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Group Discussions

Group Discussion I Policy in Tobacco and Obesity

Dr. Clement Bezold, President, Institute for Alternative Futures, Moderator: There is a paragraph in the agenda that outlines some of the questions about tobacco and obesity. We want to address those and think about what needs to be done to implement Recommendations 1, 2 and 3 from the report.

Dr. Harvey Fineberg, President, Institute of Medicine: I’d like to begin by telling you a story about New Liquid Tide. I don’t know how many people use this product. It was introduced about 20 years ago by Procter & Gamble at a time when they already had the leading washing detergent in the country, which was—guess what? Tide. But it was the powdered Tide. They developed a new, liquid product that they wanted to promote. This was a company that already had the market leader by the same name, so the consumer didn’t have to learn a new name.

I just want us to think for a moment about the behavior change that the company was aiming for. You are a shopper. You wash clothes. You are in the supermarket. Picture yourself going down the aisle with your shopping basket, and you come to the detergent section. As you pass the detergents, you come to a detergent you used to buy, and there is next to it New Liquid Tide. This is the behavior change that the company was seeking. Instead of reaching like this, you had to reach like that. You were already prepared to buy. You already needed the product. You already knew the name. You just had to reach to another neighboring spot. That is the entire behavior change they were aiming for. In the early 1980s over the first six months of new product introduction, they spent $38 million to educate the American public, to promote this product, and accomplish the change.



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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium 3 Group Discussions Group Discussion I Policy in Tobacco and Obesity Dr. Clement Bezold, President, Institute for Alternative Futures, Moderator: There is a paragraph in the agenda that outlines some of the questions about tobacco and obesity. We want to address those and think about what needs to be done to implement Recommendations 1, 2 and 3 from the report. Dr. Harvey Fineberg, President, Institute of Medicine: I’d like to begin by telling you a story about New Liquid Tide. I don’t know how many people use this product. It was introduced about 20 years ago by Procter & Gamble at a time when they already had the leading washing detergent in the country, which was—guess what? Tide. But it was the powdered Tide. They developed a new, liquid product that they wanted to promote. This was a company that already had the market leader by the same name, so the consumer didn’t have to learn a new name. I just want us to think for a moment about the behavior change that the company was aiming for. You are a shopper. You wash clothes. You are in the supermarket. Picture yourself going down the aisle with your shopping basket, and you come to the detergent section. As you pass the detergents, you come to a detergent you used to buy, and there is next to it New Liquid Tide. This is the behavior change that the company was seeking. Instead of reaching like this, you had to reach like that. You were already prepared to buy. You already needed the product. You already knew the name. You just had to reach to another neighboring spot. That is the entire behavior change they were aiming for. In the early 1980s over the first six months of new product introduction, they spent $38 million to educate the American public, to promote this product, and accomplish the change.

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium Now, I tell that story so you can think about that behavior change, that investment, that prior predisposition compared to the challenge of tobacco or obesity. I think a moment’s reflection will persuade any of us that we are really not yet serious about the investment needed to make significant changes in smoking, eating, and activity behaviors, although we have had significant success in reducing tobacco use. The 50 million people who are former smokers is an extraordinary success, but one fact that wasn’t mentioned this morning is that, on average, the remaining smokers smoke more than the people who quit smoked before they quit. We are getting down to a harder core than in the previous smokers, and we still have the problem of new beginning smokers. Now, to our question about policy for tobacco and obesity, I think first there are meaningful lessons to be learned from the tobacco story thus far, because it is a tremendous partial success. The lessons to be learned and to be translated include the scale of investment subsequent to the tobacco settlement that has been deployed and, in public health terms, lavished on the problem, the degree of success yet with still more to do, and how far we are from similar progress in obesity. If we had done a color chart of the country’s smoking rates like the color chart of obesity rates we saw this morning, it would have gotten progressively lighter but there would still be plenty there to work on. The main message is that the scale of commitment required is orders of magnitude beyond where we are accustomed to thinking in preventive programs aimed at fundamental behavior change. For obesity and for tobacco, the amount of investment is still not where it needs to be. The reason for that is simply that there isn’t any one entity with the resources that has an interest in making the changes in the right direction. It is a social good for which social investment is required, and that is hard to mobilize. Part of our task is thinking together about how we can and will be successful in mobilizing the necessary investment. I am eager to hear what stimulating thoughts others here have and what we can discuss together. Dr. Robert Croyle, Director, Division of Cancer Control and Population Sciences, NCI: One of the lessons of the tobacco control movement from a science perspective is that there were a lot of programmatic activities that we tried out early on in school-based prevention and other domains that were not terribly informed or effective. One of the reasons was that we grossly underestimated the importance of addiction and that we were dealing with an addictive drug. Once that was more clearly recognized, we were able to bring to bear pharmacological agents to help deal with the addiction, and we were able to double cessation rates. Therefore, in obesity and physical activity, given so much of the research effort is focused on obesity and weight loss at a clinical level as opposed to the public health effort, we, in collaboration with CDC and others,

