NCQA - Quality Profiles-Smoking

Focus on Tobacco Dependence
and Smoking Cessation

The Leadership Series
QUAL I T Y P R OF I L E S
T M
MCE00042B 2008 by NCQA Printed in USA/June 2008
|
Table of Contents
A Joint Message From NCQA and Pfizer 4
A Word About Tobacco Dependence and Smoking Cessation 6
Introduction 9
The Current State of Quality of Care for Tobacco Use and Dependence 15
An Integrated Health Systems Tobacco-Dependence Program 24
Employer EffortGet Ready...Get Set...Get Quit: An Employee Nicotine Cessation Program 30
Principles for Reducing the Burden of Tobacco Use 37
Health Plan: Yes, You Can! 39
State Collaborative Focused on Clinicians 45
Employer-Based Tobacco Policy 51
Smoke-Free Campuses: Policies to Change Social Norm Behavior 54
Special Populations: Pregnant Members & Youth 57
Barriers to Reducing the Burden of Tobacco Use 61
Using the Electronic Medical Record: Smoking as a Vital Sign 65
Tobacco-Use Treatment Training for Clinicians 72
Addressing the Quality Gaps in Reducing the Burden of Tobacco 79
Impacting a State: A Health Plans Multiple Strategies 82
The Value of Effective Tobacco Cessation Initiatives 101
A Look to the Future 107
Appendix 115
3
| Q U A L I T Y P R O F I L E S 4
A Joint Message From
NCQA and Pfizer
The National Committee for Quality Assurance (NCQA) and Pfizer Inc are pleased to present the
sixth edition of Quality Profiles
: The Leadership SeriesFocus on Tobacco Dependence and Smoking

Cessation. Tobacco use and dependence has been a focus of national attention for more than
four decades, yet reducing tobacco-related morbidity and mortality is an ongoing challenge for
individuals, health care clinicians, health care systems, employers, and public health programs.
NCQA and Pfizer hope that this edition of Quality Profiles: The Leadership Series will provide the
reference and direction to implement effective, evidence-based interventions that deliver and
support effective treatments in tobacco dependence, encourage smoking cessation, prevent
tobacco use initiation, and reduce exposure to environmental tobacco smoke, contributing to the
improved health of the American people.
Despite greater public awareness of the negative health effects of smoking, tobacco use is
still the nations leading preventable cause of disease and death. The list of diseases linked
to tobacco use is expanding well beyond the general health risks of coronary heart disease,
stroke, cancer, and chronic lung disease. As smoking is responsible for over 435,000 deaths and
more than $50 billion in direct medical costs per year, it is time to view tobacco dependence
as a chronic condition and treat it as sucha condition that requires ongoing assessment and
repeated intervention to support users in their extended efforts to quit. In spite of the knowledge
of the immediate and long-term benefits of cessation of tobacco use and the availability of
effective treatments, quality gaps still exist in the health care industry with treating tobacco use
and dependence. We believe treating tobacco use should be a requirement for an acceptable
standard of care.
| A J O I N T M E S S A G E F R O M N C Q A A N D P F I Z E R 5
By providing practical examples of successful initiatives to serve as models of smoking cessation
interventions, we hope to assist organizations in targeting appropriate individuals, establishing
interventions, changing patient and physician behavior, and evaluating the results of these
efforts. Implementing and maintaining tobacco control initiatives that work and are well matched
to the needs and capabilities of the community are essential to reducing tobacco use on a greater
scale. The purpose of Quality Profiles: The Leadership SeriesFocus on Tobacco Dependence and
Smoking Cessation is to present a single-source publication that summarizes the latest research,
reviews barriers to success, addresses quality gaps in care advancement, and provides examples
of successful smoking cessation initiatives.
This issue of Quality Profiles highlights collaborative efforts among health plans, employers,
pharmaceutical companies, health care providers, and others that have launched successful
smoking cessation initiatives.
It is the sincere hope of NCQA and Pfizer that Quality Profiles: The Leadership SeriesFocus on
Tobacco Dependence and Smoking Cessation will help health care organizations and payers address
the challenges to providing effective smoking cessation initiatives. Treating tobacco use and
dependence and integrating smoking cessation into the continuum of health care offers the
opportunity to raise the quality of care in America, improve clinical outcomes, and reduce health
care expenditures.

Margaret E. OKane Joseph M. Feczko, M.D.
President Senior Vice President, Chief Medical Officer
National Committee for Quality Assurance Pfizer Inc
A Word About Tobacco Dependence
Steven A. Schroeder, M.D.
Department of Medicine
University of California at San Francisco
Tobacco use is devastating the health of this nation. Although the good news is we have made
progress in the last few years, the bad news is there are still over 435,000 people dying each year
from tobacco use, and up to eight million are disabled by its effects.
1,2
The toll is staggering.
Consider that more women today die from lung cancer than breast cancer.
3
In addition, smoking
among pregnant women is a major contributor to premature births and infant mortality.
1
We can
do better. We must do better.
Tobacco use may begin earlyas a teenage fascination. Adolescents discover smoking at an age
when they do not truly understand its destructive effects or comprehend their own mortality.
Once hooked on nicotine, teens continue smoking into adulthood.
Even when they recognize the need to stop, quitting may seem quite
difficult or even impossible.
Of the 44.5 million smokers in the United States, 70% would like to
quit.
2
However, each year fewer than 5% of smokers are able to quit
without assistance.
2
The odds of quitting successfully can be doubled
or tripled if clinicians can recognize and act to address smoking habits
in their patients. Employers and health plans should be included
in this smoking cessation discussion, too. Employer trends toward
smoke-free workplaces along with policies that prohibit smoking on company grounds send clear
messages that smoking is unacceptable. The creation of smoke-free areas has undermined the
social acceptability of smoking, while concern about secondhand smoke has served to counter
the tobacco industrys claims that smoking is a matter of choice. Health plan initiatives that
include financial support to enrollees for smoking cessation counseling and medications are
proving effective as well.
I would like to see smoking become more central to the way we look at health. Tobacco use
needs to be defined as a disease state. Clinicians need to elevate smoking and tobacco use
to the level of a true disease. Similar to diabetes, asthma, and the host of chronic illnesses, if
tobacco use hit the same radar screen as other chronic illnesses, clinicians would focus more
on its symptoms. Defining smoking as a chronic disease state may also negate the stigma that
The central message
for clinicians is that
you have a responsibility
to help your patients
who smoke.
| A W O R D A B O U T T O B A C C O D E P E N D E N C E A N D S M O K I N G C E S S A T I O N 7
surrounds tobacco use, allowing clinicians to take that first step toward
discussing tobacco cessation with their patients.
We have issues to combat in defining tobacco use as a chronic illness.
There is a staggering gap between the damage that smoking causes
and the amount of resources and attention paid to combat those ills. This edition of Quality
Profiles
furthers the national dialogue on smoking cessation, examining the necessary changes in
health care delivery and quality outcomes.
There are four well-documented strategies to prevent children from initiating smoking and/or
reduce its use among current tobacco users. These four strategies are:
Raise the price of a pack of cigarettes. Smokers are price sensitive, especially adolescents
Continue to promote/demand the smoke-free setting. The movement toward smoke-free
workplaces is proving to reduce the effects of secondhand smoke for nonsmokers. Additionally,
this creates a barrier for current tobacco users, many of whom are motivated to quit as smoking
becomes more burdensome socially
ncrease counter-advertising. Although the tobacco industry spends $15 billion annually in
marketing, national and state resources devoted to counter-marketing are meager. Yet, there
is strong evidence that the counter-marketing efforts in several states as well as the American
Legacy Foundations truth
campaign have reduced the rates of smoking initiation. This

represents a wonderful opportunity for states and public health departments to truly promote
the antismoking message
ncrease smoking cessation efforts by clinicians. Some will wish to
become smoking cessation educators. But, unfortunately, most
will not. Yet there are successful tools available for the bulk of
cliniciansdoctors, nurses, dentists, dental hygienists, pharmacists,
physician assistants, respiratory therapists, and othersto help
smokers quit. They can establish systems in their clinical settings, as has occurred in the
Veterans Health Administration and Kaiser Permanente health care systems. Or, they can refer
smokers to a local quit line that will offer customized counseling to help them quit. A national
number1-800-QUIT NOWwill direct callers to their states quitline
It is tempting to be lulled
by current progress...
Telephone quitlines
work. Although the
number of smokers who
use these lines is small,
their success rates are high.
Policy initiatives have helped consumers understand the gravity of smoking. The 1998 Master
Tobacco Settlement between the attorney generals of 46 states and the tobacco industry was a
notable opportunity to reduce tobacco use. Unfortunately, little of
the $206 billion awarded to the states has been used for public health
efforts.
2
The settlement did prohibit advertising targeted to young
people, and made available tobacco industry documents that have
helped scholars understand how tobacco use became so prevalent.
2
The United States is approaching a tobacco tipping pointa
state of greatly reduced smoking prevalence. Segments of the
population already show low rates of smoking, including physicians
(less than 2%) and people with postgraduate education (8%), along
with residents from Utah (11%) and California (14%).
1
Increasingly,
smoking is concentrated in the lower socioeconomic classes, begging for more public health
attention and governmental interventions. Two of the strongest evidence-based tobacco-control
measuressmoke-free public places and increases in cigarette taxeswere successfully driven
by state and community regulations and litigation.
1
While reading this edition of Quality Profiles
, you will be inspired by the numbers and types

of efforts being made in tobacco use and smoking cessation initiatives. This issue includes case
studies from employers, health plans, integrated health systems, university clinics, clinician
practices, and a clinical guidelines collaborative. Although many excellent programs and projects
are underway, so much more needs to be accomplished.
In 25 years, the damage from tobacco use
(even if everyone ceased using it today)
would still be enormous. As such, legislators,
practitioners, employers, health plans, and
consumers must continue to embrace all
available modes to reduce tobacco dependence
and encourage tobacco cessation.
References
1. Schroeder SA. We can do betterimproving the health of the American
people. N Engl J Med. 2007;357(12):1221-1228.
2. Schroeder SA. Tobacco control in the wake of the 1998 Master Settlement
Agreement. N Engl J Med. 2004;350(3):293-300.
3. Zeller JL. Lung cancer. JAMA. 2007;297:1022. http://www.jama.ama.assn.
org/cgi/content/full/297/9/1022. Accessed April 28, 2008.
Increasing the
baseline quit rate of
smokers to 10%
would prevent 1,170,000
premature deaths.
1
Since smoking has been
around for so long and the
damages have been around
equally as long, people
may be blind to the
real tragic outcomes.
| I N T R O D U C T I O N 9
Supporting the
Health Care Industry
Quality Proles: The Leadership Series is
the result of collaboration between two
organizationsNCQA and Pzer Inc
that share a deep and profound interest in
promoting quality health care. This series
of publications is intended to help health
care organizations, clinicians, and other
stakeholders progress along the quality
continuum toward excellent patient care.
There is a national awareness of the health
risks associated with tobacco use and
dependence, yet it remains the leading
preventable cause of death among Americans.
The need to increase our efforts in tobacco
control and smoking cessation initiatives
for individuals, and reach beyond into more
population-based interventions, has never
been greater. This edition has been published
to increase dialogue about this epidemic by
exploring the latest research and trends
for treating tobacco use and dependence,
promoting smoking cessation, prevention
initiatives, and clinician efforts for creating
system-wide policy changes.

Introduction
Quality Proles
: The Leadership Series

The Evolution of Quality Proles
1999
Quality Proles summarizes quality improvement activities (QIAs) in
chronic illness, womens health, preventive care, behavioral health,
and service.
2000
Quality Proles includes more in-depth QIA summaries across the same
health care areas as in 1999, and includes practical tools for quality
improvement.
2003 to 2005
The Leadership Series features expanded discussions, case studies,
and tools for improvement in selected disease states:
Cardiovascular disease (CVD) (2003)
Depression (2004)
Diabetes (2005)
2006
The 2006 edition of Quality Proles: The Leadership SeriesFocus on
Enhancing Care for Older Adults was developed to address the health
care needs of older adults by exploring the changing portrait of illness in
the context of longer life expectancy, as well as the very nature of aging,
which presents unique challenges and barriers to effective care within the
current health care system.
2007
Quality Proles: The Leadership SeriesFocus on Wellness and
Prevention addressed the growing awareness that promoting health and
preventing disease and disability are as important as providing quality
care after an illness is diagnosed. Decreasing obesity in adults and
children, controlling risk factors for CVD, cold and u prevention, and
smoking cessation are the topics highlighted in this edition.
Whats New?
This edition of Quality Proles
: The Leadership
Series focuses on an orientation in the provision
of wellness and prevention in health care
tobacco use and dependence. Its express
purpose, to provide evidence-based strategies
and practical support to reduce and prevent
tobacco use, departs from the earlier editions,
which focused on particular health conditions
cardiovascular disease, depression, and
diabetes. It also differs from an earlier edition,
which specically focused on the older adult
population, with its unique challenges and
needs that cut across clinical conditions and
require a broader, more patient-centered
perspective.
This edition gives tobacco use and dependence
the much-needed attention it deserves. It
provides a greater emphasis on what steps
health plans and employers are taking
to promote initiatives that treat tobacco
use and dependence. By viewing tobacco
dependence as a chronic relapsing condition
and emphasizing smoking cessation in the
prevention and management of other major
chronic diseases, we can alter the current
mindset that tobacco use is a choice. In
addition, employers offer another avenue
to reducing tobacco use and dependence.
Employers that promote tobacco-related
initiatives realize that earlier identication
and intervention minimizes the likelihood of
expensive complications, and that a tobacco-free
workplace is a healthier, more productive one.
A Snapshot of the Proles
In Quality Proles: The Leadership Series
Focus on Tobacco Dependence and Smoking
Cessation, we provide comprehensive
descriptions of six case studies that demonstrate
best practices, along with summaries of
several additional activities. These case
studies address a variety of efforts associated
with tobacco use and dependence such as
smoke-free workplace policies; the role of
electronic medical records (EMR) in elevating
tobacco use to a vital sign; creation of state-
specic clinical guidelines for clinicians;
integrating pharmacist consulting and referral
to quitlines; the need for specialized clinicians
to serve as tobacco treatment specialists; along
with examples of employer, health plan, and
integrated health system initiatives. The case
studies represent successful approaches that
organizations have piloted or implemented
on a broad scale. The case study format
generally includes:
Organization at a glance
Backgroinu
Case uescrition
Resilts
n tleir own worus
Conclision
Unique to this years Quality Proles: The
Leadership Series, each case study includes a
brief section that reects on the contributors
own worus. Hearing tle reective
impression from each contributor grounds the
case study in its effect on the contributing
organization and that organizations efforts to
produce real change in tobacco use.
Methodology
The initiatives highlighted in this edition
of Quality Proles: The Leadership Series were
selected based on a review process led by
NCQA staff. With the topic dened, NCQA
convened an advisory panel. This panel
advised NCQA on the current state of the art
in management of tobacco dependence and
provided direction regarding the content and
focus of this Quality Proles.
Oir auvisory anel las also leen instrimental
in determining the specic content and direction
of this text. Through the advisory boards
recommendation, a methodology was created
to call for case submissions. This edition of
Quality Proles used a four-step process:
1. Call for submissionorganizations
were encouraged to submit applications
in response to a posting on the NCQA
Web site.
2. Applicationresponding organizations
completed an extensive application.
3. Review and selectionapplicants
underwent a review process for scoring
purposes.
4. Interviewrepresentatives from chosen
organizations were interviewed for further
clarication and to obtain additional
information.
Initiatives selected for inclusion exemplify
quality improvement in reducing tobacco
use and dependence. Chosen organizations
were then interviewed to gather information
on the methodology, barriers, adjustments
to the intervention (if any), and current
status of the initiative. This information was
then integrated to develop the case studies
included in Quality Proles: The Leadership
SeriesFocus on Tobacco Dependence and
Smoking Cessation.
| I N T R O D U C T I O N 11
NCQA and Pzer:
The Quality Proles

Partnership
Quality Proles: The Leadership Series has been
developed as a useful resource for organizations
undertaking quality improvement activities.
It provides both a clinical rationale for
improvement and examples of challenges
and successes of specic initiatives. The
series is the product of a partnership between
two organizations that share a deep commitment
to advancing quality in health care. The initial
draft of this edition was developed by The
Eden Communications Group, who were
funded by Pzer Inc. Editorial oversight and
content decisions were the joint responsibility
of NCQA and Pzer Inc.
NCQA is a private, nonprot organization
dedicated to improving health care quality.
NCQA accredits and certies a wide range
of health care organizations and recognizes
physicians in key clinical areas. NCQAs
Healtlcare ffectiveness Lata anu
nformation Set (HLS
) is the most widely

used performance measurement tool in
HEDIS is a registered trademark of NCQA.
health care. NCQA is committed to providing
health care quality information through the
Web, media, and data licensing agreements
in order to help consumers, employers, and
others make more informed health care
choices. For more information, visit http://
www.ncqa.org/.
NCQA has worked for 18 years to improve
health care delivery through its accreditation,
certication, and physician recognition
programs and the ongoing development of
HLS measires,
and
Pzer Inc is the worlds leading research-based
pharmaceutical company, which partners
with health plans, medical groups, and other
health care organizations to facilitate clinical
excellence and improve patient outcomes.
Pzer has also long been a supporter of
NCQA and its mission to improve the quality
of health care.
Acknowledgments
We would like to thank the following people
and organizations, whose dedication to the
delivery of quality health care has made this
edition of Quality Proles: The Leadership Series
possible.
Participating Organizations
Blue Cross and Blue Shield of Minnesota
Colorado Clinical Guidelines Collaborative
Concoru Hosital Plysician Groi,
New Hamslire
CSX Transportation, Florida
Kaiser Permanente Northern California
Passort Healtl Plan, Kenticky
Contributing Organizations
Henry !oru Healtl System, Micligan
Independence Blue Cross, Pennsylvania
\niversity of Meuicine anu Lentistry of New
]ersey (\MLN])-Sclool of Pillic Healtl
University of Pittsburgh Medical Center
(\PMC) Healtl Plan, Pennsylvania
Advisory Panel
John Clymer
President
Partnership for Prevention
Washington, DC
]onatlan !oilus, M.A., M.S., Pl.L.
Professor
UMDNJSchool of Public Health
New Brunswick, New Jersey
Plili P. Gerlino, Plarm.L.
President
University of the Sciences in Philadelphia
Philadelphia, Pennsylvania
Kenneth Glover, M.S., R.C.E.P., C.S.C.S.
Director of Health and Wellness
CSX Transportation
Jacksonville, Florida
Corinne Histen, M.L., M.P.H.
Chief of Epidemiology Branch Ofce
on Smoking and Health
National Center for Chronic Disease Prevention
Centers for Disease Control and Prevention
Atlanta, Georgia
| A C K N O W L E D G M E N T S 13
Advisory Panel (contd)
Norm Linuenmitl, M.L.
Vice President, Chief Medical OfcerQuality
Excellus
Syracuse, New York
Riclaru Poiel, M.L., M.B.A.
Vice President, Chief Medical Ofcer
Horizon Blue Cross Blue Shield of New Jersey
Newark, New Jersey
Bruce Sherman
Director of Health and Wellness
Medical DirectorGlobal Services
Good Year Tire and Rubber Company
Washington, DC
NCQA Staff Members
Kathleen C. Mudd, M.B.A., R.N.
Vice President, Product Delivery
L. Gregory Pawlson, M.L., M.P.H.
Executive Vice President
Richard Sorian
Vice President, Public Policy
and External Relations
Elizabeth M. Usher
Assistant Vice President, Customer Resources
Pzer Staff Members
Marie Howson, R.N., M.B.A.
Consultant to Pzer
!auy Ntanios, Pl.L.
Clinical Director
Laviu Sclaaf, M.L.
Senior Medical Director
NCQA and Pzer Inc would like to acknowledge and thank The Eden Communications
Group for assisting in the development of the publication through funding by Pzer Inc.
Secifcally, we woilu like to tlank Cleryl Anuerson, anu Lairie Hammonu at uen for
tleir euitorial siort. Auuitionally, acknowleugment anu tlanks go oit to Lianne LiBlasi,
Mary Lracl, Sie Linuley-Howaru, ]essica Killick, Anuria Loez, Lonna Malik, Krista
Scavone, and Perianne Walter at Eden.
These efforts are laudable and certainly
an improvement over the past. Yet, the
current use of tobacco abatement programs
is well below the goals set by numerous
governmental agencies and expert panels.
Screening for tobacco use, urged for all adults
by the Agency for Healthcare Research and
Quality (AHRQ), has yet to become consistent
clinical practice.
5
Interventions known to
be effective and recommended by leading
experts are not universally covered by health
plans and employers or implemented by
clinicians.
6,7
Tobacco prevention initiatives are
losing funding at the same time the tobacco
industry is stepping up marketing efforts
to attract potential smokers.
8
Aggressive
interventions to prevent and treat tobacco
addiction must continue to be implemented to
address the still-major health threats, as
millions of American smokers and tobacco
users face the damaging consequences of a
lifetime of tobacco addiction and use. For
those who are dependent on smoking, unless
they are helped to quit, half will die from the
consequences of their habit, and they will be
less productive and more disabled while they
are alive.
9
| T H E C U R R E N T S T A T E O F Q U A L I T Y O F C A R E F O R T O B A C C O U S E A N D D E P E N D E N C E 15
The Current State of Quality of Care
for Tobacco Use and Dependence
Cigarettes, once images of sophistication and elegance, are now recognized by many, but unfortunately not
everyone, as a cause of serious diseases that exact a high toll on smokers, employers, health plans, and society
as a whole. Employers are increasingly creating tobacco-free environments and offering smoking cessation
programs in benets packages, and health care organizations are collaborating more than ever with government
agencies to affect larger populations and reinforce efcacy of programs.
1,2
There is a general trend toward
expansion of smoking cessation efforts to include population-wide interventions that encompass prevention,
cessation, and reduction of exposure to environmental tobacco smoke (ETS) (Table 1).
2
At the broadest level,
19 states now have laws mandating 100% smoke-free air in bars, restaurants, and worksites, while all 50 states
prohibit the sale of tobacco to minors.
2-4
Table 1. Components of Population-Based Smoking
Interventions
2
Prevention of smoking initiation
(e.g., implementation of school-based programs for adolescents)
Reduction of exposure to environmental tobacco smoke
(e.g., implementation of worksite restrictions on tobacco use)
Policy changes in health care systems to promote smoking cessation
(e.g., implementation of systems to identify and intervene with smokers
during every health care visit)
Current understanding of the personal,
nancial, and social costs of tobacco use has
spurred the U.S. Department of Health and
Human Services to call for an increase in
cessation efforts in their Healthy People 2010
objectives.
10
NCQA supports this goal through
its HEDIS measures that evaluate quality of
care based on the latest research in this eld.
10

Further, NCQA efforts are also reected in
its Physician Recognition Programs such as
the Heart/Stroke Recognition Program and
the Diabetes Recognition Program.
11
Each of
these programs includes criteria for physicians
to measure their performance.
Denition of Tobacco
Use and Dependence
Tobacco addiction has been characterized
as the most common chronic disease in
the developed world.
12
Beginning with
the rst puff, smoking disturbs the bodys
natural homeostasis.
12
Approximately
10 seconds after inhalation, a high-
concentration dose of nicotine reaches
the brain, generating a cascade of effects
in the central nervous system, as well as
exerting behavioral, neuromuscular, endocrine,
renal, metabolic, and cardiovascular changes.
12,13

While it alters hormone levels, heart rate,
blood pressure, and other bodily processes,
smoking also causes the release of dopamine,
ensuring a reward effect that encourages
continued use.
13

Smokeless tobacco elicits similar responses.
While some forms of smokeless tobacco may
be sniffed or inhaled, most smokeless tobacco
users place the product against their cheek or
between their gum and cheek. Nicotine enters
the body directly through the mouth mucosal
lining.
13,14

Nicotine is the addictive substance in all forms
of tobacco, keeping smokers and those who
use smokeless tobacco in their habit long after
they want to quit. It has been theorized that
initial motivation for using tobacco is based on
social and other nonpharmacologic rewards.
Over time, the physiologic effects of nicotine
exert increasing control so that later motivating
factors become the drugs sedative and
stimulatory effects in the brain.
13
No clearly
dened threshold marks the point at which
tobacco dependency occurs; however, several
clinical measures are used to establish an
addiction (Table 2).
12
The presence of
withdrawal symptoms is a key measure,
Table 2. Clinical Measures of Tobacco
Dependency
12
Daily tobacco use for several weeks or longer
Evidence of tolerance: increasing amount of
tobacco use with lack of adverse effects
(e.g., no dizziness or nausea from nicotine
inhalation)
Manifestation of symptoms upon withdrawal of
nicotine: cravings, anxiety, irritability, decreased
heart rate, increased blood pressure, difculty
concentrating, increased appetite, weight gain,
restlessness, and mood changes
and these make quitting especially difcult.
While some withdrawal symptoms begin
to decline after a few days of abstinence,
otherssuch as cravings, increased appetite,
and impaired concentrationmay persist
for more than a year.
12
Not surprisingly,
few smokers are able to quit on their own,
often making this dependency a lifelong
afiction.
12,13
Rather than quit, some smokers may attempt
to smoke fewer cigarettes or switch to low-tar
products. However, research demonstrates
that there is no safe way to smoke. Even one
cigarette smoked a day causes damage, and
the risk of lung cancer is not reduced among
smokers who use low-tar cigarettes.
15
Prevalence of Tobacco
Use in the United States
Although most smokers in the United States
want to quit, fewer than 10% are able to
quit themselves, and more than 45 million
American adultsover 20% of the adult
populationcontinue to smoke or use
other forms of tobacco.
16-18
This is especially
concerning, as it reects a lack of progress
in reducing the prevalence of tobacco use.
Between 1965 and 1990, early cessation efforts
successfully reduced smoking rates by 40%.
Yet, over the past several years, rates have
remained virtually unchanged (Figure 1).
18
40
45
30
35
*National Health Interview Survey (NHIS) redesigned in 1997; comparisons with prior years should be conducted with caution.
10
5
0
15
20
25
1965 1970 1974 1980 1985 1990 1997* 2000 2001 2002 2003 2004 2005
A
d
u
l
t
s

W
h
o

W
e
r
e

C
u
r
r
e
n
t

S
m
o
k
e
r
s

(
%
)
Year
Figure 1. Adult Smokers in the United States: 1965-2005
18
| 18 Q U A L I T Y P R O F I L E S
Additionally, 2.2% of American adults smoke
cigars, and 2.3% use smokeless tobacco.
19

