Special Presentations on Implementing Cessation Programs
August 14, 2001: Smoking Cessation: Facing the Challenges of Tobacco Addiction
Pauline Lapin, M.H.S., Healthy Aging Project Director, Division of Health Promotion and Disease Prevention, Centers for Medicare and Medicaid Services, Baltimore, Maryland
Ms. Lapin presented information about the Medicare Stop Smoking Program (MSSP), a demonstration study currently underway to determine the most feasible and effective smoking cessation intervention for seniors, and to provide facts to inform legislation for a potential Medicare smoking cessation benefit. Ms. Lapin began by dispelling myths about seniors who smoke and want to quit, and emphasized the benefits—improved breathing and circulation, reduction in risk for heart disease and stroke, and improvement in functional status and quality of life—experienced by seniors when they quit smoking. Because of the misplaced sentiment that "the damage is already done" or "you can't teach an old dog new tricks," health care professionals often miss an important opportunity to help older smokers quit. In fact, seniors are often very interested in quitting and they are more likely to be successful in their quit attempts and respond more favorably to provider advice then their younger counterparts. A final argument that Ms. Lapin presented in favor of helping older smokers quit is the cost burden to Medicare for treating smoking-related illnesses. It is estimated that these expenditures will exceed $800 billion between 1995-2015.
Ms. Lapin explained that the Medicare Stop Smoking Program is part of CMS' Healthy Aging Project (HAP). The purpose of this effort is to identify what works to promote senior health and translate these findings into Medicare programs and policies. Based on evidence reviews, the HAP determined the following: both provider and telephone counseling increase quit rates; FDA-approved drugs double quit rates when combined with counseling; and CMS should conduct a demonstration to test a Medicare smoking cessation benefit.
The goals for the MSSP are to test the effectiveness of three benefit options, evaluate the feasibility, and assess the costs and cost effectiveness of the potential benefit. The three benefits are 1) coverage for provider counseling; 2) coverage for provider counseling and bupropion (Zyban) or the nicotine patch; and 3) telephone counseling quitline and the nicotine patch (only covered for those who participate in proactive counseling). All of the three benefits are being compared to usual care. The study will be conducted in seven states (Alabama, Florida, Missouri, Nebraska/Wyoming, Ohio, and Oklahoma) with four randomized strata in each state. States were selected based on smoking prevalence, number of eligible beneficiaries in the state, the ability to divide the state into quadrants and the absence of quitlines. Seniors who are 65 or older, current smokers, receive Medicare benefits through fee-for-service, and plan to live in the state for the next nine months are eligible to participate. CMS will determine baseline and conduct 6- and 12-month follow-up for the following measures: cessation rates, quit attempts, prolonged abstinence, patient satisfaction, program reach and costs and cost effectiveness. Finally, CMS is in the process of identifying vendors to implement the demonstration project and determining the most effective approach to recruiting approximately 43,000 participants over the next 12 months.
Ms. Lapin concluded her remarks by discussing some of the future challenges for the Medicare Stop Smoking Program. In addition to the usual challenge of taking a program from a demonstration project to an actual benefit, there is also no precedent for drug coverage through Medicare, which will need to be appropriately addressed. Finally, influencing other insurers to follow Medicare's lead may also be challenging.
Following Ms. Lapin's presentation, Dr. Satcher asked the approximate cost of providing cessation services to all Medicare patients who smoke. Ms. Lapin replied that the number that CMS has is based on seven states that are included in the demonstration project. A representative from the Campaign for Tobacco Free Kids said that he could get the figure and would provide it after the meeting. Clarification about the definition of smoker was requested and Ms. Lapin responded that it was the usual definition used by the National Cancer Institute (smoked 100 cigarettes or more in one's lifetime or one cigarette in the past seven days).
Purchaser, State and Managed Care Purchaser Perspectives
Dennis Richling, M.D., Assistant Vice President, Health Services, Union Pacific Railroad, Omaha, Nebraska
Dr. Richling began his talk about the smoking cessation program at Union Pacific Railroad (UPRR) by mentioning some of the challenges of addressing this issue in a company with historically large numbers of smokers, many of whom are mobile or based in largely rural areas and members of large labor organizations. He described the development of UPRR's "Butt Out and Breathe" program as a process that now incorporates policy changes with raising awareness and providing education, risk identification, and clinical intervention. In the beginning of this process, UPRR's smoking policy was to prohibit smoking in offices (1987) but smoking rooms were available until 1996 when they were closed. It was not until 1999 when smoking was prohibited at all sites and on all equipment.
