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Testimony on Smoking Cessation

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John M. Eisenberg, M.D., Administrator, AHCPR

Before the Senate Labor and Human Resources Committee
February 10, 1998


What Works in Smoking Cessation
AHCPR's Smoking Cessation Programs and Partnerships
AHCPR Comments on the Draft Tobacco Bill
Health Services Research Is Critical


Mr. Chairman and members of the Committee, thank you for asking me to appear before you to talk about the critical issue of smoking cessation. I am very proud that the Agency for Health Care Policy and Research (AHCPR) is part of the historic and important tobacco legislation that is the subject of this hearing.

As you may know, on September 19, 1997, the President called for comprehensive tobacco legislation with a goal of reducing the smoking rate among young people by 50 percent within 7 years. The President stressed that the following five key elements must be at the heart of any tobacco legislation:

  • A comprehensive plan to reduce teen smoking, including a combination of penalties and price increases that raise cigarette prices up to $1.50 per pack over the next 10 years as necessary to meet youth smoking targets.
  • Express reaffirmation that the Food and Drug Administration (FDA) has full authority to regulate tobacco products.
  • Changes in the way the tobacco industry does business.
  • Progress toward other critical public health goals, such as the expansion of smoking cessation and prevention programs and the reduction of secondhand smoke.
  • Protection for tobacco farmers and their communities.

The primary focus of my testimony today will be on smoking cessation in general and AHCPR's efforts in particular. AHCPR-sponsored research has found that most smokers want to quit, and that clinicians—in partnership with public and private payers—can help them succeed. However, I would like to take a few minutes to discuss with you additional research that is needed to make the potential of effective and cost-effective smoking cessation a reality.

I don't need to tell you the human toll that smoking exacts or the serious financial impact it has on health care costs. However, I would like to describe to you the statistics of smoking cessation. There are currently some 50 million smokers in the United States, and according to the Centers for Disease Control and Prevention (CDC), 70 percent have tried to quit, and one-third of them try to quit at least once a year. Most are unsuccessful. Why? Evidence suggests that as many as 90 percent try to quit "cold turkey." The bottom line is that only 7 percent of smokers who try to quit succeed.

This is particularly tragic because research, some of it supported by AHCPR, clearly and unequivocally shows that simple smoking cessation interventions work.

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What Works in Smoking Cessation

In 1996, AHCPR released an evidence-based clinical practice guideline on smoking cessation developed by a private sector panel headed by Dr. Michael Fiore, Director of the Center for Tobacco Research and Intervention at the University of Wisconsin Medical School. This effort, for the first time, looked at what was then the total body of scientific data on smoking cessation interventions to determine what works best. Dr. Fiore testified before the Subcommittee on Public Health and Safety last fall. The panel concluded that:

  • Clinicians have a powerful impact in motivating their patients who smoke to try to quit.
  • As little as three minutes of a physician's time can about double the rate of quitting among his or her patients and the more time spent with smokers, the higher their quit rates.
  • One simple, essentially no-cost intervention—expanding the vital signs to include smoking status—markedly enhances the rate at which physicians then go on to help their patients quit.
  • Every patient who tries to quit should be offered effective treatments including social support, simple advice on how to quit successfully, and pharmacotherapies that have been demonstrated to increase the likelihood that a smoker will quit successfully (such as nicotine replacement therapies, like the patch and the gum, and the new non-nicotine medicine, Zyban).

The panel found that this program will succeed only if the entire health care delivery team—including traditional fee-for-service insurers and managed care plans—support and promote smoking cessation programs. They can provide the financial incentives that will reinforce clinicians' commitment to helping their patients quit smoking, and for them, smoking cessation can help reduce health care costs.

AHCPR estimates that widespread implementation of the smoking cessation guideline will, conservatively, double the annual quit rate, increasing the number of new nonsmokers by an additional 1.3 million. This would save the health care system $2.6 billion in smoking-related health care costs.

An AHCPR-supported analysis of the cost-effectiveness of smoking cessation, published in the December 3, 1997, Journal of the American Medical Association, found that smoking cessation treatments cost about $165 per smoker, and overall, cost $2,500 per year of life saved. This compares to $50,000 per year of life saved for mammography screening and $100,000 per year of life saved for cholesterol screening.

Other than immunization, smoking cessation is the most cost-effective prevention intervention for adults. Leading authority on guidelines and cost-effectiveness analysis, David Eddy, M.D., has referred to smoking cessation as the "gold standard" in prevention interventions. Dr. Tim McAffee, from Group Health Puget Sound in Washington State, called cessation services "the health care bargain of the millennium" in testimony before your Subcommittee on Public Health and Safety.

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AHCPR's Smoking Cessation Programs and Partnerships

Over the past 2 years, AHCPR has been working with public and private sector organizations to advance the implementation of smoking cessation programs. We have worked with key clinician groups, such as the American Medical Association (AMA), National Medical Association, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, and American College of Chest Physicians. These organizations are helping promote use and adaptation of the AHCPR guideline by disseminating it to their members. For example, the AMA mailed copies of the guideline physician pocket guide to 200,000 primary care physicians across the country.

In addition, the American Cancer Society, following the recommendations of the AHCPR guideline, has revamped its tobacco cessation program for pregnant women and mothers who smoke.

One of our most exciting initiatives is a partnership with the Robert Wood Johnson Foundation and the American Association of Health Plans to promote the adoption of innovative approaches to help Americans enrolled in managed care plans avoid the harm caused by tobacco. The "Addressing Tobacco in Managed Care" Initiative (which was developed in collaboration with AHCPR, CDC, the National Institutes of Health (NIH), and the American Association of Health Plans) will promote the adoption of innovative approaches by managed care organizations to identify enrollees who smoke and to help them quit, and to evaluate scientifically the effectiveness of these approaches. This initiative was launched last week at a conference here in Washington.

