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Interagency Committee on Smoking & Health

Introductory Meeting Summary

Interagency Committee on Smoking and Health
Cessation Subcommittee
October 1, 2002
10:00 am to 4:00 pm
Hubert Humphrey Building, Washington, DC

Welcome and Introductions

Overview of Cessation Subcommittee and Discussion

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.

Michael Schooley, M.P.H., Executive Secretary, Interagency Committee on Smoking and Health, Acting Associate Director for Policy, Planning and Coordination, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

Dr. Fiore welcomed the subcommittee, described its role and reviewed the agenda. Dr. Fiore also welcomed U.S. Surgeon General Richard Carmona who briefly joined the group through Envision to add his welcome, thanks and support for the project. As Surgeon General, Dr. Carmona serves as chairperson of the Interagency Committee on Smoking and Health.

Michael Schooley provided background on the Interagency Committee on Smoking and Health and the meetings and initiatives leading to the creation of the cessation subcommittee.

Dr. Fiore then reviewed the charge and purpose of the subcommittee, the scope of its work, and the logistics of the five meetings that will occur during the subcommittee’s tenure.

Charge and Purpose: To take the existing evidence base on effective cessation interventions, supplement it (if necessary) based on input from the regional meetings, and develop an action plan for the Secretary of Health and Human Services. This action plan will serve as the basis for a Secretary’s initiative on cessation beginning in 2003. There are two primary goals for the initiative: to increase the number of quit attempts among the U.S. population of smokers and to encourage the use of evidence-based treatment that is widely available but under-utilized by those trying to quit and to ensure such treatment is widely available.

Scope: The work of the subcommittee will lead to a brief report including action steps which the Secretary can move forward through a Secretary’s initiative and by fostering public-private partnerships to achieve these action steps. Dr. Fiore emphasized that the subcommittee’s work will be brief but intense, and will be completed by January of 2003, after a total of five meetings. Following October 1st, three regional meetings will be held across the country to gather public comments and a fifth and final meeting will be held to finalize the recommendations. The recommendations will then be presented to the Secretary. Dr. Fiore reminded the subcommittee that its work would focus specifically on tobacco use cessation and not on the broader issue of tobacco control.

Logistics: Dr. Fiore encouraged subcommittee members to attend all of the five meetings, including those held in Washington, D.C.; Denver; Colorado; and Chicago, Illinois, intended to gather public comments.

Dr. Fiore described in greater detail the logistics of this day’s meeting: first a review of the evidence base and the four documents serving as the foundation for the action plan; next, presentations from representatives of many of the federal agencies involved in tobacco cessation; and finally, initial steps to identify some recommendations. Dr. Fiore suggested segmenting the recommendations into four sectors: consumers (tobacco users and their families); clinicians; health systems, employers and insurers; and populations. Additionally, recommendations will be divided into those that focus on federal and/or state initiatives and those that focus on public and private partnerships.

Following this overview, subcommittee members introduced themselves. Two members were unable to attend: Rosemarie Henson, M.S.S.W., M.P.H., Director, Office on Smoking and Health, Centers for Disease Control and Prevention and Cheryl Healton, Dr.P.H., President and Chief Executive Officer, American Legacy Foundation.

Using the Evidence Base to Strengthen Tobacco Use Cessation Efforts

Following a break, subcommittee members heard presentations summarizing each of the four evidence-based documents serving as the basis for the recommendations:

Public Health Service’s Clinical Practice Guideline: Treating Tobacco Use and Dependence

Carlos Roberto Jaen, M.D., Ph.D; John M. Smith, Professor and Chair, University of Texas Health Sciences Center at San Antonio, Department of Family and Community Medicine, San Antonio, Texas.

Summary of presentation:

  • PHS Guideline was sponsored by a consortium of 7 non-profit and government agencies (AHRQ, CDC, NCI, NHLBI, NIDA, RWJF, and CTRI).
  • Guideline was created by a multidisciplinary panel of 18 tobacco treatment experts.
  • 6,000 articles published between 1975 and 1999 were reviewed and 180 articles were coded for possible meta-analysis.
  • The major findings and panel recommendations presented by Dr. Jaen are attached in Appendix 1.

U.S. Task Force on Community Preventive Services’ Guide to Community Preventive Services: Tobacco Use Prevention and Control

Corinne Husten, M.D., M.P.H., Chief, Epidemiology Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

Summary of presentation:

  • The Task Force on Community Preventive Services is an independent non-governmental group that makes recommendations on a number of health conditions, including tobacco use.
  • The Task Force evaluated 15 interventions, screened 16,000 citations and found 166 studies that provided evidence on effectiveness.
  • Recommendations were made for both health care system-level interventions and population-based strategies.
  • The recommendations presented by Dr. Husten are in Appendix 1.

