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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:
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.
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.
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.]
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Federal/State Initiatives |
Public/Private Partnerships |
Goals |
Consumers
(Smokers and families)
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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 |
|
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
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- Increase identification of tobacco users and
use of the 5 As.
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Health Systems/
Employers/
Insurers/Consultants
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(Remember policymakers as audience – (e.g.,
CEOs) |
Translation of science into practice for employers using
simple models/solutions
Corporate leadership
Identify key leverage points
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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
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Uniform/barrier-free access to evidence-based quit lines
Development of strong paid (preferable) and PSA media campaigns
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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
- 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
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
- 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
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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