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium have got a big public health research agenda. I am concerned that NIH hasn’t quite gotten that yet. When we talk to colleagues across NIH, public health relevant research is always a bit of a struggle and is always a fairly small slice of the pie. Therefore, the speed of responsiveness to something like the obesity epidemic which is changing so rapidly is going to be tough to achieve. This kind of group, this report, and these collaborations can help each of us to get our own broader organizational entities involved, although that is difficult because being organized around diseases, not risk factors, makes it hard to marshal rapid coordinated efforts targeted towards public health issues and risk factors. Another lesson is the importance of changing social norms and social climate. Part of turning the corner in terms of tobacco, even as we lose ground with the cutting of state programs, is the changing social norm about tobacco use and its acceptability. This has been reflected in clean indoor air laws and other policy efforts. For tobacco, policy changes have been important in addition to individual level efforts and have been enabled by the shifting of attitudes and social norms. Also important for tobacco control has been understanding the industry. You have got to understand the product that the industry is marketing. Clearly, it is easier in the case of tobacco than it is in the case of food, nutrition, and diet, but I think we need to get more folks in the public health program health research world learning more about and understanding more about the food industry, how it operates, how it functions. People in public health education and promotion need to understand how to work on obesity and diet, sometimes around but sometimes with industry. It will be harder than for tobacco in the sense that it is more complex. It is more varied. It is much harder to determine who the good guys and the bad guys are, because with large industries there are good and bad elements and products and sectors throughout. Another lesson was the ineffectiveness of the use of single isolated channels for behavior change and public health change. School programs sound great, but they are not enough on their own. Communication campaigns are great but not terribly effective on their own. A lot of the debate emerging in obesity and diet is the same debate we had 15 or 20 years ago in tobacco; people were arguing over whether we should we do school prevention, or media campaigns, or should we focus on policy, or is it just all about taxation, or is it all about drug development for nicotine replacement. Of course, the answer is that it is all of those. The effect size of each one of those is greater when used in conjunction with others. The interaction effects make for synergy. Another lesson is looking to simple things that can be done with big impact. Dr. Dietz has talked about the number of venues in the area of physical activity. It took a while with tobacco. It took too long to figure out

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium that sometimes you could do something that didn’t cost a whole lot but would have a big impact. Some of those things were in the policy domain. When I addressed the committee for the IOM report as they were first talking about this report, I spoke about what I labeled as MINC, minimal intervention necessary for change. When dollars are tight, one of our focuses should involve trying to identify those things that have a big bang for a little buck. Finally, in communication and campaigns which was Recommendation 10, we have had a real struggle trying to get other Institutes at the NIH talking about how to synergize all the fragmented health promotion campaigns that are scattered about, the National Cholesterol Education Program, National High Blood Pressure Education Program, the Obesity Initiative, our Five-a-Day Initiative, and on and on. There are bits and pieces of health communication campaigns all focused on chronic disease prevention, most of them focusing on similar risk factors. The effectiveness of these is undermined by the fact that they are scattered. They are independent. They are not synergistic or coordinated. How do we avoid the diffusion of responsibility that occurs once we are not talking about disease specific problems? Here we are talking about cancer prevention and early detection, but I think it really does make sense in terms of planning and coordination to talk about chronic disease prevention. Therefore the disease groups, both public, private, non-profit advocacy, all of us government and non-government, still have a way to go in terms of putting our forces together. Bill Corr, Esq Executive Director, National Center for Tobacco-Free Kids: I am very pleased to be here and hope that I can try to adapt what I was going to say given the very thoughtful comments that have already been made so we can get to the discussion. There are three big lessons that have been learned from tobacco that still need to be applied in tobacco and maybe have a good deal of relevance for obesity. First, with all the attention that is being paid to tobacco reduction, with all the money, and resources that are available, with all of the study that has been done on the impact of tobacco and how to address it, there are still a number of major misunderstandings. I say this not based on a scientific sample but on my own personal experience as I have gone around the country talking to state legislators and city council people and members of Congress. You would be amazed at how many people think the tobacco problem is fixed. I think that is because they are part of the 75 percent that don’t smoke, and they don’t see it very much anymore. They hear things like a 27 year low in high school seniors smoking. Although 26.5 percent or so of high school seniors are smoking. They hear the first half of that and not the second. They hear adult consumption is declining overall, but we still have 25 percent of adults smoking, and, as has been said, this may be the tougher group. They hear about all the people who want to quit, but they don’t hear about the