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.")

David Satcher, M.D., Ph.D., Director, National Center for Primary Care, Morehouse School of Medicine, Atlanta, Georgia.

Summary of presentation:

  • Dr. Satcher, in his role as Surgeon General and Chair, requested the development of an action plan on cessation following the August 14, 2001, meeting of the Interagency Committee on Smoking and Health.
  • The action plan offers concrete and tangible steps that governments, health care systems, providers, employers and purchasers can take to achieve HP 2010 tobacco use cessation goals.
  • The plan was presented to the Secretary who recommended the creation of a Cessation Subcommittee of the Interagency Committee on Smoking and Health.
  • The recommendations presented by Dr. Satcher are included in Appendix 1.

National Blueprint for Disseminating and Implementing Evidence-Based Clinical and Community Strategies to Promote Tobacco Use Cessation

C. Tracy Orleans, Ph.D., Senior Program Officer and Senior Scientist, Research and Evaluation, Robert Wood Johnson Foundation, Princeton, New Jersey.

Summary of presentation:

  • The goal of the Blueprint is to improve health and reduce tobacco-related illness and death by implementing evidence-based clinical and community strategies shown to increase tobacco-use cessation in the United States.
  • Collaborating members represent 10 public and private entities that have been working on the development of the Blueprint since Fall 2001.
  • Objectives and strategies are divided into four subgroups: clinicians, systems, consumers/users and community.
  • Next steps for the Blueprint are to complete the AHRQ review process, expand partners, develop an implementation plan and evaluate the results of this plan.
  • The objectives included in the Blueprint document are in Appendix 1.

Following each of the four presentations, subcommittee members asked questions of the presenters and held brief discussions. The following summarizes the major issues discussed:

  • Regarding the process for the five subcommittee meetings, a question was asked about a website for submitting public comments that would allow those accessing the website to view all submitted comments. It was also noted that this website should be available for input for a short period beyond the last regional meeting.
  • A question was asked about how much we know about how the various guidelines are being implemented and how they may have led to changes in practice. While progress has been made, particularly in managed care’s use of the Clinical Practice Guidelines, as well as in providers increased use of the "asking" and "advising" recommendations, there is still much progress to be made. This is especially the case regarding assistance with referrals for tobacco use dependence treatment and covering the cost of this treatment.
  • The subcommittee discussed the issue of how to better increase consumers’ demand for tobacco use dependence treatment. The use of mass media campaigns was offered as an effective strategy as was increasing the price of tobacco products.
  • Insurance coverage for tobacco use dependence treatment and the importance of helping insurers better understand the return on their investment in these services was discussed. The challenge to this is that tobacco cessation services are often viewed as a preventive health service rather than treatment for a medical condition — thus making it more difficult to justify insurance coverage.

Dr. Eve Slater, Assistant Secretary for Health, U.S. Department of Health Human Services, briefly visited with the group and added her support for the work of the subcommittee. She reiterated that Secretary Thompson is strongly supportive of the subcommittee’s work and is eager to receive the recommendations and act on their implementation.

Federal Agency Panel on Current Cessation Activities

Following an hour break for lunch, a panel of federal agency representatives (see attached list) was asked to respond to the following question:

Describe one activity that your agency could do that would promote dissemination of evidence-based strategies (with no limitations placed cost.)

Jared Jobe, Ph.D., National Heart, Lung and Blood Institute

  • To develop better brief tobacco cessation interventions for primary care physicians.

Cindy Miner, Ph.D., National Institute on Drug Abuse

  • To develop new treatments, therapies and behavioral interventions and more specifically, to identify molecular targets for new medications.

Lynn Pahland, Department of Defense

  • To achieve a uniform, system-wide tobacco use dependence treatment benefit.

Barry Portnoy, Ph.D., National Institutes of Health

  • Facilitate collaboration among all the Institutes.

Aron Primack, M.D., M.A., Fogerty International Center, NIH

  • To further expand international research and capacity building in tobacco use dependence treatment.

Christine Williams, Agency for Health Care Research and Quality

  • To support academic detailing with physicians meeting together to train on the use of the PHS Guidelines.

Scott Leischow, Ph.D., National Cancer Institute

  • To support additional translational research.

