Planning for the Future
August 14, 2001: Smoking Cessation: Facing the Challenges of Tobacco Addiction
Michael C. Fiore, M.D., M.P.H., Professor, Department of Medicine, Director, Center for Tobacco Research and Intervention, University of Wisconsin Medical School, Madison, Wisconsin
Dr. Fiore began by summarizing some of the information that is already known about smoking cessation that had been presented to the committee during the course of the meeting. Tobacco is highly addictive, and approximately 50 million Americans currently smoke. Of those, 35 million would like to quit, and 20 million try every year. However, only one million of those who try actually succeed. He emphasized that this low success rate could be markedly increased if we effectively prompt more smokers to use evidence-based counseling and medications in their quit attempts. Dr. Fiore further reiterated that there are effective clinical and community interventions that exist and that these are described in two of the guidelines described earlier in the day – the PHS Clinical Practice Guideline and the CDC's Guide to Community Preventive Services. These guidelines tell us that not only do health care providers have unique access to smokers and can be highly effective in promoting cessation, but system level changes must also be institutionalized to maximize clinical effectiveness. Furthermore, population-based interventions such as media campaigns, price increases and reduced out-of-pocket costs for treatment are also important. During the course of the meeting, committee members were told about some of the many populations that are currently being targeted in cessation efforts; seniors, pregnant women, socioeconomically disadvantaged, young people, rural and inner city smokers, and those who visit health care facilities.
To conclude his remarks, Dr. Fiore offered several recommendations to the federal government about ways that it could further promote cessation efforts. First, increase access to effective treatments by Medicaid and Medicare recipients, federal employees, veterans, and those in the military through universal (50 state) quitline access and mandated insurance coverage for cessation services. Second, disseminate and implement evidence-based interventions that we already know are effective. This can be done through increased training for health care providers, and system-level changes that include provider reminder systems and prompting of purchasers to require provision of cessation services. The PHS Tobacco Guidelines Collaboration, a joint public and private initiative described by Ms. Williams, is another way that evidence-based information can be disseminated. Third, increase federal funding of research and increase coordination of current research efforts. Although there are several examples of public/private research partnerships currently underway (Treating Tobacco Use Research Centers [TTURC], a model NIH/RWJF initiative), more of these alliances should be encouraged as should non profit and private sector initiatives such as the American Legacy Foundation, Robert Wood Johnson Foundation, the Pharmaceutical Industry and the Wisconsin Women's Health Initiative. Fourth, continue to promote coordination and partnership development to address the needs of special populations and increase access to treatment. Dr. Fiore believes that all of these four components should be part of a new highly visible initiative led by Surgeon General Satcher and Secretary Thompson, whose leadership in the area of prevention could enable us to make great progress in our tobacco control efforts.
Dr. Satcher thanked all speakers and told the committee that it was his responsibility to communicate the importance and urgency of these issues to HHS Secretary Thompson.
Dr. Satcher then asked Nancy Kaufman from the Robert Wood Johnson Foundation to announce an exciting new public/private partnership between NCI, CDC, RWJ, and the Canadian Tobacco Control Research Initiative. Ms. Kaufman described the new initiative, which will focus on tobacco use treatment for youth smokers beginning with a survey of existing programs and a review of best practices as well as ineffective interventions. Following the survey, the collaborative will fund between 40 and 50 two-year evaluation studies of various interventions. With the evidence from those evaluations, common measures will be designed and meta-analyses will be conducted. During the fourth year of the initiative, the field will be resurveyed to determine changes and improvements in youth tobacco use treatment. Approximately 11.2 million dollars will be dedicated to this effort.
Dr. Satcher reacted to the announcement by telling the committee how encouraged he is by the emphasis on youth, given that although black youth smoke less than their white counterparts, this advantage disappears as they move into adulthood.
Susan Rossi from NIH followed this comment by asking speakers what they knew of research linking cigarettes, as drug delivery devices, to self-medication for psychiatric conditions. The response was that while the tobacco industry has researched this issue, we do not have adequate research on ingredients and design of tobacco products to know their effect on self-medication.
Dr. Satcher directed a question to all speakers concerning the extent to which they have been able to segment their target populations. Dr. Richling from Union Pacific Railroad responded that his organization has only segmented by geographic region, but is interested in developing a better instrument to enable them to further segment the population. Sarah Rosenberg from the Oregon Health Division responded that they are only able to monitor their target population based on Medicaid enrollment and that they really do not have a good answer to the issue of segmentation. Dr. Timothy McAfee from Group Health Cooperative of Puget Sound confirmed that there are extreme measurement complexities, but added that in the Medicaid population we know that the tobacco use rate is almost double that for the non-Medicaid population. Dr. Lyndon Haviland from the American Legacy Foundation addressed the segmentation issue by reporting that the American Legacy Foundation had conducted a National Youth Tobacco Survey and had over- sampled for Asian Americans. Results indicated that while Asian American youth have the second lowest rates of tobacco use in 6th grade, by the time they reach 12th grade, they jump to the second highest use rate. The survey also identified that Asian American youth are 65% more likely to smoke menthol than regular cigarettes, but we do not yet understand the reason for this.
Before moving to public comments, Dr. Satcher gave committee members an opportunity to make final comments. Nancy Kaufman from the Robert Wood Johnson Foundation mentioned the Smokefree Families project and how it is an example of a low cost intervention with positive outcomes achieved by providing incentives to pregnant women and their buddies to encourage cessation. Dr. Scott Leischow from NCI addressed the issue of disparities by announcing a plan to convene a national conference to focus on disparities and tobacco use to identify key research directions. Dr. Leischow also remarked on the tremendous number of federally funded efforts that are currently ongoing and how much data already exists that should continue to be optimized and analyzed.
