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Regional Meeting
Public
Meeting on Promoting
Smoking Cessation Efforts
November 14, 2002
8:30 am to 1:00 pm
The Westin Westminster, Westminster, CO
Discussion Topics
Michael Fiore, M.D., M.P.H., Professor, Department of Medicine, Director,
Center for Tobacco Research and Intervention, University of Wisconsin Medical
School, Madison, Wisconsin
Chair, ICSH Cessation Subcommittee
Dr. Fiore began the meeting by reviewing the purpose and objectives of the
Cessation Subcommittee of the Interagency Committee on Smoking and Health (ICSH).
In August 2002, the ICSH established a separate working subcommittee to focus
national attention on cessation. This subcommittee is an advisory group to the
ICSH and is charged with developing a set of proposed action steps that will
presented to HHS Secretary Tommy Thompson in the winter of 2003. These
recommendations will serve as the basis for a Secretary’s initiative on
cessation, beginning in 2003, that will involve a series of federal initiatives
and public-private partnerships designed to reduce tobacco prevalence in the
United States by promoting evidence-based cessation.
The action plan will be informed by four evidence-based documents:
- Public Health Service’s Clinical Practice Guideline: Treating Tobacco
Use and Dependence
- U.S. Task Force on Community Preventive Services’ Guide to Community
Preventive Services: Tobacco Use Prevention and Control
- Action Plan on Tobacco Use Cessation: Recommendations from the
Interagency Committee on Smoking and Health (after the August 14, 2001
meeting entitled “Smoking Cessation: Facing the Challenges of Tobacco
Addiction.”)
- National Blueprint for Disseminating and Implementing Evidence-Based
Clinical and Community Strategies to Promote Tobacco Use Cessation
The action plan will also be informed by the oral and written public
testimony presented to the subcommittee during three regional meetings and up
until December 20, 2002. During this period of public comment, the subcommittee
hopes to hear from smokers and their families, clinicians, health care
administrators, researchers, purchasers, insurers, and others regarding
opportunities to promote cessation, barriers to action in promoting cessation,
and recommendations for overcoming these barriers.
HHS Secretary Tommy Thompson has challenged the subcommittee to present him
with a bold and innovative plan that will substantially decrease tobacco use
rates in the United States by promoting smoking cessation.
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The subcommittee’s task is specific and time limited. The group will meet
only five times: the first introductory meeting was held on October 1, the first
regional hearing on October 24 in Washington, D.C.; the second regional hearing
today in Westminster, Colorado; and the third and final hearing on December 3 in
Chicago, Illinois. The committee will meet a fifth and final time in January,
2003 to finalize the action plan before presenting it to Secretary Thompson by
the end of January, 2003.
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Testimony can be submitted both orally and written, and those presenting oral
testimony are encouraged to follow-up with written comments which will be
accepted until December 20, 2002. It was emphasized that the focus of the
subcommittee is on cessation and testimony should reflect this focus.
Each individual testifying during any of the three regional hearings is given
a limit of three minutes for remarks, with two minutes following the testimony
for subcommittee members to ask clarifying questions if necessary.
At the end of the morning, two invited presentations by Dr. Shu-Hong Zhu and
Captain Larry Williams (Cessation Subcommittee member) were added to provide
background for the subcommittee. Their comments are included with this report.
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Challenge and Promise of the Initiative
Dr. Fiore ended his introductory remarks by reminding the subcommittee
and meeting participants of the challenge and promise presented by this
effort. While we have a strong body of evidence supporting effective
interventions to help smokers quit, and the majority of tobacco users want
to quit, there is widespread reluctance among clinicians, health care
systems and the federal government to put what we know is effective into
practice. The charge of the subcommittee is to change this situation by
ensuring that clinical and population-based strategies are implemented
thereby reducing tobacco use and improving lives for millions of Americans.
