No. 4, October 2004
Addressing Tobacco in
Managed Care: Results of the 2002 Survey
Carol McPhillips-Tangum, MPH, Carmella Bocchino, MBA, RN, Rita Carreon,
Caroline Erceg, MJ, Bob Rehm, MBA
Suggested citation for this article: McPhillips-Tangum C, Bocchino C,
Carreon R, Erceg C, Rehm B. Addressing tobacco in managed care: results of
the 2002 survey. Prev Chronic Dis [serial online] 2004 Oct [date
cited]. Available from: URL:
In the United States, tobacco use is the leading
preventable cause of death and disease. The
health and cost consequences of tobacco dependence have made treatment and
prevention of tobacco use a key priority among multiple stakeholders,
including health plans, insurers, providers, employers, and policymakers.
In 2002, the third survey of tobacco control practices and policies in
health plans was conducted by America’s Health Insurance Plans’ technical
assistance office as part of the Addressing Tobacco in Managed Care (ATMC)
The ATMC survey was conducted in the spring of 2002 via mail, e-mail,
and fax. A 19-item survey instrument was developed and pilot-tested. Of the
19 items, 12 were the same as in previous years, four were modified to
collect more detailed data on areas of key interest, and three were added to
gain information about strategies to promote smoking cessation. The sample
for the survey was drawn from the 687 plans listed in the national directory
of member and nonmember health plans in America's Health Insurance Plans.
Of the 246 plans in the sample, 152 plans (62%)
representing more than 43.5 million health maintenance organization members
completed the survey. Results show that health plans are using evidence-based programs and clinical
guidelines to address tobacco use. Compared to ATMC survey data collected in
1997 and 2000, the 2002 ATMC survey results indicate that more health plans
are providing full coverage for first-line pharmacotherapies and telephone
counseling for smoking cessation. Plans have also shown improvement in their
ability to identify at least some members who smoke. Similarly, a greater
percentage of plans are employing strategies to address smoking cessation
during the postpartum period to prevent smoking relapse and during pediatric
visits to reduce or eliminate children’s exposure to environmental tobacco
The results of the 2002
ATMC survey reflect both tremendous accomplishments and important
opportunities for health plans to collaborate in tobacco control efforts. With appropriate support, analytical tools, and resources, it is likely that
health plans, clinicians, providers, and consumers will continue to evolve
in their efforts to reduce the negative consequences of tobacco use.
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In the United States, tobacco use is the leading preventable cause of
death and disease. Smoking kills more than 440,000 people in the United
States each year, with most deaths occurring from lung cancer, ischemic
heart disease, and chronic airway obstruction (1). Yet approximately 23% of
American adults continue to smoke cigarettes (2). In 2000, it was estimated
that approximately 8.6 million persons in the United States were living with
at least one condition attributed to smoking (3).
The health consequences of tobacco use are accompanied by a staggering
economic burden. Smoking caused more than $157 billion in annual
health-related economic losses between 1995 and 1999, including $81.9
billion in smoking-related productivity losses and $75.5 billion in excess
medical expenditures (1). Smoking-attributable neonatal expenditures were
estimated at $366 million in 1996, or $704 per maternal smoker (1).
Together, the consequences and costs of tobacco dependence have made
treatment and prevention of tobacco use a key priority among multiple
stakeholders, including health plans, insurers, providers, employers, and
In 1997, The Robert Wood Johnson Foundation established a
collaborative program, Addressing Tobacco in Managed Care (ATMC). This
program is based on the understanding that health plans’ comprehensive
benefits, sophisticated information systems, and defined populations, as
well as their ongoing partnerships with health care providers, are well
suited to implement, evaluate, and sustain tobacco control interventions.
ATMC includes a National Program Office based at the University of
Wisconsin Medical School’s Center for Tobacco Research and Intervention, and
a national technical assistance office (NTAO) managed by America’s Health Insurance Plans
(AHIP), formerly known as the American Association of Health Plans (AAHP). The mission of the NTAO is to advance the integration of tobacco cessation and
prevention programs into routine health care by increasing the number and
quality of tobacco control initiatives within health plans.
