Federal Government's Role
November 6, 2003: Public and Private Sector Roles in Tobacco Use Reduction
Dr. Larry Fields, M.D., M.B.A., F.A.C.C., Senior Executive Advisor to the Assistant Secretary for Health, U.S. Department of Health and Human Services
In the last 40 years, the United States has made great strides in its efforts to control the epidemic of tobacco use. The prevalence rates of tobacco use among adult men and women have continued to decline and data tell us that 70 percent of current adult smokers in the United States want to quit. Youth tobacco use has also been on the decline and if it continues to decline at the current rate, we may meet our Healthy People 2010 objective of reducing current smoking rates among high school students to 16 percent. Some of the most impressive declines have occurred in the area of exposure to secondhand smoke. During the last decade, there has been more than a 75 percent decrease in median cotinine (a metabolite of nicotine) levels for nonsmokers in the United States. All of these successes have been due to strong public and private partnerships.
It is fortunate that those who work in tobacco control have a strong body of evidence on which to rely which supports effective tobacco prevention and control interventions. The Task Force on Community Preventive Services has released recommendations on such effective interventions including: smoking bans and restrictions; increasing the price of tobacco products; mass media campaigns; telephone counseling and support to help tobacco users quit; and reducing patient out-of-pocket costs for effective cessation treatment. Therefore, we know a lot about "what" to do, but continue to be challenged by the "how-to"—getting these evidence-based approaches into practice.
Dr. Fields continued his remarks by describing some of the activities in which the federal government is currently involved to address tobacco use. He followed the four goal areas that many states as well as CDC have identified which are: preventing initiation of tobacco use among young people; promoting quitting among young people and adults; eliminating nonsmokers' exposure to environmental tobacco smoke (or secondhand smoke); and identifying and eliminating disparities related to tobacco use and its effects among different population groups. Dr. Fields also reviewed the nine elements of statewide comprehensive tobacco control programs as described in the CDC publication, Best Practices for Comprehensive Tobacco Control Programs. These elements include: community programs to reduce tobacco use; chronic disease programs to reduce the burden of tobacco-related diseases; school programs; enforcement; statewide programs; counter-marketing; cessation programs; surveillance and evaluation; and administration and management.
I. Reducing Youth Initiation
Although more than one of four U.S. high school students still smoke cigarettes, rates among this group have been declining since 1997. This positive trend is a result of a combination of factors including: a 70% increase in the retails price of cigarettes from 1997-2001; exposure to effective counter-marketing campaigns such as the American Legacy Foundation's truth campaign; and an increase in the percentage of schools required to teach tobacco use prevention and having strict tobacco free policies.
To maintain this positive downward trend in youth tobacco use, and to counter tobacco industry marketing to teens, we must remain vigilant in our efforts to alter social norms around smoking. One of the most effective strategies for doing this is to raise the price of tobacco products and the Department of Health and Human Services is supportive of states' efforts in this area. Raising the price is also an effective strategy for getting current smokers—youth and adults alike—to quit. Dr. Fields cited as an example the Department of Defense's successful effort to decrease discounts of tobacco products in commissaries to within 5–10 percent of prevailing local rates.
The Department also supports efforts to reduce youth tobacco use by curtailing access and availability of tobacco products through the Synar regulation, which is implemented and monitored by SAMHSA's Center for Substance Abuse Prevention.
II. Promoting Cessation
Dr. Fields began by acknowledging the creation of the first ever subcommittee of the ICSH focused on cessation and chaired by Dr. Michael Fiore. He recognized Dr. Fiore, and asked that a brief update on the cessation subcommittee be provided later in the meeting.
In the area of smoking cessation, there is a strong body of evidence indicating the most effective strategies to help people quit smoking. The Public Health Service's Treating Tobacco Use and Dependence: A Clinical Practice Guideline and the CDC's Guide to Community Preventive Services: Tobacco Prevention and Control provide clinical, health system and population-based recommendations on the most effective interventions. "A National Blueprint for Disseminating and Implementing Evidence-Based Clinical and Community Strategies to Promote Tobacco-Use Cessation" (still in draft form) is a consensus document developed through a public-private partnership that aims to ensure that effective interventions are implemented nationwide.
Cost is a barrier
One of the barriers to reaching smokers who want to quit is the cost associated with treatment, and current coverage varies widely. Medicare does not currently provide coverage for tobacco use treatment, but a demonstration program through the Centers for Medicaid and Medicare Services is currently underway to determine the most feasible and effective cessation intervention for older Americans. HHS has also worked to expand coverage of tobacco dependence treatment for federal employees and dependents whose benefits come under the Federal Office of Personnel Management. Participating health plans are now "encouraged" to cover tobacco use treatment consistent with the PHS Clinical Practice Guideline.
Brief interventions are effective
Unfortunately, many health care systems do not have systems in place to screen patients for tobacco use and providers often do not feel equipped to assist patients who want to quit. Evidence demonstrates that even with a relatively simple and brief intervention such as advising a patient to quit, cessation rates can be increased to 5–10 percent annually. More intensive interventions such as those that combine behavioral and pharmacologic treatment can produce 20–25 percent quit rates in a year.
Federal support is available
Through the National Cancer Institute's Cancer Information Service, its manual called "Clearing the Air," and a state-of-the-art website currently in development in partnership with the CDC, there are ways that people who are ready to quit smoking can get support. Additional research underway through the NCI, National Institute for Drug Abuse, and private foundations, will help us better understand the most effective tobacco cessation interventions.
III. Eliminating Nonsmokers' Exposure to Secondhand Smoke
Secondhand smoke is a leading cause of disease and death in adult nonsmokers and serious health problems in children. Clean indoor air policies in schools, health care facilities and workplaces have been shown to promote health by contributing to changes in community norms regarding smoking and by reinforcing the smoking prevention message to youth. Such restrictions lead many to reduce their consumption or quit entirely and similar results are found from self-imposed restrictions in the home. Efforts such as the Smoke-Free Home Pledge and the "Go Out for Your Kids" campaign produced by the Environmental Protection Agency, the American Medical Association and the Consumer Federation of America Foundation are a great step forward.
IV. Reducing Disparities
Both the CDC's Office on Smoking and Health and the NCI have committed significant resources to helping eliminate disparities in tobacco use. These two groups, together with other key partners such as the Robert Wood Johnson Foundation, American Legacy Foundation and the American Cancer Society are sponsoring the National Conference on Tobacco and Health Disparities in Tampa Florida on December 11-13, 2002. The purpose of the conference is to review the current science regarding disparities and define a research agenda necessary for a richer understanding of how to define and eliminate population disparities. Although progress as been made in this area, there is more that needs to be done to effectively decrease tobacco related diseases.
Dr. Fields concluded his remarks by outlining three roles that he believes the federal government should play in tobacco use prevention and control.
First, the federal government must continue to support strong research in tobacco use prevention and control to better understand and develop effective interventions.
Second, the federal government must continue to provide leadership in the translation of science into effective interventions and the dissemination of these interventions at the national, state and community levels.
Third, the federal government should continue to monitor and evaluate the impact of our efforts on reducing tobacco use and improving the health of our nation.
In conclusion, Dr. Fields stressed the critical importance of developing, facilitating and supporting partnerships with all of the various individuals and groups—public and private—involved in tobacco prevention and control.
Following Dr. Fields' remarks, Surgeon General Carmona asked ICSH members to introduce themselves.
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