Book Review
The Tobacco Dependence Treatment Handbook: A guide to best practices, by David Abrams, Ray Niaura, Rick Brown, Karen Emmons, Michael Goldstein, & Peter Monti
Reviewed by Theodore W. Marcy, MD, MPH
David Abrams, Ray Niaura, Rick Brown, Karen Emmons, Michael Goldstein, & Peter Monti. (2003). The tobacco dependence treatment handbook: A guide to best practices. New York: Guilford. 359 pages.
Evidence-based methods to improve the low spontaneous quit rates of smokers do exist. The U.S. Public Health Service, the Cochrane Reviews, and the American Psychiatric Association document the success of these methods in their systematic reviews and practice guidelines. Where we fail is making certain these methods are actually used. For example, among 259 smokers whose visit with their primary care physician was directly observed, 66% were asked about their smoking and advised to quit. Among those smokers ready to quit, only 37% received any assistance from their physician (Ellerbeck et al., Preventive Medicine 2003). The standard of quality for both of these processes of care should be close to 100%. Clearly, a primary task of the tobacco control community is to put the lessons from research into widespread practice. Guidelines describe where we want to go, but not necessarily how to get there.
The Tobacco Dependence Treatment Handbook: a Guide to Best Practices is, instead, a road map, but with scientific rigor. All nine authors have experience in both the research and the clinical use of these cessation techniques. Six are colleagues at Brown Medical School, where the Center for Behavioral & Preventive Medicine is located. The text is extensively referenced, and frequently refers to USPHS and American Psychiatric guidelines. The authors first provide a conceptual overview of the treatment of tobacco dependence. Next, they examine the nuts and bolts of a variety of the components of cessation interventions: assessment, increasing motivation, brief and intensive behavioral treatment, working with those with comorbidities including depression and other substance abuse, and pharmacotherapy. One chapter is devoted to the systems changes needed to put these methods into effect in the workplace and the primary care clinic. Realistic clinical vignettes provide additional insights into taking these techniques into the real world. The last chapter reviews gaps in our knowledge, and ongoing research to fill these gaps, though this is heavily weighted towards work at Brown. The authors discuss (and reproduce in the appendices) 36 assessment instruments, worksheets, and handouts. The publisher’s copyright allows individual who purchase the book to copy these for use with clients and patients.
Despite the high quality, certain audiences should be selective in their reading of this book. The second chapter on assessment may overwhelm a physician (such as myself) reading the book cover to cover. Here, even the basic assessment requires 10 different instruments estimated to take 15 minutes of a patient’s time to complete and only (?) 2 minutes of a physician’s time to review. The busy primary care physician–a prime target of our efforts to expand the guidelines’ use—may despair at yet more paperwork and close the book (and their minds) for good.
This emphasis on assessment is odd as it conflicts with the judgment expressed in the USPHS guidelines that use of specialized assessments is not yet supported by the evidence and should not be a prerequisite for tobacco users to receive an intervention. Even the authors acknowledge this in other sections of the book. On the other hand, the chapters on assessment and intensive behavioral interventions may be of interest to those planning or reviewing their own intensive interventions at mental health clinics, smoking cessation clinics, telephone quit lines, or those primary care clinics able to mount such an effort.
Chapters 3 (increasing motivation), 4 (brief interventions), 7 (pharmacotherapy), and 8 (the section on system factors in primary care offices) should be mandatory reading for all providers of primary care and for medical students. Perhaps a future edition might list the important chapters for each of the major audiences. The chapter on pharmacotherapy, while excellent in its discussion and its use of case examples, would have benefited from an additional table or tables that outlined the adverse effects, cautions and contraindications, and dosage regimens of the approved medications for easy reference. Not surprisingly, given the lag from writing to publication, the authors do not discuss the use of nicotine lozenges in any detail.
Regardless of its quality and breadth, this book is a necessary, but not sufficient, reference for anyone doing even brief tobacco dependence counseling. Each provider must learn of the resources in his or her own local area: local cessation groups, state Quit Lines, subsidized pharmacotherapy programs, and community programs. This information is fluid and can be hard to find. Nonetheless, connecting a smoker to such programs can turn the physician’s brief intervention into an intensive one provided with the help of others. I welcome the addition of this volume, have already incorporated some of its lessons into my practice, and will be recommending a number of its chapters to my colleagues.
-- Dr. Marcy is Associate Professor of Medicine at the University of Vermont College of Medicine