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Linda Bailey, JD, MHS (for John Seffrin)
Center for Tobacco Cessation/American Cancer Society
Susan Curry, PhD
Health Research and Policy Centers, University of Illinois at Chicago
Ronald Davis, MD
Center for Health Promotion and Disease Prevention
Henry Ford Health System
Michael Fiore, MD, MPH
Center for Tobacco Research and Intervention, University of Wisconsin Medical
School
Catherine Gordon, RN, MBA
Office of Clinical Standards and Quality, Center for Medicare and Medicaid
Services
Cheryl Healton, DrPH
American Legacy Foundation
Rosemarie Henson, MSSW, MPH
Office on Smoking and Health, CDC
Scott Leischow, PhD (for Robert Croyle)
National Cancer Institute
Kevin Murray (for Christine Williams)
Agency for Healthcare Research and Quality
Dennis Richling, MD
Health Services, Union Pacific Railroad
Michael Schooley, MPH
Office on Smoking and Health, CDC
Capt. Larry N. Williams, DC, USN
Dental Department, Military Medical Support Office, US Navy
Members unable to attend on November 14:
Robert Croyle, PhD
National Cancer Institute
Charles Cutler, MD, MS
American Association of Health Plans
Howard Koh, MD, MPH, FACP
Commonwealth of Massachusetts
James Marks, MD, MPH
National Center for Chronic Disease Prevention and Health Promotion, CDC
C. Tracy Orleans, PhD
The Robert Wood Johnson Foundation
David Satcher, MD, PhD
National Center for Primary Care, Morehouse School of Medicine
John Seffrin, MD
American Cancer Society
Christine Williams
Agency for Healthcare Research and Quality
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Thirty-one individuals presented testimony during the meeting. A summary
of the recommendations follows, and it should be noted that these
recommendations are paraphrased and are not presented in any specific order.
- Strong HHS leadership on this initiative will lead to greater public
momentum which will in turn reach many more tobacco users who want to
quit. (Bjornson)
- The United States would benefit from effective regulation of tobacco
products by the Food and Drug Administration. Through increased regulatory
authority, the federal government can require ingredient and design
disclosure. (Bunn/Keane/Doyle)
- The federal government should place restrictions on tobacco industry
marketing, including the targeting of tobacco products to American Indians
and other ethnic minority populations. (Bunn/Doyle/Shorty)
- HHS must work with tribal communities and other agencies to develop
and encourage the use of evidence-based, culturally competent strategies
to understand and overcome the barriers faced by American Indians and
Alaska Natives who want to quit smoking. (Shorty/Staples)
- Although the focus of this subcommittee is on cessation, it is crucial
to not lose sight of a comprehensive approach to tobacco control. The
Department should continue to support the establishment, implementation
and continuation of such comprehensive state and tribal-based programs.
(Lopez/Keane)
- To be successful, there must be sustainable, dedicated and
non-vulnerable funding to support state-based comprehensive tobacco
control programs. (Moore/Bjornson/Jolte/Henderson/Reister)
- Funding to the CDC’s Office on Smoking and Health should be increased
to enable this office to continue to provide leadership and better support
states’ efforts in implementing comprehensive tobacco control programs. (DeLeeuw)
- HHS should assure that evaluation of cessation initiatives is required
of federally funded health care programs to improve quality and build an
evidence-base for delivery of cessation services. (Bjornson)
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- Consumers should be educated about the availability and importance of
evidence-based treatments as well as the myths associated with “safer
cigarettes.” (Bunn/Doyle)
- Coverage of effective tobacco dependence treatment in all federally
funded health care programs (e.g. community and migrant health centers,
rural health clinics, Indian Health Service clinics, WIC programs) should
be required as a regular part of medical care. (Moore/Bjornson/Jolte/Yetman/Henderson/Jacobellis)
- Federal financial support should be available to local organizations
providing cessation services to enable the provision of incentives to
tobacco users to attend classes, AND provide NRT (or a stipend to purchase
NRT) regardless of class attendance. (Hanson)
- Insurance should cover the more intensive treatment required by
heavily addicted tobacco users. (Bunn)
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- The “5 A’s” for treating tobacco dependence must be institutionalized
into all visits with health care professionals. (Bjornson/Bunn/Jotte/Yetman/Henderson/Jacobellis)
- A core curriculum for tobacco intervention should be developed and
integrated into medical and allied health professional training. (Bunn/Yetman/Henderson)
- Smoking cessation intervention must be integrated into patient care
plans and disease management programs, including indicating tobacco use
status as a key vital sign. (Bunn/Schwartz)
- Providers should discuss tobacco use in the context of cancer
treatment and recurrence. (Bunn)
- School health personnel should receive training in brief interventions
for assisting youth in their quit attempts. (Yetman/Davis)
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- There is a need to expand population-based approaches to tobacco
control because the success of cessation efforts depends on other elements
such as media and community programs. (Moore/Jolte/Yetman/Henderson/Jacobellis)
Such population-based approaches should also be employed to address
smokeless tobacco use. (Scardino)
- All tobacco users should have barrier-free access to telephone quit
lines. These quit lines can either be state-based and operated or a single
national service that bridges to state-based services can be developed.