Young people, who may carry their habits into
adulthood, are faring even worse. Approximately
23% of high school students smoke cigarettes,
14% smoke cigars, and 8% use smokeless
tobacco.
20
Among adults, smoking is most prevalent in
those under age 45, individuals with lower
education and incomes, gay men, and some
ethnic minorities (Table 3).
19,21
The considerable
disparity between younger adults (24%
prevalence) and older adults (9% prevalence)
may have many explanations. Over 80% of
adult smokers began using tobacco when they
were teenagers, and younger smokers may be
those who havent yet quit.
22
Unfortunately,
smokers tend to die much earlier than
nonsmokers, leaving fewer smokers to reach
elderly status.
21
Of all ethnicities, American Indians and Alaska
natives have the highest rate of smoking
at 32%.
19
While African Americans are no
more likely to smoke than nonHispanic whites
(both 22%), they experience higher rates of
smoking-related illnesses, including lung
cancer and cardiovascular disease (CVD).
19,21

Reasons for this disparity are not clear.
Table 3. U.S. Adult Smokers by
Selected Demographics
19,21
Demographic Smoking
Characteristic Prevalence (%)
Age
18-24 24
25-44 24
45-64 22
65 10
Education
GED* diploma 43
High school graduate 25
Undergraduate degree 11
Graduate degree 7
Poverty status
Below poverty level 30
At or above poverty level 21
Sexual orientation
Gay men 33
Lesbian women 25
Sex
Men 24
Women 19
Ethnicity
White, nonHispanic 22
African American, nonHispanic 22
Hispanic 16
American Indian/Alaska native,
nonHispanic 32
Asian, nonHispanic 13
* GED=General Educational Development.
| 19 T H E C U R R E N T S T A T E O F Q U A L I T Y O F C A R E F O R T O B A C C O U S E A N D D E P E N D E N C E
Although African Americans tend to smoke
cigarettes higher in tar and nicotine and
are less successful in their attempts to quit,
both African Americans and Hispanics tend
to smoke fewer cigarettes per day than
nonHispanic whites.
21
Across all ethnicities,
men are more likely to smoke than women
(Figure 2) and tend to smoke more cigarettes
per day.
19,21
In fact, the low rate of smoking
among Asians is due to the few numbers of
Asian women who smoke: 21% of Asian men
and only 6% of Asian women use tobacco.
19
40
30
35
10
5
0
15
20
25
White,
NonHispanic
African
American
Hispanic American
Indian/Alaskan
Native
Asian Overall
C
u
r
r
e
n
t

S
m
o
k
e
r
s

(
%
)
Ethnicity
Men
Women
Figure 2. U.S. Adult Smokers According to Ethnicity and Sex
19
Morbidity and Mortality
Associated With
Tobacco Use
Cigarette smoke damages multiple organ systems,
making it the single most preventable cause
of disease, disability, and death in the United
States.
23,24
Beyond causing nearly 90% of all
lung cancers, smoking leads to numerous
other forms of cancer, CVD, aneurysms,
stroke, chronic obstructive pulmonary disease
(COPD), and other respiratory illnesses
(Table 4).
15
Asthmatic smokers experience a
worsening of symptoms and an accelerated
decline of lung function; further, tobacco use
reduces the efcacy of the corticosteroids used
to treat their condition.
25
An estimated 8.6 million smokers currently
live with at least one smoking-related
illness, most commonly COPD (Figure 3).
29

Its prevalence is growing. Even though it is
still underdiagnosed, COPD is the fourth
leading cause of death in the United States.
30,31
The National Institutes of Health projects that
COPD will be the third most common cause
of death by the year 2020.
31
Smoking is the
primary cause of this progressive respiratory
disease, which includes chronic bronchitis and
emphysema.
31,32
There is no known cure for
COPD, and lung function inevitably worsens
over time, especially if individuals continue
their tobacco use.
31
Table 4. Diseases Caused by Tobacco Use
Smoking
15

Lung cancer
Cancers of the larynx, mouth, pharynx,
esophagus, bladder, pancreas, cervix, kidney,
and stomach
Some leukemias
COPD
CVD
Aneurysms
Bronchitis
Stroke
Severity of pneumonia and asthma
Emphysema
Smokeless tobacco
26

Oral cancer
Leukoplakia (mouth lesions that may become
cancerous)
Periodontal degeneration
Environmental tobacco smoke
CVD
27

Lung cancer
27

Effects in children
28

Asthma
Sudden infant death syndrome
Middle ear disease
Pneumonia
Cough
Upper respiratory infections
Abnormal lipid levels
Increased risk of leukemia and lymphoma
as an adult
Cancer, COPD, and heart disease account for
the majority of deaths related to tobacco use
(Figure 4).
23
Taken together, smoking-related
illnesses cause signicant premature mortality:
Smoking kills nearly 435,000 Americans
every year
18

Jolacco ise caises nearly 20% of all ueatls
in the United States
15
Smokers uie an average of 14 years earlier
than nonsmokers
18
Smokers are 10 times more likely tlan
nonsmokers to die from COPD
33
Among miuule-ageu men anu women,
smoking triples the risk of dying from
heart disease
34
Signicant mortality also occurs in nonsmokers
who are exposed to the effects of tobacco.
Every year, ETS causes 3,000 deaths from
lung cancer and more than 35,000 deaths from
CVD in nonsmokers.
23
Also, over 900 infants
die each year because their mothers smoked
during pregnancy.
23
Stroke
17,436
Infant Deaths
910
Secondhand
Smoke
38,112
Other Cancers
34,693
Other Diagnoses
46,442
COPD
90,582
Ischemic Heart
Disease
86,801
Lung Cancer
123,836
Figure 4. Annual Deaths Attributable to Cigarette
Smoking Among U.S. Adults
18,23
*COPD includes chronic bronchitis and emphysema.
Hispanic
Lung Cancer
Stroke
Other Cancers
Heart Attack
COPD*
Figure 3. Cigarette-Smoking Attributable Conditions
Among Current Smokers
29
Economic Impact of
Tobacco Use
The economic costs of tobacco use are
also devastating. On a personal level,
smokers spend nearly 10% of their medical
expenditures on smoking-related illnesses.
15

Similar data is not available for users of
smokeless tobacco. Expenses for employers
due to death-related productivity losses
amount to $92 billion a year, and direct
medical costs account for more than $75
billion annually, for a total cost to the economy
of $167 billion every year (Figure 5).
15
These
numbers do not account for diminished
on-the-job productivity of smokers, who
have more accidents and injuries, as well as
higher rates of turnover and absenteeism, than
nonsmokers.
35
Because the most profound
health effects of tobacco use may manifest at
midlife, workers often become disabled at the
height of their productivity.
9
It is important to note that while the
prevalence of smoking has remained relatively
stable in recent years, health care costs
associated with tobacco use continue to
escalate. In 1999, medical and productivity
costs were $7.18 for every pack of cigarettes
sold.
17
By 2004, these costs had grown
to $10.47 per pack (Figure 6).
36
With
approximately 47.5 million smokers in the
United States, it was recently estimated that
the average tobacco-related health care cost is
$3,400 annually per smoker.
17
180
40
60
80
100
120
140
160
20
0
Medical Costs Death-Related
Productivity Costs
Smoking-Attributable Health Costs
Total
$75
$92
$167
E
x
p
e
n
s
e
s

i
n

(
D
o
l
l
a
r
s
)
Figure 5. Annual Smoking-Attributable Health Costs
15
10
12
4
6
8
2
0
Medical Care
Lost Productivity Total

E
x
p
e
n
s
e

i
n

D
o
l
l
a
r
s
Health Care Costs per Pack of Cigarettes
1999
2004
Figure 6. Escalating Health Care Costs Attributable to
Smoking: 1999-2004
17,36
Related HEDIS
Measures and CAHPS

Questions
Reducing the morbidity and mortality of
tobacco use will require broad implementation
of health care protocols that address the
importance of smoking cessation. NCQA
recognized this need by incorporating
relevant quality-of-care standards in HEDIS
measures, both at the health plan and
physician practice level (see CAHPS).
The most directly related measures are
within the part of HEDIS represented by
the Consumer Assessment of Healthcare
Providers and Systems (CAHPS). CAHPS
was developed by the AHRQ and has been
adapted by NCQA for use within HEDIS.
HEDIS measures set a standard of care for
health plans to follow across a broad range
of health care services, and CAHPS surveys
assess health care provider performance
from the patients perspective.
10
In this way,
health plans and providers are encouraged to
implement protocols that ensure quality of
care for everyone.
CAHPS is a registered trademark of the Agency for Healthcare Research
and Quality (AHRQ).
Background
Steeped in a rich history of foundational
beliefs focusing on prevention and treatment,
this large, integrated health system boasts a
comprehensive tobacco-dependence program.
This multifocal effort embraces the shortened
U.S. Public Health Service Best Practice
recommendations from its 2000 Clinical
Practice Guideline.
Similar to other case study efforts, this
program focused on elevating tobacco use
to a vital sign. Instead of an optional piece
of information gathered during a clinic visit,
patients are now routinely asked about their
tobacco use with the response documented in
their respective medical record.
Case Description
Implementing all of the Public Health
Service Best Practice recommendations meant
that multiple efforts had to be effectively
integrated and implemented across a large
segment of the health systems enrollees and
employees. Initiated in 1998 and still ongoing
today, the tobacco-dependence program
employs four main strategies:
1. For patients: routine tobacco use
assessment, counseling, and referrals during
clinic visits; for clinicians: training, audit, and
feedback linked to incentives
2. Enhanced health plan benets ensuring
access to tobacco cessation medications at
the level of a members pharmacy copay
when the member is participating in any
one of the programs
3. Menu of no-cost tobacco cessation programs
for members
4. Work site and community tobacco control
efforts
In addition to these strategies, member
satisfaction is considered an important
measure of program success. Since 2001,
routine member satisfaction surveys include
a question regarding whether the member
smokes and if the member was advised to quit
Case Study: An Integrated Health Systems
Tobacco-Dependence Program
Organization at a Glance:
Organization Type: Managed care organization
Target Population: All product lines
Enrollment: 3.2 million
Location: West coast
U.S. Public Health Service Best Practice2000 Clinical Practice Guideline
The key recommendations of the 2000 Guideline Treating Tobacco Use and Dependence, based on literature
review and expert panel opinion, includes
1
:
1. Tobacco dependence is a chronic condition that often requires repeated intervention. However, effective
treatments exist that can produce long-term or even permanent abstinence.
2. Because effective tobacco-dependence treatments are available, every patient who uses tobacco should be
offered at least one of these treatments:
a. Patients willing to try to quit tobacco use should be provided with treatments identied as effective in this
guideline.
b. Patients unwilling to try to quit tobacco use should be provided with a brief intervention designed to increase
their motivation to quit.
3. It is essential that clinicians and health care delivery systems (including administrators, insurers, and
purchasers) institutionalize the consistent identication, documentation, and treatment of every tobacco user
seen in a health care setting.
4. Brief tobacco-dependence treatment is effective, and every patient who uses tobacco should be offered at least
brief treatment.
5. There is a strong dose-response relationship between the intensity of tobacco-dependence counseling and
its effectiveness. Treatments involving person-to-person contact (via individual, group, or proactive telephone
counseling) are consistently effective, and their effectiveness increases with treatment intensity (e.g., minutes of
contact).
6. Three types of counseling and behavioral therapies were found to be especially effective and should be used
with all patients attempting tobacco cessation:
a. Provision of practical counseling
b. Provision of social support as part of treatment
c. Help in securing social support outside of treatment
7. Numerous effective pharmacotherapies for smoking cessation exist. Except in the presence of contraindications,
these should be used with all patients attempting to quit smoking.
8. Tobacco-dependence treatments are both clinically effective and cost effective relative to other medical and
disease prevention interventions. As such, insurers and purchasers should ensure that:
a. All insurance plans include as a reimbursed benet the counseling and pharmacotherapeutic treatments
identied as effective in this guideline, and
b. Clinicians are reimbursed for providing tobacco-dependence treatment just as they are reimbursed for treating
other chronic conditions.
on his or her last clinician visit. This question
mirrors a CAHPS question regarding whether
a patient received advice to quit smoking
from his or her clinician during a visit in the
past year. Because this measure relies on
patient recall, it implicitly measures whether
the advice given was memorable and, thus,
effective.
Having a fully integrated health system allows
assessments and interventions to occur at
both primary care and specialty care visits.
The clinicians provide routine assessments of
tobacco use status, advice to quit, and referrals
to cessation programs. The referrals are to
an array of in-house resources and programs
available to members on an unlimited basis
without charge. Participation in the programs
entitles members to receive tobacco cessation
medications at their copay amount.
Walking-the-talk has led the entire
integrated health system to work toward
smoke-free environments. By 2008, this entire
multicampus organization will be entirely
tobacco free.
Providing support to clinicians, the tobacco-
dependence program conducts quarterly
audits and provides feedback regarding the
clinicians performance in advising smokers
to quit. In the initial implementation years
of this program, it also included an incentive
for clinicians who counsel patients to quit
smoking. As part of a Quality Goal package,
clinicians were encouraged to advise their
patients to quit smoking through a pay-for-
performance model.
61.80%
57.20%
67.00%
68.90%
74.70%
75.10%
81.19%
83.00%
50.0%
55.0%
60.0%
65.0%
70.0%
75.0%
80.0%
85.0%
%

M
e
m
b
e
r
s

R
e
p
o
r
t
i
n
g

A
d
v
i
c
e

R
e
c
e
i
v
e
d
1998 1999 2000 2002 2003 2004 2005 2006
Figure 1. HEDIS/CAHPS Performance: Advising Smokers to Quit
Population
The target population of 3.2 million adult
patients is served by 20 medical centers (with
over 55 sites). Also, the integrated health
system is including its employees through
similar initiatives and campus-wide, smoke-
free environments.
Results
The tobacco-dependence program has
achieved a more than 33% reduction in
smoking prevalence in the adult patients.
Further, it reports a 25 percentage-point
increase in the HEDIS/CAHPS scores on
the advising smokers to quit measure and
a signicant increase in tobacco cessation
program attendance and medications use
(Figure 1).
Sustainability
Sustainability is a key to success of any
population-based health program. The
ongoing efforts of this program are managed
through dedicated resources. This integrated
health system has dedicated one regional lead
manager, a health educator, and physician
champion at most of its 20 medical centers.
In Their Own Words
The system reports:
This long-term program has increased
awareness of the unique and powerful position
of medical staff and physicians in encouraging
cessation. Most of our clinicians now feel
empowered to take the step and discuss
tobacco use with their patients since they
know that, not only does their brief advice
statement have an impact, but also that they
are supported by proven programs to help
their patients quit tobacco.
Future Thoughts
Going forward, the program is looking to
provide more clinician training on medication
management for smoking cessation. As the
population of patients who smoke declines,
the health system may be faced with patients
who are more heavily dependent on nicotine
and who need more intensive interventions to
be successful in quitting.
Conclusion
This integrated health system case study
highlights the multiple efforts underway
to decrease tobacco use. Integrated health
systems have opportunities to impact patients
and clinicians through program delivery
modes, incentives, and barrier reduction.
Please refer to Appendices 1-3 for tools and
resources used by this organization.
Reference
1. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence.
Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and
Human Services. Public Health Service. June 2000. http://www.ncbi.nlm.nih.
gov/books/bv.fcgi?rid=hstat2.chapter.7644. Accessed March 5, 2008.
Two HEDIS measures focus specically on
issues related to smoking: cessation efforts and
COPD diagnosis (Table 5). Related CAHPS
questions directly assess the components of
the HEDIS measure on Medical Assistance
With Smoking Cessation (Table 6).
Compared with results from 2005, commercial
plans on average showed slightly improved
performance on Medical Assistance With
Smoking Cessation in 2006 (Table 7). Yet,
both detection and interventions still fall far
short of recommended levels. While about
75% of smokers were advised to quit, less than
half were counseled about medications and
other smoking cessation strategies available
to them.
10
Published guidelines from the
U.S. Preventive Services Task Force strongly
recommend that clinicians ask all adults about
tobacco use and give every smoker counseling
and pharmacotherapy to help them quit.
5
Use of spirometry in the assessment
and diagnosis of COPD also improved
slightly from the previous year.
10
However,
performance is still far less than desirable.
Fewer than half of adults with COPD on
systematic health exams have been previously
diagnosed by their physicians.
30
Lack of an
appropriate diagnosis prevents appropriate
treatment, including smoking cessation
counseling, for the majority of people
suffering from this progressive disease. As a
rst-line measure, spirometry is essential for
an accurate diagnosis providing an objective
measure for evaluating disease severity.
39

Spirometry is indicated for any patient with
persistent dyspnea, chronic cough, or ongoing
sputum productionespecially if the patient
has a history of smoking.
39
Since symptoms
of COPD may be confused with other
conditions, such as asthma or heart failure,
spirometry guides appropriate treatment.
Further, the simple act of spirometry testing
has been shown to motivate smokers to quit.
40

Table 5. HEDIS Measures Related to Quality of Care for Smokers
37
Measure Description
Medical Assistance With Smoking Cessation Evaluates three components of an effective smoking cessation program: advice
to quit, discussion of medication options, and recommendations for specic
cessation strategies
Use of Spirometry in the Assessment and Estimates the percentage of members, or at the physician level, patients with
Diagnosis of COPD visits, who are 40 years of age and older who received spirometry testing to
conrm a diagnosis of COPD
Table 6. CAHPS Questions Regarding Performance on HEDIS Measure: Medical Assistance
With Smoking Cessation
38
Question Response Choices
Do you now smoke cigarettes every day, Every day
some days, or not at all? Some days
Not at all (skip next three questions)
Dont know (skip next three questions)
In the last 12 months, on how many visits were you None
advised to quit smoking by a doctor or other health care One visit
provider in your plan? Two to four visits
Five to nine visits
10 or more visits
I had no visits in the last 12 months
On how many visits was medication recommended or None
discussed to assist you with quitting smoking One visit
(e.g., nicotine gum, patch, nasal spray, inhaler, Two to four visits
prescription medicine)? Five to nine visits
10 or more visits
On how many visits did your doctor or health care None
provider recommend or discuss methods and strategies One visit
(other than medication) to assist you with quitting smoking? Two to four visits
Five to nine visits
10 or more visits
Table 7. Commercial Plan Performance on HEDIS Measures Related to Quality of Care
for Smokers
10
Measure Performance (%)
2005 2006
Medical Assistance With Smoking Cessation
Advising smokers to quit 71.2 73.8
Discussing medications 39.4 43.9
Discussing strategies 39.0 43.2
Use of Spirometry in the Assessment and Diagnosis of COPD 34.8 36.1
Case Study: Employer Effort
Get Ready...Get Set...Get Quit: An
Employee Nicotine Cessation Program
Background
With 33,500 union and nonunion employees
in 23 states, the District of Columbia, and
two Canadian provinces, this employer
implemented a tobacco cessation policy
and created a program to support its
implementation.
The tipping point for action occurred
in November 2004 when the company
introduced health and wellness into the
organizations culture. Beginning with top
leadership, pilot programs were launched to
assess employee health status. Tobacco use
was one measure of health status assessed.
Data from the pilots led to the development
and implementation of 12 health and wellness-
related programs, including placement of
onsite Wellness Centers in large employee-
based areas along with creation of 19 tness
centers.
Case Description
Investing in employee wellness made good
business sense for this large employer. The
company created a comprehensive health
screening that incorporated biometric
screenings, pulmonary function testing, and
health risk assessments. The screenings
were designed to inform employees about
behavioral health issues. A multidisciplinary
team of American Dietetics Association
(ADA) Registered Dietitians and American
College of Sports Medicine (ACSM) Health
Fitness Instructors used the biometric
data to stratify employees disease risk and
developed individualized behavior change
programs. Through the data collected, this
company found that at least 34% of employees
used tobacco products and were at risk for
pulmonary disease.
Organization Type: Large employer
Target Population: 33,500 union and nonunion
employees
Location: Dispersed locations across
the United States & Canada
T H E C U R R E N T S T A T E O F Q U A L I T Y O F C A R E F O R T O B A C C O U S E A N D D E P E N D E N C E 31
Further, the company assessed the nancial
impact of tobacco dependency on health
care and productivity costs. A cost model
was developed using comparative data from
national data sets. Using estimates that 9% of
smokers would maintain nicotine abstinence
for one year, the company concluded that
health care and productivity savings would
offset program costs. The pharmacoeconomic
analysis combined with the high prevalence
of tobacco users prompted the employer
senior leadership to invest in creating a
comprehensive nicotine cessation program.
A company-specific program was designed based
on identified best practices from the Centers for
Disease Control and Prevention (CDC) Guidelines
for Tobacco Dependency. Table 1 highlights the
six components of the program along with methods
used for program implementation.
Table 1. Employer Components for Nicotine Cessation Program
Component Methodology
1. Behavioral Health Self-Assessment Uses the Transtheoretical Behavior Change Model to
assess the smokers readiness for behavior change.
2. Nicotine Cessation Brochure Promotes the program and increases employee
awareness of the new benet.
3. Nicotine Cessation Toolkit
Fagerstrom Test for Nicotine Dependence Assesses nicotine dependence level.
Nicotine Triggers Quiz Identies triggers for nicotine use and assesses
associative reasons for nicotine use.
Are You Ready to Quit? Assesses motivation level.
The Craving Journal Provides a visual log for craving occurrences.
The Nicotine Trigger Plan Allows smokers the ability to identify nicotine coping
strategies, craving periods, and triggering cues.
Reimbursement Policy Provides smokers an incentive to attempt the
cessation program.
Initial Physician Cessation Visit Form Prompts physicians to review the toolkit with the
patient, facilitates the creation of the patients quit
plan, and is required for initial reimbursement.
Follow-Up Physician Cessation Visit Form Certies successful completion of the nicotine
cessation program.
4. Medical Oversight Facilitates employees use of the physician community
to receive nicotine cessation advice and if needed,
pharmacotherapy.
5. Program Reimbursement Participants are reimbursed up to $250 for physician
ofce visit and copayments for nicotine cessation
prescriptions. Additionally, participants can receive
reimbursement for 100% of Nicotine Replacement
Therapy with a maximum of two attempts per year.
6. Behavioral Support Counseling Contracts services offered through a medical center.
Recognizing the difculty that employees
may have with quitting, the program provided
coverage for up to two quit attempts per year
with a lifetime maximum of six quit attempts.
Results
To determine the impact of the nicotine
cessation programs success, participation,
abstinence, and recidivism rates were
measured:
Particiation rates were measireu tlroigl
receipt of the Initial Physician Cessation
Visit Form
Alstinence rates were measireu tlroigl
receipt of the Follow-Up Physician
Cessation Visit Form
Reciuivism rates were measireu tlroigl
follow-up telephone surveys at six and 12
months with the medical center contracted
to provide behavioral support counseling
In addition, the following variables are also
measured and tracked for ongoing program
enhancements and reporting:
Lemogralics. age, genuer, state of
residence, union/nonunion status, years of
smoking, and daily usage rate
ntensity of ueenuence. !agerstrom Score
determined from the Fagerstrom Test for
Nicotine Dependence
Jreatment. larmacotlereay tye, qiit
date, and relapse date
Based upon an ongoing pilot of initial
participants, the program has shown initial
success. The mean age of participants was
44.6 years; with a 24.4-year smoking history;
averaging 1.4 packs per day. Twenty-ve
percent of those enrolled have completed
the program and remain smoke free. Of
the quit group, 80% received an average
reimbursement of $215 to cover physician
and pharmacy costs. An additional 5% of
participants have abstained from smoking,
but have yet to seek reimbursement.
Unfortunately, 10% abstained and have since
relapsed. The remaining 5% were lost to data
collection.
Leadership/Sustainability
Company leadership supports the action
of the wellness program including the
nicotine cessation program. This support
is demonstrated through program policies,
nancial support, and staff assignments. Ten
dedicated eld-based staff are responsible for
marketing program services and providing
nicotine coaching; one person is dedicated to
program tracking and participant follow-up
and reimbursement; and health counseling
continues to be offered through an outside
vendor.
In Their Own Words
The company observes:
Prior to this, the company did not have a
comprehensive nicotine cessation program.
The previous program lacked sophistication
to address the complexity of nicotine
dependence and did not demonstrate the
companys commitment to overall employee
health and well being. Unique aspects of
this program are senior leadership support,
coverage for multiple quit attempts, signicant
staff support, high reimbursement level, and
collaboration with the medical community.
Conclusion
This case represents a large employers efforts
to change tobacco use among employees.
Using a top-down, leadership-driven effort,
this company created a comprehensive
health and wellness program. This company
recognized nancial barriers and issues with
chronic relapse of behaviors for nicotine users
and offered solutions for each barrier. This
effort is a work in progress with the company
continuing to hone its program investing
in employee wellness while continuously
assessing the economic impacts that such
programs have on this company.
Successful program replication requires
having senior leadership support, obtaining nancial resources,
dedicating professional resources, involving the employees
primary care physician, and understanding the organizational culture.
Use of Health Risk
Appraisals
Another widely used screening tool is
the Health Risk Appraisal (HRA). Both
health plans and employers rely on these
instruments to help identify risk factors and
provide interventions in the populations they
serve. A typical HRA gathers information
from individuals regarding demographic
characteristics (e.g., age, sex), lifestyle (e.g.,
smoking status), and personal and family
medical history.
41
HRAs also may include
feedback and intervention services.
41
Numerous HRAs are commercially available,
including instruments designed specically
to assess and manage lifestyle risk factors.
41

While benets can be signicant, several
caveats accompany the use of HRAs,
including ethical considerations and reliability
of data (Table 8).
Table 8. Benets and Caveats of Health Risk Appraisals
41,42
Benets Caveats
Widely available in numerous formats
Claries goals for interventions
Improves cost-effectiveness of resources
where need is greatest
Quanties progress when HRA is given
at baseline and repeated posttreatment
Increases employee awareness
and motivation
Ethical Considerations:
Goals, methods, and requirements for participation
must be clearly communicated
Materials must be appropriate for population,
including cultural and ethnic sensitivity
Condentiality must be maintained
Individuals must be free to decline participation
without consequences
Data must be secure
Results and their implications must be
clearly interpreted
Referrals or on-site interventions must
be provided to address tobacco use
Conclusion
Nicotine dependency is a chronic condition
that harms nearly every organ in the body.
23

