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CDC Telebriefing: Quitting Smoking Among Adults - United States, 2001-2010 November 10, 2011, Noon E.T.

Tuesday, November 10, 2011 – 12:45pm ET

Operator: Welcome back and thank you for attending. During the question and answer session today, you may press star one to ask a question. Today′s conference is being recorded. You may begin. 

Llelwyn Grant: Good afternoon.  Thank you all for joining us for today's media telebriefing on an article titled “Quitting Smoking Among Adults– United States, 2001 to 2010”, published in this week′s Morbidity and Mortality Weekly Report.  My name is Llelwyn Grant. I'm the acting branch chief for CDC's News Media Branch.  Dr. Tim McAfee who is the director of the Office of Smoking and Health will make some brief remarks about the study and then we'll open it up for questions. Joining Dr. McAfee during the question and answer session, will be Ann Malarcher. Dr. Malarcher is senior scientific adviser for the director of the Office of Smoking and Health and is also the lead author for the report.  I would like to turn it to Dr. McAfee.

Tim McAfee: Thank you for your interest in the topic.  This study is being released today, a week ahead of the Great American Smokeout and just to give a little plug, the American Smokeout is an annual event sponsored by the American Cancer Society, and encourages smokers to quit for at least one day and then to go on and stop permanently. This year's great American Smokeout will be held on Thursday, November 17th.  So currently, just under 20 % of adults in the United States smoke. And what this study looked at was how smokers are thinking about quitting, what kind of actions they're taking around quitting, what kind of success they're experiencing and how they are interacting with their health care providers and the use of medications and counseling which have shown to be effective.  And what we found – and this was with the done with the National Health Interview Survey, a household survey that was done with about 27,000 U.S. Americans.  And what the study found was that about 68.8 % more than two thirds of current adult smokers say they want to completely stop smoking.  And within the 25 to 64–year old range, this is actually an increase in quit attempts, which are at the level of about 52.4 % for all current adult smokers. And a quit attempt for this study means someone quits successfully for at least one day or more, this is not somebody with an idle thought, “I think I′ll quit for a few hours”, they had to actually abstain from cigarettes for at least a day.  This study also found that about 6 % of smokers successfully quit within the past year. 

Now, there was a quite a bit of variation from different subgroups that we looked at for all of these elements. However, one of the most exciting findings from our perspective, was that, if you looked at all of the different subgroups that we looked at, which ranged from age, sex, race/ethnicity, social economic status, for all of these different groups, at least more than half of the smokers were interested in quitting completely.  Other things that we found were that, about 1 in 3 smokers who tried to quit used counseling and/or medication when they made their attempt.  And this means there is significant room for improvement in this arena, because these –– use of these treatments can double or triple success rates.  We also found that a little less than half of smokers, who saw a health professional in the past year, recalled getting advice to quit.  Advice from health professionals can be of assistance in increasing the chances that someone will make a quit attempt as well as be successful. This is also an area that we– health care providers can increase their patient's chances by –– by identifying tobacco use and giving free cessation advice and healthcare administrators and insurers of purchases can increase successful cessation by providing comprehensive coverage of these treatments without deductibles or copays. 

There were a couple of other specific areas of interest within sub populations that I′ll manage and then I′ll see if Dr. Malarcher has anything to add and we′ll open it up for questions. Of particular interest to the fact, that there were marked differences in recent successful cessations based on the level of education of responders to the survey– ranging from 3.2 % for people who have less than a high school graduate education, versus a 11.4 % for those who completed a college degree.  Another very important finding is that somewhat paradoxically, non–Hispanic blacks had the highest interest of any group in quitting and the highest quit attempt rate of any group in quitting but had the lowest rate of recent successful quitting, 3.3 %.  And we also found they were less likely to use counseling or medication with 36 % of whites versus 21.6 % of blacks using counseling or medication. And, this is –– this is a group that is also three times more likely to use menthol cigarettes, which the Tobacco Product Scientific Advisory Committee and FDA has found menthol decreases the likelihood of successful quitting.  So these two factors may have contributed to this lower successful cessation rates. There were also variations with health professional advice.  The health professional advice was almost twice as high for those over 65 with a rate of 57 % versus those who are 18 to 24, which had a rate of 31 %.  We did again see one of the most encouraging pieces of news in this was that for those 25 to 64 year olds over the past ten years we have seen an increase in annual quit attempts.  So with that I'm going to see if Dr. Malarcher has anything to add. 