Following these remarks, Dr. Satcher invited public comments. A question was asked regarding the effect of increasing excise taxes on reducing youth smoking prevalence, and Dr. Satcher responded that a 10% increase in taxes has been found to reduce prevalence by 7%. In response to an earlier question posed by the Surgeon General regarding the cost of covering cessation services for all smokers currently enrolled in Medicare, Matt Barry from the Campaign for Tobacco Free Kids said that the Campaign had studied the issue and estimated that the benefit would cost between $120 million over 10 years (assuming a 2% utilization rate) to $600 million over 10 years (assuming a 10% utilization rate). Mr. Barry also mentioned a bill introduced by Senators Durbin and Brownback (S.854) that includes both a counseling benefit for Medicare enrollees and a counseling and pharmaceutical benefit for Medicaid enrollees.
Maris Bondi from Partnership for Prevention asked a question about the enormous influence of tobacco use in the media on youth smoking rates. Dr. Satcher reported that he had been involved in a meeting with Hollywood executives to talk about public health issues in the media, including smoking, and that these talks would continue. Nancy Kaufman from the Robert Wood Johnson Foundation added that Stan Glanz, a researcher from California, had received an innovators award from the Robert Wood Johnson Foundation and was using the award for an initiative to educate Hollywood executives about the negative consequences of the glamorous portrayal of tobacco use in the media. Dr. Cathy Backinger from NCI added that NCI-supported research has shown a strong link between young people who watch PG movies and above and their smoking rates. Dr. Lyndon Haviland from the American Legacy Foundation mentioned that Legacy had been working with the Entertainment Industry Foundation to better understand the perception of smoking in movies and would be announcing a new initiative in this area shortly.
Marcela Gaitan from the National Alliance of Hispanic Health requested comments from speakers regarding the increasing prevalence among young Hispanic girls as well as differing risk behaviors among first and second generation Hispanic Americans. Dr. Satcher responded by saying that he had been involved in a meeting of editors of Latino magazines who discussed the high rates of school dropout and teenage pregnancy among Latino youth and how these youth were more likely to smoke.
Katherine Pruitt from the American Lung Association asked for some comments regarding the efficacy of group approaches to smoking cessation. She briefly mentioned her organization's evidence-based cessation program for young people called "Not On Tobacco." Dr. Michael Fiore from the University of Wisconsin responded that the PHS Clinical Practice Guideline identifies that group counseling can be effective, but many smokers self-select away from group approaches to cessation. He said that many professionals see group counseling as an option, but one that is infrequently selected by smokers. Dr. Corinne Husten from CDC confirmed that evidence supports the efficacy of group counseling, but that the reach of these groups is often limited and more emphasis is often placed on trying to engage smokers in more intensive cessation efforts. Dr. Timothy McAfee from Group Health Cooperative of Puget Sound added that as more people attempt to quit, the telephone counseling approach appears to be gaining favor. Dr. Scott Leischow from NCI reminded the committee that in the 1990s the public health community had great hopes for the power of new pharmacotherapy to assist in cessation efforts but we now acknowledge that there is no panacea and we must remain vigilant in our efforts to address behavioral change approaches.
Tom Glynn from the American Cancer Society asked for Dr. Gerald Keusch of the NIH's Fogarty International Center to talk a bit more about the recent RFA focused on international tobacco control. Dr. Keusch talked about the working group that had convened for a year that led to developing the recently released RFA, cosponsored by the World Health Organization, entitled "International Tobacco and Health Research and Capacity Building Program." Dr. Keusch also talked about efforts to network applicants and link them to other efforts currently underway. Dr. Anthony So of the Rockefeller Foundation praised NIH's work, emphasizing how important international efforts are given the globalization of health threats such as tobacco use. Dr. Satcher reported that he had an opportunity to meet with China's Minister of Health and talk about the high rates of smoking among men in China, including many physicians.
Matt Barry from the Campaign for Tobacco Free Kids asked for comments about how the tobacco control field viewed recent harm reduction activities and whether they should be seen as a threat or an opportunity. Dr. Scott Leischow from NCI responded by talking about the recent NCI-sponsored meeting on the issue and how the intention of the meeting was to consider both the opportunities and challenges. Acknowledging that the tobacco industry has already moved ahead on new developments in this area, Dr. Leischow believes that it is still too early to tell where we should go and what additional research is required in this area. Dr. Jack Henningfield from Pinney Associates agreed that it is still premature to say that harm reduction is a good thing because we currently have no surveillance system in place to determine whether harm reduction approaches will undermine our goal of preventing initiation and helping people quit. Dr. Timothy McAfee from Group Health Cooperative of Puget Sound agreed with this assessment, encouraged more research in this area, and cautioned that both the tobacco and pharmaceutical industries have a lot more to gain with harm reduction then they do in promoting cessation. Dr. Tom Glynn from the American Cancer Society encouraged the field to continue to work together in this area and not to become splintered. Dr. Satcher then announced that the issue of harm reduction would be the likely topic for the next meeting of the Interagency Committee on Smoking and Health.
Without further comments, Dr. Satcher offered his closing remarks. He thanked the committee members, speakers, participants, and staff for their many contributions to what he called an "outstanding" meeting. Dr. Satcher told participants that he thought it had been a very productive day of learning about the current status of smoking cessation research and program activities and ways in which we can advance our knowledge and program implementation. As chair of the committee, he reported that he would transmit the ideas to the Secretary "in a very enthusiastic manner" and confirmed his commitment to achieving the Healthy People 2010 objectives in tobacco control that could only happen with significant investment in cessation. Dr. Satcher encouraged all meeting participants to take the messages back to their organizations and to work with him on a smoking cessation agenda. The Surgeon General adjourned the meeting and told the participants that a meeting summary would be available on CDC's Web site in the fall.
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