Despite this well-known fact, the number
of smokers in the United States has not
decreased signicantly in recent years.
18
Of
the more than 47 million current smokers,
nearly 20% live with a chronic smoking-related
illness, and all are at increased risk of dying
prematurely from cancer, heart disease, or a
respiratory condition.
19,23,29
Even to those who
never hold a cigarette, ETS expands the damage
These consequences cause considerable
personal suffering and escalating economic
costs that affect all of us. Smoking-related
HEDIS measures and CAHPS
questions,
as well as results from HRAs, should spur a
greater emphasis on quality care for these
populations. While health plans and employers
are taking notice, improved adherence to
smoking cessation protocols is required if
we are to stem the growing burden of tobacco
use and dependency.
References
1. Freudenheim M. Seeking savings, employers help smokers quit. The New
York Times. October 26, 2007. http://www.nytimes.com/2007/10/26/
business/26smoking.html?_r=1&n=Top/Reference/Times%20Topics/
People/F/Freudenheim,%20Milt&oref=slogin. Accessed October 27, 2007.
2. U.S. Department of Health and Human Services. Healthy People 2010:
Volume II (second edition) Tobacco Use. http://www.healthypeople.gov/
Document/HTML/volume21/27Tobacco.htm. Published November 2000.
Accessed October 9, 2007.
3. American Nonsmokers Rights Foundation. States, commonwealths, and
municipalities with 100% smoke-free laws in workplaces, restaurants, or
bars. http://www.no-smoke.org/pdf/100ordlist.pdf. Updated April 1, 2008.
Accessed April 28, 2008.
4. Centers for Disease Control and Prevention. State Tobacco Activities
Tracking and Evaluation (STATE) system: state smoke-free indoor air fact
sheet. http://www.cdc.gov/tobacco/statesystem. Accessed December 8,
2007.
5. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventative
Services Task Force. Counseling to prevent tobacco use and tobacco-caused
disease: recommendation statement. Rockville, MD: AHRQ publication
04-0526; November 2003
6. Tokarski C. Smoking cessation treatment cost-effective for health plans.
Medscape Medical News. June 7, 2004. http://www.medscape.com/view-
article/480313. Accessed April 30, 2008.
7. Holtrop JS, Malouin R, Weismantel D, Wadland WC. Clinician perceptions
of factors inuencing referrals to a smoking cessation program. BMC Fam
Pract. 2008;9:18. http://www.biomedcentral.com/1471-2296/9/18.
Accessed April 30, 2008.
8. California Department of Health Services. Confronting a relentless adversary:
a plan for success. Toward a tobacco-free California 2006-2008. http://
www.dhs.ca.goc/tobacco/documents/pubs/MasterPlan05.pdf. Published
March 2006. Accessed April 30, 2008.
References (contd)
9. World Health Organization. Why is tobacco a public health priority? http://
www.who.int/tobacco/health_priority/en/index.html. Accessed October 6,
2007.
10. National Committee for Quality Assurance. The State of Health Care Quality
2007: Industry Trends and Analysis. Washington, DC: National Committee
for Quality Assurance; 2007.
11. National Committee for Quality Assurance. ProgramsAccreditation,
certication, and recognition. http://www.ncqa.org/tabid/58/Default.aspx.
Accessed May 1, 2008.
12. Mitrouska I, Bouloukaki I, Siafakas NM. Pharmacological approaches to
smoking cessation. Pulm Pharmacol Ther. 2007;20:220-232.
13. Frishman WH, Mitta W, Kupersmith A, Ky T. Nicotine and non-nicotine
smoking cessation pharmacotherapies. Cardiol Rev. 2006;14:57-73.
14. Centers for Disease Control and Prevention. Fact sheet: smokeless tobacco.
http://www.cdc.gov/tobacco/data_statistics/Factsheets/smokeless_
tobacco.htm. Updated April 2007. Accessed March 25, 2008.
15. American Cancer Society. Questions about smoking, tobacco, and health.
http://www.cancer.org/docroot/PED/content/PED_10_2x_Questions_
About_Smoking_Tobacco_and_Health.asp. Accessed October 2, 2006.
16. Schroeder SA. What to do with a patient who smokes. JAMA.
2005;294:482-487.
17. Balkstra CR, Fields M, Roesler L. Meeting Joint Commission on
Accreditation of Healthcare Organizations requirements for tobacco
cessation: the St. Josephs/Candler Health System approach to success.
Crit Care Nurs Clin North Am. 2006;18:105-111.
18. American Lung Association. Trends in tobacco use. http://www.lungusa
org/atf/cf/%7B7A8D42C2-FCCA-4604-8ADE-7F5D5E762256%7D/
TREND_TOBACCO_JUNE07.PDF. Published June 2007. Accessed October
6, 2007.
19. Centers for Disease Control and Prevention. Tobacco use among
adults-United States, 2005. MMWR Morb Mortal Wkly Rep.
2006;55(42):1145-1148. http://www.cdc.gov/mmwr/preview/mmwrhtml/
mm5542a1.htm. Accessed May 19, 2008.
20. Centers for Disease Control and Prevention. Healthy Youth! Health
topics: tobacco use. http://www.cdc.gov/HealthyYouth/tobacco/index.htm.
Updated November 7, 2007. Accessed December 7, 2007.
21. Doolan DM, Froelicher ES. Efcacy of smoking cessation intervention
among special populations. Nurse Res. 2006(suppl 4):S29-S37.
22. American Cancer Society. Cigarette use among teens inches downward:
rate is higher in rural areas. CA Cancer J Clin. 2002;52:3-4. http://www.
caonline.amcancersoc.org/cgi/content/full/52/1/3. Accessed May 1,
2008.
23. Centers for Disease Control and Prevention. Annual smoking-attributabl
mortality, years of potential life lost, and productivity lossesUnited States,
1997-2001. MMWR Morb Mortal Wkly Rep. 2005;54(25):625-628. http:/
www.cdc.gov/mmwr//preview/mmwrhtml/mm5525a1.htm. Accessed May
1, 2008.
24. Free & Clear. Why tobacco cessation for health plans? http://www.
freeclear.com/services/tobacco_cessation/health_plan/?nav_section=1.
25. Chaudhuri R, Livingston E, McMahon AD, et al. Effects of smoking
cessation on lung function and airway inammation in smokers with
asthma. Am J Respir Crit Care Med. 2006;174:127-133. http://www.
medscape.com/medline/abstract/16645173. Accessed May 19, 2008.
26. Centers for Disease Control and Prevention. Guidelines for school health
programs to prevent tobacco use and addiction. MMWR Morb Mortal Wkly
Rep. 1994;43(No. RR-2):1-19. ftp://ftp.cdc.gov/pub/Publications/mmwr/
rr/rr4302.pdf. Accessed December 18, 2007.
27. Centers for Disease Control and Prevention. Fact sheet: secondhand
smoke. http://www.cdc.gov/tobacco/data_statistics/Factsheets/
SecondhandSmoke.htm. Updated September 2004. Accessed December
7, 2007.
28. American Academy of Pediatrics Committee on Substance
Abuse. Tobaccos toll: implications for the pediatrician. Pediatrics.
2001;107:794-798.
29. Centers for Disease Control and Prevention. Cigarette smoking-
attributable morbidityUnited States, 2000. MMWR Morb Mortal Wkly Rep.
2003;52(35):842-844.
30. Celli BR. Chronic obstructive pulmonary disease: from unjustied nihilism to
evidence-based optimism. Proc Am Thorac Soc. 2006;3:58-65.
31. National Heart Lung and Blood Institute. National Institutes of Health. U.S.
Department of Health and Human Services. Chronic obstructive pulmonary
disease. http://www.nhlbi.nih.gov/health/public/lung/other/copd_fact.pdf.
Published March 2003. Accessed October 6, 2007.
32. Hylkema MN, Sterk PJ, de Boer WI, Postma DS. Tobacco use in relation to
COPD and asthma. Eur Respir J. 2007;29:438-445.
33. Missouri Department of Health and Senior Services. Facts: health risks of
smokingfrom A to V. http://www.dhss.state.mo.us/SmokingAndTobacco/
HealthRisks.pdf. Accessed May 1, 2008.
34. Centers for Disease Control and Prevention. Fact sheet: cigarette smoking-
related mortality. http://www.cdc.gov/tobacco/data_statistics?factsheets/
cig_smoking_mort.htm. Updated September 2006. Accesssed May 1,
2008.
35. Free & Clear. Economic impact of tobacco use. http://www.freeclear.com/
case_for_cessation/econ_impact.aspx?nav_section=2. Accessed May 9,
2006.
36. Centers for Disease Control and Prevention. Department of Health and
Human Services. Sustaining state programs for tobacco control: data
highlights 2006. http://www.cdc.gov/tobacco/data_statistics/state_data/
data_highlights/2006/00_pdfs/DataHighlights06rev.pdf. Accessed May
19, 2008.
37. Fallon Community Health Plan. 2008 HEDIS
measures. http://fchp.
org/NR/rdonlyres/7793DFDF-5308-41D1-8A0D-CBA7F16918E3/0/
HEDIS_2008MeasuresForFCHPWeb.pdf. Accessed May 14, 2008.
38. National Committee for Quality Assurance. CAHPS 3.0H, 4.0H Survey
Crosswalk. http://web.ncqa.org/Portals/O/PolicyUpdates/HEDIS%20
Technical%20Updates/CAHPS_Crosswalk_30H_to_40H.pdf. Published
2006. Accessed October 7, 2007.
39. Rabe KF, Hurd S, Anzueto A, et al. Global strategy for the diagnosis,
management, and prevention of chronic obstructive pulmonary disease.
Am J Respir Crit Care Med. 2007;176:532-555.
40. Johansson S, Johansson G, Green Y. Screening with spirometry reduces
smoking [abstract]. http://www.thepcrj/journ/vol15/15_3_213_c.pdf.
Accessed December 17, 2007.
41. Centers for Disease Control and Prevention. Health risk appraisals. http://
www.cdc.gov/nccdphp/dnpa/hwi/program_design/health_risk_appraisals.
htm. Accessed December 8, 2007.
42. Centers for Disease Control and Prevention. Ethics guidelines for development
and use of health assessments. http://www.cdc.gov./nccdphp/dnpa/hwi/
program_design/ethical_guidelines.htm. Updated May 22, 2007. Accessed
December 6, 2007.
| P R I N C I P L E S F O R R E D U C I N G T H E B U R D E N O F T O B A C C O U S E 37
Principles for Reducing the
Burden of Tobacco Use
The health and economic burdens of tobacco use call for aggressive interventions to reduce its initiation,
improve cessation rates, and decrease exposure to environmental tobacco smoke (ETS). Along with Healthy
People 2010, the U.S. Public Health Service Best Practice recommendations offer health plans, employers, and
clinicians a structure to develop effective services to address these goals. Repeatedly, these recommendations
emphasize the value of combined interventions and collaborative efforts to improve smoking cessation rates. As
the most widespread form of addiction, this chapter focuses primarily on smoking cessation.
Self-Help/
Cold Turkey
Nicotine Patch
Nicotine Inhaler
Nicotine Gum
Nicotine Nasal Spray
Medications
Behavioral Support/
Counseling
Combining Physiological
and Psychological Support
Success Rates (%)
0 10 20 30 40 50 60 70
*Success rates for single approaches are based on studies with at least five months of follow-up after target quit date.
Figure 1. Success Rates for Smoking Cessation Methods
1,5
*
Principles for Successful
Smoking Cessation
Initiatives
Most smokers attempt to stop using tobacco
on their own by quitting cold turkey, yet
this is the least successful method of smoking
cessation (Figure 1).
1
Withdrawal symptoms
are often intense and persistent, and
psychological, behavioral, and social factors
also make cessation difcult.
2,3
Consequently,
although 70% of smokers want to quit, just 5%
of them are able to quit without assistance.
4

Increasing the odds of success requires a
multifaceted approach that accounts for the
various temptations smokers face as they
attempt to quit. Underlying this approach is
an awareness of the factors that encourage
smoking cessation and the clinical approaches
that motivate smokers to quit. Building on
this base are pharmacologic interventions,
counseling approaches, and incorporation of
repeat treatment for smokers who relapse
after an initial quit attempt.
Factors That Encourage
Smoking Cessation
Effective smoking cessation initiatives
incorporate numerous factors that encourage
success. Outside assistance in various forms is
pivotal. For example, consistent support from
a health care clinician can more than double
the likelihood of quitting compared with
self-help methods.
6
Tailored to individual
needs, pharmacotherapy may double or
triple success rates.
7
Environmental factors
also signicantly inuence cessation efforts.
No-smoking policies at work sites and other
locations lead to increased cessation rates, and
social support from friends and coworkers
provide the same effect.
8
The number of
smokers who attempt to quit is greatly
increased when the cost of cessation programs
is covered by their health plans. In one study,
it was estimated that 50% more
smokers would quit every year under
full coverage, compared with partial
reimbursement.
9
Thus, the odds of smokers
quitting successfully are greatly increased
when interventions address physiologic,
psychological, social, and economic factors.
10

Further, raising the cost of tobacco products
may also be a successful solution for
assisting smokers to quit. Increasing tobacco
taxes by 10% has been found to decrease
tobacco consumption by 4% in high-income
countries and by 8% in low- and middle-
income countries. A 70% increase in the
price of tobacco could prevent up to 25%
of all tobacco-related deaths among todays
smokers.
11
| T H E V A L U E O F E F F E C T I V E W E L L N E S S A N D P R E V E N T I O N I N I T I A T I V E S 39

Background
Located within a tobacco-growing state, this
NCQA-accredited Medicaid health plan
created a pilot program to address smoking
cessation. This state is noteworthy as having
the highest rate of smokers at 28.7%. Each
year more than 8,000 residents die from
illnesses caused by tobacco use.
This effort is the plans rst attempt to
address smoking within its membership. The
health plans Quality Medical Management
Committee was involved in guiding the initial
pilot portion of the program. This committee
formed a multidisciplinary workgroup that
provided input into the smoking cessation
program development.
The workgroup dened the smoking cessation
program objectives:
Jo reuice lealtl risks anu illnesses
associated with tobacco use and secondhand
smoke
Jo reuice reventalle anu rematire
deaths attributed to tobacco use
Jo uecrease tle risk for ling anu otler
types of cancer
Jo roviue siort to memlers wlo uesire
to quit by assisting them in becoming and
remaining smoke-free
The workgroup also identied cost for
cessation programs and cessation medications
as signicant barriers to members. Thus,
the health plans rst step was to provide
100% coverage for the cost of services and
medications for members enrolled in its
smoking cessation pilot program.
Case Study:
Health Plan: Yes, You Can!
Organization Type: Medicaid health plan
Target Population: State Medicaid enrollees
Location: Tobacco state
Case Description
Called the Yes, You Can! program, this
initiative used behavioral and pharmacological
approaches to smoking cessation. The health
plan used an internal system of care managers
specically trained in smoking cessation
techniques. The behavioral approach was
modeled using the Cooper Clayton smoking
cessation behavioral techniques (Table 1).
According to the plans research, the Cooper
Clayton method has a 20-year history of
success as a comprehensive behavioral
smoking cessation program. This method
was created by two faculty members at the
University of Kentucky. Thomas Cooper,
D.D.S., a dentist and former heavy smoker,
developed the program with Richard
Clayton, Ph.D., a clinician working in the
eld of drug addiction.
Yes, You Can! is a specialized disease-
management model created to address
tobacco use.
The plan initially piloted this program with
200 tobacco-using members who went through
the 12-week program. In the pilot group,
37% (74) of the 200 members were smoke-
free at 12 weeks. Considered a success, the
pilot project was rolled out to an additional 800
adult health plan members as a second-phase
pilot. The Yes, You Can! program is now
available to all adult health plan members.
Key pieces of Yes, You Can! include:
Self referrals
Wel site annoincements for memlers
and clinicians
Proviuer newsletter articles
Memler newsletter articles
Healtl ueartment anu family lealtl
centers yers
Practitioner referrals
Plarmacy/larmacist referrals
The program focused on individual success.
Each participant went through an interview
process to identify readiness and a
willingness to change. The member was
also asked to sign an agreement detailing
his or her own responsibility in smoking
cessation. To encourage members, services
were provided free as a covered benet for
those members in the pilot program. Members
also received refrigerator magnets, targeted
educational materials, and phone numbers to
access support.
Table 1. Cooper Clayton Method to Stop Smoking
1
Principle #1 Success is nothing more than a plan that is
adhered to.
Principle #2 A major problem can be solved when cut up
into a series of smaller problems.
Population
The health plan directed this effort at
Medicaid members 18 years of age or
older who were not pregnant. (The plan
had other initiatives that specically
targeted health behaviors in pregnant
women.) Total membership in the plan
is approximately 140,000.
Lessons Learned
In retrospect, the plan would work toward
a more automated system. In the piloting
phase, the plan used a very personal approach
working one-on-one with each member.
However, this method soon snowballed with
the number of enrollees increasing versus the
number of care managers available to provide
support. The plan also noted that it is easy to
lose momentum. As a result, they recommend
that dedicated staff be tasked with achieving
the goals of a program such as Yes, You Can!
In Their Own Words
The health plan commented:
Many members expressed a desire to quit
smoking but had difculty paying for the
smoking cessation medications. The plan
recognizes the health risks of smoking along
with nancial barriers our members had to
smoking cessation and decided to cover this
above the established benet package.
Conclusion
Health plan efforts that look at enhanced
benet sets may provide a mechanism for
people to quit smoking. Removing cost
barriers associated with behavioral support
and tobacco cessation medications allows
members the opportunity to change their
tobacco use practices.
Please refer to Appendix 6 for tools and
Reference
1. The Cooper Clayton Method to Stop Smoking. http://www.stop
smoking4ever.org/. Accessed March 5, 2008.
Clinical Approach to Cessation:
The 5 As
Clinical screenings serve as the foundation
for successful smoking cessation efforts. A
clear protocol is provided by the 5 As
approach, which is considered the gold
standard for assisting smokers to quit
(Table 1). Health care clinicians should Ask
about tobacco use, Advise smokers to quit,
Assess the smokers willingness to quit, Assist
with the quit attempt, and Arrange follow-up
care.
12
Familiarity with the basic tenets of
this method will help clinicians target their
efforts and guide employers and health plans
in choosing optimum coverage for employees
and members.
Stages of Smoking Cessation
The 5 As are most effective when the strategies
align with the stages of smoking cessation.
Smokers typically move through ve distinct
steps in the process of quitting smoking:
precontemplation, contemplation, preparation,
action, and maintenance (Table 2).
10
As
a clinician assesses a smokers willingness
to quit, discussions will be very different
based on whether the smoker is in the
precontemplation or contemplation stage. In
the precontemplation stage, a smoker may be
unaware of the risks associated with tobacco
use or in denial that these risks apply to him
or her.
10
This individual is best approached
with exploratory questions that identify the
perceived benets of tobacco use then raise
doubts about their validity.
10
A smoker in the
contemplation phase is considering quitting
but often has mixed feelings about whether
quitting is desirable or even possible. In this
case, brief counseling and encouragement
are useful in resolving ambivalence.
10

A smoker ready to attempt cessation is in the
preparation stage, which is when assistance
should be offered to help him or her in
his or her quit attempt.
10
In the action and
maintenance stages, the individual no longer
smokes and should receive ongoing support
in following the treatment strategies.
10
Pharmacologic Support
Pharmacologic treatment for smoking
cessation was introduced more than 20 years
Table 1. The 5 As Model for Facilitating Smoking Cessation
12
Ask about tobacco use at Include tobacco use as a vital sign to be identied along with blood pressure, weight, and
every health care visit other regular evaluations.
Advise all smokers to quit Provide advice that is clear, strong, and personalized (e.g., Its important for you to quit smoking now,
especially with your grandchildren in the house).
Assess the smokers Offer assistance if the smoker is ready to quit. Provide motivation if smoker is unwilling to quit.
willingness to quit
Assist the smoker to quit Provide patient education materials and guide the smoker in developing a quit plan, which should
include counseling, social support, and pharmacotherapy.
Arrange follow-up contact Schedule follow-up contact in person or via telephone within the rst week after the quit date,
and again within the rst month; schedule additional follow-up as needed.
ago when the Food and Drug Administration
(FDA) approved the use of nicotine gum.
1

In the years since, additional medications
have been approved, and several over-the-
counter nicotine replacement therapies
(NRTs) became available.
14
Because
success rates improve signicantly with
pharmacotherapy, the U.S. Department
of Health and Human Services (DHHS)
recommends that all smokers should receive
medication unless contraindications prohibit
it.
5,12
Among available options, the choice of
medication for a particular individual should
be guided by patient-related factors (e.g.,
patient preference, previous experience,
contraindications) and determined by the
patients clinician.
12
Ethnic Disparities in Treatment
Utilization
Despite the improved success rates seen
with pharmacotherapy, few members of
ethnic minority groups take advantage of this
approach.
15
It is not because these groups are
disinterested in quitting; in fact, more ethnic
minorities than Caucasians attempt to quit
tobacco use. However, perhaps because they
are less likely to receive treatment, these
populations have lower rates of successful
cessation.
16
A recent survey that focused
specically on NRT use revealed that more
African Americans than Caucasians attempted
cessation in a given year (55% versus 43%,
respectively), but that Caucasians were far more
likely to report using an NRT (Figure 2).
16
Several studies indicate that ethnic minorities
50
60
20
30
40
10
0
Hispanics
African Americans Caucasians

E
v
e
r

U
s
e
d

N
R
T

D
u
r
i
n
g

a

Q
u
i
t

A
t
t
e
m
p
t

(
%
)
Figure 2. Use of an NRT as a Cessation Aid Among
Hispanics, African Americans, and Caucasians
16
Table 2. Stages of Smoking Cessation
10
Precontemplation Not considering quitting Identify and address reasons for resistance.
13
Contemplation Thinking about quitting Explore ambivalence and encourage awareness
of cessation benets.
10
Preparation Preparing to make a Help develop a course of action (i.e., set a quit
quit attempt date, determine pharmacotherapy and counseling
support, schedule follow-up contact).
10
Action Implementing measures to quit Support initial quit strategies (e.g., discuss initial
successes, as well as any potential problems).
10
Maintenance Maintaining successful Provide ongoing support (e.g., congratulate
quit attempt successes; address relapses, problems, or concerns).
10
are less likely to be informed about the
safety, efcacy, and functional benets of
pharmacotherapy and underestimate the
damaging effects of smoking.
15-17
In some
cases, minority smokers report that they fear
the side effects of medication would be worse
than the side effects of smoking, or that they
might be trading one addiction for another.
16
These individuals are not as likely to have
received information from their health care
clinicians as from friends and family.
15
Overall,
ethnic minorities are less likely to receive
appropriate interventions and less likely to be
aware that these interventions are available
to them.
15,17
Therefore, smoking cessation
initiatives should expressly include culturally
appropriate interventions designed to reach
this segment of the population.
Counseling
Cessation rates are highest when
pharmacotherapy is combined with
counseling.
18
While pharmacotherapy
addresses the physiologic aspects of nicotine
withdrawal, individual and group counseling
support the behavioral, psychological, and
social changes necessary in the cessation
process.
12
Two aspects of therapy have proven
effective in smoking cessation initiatives:
behavior modication and psychological
support. Behavior modication outlines
specic actions, such as avoiding alcohol,
that help reduce the possibility of relapse.
Psychological support supplements these
actions with encouragement, motivation,
and assistance by reframing the way smokers
think about cigarettes.
6
These forms of
therapy are integrated in clinical guidelines
set forth by the DHHS (Table 3).
12