Smoking cessation services are available for UPRR employees who are interested in quitting. Behavioral interventions include a readiness review survey, health risk appraisal, self-directed workbooks, telephone counseling, in-person counseling, Internet counseling, health coaches, and periodic assessments. Clinical interventions currently include access to Zyban through employee health plans and may include nicotine replacement therapy in the future.
UPRR's cessation program is having positive results. In 1993, approximately 40% of employees were smokers and that rate has dropped to 25% in 2001. While it will be a challenge, the company's goal is to reduce the prevalence of employees who use tobacco to 15% by 2004. Dr. Richling attributes the continuing drop in prevalence to a commitment by the company to view smoking cessation as one of its major business objectives. He hopes that other businesses will follow UPRR's lead and believes that partnerships with other large employers will be critical to reaching the Healthy People 2010 objectives. Dr. Richling stated his belief that current industry efforts are not adequately coordinated and believes that somehow occupational and public health professionals need to work more closely together on smoking cessation efforts.
Sarah Rosenberg, J.D., Cessation Services Specialist, Oregon Health Division, Oregon Department of Human Services, Portland, Oregon
Ms. Rosenberg began by describing Oregon's tobacco cessation efforts as part of a larger comprehensive tobacco control program. The three major themes of this program are that second-hand smoke is harmful, youth initiation should be prevented, and cessation assistance should be provided. Oregon's approach to cessation is based on the PHS Clinical Practice Guideline that encourage health practitioners to follow the "Five A's" (Ask, Advise, Assess, Assist and Arrange) and to combine behavioral assistance with pharmacotherapy. Ms. Rosenberg mentioned that the state's quitline is the way that most smokers enter into cessation services.
Ms. Rosenberg attributes Oregon's success in developing effective cessation services to a combination of factors. First, health care providers and health plans were active participants in the creation of the state's guidelines and continue to be invested in the program. Second, cessation services are covered by Medicaid, and although Oregon anticipated that commercial insurers would follow suit, the state has had mixed success in this area. Third, there has been an emphasis on strong training and education for providers coupled with an effective quitline, which has been able to funnel people to appropriate services. Finally, Oregon has placed a heavy emphasis on evaluation through multiple methods – BRFSS with added tobacco questions, Medicaid surveys, quitline surveys and an NCI-supported study of the quitline.
Several positive outcomes have been reported. Smoking in Oregon is declining among young people and adults and a greater number of health care providers are advising smokers to quit and are offering assistance in their quit attempts. In addition, annual cigarette sales per capita have decreased more rapidly than in 46 other states with no such program. Finally, evaluation results from six months following the initial call to the Oregon quitline indicate that 48% have either quit (13%) or have made a serious attempt to quit (36%).
Ms. Rosenberg concluded her remarks by talking about some of the challenges to the program, including lack of commercial insurance coverage for cessation services, difficulties in access to services by disadvantaged populations, post-partum relapse and the need for constant education of providers that tobacco dependence is a chronic illness. In terms of assistance from the federal government, Ms. Rosenberg believes that the PHS Clinical Practice Guideline has been and will continue to be an essential resource and she also believes there is a need for more research on improving access to cessation services by underserved populations (low income, low literacy, nonwhite, highly mobile, postpartum, and adolescent tobacco users). Finally, encouraging employers to include a cessation benefit is critical.
Timothy McAfee, M.D., M.P.H., Executive Medical Director, Center for Health Promotion and Disease Prevention, Group Health Cooperative of Puget Sound, Seattle, Washington
Dr. McAfee began his presentation by talking about the opportunities for successful tobacco prevalence reduction provided by health systems. Approximately 70% of tobacco users visit a physician each year, which provides potential to repeatedly identify, motivate, and help tobacco users quit. However, barriers also exist to providing tobacco services through health systems including short-term enrollment due to health plan switching; perception that changing behavior is impossible and that smoking is just a "bad habit"; lack of pressure by purchasers to offer cessation services; and limited time of clinicians to address behavioral issues. A survey of health plans conducted in 2000 found that only 56% of respondents had a written tobacco clinical guideline and less than half of respondents fully cover pharmacotherapy or behavioral support. Measures of advice to quit show approximately 55-60% of smokers recall receiving advice to quit which is approximately twice the rate in the mid-1970s but only a slight increase from the mid-1980s.
Group Health Cooperative of Puget Sound is a mixed-model, nonprofit health system that includes more than 29 medical centers and hundreds of primary care network practices. The membership with more than 500,000 enrollees, is representative of the state with about a 10% minority and 26% Medicaid or state low-income plan enrollment. GHC has always maintained a strong commitment to population-based health improvement as evidenced by its experience with tobacco control programs. The system maintains a continuous quality improvement framework, following the PHS Clinical Practice Guideline of the 5 A's (Ask, Advise, Assess, Assist, and Arrange) and linking pharmacotherapy with easily accessible behavioral counseling.
