Best Practices and Their Impact
August 14, 2001: Smoking Cessation: Facing the Challenges of Tobacco Addiction
Corinne Husten, M.D., M.P.H., Chief, Epidemiology Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Dr. Husten began her presentation by talking about the importance of cessation efforts as part of a comprehensive approach to tobacco control. To reduce mortality related to tobacco use and achieve our Healthy People 2010 goals for the nation, it is critical that we get current smokers to quit. Because nicotine addiction is a complex combination of physiological dependence and social factors, most smokers need assistance with their cessation attempts to avoid relapse over time.
While there was a time when we had insufficient evidence to understand best practices for tobacco cessation, it is no longer the case. We now have a series of recommendations, focused on three levels of cessation interventions (individual, health care system and population) that have similar conclusions and recommendations. Dr. Husten quickly reviewed the six sets of guidelines and the level or levels that each addresses.
Individual Level Interventions
The most comprehensive document addressing treatment interventions at the individual level is the Public Health Service's Clinical Practice Guideline: Treating Tobacco Use and Dependence (2000). This guideline illustrates the efficacy of a clinician's advice to quit and how between 1-2 million more smokers could quit each year solely based on a physician's advice to do so. Evidence also suggests that the more time a health care provider spends providing this advice, the greater the likelihood of cessation. Furthermore, there are several different types of effective counseling and behavioral therapies (intra-treatment social support, extra-treatment social support, general problem solving, rapid smoking) delivered by a range of clinicians (nonphysician clinician, physician clinician). These counseling and behavioral therapies can be delivered through individual, group, or telephone counseling. Common elements of supportive counseling provide basic information about smoking and quitting; encourage patient in the quit attempt; communicate caring and concern; encourage the patient to talk about the quitting process; identify danger situations; and develop a plan to deal with these danger situations.
The PHS guideline also addresses the efficacy of various types of pharmacotherapy. Because all five forms of FDA-approved pharmacotherapy contribute to an approximately doubled rate of cessation, personal preference is critical. Regarding second-line pharmacotherapy (drugs that are on the market for other purposes but can be effective for tobacco cessation), dosage is not yet well established and side effects are more likely, so it is recommended that these be used solely as second line approaches.
Dr. Husten briefly summarized the four major guidelines that address clinical interventions and illustrated how they offer similar and consistent recommendations. The four sets of recommendations are—
- Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force (1996)
- Reducing Tobacco Use: A Report of the Surgeon General (2000)
- Treating Tobacco Use and Dependence. Clinical Practice Guideline. (2000)
- Cochrane Collaboration (various reports)
The guidelines offer consistent recommendations in favor of health care provider delivery of brief advice to quit, health care provider counseling to patients on tobacco cessation, and the use of pharmacological treatments for tobacco use and dependence. Finally, the efficacy of self-help education materials is weak and inconsistent, but these materials can be helpful reinforcement for other approaches.
Results from a population-based study conducted by Shu-Hong Zhu and colleagues suggested that 20% of the 4,480 adults who tried to quit smoking in the 12 months prior to the survey, used one or more forms of assistance such as self-help, counseling and nicotine replacement therapy (NRT). Heavy smokers, women, and whites were more likely to use this assistance and quit rates were twice as high among those who used assistance compared to those who did not. Unfortunately, there remains much to be done to encourage more physicians to counsel patients about smoking cessation and to help smokers understand the range of assistance that is available to help in their quit attempts.
Health Care System Interventions
Next, Dr. Husten addressed the effectiveness of health care system interventions in helping people stop smoking and talked about the Guide to Community Preventive Services as being the document that best addresses this level of intervention. While provider reminder systems have a substantial effect in increasing advice to quit, continuing medical education courses alone do not seem to be as effective. However, if reminder systems are combined with provider education, the effect is substantial. Not surprisingly, when insurance covers the cost of tobacco cessation, there is a significant increase in the use of effective treatments and an increase in the number of successful quitters.
The guidelines that address system-level changes (Community Guide, Surgeon General Report, PHS Clinical Practice Guideline and Cochrane Collaboration), consistently note that when screening systems are in place to identify smoker status, there is a much greater likelihood of successful cessation. The guidelines encourage the use of provider reminder systems alone but strongly recommend the use of the combination of provider reminders and provider education as being highly effective. While the Cochrane Collaboration also does not address the issue of reducing patient out-of-pocket costs for treatment, the other three found that this increased the likelihood of successful cessation.