Table 3. Elements of Effective Counseling for Smoking Cessation
12
Practical Counseling Supportive Counseling Help in Obtaining Outside Support
Anticipate high-risk situations
(help smoker identify events,
feelings, or activities that increase
the temptation to smoke)
Develop coping skills (help
smoker practice handling
high-risk situations)
Provide information (educate
smoker about the dangers
of smoking and the process
of quitting)
Provide encouragement
(communicate belief in the
smokers ability to quit)
Communicate caring
(listen to fears and
difculties around quitting)
Encourage discussion
(ask about reasons
for quitting)
Provide training in seeking
outside support (role-play
requesting support from family,
friends, and coworkers)
Prompt support seeking (inform
smoker of community resources,
such as hotlines and help lines)
Arrange outside support
(invite family members
to counseling sessions)
| T H E V A L U E O F E F F E C T I V E W E L L N E S S A N D P R E V E N T I O N I N I T I A T I V E S 45 | P R I N C I P L E S F O R R E D U C I N G T H E B U R D E N O F T O B A C C O U S E 45
Organization Type:
Clinical guideline collaborative
Target Population: All residents of the state
Location: Western state
Background
A state-wide, broad-based clinical guideline
collaborative embraced the opportunity to
reduce tobacco use among its states residents.
The collaborative is comprised of more than
50 organizations including health plans,
universities, medical societies, public health
departments, local health agencies, clinicians,
state agencies, and the local Veterans
Administration Health Care System.
Case Description
Smoking is a state-wide health concern with
multiple stakeholders. Through a state-wide
grant, this clinical guideline collaborative was
named lead agency for the State Tobacco
Education and Prevention Partnership
(STEPP). STEPP tasked this organization
with creating systems change aimed at
tobacco cessation education in health care
organizations across the state.
As a clinical guideline collaborative that
studies, creates, and seeks to implement
evidence-based efforts through clinical
guideline development, the organization
created a guideline for managing tobacco use.
Termed the clinical guideline for Tobacco
Cessation and Secondhand Smoke Exposure,
the guideline was developed for application
in clinician ofces. The guideline calls for
clinicians to routinely and systematically
address tobacco use with patients.
Case Study:
State Collaborative Focused on Clinicians
A key component of the initiative is the
Tobacco Rapid Improvement Activity
(TRIA), an adaptation of the rapid cycle
improvement quality strategy (Figure 1).
TRIA is a clinician training process offered
free to medical practices through lunch-and-
learn formats. Led by a trained facilitator, the
practice is instructed in the tobacco cessation
clinical guideline and available resources.
Following the introductory piece, there is a
brainstorming session with the entire practice
staff. The local health agency representative is
present to provide information about additional
resources. This session allows the practice to
consider how to improve its own internal
systems of care related to the guideline for
tobacco cessation and secondhand smoke
exposure reduction. The medical practices
receive follow-up contact from the clinical
guideline collaborative at one week, six weeks,
three months, and six months following the
initial TRIA training.
The goals of TRIA are to improve:
Patient oitcomes tlroigl emleuuing
evidence-based guidelines into clinical
practices
Offce effciency
Satisfaction of tle lealtl care team
and patients
The tobacco cessation guideline incorporates
the 5 As intervention approach (Ask, Advise,
Assess, Assist, and Arrange). The TRIA process
references this guideline while stressing the
streamlined version 2A-1R (Ask, Advise, and
Refer) approach may be more practical for busy
practices. Practices are also encouraged to refer
patients to the state-wide QuitLine, especially
if the practitioner is not comfortable or does
not have time to coach patients in quit plans.
Since the QuitLine boasts a cessation success
rate of close to 40% in six months, this is an
easy solution for clinicians to incorporate.
Figure 2 highlights the trends of QuitLine use
following TRIA training sessions.
Rapid cycle change was focused at the practice
site level. The clinical guideline collaborative
theorized that rapid cycle changes in clinician
practices would result in smoking reduction in
patients. This method was based on the 2006
Partnership for Prevention study on effective
clinical preventive services. Tobacco cessation
intervention (screening patients to determine
if they smoke, providing brief counseling,
and offering therapies and referrals to help
them quit) is one of the most important and
cost-effective preventive services that can be
offered in medical practices.
1
ASK
ADVISE
ASSESS
ASSIST
ARRANGE
If you have limited time:
ASK ADVISE REFER
Figure 1. Tobacco Rapid Improvement Activity (TRIA)
The TRIA strategy empowers clinicians and
their staffs to change their own internal systems.
The changes encouraged are to identify
tobacco-use behaviors in patients and create
methods to assist patients in ceasing tobacco
use. However, the real focus of this particular
initiative is clinician education.
Population
The population of this initiative includes
all clinicians within the state. However, the
clinical guideline group goes a step further by
identifying clinical practices that serve target
populations of tobacco users with specic
efforts aimed at high-risk adults, low-income
minority groups, and populations with
secondhand smoke exposure.
Results
Through December 2007, TRIA trained
69 practices with over 200 physicians, 60
physician assistants, 45 medical assistants,
45 nurses, and 110 ofce staff participating.
Satisfaction surveys indicated that 89% felt
that their time was well spent; 92% reported
they received some helpful tools and ideas
to make changes in their practices; and 93%
said they would recommend the activity to
other practices.
Data collected from 45 practices trained
prior to December 2007 demonstrated that
93% of the practices have made at least
one change to their daily processes. Most
practices brainstormed ve to 10 changes
that they could make in their practice to
improve their practices tobacco cessation
process. The survey found 67% of the
brainstorm action items had been
implemented at six weeks. Of the practices
responding to the survey, 72% of goals that
were identied as action plans were still being
implemented at three months. Table 1
provides examples of actions that practices
implemented through the TRIA process.
20
25
30
5
10
15
0
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m
b
e
r

o
f

R
e
f
e
r
r
a
l
s

F
r
o
m

T
R
I
A

P
r
a
c
t
i
c
e
s
M
a
y

0
6
J
u
ly

0
6
S
e
p
t

0
6
N
o
v

0
6
J
a
n

0
7
M
a
r

0
7
M
a
y

0
7
J
u
l
0
7
S
e
p

0
7
N
o
v

0
7
Month
Figure 2. QuitLine Fax Referrals
Table 1. Examples of Practice Changes Following the TRIA Process
WHAT WHO HOW MATERIALS NEEDED
(Tobacco Guideline
Component)
ASK about Front desk staff, Intake form: add Do you smoke?; Change intake forms to include tobacco
tobacco status intake nurse, or Have you quit smoking in the last cessation question with the vital signs.
medical assistant 12 months? If marked yes, place Be sure the most current version is on
QuitLine fax referral form or brochure charts, and they are updated each visit
on top of patients chart. with new date.
Use QuitLine fax referral forms and
QuitLine brochures.
Identify smokers by marking Place smoker or tobacco user sticker
patient charts or adding smoker on patient charts; add smoker to
to problem lists (on paper or problem list. Add a Tobacco Use tab
electronic medical record [EMR]). in EMR.
Amend vital sign stamp/sticker to include
smoking status so every patient is asked
at every visit.
Staff wear QuitLine buttons on special
days (receptionist to remind everyone).
ADVISE to quit M.A., R.N., N.P., Place QuitLine brochures, fax forms, Display and distribute QuitLine and/or
P.A., M.D. & prescription pad on top of chart other cessation posters, brochures,
as a prompt to advise. magnets, etc.
Advise to quit during exam Include smoking cessation advice and
(document in chart/medical record). resources (QuitLine, etc.) in patient
newsletters, Web site, etc.
Place a QuitLine magnet on the door
jam to remind clinician to prepare to
ADVISE.
REFER for help R.N., N.P., P.A., Refer to QuitLine or local cessation QuitLine brochures, fax referral forms,
M.D., staff cessation class. Place QuitLine fax referral forms and prescription pad
specialist and educational materials in exam
rooms or close to referral station.
And/or COUNSEL R.N., N.P., P.A., Counsel during exam (and document Quit kits, cessation literature
M.D., staff cessation in medical record).
specialist
Prescribe smoking cessation medications. State Collaborative Tobacco Guideline

ARRANGE Offer self-help resources. Keep copy of patients QuitLine fax
follow-up referral in chart.
Schedule follow-up contact to
discuss tobacco cessation.
Ask again on next visit.
Lessons Learned
This clinical guideline group shared several
lessons learned:
Conuict regilar follow-i witl eacl
practice setting to help each stay focused
on TRIA activities to be implemented
nstill excitement anu assion in clinician
ofce settings
Seek to emower all emloyees witlin
the ofce practices
In Their Own Words
The collaborative reports:
The implementation of this unique,
rapid-cycle quality strategy into clinical
practices is a fun and engaging process and
has resulted in sustained systematic clinical
practice changes increasing tobacco cessation
control efforts in the state.
Conclusion
State-wide initiatives comprised of many
stakeholders can create real change for
residents. This case study highlighted the
efforts of a clinical guideline collaborative
that focused efforts on changing and
enhancing physician ofce practices. The
idea of training medical practice groups
across a large geographic area is novel.
Further, the collaborative sought to impact
the entire population through activities
aimed at medical practices.
Please refer to Appendix 7 for tools and
Reference
1. Partnership for Prevention. Priorities for Americas health: capitalizing on life-
saving, cost-effective preventive services. http://www.prevent.org/images/
stories/clinicalprevention/executive%20summary.pdf. Published July 2006.
Accessed March 5, 2008.
Approximately one-third of all tobacco users in this country
will die prematurely of their dependence on tobacco.
Successful outcomes are strongly related
to intensity and duration of counseling.
12

However, even a ve-minute discussion
with a primary care clinician improves quit
rates, yet efcacy is greatly improved with
longer and more frequent person-to-person
contact via individual clinician-patient
discussions, group sessions, or telephone
counseling.
12,13
The Centers for Disease
Control and Prevention (CDC) strongly
recommends that telephone counseling be
included as a component of a multifaceted
approach to smoking cessation.
19
Free state
and national quit lines offer smokers ongoing
support and guidance through the difcult
process of quitting. The DHHS instituted a
national number1-800-QUITNOWthat
routes callers to services in their local area.
6

Telephone quit lines are most effective when
combined with other approaches, such as in-
person educational counseling.
19
Because efcacy
increases with treatment duration, clinical
guidelines recommend that overall counseling
for tobacco dependence includes at least four
sessions lasting longer than 10 minutes each.
12

Employer-Based Tobacco Policy
Background
A large Midwestern health system made
available to its employees a proactive
Smoking Intervention Program (SIP) aimed
at supporting those who smoked and those
with whom the employee lives. During the
implementation of a workplace tobacco-
free policy, this large employer recognized
that simple no-smoking mandates might
prove ineffective, alienating employees
who smoked.
Case Description
Beginning in the months prior to the
implementation of the tobacco-free
workplace policy, the SIP supported
employee quit efforts through a range of
quality-improvement strategies. The SIP is
a proactive, telephone-based counseling
service tailored to each participants
readiness to quit. Further, prescription
medications and over-the-counter therapies
are covered benets for employees and
their family members or one cohabitant.
Employees who enrolled in the SIP were
incentivized to participate through a $50
payment provided through the employee
wellness program.
This health system invited employees,
contracted employees, volunteers, family
members, and one other nonrelated
household cohabitant (e.g., roommate) to
make use of the SIP. This type of coverage
continued to be available until a complete
transition to a tobacco-free working
environment was achieved.
Conclusion
The SIP model is noteworthy, as the employer
recognized the inuence that social settings
and the nonwork environment have on smokers.
The employer recognized that if a smoker is
going to be successful, these factors need to
be addressed. Offering the SIP to employees
and employees signicant others addressed
these factors to increase tobacco quit rates.
QUALITY LESSON
Relapses and Subsequent
Quit Attempts
The cessation of tobacco use is rarely a
one-time event. Smokers who quit successfully
have had, on average, eight prior unsuccessful
attempts.
6
Cessation initiatives should therefore
incorporate the reality that for the vast majority
of people, tobacco dependence is a chronic,
relapsing disorder that requires ongoing
surveillance and repeated interventions.
Measures should be included to both prevent
and detect relapse and provide support for
smokers who return to tobacco use after a
quit attempt. To minimize the possibility of
relapse, the last step of the 5 AsArranging
for follow-up careis critical. Because relapse
is most likely during the rst few days after
quitting, the initial follow-up session should
take place within one week of the quit date.
13

Several key topics should be included in all
follow-up appointments
12
:
Congratilations on siccesses. ven if tlere
has been a relapse, any period of abstinence
can be acknowledged
Reminuer of tle lenefts of cessation.
Benets should be elicited from the
individual quitting so that they are
personally meaningful
Liscission of rollems or otential
challenges to maintaining abstinence.
Depression, weight gain, social pressure,
and other issues should be addressed
as necessary
Because a combination of pharmacotherapy
and psychological counseling provides the
best chance for successful cessation, this
approach may be used to prevent relapse,
as well as treat smokers who have failed
in previous attempts.
20
Most smokers who
relapse want to try quitting again and desire
both medication and counseling assistance
(Figure 3).
20
It is important for these individuals
and clinicians to understand that prior
unsuccessful quit attempts do not predict
failure in future cessation efforts.
21
The
circumstances surrounding the relapse should
be reviewed and reframed as an opportunity
to identify potential triggers and develop
improved coping strategies.
20
Intensied
treatment, such as combination
pharmacotherapy for smokers who
have relapsed on monotherapy, should
be considered.
21
As with all smokers making
a quit attempt, ongoing support is advised
to maintain motivation and resolve issues
that could lead to another relapse.
13
50
60
70
20
30
40
10
0
Counseling Only Meds Only Meds Plus
Counseling
No Treatment

P
r
e
f
e
r
r
e
d

I
n
t
e
r
v
e
n
t
i
o
n

(
%
)
Figure 3. Treatment Preferences Among Relapsed
Smokers Interested in a Subsequent Quit Attempt
20
Principles for Reducing
Exposure to ETS
Because ETS continues to cause signicant
morbidity and mortality among nonsmokers,
measures to reduce exposure must be
accelerated.
22
Cessation initiatives that help
individuals stop smoking also help those
who breathe secondhand ETS. When adult
smokers quit, their families are no longer
exposed to ETS at home, and their coworkers
no longer breathe the 250 toxic chemicals
found in ETS.
22
Currently, almost 60% of
American children between the ages of 3 and
11 (22 million children) are exposed to ETS.
22

Strategies that help their parents and caregivers
quit smoking, such as combined pharmacotherapy
and counseling, will improve the current and
future health of these children.
However, measures to assist individual
smokers are not enough to protect the health
of nonsmokers. Population-wide initiatives,
such as smoking bans at work sites and public
places, are required to fully address the health
consequences of ETS. Because work sites
are one of the primary places nonsmokers are
exposed to ETS, workplace smoking bans are
strongly recommended by the CDC (Table
4).
22,23
This strategy has the further benet of
encouraging smokers to quit. Several studies
have documented increased cessation rates
among smokers after the introduction of
smoking bans.
23
Supported by workplace bans and public
ordinances, education about the harm of ETS
can make smoking less socially acceptable.
Results from a collaborative effort in California
found that after implementation of a multifaceted
approach that included education, policies
restricting tobacco use, and coverage of
cessation services, approximately 50% more
residents forbade smoking in their homes.
24,25
This type of approach, which encompasses
efforts from employers, health plans, clinicians,
and communities, provides the best opportunity
for healthy environments.
Table 4. Population-Wide Interventions to Reduce
Exposure to ETS
23
Intervention CDC Position
Smoking bans or restrictions at work sites Strongly recommended
Smoking bans or restrictions in public areas Strongly recommended
Smoke-Free Campuses: Policies to Change Social Norm Behavior
Background
A collaboration of an NCQA-accredited
health plan and a health care system
that includes 19 hospitals and two large
medical groups determined that changing
tobacco use required changing the social
norm of tobacco acceptance. Located in
a large, northeastern state that lacked state-
wide mandates on workplace smoking, this
collaborative was committed to reducing
tobacco use within its own circles of inuence
by implementing smoke-free campus
policies.
Case Description
The smoke-free workplace policy initiative
began with the health plan. The health plan
designed a multimodal-treatment approach
to support the implementation of a smoke-
free workplace policy. These options included
on-site groups, a telephone-based program,
an individual face-to-face program, a self-
guided online program, and a waiver of
copays for any cessation medication.
Further, the health plan created a multimedia
communications campaign that informed
employees of the benets of smoking
cessation and the treatment options available
to help them quit smoking. The health plan
also developed and distributed physician
tool kits supporting the treatment of
tobacco dependence.
The health plan had two major goals related
to tobacco dependence. They were:
1. To promote social and behavioral change
by creating an environment that reinforces
nonsmoking behaviors and supports
healthy lifestyles.
2. To reduce the overall prevalence of
tobacco use among employees by 3%
per year.
QUALITY LESSON
Eliminate the appearance of the tacit approval of tobacco use.
The health plan recommended the
implementation of the initiative to the health
care system, which is the largest employer
in the area. The health plan, in collaboration
with the health care system, worked to
create system-level changes to support the
smoke-free workplace policy. To that end,
this collaborative developed objectives for
its smoke-free campus initiative. The
objectives were:
l||r|rate t|e appeararce of t|e tac|t
approval of tobacco use
Support a c|arge |r t|e soc|a| rorr of
the acceptance of tobacco use
lro|de rot|at|or to qu|t ard resources
for employees who smoke
ut|||te treatrert opt|ors aa||ab|e t|roug|
the health plans MyHealth Ready to Quit
smoking cessation program
l\pard t|e aa||ab|||t] of sro||rg
cessation behavioral programs to all
employees
The collaborative stated this implementation
was important because it:
lrpacted t|e |argest group of erp|o]ees
in that part of the state
0reated a rode| for ot|er erp|o]ers
Ra|sed aWareress arorg rorsro|ers
as well as smokers of the positive impact
of a smoke-free environment and the
challenges of smoking cessation
lrcreased t|e use of c||r|ca| pract|ce
guidelines to treat tobacco dependence
Conclusion
This case study presented a strong collaborative
model between a health plan and a health
care delivery system to create a smoke-
free workplace initiative based on policy
implementation and supportive programs to
aid employees in tobacco cessation.
Support a change in the social norm of the acceptance of tobacco use.
Principles for Prevention
of Tobacco Use
Because more than four out of ve smokers
begin using tobacco before the age of 18,
preventive efforts must be targeted to
youth.
26,27
Each day in the United States,
approximately 4,000 teenagers between the
ages of 12 and 17 try their rst cigarette.
28
While many of these adolescents believe
they are simply experimenting, a signicant
number become dependent on nicotine and
nd themselves unable to quit.
29
Without
population-wide preventive services, these
young people face a potentially lifelong habit
that can damage their own health, their
childrens health, and the well-being of those
around them. The American Cancer Society
(ACS) offers three strategies for dealing with
teen smoking. First, adolescents are price
sensitive. Raising the price on a pack of
cigarettes does decrease the number of
adolescents who smoke.
30
The ACSs How
to Fight Teen Smoking Web site notes
that a 10% hike in cigarette cost equates to
10% fewer teens who smoke.
30
The second
strategy is counter-advertising. Teen voices
in the media and in person have proven
pivotal in capturing the attention of peers
and changing attitudes.
30
The third targeted
strategy is increased school-based efforts to
prevent tobacco use.
30
Health plans and employers can work with
communities to design strategies that reduce
initiation of tobacco use (Table 5). The CDC
strongly recommends joint efforts to increase
the cost of tobacco products and educate youth
through mass media campaigns.
23
School
programs focusing on tobacco education are
a primary strategy for reducing tobacco use
in the United States.
31
Table 5. Population-Wide Interventions to Reduce Initiation of Tobacco Use
23
Intervention Description
Increase price of tobacco products Collaboration with communities to raise excise taxes on cigarettes
Mass media campaigns Population-wide education through antitobacco advertising
Clinician feedback Assessment of clinician performance in delivery of appropriate
preventive interventions
Youth access restrictions Collaboration with communities to regulate and enforce bans on the
purchase or consumption of tobacco products by youth
School-based education Collaboration with schools to provide information and motivation to
reduce initiation of tobacco use
Tobacco industry restrictions Collaboration with government entities to regulate tobacco product
content, labeling, or industry promotion and advertising
Special Populations: Pregnant Members & Youth
Background
This East-coastbased health plan targeted
smoking cessation and prevention programs
to special populations including pregnant
members and children ages 10 to 11. For
pregnant members, the health plan provided
reimbursement for smoking cessation
programs, nicotine replacement therapy,
and telephonic support. The health plan
offers a smoking cessation component in
its prenatal program. Pregnant smokers
are encouraged to enroll through the use
of maternity education materials, direct
mail, and telephone. The program includes
up to 11 regularly scheduled calls over 15
months. Throughout the enrollment period,
the member can make unlimited inbound
calls to a counselor. Enrollees also receive
pregnancy-oriented printed materials as well
as options for online versions. Additionally,
the plan used a specially equipped 31-foot
mobile van and trained educators to
deliver a Do the SMART Thing
smoking
prevention program to fth-grade students.
Case Description
Since its debut in 1998, the Do the SMART
Thing youth smoking prevention program
has provided outreach to local schools
fth-grade classes. Through coordination
with participating schools, the health plan
provides an on-site, interactive mobile van
equipped with antitobacco information,
games, hands-on play, and age-appropriate
lectures. The children receive pencil
cases that include pencils, stickers, and
bookmarks carrying antitobacco messages.
The children are also encouraged to sign a
smoke-free pledge banner, which is left for
display at the school.
Each program showed measurable impact.
Since 2002, 111 pregnant women have
enrolled in the 11-call prenatal smoking
cessation program. Quit rates for prenatal
participants is tracked. As of September
2007, the quit rate is 23.4% at three
months postenrollment and 16.2% at 15
months postenrollment.
QUALITY LESSON
continued on following page
For the Do the SMART Thing program, the
health plan surveyed eighth-grade students
who had been involved in the program as fth-
grade students. Nearly 12% of the eighth-
grade students remembered the antismoking
message that had been delivered three
years earlier. The fth-grade program also
seemed to have a positive correlation to
reported reduced tobacco use for youth
without a smoker in the family. For youth at
higher risk for tobacco use, participation in
the fth-grade program did not show a direct
correlation for reduced tobacco use or intent
to reduce use of tobacco. Nearly one half of
the survey sample did have smokers in the
family, a factor that appeared to outweigh
the effects of this prevention program. The
health plan noted the need for continued
specialized programming targeting these
youth.
Conclusion
This health plans corporate mission is to
contribute to the good health of its members
stating, Getting members to quit smoking
has always been an important element of
our wellness programs.
QUALITY LESSON (contd)
It is essential that clinicians become involved
in preventive efforts during ofce visits with
both parents and young children. The American
Academy of Pediatrics species interventions
for clinicians according to the age of the patient
(Table 6).
32
Health plans can incorporate
these guidelines into clinician feedback
to encourage adherence.
Environmental factorsincluding parents,
siblings, and peers who smoke; tobacco
advertising; and portrayal of tobacco in the
mediaare strongly correlated with initiation
of tobacco use.
32
Like smoking cessation and
reduced exposure to ETS, preventing tobacco
use also requires health plans, employers,
clinicians, and communities to work together
in implementing comprehensive, population-
wide interventions.
Table 6. Guidelines for Clinical Preventive Efforts
32
Patient Age Intervention
Prenatal visits Discuss effects of smoking on unborn infant
Infants and toddlers Assess tobacco use and ETS exposure in the extended family and environment
Encourage smokers to smoke outside the home and consider quitting
Provide relapse prevention support for women who quit during pregnancy
and for other family members who quit
Young children Discuss childs thoughts and beliefs about smoking
Identify children from families whose members smoke or use drugs
and encourage treatment for these family members
Promote protective factors, such as positive parenting skills and
good communication
Children who are Provide brief motivational interview to stop smoking
experimenting Encourage child to explore activities that promote a smoke-free lifestyle
Teenagers Discuss tobacco, alcohol, and other drug use condentially at virtually
every visit
Explore teens knowledge of risks associated with tobacco use, clarify
misperceptions, and rehearse refusal skills
Advise parents to be role models for a tobacco-free lifestyle
Encourage parents to set clear standards against tobacco use
References
1. American Lung Association. Trends in tobacco use. http://www.lungusa.org/
atf/cf/%7B7A8D42C2-FCCA-4604-8ADE-7F5D5E762256%7D/TREND_
TOBACCO_JUNE07.PDF. Published June 2007. Accessed October 6, 2007.
2. Mitrouska I, Bouloukaki I, Siafakas NM. Pharmacological approaches to
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3. Fernndez E, Schiafno A, Borrell C, et al. Social class, education, and
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4. Schroeder SA. Tobacco control in the wake of the 1998 Master Settlement
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8. Ohio Department of Health. Solutions: Ohios comprehensive cancer
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CDA0CE2EE6C/can10. Accessed May 15, 2008.
9. Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost effectiveness of
smoking-cessation services under four insurance plans in a health mainte-
nance organization. N Engl J Med. 1998;339:673-679.
10. Pbert L, Ewy BM, Jolicoeur D, Rigotti N. Smoking cessation approaches
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11. World Health Organization (WHO). WHO report on the global tobacco
epidemic, 2008The MPOWER package. http://www.who.int/tobacco/
Mpower/Mpower_report_full_2008.pdf. Accessed April 28, 2008.
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14. Steinberg MB, Akincigil A, Delnevo CD, Crystal S, Carson JL. Gender
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15. Fu SS, Burgess D, van Ryn M, Hatsukami DK, Solomon J, Joseph AM. Views
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17. Doolan DM, Froelicher ES. Efcacy of smoking cessation intervention among
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SecondhandSmoke.htm. Updated September 2004. Accessed December 7,
2007.
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MMWR Morb Mortal Wkly Rep. 2000;49:1-11. http://www.cdc.gov/mmwr/
preview/mmwrhtml/rr4912a1.htm. Accessed December 6, 2007.
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Teen_Smoking.asp. Accessed February 24, 2008.
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| B A R R I E R S T O R E D U C I N G T H E B U R D E N O F T O B A C C O U S E 61
Barriers to Reducing the
Burden of Tobacco Use
Tobacco products, including cigarettes and smokeless tobacco, contain nicotine. Nicotine is the highly addictive
component that leads to dependence for all tobacco users.
1
Though most discussions regarding tobacco
dependence focus on cigarette use, smokeless tobacco also poses signicant health risks and is not a safe
substitute for smoking cigarettes.
1
Smokeless tobacco is estimated to be used by about 3% of all adults and
is used more by men (6%) than women (0.4%).
1
Though the barriers discussed may be focused more toward
smokers, these barriers may be mirrored for smokeless tobacco users.
Although 70% of smokers in the United
States want to quit, cessation rates have not
improved in recent years.
2,3
Lack of progress
is not due to a deciency in treatment, as
effective interventions are well described.
4

However, availability and awareness of these
services remain limited. Interventions are
frequently underfunded by public agencies,
health plans, and employers, many of which
offer only partial coverage for smoking
cessation.
4,5
Smokers, who are unlikely to quit
successfully without assistance, and the health
care clinicians who might assist them, often
are unaware of what interventions
are useful or what services are available.
6

Compounding these difculties are societal
pressures that effectively inhibit demand for
improvements. Examples of societal pressures
include aggressive and promotional cigarette
advertising, cigarette events at adult-only
venues, and indirect marketing such as
movie actors using tobacco within scenes to
create the appearance that cigarette smoking
is acceptable and a desirable trait that one
should emulate.
7
Barriers at all of these levels
must be overcome to increase utilization
and reduce the burden of tobacco use.
Barriers at the
Individual Level
Nicotine addiction is a signicant barrier
at the individual level. Nicotine is a potent
psychoactive drug that induces euphoria,
serves as a reinforcer for its continued use,
and leads to nicotine withdrawal syndrome
when it is absent.
8
Nicotine clearly meets
the criteria for being a highly addictive drug.
As an addictive drug, nicotine has two very
potent effects: it is both a stimulant and a
depressant that affects different parts of
the nervous system.
8

Nicotine affects mood and performance and
is the real source of addiction to tobacco.
From a pathophysiological standpoint, nicotine
releases hormones that act on various receptors
in the brain producing euphoria when
nicotine is used and withdrawal depression
when nicotine blood levels are decreased.
Directly related to the absolute blood levels
of nicotine, a nicotine user may experience
more efcient processing of information and
reduction of fatigue. In addition, nicotine may
have a sedative action that reduces anxiety
and induces euphoria.
8
To maintain the
pleasurable, stimulating effects of nicotine, a
nicotine user must continually increase dose
levels of nicotine.
8

As highlighted in Table 1, nicotine addiction
should become classied as nicotine use
disorder according to the Diagnostic and
Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (DSM-IV-TR).
Because nicotine is highly addictive, a
signicant barrier for tobacco users is the
experience of withdrawal symptoms that
accompany the effort to quit. Cravings,
irritability, difculty concentrating, and other
symptoms are key reasons for relapses, even
when smokers have the best of intentions to
avoid tobacco.
9-11
While these experiences
can be ameliorated with appropriate cessation
therapy, many smokers also face barriers of not
understanding the benets of therapy, or not
knowing that treatments may be covered by
their employer or health plan.
5,6

