneltocollaborativelydevelopcessationprogramsinprisonsandthemilitaryserviceswheresmokingprevalenceremainsextremelyhigh.79

CigarettesmokingcontinuestodecreaseintheUSgeneralpopulation(15.1%asof2015),80whilethesmokingprevalenceamongindividualsinsubstanceusetreatmentintheU.S.remainshigh(approximately76.3%).81Thisresultsinadisproportionateburdenoftobaccorelateddiseaseamongindividualswithsubstanceusedisorders.82Despitethesehighlevelsofsmoking,prevalencehasbeenfallingamongthesepeopleinparalleltotherestofthepopulation(albeitfromahigherbaseline)andquitattemptshavebeenincreasing,suggestingincreasingreceptivenesstosmokingcessationinterventions.83Inaddition,quittingsmokinghaspositiveimpactonsubstanceuseoutcomes,84,85and

79SmithEA,PostonWSC,HaddockCK,MaloneRE.InstallationTobaccoControlProgramsintheU.S.Military.Militarymedicine.2016;181(6):596-601.doi:10.7205/MILMED-D-15-00313. 80JamalA,KingBA,NeffLJ,WhitmillJ,BabbSD,GraffunderCM.CurrentCigaretteSmokingAmongAdults-UnitedStates,2005-2015(2016)Mmwr-MorbidityandMortalityWeeklyReport65:1205-1211.81GuydishJ,PassalacquaE,TajimaB,ChanM,ChunJ,BostromA(2011)SmokingPrevalenceinAddictionTreatment:AReview.Nicotine&TobaccoResearch13:401-411.82BandieraFC,AntenehB,LeT,DelucchiK,GuydishJ(2015).Tobacco-relatedmortalityamongpersonswithmentalhealthandsubstanceabuseproblems.PLoSOne10.83KulikMC,GlantzSA.SofteningAmongU.S.SmokersWithPsychologicalDistress:MoreQuitAttemptsandLowerConsumptionasSmokingDrops.AmJPrevMed.2017Dec;53(6):810-817.doi:10.1016/j.amepre.2017.08.004.Epub2017Oct10.84McKelveyK,ThrulJ,RamoD(2017)Impactofquittingsmokingandsmokingcessationtreatmentonsubstanceuseoutcomes:Anupdatedandnarrativereview.AddictBehav65:161-170.85ThurgoodSL,McNeillA,Clark-CarterD,BroseLS(2016)ASystematicReviewofSmokingCessationInterventionsforAdultsinSubstanceAbuseTreatmentorRecovery.NicotineTobRes18:993-1001.

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noimpactonrelapseamongpatientswhosmoke.86TheCDCshouldpromoteaggressivesmokingcessationinterventionsbyfacilitiestreatingthesepatients.Tobacco-freegroundspolicies(restrictinguseofanytobaccouseonprogramproperty)areeffectiveinreducingclientsmoking.RecentworkbyDr.JosephGuydishandcolleagues,notyetpublished,foundasignificantdecreaseinclientsmokingbehaviorsafterimplementationoftobacco-freegroundsin3residentialaddictiontreatmentprograms.87Thisincludedareductioninsmokingprevalence,areductioninnumberofcigarettessmokedperday,increasedtimetofirstcigaretteandanincreaseintheproportionofclientswhoreducedsmokingduetoprogramrequirements.Similarly,otherstudieshavefoundthatimplementationofatobaccofreegroundspolicyatsubstanceusetreatmentprograms(includingstatewidepoliciesinNewYorkandNewJersey)resultedinreducedclientsmoking.88,89,90,91Contrarytothebeliefthatclientenrollmentwilldecreaseiftobaccouseisrestrictedbytobacco-freegrounds,twostudieshavereportednodropincensusfollowingsuchpolicies.92,93

Tobaccofreegroundspolicieshavebeenwidelyimplementedinotherhealthcaresettings,includingprimarycareclinics,hospitals,andpsychiatricfacilities.WerecommendthattheCDCsupportimplementationoftobacco-freegroundspoliciesinsubstanceusetreatmentprogramsandtreatmentsystems.TheCDCshouldworkwithstateagenciesconcernedwithregulationandlicensingofaddictiontreatmentprogramstoimplementtobacco-freegroundsasawaytoreducetobacco-relatedhealthrisksforbothprogramstaffandclients.

