The Future of Tobacco Treatment in the Health Care System

We face a conundrum in our efforts to treat tobacco use and dependence, the leading preventable cause of death in the United States (1). Most smokers know they should quit, 70% say they want to quit, and 40% report having tried to do so in the past year (2, 3). Yet the large majority of these quit attempts failed to produce long-term tobacco abstinence, despite the availability of effective treatments. The reason? Most smokers trying to quit do not use these treatments (4).

We could improve the impact of tobacco treatment at the population level by delivering the message to more smokers who try to quit and by identifying ways to maximize the effectiveness of current treatments. In this issue, 2 articles aim to do this by focusing on improving the reach of treatment (5) and testing a strategy to improve the effectiveness of existing treatments (6). Each article describes a cutting-edge strategy that health care providers and health care systems could use to reduce the enormous health and economic burden of tobacco use.

Although no tobacco treatment is a “magic bullet,” the evidence base now includes several treatments that increase the odds of achieving long-term cessation (7). Having several treatments with different mechanisms of action presents an opportunity to improve treatment efficacy by combining treatments. The 2008 update of the U.S. Public Health Service (USPHS) Clinical Practice Guideline strongly encouraged combinations of different treatments (7). Meta-analyses in this guideline summarized a body of evidence that long-term quit rates could be improved by adding behavioral counseling to pharmacotherapy (and vice versa) and combining individual pharmacotherapies.

However, few studies have directly compared combined treatment with monotherapy. Steinberg and coworkers (6) report such a …