Lack of awareness of the additive effects of
tobacco is a common obstacle to reducing
tobacco use, both in prevention and treatment.
Before they try their rst cigarette, young
people often dont know how difcult it
can be to quit.
9
While they are likely to
have heard that cigarettes are bad for their
health, they may not realize that immediate
Table 1. Nicotine Use Disorder
DSM-IV-TR Criteria
Nicotine use disorder includes any three of
the following within a one-year time span
8
:
Tolerance to nicotine with decreased effect
and increasing doses to obtaine same effect
Withdrawal symptoms after cessation
Smoking more than usual
Persistent desire to smoke despite efforts
to decrease intake
Extensive time spent smoking or purchasing
tobacco
Postponing work, social, or recreational events
in order to smoke
Continuing to smoke despite health hazards
consequences of tobacco use include addiction
and the need to hide their habit from others,
fear their parents might discover them,
and arguments with friends or dates who
are nonsmokers.
9

Habituated smokers who want to quit also
may suffer from lack of awareness. Many
are misinformed about effective treatments,
believing them to be too risky or addictive;
others are simply unaware that their employer
or health plan offers cessation therapy that
might assist them.
6
It is disturbing to note how
many individuals are in the latter situation.
In one large survey of 860 smokers with
insurance coverage for smoking cessation,
less than 30% of them were aware they had
a smoking cessation benet.
5

If individuals lack coverage for cessation
treatment, or do not know they have this
coverage, perceived cost of treatment can
prevent them from taking action to quit.
Smokers may not consider long-term costs of
using tobacco, but instead contrast the price
of a few packs of cigarettes to the cost of
paying out-of-pocket for therapy.
6

While withdrawal symptoms, lack of
awareness, and cost make it hard for
smokers who want to quit, other obstacles
may convince smokers that their habit is
benecial. Some believe that smoking keeps
them thin, and quitting would lead to weight
gain.
9,11
Many smokers do gain weight when
they stop using tobacco. A study by Pisinger
and Jorgensen (2007) studied the effect of
tobacco cessation on weight gain.
12
They
noted that abstinence from smoking was
the most important predictor of short-term
weight gain.
12
Also, the amount of weight gain
was predictable. For every additional gram
of tobacco that was consumed at baseline,
there was a 4% increase in the likelihood
of an increase of waist circumference of
ve centimeters. Also, those quitters who
also reported a decrease in physical activity
after the baseline data was gathered were
three times more likely to show increased
waist circumference than those who had not
changed their physical activity patterns.
12

These researchers pointed out the need for
weight control measures to be considered
in smoking cessation interventions.
Many teens do smoke as a form of weight
control. Girls who believe themselves to be
overweight are about 50% more likely to be
smokers than those who believe themselves
to be of average weight or too thin.
13
After a
teen has become a smoker, there is concern
that quitting will lead to weight gain. For
teens, nicotine withdrawal does lead to a
short-term weight gain.
14
However, this gain
is likely caused by the need for fewer calories
once smoking ceases as the body returns to
the weight it would have been if smoking
had never started. Thus, known weight
gains, though small, may present a barrier
for assisting a teen to quit smoking.
14
Workers who smoke also may see cigarettes
as an excuse to take breaks and socialize with
coworkers.
6
Teenagers echo the social support
for smoking, often feeling they need to smoke
to be part of an in group.
9
In this way, peer
pressure can be a signicant barrier for
adolescents, most of whom report that friends,
cousins, or siblings were present when they rst
tried cigarettes.
15
Social connections thus may
promote the onset of tobacco use, as well as
encourage its persistence.
Barriers at the
Clinician Level
Clinicians are in an ideal position to encourage
smoking cessation, as most smokers see
their physicians every year.
16
Yet cessation
counseling occurs in less than 25% of these
visits, and prescriptions for appropriate
pharmacotherapy are written in only about
2% of cases (Figure 1).
16
In the rare instances
when medication is prescribed, it is almost
always because the patient asks for help in
quitting, rather than because the physician
initiates a discussion.
16

One fundamental reason more smokers are
not counseled or given medication is that
clinicians do not consistently screen for
tobacco use. Unlike other risk factors that
are evaluated at every ofce visit, such as
routine blood pressure screening, tobacco use
is rarely discussed unless the patient brings it
up or suffers from a smoking-related illness.
17

Thus, clinical practice does not reect current
guidelines, which emphasize the importance
of regularly screening all patients for tobacco
use.
18
Explanations for this discrepancy range
from time constraints to lack of training and
minimal reimbursement.
17,19
60
50
80
70
40
30
20
10
0
See Physician Receive Counseling Receive Medication
S
m
o
k
e
r
s

R
e
c
e
i
v
i
n
g

I
n
t
e
r
v
e
n
t
i
o
n

(
%
)
Annual Smoker-Provider Interactions
Figure 1. Missed Opportunities for Clinician Interventions
16
| T H E V A L U E O F E F F E C T I V E W E L L N E S S A N D P R E V E N T I O N I N I T I A T I V E S 65 | B A R R I E R S T O R E D U C I N G T H E B U R D E N O F T O B A C C O U S E 65
Background
A large hospital-based physician group was
determined to integrate the power of its
electronic medical record (EMR) system
into clinician ofce practices. Through a
collaborative planning process, the physician
group, the hospital administration, and
physician EMR facilitators, along with
other hospital representatives, created a
multidisciplinary team to embed a smoking
cessation tool into the EMR.
This effort began when the hospitals center
for health promotion reported that a once-
popular, traditional eight-week outpatient
smoking cessation class had fallen into disuse.
There had been no enrollees in this program
for the preceding 15 months. However, a
community needs assessment continued to
identify smoking cessation support as one of
the most pressing needs of the communities
served by the hospital.
Spurred by the obvious community need
and the currently ineffective program, the
multidisciplinary team investigated evidence-
based solutions to effect change. With over
90% of its primary care clinicians already
transitioning to EMRs, there appeared to be
value in considering options for improved
care that might be based on EMR system
reminders, prompts, and information-gathering
capabilities.
The team began with a literature review
of evidence-based techniques for changing
behaviors for both patients and clinicians.
This included:
1. Systematic reviews that showed brief
counseling on smoking cessation by a
clinician improves the success rate of
patients who quit smoking and do not
relapse for one year.
2. Four random control trials (RCTs) that
found antismoking advice improves
smoking cessation in people at high risk
of smoking-related disease.
Organization Type: Hospital-owned primary care
practices
Target Population: 50,000
Location: Northeast
Case Study:
Using the Electronic Medical Record:
Smoking as a Vital Sign
3. A systematic review that found limited
evidence that telephone counseling
improved quit rates compared with no
personal contact interventions.
4. A multicomponent program that included
reminder systems and clinician education
that was strongly recommended by the
Task Force on Community Preventive
Services, 2000.
5. A review that found audit and feedback
to be effective in improving professional
practices that are small-to-moderate sized.
Case Description
Based on the literature documenting the
efcacy and cost effectiveness of brief, ofce-
oriented counseling by primary care clinicians,
the hospitals administration redeployed
patient education resources to support
ofce-based smoking cessation efforts. The
vice president of physician affairs formed a
multidisciplinary team to create and embed a
smoking cessation tool within the EMR.
Based on the Nolans Rapid Cycle
Improvement methodology, the team sought
to formulize its efforts through a series of
questions and responses. An explanation
of Nolans Rapid Cycle Improvement
Methodology is outlined in Table 1.
To achieve the objectives outlined in Table
1, the team chose to use a pre-existing,
electronic Risk Assessment form that was
already in use by a majority of the primary
care clinicians. This form was embedded in
the EMR. To specically address smoking,
the following enhancements were made to
the form:
A reu-letter romt in tle MR of atients
whose smoking status was not yet
documented within a structured data eld
A link from tle MR Vital Signs form
to the Risk Assessment form, designed to
prompt and encourage medical assistants
to assess smoking status and readiness to
change prior to clinician-patient interaction
An MR screen litton tlat isleu tle
International Classication of Diseases
ninth revision (ICD-9) diagnosis code of
smoking directly to the medical record
problem list
An MR talle tlat uocimenteu tle
patients previous smoking cessation
attempts and methods used for each attempt
A tool for assessing reauiness for clange,
based on Prochaska and DiClementes
Stages of Change Model (see Table 2)
1
MR littons tlat woilu create rinteu
documents including:
Patient handouts specic to the patients
readiness stage
A patient permission form for participation
in a telephonic support program. Through
the EMR system, a direct fax is sent to
the program so that the patient can be
contacted for phone cessation counseling
around a quit date
A planning form, given to the patient,
that encouraged the patient to proactively
identify the challenges faced and
to formulate strategies to address
those challenges, thus leading to
a healthier lifestyle
uentifcation of qiit uate, if reauy
Late of follow-i aointment witl
clinician
Jime sent ly tle roviuer in coinseling
Analysis
Integrating tobacco use information into the
EMR elevated its use to a vital sign. Similar
to the normally gathered height, weight,
temperature, and blood pressure readings,
Table 1. Nolans Rapid Cycle Improvement Methodology Applied to Smoking Cessation Methods
Question Response
What are we trying to accomplish? Increase the number and percentage of patients in our primary care ofce who are
18 years of age and older whose smoking status is identied
Increase the number and percentage of patients who have documentation of having
received smoking cessation counseling within the last year
Increase the number and percentage of patients whose status changes from current
to previous over dened periods of time
Achieve smoking benchmarks of the NCQAs Heart/Stroke Recognition Program
How will we know that changes Run quarterly reports to create trend graphs for the parameters outlined in the
are improvements? rst question
Apply for recognition by NCQA when benchmarks have been met
What steps can we take to accomplish Establish baseline statistics:
those changes? Document the percentage of patients in the seven participating ofces
whose smoking status is identied
Identify the percentage of patients who smoke
Identify the percentage of smokers who have been counseled to
quit within the last year
Create the case among primary care physicians for the need to do this
Target high-risk populations by incorporating the smoking cessation initiative into
NCQAs Heart/Stroke Recognition Program, which includes a smoking metric
Create reports for the number of patients >18 years of age whose smoking status has
been identied and smokers who have been counseled to quit in the last year
Distribute reports to primary care clinicians, illustrating the scores in comparison to
colleagues scores and Heart/Stroke Recognition Program benchmarks
Use a health educator to train clinicians in smoking cessation readiness strategies
and motivational interviewing to facilitate motivation based on patients level of
contemplation
Create a smoking cessation form within the EMR to increase ease for clinicians to
apply counseling strategies at the point of care
Create patient education materials that may be customized to the patients stage
of readiness to change
tobacco use information is also gathered while
the patient is being interviewed by a medical
assistant prior to the clinician visit.
Based on a thorough review of literature
documenting the efcacy and cost
effectiveness of brief ofce-oriented
counseling by primary care clinicians, the
team created educational resources to support
ofce-based smoking cessation efforts.
However, these resources could not be used
effectively without information regarding
patient tobacco use behaviors.
Working to effect a true population change,
the teams goal was to identify 100% of
tobacco-using patients through vital sign
collection during each clinician visit. The next
protocol step required patient counseling by
the clinician. However, the organization
Table 2. Prochaska and DiClementes Stages of Change Model
1
Stage of Change Characteristics Techniques
Precontemplation

Contemplation

Preparation

Action

Maintenance

Relapse
Not currently considering change:
Ignorance is bliss

Ambivalent about change:
Sitting on the fence
Not considering change within the
next month
Some experience with change and are
trying to change: Testing the waters
Planning to act within one month
Practicing new behavior for
three to six months
Continued commitment to sustaining
new behavior
Post-six months to ve years
Resumption of old behaviors:
Fall from grace
Validate lack of readiness
Clarify: decision is theirs
Encourage reevaluation of current behavior
Encourage self-exploration, not action
Explain and personalize the risk
Validate lack of readiness
Clarify: decision is theirs
Encourage evaluation of pros and cons of behavior change
Identify and promote new, positive outcome expectations
Identify and assist in problem solving re: obstacles
Help patient identify social support
Verify that patient has underlying skills for behavior change
Encourage small initial steps
Focus on restructuring cues and social support
Bolster self-efcacy for dealing with obstacles
Combat feelings of loss and reiterate long-term benets
Plan for follow-up support
Reinforce internal rewards
Discuss coping with relapse
Evaluate trigger for relapse
Reassess motivation and barriers
Plan stronger coping strategies
lacked standard tools and resources to assess
tobacco use and provide counseling support.
Thus, a tool was developed to ex with
clinician availability. The tool offered various
counseling approaches a clinician could
implement, along with a documentation item
to account for actual time spent counseling
during an ofce visit. For a clinician with
limited time, the tool offered a referral
mechanism to telephonic support.
This EMR effort incorporated the U.S. Public
Health Services 5 As of smoking cessation.
The ve As include Ask, Advise, Assess, Assist,
and Arrange follow-up. The Vital Sign link
of the EMR represented the Ask piece
the rst A in the model. To use this link, the
clinician can click on the ICD-9 trigger button,
pushing the self-reported smoking diagnosis
directly to the medical record problem list.
Through this EMR project, multiple types of
reports were created. The reports included the
percentage of patients whose smoking status
was identied, the percentage of patients
who smoke, and the percentage of smokers
who had been counseled to quit. By design,
these reports were not blinded. As a result,
the clinicians engaged in friendly competition
to improve their own scores for having the
smoking status EMR elds completed and
acknowledgement of a counseling effort with
tobacco-using patients.
Population
The target population was all adult patients
18 years of age and older receiving care at
seven primary care ofces, estimated to
include 50,000 patients.
Results
Over the three-year reporting period from
September 2004 to September 2007, the
number of adult patients whose smoking
status was identied increased from 22,825
to 34,531. This represented a percentage
increase from 68% to 96% of all adult patients
served by the seven primary care clinics. The
percentage of all adult patients whose smoking
status was considered current increased
from 11% to 15%, likely a function of more
completed smoking status identication rather
than a real change in the smoking rate over
the three-year study period. The percentage
of smokers who had been counseled during
the period increased from 43% to 68%, and
the percentage of patients whose smoking
status had changed from current to
previous had increased from 18% to 29%.
Also, in June 2006, all 25 eligible physicians
in the targeted clinician group received
recognition from the NCQA for meeting the
criteria for the Heart/Stroke Recognition Program.
This NCQA program includes metrics for
assessing smoking status of patients with
cardiovascular disease and counseling current
smokers within the preceding year.
Lessons Learned
The organization identied several lessons
learned. These include:
n tle fitire, uocimentation of any clinician
counseling occurring must be carried out
ngaging clinical teams from creation to
application will help move the project from
idea to action
Clinical informatics neeus to also le
dedicated to the project. Designated staff
must support clinicians from the talk
through to deliverables
Leverage oints mist le realizeu ly
capturing data that is retrievable. Through
data analysis, create reports that provide
benchmarks for clinicians and the health
care system
t is vital to recognize tlat clange takes a
team effort within the health care system
In Their Own Words
From a current perspective, the team notes:
Through this EMR initiative in the last
three months prior to case submission,
Clinicians have identied the smoking status
of 98% of patients and provided cessation
counseling to 72% of recently seen smokers.
The percentage of patients seen within the
last three months whose smoking status is
previous has increased from 26% to 33%.
Conclusion
Harnessing the power of EMR is a new
frontier in smoking cessation efforts. Elevating
smoking to a vital sign focuses a health care
system on improvement efforts from patient,
to ofce staff, to treating clinician. This case
study brings an evidence-based method
complete with benchmarking to the forefront
of best practices in clinical care for people
who use tobacco.
Reference
1. UCLA Center for Human Nutrition. Prochaska and DiClementes Stages of
Change Model. http://www.cellinteractive.com/ucla/physcian_ed/stages_
change.html. Accessed March 15, 2008.
| T H E V A L U E O F E F F E C T I V E W E L L N E S S A N D P R E V E N T I O N I N I T I A T I V E S 71
Perhaps it is a lack of educational experiences
that leads some physicians to see tobacco
use as a simple choice, rather than a chronic
condition to be treated by a physician. The
process of quitting, which often includes
relapses on the way to permanent cessation,
is seen by some clinicians as evidence that
most smokers either cannot or will not quit.
17

Clinicians who are not familiar with the
chronic nature of tobacco addiction may feel
their efforts are ineffective when a patient
does not quit immediately. After providing an
initial suggestion to quit, these practitioners
may not recognize the need to follow up with
ongoing support and assistance.
17

Lack of training may also explain why many
physicians are unaware of clinical guidelines
and appropriate treatment measures for
addressing tobacco use.
20
Consequently,
clinicians may feel unprepared to counsel
patients and may not realize that external
support such as telephone quit lines and
Internet sites are available.
20
These external
sources might also address another key barrier
cited by physicians, which is that a normal
ofce visit does not allow adequate time to
provide interventions for smoking cessation.
17

Along with time constraints, lack of
reimbursement also makes smoking
cessation a low priority for clinicians.
21

Even though the benets of smoking
cessation interventions are well established,
many health plans still do not provide full
coverage for counseling or pharmacotherapy.
Thus, physicians have little incentive to
make the time to provide these services.
17
Other obstacles that inhibit clinicians from
counseling patients about smoking prevention
and cessation include reluctance to intrude
into patients personal lives, fear of losing
patients, and concern about stigmatizing
patients who have made a poor health choice.
2

These concerns are often misplaced, as most
smokers want to quit and would welcome
assistance in doing so.
22

Tobacco-Use Treatment Training for Clinicians
Background
This university clinic recognized that many
health professionals lacked the needed
training and expertise to effectively treat
patients who wish to stop smoking or
eliminate a nicotine addiction. It noted,
Just as we would not send a [patient with
a] suspected heart condition to a doctor
who had not received specialist training in
cardiology, we should not send our addicted
smokers for treatment to a clinician who
has not received any training in tobacco-
dependence treatment.
Case Description
The development of an intensive training
served to initially educate health professionals
who work in the state-funded quit centers
and then lead to a qualication for Certied
Tobacco Treatment Specialists.
1
Since
its inception in 2000, over 750 health
professionals from the United States,
Canada, Belgium, Ireland, and Mexico
have completed the training and practice
not only in quit centers, but in various
medical and counseling practices across
the country. This training currently meets the
Association for the Treatment of Tobacco
Use and Dependence (ATTUD) Standards for
Core Competencies for Tobacco Treatment
Specialists (Table 1).
The ve-day, 42-hour course includes
intensive instruction, homework/case
presentation, and standardized tests to
demonstrate knowledge competence.
Additional clinical experience may also be
needed to meet all of the requirements as a
Certied Tobacco Treatment Specialist.
Conclusion
Bringing academia, medical care, and
specic tobacco-dependence treatment skills
training to health care providers represents
a successful collaborative method. Through
a research-based focus, application of
new knowledge, and specic educational
formats, this approach not only increases
tobacco-treatment knowledge among health
professionals, but can double the chances of
their patients quitting this deadly addiction.
QUALITY LESSON
Table 1. ATTUD Standards for Core Competencies
2
Clinician Competency Descriptor
1. Tobacco-dependence knowledge Provide clear and accurate information about tobacco use,
education strategies for quitting, the scope of the health impact on the
population, and the causes and consequences of tobacco use.
2. Counseling skills Demonstrate effective application of counseling theories and
strategies to establish a collaborative relationship and to facili-
tate client involvement in treatment and commitment to change.
3. Assessment interview Conduct an assessment interview to obtain comprehensive and
accurate data needed for treatment planning.
4. Treatment planning Demonstrate the ability to develop an individualized treatment
plan using evidence-based treatment strategies.
5. Pharmacotherapy Provide clear and accurate information about pharmacotherapy
options available and their therapeutic use.
6. Relapse prevention Offer methods to reduce relapse and provide ongoing support for
tobacco-dependent persons.
7. Diversity and specic health issues Demonstrate competence in working with diverse population
subgroups and those who have specic health issues.
8. Documentation and evaluation Describe and use methods for tracking individual progress, record
keeping, program documentation, outcome measurement, and
reporting.
9. Professional resources Utilize resources available for client support and for professional
education or consultation.
10. Law and ethics Consistently use a code of ethics and adhere to government
regulations specic to the health care or work-site setting.
11. Professional development Assume responsibility for continued professional development
and contribution to the development of others.
References
1. Foulds J, Gandhi KK, Steinberg MB, et al. Factors associated with quitting
smoking at a tobacco-dependence treatment clinic. Am J Health Behav.
2006;30(4):400-412.
2. Association for the Treatment of Tobacco Use and Dependence. Core
competencies for evidence-based treatment of tobacco dependence.
http://www.attud.org/docs/Standards.pdf. Published April 2005.
Accessed March 4, 2008.
Barriers at the Health
Plan Level
Health plans can play a pivotal role in
reducing the burden of tobacco use, as they
have opportunities for directly inuencing
members, employers, and clinicians (physicians
and other members of the health care
team). Insurers also are in a position to work
collaboratively with communities in adopting
policies that lower tobacco use and reduce
costs. Yet, despite these opportunities,
nearly all health plans report barriers to full
implementation of recommended guidelines.
23

Limited resources (e.g., inadequate staff,
competing priorities) and inefcient systems
(e.g., poor data collection, inadequate record
maintenance) are the most common obstacles
(Figure 2). Another predominant barrier is the
belief that provision of tobacco control services
will not provide an immediate economic
return on investment.
23
Despite strong
evidence of cost effectiveness, health plans
may not be convinced that the additional costs
of covering smoking cessation interventions
will be offset by reductions in smoking-related
health expenditures.
24,25

Additional barriers for health plans include
lack of clinician compliance, lack of purchaser
and member demand, fear of becoming a
smokers health plan, and uncertainty
about how coverage affects member usage of
services.
23,26,27
Insurers who are unaware of the
notable increase in cessation rates with full
insurance coverage protest that smokers can
obtain over-the-counter nicotine replacement
therapy and quit on their own; thus, they see
coverage as unnecessary.
5

Delayed ROI*
Lack of Provider
Compliance
Resouce Barriers
System Barriers
Lack of Purchaser
Demand
Lack of Member Demand
0% 20% 40% 60% 80% 100%
Percentage of Health Plans Reporting Cited Barrier
*ROI =Return on investment.
Figure 2. Most Common Barriers at the Health Plan Level
23
Barriers at the
Employer Level
Employers echo health plans in their
concern about return on investment (ROI)
with tobacco control initiatives. Whether it
is up-front charges for coverage or overall
ROI, cost appears to be the primary reason
that employers hesitate to include smoking
cessation treatment in employee health
plans.
5,26,28
Although many employers sense
that reducing tobacco use among employees
would provide health and productivity gains,
only 23% to 64% of employers offer any form
of coverage for treatment of tobacco use.
5,6

Few see tobacco as an addictive disease
that can be successfully treated by existing
interventions.
Generally, preventive services rank as a low
priority for corporate benet managers, who
focus on more expensive coverage issues, such
as treatment of chronic disease and disability.
29

Yet, even among preventive services, smoking
cessation falls close to the bottom of covered
treatments.
28
Employers often associate these
services with more cost than benet, despite
substantial evidence that demonstrates the
cost effectiveness of smoking cessation
coverage for employers.
28
In many cases,
employers simply have not been informed
of this evidence, illustrating another barrier:
lack of information about costs of coverage
and potential ROI.
5,30
Understandably, this
information is crucial for benet managers to
make a business case for coverage of smoking
cessation interventions.
Other barriers cited by employers include
insufcient demand from employees for
smoking cessation services and concern about
intruding into employees private lives to
promote cessation coverage.
6,28

Barriers at the
Societal Level
As individuals, clinicians, health plans,
employers, and communities struggle to
overcome barriers to smoking cessation,
the tobacco industry has stepped up
counterstrategies. A powerful barrier at the
societal level is the relentless effort of tobacco
companies to discredit evidence of the harms
of tobacco use.
31,32
The ve largest cigarette
manufacturers nearly tripled their advertising
expenditures between 1995 and 2005 (Figure
3).
3
These expenditures include steep price
$10
$14
$6
$4
$0
1995 2005
$2
$8
$12
E
x
p
e
n
d
i
t
u
r
e
s

i
n

B
i
l
l
i
o
n
s

o
f

D
o
l
l
a
r
s
Figure 3. Annual Tobacco Company
Advertising and Promotion Expenditures
3
discounts on cigarettes for retailers; in-store
marketing materials; and sponsorship of
events at bars, community functions, fraternity
activities on college campuses, and sports
events.
7,33
More covert activities include
hired lobbyists and contributions to political
campaigns.
32
A report from the Centers for
Disease Control and Prevention (CDC)
suggests that one reason tobacco use has not
declined in recent years may be substantial
spending by the tobacco companies
combined with decreases in state funding for
comprehensive tobacco-control programs.
33

While cigarette use garnered most of the
tobacco manufacturer advertising dollars,
smokeless tobacco has also had record
advertising and promotional costs. During
2005, the ve largest tobacco manufacturers
spent a new record of $250.8 million on
smokeless tobacco advertising and promotion,
up from the previous record of $236.7 million
in 2001.
1