Ann Malarcher: Thanks, Tim. I had one clarification, when we looked at whether smokers made a quit attempt in the past year, it was for greater than one day. So they reported if they quit for more than one day in the past year.  Thanks. 

Llelwyn Grant: Okay, Shirley, I believe we're now ready to take some questions. 

Operator:  Thank you. We're ready to begin the question and answer session.  If you would like to ask a question, please press star 1 to ask a question.  One moment for our first question. Thank you. Our first question comes from Mike Stobbe from the Associated Press.

Mike Stobbe: Hi, thanks for taking my question, I was interested in the statistic that less than half of smokers, 48 % who saw a health professional in the past year reported receiving advice to quit.  Can you compare that to earlier years? Is there a trend?  Are they getting counseled to quit less than often than they used to or more often? 

Tim McAfee: Well, that is a very good question. And unfortunately, I′ll give you –– the first answer is that the number is lower than numbers that were in prior surveys, we're not sure what to make about this. There was a change in the survey instrument in how the question –– the wording remains the same, but, there was a proceeding question whether a health professional asked a participant about tobacco use, and that question was removed from the 2010 survey. So one possibility– we're not sure whether this is a real trend finding or simply an artifact of a change in the way that the survey questions were administered. 

Ann Malarcher:  I′ll just add that, there are other national data sites –– surveys that examine the –– whether smokers received advice to quit.  They're showing no change over time. So, that's why we're questioning whether this slight decrease is really real or not. Given that the questionnaire did change from 2005 to 2010.

Tim McAfee: Those were in the 50 % to 60 %. 

Mike Stobbe:  Okay, thank you. 

Operator:  Thank you, next question comes from Tom Corwin from the Augusta Chronicle.

Tom Corwin: Thanks for taking my question. That 6 % quit rate, can you compare that to any kind of historic trend, is that better or worse than what we have seen in the past and, if there's any sort of cross correlation between the number of people who are getting counseling or medication to help? 

Ann Malarcher:  Yes. So, we think that really has not changed over time.  I think the issue there is that this –– we typically have not published this measure in the past, it is a new measure for tracking, for the Healthy People 2020 objective and why we added that measure for those objectives was we really wanted to look at recent success, so we hope to move the needle and get more people to quit each year over time. 

Tim McAfee: And again, one of –– so, again, we don't have a very good comparator. But we –– the thing that was most –– the thing that was most striking was the variation between different groups again particularly with education, having threefold difference –– but there were also variations in age, with a lower cessation success rate in those for instance between the ages of 45 and 64. And then we had the markedly lower success rate for black/non–Hispanics. 

Ann Malarcher:  I want to add one thing that we saw a positive trend for people aged 25 to 64, it looks like over the past ten years, they increased their quit attempts. 

Tom Corwin: Any correlation between insurance coverage and those rates? 

Tim McAfee: There are –– there is variation on several of these categories related to insurance rates.  The lowest, not surprising, the lowest rate is for the uninsured. And again, people who are uninsured are both –– of course, there is also overlap with having lower educational status and higher poverty rates.  They're also less likely to see a physician, if they see a physician, they're less likely to be advised and less likely to use –– they're the lowest group for use of medications or for receipt of counseling.  Whereas, for instance, private insurance is quite higher, 7.8 %.  With military insurance being the highest of all, over 9 %. 

Tom Corwin: Thank you. 

Operator:  Thank you, next question comes from Maia Szalavitz with Time magazine.

Maia Szalavitz: Thank you, I have actually two questions, the first is do we know how the people who successfully quit did so? 

Tim McAfee: We have not done a sub analysis, this is really a surveillance report for MMWR. We're intending to do a deeper dive in this data set for –– to look specifically at the people who succeeded. We do know that of those who made a quit attempt, we know that just under a third of them used medication or counseling. 

Maia Szalavitz: But we don't know if they succeeded and we don't know if that affected their success rate in.