Rita Goodman, Health Resources and Services Administration

  • To make tobacco use dependence treatment counseling reimbursable and at low cost for the uninsured.

Catherine Gordon, R.N., M.B.A., Centers for Medicare and Medicaid Services

  • To have the current Medicare demonstration project lead to a tobacco use dependence treatment benefit, not only for Medicare but also for private insurers.

Frank Hearl, National Institute for Occupational Safety and Health

  • To develop partnerships between employers, labor representatives and others to increase credibility of smoking cessation programs among blue-collar workers. This may be achieved by helping employers better understand the combined negative effects of multiple workplace exposures (such as asbestos and tobacco smoke).

Corinne Husten, M.D., M.P.H., Office on Smoking and Health, CDC

  • To provide additional earmarked funding to states for quit lines to reach all tobacco users.
  • Support for matching grants to health care systems to institutionalize brief interventions.

Following these responses, subcommittee members were asked if they had questions for federal agency panel members. The following bullets summarize the major issues discussed:

  • Pharmaceutical companies are reluctant to develop tobacco use dependence treatments because of the lack of reimbursement for their use. Members discussed the need to increase development of effective therapies.
  • The NCI is increasingly funding communications science research to better understand how to increase consumers’ demand for cessation services.
  • The need for a clearinghouse of all health education materials that can easily be downloaded was noted. CDC and AHRQ discussed their respective agencies’ plans for cessation-specific clearinghouses.
  • The need for more data on harm reduction was discussed and this will be a priority for NCI tobacco research efforts in the coming year.
  • Members discussed how best to develop recommendations for the Secretary so that there will be shared responsibility among agencies.
  • The availability of models for successfully translating science into practice was discussed, and several examples were shared.
  • Finally, members discussed the importance of gaining a better understanding of the amount of money currently being spent in the country on tobacco use dependence treatment research and services.

Public Comments

Following the panel presentation, Dr. Fiore asked for public comment. None was offered.

Tommy Thompson, Secretary of Health and Human Services, joined the meeting to welcome everyone and thank them for their involvement on the committee. He reiterated his support for the work of the subcommittee and his interest in receiving the recommendations. Secretary Thompson challenged the subcommittee to present him with forward-looking, evidence-based strategies that will substantially decrease tobacco use rates in the United States by promoting smoking cessation.

Committee Discussion

The final session of the meeting was a discussion about a framework for soliciting public comments and a structure for the recommendations. Dr. Fiore provided a matrix and asked the committee to begin to discuss possible recommendations.

The issues discussed are summarized in the table on the following page.

[Please note that these are discussion items only and do not represent formal recommendations with subcommittee consensus.]

  Federal/State Initiatives Public/Private Partnerships Goals

Consumers 
(Smokers and families)

Mandate tobacco cessation benefit coverage for all federal employees and covered lives (e.g., OPM, DOD, VA, and Medicaid) so that they have access to evidence-based treatments. Strategies to motivate smokers not willing to make a quit attempt to quit
  • Uniform coverage for evidence-based treatments

  • Increase quit attempts

  • Increase successful quit rates
  • Increase cost of tobacco products
Clinicians Trained prevention specialists (need to review evidence of effectiveness)

Certification (discussed pros and cons)

Movement toward a prevention model in medical schools rather than a disease model

  • Increase identification of tobacco users and use of the 5 As.

Health Systems/
Employers/
Insurers/Consultants

 

(Remember policymakers as audience – (e.g., CEOs)

Translation of science into practice for employers using simple models/solutions

Corporate leadership

Identify key leverage points

  • Stimulate demand for cessation services

  • Uniform health coverage with stimulated use

Community/Populations

Uniform/barrier-free access to evidence-based quit lines

Development of strong paid (preferable) and PSA media campaigns

Strategies to prevent further decline in state spending of MSA dollars on tobacco control efforts

HHS Secretary issue challenge to consumers and CEOs

Uniform/barrier-free access to evidence-based quit lines

Development of strong paid (preferable) and PSA media campaigns

  • Increase demand for tobacco use dependence treatment

  • Uniform messages that promote targeted cessation treatments

Next Steps and Closing Comments

The meeting concluded with a brief discussion of next steps, including an agreement to draft questions for the solicitation of public comment. Staff was also encouraged to look at previous Secretaries’ initiatives to determine factors leading to their success or failure. Finally, subcommittee members were encouraged to invite people, including tobacco users, to attend regional meetings and provide written or oral testimony.

The meeting was adjourned at 3:45 p.m.