Other societal barriers that may be connected
with tobacco-company spending include
aversion to government regulation of the
private sector, doubts about the dangers of
tobacco use, personal tobacco use among
community ofcials, and positive media
portrayal of smoking.
7,31
Movies, print,
billboards, and the Internet all play
an inuential role in the initiation and
continuance of tobacco use. In one review,
more than half of movies released between
May 2004 and April 2005 showed tobacco use
and contained protobacco messages.
7
Another
study found that mens magazines showed
smokers as sensual, independent, and
mysterious.
34
These positive images of
tobacco use may not only persuade young
people to start smoking, but they reinforce
those already addicted to nicotine.
7,33
Societal barriers that encourage teens to begin
using tobacco or inhibit smoking cessation
efforts are meaningful for clinicians, health
plans, and employers, because collaboration
among all stakeholders is vital in addressing
these issues. Clearly, coordinated action is
necessary to overcome the barriers facing
every stakeholder, which are multiple and
complex (Table 2). Communities need the
assistance of those in the health care industry
as much as individuals need support from
their clinicians, employers, and health plans.
Table 2. Barriers to Reducing the Burden of Tobacco Use
Individual Withdrawal symptoms
Misinformation about treatment
Lack of awareness of coverage for cessation therapy
Cost of treatment
Fear of weight gain
Loss of socialization opportunities
Youth unaware of difculty of quitting and social stresses related to tobacco use
Peer pressure
Clinician Time constraints
Lack of training
No routine screening protocol
Belief that tobacco use is a choice, rather than a chronic condition
Lack of awareness of guidelines and treatment options
Lack of awareness of external support for treatment
Minimal reimbursement
Reluctance to intrude into patients personal lives
Concern about stigmatizing patients
Fear of losing patients
Health Plan Limited resources
Inefcient systems
Concern about ROI
Lack of clinician compliance
Lack of purchaser demand
Lack of member demand
Fear of becoming a smokers health plan
Uncertainty about the effects of coverage on member usage of services
Employer Cost of coverage
Concern about ROI
Lack of information about costs
Preventive services a low priority
Low employee demand
Concern about intruding into employees private lives
Society Tobacco company spending on advertising and promotion
Lobbying by tobacco industry
Decreased funding for tobacco-control programs
Positive media protrayal of tobacco use
References
1. Centers for Disease Control and Prevention. Fact sheet: smokeless tobacco.
http://www.cdc.gov/tobacco/data_statistics/Factsheets/smokeless_
tobacco.htm. Updated April 2007. Accessed March 25, 2008.
2. Schroeder SA. What to do with a patient who smokes. JAMA. 2005;294:482-487.
2006;12:235-243.
5. Burns ME, Rosenberg MA, Fiore MC. Use of a new comprehensive insurance
benet for smoking-cessation treatment. Prev Chronic Dis. 2005;2:1-12.
http://www.cdc.gov/pcd/issues/2005/oct/05_0007.htm. Accessed May
15, 2008.
6. Tiede LP, Hennrikus DJ, Cohen BB, Hilgers DL, Madsen R, Lando HA.
Feasibility of promoting smoking cessation in small worksites: an exploratory
study. Nicotine Tob Res. 2007;9:S83-S90.
7. California Department of Health Services. Tobacco Control Section.
Approach. Sacramento, CA: CDHS/TCS; 2006.
8. Sharma S. Nicotine addiction. http://www.emedicine.com/med/topic1642.
htm. Published April 2006. Accessed February 25, 2008.
10. American Cancer Society. Freshstart: staying quit and enjoying it forever.
http://www.cancer.org/downloads/com/FreshStart_Brochure_nal.pdf.
Published 2005. Accessed January 7, 2008.
11. Lamberg L. Patients need more help to quit smoking: counseling and
pharmacotherapy double success rate. JAMA. 2004;292:1286-1290.
12. Pisinger C, Jorgensen T. Waist circumference and weight following
smoking cessation in a general population: the Inter99 study. Prev Med.
2007;44:290-295.
13. Winter AL. Teens with weight concerns likely to smoke. http://www.
annecollins.com/weight_health/body-image-smoking.htm. Accessed
March 25, 2008.
14. Teen-help-desk.com. Quit smoking now! http://www.overweight-teen-
solutions.com/smoking.html#causes. Accessed March 25, 2008.
15. Peters R, Kelder SH, Prokhorov AV, Agurcia CA, Yacoubian GS, Essien EJ.
Beliefs regarding cigarette use, motivations to quit, and perceptions on
cessation programs among minority adolescent cigarette smokers. J Adol
Health. 2006;39:754-757.
2006;30(5):405-412.
17. Pederson LL, Blumenthal DS, Dever A, McGrady G. A web-based smoking
cessation and prevention curriculum for medical students: why, how, what,
and what next. Drug Alcohol Rev. 2006;25:39-47.
Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department
of Health and Human Services. Public Health Service. June 2000. http://
www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.7644. Revised
2000. Accessed May 19, 2008.
19. Ulbricht S, Meyer C, Schumann A, Rumpf HJ, Hapke U, John U. Provision of
smoking cessation counseling by general practitioners assisted by training
and screening procedure. Patient Educ Couns. 2006;63:232-238.
20. Strayer SM, Rollins LK, Martindale JR. A handheld computer smoking
intervention tool and its effects on physician smoking cessation counseling.
J Am Board Fam Med. 2006;19:350-357.
21. U.S. Department of Health and Human Services. Public Health Service.
Treating tobacco use and dependencea systems approach. 2008 update.
http://www.surgeongeneral.gov/tobacco/systems.htm. Updated May 2008.
Accessed January 7, 2008.
22. Balkstra CR, Fields M, Roesler L. Meeting Joint Commission on
Accreditation of Healthcare Organizations requirements for tobacco
cessation: the St. Josephs/Candler Health System approach to success.
Crit Care Nurs Clin North Am. 2006;18:105-111.
23. McPhillips-Tangum C, Rehm B, Carreon R, Erceg C, Bocchino C. Addressing
tobacco in managed care: results of the 2003 survey. Prev Chronic Dis.
2006;3:No. 3.
24. Americas Health Insurance Plans. Making the business case for smoking
cessation programs. http://www.businesscaseroi.org/roi/apps/execsum.
aspx. Accessed January 7, 2008.
25. Levy DE. Employer-sponsored insurance coverage of smoking cessation
treatments. Am J Manag Care. 2006;12:553-562.
26. Tobacco Cessation Leadership Network. Trends in the delivery and
reimbursement of tobacco dependence treatment. http://www.tcln.
org/resources/pdfs/Trends_in_Delivery_and_Reimbursement_nal.pdf.
27. Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost effectiveness
of smoking-cessation services under four insurance plans in a health
maintenance organization. N Engl J Med. 1998;339:673-679.
28. Woolf NH, Burns ME, Bosworth TW, Fiore MC. Purchasing health insurance
coverage for smoking cessation treatment: employers describe the most
inuential information in this decision. Nicotine Tob Res. 2006;8:717-725.
29. Greenbaum E. The Center for Prevention and Health Services. Ten
recommendations for promoting prevention. Issue brief. http://www.
businessgrouphealth.org/pdfs/ib_promotingprevention.pdf. Published
March 2006. Accessed August 15, 2006.
30. Burns ME, Rosenberg MA, Fiore MC. Use and employer costs of a
pharmacotherapy smoking-cessation treatment benet. Am J Prev Med.
2007;32:139-142.
31. Andersen PA, Buller DB, Voeks JH, et al. Predictors of support for
environmental tobacco smoke bans in state government. Am J Prev Med.
2006;30:292-299.
32. Institute for Global Tobacco Control. Evaluating comprehensive tobacco
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Tobacco Control. 2002;11:140-145.
33. Dutta MJ, Boyd J. Turning smoking man images around: portrayals
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34. Centers for Disease Control and Prevention. State-specic prevalence of
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Mortal Wkly Rep. 2006;55:1148-1151.
| A D D R E S S I N G T H E Q U A L I T Y G A P S I N R E D U C I N G T H E B U R D E N O F T O B A C C O 79
Addressing the Quality Gaps in Reducing
the Burden of Tobacco
Compelling evidence conrms the enormous health and economic costs of tobacco use, and interventions that
reduce these costs are known and available.
1
Yet, due to the multiple barriers facing every stakeholder, gaps
between knowledge and practice remain substantial (Table 1).
2
System-wide strategies, including comprehensive
efforts on the part of health plans, employers, clinicians, and public health entities, must be implemented to
address these quality gaps. Numerous organizations have responded to this challenge, offering examples of
effective strategies for reducing the burden of tobacco use.
Table 1. Quality Gaps in Tobacco Control, According to Healthy People 2010 Objectives
2
Targeted Condition
Cigarette smoking
Any tobacco use
(past month)
Smoking cessation
attempts
Smoking cessation
attempts
Exposure to ETS
Exposure to ETS

at home
Insurance coverage of
evidence-based treatment
for nicotine dependency

Work sites with smoke-
free workplace policies
* Years indicate date of baseline.
ETS=Environmental tobacco smoke.
Population
Adults
Adolescents
(grades 9-12)
Adult smokers
Adolescent smokers
Nonsmokers
Children
Managed care
organizations

Employers
Baseline*
21% (2005)
23% (2005)
43% (2005)
55% (2005)
43% (2002)
60% (2006)
88% cover some type
of pharmacotherapy;
72% cover some type
of behavioral intervention
(2003)
73% (2005)
2010 Objective
Decrease to 12%
Decrease to 21%
Increase to 75%
Increase to 84%
Maintain at 45%
Decrease to 10%
Increase to 100%

Increase to 100%
System-Wide Strategies
for Treating Tobacco
Use and Dependence
Population-based interventions, which
maximize the broad inuence of health plans
and employers, enhance the success of
tobacco control initiatives.
3
Broad-based
approaches are supported by the U.S. Public
Health Service, which has published
guidelines to encourage implementation of
strategies that may help reduce tobacco use
and reduce health care costs.
4
Making these
guidelines practical for health plans, Americas
Health Insurance Plans (AHIP) formerly
known as the American Association of Health
Plans (AAHP), has proposed specic
implementation strategies for each
recommendation (Table 2). Health plans can
adopt these strategies, and employers can use
them as a guide in choosing benets packages
to optimize tobacco control efforts for
members and employees.
The U.S. Public Health Service emphasizes
that its six recommendations are intended to
be part of a coordinated effort that takes
advantage of the synergy among public,
population, and personal health.
4
Integrated
strategies should include activities to prevent
initiation of tobacco use, increase cessation
rates, and reduce exposure to environmental
tobacco smoke (ETS). Interventions in one of
these areas contribute to improvements in
the others.
2
For example, providing coverage
for cessation treatment increases cessation
rates, which in turn reduces exposure to
ETS.
2,5
Health plans, employers, clinicians,
and communities can improve efciency and
effectiveness of their efforts when they are
based on this synergistic approach.
Comprehensive
Approach to Reducing
the Burden of Tobacco
Use at the Health
Plan Level
Uniquely positioned to inuence the health of
millions of people, health plans are called on
to expand access to tobacco cessation services,
model new cessation benets, promote these
benets to members and purchasers, and
participate in policy initiatives that support
tobacco cessation at the public health level.
6
A
model for this comprehensive approach to
tobacco cessation is described by the Four Cs
7
:
1. Cover effective treatments
2. Collaborate with employers,
clinicians, and public health entities
3. Capitalize by dedicating staff and
resources
4. Count or measure progress
Table 2. Systems-Based Interventions: Recommendations and Suggested Implementations for Health Plans
3
Public Health Service Suggested Implementations
Recommendation
Track patients Include the documentation of smoking as a vital sign in progress note
tobacco-use status Add reminders to computerized medical records for clinicians to ask about tobacco use and record
note in the electronic medical record (EMR)
Provide education, resources, Provide lectures, seminars, or in-services with continuing medical education (CME) and/or other
and feedback to promote credit for tobacco-dependence training
clinician interventions Have patient education materials and pharmacotherapy starter kits in all exam rooms
Include provision of tobacco-dependence treatment on reports to clinicians and medical groups
Provide feedback to clinicians on the extent to which they are identifying, documenting, and
treating tobacco users
Provide and assess tobacco- Designate a tobacco-dependence coordinator at every site
dependence interventions Delineate the responsibilities of the coordinator
Communicate to each clinician (e.g., nurse, physician, pharmacist) his or her responsibilities in the
delivery of tobacco-dependence services
Promote hospital policies Implement a system to identify and document the tobacco-use status of all hospitalized patients
that support and provide Identify clinicians able to deliver tobacco-dependence inpatient treatment
tobacco-dependence services Offer tobacco-dependence treatment to all hospitalized patients who use tobacco
Reimburse clinicians for tobacco-dependence inpatient consultation services
Expand hospital formularies to include U.S. Food and Drug Administration (FDA)-approved
tobacco-dependence pharmacotherapies
Include tobacco-dependence Include effective tobacco-dependence treatments as part of the basic benets package for all
treatments as covered services health insurance products
in insurance packages Inform subscribers, members, and purchasers about the availability of covered tobacco-
dependence treatments and encourage them to use these services
Reimburse clinicians and For fee-for-service physicians, include tobacco-dependence treatment as a reimburseable activity
specialists for delivery of and inform them of the policy
effective tobacco- Specify adherence to the HEDIS measure for medical assistance with smoking cessation in
dependence treatments capitated contracts with clinics or clinician groups
For salaried physicians, make adherence to the HEDIS measure for medical assistance with
smoking cessation part of job descriptions and performance evaluations
Background
A large, Midwestern, NCQA-accredited
health plan developed and implemented
a comprehensive, multifaceted smoking
cessation program. Highlighted in this case
study are three key components of this health
plans robust approach to tobacco cessation
among members. The components are:
Worklace Jolacco Cessation Best
Practices
State-Wiue Clinic !ax Referral Program
Smoking Cessation Referrals n PlarmacieS
(SCRIPS)
Case Description
Each strategy of this health plans effort
provides a different yet integrated approach
to tolacco cessation efforts. ts Worklace
Tobacco Cessation Best Practices recognizes
the positive role that employers play in
assisting employees to quit tobacco. The
State-Wiue Clinic !ax Referral Program
highlights collaborative efforts desired to
generate patient referrals from clinics to a
tobacco quitline. The SCRIPS program, the
third approach, uses pharmacists to impact
tobacco-use behaviors among health plan
members.
Workplace Cessation Reduction
Best Practices
In January 2007, the health plan transformed
its existing services related to tobacco use into
an explicit outreach effort designed to make it
easier for employers to implement national
best practices in reducing tobacco use among
their employees.
Organization Type: PPO, MCO, HMO, Medicaid
Target Population: 2.89 million
Location: Midwest
Case Study:
Impacting a State: A Health Plans
Multiple Strategies
To assist employers in making better choices,
the plan offered data based on claims analyses.
Overall, these analyses conrmed that the
sooner employees quit smoking, the better, in
both human and economic terms. According
to the health plans internal research,
Individuals who quit smoking before they
experience a signicant health crisis (such as
a heart attack or the development of cancer)
incur an average of $243 per member per month
lower health care cost than those who do not
quit until after they have had a health crisis.
The health plan recommends that employers
implement three best practice strategies:
1. Tailored quit coaching
2. Quit medications (in combination with
quit coaching)
3. Tobacco-free workplace policies including
buildings and grounds
The health plan stop-smoking program is
free to every health plan member. More than
one out of every three enrollees is able to quit
successfully. This program uses trained Quit
Coaches to provide brief phone calls to
members. The telephone coaching sessions
assist smokers to create an individualized quit
plan. Smokers also learn tactics to help them
stay quit. Participants may call back at any
time to get extra help and also have access to
24/7 online support.
The combination of tailored quit coaching
(to help plan behavioral change) plus quit
medication (to help people cope with nicotine
cravings and wean themselves gradually from
their dependence) gives health plan members
their best opportunity to stay quit. The health
plans enhanced stop-smoking program
helps employers make smoking cessation
medications more readily available to the
stop-smoking program enrollees. This
enhanced program allows the employer to
pick up the full cost of over-the-counter quit
medications for those members who work
with a Quit Coach. Employers who choose the
enhanced program also receive a 12-month
promotion plan, including newsletter/e-mail
communications as well as promotional
materials to promote the availability of the
program, including the no-cost quit medications.
The health plan also supports employers
seeking to create tobacco-free work sites that
include buildings and grounds. The health
Employers have the ability to help employees stop smoking.
plan cites literature documenting that smoke-
free workplace policies both support employees
who want to quit smoking and also tend to
attract nonsmoking employees to the workforce.
The health plan offers online tools and
resources that help the employer to plan for,
develop, and implement a tobacco-free work
site policy tailored to the employers specic
situation. Health plan staff also consult with
employer groups that are implementing
tobacco-free work-site policies.
State-Wide Clinic Fax Referral Program
Launched in October 2007, this health plans
state-wide clinic fax referral program makes
it easier for physicians to help their patients
who want to stop smoking by allowing health
care professionals to refer a patient to stop-
smoking phone coaching support, regardless
of the patients health care coverage. (See
Appendix 4.)
This state-wide fax program is supported
collaboratively by all state organizations that
offer stop-smoking quitlines. Unlike other
states, where a single quitline is run by
the state health department, major health
plans have their own system. The clinic fax
system uses a single fax number. Member
and clinician confusion is decreased when
organizations provide a united effort.
This new program allows clinicians to fax a
single, Health Insurance Portability and
Accountability Act (HIPAA)-compliant quitline
referral form to a central triage system. This
referral results in an outbound call to the
patient from that patients appropriate quitline
service, based on the patients health care
coverage. Uninsured and underinsured
individuals are referred to the state quitline.
The outbound call explains the program and
invites the patient to enroll. Prior to this
system, clinicians had to look up a patients
insurance, then identify the corresponding
quitline phone number, and then give it to
the patient and hope the patient would call.
The process was time consuming and required
the patient to call to initiate the coaching.
Telephonic support is an effective alternative
to face-to-face counseling with clinicians in
an often-busy clinic setting. Making it easy for
clinicians to connect patients to this service
has led to successful outcomes for patients
state wide.
The health plan estimated that employer groups can save $900
per former smoker per year based on higher productivity of
former smokers compared to current smokers.
Smoking Cessation Referrals In
PharmacieS (SCRIPS)
In alignment with the health plans telephone-
based stop-smoking program, SCRIPS
uses the existing pharmacy claims system
to prompt pharmacists to connect health
plan patients lling prescriptions for tobacco
cessation medications with the health plans
stop-smoking program.
Based rmly in the science of tobacco
cessation and stage-of-change theory, this
program builds on that science to understand
pharmacy systems and workow issues. The
health plan points to literature that supports
cognitive services, including the provision of
cessation counseling, as an emerging trend for
the pharmacy industry.
To implement the program, modication of
the claims processing systems was required,
rst to identify patients lling prescriptions for
smoking cessation then to prompt pharmacists
to offer the telephone-based stop-smoking
program. SCRIPS is a successful collaboration
between the health plan and its pharmacy
benet manager to increase enrollment in an
important wellness program. SCRIPS uses
existing tools (the pharmacy claims system)
and existing processes (the interaction
between pharmacists and members) to help
those members who are most actively
interested in quitting smoking.
SCRIPS provides a new use for the existing
pharmacy structure. SCRIPS is based on
engaging existing pharmacy staff along with
the current computerized member purchasing
mechanisms to add a new dimension of
interaction with potential clients for smoking
cessation programs. Computerized pharmacy
systems use real-time linkages to central
health plan systems. As a result, pharmacists
are able to capitalize on the physical presence
of a smoker who has arrived at the pharmacy
to pick up ordered medications. Smokers are
likely motivated to quit if they have taken the
step to see a clinician and secure a prescription.
(In the health plans benet structure,
prescriptions are required to activate coverage
for any quit medications, including those
availalle over-tle-cointer.) Wlile tle smoker
is in the pharmacy, the pharmacy staff may
also offer the health plans stop-smoking
program and assist with enrollment in that
program.
Results
Workplace Tobacco Cessation Best
Practices
The stop-smoking program, including the
Worklace Jolacco Cessation Best Practices,
is available, at no cost, to all members
(covering 2.7 million health plan members and
paid for, in full, by the employer). Since the
program began in May 2000, over 35,500
members have enrolled, and over 7,000
members have quit using tobacco. The health
plans 2007 quit rate was 35.5%, and program
satisfaction was 85.5%. Also the plan estimated
that employer groups could save $900 per
former smoker per year based on higher
productivity of former smokers compared to
current smokers.
State-Wide Clinic Fax Referral Program
Jo assess tle imact of tle State-Wiue
Clinic Fax Referral Program, this health
plan supported a 22-month university study
that used a two-group, clinic randomized
design. Clinicians in the control clinics
received usual care, i.e., they received
information and materials about the fax
program pilot. Additionally, the clinics
EMR system was modied to allow for fax
referral. The intervention clinics received
a launch meeting, monthly feedback, and
nancial incentives to clinicians based on the
number of referrals to quitlines. The nancial
incentives were available to clinics that referred
at least 50 patients during the study period.
Characteristics of all clinics in both the
intervention group and the control group
did not differ signicantly, other than EMRs
were not used by the intervention group.
The primary outcome measure for the study
was the percentage of smokers referred to
phone counseling. A secondary measure was
clinic characteristics such as the number of
clinicians, the type of practice, the presence
or absence of EMR, and the clinics past
history with quality improvement activities.
The nal measure took into account costs for
development, staff, computer conguration,
and implementation, as well as nancial
incentives.
This study demonstrated that incentives to
clinicians do increase referral rates. Overall,
clinics generated more than 3,000 referrals to
stop-smoking coaching, resulting in a 27%
enrollment rate in stop-smoking programs.
Given the pilot studys success, implementation
in medical clinics across the state is the health
plans main priority. As of January 1, 2008, 371
clinics were registered to participate in the fax
referral program.
SCRIPS
SCRIPS demonstrates that health plan
systems changes can enhance the role of
pharmacists in connecting patients to
evidence-based services. As of January 2008,
SCRIPS accounts for more than 23% of all
enrollments into the health plans smoking
cessation program.
As a trusted source of health information,
pharmacists play an important role in
connecting patients to health plan programs
and services. The SCRIPS program offers
pharmacists an opportunity to coordinate their
existing interactions with patients to improve
members overall health care. SCRIPS
provides pharmacies an incentive to connect
their patients lling tobacco-dependence
medications with telephonic quit coaching,
thus improving the patients chances of
quitting successfully.
In Their Own Words
Witl regarus to tle Worklace Jolacco
Cessation Best Practices, this health plan
intends to sustain this program. Our
executives are convinced that we can and
should explain to [employers] exactly how to
reap maximum future health and economic
benet from investing in these preventive
policies and products.
The Fax Referral Program succeeded
because all members of the collaboration
were committed to removing barriers and
improving systems in a coordinated fashion,
and patient-centered care was at the very
core of the effort.
SCRIPS narrows the gap between science
and practice by seamlessly connecting
members lling prescriptions with behavioral
counselingthe best combination for
supporting a successful quit attempt.
Conclusion
Health plans have the ability to impact
smoking cessation rates in various ways.
This case study demonstrated the value
of collaborative planning. The rst project,
tle Worklace Jolacco Cessation Best
Practices, provided a collaborative opportunity
for emloyers. Jle State-Wiue Clinic !ax
Referral Program, the second project, was
a collaboration of multiple health plans
seeking a coordinated method for clinicians
to refer state residents to tobacco quitlines
and telephonic coaching. SCRIPS, the third
project, collaborated with a pharmacy benet
manager and contracted pharmacies to
motivated smokers to enroll in a tobacco
cessation program. These three different
approaches cut across multiple stakeholders,
including state residents, clinicians, and
employers, all working toward the goal of
decreasing tobacco use and thus avoiding the
preventable disease and premature deaths
(and associated costs) caused by nicotine
dependence.
Results from health plan surveys show
that when tobacco users do use medication assistance,
they are much more likely to use
pharmacological aids without substantial
behavioral support.
Cover Effective Treatments
Multiple clinical guidelines strongly recommend
full coverage of pharmacotherapy and counseling
for all health plan members to reduce tobacco
use and dependence.
2,3,8
Requiring smokers to
pay a portion of treatment costs may seem as
though it would enhance their commitment to
quit; however, it generally has the opposite
effect.
3
If smokers have any out-of-pocket
costs for treatment, they are less likely to use
the benet and less likely to quit successfully.
5

In one study comparing the use of a smoking
cessation benet among members, removing
copayments tripled the use of services.
9

Full coverage has four proven benets:
1. Increased use of effective cessation
therapies
5
2. Increased number of individuals attempting
to quit
5
3. Increased number of individuals who are
able to quit successfully
5
4. Reduced medical costs (after 10 years of
providing a cessation benet, health care
cost savings range from approximately
$403,000 to over $1.1 million per plan)
10
It is important that coverage includes repeat
use of FDA-approved pharmacotherapies
and behavioral counseling. Tobacco
dependence is a chronic, relapsing disorder,
and most smokers will need to make several
quit attempts in the process of becoming
permanently abstinent. In recognition of this
fact, covered services should be available to
these individuals until they achieve long-term
success.
1
Leading health insurers already have
adopted this strategy, providing coverage for
multiple counseling sessions, pharmacotherapy,
and more than one course of treatment per year.
11
Collaborate With Employers, Clinicians,
and Public Health Entities
Collaboration with employers, clinicians, and
public health entities also is being incorporated
into best or effective practices. Social norms
are a powerful inuence on tobacco use, and
the most cost-effective strategy to reduce
tobacco consumption may be population-
wide efforts, such as smoke-free policies in
workplaces and public areas, bans on tobacco
advertising, tobacco tax and price increases,
and increased public awareness of health
consequences associated with tobacco use.
12-14
Health plans bring a valuable resource to
collaborative work on these issues. Health
plans may collaborate with clinicians to create
guidelines and benchmark performance
criteria which can be applied to community-
wide programs. Their data also may help
establish efcacy and cost effectiveness of
proposed interventions.
15
Blue Cross and Blue Shield of Minnesota
responded to the need for collaboration by
creating Minnesota Decides: A Community
Blueprint for Tobacco Reduction. The
health plan partnered with the local chapter
of the American Cancer Society, the
Minnesota Smoke Free Coalition, the state
health department, the state attorney generals
ofce, and local government to develop a plan
of action for tobacco reduction. Community
meetings were held to discuss issues and
strategies, followed by a state summit to
present and evaluate the ndings. The
resulting 72-page blueprint provided goals
and strategies for a state-wide tobacco control
program. This blueprint is now being used
by the Minnesota legislature to disseminate
proceeds from the state tobacco settlement.
3
Count or Measure Progress
Evaluations are an important component of
any initiative. For comprehensive analyses,
measurement systems should track two
distinct areas:
1. Factors that inuence the use of tobacco
(e.g., availability of coverage for cessation
services and establishment of policies and
clinical guidelines)
16
2. Factors that quantify outcomes (e.g., usage
of the benet, quit rates, clinician adherence
to guidelines, and health outcomes)
7,16
AHIP suggests that evaluations of tobacco
control initiatives answer a series of questions
about program operations and outcomes
(Table 3).
3
It further recommends that all
ndings be used to improve the program by
closing any quality gaps that are discovered.
3

Best Practices: Tobacco Cessation
Policies Among Leading Health Plans
Eleven managed care organizations with
successful tobacco-control initiatives were
examined to discern the policies that
Table 3. Suggested Questions for Evaluating Tobacco Cessation Initiatives
3
Question
Is the initiative being implemented as planned?
Is the program reaching its target audience?
If the initiative is not reaching the target
audience, which target audience is not being
reached, and why?
Are participants satised with the initiative?
Are participants complying with the initiative?
Is the initiative having the desired effect?