Tim McAfee: Exactly.  I would have to add, this area is often I think misunderstood not just by the media or the public but also by people within the tobacco control area. One of the challenges around this is what′s called selection bias. And it is not a random decision as to whether somebody uses counseling or uses medication. So, there is no question from the basis of dozens and dozens if not hundreds of large, very well–conducted clinical, randomized trials with thousands and thousands of people, that use of medication and use of counseling at least within the context of that kind of setting significantly increases the likelihood of quitting. There had been population studies that looked at particular use of over the counter medications and whether you're more or less likely to quit. Some of those –– the number of people in California that used nicotine replacement and compared to other people in California who quit without it, the rates may be equivalent.  The problem is, it may be an unfair –– we don't really know what is going on, because it may be an unfair comparison because people who have a harder time quitting, they may smoke larger numbers of cigarettes, be more addicted, etc. They may be more likely to use the medications or to go into counseling. So, it may be giving them the benefit, but it may bring them up to the level of a more casual smoker will become. We don't know the full answer to that question. 

Maia Szalavitz: Okay, the other question I had, was regarding the use of Chantix which has come under some controversy lately although the data seems that it's more effective than the other medications, I wondered if you had any sort of guidance for people on that? 

Tim McAfee: My short story on that one to me, this is an area that is somewhat controversial and that as you stated, the evidence of effectiveness is very strong for Varenicline. And there are somewhat conflicting results about the likelihood that these neuropsychiatric effects are actually due to Varenicline or due to other factors. Best advice is to talk to your doctor about this.  And have a solid conversation about the pros and cons of it. There have been really two studies recently with quite conflicting results. One, several studies that FDA did that were large, randomized trials didn't find virtually any relationship between hospitalizations for serious mental health problems, but there was a recent study, last week, that simply looked at what the FDA –– reports to adverse events to the FDA and did find a higher rate, of course there was a lot of publicity about Varenicline that was coming out at that time.  It's hard to interpret this.  There are many differences of opinions in the clinical, medical and public health community about this.

Maia Szalavitz: Is it still the case that most people who do quit successfully do so without any help? 

Tim McAfee: Yes.  Yes, it's probably– that a majority of people do it without at least structured organized assistance. They don't sign up for a program or they don't use a medication.  Far more using it now than did 10 or 15 years ago, but it's still a –– you know, somewhere in the range of 20 to 30 % of people who would be using a medication or signing up for counseling.  But many people are getting more brief, you know, that does not include people who got for instance brief counseling from their physician.

Operator: Thank you.  Our next question comes from Steven Reinberg, HealthDay. 

Steven Reinberg: You know, I was wondering, this same 20 % seems to have been basically the same over the past several years, is this a group that's very hard to reach or are we making progress? 

Tim McAfee: I'm sorry.  You're referring to smokers.

Steven Reinberg: The 20 % of smokers, Americans that still smoke.

Tim McAfee: Oh, yeah.  I think we're very –– I think one of the things that this specific study does is, it was actually reassuring to us, because, particularly like five years ago or so, I think there was a lot of concern as we were decreasing the level of the % of smokers in the country, there were concerns that we having hardening, meaning the remaining smokers were less and less making quit attempts and less successful when they did. In fact, what this study shows is quite the opposite. In fact the enthusiasm for smokers for becoming nonsmokers, their actual behavior of making a serious quit attempt is at least the same and in some cases, actually higher than it was ten years ago.  So, this is –– I think –– and the flip side of that is, it means, what we're concerned about, honesty, is that society has been losing its enthusiasm for supporting smokers.  We have seen a degradation in funding from the states over the last three years that's deeply concerning.  Especially considering the increasing amount of money they're bringing in through taxes. 

Steve Reinberg: So, is this 20 % being filled up again by new smokers, is that what's happening?