Evaluation results indicate that compared to the state of Washington that has seen an increase in adult smoking prevalence since the mid-1990s, GHC has seen a slow decrease among its membership. Its current prevalence is 15%, compared to 23% for the state.
Tobacco status identification and advice to quit have become institutionalized at GHC—in 2000 approximately 98% of all medical charts completed in 29 primary care centers prominently display the tobacco use status of the patient. In 1999, more than 75% of patients recalled receiving advice to quit from their physicians. GHC has also found that follow-up proactive telephone support combined with educational materials produces significantly higher sustained quit rates than does materials alone. Some of the improvements that GHC has implemented through the course of its program have been to remove access barriers such as reducing the cost to patients and then eliminating the cost altogether, offering more classes in more places and offering a telephone number to call to register for the program. Most of the increase in participation (from 180 a year to 4,500 a year) has occurred in the telephone-based "Free and Clear" program. Integrated pharmacotherapy is offered after each patient is individually assessed (70% use this benefit). Pharmacotherapy is delivered without requiring a physician visit.
Dr. McAfee offered a research example to illustrate the effectiveness of full insurance coverage for smoking cessation programs. Four benefit structures were examined covering differing levels of behavioral and drug coverage, and the results indicated that the highest participation in tobacco cessation programs was for the full-coverage group. For those enrolled in the reduced coverage groups, there was only a 0.7% population-level quit rate, compared to 2.8% in the full coverage group.
Dr. McAfee attributes GHC's successful tobacco control efforts to several factors — most importantly its commitment to keeping the program simple and relieving the burden from clinicians. Support from leadership, evidence-based decision making, accountability, persistence, resources, and a quality improvement, and systems approach have also contributed to the success.
To conclude, Dr. McAfee offered several recommendations of how the government and private sector can influence health systems to improve tobacco services. First, as purchasers of health care services, more pressure should be applied for reimbursement of tobacco cessation services. Relevant research into improved cessation services should be funded and evidence-review and dissemination should continue such as has been described earlier in the meeting. Dr. McAfee encouraged the Surgeon General to use his "bully pulpit" to move some of these recommendations forward including the consideration of regulatory pressure and the need to keep up environmental enforcers such as excise taxes, media campaigns, and smoke free environments.
Following the three presentations, speakers responded to a series of questions.
Dr. Richling was asked about the role of unions in the UPRR's efforts to increase smoking cessation and he responded that the unions had been very supportive of these efforts.
Dr. McAfee was asked about the switching behavior of health care purchasers and how often switching decisions are made based on the services provided versus cost factors. Dr. McAfee responded that very often purchasers see cessation services as a nice "side benefit" but they are not, unfortunately, often a distinguishing factor in choosing a health plan. Due to often short lengths of stay in a health system, there is a perception (which may or may not be accurate) that while the cost of providing smoking cessation services is immediate, the benefit of reduced health care costs does not come until later when the patient may have moved on to another health plan. Therefore, smoking cessation services are most often provided with the intention of offering quality health care and improving patient's lives rather than as a cost saving measure. Further investigation and framing of the economic advantages of cessation to individuals, health systems, and purchasers is needed.
Following a break for lunch, Dr. Satcher told the committee that he had found the morning sessions rich and enlightening and was looking forward to the next set of presentations which would be followed by opportunities for member and public comments.
Quitline Programs—State and National Perspectives
Shu-Hong Zhu, Ph.D., Associate Professor, University of California at San Diego
Dr. Zhu began his presentation by providing a brief overview of the California Smokers' Helpline, the 10-year statewide program, and the growing popularity of statewide quitlines in the United States. From a smoker's viewpoint, telephone counseling is attractive because it is more accessible than traditional cessation clinics. Telephone counseling has also been shown to reduce the ethnic disparities in the use of smoking cessation services. In California, both African American and Hispanic smokers are active participants in the statewide quitline, with the latter especially encouraged by the availability of Spanish language service. From the program operation perspective, telephone counseling is more cost-efficient than traditional cessation clinics because it can centralize the statewide operation in one location, which makes it financially more feasible to provide multilingual services. More importantly, there is a synergistic effect between a statewide quitline and other population-based approaches to cessation such as tagging the quitline number to a statewide antismoking media campaign.
The California Smokers' Helpline is available in six languages (English, Spanish, Mandarin, Cantonese, Viet Namese and Korean) and a TTY line for the hearing impaired. Specific protocols are used depending on whether the caller is an adult, teen, or pregnant smoker. The Helpline currently serves about 45,000 callers per year, of which 34% are ethnic minorities. Rural smokers are over-represented. The quitline's protocol has been shown effective through a large randomized trial that indicated that smokers who receive multiple telephone counseling sessions have a higher one-year quit rate than those who receive only one session or who rely on self-help approaches. These results have been replicated in another study with the "real world" application of the protocol.