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium small percent that succeed. They understand that there is lots and lots of money—would you believe that over $20 billion a year is generated by the master settlement agreement and by tobacco excise taxes. But of that $20 billion, only about 3.5 percent this year is being spent on tobacco prevention. Unfortunately, much of the rest is going into deficit reduction. Many people think that the effort that we are making now will suffice, that we just have to keep doing what we are doing. What they don’t realize is that the industry, in the three years since the national settlement agreement, has increased its promotion and marketing expenditures by 66 percent. The industry is not letting go of this issue by any means, which makes it all the harder to succeed with prevention and cessation programs. All of these misunderstandings lead to the possibility that we will actually undercut, not succeed with, our current efforts in tobacco. Many people think there is enough tobacco money so that we can share some of it for this other major public health crisis we have got in obesity. We would undermine our tobacco efforts. We would underfund our obesity intervention efforts. We simply cannot allow those kinds of misunderstandings to continue which is why this report is so valuable. We have to find some new ways to overcome these misunderstandings. I know that it is daunting to think in terms of new resources for public health. At the federal level we have got huge deficits. At the state level, you have all been reading about unprecedented levels of deficits in many states. However, I can tell you personally from over 20 years of experience in Washington, on the Hill, in the Executive Branch, that if we in the public health community are shy about raising our voices for what is needed in public health, we will get nothing. A long time ago a fellow Hill staffer was pushing very hard for money at a time when there were limited dollars and I said, Brian, don’t you think you ought to take into consideration all these other needs?” and he said, Somebody else who is advocating for those needs has got to speak for them, but if we don’t speak up for our needs we are not going to get any money,” and it is true about public health. We simply cannot be intimidated by the difficult budget situations. We have to take a crystal clear message to our elected officials and to our policy makers that we must spend more money on public health. We need to spend more money on obesity, and we have got to use the money that we have for tobacco prevention and cessation. We are an advocacy organization so we can speak out. I know that there are many organizations, including the IOM, that have some limits on what they can do in terms of being advocates as opposed to providing objective advice, but the public health community is going to have to be more aggressive if we are going to get the additional resources that we need. Second, I mentioned this morning that elected officials, as a general rule, do not know about the evidence-based solutions that have already been

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium developed and that are being used. I was in the State of Maine talking to a legislator. Maine is one of the most progressive states in terms of its tobacco prevention efforts—36 percent reduction in high school smoking in three years. They have got a state-wide clean indoor air law. They just amended it to strengthen it. They have taken all their master settlement agreement money and put it into the Fund for a Healthy Maine. Part of it goes to tobacco prevention and cessation. Part of it goes to other health care. They are exercising leadership across the board; both parties are dedicated to creating a healthier Maine because they think it is going to be a more economically advanced Maine, and they have just done a spectacular job. But even in Maine, talking to a legislator, you hear comments such as: If I take a dollar and put it into expanding one of our research centers, we will get $8 from the NIH. That is a lot of research funding. So, I know a dollar spent there will get me $8. What will a dollar spent on tobacco control get me? I will feel better, but will it get me anything?” It is a very important question, one that we have to be able to answer with legislators across the country. There is a strong evidence base for raising excise taxes; a 10 percent increase in tobacco prices causes a 7 percent reduction in the number of kids who use tobacco, 3 to 5 percent reduction in the amount that adults smoke. Since, January 2002, 30 states have raised their tobacco taxes, some to very high levels that no one ever dreamed possible. The problem is, as soon as these state deficits are solved you will see the end of tobacco tax increases. They use health rhetoric now, that it is good to stop kids from smoking. However, what they are really trying to do is solve the deficit problem. We are again going to have to fight hard to keep people using evidence-based solutions for public health purposes. Many states, New York, Delaware, Connecticut, Florida, have all passed statewide clean indoor air laws. Yet you still hear many, many legislators espousing the industry’s line that this is going to hurt business. All the evidence is that it either has no effect, or it actually improves business. The third big issue is that we have to have an implementation plan. I know everyone is committed to seeing the report implemented, but you have got to have an action plan and that means that organizations have really got to pull together to figure out how are we going to get legislators better educated; how are we going to get the provider community, the health insurance and health plan community, and employers better educated about the value of cessation. We have got to get down to concrete steps if we are going to make progress. I think it will be all the tougher with obesity. As was said, so much time and energy has been spent on tobacco, a great deal has been learned. Now that same learning curve is going to occur with obesity. Hopefully, it will be faster, but organizations have got to be assigned responsibilities. They have got to take responsibilities and be coordinated and really push the implementation of these kinds of recommendations. Too often these