86WeinbergerAH,PlattJ,EsanH,GaleaS,ErlichD,GoodwinRD(2017)CigaretteSmokingIsAssociatedWithIncreasedRiskofSubstanceUseDisorderRelapse:ANationallyRepresentative,ProspectiveLongitudinalInvestigation.JClinPsychiatry78:e152-e160.87GubnerNR,WilliamsDD,LeT,GuydishJ(Manuscriptinpreparation)ExploringSmokingRelatedOutcomesBeforeandAftertheImplementationofaTobaccoFreeGroundsPolicyinResidentialAddictionTreatmentPrograms.88GuydishJ,YipD,LeT,GubnerNR,DelucchiK,RomanP(2017)Smoking-relatedoutcomesandassociationswithtobacco-freepolicyinaddictiontreatment,2015-2016.DrugAlcoholDepend179:355-36189GuydishJ,TajimaB,KulagaA,ZavalaR,BrownLS,BostromA,ZiedonisD,ChanM(2012)TheNewYorkpolicyonsmokinginaddictiontreatment:findingsafter1year.AmJPublicHealth102:e17-25.90RicheyR,Garver-ApgarC,MartinL,MorrisC,MorrisC(2017)Tobacco-FreePolicyOutcomesforanInpatientSubstanceAbuseTreatmentCenter.HealthPromotPract18:554-560.91WilliamsJM,FouldsJ,DwyerM,Order-ConnorsB,SpringerM,GaddeP,ZiedonisDM(2005)Theintegrationoftobaccodependencetreatmentandtobacco-freestandardsintoresidentialaddictionstreatmentinNewJersey.JSubstAbuseTreat28:331-340.92RicheyR,Garver-ApgarC,MartinL,MorrisC,MorrisC(2017)Tobacco-FreePolicyOutcomesforanInpatientSubstanceAbuseTreatmentCenter.HealthPromotPract18:554-560.93WilliamsJM,FouldsJ,DwyerM,Order-ConnorsB,SpringerM,GaddeP,ZiedonisDM(2005)Theintegrationoftobaccodependencetreatmentandtobacco-freestandardsintoresidentialaddictionstreatmentinNewJersey.JSubstAbuseTreat28:331-340.

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(6)HOWCANCDCSUPPORTSTATEANDLOCALHEALTHDEPARTMENTS,TRADITIONALHEALTHCAREPROVIDERS,NOTFORPROFITHEALTHINSTITUTIONS,ANDPROFESSIONALHEALTHCAREPARTNERORGANIZATIONSTOENSURETHATEVIDENCE-BASEDTOBACCOCESSATIONINTERVENTIONSAREINTEGRATEDINTOPRIMARYANDBEHAVIORALHEALTHCARESETTINGSONACONSISTENTANDSUSTAINABLEBASIS?

CDCshouldsupporttheimplementationofhomehealthportalsand/orpoint-of-caretechnologicaltoolslikecomputertabletstoofferimportantopportunitiesfordeliveringscreeningandbriefinterventionsfortobaccoandotherbehavioralhealthchallenges.CDCshouldemphasizetheimportanceofscreeningandinterventionofe-cigaretteandothernewtobaccoproductuse.Importantly,CDCshouldemphasizetheimportanceofpubliceducationaboutthedangerofe-cigaretteusespecificallyindeterringsuccessinquitattempts.

DigitalizescreeningandreferralservicesaspartofEHRareexamplesofpathwaysforintegratingtobaccocessationinterventionsintoprimaryandbehavioralhealthcaresettingsinaconsistentandsustainablebasis.LinkagestoEHR’smustbeincorporatedalongwithcarefulattentiontoexistingclinicflows.Linkagestobillinganddocumentationwouldimproveacceptanceofthetechnologyandraisethevalueadded.Thesetoolsshouldberecommendedforproviders,patients,andevenlearnersinhealthprofessionseducation.94,95,96CDCshouldmountequationalcampaignstocounterclaimsthate-cigarettesareaneffectivesmokingcessationintervention.97Whilesomepeopledosuccessfullyquitsmokingwithe-cigarettes,probablydailyusersofhighdeliverysystems,thesepeopleareasmallminorityofe-cigaretteusers(around10-20%).Formostsmokers,includingyouth,usinge-cigarettesisassociatedwithlargeandstatisticallysignificantreductionsinquitting.Asaresult,theoverallpopulationeffectisthat,combiningthesetwocompetingeffects,smokerswhousee-cigarettesareless,notmore,likelytoquitsmoking(Figure1).