The NTAO provides resources to health plans and insurers striving to
develop tobacco control programs; conducts a benchmarking awards program to
highlight exemplary health plan tobacco control initiatives; promotes best
practices and partnerships through national conferences; and oversees the
development of a business case model for smoking cessation. The NTAO has
also conducted three surveys of health plans over the past six years to
assess practices and policies related to tobacco control.
The ATMC baseline survey was conducted in 1997, followed by a similar
survey in 2000. The results of both surveys were published in peer-reviewed
journals in 1998 and 2002 (4,5). The purpose of this paper is to present the
results of the 2002 ATMC survey; highlight changes from 1997 to 2002; cross-reference the findings with national guidelines and recommendations; and
explore these findings and trends in light of the changing environment in
which health plans operate and the public’s attitude toward tobacco use.
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A 19-item survey instrument was developed and pilot-tested in the fall of
2001. The instrument was designed to assess new trends, barriers, and
opportunities related to addressing tobacco control in health plans,
identify new models or frameworks of care, and assess changes in health-plan–based tobacco control activities between 1997 and 2002. The sample for
the survey was drawn from the 687 plans listed in AHIP’s national directory
of member and nonmember health plans. The directory was stratified based on
health plan enrollment size, and a random sample of 246 health plans was
selected. The sample size enables the detection of a 5% difference between
proportions at ∝ = .05 and β = .80.
The ATMC survey was conducted in the spring of 2002. As in 1997 and 2000,
the 2002 survey was conducted via mail, e-mail, and fax, with telephone
follow-up with nonrespondents at two, four, and six weeks after initial
contact. The sample included large national plans that have local plans in
multiple states. As in previous years, the corporate office of each national
plan was asked to review the questionnaire and determine whether they would
respond on behalf of their local plans or ask local plans to complete the
questionnaires individually. Three of four national plans opted to respond
on behalf of their local plans and their responses reflect 64% (97/152) of
The 2002 survey questionnaire was similar to the 2000 survey. Of the 19
items in the 2002 questionnaire, 12 were the same as in previous years, four
were modified to collect more detailed data on areas of key interest (i.e.,
pharmaceutical coverage and system-level interventions), and three were
added to gain information about strategies to promote smoking cessation.
Based on feedback provided during pretesting, the majority of survey
questions focused on smoking cessation despite recognition that tobacco
cessation or tobacco control is a more encompassing term. Although we
recognize that the preferred provider organization (PPO) product has grown
in popularity, the 2002 ATMC survey asked respondents to answer all
questions based on their best-selling commercial health maintenance
organization (HMO) product to preserve the ability to make comparisons with
All analyses were performed with SPSS software (SPSS, Inc, Chicago, Ill).
Chi-square tests and t-tests were used for comparisons, and results
of these tests were considered statistically significant when the
corresponding P value was ≤ .05. Consistent with previous years, the
data are unweighted to best describe the policies and practices of health
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Of the 246 plans in the sample, 152 (62%) completed and returned the
survey. Collectively, the 152 plans represent more than 43.5 million HMO
members. Respondent plans were predominantly independent practice
association, network, and mixed models. Fifty-one percent were
for-profit and publicly held; 24% were for-profit and privately held; 23%
were not-for-profit; and 2% were mutual companies. A comparative analysis of
respondents and nonrespondents to the 2002 survey indicated that there were
no significant differences in size, tax status, or predominant model type
between respondents and nonrespondents.
Among plans that responded to the 2002 ATMC survey, 71% reported having
written clinical guidelines for smoking cessation. The majority of plans
reported having guidelines that had been internally developed by the plan;
few plans reported using the 2000 U.S. Public Health Service Clinical
Practice Guideline on
Tobacco Use and Dependence or the 1996 Agency for Health Care Policy and
Research (now the Agency for Healthcare Research and Quality [AHRQ]) Practice Guideline on Tobacco Cessation (Table 1).