Are HEDIS measures being used to determine
improvements?
Comment
Conrms that outcomes are connected with adherence to
the initiative.
Ensures that target audience is aware of services available.
17
Assesses reasons why target audience may not be taking
advantage of services.
Evaluates factors that encourage use of services.
Measures adherence to guidelines and treatment measures
to identify gaps in program.
Quanties short- and long-term outcomes (increased public
awareness, improved cessation rates, reduced morbidity) as
measured against goals of the initiative.
Benchmarks and measures a health plans ability to change
health behaviors for enrollees.
contributed to their effectiveness.
7
Of
the plans, located across the United States,
six had won awards from the AAHP (now
AHIP) for their tobacco-control activities,
and all exceeded the national average
performance on the HEDIS
measure for
medical assistance with smoking cessation.
7

After extensive interviews and analyses of
plan documentation, investigators found
that the plans employed multiple strategies
to implement clinical recommendations for
tobacco control.
7
Integration of the Four Cs
was a central aspect to many of their initiatives
(Table 4). The comprehensive approach to
tobacco control exemplied by these health
plans provides a model of what is possible and
a benchmark for other health plans to follow.
Comprehensive
Approach to Tobacco
Cessation at the
Employer Level
Employers are the primary source of health
insurance for nonelderly Americans; thus, the
benets they provide determine availability of
smoking cessation services for the majority of
the population.
15
Businesses further have the
opportunity to improve the health of nonsmokers,
as work sites are a major source of ETS
exposure.
18
In addition to improvements in
their employees health, employers benet
from tobacco-control initiatives through
increased productivity, reduced absenteeism,
Table 4. Implementation of the Four Cs Among 11 Leading Health Plans
7
Four Cs Implementation Strategies
Cover effective treatment All plans fully covered at least one pharmacotherapy option
All plans offered group classes in smoking cessation
Six plans had telephone quit lines for members at no cost
Collaborate with employers, Ten plans sponsored work site tobacco-control programs
clinicians, and public health Eight plans sponsored school-based prevention activities
entities Seven plans reviewed tobacco-related legislation or policies for
policymakers
Four plans sponsored tobacco counteradvertising messages
Capitalize by dedicating Ten plans designated a tobacco coordinator
staff and resources Nine plans established a tobacco oversight committee and had dedicated
counseling and training
Eight plans had a distinct budget for tobacco control
Seven plans had a clinician champion for tobacco control
Count or measure progress Nine plans monitored clinicians adherence to tobacco guidelines; six
of these plans gave performance feedback to clinicians; and ve also
provided nancial incentives based on clinicians performance on
tobacco guidelines
and decreased health care costs.
15
Recognizing
this fact, more employers than ever before are
instituting tobacco-control initiatives: over
30% of large employers now include smoking
cessation services in employee benets
packages, and an even greater percentage
have instituted smoke-free workplace policies
(Figure 1).
19,20
Yet, much work remains to be
done to reach the Healthy People 2010 goals
of 100% participation in both of these areas.
21
For large and small companies alike, several
strategies facilitate the success of work site
tobacco-control initiatives:
nstitite a lealtly worklace ciltire
Give incentives to qiit smoking anu aclieve
good health
Siort smoking cessation initiatives witl
no-cost pharmacotherapy
Institute a Healthy Workplace
Culture
Since the workplace environment strongly
inuences individual behaviors, including the
use of tobacco, policies and social norms at the
workplace should support employee health
and discourage tobacco use.
22
An especially
strong component of a healthy workplace
culture is the adoption of a smoke-free
work site policy. Consider that smoke-free
policies are inexpensive to put into place and
yield broad benets
23
:
Less smoking among emloyees
24
ncreases in qiit attemts among smokers
22
ncreases in siccessfil tolacco-ise
cessation
22
Reuiceu rates of relase among tlose wlo
quit
13
limination of JS exosire
18
In a large study based on the 2000 National
Health Interview Survey (NHIS), individuals
who reported working for employers with
a no-smoking policy were four times more
likely to attempt quitting and ve times
60
80
50
30
20
0
Smoking Cessation Benefits Smoke-Free Workplace Policies
10
40
70
E
m
p
l
o
y
e
r
s

W
i
t
h

I
n
i
t
i
a
t
i
v
e

i
n

P
l
a
c
e

(
%
)
Tobacco Control Initiatives
Figure 1. Tobacco Control Initiatives at the Employer
Level
19,20
more likely to be successful in their attempts
(Figure 2).
22
Smoke-free work sites also are the
only measure that eliminates nonsmokers
inhalation of ETS in the workplace. Providing
separate smoking areas, cleaning the air, or
improving ventilation does not extinguish
ETS.
25
One caveat should be considered before
establishing a smoke-free work environment.
It is important that bans on tobacco use be
focused on behavior at the workplace. The
National Workriglts nstitite las lollieu to
oppose employer smoking bans that extend to
cover personal time.
26
Wlile some comanies
have successfully implemented policies that
require all employees to be nonsmokers,
30 states and the District of Columbia have
laws that specically allow people to smoke
outside their workplace.
27
Individuals and
organizations that support this view consider
smoking on personal time to be a legally
protected privacy issue.
26,27
Some smokers
appreciate total bans on smoking as a
motivation to quit; however, employers
are cautioned to honor the rights of all
smokers, many of whom may feel invaded
and pressured if policies extend beyond
the workplace.
27
Another valuable component of a healthy
workplace culture is a shift in the social
environment. Because smoking often
gives tobacco users a way to socialize with
coworkers, a healthy workplace culture is
strengthened by creating an alternative
form of socialization that supports quitting.
17
Worklace e-mails, lilletin loarus,
newsletters, and meetings can be used
to establish social connections among
successful quitters and build peer support
for those attempting to quit.
17
Providing
on-site cessation services also creates an
immediate group of supportive coworkers
who can encourage and motivate each
other through the quitting process.
10
Give Incentives to Quit Smoking
and Achieve Good Health
One intervention that effectively motivates
smokers to quit is the availability of incentives
for smoking cessation and achievement of
good health. Financial incentives for employees
who stop using tobacco for a specied period
of time provide a positive means of motivation.
Wlile uisincentives for smoking may also
be effective (e.g., bans on smoking at the
workplace), smokers especially appreciate
incentives, feeling that their employer is
60
80
50
30
20
0
Smoking-Free Workplace Policy No Smoke-Free Workplace Policy
10
40
70
90
Workplace Tobacco Policy
S
m
o
k
e
r
s

W
h
o

T
a
k
e

A
c
t
i
o
n
s

t
o

Q
u
i
t

(
%
)
Quit Attempts
Successful Cessation
Figure 2. Smoking Cessation Among Employees,
Based on Workplace Policies
22
afrming their health and acknowledging the
difculties of the quitting process.
17,22
Clinical
evidence also supports this intervention.
Wlile long-term uata are not yet availalle,
incentives appear to increase involvement in
tobacco cessation activities and improve
cessation rates.
17
Support Smoking Cessation
Initiatives With No-Cost
Pharmacotherapy
A nal important component that may be
included in employer benets packages is
pharmacotherapy for smoking cessation at no
or reduced cost to employees. Fiore (2000)
suggests that medication is recommended for
all smokers attempting to quit, noting that out-
of-pocket costs may effectively prevent many
individuals from taking advantage of this
support.
8,9
Employers that cover the cost of
pharmacotherapy for tobacco cessation will
increase the success of quit attempts among
employees, as well as reduce health care costs.
5
An example of full coverage is illustrated by
the cessation benets available to employees
of The Boeing Company, known for innovation
in the aerospace industry. Boeing fully covers
pharmacotherapy for employees, as well as
spouses and dependents, who sign up for its
tobacco-treatment program.
28
The company
chose to adopt this no barriers approach
after discovering that tobacco use was costing
the company more than $180 million per
year.
28
All expenses are covered for the
initiative that includes one-on-one phone-
based treatment sessions, unlimited toll-free
telephone support, medication, and self-help
materials.
29
Acknowledging that tobacco
dependence is a chronic condition, Boeing has
made this a lifetime benet, allowing employees
to re-enroll as many times as necessary.
28
To
increase awareness and encourage participation,
program information is included in company
newsletters sent to employees homes,
yers in employee mailboxes, e-newsletters,
information distributed at on-site health
clinics and tness centers, and the companys
lealtl anu wellness Wel site.
28
The manager
of Boeings enterprise wellness programs
believes that the companys investment in
fully covered tobacco-dependence treatment
provides a greater return than any other adult
treatment or prevention benet they offer.
28
Comprehensive
Approach to Tobacco
Control at the Clinician
Level
Clinicians are on the front lines with tobacco
users, seeing most of them at least once a year.
30

This gives clinicians an ideal opportunity to
incorporate tobacco control as a regular aspect
of care. A comprehensive approach to these
services can encompass several tactics, without
demanding excessive time on the part of the
clinician:
ncliue tolacco ise as a vital sign
Jreat tolacco ise as a uisease
ncororate tle 5 A`s (Ask, Advise, Assess,
Assist, and Arrange)
stallisl a roceuire to roviue referrals
for treatment
Include Tobacco Use as a
Vital Sign
Clinical guidelines recommend making
tobacco use a vital sign to be measured as
consistently as weight and blood pressure.
8

Clinicians can use chart stamps or stickers,
which are readily available and inexpensive, to
identify status on patient charts.
3
To enhance
the screening process, clinicians may want to
consider using a breath carbon monoxide (CO)
monitor to measure tobacco use. Breath CO
monitors are simple instruments that give
smokers instant visual evidence of the level of
dangerous carbon monoxide in their lungs.
31,32
Any inhaled tobacco is measured, including
cigarette, pipe, or cigar smoke.
31
Patients
simply blow into a disposable mouthpiece
attached to the device, which displays a CO
reading within seconds. A clear visual display
gives a reliable indication of smoking status,
from nonsmoker (0-6 parts per million [ppm]),
to light smoker (7-10 ppm), average smoker
(11-20 ppm), and heavy smoker (20+ ppm).
31

In addition to conrming smoking status, use
of the monitor provides motivation for smokers
who may be thinking about quitting, as well as
reinforcement of health improvements during
the quitting process.
32

Wletler or not a CO monitor is iseu, consistent
screening of all patients for tobacco-use status
should be an integral part of clinical practice.
4
A screening protocol is suggested by the U.S.
Public Health Service that incorporates
ongoing assessments to encourage cessation,
provide support, and prevent relapse (Figure 3).
8

Treat Tobacco Use as a Disease
Throughout the process of screening and
treatment, clinicians are encouraged to view
tobacco dependence as a disease. Rather
than expecting a one-time decision to end
the discussion of tobacco use, clinicians can
anticipate that the quitting process will take
If yes....
Is patient now
willing to quit?
If yes.... If no....
Provide appropriate
tobacco-dependence
treatments
Promote
motivation
to quit
If no....
Did patient once
use tobacco?
If yes.... If no....
Prevent
relapse*
No intervention
required;
encourage
continued abstinence
Figure 1. Tobacco Control Initiatives at the Employer Level Figure 1. Tobacco Control Initiatives at the Employer Level
Figure 1. Tobacco Control Initiatives at the Employer Level
Figure 1. Tobacco Control Initiatives at the Employer Level
Does patient use tobacco now?
Figure 3. Screening Protocol for Tobacco-Use Status
8
*Relapse prevention interventions are not necessary in the case of the adult who has not used tobacco for many years.
place over time and, just as with other chronic
diseases, will be characterized by periods of
relapse and remission.
3
Witl tlis view, atients
can be reassured that success is achieved with
every attempt to quit, no matter how long
abstinence lasts.
33
One investigator, who
studies factors leading to relapse, notes that
smokers who are less afraid of failure are more
likely to try to quit. His suggestion is to tell
smokers that just trying (to quit) means
youre succeeding.
33

Incorporate the 5 As
Clinicians are encouraged to use the 5 As
approach for discussions with tobacco users.
34

Asking about tobacco use, Advising users to
quit, Assessing the tobacco users willingness to
quit, Assisting with the quit attempt, and
Arranging follow-up care are interventions that
can be assigned to various health care staff. To
save physician time, nurses, assistants, or other
appropriate individuals may fulll specic
elements of the process. For example, if a
medical assistant already is responsible for
measuring vital signs, this person may be
given the responsibility for asking about
tobacco use and noting it on the chart along
with other vital signs.
4
In this way, the
physician can devote more time to the other
components of counseling.
Provide Referrals for Treatment
Because many physicians do not feel they
have the time or expertise to provide
comprehensive counseling for tobacco-use
cessation, referrals to external sources of
support can be a useful part of the clinical
protocol.
35
Wel sites anu toll-free qiit lines
provide education, guidance, and support to
individuals in every phase of the cessation
process. Selected examples of national support
resources are included in Table 5. These
sources should be considered an augmentation
of, rather than a replacement for, personal
attention from the clinician. Direct support
from the physician that includes regular
screening, a long-term perspective on quitting,
and incorporation of the 5 As into the clinical
practice more than doubles the likelihood that
a smoker will succeed in his or her attempt to
quit.
34
Table 5. Selected Examples for National Support of Referrals for External Support
36
Description
American Academy of Family Physicians patient smoking cessation guides
National Cancer Institutes cessation guide, patient education materials,
and links to regional quit lines
37
National Cancer Institutes toll-free quit line
Contact Information
www.aafp.org
www.smokefree.gov
1-800-QuitNow
Comprehensive
Approach to Tobacco
Cessation at the Public
Health Level
Collaboration with public entities must be
included in a comprehensive approach to
tobacco control. The social environment
inuences whether a smoker will consider
quitting and whether a young person will
begin using tobacco.
38,39
Public health
initiatives have the capacity to shift social
norms away from tobacco use, inuencing
large numbers of people at minimal cost.
23

Multiple stakeholders, including health
plans, employers, clinicians, community
organizations, and schools, bring diverse
areas of expertise to the issue of tobacco
control and allow initiatives to incorporate
a variety of components that work together
to reduce the burden of tobacco use
39,40
:
Meuia camaigns
Pillic lealtl euication
ncreases in tolacco taxes
Restriction of tolacco accessilility
Sclool-laseu revention rograms
Prolilition of tolacco auvertising
Smoke-free laws anu olicies
Each component supports the others, creating
synergy when all components are included in
a comprehensive plan. Media campaigns,
proven to reduce tobacco use and increase
cessation among tobacco users, also support
public health education with their informational
messages.
41
Increases in tobacco taxes help
fund tobacco-control initiatives and reduce
consumption of tobacco.
2,16
Restricting tobacco
accessibility, through such measures as
prohibition of cigarette vending machines,
works synergistically with school-based
prevention programs and bans on tobacco
advertising to reduce tobacco use among
adolescents.
31,42,43
Smoke-free laws and policies are a core
component of public health initiatives,
supporting other tactics to decrease smoking
rates and providing the most effective means
of reducing ETS exposure in public areas.
44,45

20
25
15
10
5
0
Government
Work Sites
Private
Work Sites
Restaurants Bars All Four
Locations
N
u
m
b
e
r

o
f

S
t
a
t
e
s

W
i
t
h

L
a
w
s

C
o
v
e
r
i
n
g

E
a
c
h

S
i
t
e

Locations Covered by Smoke-Free Indoor Air Laws
Figure 4. State Smoke-Free Indoor Air Laws
44
As with many other tobacco-control initiatives,
smoking bans have high levels of public support
and compliance.
13,44
Recognizing their value
and public support, a growing number of
states are passing laws that prohibit smoking
in numerous locations, including bars,
restaurants, government work sites, and
private workplaces. Nearly half of states
have 100% smoke-free indoor air laws for
government work sites (Figure 4),
43
and
20 states have eliminated smoking from bars,
restaurants, government sites, and private
workplaces (Table 6).
44
Best Practices: Californias
Tobacco-Control Initiative
Californias Tobacco Control Prevention
(CTCP) and Education Program integrates
the components of an effective tobacco-control
strategy at the public health level. As one of
the most aggressive antitobacco campaigns
ever launched, the CTCP has been recognized
by the Centers for Disease Control and
Prevention (CDC) as a model of best practices
for a comprehensive tobacco-control and
prevention program.
13,16
The CTCP was initiated in 1988 with the goal
of decreasing tobacco-related diseases and
deaths in California by reducing tobacco use
across the state.
13
A tax increase on all forms of
tobacco launched the program by providing
funds for public health education and other
initiatives.
16
A key focus of the program was to
change social norms by creating a climate in
which tobacco becomes less desirable, less
acceptable, and less accessible.
13
Numerous
interventions, including media campaigns,
restriction of tobacco accessibility, school-
based prevention programs, and smoke-free
laws and policies, were developed largely
at the community level.
13,16
For example,
hundreds of local ordinances mandate
smoke-free public areas, from restaurants
and workplaces to playgrounds and public
beaches.
13
Ongoing state-wide objectives
include strengthening efforts to reduce ETS
and providing smoking cessation services as a
core benet of all health insurance plans in
California.
40
Efforts at all levels have been resoundingly
successful. The social norm change model has
led to a culture in which smoking is socially
unacceptable. Most adults in California work
in smoke-free environments. Their children
attend smoke-free schools, shop in smoke-free
Table 6. States That Ban Smoking in
Bars, Restaurants, Government Work
Sites, and Private Workplaces
as of January 2, 2008
46
Arizona Montana
California Nevada
Colorado New Jersey
Delaware New York
Florida North Dakota
Hawaii Ohio
Illinois Rhode Island
Louisiana South Dakota
Massachusetts Utah
Minnesota Washington
stores, and largely live in smoke-free homes
and play in smoke-free public places.
47
In this
environment, tobacco use has dropped and
health has improved. Rates of smoking are
well below the national average for all age
groups (Figure 5), and tobacco-related diseases
have declined faster in California than in the
rest of the United States. Evidence has associated
these declines with CTCP interventions, and
further health improvements are expected as
tobacco-control efforts continue.
13
The California Department of Health Services
credits collaboration among multiple stakeholders
for much of the success of the tobacco-control
initiative.
13
Health care professionals, community
coalitions, ethnic networks, schools, and state-
wide campaigns all contribute to the design
and implementation of interventions.
47
Input
from these groups ensures participation and
support from diverse organizations, extensive
reach into all levels of society, and resulting
shifts in public attitudes toward the use of
tobacco.
Collaboration Among All
Levels
As illustrated by Californias tobacco-control
program, collaboration is vital to the success
of comprehensive tobacco-control initiatives.
Comprehensive strategies at the health plan,
employer, clinician, and public health levels
must support one another in a coordinated
approach. Multiple factors contribute to
tobacco use and dependence, and each should
be addressed for maximum effectiveness. For
example, full coverage for cessation benets
on the part of health plans, smoking bans at
workplaces, counseling from clinicians, and
tobacco-control policies at the public health
level all reinforce consistent support for
reuicing tle liruen of tolacco. Wlen
multiple stakeholders work together to
develop comprehensive plans for tobacco-
control initiatives, these interventions can
work synergistically to reduce the prevalence
of tobacco use and improve the health of
millions of individuals.
47

15
10
0
Adults High School Students
5
20
25
Population
S
m
o
k
e
r
s

R
a
t
e

(
%
)
U.S. Average
California
Figure 5. Smoking Rates in California and the United
States
12,47
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29. Free & Clear. How the Free & Clear Quit for Life program works. http://
www.freeclear.com/services/tobacco_cessation/how_it_works/default.
aspx?nav_section=1. Accessed November 28, 2007.
30. Steinberg MB, Akincigil A, Delnevo CD, Crystal S, Carson JL. Gender and
age disparities for smoking-cessation treatment. Am J Prev Med.
2006;30(5):405-412.
31. Micro Direct. Frequently asked questions. http//www.breathcotest.com/faq.
asp. Accessed December 8, 2007.
32. EBME. Carbon monoxide (CO) monitoring (Smokerlyser). http://www.ebme.
co.uk/arts/smoke/index.htm. Accessed December 8, 2007.
2005;292:482-487.
35. Ulbricht S, Meyer C, Schumann A, Rumpf H, Hapke U, John U. Provision of
J Am Board Fam Med. 2006;19:350-357.
References (contd)
37. National Cancer Institute. About smokefree.gov. http://www.smokefree.gov/
about.html. Accessed December 8, 2007.
38. Ohio Department of Health. Solutions: Ohios comprehensive cancer
newsletter. http://www.odh.ohio.gov/ASSETTS A0489538F8FD4DB1A7E8B
CDA0CE2EE6C/can1003a.pdf. Accessed May 15, 2008.
39. Miller MC, ed. Helping teens stop smoking. Harv Ment Health Lett.
2007;24:4-5.
40. California Department of Health Services. Confronting a relentless adversary:
a plan for success. Toward a tobacco-free California 2006-2008. http://
www.dhs.ca.gov/tobacco/documents/pubs/MasterPlan05.pdf. Published
March 2006. Accessed April 30, 2008.
therapies to stop using tobacco. The Community Guide http://www.the
communityguide.org/tobacco/tobac-int-out-of-pocket.pdf. Accessed
December 18, 2007.
42. Centers for Disease Control and Prevention. Guidelines for school health pro-
grams to prevent tobacco use and addiction. MMWR Morb Mortal Wkly Rep.
1994;43(No RR-2):1-18.
43. American Academy of Pediatrics. Tobaccos toll: implications for the pediatri-
cian. Pediatrics. 2001;107:794-798.
44. Centers for Disease Control and Prevention. State Tobacco Activities Tracking
and Evaluation (STATE) system: state smoke-free indoor air fact sheet.
http://www.cdc.gov/tobacco/statesystem. Accessed December 8, 2007.
45. Centers for Disease Control and Prevention. Preemptive state smoke-free
indoor air lawsUnited States, 1999-2004. MMWR Morb Mortal Wkly Rep.
2005;54:250-253. http://www.ncbi.nlm.nih.gov/sites/entrez?Db=
pubmed&Cmd=ShowDetailView&TermToSearch=15772586&ordinalpos=
1&itool=EntrezSystem2.Pentrez.Pubmed.Pubmed_ResultsPanel.Pubmed_
RVAbstractPlus. Accessed December 7, 2007.
46. American Nonsmokers Rights Foundation. States, commonwealths, and
municipalities with 100% smoke-free laws in workplaces, restaurants, or
bars.. http://www.no-smoke.org/pdf/100ordlist.pdf. Updated April 1, 2008.
Accessed February 25, 2008.
47. California Department of Public Health. CA Success. TobaccoFreeCA.com.
http://www.tobaccofreeca.com/ca_success.html. Accessed December 6,
2007.
| T H E V A L U E O F E F F E C T I V E T O B A C C O C E S S A T I O N I N I T I A T I V E S 101
The Value of Effective Tobacco
Cessation Initiatives
The long- and short-term benets of effective tobacco cessation initiatives are well demonstrated. Health is
improved and mortality is reduced among those who quit using tobacco, as well as among nonsmokers who
no longer breathe secondhand smoke. Quality of life (QoL) is enhanced for these individuals
1
; and economic
benets are realized by individuals, health plans, employers, and society as a whole when tobacco control
initiatives are implemented.
2
Health Benets
For many smokers, improved health is the
primary motivation for quitting tobacco use.
3

Their goal is substantiated by considerable
research that demonstrates effective tobacco
dependence treatment leads to reductions in
serious, chronic diseases, including cancer,
cardiovascular disease, chronic obstructive
pulmonary disease (COPD), and other
respiratory illnesses.
4
Health benets are
immediate and considerable after quitting
smoking, and improvements continue to be
gained over time (Table 1).
There is no clinical intervention available today that can reduce illness, prevent death,
and increase quality of life more than effective tobacco treatment interventions.

