Commentary Title: Recommendations for linking client data with clinic services to improve our ability to make inferences

Abstract

Concise statement: Skinner et al’s proposed minimum dataset for global stop-smoking services is an essential tool for improving tobacco dependence treatment. We suggest insertion of additional items on treatment cost and cessation aids, including e-cigarettes, as well as items linking program- and individual-level to allow for stronger inferences about the effectiveness of specific services and cessation aids.

Skinner et al’s proposed minimum dataset for global stop-smoking services is an essential resource if our field is to improve the delivery and effectiveness of tobacco dependence treatment in the future. Below, we suggest adapting and inserting items to better link the proposed minimum dataset on program-level services with individual-level data to allow for stronger inferences about the effectiveness of specific services, cessation aids, and nicotine products often used as cessation aids (e.g., e-cigarettes).

Table 1’s Treatment Information items collect detailed information on the service setting and treatments offered, with a focus on behavioural treatment. While two items solicit information on advice about stop smoking medication, the minimum dataset does not address one key question: does the service provide pharmacological and/or nicotine replacement therapy directly, and if so, at what cost? Access to free cessation medication has been shown to increase cessation in empirical and simulation studies.(1–3) In settings like the U.S. where cessation treatment coverage may differ by health insurance provider or lack of health insurance, collecting information on the provision of free or subsidized cessation medications will improve our understanding of the relative effectiveness of different programs.

An additional way to facilitate studies of program effectiveness is to improve linkages between program-level data on services provided and client-level data on services used. This could be accomplished through the addition of items in the Core Client Data (Table 2) that link to Treatment Mode options (Table 1) for the specified program, in addition to the pharmacological and NRT support items already asked at the client level.

In Table 2 (Core Client Data), we note that the set of core client items includes a question assessing planned use of pharmacological supports, including a “nicotine vaporizing device.” We assume this is meant to assess e-cigarette/ENDS use. ENDS are a diverse class of devices with varied behavioural effects. (4, 5) Like the “NRT support used” item, we recommend inclusion of an item (“Nicotine vaporizing device used”), as we know that device type is associated with nicotine delivery and smoking cessation success. (4, 6) As recommended in a previous publication on core measures assessing ENDS use (7), we recommend assessing ENDS device type with the following question: “What e-cigarette or vaping device do you plan to use? (a) A disposable e-cigarette or vaping device. (b) An e-cigarette or vaping device that uses replaceable prefilled cartridges. (c) An e-cigarette or vaping device with a tank that you refill with liquids, (d) A modular system that you refill with liquids (you use your own combination of separate devices: batteries, atomisers etc) (e) Don’t know.” We note that the types of products available is always evolving, and these response categories may need to be adapted depending on the products available in the study setting. Indeed, as heat-not-burn and other emerging modified risk tobacco products are introduced, smokers may turn to these products to quit smoking. Though they are not conventional cessation aids, their planned use and follow-up data on their effectiveness will inform treatment guidelines and public health policy making.

We have previously highlighted the limited utility of assessing all previous cessation aids rather than the most recently used aid, and the shortcomings neglecting to assess the frequency and intensity of use of smoking cessation aids, including unconventional aids such as ENDS. (8, 9) In Table 3, (“Extended Client Data”), interviewers are instructed to ask about the amount of time since the last quit attempt and how long that most recent quit attempt lasted. However, they are instructed to ask about lifetime use of smoking cessation aids, rather than the aid used during the most recent quit attempt. While lifetime use is useful for a patient chart, it is not useful when trying to understand the relationship between amount of time quit and cessation aids. (9) At minimum, it is essential to ask for how long (number of days) the client used the most recent cessation aid. While we have previously highlighted the importance of intensity data (i.e., number of pieces of NRT gum consumed in a day), we recognize that this construct is difficult to measure with even one product. In this case, each aid would need measurement on a different scale, a task that may be incompatible with a minimum data set.

We applaud the authors for proposing novel sets of core measures for cessation services. These types of shared resources – in all areas of tobacco research – are essential to facilitating comparisons locally, nationally, and internationally.