Nearly three quarters of all plans indicated that they could identify at
least some individual plan members who smoke (Table 1). Among those plans
that reported being able to identify individual smokers, the most common
data sources are health risk appraisals and telephone interviews. Only 6% of
plans use enrollment data to identify individual smokers.
The vast majority of health plans that responded to the survey reported
that they provide full coverage for at least one type of pharmacotherapy
used for tobacco cessation (Table 1). Bupropion, in the form of Wellbutrin,
was the most commonly covered pharmacotherapy. Only 11% of plans reported
that provision of full coverage for tobacco cessation pharmacotherapies is
dependent on enrollment in a counseling or cessation program.
Full coverage for at least one type of behavioral intervention used for
tobacco cessation was reported by the vast majority of health plans (Table
1). Telephone counseling was the most commonly covered behavioral
intervention, followed by face-to-face counseling and self-help materials.
Health plans reported having a variety of strategies to encourage members
to stop smoking during times that might be considered important teachable
moments. The majority of health plans reported having a specific strategy to
address smoking cessation during pregnancy and during treatment for chronic
illnesses (Table 1).
Plans reported that a variety of strategies are used with providers and
their office staff to promote smoking cessation among plan members. The
majority of plans reported offering provider education and offering prompts
and reminders to providers (Table 1). Provider prompts and reminders were
coupled with provider education by 44% of plans. Few plans reported offering
incentives to providers and their staff to promote smoking cessation.
Health plans reported that they require providers to carry out a variety
of assessments and activities related to smoking that are in accordance with
the clinical model of the 5 As: Ask, Advise, Assess, Assist, and Arrange (6).
(The 2002 ATMC survey was fielded before the development of Assess willingness to quit.) The majority of plans require providers to ask
new patients about smoking status and include smoking status as a vital sign
(ask about smoking status at every visit) (Table 1). Fewer plans reported
requiring providers to carry out activities aimed at advising, assisting,
and following up with patients trying to quit smoking.
Although health plans reported a variety of barriers that limit their
ability to effectively address tobacco control, the most common barriers
relate to resources (e.g., inadequate staff, funding, competing priorities)
and system issues (e.g., poor data collection, reporting, record
maintenance). Other barriers included lack of patient demand, lack of
purchaser demand, and delayed economic return on investment.
Tobacco control activities used by larger health plans are different from
those used by smaller plans (Table 2). Based on the enrollment distribution
of health plans in our sample, we defined larger plans as those with more
than 250,000 members and smaller plans as those with less than or equal to
250,000 members. Larger plans were more likely than smaller plans to have
written clinical guidelines for smoking cessation (P < .001) and to
have a specific strategy to address smoking cessation during specific times,
such as adolescence, pregnancy, postpartum visits, and hospitalization (P
ranged from < .001 to .02). Smaller plans, more likely to be staff and
group-model plans, were more likely to be able to identify individual plan
members who smoke (P < .001) and provide full coverage for some
prescription pharmacotherapies used for smoking cessation (P ranged
from <.001 to .02).
Although the ATMC survey instruments used in 1997, 2000, and 2002 were
not identical, the majority of core questions on pharmacotherapies,
behavioral health, and smoking cessation strategies remained unchanged. The
percentage of plans that provide full coverage for any type of
pharmacotherapy used for smoking cessation more than tripled from 1997 to
2002 (P < .001) (Table 3). The percentage of plans able to identify
individual smokers also increased (P < .001). More plans reported
providing full coverage for telephone counseling (P = .04) and
face-to-face counseling (P = .011) in 2002 compared with both previous
From 1997 to 2002, there were large increases in the percentage of plans
with strategies to address relapse prevention during the postpartum period (P
= .02) and smoking cessation during treatment for chronic illness (P
= .002) and following a heart attack (P = .004) (Table 3).
Health plan performance on measures related to requiring providers to
adhere to four of the 5 As varied in both directions between 2000 and 2002
(Table 3). Although comparable data on these variables were not collected in
1997, the percentage of plans that require providers to ask new patients about
smoking status (P = .02) and strongly advise all smokers to quit (P
= .02) decreased from 2000 to 2002, and the percentage of plans that require
providers to include smoking as a vital sign (i.e., ask about it at every
visit) (P = .28) and assist smokers by referring them into
appropriate treatment (P = .33) increased modestly.