U.S. Public Health Service
1
Table 1. Disease Risk Factors Reduced by
Smoking Cessation
5
Risk of myocardial infarction is reduced after 24 hours of not smoking
Lung function and circulation are improved within three months of
quitting
Excess risk of coronary heart disease (CHD) is half that of a smokers
after one year of not smoking
Stroke risk is reduced to that of a nonsmokers after ve years of
abstinence
The death rate from lung cancer is half that of a smokers, and risks for
cancer of the mouth, throat, esophagus, bladder, kidney, and pancreas
are reduced after 10 years of not smoking
CHD risk is reduced to that of a nonsmokers after 15 years without
cigarette use
Increased lung function is especially important
in individuals with asthma or COPD. One
investigation found that smokers with asthma
who quit achieved considerable improvement
in lung function and a fall in sputum neutrophil
count within six weeks of quitting.
6
In smokers
with COPD, smoking cessation improves
airow, relieves symptoms, and preserves lung
function (Figure 1).
7
As a result, health, QoL,
and longevity are improved. A 14-year study
found that COPD patients who quit smoking
at the outset of the study had an 18% reduction
in all-cause mortality compared with those
who had not quit.
8
Understandably, the
Global Initiative for Chronic Obstructive
Lung Disease (GOLD) has emphasized that
smoking cessation is the single most important
intervention to reduce the morbidity and
mortality of COPD.
9
Interventions on the part of health plans
and employers play a key role in achieving
these health outcomes. A recently published
analysis based on data from the U.S. Current
Population Survey,
10
the National Health
Interview Survey (NHIS),
10
and the Centers
for Disease Control and Prevension (CDC)
10

found that coverage of a smoking cessation
benet leads to improved employee health,
which is measurable within two years of
quitting.
10
Smokers whose employers cover
the cost of counseling plus pharmacotherapy
are more likely to quit successfully and less
likely to suffer from CHD, COPD, or lung
cancer compared with employees who are not
covered by this benet.
10
Nonsmokers also reap health benets from
tobacco control interventions. Policies that
establish smoke-free environments at work
sites and public places have led to decreases
in smoking-related health complications.
11
It
was recently discovered that these decreases
are largely seen in nonsmokers.
12
In one study,
researchers compared hospital admission
rates for acute myocardial infarction (MI)
in two Indiana counties. In August 2003,
Monroe County banned smoking in public
places, while Delaware County, with similar
population, income, and heart disease rates,
had no smoking ban.
12
Smoking status and
MI rates were documented in both counties
before and after Monroe County established
its smoking ban.
12
After the ban took effect
(Figure 2),
12
results showed a large drop in
admissions for MI among nonsmokers in
2.5
2.6
2.2
2.3
2.4
2
1 Year 10 Years
2.1
2.7
2.8
2.9
Time
F
E
V
1

(
L
)
*
Continuous smokers Intermittent quitters Sustained quitters
*FEV
1
=Lung function measured in liters of forced expiratory volume in 1 second.
Figure 1. Lung Function in Patients With COPD
8
Monroe County. No signicant decrease was
seen in Delaware County.
12
To rule out other
causes, patients with any previous cardiac
disease, hypertension, or high cholesterol
were excluded from the analysis.
12
The immediate improvement in nonsmokers
health conrmed the harm caused by
secondhand smoke, including blood vessel
constriction and platelet aggregation, which
increase the risk of MI.
12
Importantly,
these ndings also conrm the health
benets of population-based tobacco control
interventions, which are evident shortly
after implementation.
Quality-of-Life Benets
Quality of life (QoL) pervades all aspects of
living, from perceived general health to social
and physical functioning, levels of vitality, and
emotional well-being.
13
Thus, improvements
from tobacco-use cessation may include
diverse benets that range from subtle to
dramatic
1
:
General lealtl imroves
!oou tastes letter
Sense of smell slarens
Self-esteem imroves
Home, car, clotling, anu lreatl smell letter
Worries aloit qiitting are eliminateu
Role moueling for cliluren imroves
Concern aloit exosing otlers to
secondhand smoke is eliminated
Plysical erformance imroves
Skin aging is reuiceu
Additionally, QoL may also improve as a
result of smoke-free policies in workplaces
and public areas.
10
In social environments
that prohibit smoking, it would be expected
that social functioning would improve after
a smoker quits.
12
8
10
0
August 2001May 2003 August 2003May 2005
4
6
2
14
16
18
20
H
o
s
p
i
t
a
l

A
d
m
i
s
s
i
o
n
s

f
o
r

M
I

A
m
o
n
g

N
o
n
s
m
o
k
e
r
s
Monroe County
Delaware County
Period studied: Before and after smoking ban in Monroe County.
Figure 2. MI Rates Among
Nonsmokers With No History
of Cardiac Disease, Hypertension,
or High Cholesterol
12
Investigations of QoL changes after smoking
cessation have found that benets tend to
accrue over time.
13,14
In one large trial of
smokers who participated in a work site
smoking cessation initiative, those who
remained tobacco-free three months after
the intervention reported improvements
in ve QoL parameters, compared with
those who continued to smoke (Table 2).
At 12 months, those who remained abstinent
reported additional improvements in their
emotional and physical status compared
with those who had relapsed or never quit.
13
Economic Benets
The Harvard Health Letter has ranked smoking
cessation treatment as the gold standard of
health care cost effectiveness.
15
Numerous
analyses demonstrate the economic value of
a variety of tobacco control interventions.
15-17

Costs are minimal compared with many other
routine health care services, and returns are
considerable.
4,15
The nancial outlay for
tobacco-dependence treatment is signicantly
less than that for other generally reimbursed
medical interventions. A recent analysis found
that health plans invested up to $0.79 per
member per month to cover a one-year
smoking cessation program that included the
5 As (Ask, Advise, Assess, Assist, and Arrange)
plus pharmacotherapy and counseling.
15

This compares favorably with costs for routine
treatment of hypertension or high cholesterol,
and for preventive measures, such as
mammography or Papanicolaou (Pap) tests.
4

Since retirns on investment (RO) are
important, health plans and employers rightly
want to ensure that the money spent on
tobacco control interventions will be offset
by savings on medical expenditures. The
basis for these savings is the prevention of
tobacco-related health care costs, which are
estimated at $16,000 or more, plus the costs of
absenteeism and reduced productivity, over
the lifetime of a typical smoker.
18
The concern
for many health plans and employers is
whether an adequate amount of these returns
will be realized in the near term.
15
Economic
benets are not motivating if the cost of an
intervention does not yield returns until after
an individual has moved on to another health
plan or employer. Typical turnover rates for
health plans are approximately 20%, and the
average employee remains with one employer
for just 3.6 years.
19,20
Thus, an investment in
treating tobacco use and dependence must
yield returns within several years for economic
benets to outweigh costs.
15
Americas Health Insurance Plans (AHIP),
in collaboration with the Center for Health
Researcl, Kaiser Permanente Nortlwest,
Table 2. QoL Improvement Parameters
Observed in Smokers Abstaining for
Three and 12 Months
13
Mental health
Vitality
General health
Social functioning
Physical functioning
ueveloeu an RO calcilator tlat las
demonstrated a positive return from tobacco
cessation treatment within two years for health
plans and employers alike.
15
Usual care (the
rst 2 As: Ask and Advise) was compared
with a comprehensive tobacco control
initiative that included the 5 As, as well as
pharmacotherapy and proactive telephone
counseling. Accounting for relapses and
disenrollment, the analysis included annual
medical expenditures as well as productivity
losses. Wlen tle two interventions were
compared, investigators found that health
plans investing as much as $410 per participant
in the comprehensive one-year program
realized a positive return at two years (Figure
3).
15
Employers that realized the additional
benets of increased productivity and reduced
absenteeism among nonsmokers achieved a
ositive RO witlin tlree years.
15,16
After ve
years, lealtl lans lau aclieveu an RO of
$750, while employers gained $200 for every
participant in the program.
15
Jle RO calcilator inuicates tlat economic
benets increase over time for both health
plans and employers alike, yet health plans
realize the greatest long-term return.
15

Hospitalization rates may account for much
of this discrepancy. Smokers typically
experience increasing rates of hospitalization
as long as they continue to use tobacco, and
their rate of hospitalization declines beginning
the year after they quit.
19
Beyond providing returns for health plans and
employers, economic benets serve individuals,
who no longer have to pay for increasingly
expensive cigarettes or for their share of
associated medical expenses. Society as a
whole also prots from the benets of tobacco
control. Improvements in individual health
and QoL promote a robust culture, and,
with health care savings from tobacco control
initiatives estimated at $441 million annually,
the economic health of society also benets.
2
$600
$400
$1,000
$800
$200
$0
-$200
-$400
-$600
1 2 3 4 5
R
O
I

C
o
m
p
a
r
e
d

W
i
t
h

2

A
s
Year
Health Plan
Employer
Figure 3. Cumulative ROI per Intervention Participant
15
References
1. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence.
Clinical Practice Guidline. Rockville, MD: U.S. Department of Health and
Human Services, Public Health Service. June 2000. http://www.ncbi.nlm.
nih.gov/books/bv.fcgi?rid=hstat2.chapter.7644. Revised 2000. Accessed
May 19, 2008.
2. Greenbaum E. The Center for Prevention and Health Services. Ten
recommendations for promoting prevention. Issue brief. http://www.
businessgrouphealth.org/pdfs/ib_promotingprevention.pdf. Published March
2007. Accessed August 15, 2006.
3. Lee C, Kahende J. Factors associated with successful smoking cessation
in the United States, 2000. Am J Public Health. 2007;97:1503-1509.
About_ Smoking_Tobacco_and_Health.asp. Accessed January 30, 2008.
6. Chaudhuri R, Livingston E, McMahon AD, et al. Effects of smoking
cessation on lung function and airway inammation in smokers with
asthma. Am J Respir Crit Care Med. 2006;174:127-133. http://www.
medscape.com/medline/abstract/16645173. Accessed May 19, 2008.
7. Celli BR. A 62-year-old woman with chronic obstructive pulmonary disease.
JAMA. 2003;290:2721-2729.
8. Anzueto A. Clinical course of chronic obstructive pulmonary disease:
review of therapeutic interventions. Am J Med. 2006;119:S46-S53.
9. U.S. Department of Health and Human Services. National Heart Lung and
Blood Institute. Chronic obstructive pulmonary disease. NIH Publication No.
03-5229. http://www.nhlbi.nih.gov/health/public/lung/other/copd_fact.
pdf. Published March 2003. Accessed October 6, 2007.
10. Halpern MT, Dirani R, Schmier JK. Impacts of a smoking cessation benet
among employed populations. J Occup Environ Med. 2007;49:11-21.
11. Bartecchi C, Alsever RN, Nevin-Woods C, et al. Reduction in the incidence
of acute myocardial infarction associated with a citywide smoking
ordinance. Circulation. 2006;114:1490-1496.
12. Hughes S. Major MI benet of smoking ban seen in nonsmokers. Heartwire.
2007. http://www.medscape.com/viewarticle/566370. Accessed
November 26, 2007.
13. Hutter HP, Moshammer H, Neuberger M. Smoking cessation at the
workplace: 1 year success of short seminars. Int Arch Occup Environ
Health. 2006;79:42-48.
14. Quist-Paulsen P, Bakke PS, Gallefoss F. Does smoking cessation improve
quality of life in patients with coronary heart disease? Scand Cardiovasc J.
2006;40:11-16.
15. Americas Health Insurance Plans. Making the business case for smoking
cessation programs. http://www.businesscaseroi.org/roi/apps/execsum.
aspx. Accessed January 30, 2008.
16. Levy DE. Employer-sponsored insurance coverage of smoking cessation
treatments. Am J Manag Care. 2006;12:553-562.
17. Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost effectiveness
of smoking-cessation services under four insurance plans in a health
business/26smoking.html?_r=1&n=Top/Reference/Times%20Topics/
19. American Association of Health Plans. Addressing tobacco in managed
care: a resource guide for health plans. http://www.ahip.org/content/
default.aspx?docid=2270. Accessed January 30, 2008.
| A L O O K T O T H E F U T U R E 107
A Look to the Future
We hold in our hands the solution to the global tobacco epidemic that threatens the lives of one billion men,
women, and children during this century. In fact, tobacco use can kill in so many ways that it is a risk factor for
six of the eight leading causes of death in the world. The cure for this devastating epidemic is dependent not on
medicines or vaccines, but on the concerted actions of government and civil society, World Health Organization
(WHO) Director-General Margaret Chan announced in the introduction of the landmark 2008 document WHO
Report on the Global Tobacco Epidemic.
1

As we look to the future, we see tobacco use under increasing scrutiny. Since the 1998 multistate tobacco
settlement, awareness of the dangers of tobacco use has grown, and improved tobacco control strategies have
been developed, despite the ndings that much of the tobacco settlement funding was diverted to nontobacco-
related uses.
2
Yet, despite greater focus on the problem, millions of men, women, and children in this country
continue to suffer from signicant morbidity and mortality, and society continues to bear the tremendous
economic burden created by tobacco use and dependence.
3

To address the persistent tobacco use problem and move into a healthier future, tobacco control efforts should
be carefully focused on the most effective solutions:
Create youth-focused efforts to prevent adolescents from ever developing nicotine dependence
Coordinate within communities
Decrease clinician knowledge gap between best practices and application
Increase public awareness and education
Increase the cost of tobacco products
Improve delivery of cessation programs to high-use/high-risk populations
Increase collaboration combining personal, population, and public health strategies
To demonstrate current efforts, this edition of Quality Proles
includes 10 case studies contributed by

organizations that have focused on ways to reduce tobacco use and nicotine dependence. These case studies
are located within sections related to the methods or directions the contributing organization employed to
address tobacco dependence.
SOLUTION:
Address Prevention:
Begin With Youth
Smoking often begins in the adolescent years.
Statistics show that more than four out of ve
smokers begin using tobacco before the age of
18.
4
Thus, preventive efforts should be aimed
at young people and their parents.
5,6
Because
over 80% of current smokers wish they had
never started, directing efforts at youth is a
powerful step towards not creating another
generation of smokers.
5

Youth-focused initiatives must be broad based
in order to inuence all aspects of the social
environment that may encourage teens to
begin using tobacco.
6
From encouraging
clinicians to educate and counsel their young
patients to working collaboratively on school-
based prevention initiatives, all stakeholders
can get involved in preventing tobacco use
before children become addicted to nicotine.
SOLUTION:
Coordinate Efforts
Within Communities
The most cost-effective tobacco control
strategies involve coordination with
communities.
7
Population-wide initiatives,
including establishment of smoke-free
environments, bans on tobacco advertising,
and tobacco tax and price increases, are
low-cost, effective measures that contribute
to reduced tobacco use.
7,8
Health plans,
employers, and clinicians can coordinate
efforts with community-based organizations
in several ways:
Partner witl local organizations to uevelo
a comprehensive plan for tobacco control
9

Review tolacco-relateu olicies for
policymakers
10

Sonsor tolacco cointer-auvertising
messages
10

Auvocate for illic euication aloit tle
dangers of tobacco use
6

Proviue information to tle meuia anu
promote their coverage of tobacco-related
issues
6

Siort tolacco tax anu rice increases
6

Collalorate on sclool-laseu revention
activities
10

Comminities areciate tle exertise
provided by health plans, employers, and
clinicians, and coordinated efforts at the
community level often lead to regional
or state-wide tobacco control policies.
11

Comminity efforts roviue local solitions
to decreasing tobacco dependence.
SOLUTION:
Decrease Clinician
Knowledge Gap
A considerable gap exists between clinicians
desire to offer tobacco-related counseling
and their condence to do so.
12
Rarely uo
physicians receive training in this area. Less
than half of surveyed U.S. medical schools
offer any training in counseling skills for
smoking cessation and prevention.
12
The
lack of training extends to continued medical
education, as many practicing physicians are
unaware of clinical guidelines and appropriate
treatment measures for addressing tobacco
use.
13
Conseqiently, a large ercentage of
clinicians cite lack of skill as the reason they
do not discuss this topic with patients.
14

Further frustrating the situation is the fact
that smokers would welcome cessation
counseling from their physicians. One study
of nearly 1,500 smokers found that more than
lalf areciateu tleir uoctor`s auvice to qiit,
and that this advice strongly inuenced the
smokers decision to stop using tobacco.
15

Closing tle ga letween coinseling roviueu
and counseling desired is therefore an
imortant strategy to increase qiit rates
among smokers.
Health Plan Role in Clinician
Training
Health plans should use multiple strategies to
provide training that will improve counseling
rates among clinicians.
9
Existing interactions
with clinicians can be expanded to include
educational information on tobacco cessation
counseling.
9
Specic training provided through
Internet-based tutorials or point-of-care
handheld computers also has been found
to increase physicians knowledge and
condence in providing cessation counseling.
12,13

Many clinicians already use handheld computers
to check reference data during ofce visits,
and clinical guidelines, pharmacotherapy
information, and other point-of-care data
can be incorporated into these tools.
13
SOLUTION:
Increase Public
Awareness and
Education
Warning people about the dangers of tobacco
is one of the most effective policies that can
curb the tobacco epidemic.
16
Increased
public awareness does effect change. Smokers
wlo ask tleir lysicians for assistance to qiit
smoking are 15 times more likely to receive
effective treatment than those who do not
initiate the topic.
17
Thus, health plans and
employers should target educational initiatives
directly at smokers, enabling them to bring up
the issue with their physicians. The success of
this approach has been demonstrated in the
direct-to-consumer marketing of antidepressants,
which has led to greater public awareness
of medical interventions for depression and
increased demand for treatment.
17,18
Similar
efforts to increase public awareness and
education about smoking cessation could
leau to ligler qiit rates.
17

Cirrently, many smokers are inaware of tle
treatments available to help them stop using
tobacco.
19
Reacling tlese inuiviuials witl
information about the health effects of tobacco
ise anu siccessfil strategies for qiitting can
be done cost effectively. Smokers cite a wide
range of sources for health information, so
using multiple avenues of public awareness
campaigns may be the best way to increase
the publics knowledge base.
Product Packaging
Product packaging presents another opportunity
for increasing public awareness and providing
euication. Jle WHO 2008 MPOWR
Package proposes two policies that speak to
this point
16
:
Warnings aloit tle uangers of tolacco.
Graphic warning on tobacco product
package deters tobacco use
nforcing lans on tolacco auvertising,
promotion, and sponsorship
National-level studies before and after
advertising bans found a decline in tobacco
consumption of up to 16% following
prohibitions.
16
Antitobacco advertising is an
effective solution to decreasing tobacco use.
SOLUTION:
Increase the Cost of
Tobacco Products
The use of tobacco is price sensitive. A simple
solution for decreasing tobacco use is increasing
the cost of such products. Increasing tobacco
taxes by 10% generally decreases tobacco
consumption by 4% in high-income countries
and by about 8% in low-and middle-income
countries. A 70% increase in the price of
tolacco coilu revent i to a qiarter of all
tobacco-related deaths among todays smokers.
16

SOLUTION:
Improve Delivery of
Programs to High-Use/
High-Risk Populations
While tobacco control efforts must be
strengthened across all levels of society, a
targeted focus is necessary to reach low-
income, minority, and adolescent tobacco
users. These populations tend to have
high rates of tobacco use, limited access to
interventions, and low rates of successful
cessation
20-22
:
Smoking rates among auilts living lelow
the poverty line are nearly 50% higher than
for individuals with higher incomes
20

tlnic minorities accoint for less tlan
20% of tlose wlo siccessfilly qiit
using tobacco
23
Auolescent smokers wlo try to qiit are
much more likely to fail than adults
(58% failure rate vs. 43% among adults)
22

Reasons for tlese uisarities are not comletely
clear, yet numerous investigations have
conrmed that it is not due to lack of interest
in qiitting. Across all etlnicities, income
groups, and age ranges, smokers overwhelmingly
want to stop using tobacco.
20,24-25
Lack of knowledge, reduced access to care,
perceived cost, and cultural factors appear to
be important obstacles:
Altloigl lack of knowleuge aloit effective
smoking cessation treatment is pervasive in
tle general oilation, nonCaicasian
smokers and adolescents are less
knowleugealle tlan Caicasian auilts
22,26

Ethnic minorities are more likely to get
treatment information from friends,
family, and mass media, rather than
from health care professionals
26
- Auolescents often try to qiit smoking
by exercising more, telling others they
no longer smoke, or switching to other
tobacco products
22
tlnic minorities are less likely to le tolu
by their physicians to stop smoking and less
likely to receive appropriate treatment
measires to lel tlem qiit tlan are
Caicasians
26

Cost is a larrier for low-income anu
minority smokers, wlo freqiently eitler
have no insurance or are unaware that
insurance or other programs might cover
the expense of treatment
26,27

tlnic minorities may lelieve meuical care
is only for treating serious illnesses, or may
mistrust conventional health care, so they
do not talk with their doctors about smoking
cessation
26

High rates of tobacco use and distinct obstacles
to cessation suggest that socioeconomic status,
culture, and age must be considered in any
comprehensive approach to tobacco control.
SOLUTION:
Increase Collaboration
Combining Personal,
Population, and Public
Health Strategies
A shift is taking place in tobacco control,
from stand-alone programs focused on single
interventions to collaborative initiatives
that combine personal, population, and public
health strategies.
28
This cooperative approach
is more effective and less expensive than
individual efforts and also has the potential
to bring about lasting, population-wide
change.
11,28
Thus, oversight agencies, including
the U.S. Department of Health and Human
Services, the Institute of Medicine, the
WHO, and others, emphasize the necessity of
developing more expansive, comprehensive
strategies for tobacco control.
28,29

Because health care coverage, workplace
environments, clinician interventions, and
social norms all affect a smokers ability to
qiit, eacl of tlese factors mist le incliueu
in effective tobacco control initiatives.
11,23,30,31

Health plans, employers, clinicians, smokers,
and communities therefore play key roles in
creating comprehensive plans to reduce the
burden of tobacco.
Call to Action
The tobacco epidemic is preventable.
Hundreds of millions of people do not have
to die this century from tobacco-related illness
but only if the leaders of governments and
civil society take urgent action.
32
Now is the time to implement comprehensive
strategies for tobacco control. Smoking rates
are no longer decreasing; tobacco-related
deaths continue to account for nearly 20%
of all mortality in the United States; and
current medical costs and productivity losses
from tobacco-related conditions amount to
nearly $167 billion per year.
3,33
Against this
backdrop, funding for state tobacco control
programs has dropped,
34
and tobacco companies
have stepped up their efforts to increase
tobacco use: the ve largest cigarette makers
now spend more than $35 million per day to
market their products.
8,34

Recognizing tle irgency of tlis sitiation, tle
President of the Institute of Medicine issued
a plea in January 2008 for stronger measures
to reduce the burden of tobacco use in this
country. Urging all stakeholders to work
together, his recommendations include actions
to be taken by health plans, employers, and
clinicians, as well as comprehensive measures
based on collaboration with policymakers.
33

Action taken today will determine the reality
of tomorrow.
35
The viability of strong
antitobacco measures has been demonstrated
by numerous organizations with innovative
tobacco control strategies. In alignment with
these pacesetters, health plans, employers,
medical centers, clinicians, interested citizens,
and smokers must work together toward
societal change and continue the efforts to
reduce tobacco use. We have the opportunity
to demonstrate global leadership in a critical
issue facing the world as a whole. The tobacco
epidemic must not be allowed to ravage
across the world leaving death and disease in
its wake. By working collaboratively, we can
imrove oir own rouictivity, qiality of life,
and economic health. And, in so doing,
provide a model for other nations to follow.
References
1. World Health Organization. World Health Organization (WHO). WHO report on
the global tobacco epidemic, 2008The MPower package. http://www.who.
int/tobacco/MPower/MPower_report_full_2008.pdf. Accessed April 28,
2008.
2006;3:No.3.
About_Smoking_ Tobacco_and_Health.asp. Accessed January 3, 2008.
Rep. 1994;43(No RR-2):1-18.
6. American Academy of Pediatrics. Tobaccos toll: implications for the
pediatrician. Pediatrics. 2001;107:794-798.
2007.
9. American Association of Health Plans. Addressing tobacco in managed care:
a resource guide for health plans. http://www.ahip.org/content/default.
aspx?docid=2270. Accessed January 30, 2008.
10. Rigotti NA, Quinn VP, Stevens VJ, et al. Tobacco-control policies in 11
leading managed care organizations: progress and challenges. Eff Clin Prac.
2002;5(3):130-136. http://www.acponline.org/journals/ecp/mayjun02/
rigotti.htm. Accessed December 7, 2007.
11. California Department of Health Services. California Tobacco Control
Update 2006: The Social Norm Change Approach. Sacramento, CA:
CDHS/TCS; 2006. http://www.dhs.ca.gov/tobacco/documents/pubs/
CTCUpdate2006.pdf. Accessed December 6, 2007.
12. Pederson LL, Blumenthal DS, Dever A, McGrady G. A web-based smoking
cessation and prevention curriculum for medical students: why, how, what,
and what next. Drug Alcohol Rev. 2006;25:39-47.
J Am Board Fam Med. 2006;19:350-357.
14. Ulbricht S, Meyer C, Schumann A, Rumpf H, Hapke U, John U. Provision of
15. Weber D, Wolff LS, Orleans T, Mockenhaupt RE, Massett HA, Vose KK.
Smokers attitudes and behaviors related to consumer demand for
cessation counseling in the medical care setting. Nicotine Tob Res.
2007;9:571-580.
16. World Health Organization. 10 facts on the tobacco epidemic and global
tobacco control. http://www.who.int/features/factles/tobacco_epidemic/
tobacco_epidemic_facts/en/index3.html. Accessed March 18, 2008.
2006;30(5):405-412.
18. Frosch DL, Krueger PM, Hornik RC, Cronholm PF, Barg FK. Creating demand
for prescription drugs: a content analysis of television direct-to-consumer
advertising. Ann Fam Med. 2007;5:6-13. http://www.medscape.com/
viewarticle/553023_print. Accessed January 28, 2008.
Feasibility of promoting smoking cessation in small worksites: an
exploratory study. Nicotine Tob Res. 2007;9:S83-S90.
20. Okuyemi KS, James AS, Mayo MS, et al. Pathways to health: a cluster
randomized trial of nicotine gum and motivational interviewing for smoking
cessation in low-income housing. Health Educ Behav. 2007;34:43-54.
21. Centers for Disease Control and Prevention. Healthy youth! Health topics:
tobacco use. http://www.cdc.gov/HealthyYouth/tobacco/index.htm.
22. Centers for Disease Control and Prevention. Use of cessation methods
among smokers aged 16-24 yearsUnited States 2003. MMWR Morb
Mortal Wkly Rep. 2006;55:1351-1354.
23. Lee C, Kahende J. Factors associated with successful smoking cessation in
the United States, 2000. Am J Public Health. 2007;97:1503-1509.
24. Fu SS, Sherman SE, Yano EM, van Ryn M, Lanto AB, Joseph AM. Ethnic
disparities in the use of nicotine replacement therapy for smoking
cessation in an equal access health care system. Am J Health Promot.
2005;20(2):108-116.
26. Fu SS, Burgess D, van Ryn M, Hatsukami DK, Solomon J, Joseph AM.
Views on smoking cessation methods in ethnic minority communities: a
qualitative investigation. Am J Prev Med. 2007;44:235-240.
27. Wetter DW, Mazas C, Daza P, et al. Reaching and treating Spanish-
speaking smokers through the National Cancer Institutes Cancer
Information Service: a randomized controlled trial. Cancer.
2007;109:406-413.
29. Institute of Medicine. Report brief: the role of the health care industry in
reducing tobacco use. http://www.iom.edu/Object.File/Master/43/190/.
therapies to stop using tobacco. The Community Guide. http://www.
thecommunityguide.org/tobacco/tobac-int-out-of-pocket.pdf. Accessed
December 18, 2007.
2005;294:482-487.
32. World Health Organization. MPOWER: six policies to reverse the tobacco
epidemic. http://www.who.int/entity/tobacco/mpower/mpower.report_six_
policies_2008.pdf. Accessed May 28, 2008.
33. Fineberg HV. Ending the tobacco problem. Medscape J Med. 2008;10:10.
http://www.medscape.com/viewarticle/568337_print. Accessed January
22, 2008.
34. Reuters Health Information. Anti-smoking efforts in US seem to have
stalled. http://www.medscape.com/viewarticle/565574_print. Accessed
November 11, 2007.
35. World Health Organization. WHO atlas maps global tobacco epidemic.
http://www.who.int/mediacentre/news/releases/pr82/en/. Accessed
March 18, 2008.
| 114 Q U A L I T Y P R O F I L E S
Appendix 1
| A P P E N D I X 115
Appendix 2
| A P P E N D I X 117
Appendix 3
Appendix
|
Appendix 4
| A P P E N D I X 119
Appendix 4 (contd)
| 119
Appendix 4 (contd)
| A P P E N D I X 121
Appendix 5
Appendix 5 (contd)
| A P P E N D I X 123
Appendix 5 (contd) Appendix 5 (contd)
Appendix 6
| A P P E N D I X 125
Appendix 6 (contd)
Appendix 6 (contd)
| A P P E N D I X 127
Appendix 6 (contd)
Appendix 7
| A P P E N D I X 129
Appendix 7 (contd)
Appendix 8
| A P P E N D I X 131
Appendix 8 (contd)
Appendix 9
| A P P E N D I X 133
Appendix 10
Appendix 10 (contd)
| A P P E N D I X 135
Appendix 11
Appendix 11 (contd)
| A P P E N D I X 137
Appendix 12
Appendix 12 (contd)
| A P P E N D I X 139
Appendix 13
Focus on Tobacco Dependence
The Leadership Series
QUAL I T Y P R OF I L E S
T M
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