Tim McAfee: Ultimately that is what is happening.  But to be clear, we're continuing to decrease and we did come out –– we had a couple of MMWRs that looked at this, one a couple of months ago, that showed again there has been a decline over the last five years in the rate of smoking. It's not as fast as the previous five years, but it's still significant. There were 3 million fewer smokers between 2005 and 2003 than there would have. And smokers are actually smoking less.  We're seeing that even amongst smokers that continue to smoke, there are more people who are smoking less than daily. Smokers who smoke daily are smoking fewer cigarettes. Now I think you raised the issue of the replenishment of youth, we think this is incredibly important and perhaps the most dangerous situation that we are in, is that we have seen over the past five years, the flattening of the downward trend for youth in initiation. We're very worried that a number of things have been happening in terms of the tobacco industry marketing techniques that flow over and affect youths, the use of promotional discounting for cigarettes and other tobacco products and the increase exposure in retail outlets and the number of other factors have us very, very concerned that we may need to be more aggressive as a society for protecting our children, for who this is an illegal drug from the marketing and distribution practices. 

Operator:  Thank you.  Next question comes from Dena Bunis, Congressional Quarterly. You may ask your question.

Dena Bunis: Thank you.  I wanted to get back to the issue of insurance coverage of cessation programs and medication. Do you know what the level of coverage is for Medicare and for Medicaid in particularly? Is this something that's a mandatory coverage or is it up to individual states, what is the level of Medicare coverage and Medicaid coverage? 

Tim McAfee: I′ll start a little and Dr. Malarcher can chime in.  Medicaid currently does leave most of this up to the discretion to the states except for the pregnant women, in which there is a mandatory coverage requirement. Leaving it up to the states is actually a new development up until last spring, essentially, they made it very difficult for states to provide any coverage for tobacco treatment services. So it was a major step forward that they have –– that they're allowing states to provide coverage, they're also allowing some administrative matching, federal administrative matching for states, for quit line services. They'll do a 50 % administrative match. We have some incredibly exciting data from an experiment that Massachusetts ran from 2005 to 2007 where they markedly opened up access to all forms of cessation treatments in Massachusetts and they aggressively promoted them both to the general public to people on Medicaid and to hospital and clinic systems as well as individual physicians. And they saw a dramatic decrease over a two–year period in smoking amongst Medicaid recipients, a decrease of 10 absolute %age points.  Which is an incredible population effect and almost unprecedented. 

Dena Bunis: Did the reason that these states got that –– opened up to states to do these programs, anything to do with the Affordable Care Act?  Or was this concluded in some other separate administrative ruling?

Tim McAfee:  I think both factors are relevant.  The Affordable Care Act has provisions within it that require insurers over time to provide insurance coverage. But, most of those do not come into full effect until 2014 or 2015, so Medicaid, a lot of this is, I think, momentum that CMS and Medicaid have, because they have done the math. And I didn't mention this, but in Massachusetts, what they –– they're now in the process of completing a health economics health care utilization study where they found a dramatic decrease shortly after the decline in smoking amongst Medicaid recipients in hospitalizations particularly for cardiovascular diseases but also some respiratory diseases and found they got a three to one return on investment for money that they′d spent for coverage from decreased hospitalization costs within two years. Which is quite remarkable so I think this is something that Medicaid, both because, you know, there are charges to improve the health of people on Medicaid but also because they're trying to do this in cost–conscious manner.  They're trying to more aggressively address tobacco use among Medicaid members.

Ann Malarcher:  I′ll add for Medicare, coverage has been expanded over the past two years, prior to about two years ago, coverage was only for people with a smoking related disease.  And now, coverage of these effective cessation treatments is for all covered –– all people covered by Medicare.  

Tim McAfee:  There are also several other things that are happening shortly that will probably have a significant impact on this. One is that the joint commission which accredits health organizations and programs and hospitals in the U.S., have developed a set of voluntary performance measures for hospitals for assessing and treating tobacco dependence in all hospitalized patients.  These are still voluntary, but it′s one of a small number that they choose from that will affect their accreditation. 

Ann Malarcher: The other thing that I′ll add, coverage is not the only thing that we need to have in place to have people utilize the services. People also need to be aware that these treatments are covered and so there should be promotional aspects to the insurers where they promote this coverage to their clients and make them aware they have this coverage so that they can take advantage of it. 

Operator:  Thank you. Our final question comes from Denise Mann with WebMD.

Denise Mann: Thank you. Looking at this data search, I′ve taken a macro level look at it. It says most people do want to quit.  More than half have tried. Yet, maybe, doctors aren't speaking to them as much as they could or should be. How do you piece this together and how do we bridge these two things and get more people to quit– whether November 17th or beyond? 