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The results of the 2002 ATMC survey indicate that health plans are using
evidence-based programs and clinical guidelines to address tobacco use.
Clinical guidelines detail the most effective options for helping patients
to quit smoking, and using strategies recommended in clinical guidelines is
associated with greater success in helping smokers to quit (6,7). Although a
large percentage of health plans reported having written clinical guidelines
for tobacco cessation, it is possible that even more plans address tobacco
cessation within other clinical guidelines used for managing or treating
conditions in which tobacco use is identified as a comorbidity or risk
factor (e.g., heart disease, diabetes, asthma). It is also noteworthy that
more than half of the plans reported adopting internally developed
guidelines, as opposed to guidelines developed by federal agencies and
expert panels such as the U.S. Public Health Service (USPHS) and AHRQ. However, it is possible that plans
reviewed such guidelines and integrated many or all of the key components
into their own guidelines.
Plans showed remarkable improvement in 2002, compared with previous years,
in identifying individual plan members who smoke. The ability to identify
smokers is an important indicator of a plan’s ability to remind or prompt
providers to discuss and/or advise patients about smoking cessation. Such
provider reminders are considered an effective strategy for supporting
smoking cessation and are recommended by the Task Force on Community
Preventive Services (7). The survey question, however, assesses the
percentage of plans that can identify any members who smoke (rather than all members who smoke), and the methods that plans report using to
identify smokers are most likely to identify subgroups of smokers (i.e.,
those that respond to health risk appraisals or surveys). Indeed, the
ability of health plans to identify smokers is contingent upon members
actively providing information about their smoking status during some
interaction with the health plan, whether during enrollment, through a
survey, or via some other point of contact.
The number of health plans providing full coverage for any type of
pharmacotherapy for tobacco cessation more than tripled in 2002, compared
previous years. In the 2002 ATMC survey, nearly nine out of 10 plans
reported providing full coverage for at least one type of pharmacotherapy
for tobacco cessation. Consistent with recommendations based on the
effectiveness of various prescription and over-the-counter tobacco cessation
first-line pharmacotherapies (6), the majority of plans reported providing
full coverage for bupropion. The significant increase in the number of plans
that provide full coverage for at least one type of pharmacotherapy related
to tobacco cessation is well aligned with the growing body of literature
indicating that reduced out-of-pocket cost is associated with greater use of
tobacco cessation programs and services (8-12) and may lead to increased
rates of cessation (10,11).
Consistent with literature citing the effectiveness of telephone
counseling and that smokers are more likely to use telephone counseling than
to participate in individual or group counseling sessions (13,14),
approximately half of plans surveyed provide full coverage for telephone
counseling. It is possible that even more smokers have access to telephone
counseling through the availability of state-sponsored quit lines. Less than
25% of plans impose an annual or lifetime limit on coverage for tobacco
cessation treatments, indicating widespread acceptance of the USPHS
guideline recommending coverage for repeated, intensive tobacco dependence
counseling and pharmacotherapy (6).
The results of the 2002 ATMC survey also suggest that plans are paying
close attention to pregnancy and the postpartum period to assist women to
quit smoking. The large percentage of plans reporting strategies to address
smoking cessation during and after pregnancy to prevent relapse may reflect
greater health plan awareness of research that has demonstrated the
cost-effectiveness of offering smoking cessation programs to pregnant women
Overall, our results indicate the greatest improvement in tobacco control
activities is at the health plan level as opposed to the physician
level. For example, more plans report providing full coverage for pharmacotherapies than report requiring providers to carry out activities in
support of the 5 As. This may be because most health plans (especially
those that are not staff-model HMOs) find changing physician behavior to be
a challenge. Although more plans are beginning to experiment with
performance feedback as a way to change physician behavior, prompts,
reminders, and provider training are more common strategies.