Appendix 1 — Recommendations from the four evidence-based documents presented at the subcommittee meeting

Public Health Service's Clinical Practice Guideline: Treating Tobacco Use and Dependence

  • Tobacco dependence is a chronic condition that often requires repeated intervention.
  • Because effective tobacco dependence treatments are available, every patient who uses tobacco should be offered one or more of these treatments.
  • Clinicians and health care delivery systems must institutionalize identification, documentation, and treatment of every tobacco user seen in a health care setting.
  • Brief treatment is effective, and every patient who uses tobacco should be offered at least brief treatment.
  • Treatments involving person-to-person contact are consistently effective, and their effectiveness increases with treatment intensity (e.g., minutes of treatment).
  • Three types of counseling and behavioral therapies (practical counseling, social support as part of treatment and social support outside of treatment) were found to be especially effective and should be used with all patients attempting cessation.
  • Numerous effective pharmacotherapies for smoking cessation now exist and should be used with all patients attempting to quit (except if there are contraindications).
  • Tobacco dependence treatments are both clinically effective and cost-effective relative to other medical and disease prevention interventions.

Back to the summary

Guide to Community Preventive Services Recommendations: Tobacco Use Prevention and Control

Recommended interventions for HEALTH CARE SYSTEM changes are:

  • Provider reminder systems (alone)
  • Multi-component provider reminder interventions (provider reminder + provider education)
  • Reducing out-of-pocket costs for treatment

Recommended interventions for POPULATION-BASED approaches:

  • Mass media campaigns (when combined with other interventions)
  • Increasing the unit price for tobacco
  • Multi-component telephone counseling interventions

Real-life examples in California and at Group Health Cooperative of Puget Sounds demonstrate that these interventions can have significant impact on increasing successful quit rates.

Back to the summary

Action Plan for Tobacco Use Cessation: Recommendations From the Interagency Committee on Smoking and Health

  • DHHS has an opportunity to increase the number and type of settings in which smokers are advised to quit by working through community health centers, Indian Health clinics, migrant health centers, rural health clinics and other federally funded clinical programs.
  • As the primary source of health care for approximately 75 million Americans, DHHS has the opportunity to provide adequate cessation services to smokers who desire to quit.
  • As a purchaser of health insurance benefits for 9 million federal employees and their dependents, and as an employer, the federal government has an opportunity to build on the experience of other purchasers.
  • DHHS can work with employers to promote science-based cessation initiatives
  • DHHS can work with OPM to update their guidance on model cessation coverage for consistency with PHS Guideline.
  • DHHS can encourage more implementation research.
  • DHHS can play a leadership role by encouraging collaboration to ensure that the science and progress made is shared by all.

Back to the summary

National Blueprint for Disseminating and Implementing Evidence-Based Clinical and Community Strategies to Promote Tobacco Use Cessation

Clinicians:

  • Increase utilization of the "Five As" for treating tobacco dependence.
  • Increase the use of evidence-based tobacco dependence counseling and pharmacotherapy.
  • Increase research into clinical strategies for treating tobacco dependence.

Systems:

  • Integrate evidence-based tobacco-use treatments into the mainstream health care delivery systems.
  • Increase the proportion of health care delivery systems that made evidence-based tobacco dependence treatments readily available.
  • Effectively integrate clinical tobacco dependence treatments with state and local cessation resources.
  • Decrease out-of-pocket costs for evidence-based tobacco dependence treatments (counseling and pharmacotherapy).
  • Increase research into systems strategies and policies for treating tobacco dependence, consistent with the 2001 IOM report, Crossing the Quality Chasm.

Consumers/Tobacco Users:

  • Increase the proportion of smokers who a make a serious quit attempt using evidence-based techniques.
  • Increase the number of smokers who are trying to quit who stay abstinent for a full year or longer.
  • Increase research into strategies for promoting tobacco-use cessation and demand for effective services among consumers.

Community:

  • Create work site and community environments more conducive to cessation efforts and success (mix of strategies).
  • Increase proportion of states/territories implementing effective mass media campaigns as part of multi-component tobacco control programs.
  • Increase the proportion of U.S. population having access to effective telephone support for tobacco cessation.
  • Motivate insurers, health care purchasers, and employers to cover and reimburse effective cessation services/reduce or eliminate patient payments for effective cessation therapies.
  • Increase research into community strategies to promote tobacco-use cessation.

Evaluation:

  • Conduct environmental scan
  • Create evaluation standards
  • Create a network linking evaluation activities
  • Create an evaluation feedback system
  • Develop a national data management system

Back to the summary

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