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium excellent objective recommendations based on good science and good evidence are articulated, are sent around the country, and they go on some-body’s shelf, and there just isn’t any follow through. So, we have got to become much more proactive and determined to implement these recommendations. Dr. William Dietz, Director of the Division of Nutrition and Physical Activity, CDC: What opportunities are there to link and create synergy between policy initiatives for tobacco and obesity? We have to be quite clear that there are two intersections of obesity and tobacco use. One is the co-variance of tobacco use with obesity and other risk-taking behaviors, and that suggests to me that there may be a core of individuals who are in both camps for whom much more intensive and perhaps non-public health approaches might be merited. The second is that increasingly, particularly among adolescent girls, smoking is used as a weight control measure, and concern about weight gain is one of the barriers to smoking cessation. So, I think that there is an opportunity for thinking about combined strategies that address these two overlaps. With regard to tobacco policy successes and the implementation of obesity related policies, it is very important to recognize that we are in a much more primitive state with respect to obesity control than we are with respect to tobacco control. Some of that has to do with a lack of evidence, or the lack of understanding I should say, because, although the public perceives it as a cosmetic issue, the evidence is that obesity is a health issue. In contrast, tobacco is widely perceived as a health issue. This difference was brought home to me by an African-American physician who started a weight control program in an African-American community in Kansas. She found as a result of her focus group work that African-American men and women did not understand the linkage between obesity and type 2 diabetes and its complications. In contrast, an extensive series of reports has identified tobacco as a health issue and made it possible to move forward into policy. In contrast to tobacco use, stigmatization does not work for obesity. There is no group in the United States that is as stigmatized as those who are overweight. Despite that, the prevalence of obesity is increasing. In contrast, a reasonable argument could be made that stigmatization of smoking has been quite effective at reducing smoking rates. Stigmatization has been one of the consequences of the non-smokers’ rights campaign. One of the conclusions that is quite clear from the tobacco experience and should hold true also for obesity is that the medical approach has a role that can’t exist in isolation from the public health approach, as others have said. A fourth important point is that, in contrast to tobacco use, obesity is much more complex. Tobacco is a single product, and there is no evidence that any tobacco use is beneficial, whereas you can’t survive without eating. Fifth, vilification of the industry, which has been so wide spread in the to-