Health plans continue to report that resource limitations, including
insufficient staff and inadequate funding, are leading barriers to
adequately addressing tobacco control. Health plans may benefit from
developing a business case model that stresses the importance of tobacco
cessation to purchasers and advocates for resources to implement and
maintain evidence-based tobacco cessation programs. Research supported by
the NTAO is underway to provide an estimated return on investment for
smoking cessation interventions, based primarily on smoking-attributable
costs for health plans.
The ATMC survey and its findings have limitations. The response rate of
approximately 60% is respectable, but leaves open the possibility of
selection bias. Even though no significant differences were detected between
respondents and nonrespondents on three key characteristics (size, tax
status, predominant model type), respondents possibly differed from
nonrespondents in ways that were not measured. Another limitation to the
ATMC survey is that the psychometric properties of the questionnaire were
not tested to assess reliability or validity. However, the survey design
process did include substantial pretesting to increase the probability of
including questions that were reliable and likely to yield valid responses.
Additionally, we identified a potential limitation of the 1997 survey — it
did not include a frame of reference for product type (e.g., HMO, PPO). When
the survey does not specify product type, respondents tend to answer for the
HMO product. Respondents were explicitly asked to answer for the HMO product
in 2000 and 2002. However, the possibility remains that the change in frame
of reference contributes to some differences in survey findings from 1997 to
2000 or 2002 (but not from 2000 to 2002).
Aside from the ATMC surveys, few surveys have assessed tobacco control
practices and policies of health plans. Some surveys have focused on plans
operating in a single state (9,16), some have included a narrow subset of
plans (i.e., well-established nonprofit plans with a history of offering
tobacco cessation programs) (17), and others have collected information
about subsets of smokers within a plan (i.e., pregnant women) (18,19).
Nevertheless, a 1999 survey of California health plans reported results
comparable to our results: 85% of HMOs in the California survey covered at
least one form of pharmacotherapy; 77% covered bupropion; 46% covered
telephone counseling; and 54% covered individual counseling (16). However,
the limited availability of comparable data prohibits comparisons of our
findings with other surveys and underscores the importance of ATMC data for
an adequate understanding of health plan tobacco control practices and
policies at the national level.
The results of the 2002 ATMC survey indicate that an increasing number of
health plans are using evidence-based approaches and strategies to address
tobacco use. However, in light of competing priorities for limited
resources, health plans may be challenged to sustain the improvements they
have made from 1997 to 2002. Cost modeling and the development of a business
case model for smoking cessation may hold promise by assisting some plans to
leverage the body of literature that supports the cost-effectiveness of
tobacco cessation treatment (6,20-23).
Just as challenges lay ahead, so do many important and potentially
exciting opportunities. Health plans are in a key position to implement
operational policies and programs that can reduce the prevalence of tobacco
use and positively impact the health of millions of individuals. Health
plans have the opportunity to sustain and expand access to tobacco cessation
treatments and services such as pharmacotherapies and counseling services.
As new evidence emerges, health plans have the flexibility to model new
tobacco cessation benefits and promote them widely to their membership. They
also have the opportunity to influence large purchasers of health care
services by communicating the value of tobacco cessation services and
expanding their field of influence from the clinical and provider setting to
the broader community. By participating in community-wide campaigns and
policy initiatives that support tobacco cessation and prevention,
stakeholders can influence and help control tobacco use.
In summary, the results of the 2002 ATMC survey reflect both tremendous
accomplishments and important opportunities for health plans to collaborate
in tobacco control efforts. With appropriate support, analytical tools, and
resources it is likely that health plans, clinicians, providers, and
consumers will continue to evolve in their efforts to reduce the negative
consequences of tobacco use.
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The authors thank The Robert Wood Johnson Foundation for the unrestricted
educational grant that made this survey possible.
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Corresponding author: Carol McPhillips-Tangum, MPH, CMT Consulting, 106 Geneva
Street, Decatur, GA 30030. Telephone: 404-377-4061.
Author affiliations: Carmella Bocchino, MBA, RN, Rita Carreon, Caroline Erceg, MJ, Bob Rehm, MBA, America’s Health Insurance Plans (AHIP),
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