Key Results: Increasing the Use of Smoking Cessation Treatments
Citations Listed in Key Results
- Smoking cessation can save lives. Duration of smoking is the most important factor associated with risk of premature death. The sooner someone quits the better their chances of avoiding adverse health consequences.
For all the money poured into cancer research in recent decades, most of the progress in reducing cancer mortality has been due to deaths avoided through successful tobacco control, especially efforts to persuade smokers to quit.
The American Cancer Society recently examined how much the decline in smoking had contributed to the decline in deaths from all cancers in the US. It concluded: "Even our most conservative estimate indicates that reductions in lung cancer, resulting from reductions in tobacco smoking over the last half century, account for about 40% of the decrease in overall male cancer death rates ... A more realistic straight line projection of what lung cancer rates might have become suggests that, without reductions in smoking, there would have been virtually no reduction in overall cancer mortality in either men or women since the early 1990s. The payoff from past investments in tobacco control has only just begun."
If there was any doubts about the benefits of quitting sooner than later this question was erased by a recent report based on the 50-year follow-up of over 34,439 male British doctors. It found that prolonged smoking from early adult life tripled the risk of premature mortality, but cessation by age 50 nearly halved the risk and quitting by age 30 reduced the risk to approximately the same level of someone who never smoked. Even those quitting after 65 added three years to their life expectancy.
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- Interventions that have the greatest chance of reducing tobacco use in the population are those that reach the most smokers repeatedly and make tobacco use less appealing, such as increasing tobacco taxes, restricting tobacco product marketing, implementing smoke-free policies, sponsoring hard hitting anti-tobacco media campaigns, and changing policies to dramatically increase access to cessation support.
Numerous studies by SAPRP investigators and others have found that various policies that make tobacco use less affordable, convenient and attractive can increase quit rates. The impact of such policies on reducing tobacco use appears to be enhanced when they are implemented simultaneously.
The effectiveness of such an approach was demonstrated in New York City after implementation of a comprehensive tobacco control plan that included increasing the cigarette excise tax; legal action that made virtually all work-places, including bars and restaurants, smoke free; a paid public education campaign about the risks of smoking; and improved access to cessation services, including a large-scale free nicotine-patch program.
Simulation models have also been used by SAPRP investigators to estimate how different tobacco control policies might impact smoking rates in the population. Using a dynamic simulation model of smoking trends, known as SimSmoke, it was found that by 2010, the aging of older population groups and the impact of policies implemented in years prior to 2004 would produce smoking rates of approximately 18.4%, which is substantially short of the national 2010 goal of 12%. According to SimSmoke, if policies such as higher taxes and clean air laws are implemented, smoking rates would be substantially reduced and come closer to reaching the 2010 goal.
In August 2002, the Subcommittee on Cessation of the federal Interagency Committee on Smoking and Health (ICSH) was charged with developing recommendations to substantially increase rates of tobacco cessation in the United States. The subcommittee's report, A National Action Plan for Tobacco Cessation, outlined 10 recommendations for reducing premature morbidity and mortality by helping millions of Americans stop using tobacco.
The plan includes various strategies designed to promote cessation, such as establishment of a national "quitline" network and a $2 per pack excise tax increase to pay for a Smokers' Health Fund.
The main elements of the ICSH plan also were reiterated and expanded upon in a 2007 report by the Institute of Medicine (IOM), which also outlined a national plan for reducing tobacco use. The IOM report describes a strategy that includes strengthening and fully implementing existing tobacco control measures known to be effective in discouraging tobacco use and expanding the regulatory framework for tobacco to limit the marketing of addictive products.
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- Nicotine in tobacco is the primary reason why most people find it hard to stop using tobacco. Clinical trials have provided evidence that there are several drugs that can help people quit smoking. These drugs work by either mimicking the positive impact that nicotine has on the brain of a smoker or lessening symptoms of nicotine withdrawal that typically occur a when a smoker stops using tobacco.
As summarized in the 1988 Surgeon General's Report on Smoking and Health - and more recently in tobacco industry documents- there is no doubt that nicotine in tobacco is the primary reason why most tobacco users continue to expose themselves to the known toxins found in tobacco.
Nicotine creates dependence by stimulating the release of chemicals that make a person feel better. Over time, higher levels of nicotine are required to unleash the chemicals and reproduce the positive feeling, which explains why most smokers start out smoking infrequently and eventually increase their smoking to about a pack per day. When smokers stop smoking without any assistance, the abrupt discontinuation of nicotine can cause bad moods and other symptoms of nicotine withdrawal, which make it likely that the effort to quit will fail.