AHCPR also is addressing smoking cessation through the renewed activities of the U.S. Preventive Services Task Force, and its updated report. Its 1996 report provides clinicians with information on the effectiveness and appropriateness of the full range of preventive care services, including advising patients to reduce risky health-related behaviors such as tobacco use. AHCPR also will work on implementing the recommendations of the Task Force through the Put Prevention into Practice Program, the U.S. Public Health Service national campaign to provide practical tools for patients, clinicians, and health care systems to improve the delivery of preventive care.

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AHCPR Comments on the Draft Tobacco Bill

Mr. Chairman, the draft recognizes that the implementation of smoking cessation is a team effort, by ensuring that funds are used to train health care professionals and health plans in cessation interventions methods. It also ensures that funds are used to encourage insurers and health plans to provide coverage for science-based cessation programs. Finally, I want to thank you for endorsing AHCPR's smoking cessation guideline in your proposal as the basis for cessation treatment programs.

The AHCPR guideline already is being used in States and by States to reduce health care costs. For example, it is at the center of a smoking cessation project supported by the Maine Medical Assessment Foundation and the Maine Medical Health Management Association, which represents the State's largest employers, including L.L. Bean, Bath Iron Works, and the Maine State Government. The project, which will have an impact on 10 percent of the State's population—about 120,000 people—will address the barriers to successful implementation of smoking cessation programs associated with the physician community.

The funds you have provided to AHCPR will allow us to conduct evidence-based analyses of the state-of-the-science in smoking cessation methods. These programs will continue to evolve as we learn more about the effect that tobacco has on the body and we develop new ways to counteract that effect. This is consistent with AHCPR's mission to use science to determine what works and doesn't work in medical practice, and I pledge to put our best and brightest to the task.

I want to stress that AHCPR's mission doesn't stop with building the evidence about smoking cessation. We feel it is critical that we translate the knowledge we gain through research into clinical practice. To do this, AHCPR disseminates science-based information and supports the development of tools for use by clinicians, patients, and health care systems.

For example, AHCPR has developed educational materials to educate clinicians about smoking cessation interventions. While most clinicians understand the of benefits that smoking cessation, few make a serious effort to help their patients quit. Studies have found that while 70 percent of smokers see a physician each year, only about half are urged to quit, and less than 20 percent are given advice on how to quit and information on effective interventions.

Many physicians and other clinicians operate under misconceptions about smokers and the cessation process. For example, many believe that if a smoker wants to quit, he or she will bring the issue up; others feel that they don't have enough time during their encounters with patients who smoke to make an impact. Better education could dispel these myths and provide clinicians with scientific information on smoking cessation.

AHCPR's educational materials, entitled the "Two-Three" Initiative," are based on the AHCPR guideline. It recommends that clinicians ask their patients two questions "Do you Smoke?" and "Do you Want to Quit?" as part of every medical evaluation. Clinicians should follow this with an intervention, as brief as 3 minutes, recommending smoking cessation treatments proven to work.

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Health Services Research Is Critical

Before I conclude, I also want to mention the research component which you cover in Subtitle E of your bill. There is general agreement among all the agencies of the U.S. Public Health Service on the critical importance of expanded research on tobacco, its impact on the human body, and the impact of its use on the health care system.

My colleagues at the NIH and CDC can comment on the importance of basic biomedical, clinical, and epidemiological research on smoking and smoking cessation. I would like to emphasize the importance of health services research, which consists of three components. First, we build the science base by conducting clinical research, such as outcomes and effectiveness research and cost-effectiveness analysis, that serves as the foundation for improved care. Second, we conduct and support research to develop strategies to improve the delivery of health care services. Third, we help improve the quality of health care services delivered in this country by translating and disseminating the findings of our research to the relevant audiences and evaluating ways to ensure that the research is used appropriately.

Health services research will help us answer questions such as: How do smokers use the health care system and how can smoking cessation services be organized to be most effective for all smokers? How do we change the behavior of doctors and health systems to deliver needed cessation services? What are the functional changes caused by long-term tobacco use? How does tobacco use affect nonsmokers?

For example, AHCPR's Peter Gergen found that passive cigarette smoke can be blamed for causing about half of all asthma, chronic bronchitis, and frequent wheezing in children ages 2 months to 2 years. His study, which was reported last week in the Washington Post and USA Today, found that the risk of illness is highest when adults smoke at least a pack of cigarettes a day.

A critical issue that must be answered by research, both biomedical and health services research, is what smoking cessation interventions are effective for younger smokers and teenagers. The National Cancer Institute is currently funding biomedical research on tobacco and youth, and how to help them quit using medical interventions.

Health services research needs to determine how to get the interventions to them. It has always been assumed that young smokers don't want to quit, but research indicates that this is a myth. We need to determine how to capitalize on younger smokers' desire to quit and how we can get them the information they need.

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Mr. Chairman, and members of the Committee, I want to thank you for providing me with the opportunity to comment on your proposal to curb smoking in this Nation. You have taken a significant step in your proposal by recognizing that in order for smoking cessation efforts to be effective, we must empower clinicians—and ultimately patients—with evidence-based information on smoking cessation programs that work. This is the premise of AHCPR's smoking cessation guideline. From a physician's perspective, I know the importance of evidence-based information plays by dispelling misconceptions about courses of treatments, and helping to make sound, safe medical decisions.

Mr. Chairman, I look forward to working with you and the Committee as you continue your deliberations on this critical issue. Thank you.

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Current as of February 1998


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