As a "real world" example of the potential for system changes to increase cessation, Dr. Husten talked about the Group Health Cooperative (GHC) of Puget Sound's model program. By including NRT and counseling as a covered benefit, implementing a screening and advice system in the primary health care system, implementing a readily accessible behavioral support program through telephone counseling, and actively recruiting patients, GHC was able to get 10% of smokers to use intensive interventions and of those, 30% were able to quit for one year or more. GHC determined that the cost of the program was only $.70 cents per smoker per month and the cost savings in reduced health care use would more than pay for the program in 3-4 years.
Other than the very exciting announcement by the Office of Personnel Management to encourage coverage of clinical tobacco-use treatment interventions for federal employees, the current status of system changes for tobacco use treatment in the United States is not very encouraging. Employer coverage of tobacco use treatment is limited, and when there is coverage, there are often limitations on how many opportunities a person has to use the service or how much is covered. Although there is currently a demonstration project underway to test the effectiveness of Medicare coverage for treatment of nicotine dependence, there is currently no Medicare coverage. In some states, there is Medicaid coverage for counseling and prescription tobacco-treatment medications, but there are often restrictions on the use of services or products.
The third level of intervention addressed by Dr. Husten was population-based approaches to increasing cessation. These approaches, such as media campaigns, quitlines, and price increases are important because of their broad reach and because many tobacco users are not able or interested in using clinical services. Again, the Guide to Community Preventive Services is the document that most comprehensively addresses effective population-based interventions but three others also address them as well—Surgeon General Report, Best Practices, and the Cochrane Collaboration.
While the Cochrane Collaboration does not include reviews of mass media campaigns, the other three consistently recommend the use of multi-component mass media campaigns to reduce population tobacco consumption. The Community Guide and the Surgeon General Report both recommend increasing the price for tobacco products as an effective approach to reducing population consumption, while the other two documents do not address this issue. Finally, three of the four guidelines strongly recommend the use of patient telephone support as an effective method of increasing cessation (Surgeon General Report does not address).
Dr. Husten provided a "real world" example of a telephone quitline in California in which randomized trials showed a doubling of cessation rates for telephone counseling compared with self-help materials alone. Compared with California smokers overall, callers were more dependent on nicotine, more likely to live with other smokers and more likely to have tried to quit recently and to be ready to try again. Approximately 1/3 of callers were ethnic minorities and almost 1/5 were 24 years or younger, so quitlines appear to reach people who are less apt to seek clinical services. Many states, approximately 20, are currently in the process of developing cessation quitlines. Dr. Husten also noted that cigarette excise taxes range from 25 cents to $1.11 per pack.
To conclude her remarks, Dr. Husten talked about where the United States stands in efforts to help people stop smoking. On the negative side, it appears that successful quit attempts have somewhat plateaued after several decades of slow but steady progress. Meanwhile, significant racial and ethnic differences in prevalence continue to exist and there is not much narrowing in this gap. In addition, adolescent cigarette smoking is not decreasing as quickly as it did in the seventies. In fact, in the early 1990s, there was a dramatic increase in adolescent smoking that has only recently begun to decrease. Finally, only seven states are currently meeting or exceeding CDC's Best Practices minimum funding recommendations for tobacco prevention and control.
At the same time, there has also been progress. Dr. Husten offered three state examples of comprehensive tobacco control programs that have led to decreased prevalence—Arizona, Massachusetts and California. Initiated in 1990, California's comprehensive program led to a decline in adult prevalence that was twice the U.S. rate, and lung and bronchus cancer rates were greatly reduced as a result. And while only seven states are meeting or exceeding the Best Practices' recommendations, 36 states are currently using some of their Master Settlement Agreement funds for tobacco control and five others are using excise tax dollars to fund tobacco control programs.
In summary, Dr. Husten offered a paradigm of tobacco use treatment that includes changing individual behavior together with social norms (higher prices for tobacco, reducing the cost of treatment, implementing counter-advertising campaigns and telephone quit lines) to effectively address tobacco addiction.
Following Dr. Husten's remarks, a question was asked regarding the most effective way to reach the disadvantaged in cessation efforts. Dr. Husten responded that quitlines are effective because they are free, accessible, and anonymous. Unfortunately, however, there is a dearth of published data regarding effective interventions for the disadvantaged and this is an area that the Office of the Assistant Secretary for Planning and Evaluation is currently reviewing to determine future actions.
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