94KalkhoranS.,AppelleN.A.,NapolesA.M.,MunozR.F.,LumP.J.,AlvaradoN.,GregorichS.E.,SatterfieldJ.M.(2016).BeyondtheAskandAdvise:ImplementationofaComputerTabletInterventiontoEnhanceProviderAdherencetothe5AsforSmokingCessation.JSubstAbuseTreat,60:91-100.PubMedPMID26150093;PubMedCentralPMCID:PMC4670822.95NapolesAM,ApelleN,KalkhoranS,VijayaraghavanM,AlvaradoN,SatterfieldJM.(2016).Perceptionsofcliniciansandstaffregardingtheuseofdigitaltechnologyinprimarycare:qualitativeinterviewspriortoimplementationofacomputer-facilitated5Asintervention.BMCMedicalInformaticsandDecisionMaking,16:44-57.96SatreDD,LyK,WamsleyM,CurtisA,SatterfieldJ.(2017).ADigitalTooltoPromoteAlcoholandDrugUseScreening,BriefIntervention,andReferraltoTreatmentSkillTranslation:AMobileAppDevelopmentandRandomizedControlledTrialProtocol.JMIRResProtoc.6(4):e55.PMID:28420604.97KalkhoranS,GlantzSA.E-cigarettesandsmokingcessationinreal-worldandclinicalsettings:asystematicreviewandmeta-analysis.LancetRespirMed.2016Feb;4(2):116-28.doi:10.1016/S2213-2600(15)00521-4.Epub2016Jan14.LeeS,GranaRA,GlantzSA.ElectroniccigaretteuseamongKoreanadolescents:across-sectionalstudyofmarketpenetration,dualuse,andrelationshiptoquitattemptsandformersmoking.JAdolescHealth.2014Jun;54(6):684-90.doi:10.1016/j.jadohealth.2013.11.003.Epub2013Nov22.GlantzSA,BarehamD.E-cigarettes:Use,EffectsonSmoking,Risks,andPolicyImplications.AnnRevPubHealth2018(inpress).

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Figure1.Meta-analysisofrelationshipbetweene-cigaretteuseandsmokingcessation.Whileafewstudiesshowincreasedcessation(generallyinheavyusersofhighdeliverysystems),theoveralleffectinthepopulationisreducedcessation.98CDCshouldalsocontinuetowarnthepublicaboutthedangersofdualuseofe-cigarettesandcigarettes–themostcommonpatternofe-cigaretteuse--asithasstartedtodoinitsTIPScampaign,sincethereisemergingevidencethatdualuseisworsethansmokingalone.99

98GlantzSA,BarehamD.E-cigarettes:Use,EffectsonSmoking,Risks,andPolicyImplications.AnnRevPubHealth2018(inpress).

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(7)HOWCANTHEPUBLICHEALTHSECTORMOSTEFFECTIVELYMAXIMIZETHEIMPACTOFPUBLICANDPRIVATEINSURANCECOVERAGEOFCESSATIONTREATMENTSASPARTOFEFFORTSTOENSURETHATALLTOBACCOUSERSHAVEBARRIER-FREEACCESSTOTHESETREATMENTS?

TheCDCshouldstronglyadvocatepatient-centeredinsurancecoverageofcessationtreatmentsandencouragehealthcaresystemstoincludeprovisionofsmokingcessationaspartoftheirmandatoryriskmanagementefforts.

The2017CochraneReview100assessedtheimpactsofhealthcarefinancinginterventionsonpromotingsmokingcessationandconcludedthatpatient-centeredfinancialinterventionthatprovidesfullinsurancecoveragewaseffectiveinincreasingsmokingabstinencepost6-month,aswellasinincreasingquitattemptsandutilizationofevidence-basedsmokingcessationtreatment.Ontheotherhand,providerorsystemfocusedfinancialinterventions(suchasfinancialincentivesforperformanceordirectpaymenttoproviders)didnotincreaseanyoftheprimaryorsecondarysmokingcessationoutcomes.Provider-focusedinterventionsincreasedreferral/utilizationofbehavioralcounselingbutnototheroutcomes.