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium bacco wars, is probably not going to be effective in the food arena despite what the tobacco lawyers would have us believe. Food industry groups are responding to consumer demand, and they do what they do very well. They produce an inexpensive product that is readily available, tasty, and quick, and we haven’t developed food alternatives that meet those same criteria. One of the risks that we face is that if we begin with opposition to the food industry, we lose the opportunity for alliances that I believe are going to be necessary to move this issue forward. House-wives, who 20 years ago spent an hour preparing dinner, are not going to go back to the old days. Quick service products are with us for the foreseeable future. Under those circumstances, the strategy needs to be to change the product and change the demand for the product. In contrast to the tobacco issue, the role of public health in the obesity epidemic is to help create a demand for those products if industry moves in that direction. I think there is every indication that that movement has started; the decision of PepsiCo to eliminate trans fat which has nothing to do with obesity and to lower the total fat in their products is one of the examples of industry’s responsiveness to consumer needs. Now, another reason for partnering with business is that we are not going to have the resources that business has to promote healthier alternatives. I think there are opportunities for partnership and understanding how to develop campaigns that meet needs from the public health or governmental perspective as well as the industry perspective. The other important point about industry is that we tend to think of industry only in terms of the fast food industry, when, in fact, other industries are potential allies. There may be very strong vested interests in the business community that are willing to support strategies to reduce the prevalence of obesity because so much of their income goes for paying the disease costs associated with obesity in their employees. Finally, in contrast to state tobacco programs which have been free standing, the obesity program, that we are beginning to initiate within 20 states this year, has to connect with the other chronic disease efforts. Partnerships in that respect are crucial. There is an emergent broad alliance. The American Cancer Society, the American Heart Association, and the American Diabetes Association, the American Dietetic Association, and the American Academy of Pediatrics have all initiated activities in this area, and the Washington Business Group on Health has established an institute on obesity. However, we do not yet have a clear focus on the strategy. There is a consensus that a problem exists, but there is no consensus yet about what to do about it. In contrast to tobacco where it was quite easy to say we must stop smoking, what do we do about obesity? We do have some strategies, like promotion of breast feeding, control of television time in children, and physical activity, but we don’t yet have a food-related strategy.

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium I should finish with a word on disparities. I don’t have a clear idea yet about how we craft the strategy specific for the groups that are most affected, but I think we have moved towards identifying the most vulnerable populations that may contribute a disproportionate share to the burden of disease associated with obesity. The first of these is children and adolescents. Despite the fact that they only account for 25 percent of adult obesity, obesity which has its onset in youth and persists into adulthood is much more severe in adulthood than obesity which has its onset then. The second group includes African-Americans and Mexican-American children and adults; both males and females have a higher prevalence of obesity than Caucasian youth or adults. A particular problem is the group that has a body mass index (BMI) greater than or equal to 40—roughly 100 pounds overweight. Five percent of the U.S. population have a BMI over 40, but 15 percent of African-American women have a BMI over 40. This suggests to me that African-American females are another very important and vulnerable population group for whom very specific strategies that address culture, socioeconomic status, and social justice become very important. Dr. Clement Bezold, moderator: You mentioned the PepsiCo issue. As a futurist, I read the press about this. It has been getting a lot of attention, front page of the Wall Street Journal and in Forbes. Pepsi is in effect trying to make its product line, its portfolio across the board, healthier. Do you consider them as an ally? Would you interpret that as an opportunity? Dr. William Dietz: I think it is a very important opportunity. I think their market research is telling them that this is an issue whose time has come, and they need to position their products to capitalize on what they see as a shift in consumption patterns. A couple of months ago, someone from the advertising industry commented that 15 years ago products had to begin to address diversity. That was clearly an issue whose time had come and required a response in Grafting messages from the industry. He went on to say that today we need to do the same thing for obesity. This is an issue that is going to be with us, that is going to be pervasive, and the impact of obesity on products needs to be addressed or their will be marketplace consequences. I think that reflects a growing sensitivity on the part of both industry and advertising to the importance and relevance of obesity. Participant: I am a clinical professor at George Washington University and CEO of a new company called Diet Fit, Incorporated. I find the comments very interesting, and I have a proposal regarding nutrition strategy. There is an imbalance between the motivation of the food industry that depends on increasing food consumption for its products and the desire to shrink portion sizes and slim down the population. This conflict has to be resolved through incentives or disincentives because that is the only thing that really seems to work in a free society. It is difficult to persuade people to give up food addiction or habits which have been instilled in childhood