This problem has led to the development of smoking cessation treatment methods that emphasize nicotine replacement or nicotine mimicry. Nicotine mimicry, which is the goal of the newly engineered compound Varenicline, decreases nicotine withdrawal by weakly stimulating the body's nicotine receptors, while also decreasing the "high" of nicotine itself by binding much more strongly to the receptors, blocking nicotine uptake.
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- Effective behavioral and pharmacological treatments for smoking cessation are underutilized across the population, but especially among the poor.
Based on a recent comprehensive review of the effectiveness of different smoking cessation treatments, the USPHS recommended that all smokers receive practical behavioral counseling and support to quit, preferably in combination with FDA approved smoking cessation medication. It also recommended that health care workers screen all patients for tobacco use and provide advice with follow-up behavioral treatments to all tobacco users. In addition, the USPHS recommends that smoking cessation medications be made available to all smokers who wish to quit.
Despite these treatment guidelines, population based surveys reveal that most tobacco users today are not receiving treatment assistance from their health care providers. For example, a recent survey reported that tobacco counseling occurred in less than one-fourth of doctor visits by tobacco users and cessation medications were prescribed on less than 3% of occasions.
Interestingly, the odds of getting a prescription for a stop smoking medication increased 15-fold if the patient requested it. Studies by SAPRP investigators have documented that the utilization of proven smoking treatments is lowest among those who are uninsured and those who have the greatest need for assistance in quitting tobacco (such as smokers with mental health and other substance abuse problems). Similar findings have been found by others.
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- Policies that make pharmacological and behavioral treatments more accessible and affordable, such as over-the-counter sale of nicotine replacement medications telephone "quitlines," and workplace cessation programs can increase their utilization.
Several studies have demonstrated the effectiveness of interventions developed to make smoking treatments more accessible and affordable. For example, sales of nicotine medications for smoking cessation increased when they were made available as over-the-counter, as opposed to prescription-only, products.
There is also emerging evidence that employer policies can play a role lowering smoking rates. These policies include banning smoking at work, linking health insurance premiums to smoking status, and providing easy access to cessation programs.
Telephone "quitlines" that offer easy, instant access to information on how to quit smoking have been shown to be useful interventions for promoting smoking cessation. The advertising, word of mouth, and healthcare involvement associated with quitlines helps to stimulate quit attempts while increasing demand for and easy access to low cost treatments for tobacco cessation. Studies also show that smokers, especially younger adults, like the ability to access cessation assistance over the Internet.
In addition, there is evidence that smokers are responsive to the cost of stop smoking interventions. Studies have found that more people will make use of proven treatment interventions if the cost is covered by insurance or treatment is available for free or at a discount.
Increasing awareness of effective cessation treatments does not always guarantee greater utilization. But generally speaking, it will increase use, especially if consumers get repeatedly exposed to the information. For example, requiring cigarette manufacturers to print a national quitline number on cigarette packs has been found to be a cost-effective way to increase the number of tobacco users accessing the service.
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- Inconsistent efforts by health-care providers to offer proven cessation treatment is an important barrier preventing tobacco users from gaining access to effective treatments. An approach called "pay for performance" is being used to motivate health care providers to improve their delivery of proven cessation treatments.
Despite increasing national attention to the benefits of proven smoking cessation treatment, health care providers routinely fail to identify patient tobacco status. Also, their provision of cessation counseling and recommending of cessation medications and referrals to structured counseling programs for smokers are lower than they should be. Women and elderly tobacco users and those without private insurance appear to be especially unlikely to receive prescriptions for cessation medications. Patients who request treatment and those with tobacco-related health problems are more likely to get help.
In recent years there has been improvement in private, federal and state insurance coverage for some components of treatments recommended by the USPHS. For example, Medicare now provides reimbursement for counseling and pharmacotherapy.
However, insurance reimbursement for smoking cessation remains spotty. A 2002 national survey of Medical Care Organizations (MCO) revealed that 30 percent had no written policy on coverage for tobacco cessation services and 42 percent provided no coverage for behavioral interventions.
Evidence produced by SAPRP-supported investigators has helped demonstrate that MCO's would be wise to invest in comprehensive smoking cessation services. The costs of the services are low relative to the potential return on investment in the form of reduced smoking-related health care expenditures. This work has stimulated the adoption of pay-for-performance incentives by some health insurers to motivate health care providers to improve their delivery of proven cessation treatments to their tobacco using patients.
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Steinberg MB, Akinciquil A, Delnevo C, et al. Gender and age disparities for smoking cessation treatment. American Journal of Preventive Medicine. 2006; 30(5):405-412.
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