CDCshouldencouragehospitalsandhealthcaresystemstointegratemandatedsmokingcessationeffortsaspartoftheirriskmanagementplans.101Theimportantfactorsinevaluatingtheroleofclinicalpracticeguidelinesinmedicalmalpracticelitigationhavebeendiscussed,buthavefocusedonbroadpolicyimplicationsratherthanonaconcreteexampleofhowanactualguidelinemightbeevaluated.Therearefouritemsthatneedtobeconsideredinnegligencetorts:legalduty,abreachofthatduty,causalrelationshipbetweenbreachandinjury,anddamages.TheClinicalPracticeGuidelinesforTreatingTobaccoUseandDependence,102recommendseffectiveandinexpensivetreatmentsfornicotineaddiction,thelargestpreventablecauseofdeathintheUS,andcanbeusedasanexampletofocusonimportantconsiderationsabouttheappropriatenessofpracticeguidelinesinthejudicialsystem.Furthermore,thefailureofmanydoctorsandhospitalstodealwithtobaccouseanddependenceraisesthequestionofwhetherthisfailurecouldbeconsideredmalpractice,giventhePublicHealthServiceguideline'sstraightforwardrecommendations,theirefficacyinpreventingseriousdiseaseandcost-effectiveness.Althougheachcaseofmedicalmalpracticedependsonamultitudeof

99YaoT,MaxW,SungHY,GlantzSA,GoldbergRL,WangJB,WangY,LightwoodJ,CataldoJ.Relationshipbetweenspendingonelectroniccigarettes,30-dayuse,anddiseasesymptomsamongcurrentadultcigarettesmokersintheU.S.PLoSOne.2017Nov7;12(11):e0187399.doi:10.1371/journal.pone.0187399.eCollection2017.100vandenBrandFA,NagelhoutGE,RedaAA,WinkensB,EversSMAA,KotzD,vanSchayckOCP.Healthcarefinancingsystemsforincreasingtheuseoftobaccodependencetreatment.CochraneDatabaseofSystematicReviews2017,Issue9.Art.No.:CD004305.DOI:10.1002/14651858.CD004305.pub5.101TorrijosRM1,GlantzSA.TheUSPublicHealthService"treatingtobaccouseanddependenceclinicalpracticeguidelines"asalegalstandardofcare.TobControl.2006Dec;15(6):447-51.102USPublicHealthService.Treatingtobaccouseanddependence:2008update.Clinicalpracticeguideline.Rockville,MD:USDepartmentofHealthandHumanServices,USPublicHealthService;2008.https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/treating_tobacco_use08.pdf

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factorsuniquetoindividualcases,acourtcouldhavesufficientbasistofindthatthefailuretoadequatelytreatthemaincauseofpreventablediseaseanddeathintheUSqualifiesasaviolationofthelegaldutythatdoctorsandhospitalsowetopatientshabituatedtotobaccouseanddependence.TheCDCshouldencouragehealthcaresystemstotakenoteofthisriskandincludeprovisionofsmokingcessationaspartoftheirmandatoryriskmanagementefforts.

WeapplaudCDC’seffortsinplanningandinvestingeffortstoensurealltobaccousershavereadyaccesstoevidence-basedtreatmentoptions.CDCshouldstronglyencouragehealthcaresystemstoincludeprovisionofsmokingcessationaspartoftheirmandatoryriskmanagementeffortsandadvocateinsurancecoverageforcessationtreatment.Importantly,provisionofNRTalonewithoutcounselingsupportshouldbediscouraged.Whileworkingtopromotebetterprovisionofcessationsupportasdescribedabove,itisimportanttokeepinmindthatmostpeoplestillquitontheirown;theCDCshouldcontinuetopromoteandsupportallquitattemptsacrossallhealthcare,institutional,socialservice,andcommunitysettings.CDCshouldalsocontinuetowarnthepublicaboutthedangersofe-cigarettes,specificallyindeterringquitattempts.Socialmediainterventions,clinician-extenderorpoint-of-caretechnologytools,interactivevoiceresponsesystemsandpatient-centeredinsurancecoverageforcessationareevidence-basedstrategiestoconnecttobaccouserstocessationtreatmenttosupportbothinitiationofquitattemptsandmaintaininglong-termabstinencethatCDCshouldpromote.