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium and which they have lived with all their lives. I have seen that in different cultures that live in the United States which follow their dietary patterns faithfully from childhood. Could we consider a tax on calories? Calories obviously come more from fat than from protein and carbohydrates, so a tax would be a disincentive to include fat because you would be raising the price of your product. It would encourage the creation of lower calorie products. As fat has decreased in some products, sugars have gone up to compensate for loss of taste. The result is that people who think they are consuming fewer calories because they choose low-fat products actually are consuming more calories because of the fundamental change in the formulation. That would also be overcome by a tax on calories. This could in effect subsidize healthful food but that might introduce a higher level of complexity, and I think most healthier foods can be lower in calories anyway. Dr. Tim Byers: If the goal is simply raising money with a tax on calories, we can do that, and we can raise money. Many small taxes on soft drinks currently raise a lot of money. If our strategy is to begin to tax and manipulate the prices of foods enough to affect healthy eating behaviors, I just can’t imagine that that will be successful. That is too complex and would not get broad public support. I don’t support it, and I am a nutritional public health person. Given the wide range of foods, imposing a tax in order to affect prices that would then in turn affect behavior I think is a losing strategy. Dr. William Dietz: I think that a tax requires several elements that are not in place for obesity in contrast to what is in place for cigarettes. The first is a clear linkage between what you are taxing and its consequences. You can tax tobacco because you know there is a disease consequence. I don’t think there is an adequate evidence base that justifies calorie taxation, anymore than you could justify taxation on the other side of the energy balance equation. I suspect that incentives may work better. Secondly, the one survey I’m familiar with of attitudes of Americans about various steps that could be taken in the obesity epidemic ranked taxes extraordinarily low. On the other hand, we are willing to pay for improvements in school lunches or more parks and recreation facilities. So, although you may think taxes are a good idea, I am not sure that we have an evidence base that supports them or the political will to pass them. Dr. Harvey Fineberg: You made the observation that there is the consensus more on the problem than on the solution or strategy for the obesity problem. We have been talking so far mainly about the food side, the nutrition side, not much about the activity side. From a strategic point of view, is it wise to be thinking about the obesity problem as a kind of energy balance problem which has intake and expenditure simultaneously in mind? If so what strategic implications does that have from your vantage point?

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium Dr. William Dietz: It absolutely is a problem of energy imbalance. One can think about it in terms of increased intake or reduced expenditure. I think there are two distinct strategies here. There is a nutritional strategy, but there is an equally important physical activity strategy. Ironically, even though we know much more about the changes in the food supply that have accompanied the epidemic, we have better evidence about the importance of physical activity to address it. Even though physical activity doesn’t help people reduce weight very much, once their weight has increased it does appear to have a very substantial effect on co-morbidities associated with obesity. So, although we desperately need a food strategy that we can emphasize as much as the physical activity strategy, I think we can say for sure that we need to be promoting physical activity. Participant: I am not oblivious to all the difficulties of doing this, but it seems to me price is used to control purchasing in this society constantly. Small adjustments in fuel prices for example produce hysterical reactions from the public who suddenly find the price goes up at the gas pump. It doesn’t stop them buying the gas, but it does certainly affect them. I think you have to think how we make a choice in buying food, because right now we have a disincentive. Low-fat milk or skim milk is more expensive than whole milk, and so-called “health foods,” or healthier foods, tend to be more expensive. That is working against what we are trying to do. A final point, portion sizes have pretty much doubled during the last 20 years which is the period of the epidemic because food is so cheap and because fast food joints offer, for example, two hamburgers for the price of one in a special deal. Everything is done to encourage over consumption, and very little is done to discourage it. That is really what I am searching for ways to discourage. Dr. Ron Davis: I wanted to make a couple of comments and ask for reactions from the speakers. First, on the point about synergy between tobacco and obesity (including the relationship between smoking and body weight)—one of the biggest problems we deal with in smoking cessation is that people are discouraged by the tendency to gain weight after they quit. One of the points I make in the quit smoking program where I work is that if people can exercise or increase physical activity as they are going through a quit attempt, it will help them avoid that post-cessation weight gain, and secondly, it will help them deal with the stress of nicotine withdrawal. There are powerful ways in which we can combine these two interventions (quitting smoking and increasing physical activity), and I think that this is particularly important because our DHHS guideline on smoking cessation actually states that you are better off not dealing with the weight gain situation with people who are quitting smoking, because they have all they can do to stay off cigarettes without worrying about another major behavioral change. That was the one thing that came out of our DHHS guideline on smoking cessation published in 2000, to which I took exception.