(Bunn/Reister). A paid media campaign promoting this service is essential
to motivate utilization and multi-lingual services are crucial to engaging
non-English speakers. (Hamasaka/DeLeeuw/Zhu/Carey).
- The federal excise tax on cigarettes and other tobacco products should
be increased substantially (in the range of $2). (Bunn) It is essential
that a significant portion of the tax increase be dedicated to state level
tobacco control efforts and a substantial amount of these funds dedicated
to cessation – including state sponsored quit lines. (Bjornson/Jolte/Yetman/Henderson)
- The federal government should initiate a national, evidence-based
media campaign, well coordinated with state campaigns, to increase
awareness of the effectiveness of cessation services and prompt tobacco
users to demand and seek services. (Bjornson/Jolte/Yetman/Henderson/Reister/Jacobellis)
- Tobacco-free school laws should be strictly enforced. (Yetman)
- Teen tobacco users should have barrier-free access to the widest range
of services available, including support groups, internet cessation
services, school-based services and quit lines. (Davis)
- The impact of smuggling and other illegal activities should be
considered in the context of tax increases. (Gorman)
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- Providers should be appropriately reimbursed for providing smoking
cessation counseling and treatment services. (Bunn)
- Providers should be allotted the appointment time necessary to engage
in discussions with their patients about quitting smoking. (Bunn)
- HHS should encourage private insurers to provide coverage for tobacco
dependence treatment, including pharmacotherapy, counseling, and extra
assistance. This benefit should include coverage for multiple quit
attempts. (Bunn/Yetman/Hanson/DeLeeuw)
- A standard Medicaid benefit should be developed which includes access
to telephone counseling and pharmacotherapy. States should be encouraged
to provide this standard benefit with no cost sharing requirement. (Schauffler)
- Medicare and Medicaid coverage for a comprehensive tobacco use
treatment benefit, including drug coverage and consistent with the PHS
Clinical Practice Guidelines, should be available to all tobacco using
beneficiaries. (Bunn/Keane/Schauffler/DeLeeuw/Piel)
- Employers and other purchasers should put pressure on private insurers
to provide coverage of smoking cessation. (Bunn/Schauffler)
- A standardized system to identify and support tobacco users, including
pregnant smokers, should be developed. (Barker/Schwartz)
- Pregnant smokers should have access to fully covered tobacco use
treatment, including counseling. (Barker)
- HHS should require that federally funded health care programs include
quality improvement measures for the delivery of tobacco cessation
services. (Bjornson)
- The military, as an entity that covers a large number of beneficiaries
and a direct service provider, represents a significant opportunity to
intervene using evidence-based clinical approaches and through coverage
for smoking cessation. (Williams)
- HHS should ask that NCQA measure the types of smoking cessation
programs and benefits offered as a standard of care. (Schwartz)
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The federal government should encourage and fund research in the
following areas:
- Effectiveness of cessation products in patients with cancer (Bunn)
- Tobacco product design and ingredients (Bunn)
- Degree of reversibility of effects of nicotine exposure (Bunn)
- Cultural and social basis for smoking (Bunn)
- Long-term studies of the retention rate of tobacco intervention education
for providers (Bunn)
- Improved treatments, including those tailored to youth and racial and
ethnic minority populations (Bjornson/Jolte/DeLeeuw/Jacobellis)
- More effective methods for treating underserved and high-risk populations
such as pregnant women and highly addicted tobacco users (Bjornson/Yetman/Hamasaka/Hanson)
- Tobacco use cessation products that target the genetic basis of nicotine
addiction (Bunn)
- Baseline information about the current prevalence of adults and youth
using smokeless tobacco products (Scardino)
- Effectiveness of teen specific quit lines (Zhu)
- Reasons for the ethnic disparity between Caucasians and Latinos in their
receipt of advice to quit smoking (Levinson)
- Effectiveness of NRT and Zyban for the teen population with multi-drug
addictions (Hanson)
- Neurobiology of the causes and consequences of nicotine addiction (Hanson)
- The role of stress in relapse (Hanson)
- Immunization as a way to prevent tobacco addiction (Hanson)
- More effective behavioral and pharmacological strategies (Hanson)
Following the public testimony, Michael Schooley, Executive Secretary for the
Interagency Committee on Smoking and Health, thanked all those who provided
testimony, and encouraged everyone to supplement oral testimony with written
remarks. He also encouraged subcommittee members, testifiers, and observers to
inform others about the third and final regional meeting in Chicago, Illinois on
December 3, 2002.
The meeting adjourned at 1:00 p.m.
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