Tim McAfee: Well that is the big question that you asked. I think the good news is, we have a whole series of, you know, pretty well–tested, both policy–level interventions, health systems interventions and individual–level approaches, all of which worked. That′s one of the appealing things about trying to do something about smoking and tobacco use. That's the why Centers for Disease Control has made this one of our six winnable battles. Because we think it's possible in a relatively short period of time to have a dramatic impact on the health of the American people. At the highest level, we need to keep moving forward with the policy changes, the changes in our environment that we know make it easier for smokers to do what they want to do which is to quit successfully and these include, extension of comprehensive clean indoor air ordinances from the 25 states that have already passed these to the remaining 25. 

We also need to do more to address the issue of price of cigarettes; the tobacco industry is spending about $7 billion or $8 billion a year trying to undercut the price of tobacco in a systematic way to keep people smoking.  And we also need to do more in terms of the state programs that have been so effective over the last two decades, where you′ve had the aggressive programs like California that have drastically, by continuing year after year, working at the state and community level and by having continuous counter–advertising campaigns in the media and probably one of our biggest concerns that many states have drastically cut back on their efforts, nominally because of the difficult economic times. But sometimes far in excess of other public health programs. Despite incredible gains, we have seen lung cancer has begun to –– you know, we're winning the battle against lung cancer. Clearly with men, this has been going down and even more so for women. These are the most dramatic in states that have had active tobacco control programs. 

And then finally the health care systems and individual health care providers had the opportunity to make an incredible difference, because we know at least 70 % of smokers see a health care provider every year and they have the –– they had the potential both to encourage people to make quit attempts because of the depth of relationship and the respect that they have and also to help people who make a quit attempt to actually be successful by those –– by those simple recommendations that they can give in the clinic environments, throw away your ashtrays, talk to your family and friends. Think about what happened the last time you quit. Try to avoid trigger situations. Make referrals to people to other cessation resources.  Locally, they can actually refer people to 1–800–QUIT–NOW, a quit line service that operates through all 50 states.  And then they also can provide support and information about medications that can help. Then finally, tobacco users themselves and their family and friends and co–workers can help by –– we can help by supporting them at the individual level and smokers themselves have the opportunity, bottom line is, keep on trying to quit until they're successful.

Denise Mann: One follow–up question, is it possible if you don't tell your doctor that you smoke, you know it's bad and unhealthy. Do you think they're not telling the doctor in which case the doctor is not going to tell them to quit if they're not aware that they smoke.

Tim McAfee: There is not a lot of evidence that people literally lie to their doctors about their smoking status. The only exception to that is, there's a little bit more to that with pregnant women, potentially where there's monetary damage that somebody might get in terms of insurance coverage or something, other than those specific situations, generally studies that have been done, basically did bio chemical validation have found that, the large majority of people are in fact still honest with their doctors. What is encouraging and have been shown to work is that doctors should not be nagging or harassing or making people feel bad about smoking. Because, again a large majority of smokers want to quit.  So, there have been studies done in clinic systems that implemented systematic approaches to smokers. The medical assistant asked them about smoking status, the doctor was taught techniques about how to give brief advice, in every one of those cases that have been done, if you asked smokers a year later, six months later, doing general satisfaction surveys. You compared them to before the system went in, people's general satisfaction with the medical care that they're getting, just being a patient in general, they appreciated the attention and the help that they got. 

Operator: Thank you so much. 

Llelwyn Grant: Thank you, Shirley. I wish to thank you all for participating in today's telebriefing. To learn more about CDC's work in tobacco prevention and control, please visit our website at www.CDC.gov/tobacco. To learn more about saving lives and money through prevention, visit our website at www.CDC.gov/24–7. And also, earlier this year, CDC and the Centers for Medicare and Medicaid Services launched “Million Hearts”, an initiative to prevent one million heart attacks and strokes over the next five years. Approximately 26 % of heart attacks and 12 % of strokes are attributable to smoking.  For more information on this initiative, visit www.millionhearts.hhs.gov. A transcript will be available later this afternoon.  This concludes our briefing and thanks again for joining us.

Operator: This does conclude today's meeting. At this time, you may disconnect your lines.

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