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium can do to align payment with good medical practice will eventually provide more time for physicians to spend with their patients. Dr. Ron Davis, Trustee American Medical Association, Director, Center for Health Promotion and Disease Prevention, Henry Ford Health System: One of my favorite cartoons shows a patient asking her physician, “Hundreds of years of medical progress, and all you can tell me to do is eat less?” I think that is part of the challenge we face in this day of tertiary care and high-tech medicine. Sometimes it is hard to get people to pay attention to and take seriously these important behavioral issues. When they do take it seriously, they want a quick fix—another cartoon I use shows a man at the counter of a pharmacy telling his pharmacist, “I’ll have an ounce of prevention”—but unfortunately it is not that easy. Let me address the questions posed to us for this panel discussion: first, who is responsible for ensuring that graduate curricula and continuing education programs include adequate coverage of cancer prevention and early detection; and second how can we encourage professional organizations and academic medical centers to make this an educational priority. Undergraduate medical education is controlled by the Liaison Committee on Medical Education, which is operated jointly by the AMA and the AAMC, the Association of American Medical Colleges. So that is obviously a leverage point for influencing the curricula in medical schools. ACGME (Accreditation Council for Graduate Medical Education), and the individual residency review committees (RRCs) are the bodies that accredit graduate medical education, so those are additional points at which we can influence national educational policies. Beyond that, we can work with individual medical schools, with individual residency programs, to try to ensure that they address cancer prevention and early detection. A third area for leverage, the first being accreditation organizations, the second being individual residency programs, is through the certification boards (the American Board of Internal Medicine, the American Board of Surgery, and so forth), because they write the exams people take. If you put into the exams questions on cancer prevention and early detection that will encourage residency programs to teach their trainees to master the content of those exams. So, we need to get appropriate questions in those exams. A fourth area of focus is the medical societies. If the American Academy of Family Physicians says that family practice residencies ought to teach something, then the RRC for family medicine will be more likely to put that into accreditation requirements, and the individual programs will teach it. So getting the medical societies on board will be helpful for their policy development as well as the content of their continuing medical education conferences. Next, what leverage points are there for monitoring the performance not only of health care providers, but also systems of health care delivery to in-

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium sure infrastructure and accountability for delivery of prevention interventions? First, obviously again accreditation. One of the other hats I wear is being on the board of the JCAHO as an AMA representative. When the IOM report on patient safety and medical errors came out, JCAHO took that seriously and very quickly put rules on patient safety into its accreditation standards. The IOM report on cancer prevention and early detection didn’t get anywhere near the attention that the one on medical errors did. The impact of the patient safety report (and the publicity surrounding it) is what we ought to be striving to achieve. Through its ORYX (www.jcaho.org/accredited+organizations/hospitals/oryx/index.htm) process, JCAHO is moving towards more outcomes-oriented accreditation standards. ORYX is a series of outcomes measures on which hospitals are examined. Two ORYX measures assess whether smokers hospitalized for myocardial infarction or community-acquired pneumonia receive smoking cessation advice or counseling. In 2002, JCAHO-accredited hospitals began to collect data on standardized (or “core”) ORYX measures, including those on inpatient smoking cessation counseling. This is an example of how our issues can be incorporated into accreditation guidelines. NCQA, the National Committee for Quality Assurance, which accredits HMOs in this country, includes many preventive services as quality indicators in the HEDIS “report card”—mammography; childhood, adolescent, and adult immunization; treatment for tobacco use and dependence; Pap tests, among others. There are probably six or eight preventive services in HEDIS. We also can leverage change in the health care delivery system through coverage and financial incentives. As one example of a progressive policy, Blue Cross Blue Shield of Minnesota is now paying physicians for putting down the ICD-9 code (305.1) for tobacco dependence on claims forms (Manley, 2001). If physicians record that on a claims form, regardless of whether they offer an intervention or treatment, they get a payment. This is an example of a positive incentive. The concern on the part of some people was that doctors would abuse that. That is not happening. Finally, how can state health departments and federal agencies, such as CMS, advance this priority? I’ll make three points in this regard, all pertaining to Medicaid. One is ensuring Medicaid coverage of cancer prevention and early detection. Secondly, related to that is managed care contracting. As you all know, most Medicaid programs are substantially capitated or fully capitated. Through managed care contracting, you can very effectively leverage performance in a particular area. Thirdly, Medicaid can support training and education. In Michigan, for example, our Medicaid program has given a grant to a preventive medicine residency program administered by the University of Michigan School of Public Health. This is part of a Medi-

