Increasing Tobacco Use Cessation

Research Gaps

What are Research Gaps?

Prior to and during the literature review and data analysis, the review team and the Community Preventive Services Task Force attempt to address the key questions of what interventions work, for whom, under what conditions, and at what cost. Lack of sufficient information often leaves one or more of these questions unanswered. The Community Guide refers to these as "research gaps." Research gaps can be pulled together in the form of a basic set of questions to inform a research agenda for those in the field.

Identified Research Gaps

Effectiveness

The effectiveness of increasing the unit price for tobacco products and mass media campaigns (when implemented with other interventions) is established. However, research issues regarding the effectiveness of these interventions remain.

• What intervention components contribute most to effectiveness of multicomponent interventions? What components contribute the least?
• What are the minimum and optimal requirements for the duration and intensity of mass media campaigns?
• What are the most effective combinations of messages for mass media campaigns?
• Do tobacco users respond differently to changes in product price that result from excise tax increases than to industry-induced increases?
• How long do the effects of a single excise tax increase last? Because the effectiveness of mass media cessation series and smoking cessation contests has not been established, basic research questions remain.
• Are these interventions effective in increasing tobacco use cessation in the population?
• Do recruited tobacco users exposed to these interventions quit at a greater rate than recruited tobacco users not exposed to these interventions?
• What are the rates of participation in these interventions?

Applicability

The effectiveness of increasing the unit price and of mass media campaigns in reducing tobacco use in the population is established. However, identifying differences in the effectiveness of each intervention for specific subgroups of the population remains important.

• Do significant differences exist regarding the effectiveness of these interventions, based on the level of scale (i.e., national, state, local) at which they are delivered?
• What are the effects of mass media campaigns among populations that differ by race and ethnicity?

Other Positive or Negative Effects

Several potential negative effects of tobacco product price increases were reviewed in this evaluation. Although further research on the potential negative effects is warranted, evaluating the effect of potential positive effects of reductions in tobacco use should also be investigated to provide a complete picture of the effects of increases in state and federal excise taxes.

• What are the effects of these interventions on reducing smoking-related fires? What are the effects on ETS exposure?
• What proportion of smokers substitute tobacco products, modify their smoking habits, or both in response to an increase in the price of tobacco products? How much of the potential health benefit of a price increase is reduced by these behaviors? How can these potential problems be reduced?
• Do mass media campaigns that focus on tobacco have additional effects on other drug use?

Economic Evaluations

The available economic information on mass media campaigns was limited. Considerable research is, therefore, warranted regarding the following questions:

• What are the costs of mass media campaigns, especially campaigns that achieve an effective intensity over an extended duration?
• How do the costs per additional quitter compare with other interventions intended to reduce tobacco use?
• What is the cost-benefit, cost-utility, or cost per illness averted of these interventions?

Barriers

Implementation of these interventions requires political action and support. Research issues generated in this review include the following:

• What components of successful legislative and referendum campaigns are most effective? What components are least effective?
• What information is most important in gaining public support for these interventions? In gaining legislative support?
• What are the most effective ways to maintain adequate funding levels for mass media campaigns?

Research Issues for Increasing Tobacco Use Cessation: Health Care System-Level Strategies

Effectiveness

The effectiveness of recommended and strongly recommended interventions in this section (i.e., multicomponent provider reminder plus provider education with or without patient education materials; provider reminder systems alone; multicomponent interventions that include telephone cessation support; and reduction of patient out-of-pocket costs for cessation) is established. However, research issues regarding the effectiveness of these interventions remain.

• Which characteristics of provider-based interventions contribute to increased or decreased effectiveness?
• What are the least and most effective combinations of services in multicomponent interventions?
• What is the effect of provider reminder systems on patient tobacco use cessation when implemented alone?
• What is the relative effectiveness of provider reminders that focus on determination of patient tobacco use status versus reminders that prompt for delivery of advice to quit?
• How do content and method of delivery of provider reminders relate to effectiveness?
• Can reducing patient costs for effective cessation services increase the effectiveness of provider-based interventions?
• What is the most effective level of implementation for telephone cessation support services?
• Is the use and effectiveness of telephone cessation support increased when community and clinical cessation support programs are coordinated? Because the effectiveness of two interventions (provider education when used alone and provider feedback systems) has not been established, basic research questions remain. This is especially true for provider assessment and feedback systems for which the number of available studies was small.
• What are the effects of provider assessment and feedback interventions on provider delivery of advice to quit to tobacco-using patients? On patient tobacco use cessation?
• What is the effectiveness of HEDIS, as a form of assessment, feedback, and benchmarking, in improving patient receipt of advice to quit and patient tobacco use cessation? Does effectiveness vary by practice setting?
• What frequency, duration, and format of provider education efforts are required to obtain consistent improvements in provider performance and patient response?

Applicability

Each recommended and strongly recommended provider-based intervention should be applicable in most relevant target populations and settings. However, possible differences in the effectiveness of each intervention for specific subgroups of patient and provider populations could not be determined. Several questions regarding the applicability of these interventions in settings and populations other than those studied remain.

• Do provider-based interventions differ in effectiveness in different patient populations?
• Are provider-based interventions effective in increasing cessation or in reducing initiation in adolescent populations?
• Do significant differences exist regarding the effectiveness of these interventions, based on the level of scale at which they are delivered?

Other Positive or Negative Effects

With the exception of the use of provider reminder systems to prompt action on other preventive services, studies in this review did not report on other positive and negative effects of these interventions. Research on the following questions would be useful:

• Do provider-based interventions for tobacco use cessation interfere with office flow or efficiency? If so, how can this effect be minimized?
• Do provider-based interventions increase or decrease the delivery of other preventive services?

Economic Evaluation

Available economic information was limited in this section. Considerable research is warranted regarding the following questions:

• What are the costs for provider-based interventions?
• What are the costs for patient-based interventions?
• How do the costs per additional quitter compare with other interventions intended to reduce tobacco use?
• What is the cost-benefit, cost-utility, or the cost per illness averted of these interventions?
• What is the cost-effectiveness for provider interventions that target tobacco alone compared with provider interventions that target multiple preventive services?

Barriers

Research questions regarding the potential barriers identified for the interventions evaluated in this section include the following:

• How can provider-based interventions that place minimal administrative burden on providers or systems be implemented?
• What information is needed to overcome potential barriers to the implementation of provider assessment and feedback interventions?
• What information is needed to overcome potential barriers to reducing patient out-of-pocket costs for effective cessation therapies?
• What is the effect on use of combining effective pharmacologic therapies and behavioral programs as a criterion for reimbursement? What is the effect on use and effectiveness if these cessation options are provided independently?