One of the challenges faced in California has been to encourage physicians to increase referrals of smoking patients to the Helpline. One useful strategy is to acknowledge clinicians' time constraints in providing cessation counseling and to offer the Helpline as a way to ease some of this burden. To reinforce physicians' referral, letters are sent to the physicians periodically to thank them and inform them of how many of their patients have called the Helpline because of their referrals.
Dr. Zhu concluded his remarks by indicating that quitlines have been an important component of a comprehensive approach to tobacco control efforts in many states. He recommended that federal agencies support state efforts by providing guidance on evidence-based practice. Dr. Zhu also believes that federal agencies can encourage collaboration among the state quitlines to share best practices and support the development of new cessation methodologies. Finally, more support is needed to address the disparity in the use of quitlines that is caused by the limited language capability of materials and counseling.
Following Dr. Zhu's presentation, Dr. Satcher asked whether the caller is required to take the initiative to call the Helpline after the first call, and Dr. Zhu said that the counselor is most often the person who places the next call.
M. Lyndon Haviland, Dr.P.H., Executive Vice President and Chief Granting Officer, American Legacy Foundation, Washington, District of Columbia
Dr. Haviland presented information about the American Legacy Foundation's Women and Smoking Initiative, the first program that will be called "Great Start." The goals of the program are to increase awareness of the risks of smoking during pregnancy; increase quit attempts before, during and after pregnancy; increase provider willingness to refer pregnant women to cessation services; and support pregnant women in their cessation efforts.
Great Start is a multipronged program that will include quitline services for pregnant women, as well as a television advertising component and patient education materials. Over the past year, Legacy has partnered with the First Spouses Association, American Cancer Society, and the Smokefree Families program sponsored by the Robert Wood Johnson Foundation to develop this initiative. Legacy created messages that are positive and empowering to women, provide a call to action, and educate the public about the consequences of smoking during pregnancy. Based on their commitment to going beyond solely raising awareness about the serious consequences of smoking during pregnancy, Legacy will support national telephone counseling services to support pregnant women who want to quit during pregnancy.
Committed to establishing a minimum set of cessation services for pregnant women, Legacy will establish a national quitline to address the lack of uniform national services for pregnant women interested in quitting. In operation by late fall 2001, the quitline will be available 24 hours a day and seven days a week and will offer counseling in English and Spanish. One national quitline number will be established and publicized. Working with a scientific advisory committee, Legacy has established counseling and call transfer protocols. In addition, the American Cancer Society has developed a database for local referrals for pregnant and non pregnant callers. Provider and patient education materials that support the telephone counseling will be available and widely disseminated.
Dr. Haviland concluded her remarks by sharing Legacy's commitment to providing high quality quitline services and public education through mass media. She stressed that Legacy will develop a strong evaluation component that will examine the need and demand for quitline services for pregnant women and will contribute to a better understanding of the media's role in increasing quit attempts.
Legacy is also committed to working with state and national partners to support existing quitlines and plans to share all protocols and quitline results with these partners. Dr. Haviland also shared the following recommendations for the federal government: assure a minimum set of cessation services for all smokers, regardless of age; coordinate services to assure collaboration, not competition; require cessation coverage by national health plans; support the rapid dissemination, adoption, and institutionalization of PHS guidelines; differentiate between individual and population-based cessation efforts; and pursue rapid dissemination and adoption of new and emerging cessation science.
Several questions were asked following Dr. Zhu and Dr. Haviland's remarks. The first concerned whether Legacy's Great Start program would include a web-based counseling component. Dr. Haviland responded that it would and would be operational in early 2002. A second question was asked of Dr. Haviland concerning the issue of relapse for women smokers who may have quit during pregnancy, but are likely to begin again following birth. The Great Start initiative will include an average of five proactive calls for counseling sessions, several of which may be postpartum-based on when a woman initially calls the quitline. When asked about whether the television advertising component will include testimonials of people who have successfully quit, Dr. Haviland described a cessation video that will include testimonials produced by director/actor Rob Reiner, that will be available in fall 2001. A final question was asked by Dr. Satcher concerning the much higher likelihood of lower income women to smoke during pregnancy and how this can best be addressed. Dr. Haviland responded that the Great Start project has been careful to include in its television advertising images of younger women who can be interpreted as lower income and literacy. Dr. Zhu added that in California when physicians received permission to provide telephone follow-up to pregnant women they were more likely to participate in cessation services.
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