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium caid initiative a few years ago to fund innovations in medical education. The idea is to fund projects that bring benefits to Medicaid beneficiaries. We argued that this program would train more preventive medicine physicians, many of whom would stay in Michigan and treat indigent patients on Medicaid. That is an example of Medicaid support for training and education, which I think is worth pursuing elsewhere, although given the financial constraints at the state level, which are attributable in large part to Medicaid economics, it is going to be hard to sell. Dr. Robert Smith, Director of Cancer Screening, American Cancer Society: As I looked at this report, I thought, we’ve got this critical need for undergraduate and graduate medical education. The report also emphasizes that quite a few clinicians didn’t have the benefit of exposure to this kind of material. They were already out in practice. So the entire burden of training has rested on CME. By what elective means could this material be included, or not, in education? With mammography, the way training began to take place in residencies was that radiologists got questions on mammography on the radiology boards. Accordingly, it became part of residency training. I note that repeated, heated calls for changing undergraduate medical education to include appropriate and enhanced preventive content have been routinely ignored. The real challenge is how you leverage the importance of training on the key issues that account for five or six of the leading causes of preventive mortality in this country. It seems self evident that it requires considerable leverage with the AAMC. The other thing that offers real potential is the recognition that much of CME in its present form is broken. The common lecture format is largely ineffective, and this is increasingly acknowledged. Also, it isn’t clear what drives the content of a CME course, but some topics are clearly esoteric, and others may be included because they address ways to be more efficient, for example, to reduce office costs or add additional billing. As I review primary care CME, I find it is generally weak in the area of cancer compared with other areas. The important question is whether there should be key content that ought to be included. In lots of areas were we rely on competency, key content is well defined. The FAA, for example, requires commercial pilots to demonstrate competency in key areas of knowledge and proficiency, and these competencies largely define the regular training schedules required by airlines. Could we say that for certain kinds of CME, certain key content, coverage of key topics that affect public health, is required? Then how do we build in incentives for applying this knowledge to preventive care? There has to be an incentive for the physician to assimilate and use the CME knowledge in practice. The incentive to get engaged in smoking cessation, for example, is reimbursement.

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium This CME opportunity arises because the Council of Medical Specialty Societies and the American Board of Medical Specialties have acknowledged that CME is not working and needs to be revamped. They have called for a new design including a commitment to life long learning, periodic self assessment, and demonstrated competence in patient care, communication skills, and medical knowledge. They stress the need to get away from passive lecture-based learning, greater emphasis on self assessment, focused instruction, interactive versus passive learning, and constant feedback. We now need to bring the content of this report to these boards and urge that this content be integrated into the CME structure of each specialty board including primary care. We have an opportunity to build in cancer prevention and detection as part of routine primary care. Dr. Nancy Lee: I’m glad the effectiveness of CME was brought up because that has been my concern. I think people choose it for odd reasons. What is the evidence of the effectiveness of continuing education programs for medical providers? The way it is structured right now, my understanding is that we don’t have a lot of evidence that it is having the effect we want, whether it be in cancer prevention, new treatment for hypertension, or knee surgery. The lecture-based thing in the morning and time off in the afternoon is questionable. I have been depressed in our efforts to train our providers in the cancer screening program on some basic issues about clinical and programmatic policies. We have done a series of telephone in-depth focus groups that sample across the country from our program. We find that our providers don’t really pay much attention to some evidence-based guidelines. That is just an example of how we are not doing a good job in keeping our providers up to date, giving them the tools to move forward and abandon old techniques and move towards new ones in general. Then, how do we get them to help on smoking cessation and diet and exercise? Those are both very difficult areas, and it is something that we really need to take charge of. Dr. Robert Smith: Do you think that the doctors don’t have the cognitive knowledge related to the role they might play in cancer control, or that it simply isn’t applied consistently in the practice setting? Dr. Nancy Lee: I don’t think we physicians have been given lots of skills on how to help people stop smoking and help people to lose weight. Maybe we are not the people to do this. Maybe other health care providers are needed, but in many settings they are not available, and it would be another visit for the patient. We don’t even know how to continually work with patients to get them to the point where they accept going to smoking cessation classes. I don’t think appropriate training is routinely available to many providers, and I don’t think we can get adequate reimbursement either for that kind of work. It’s not a procedure.

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium Dr. Robert Smith: That’s the thing about the Pap smear, for example, it’s a procedure and it’s a paid office visit. One of the problems with asking people to practice evidence-based medicine is that, is some instances, there is a disincentive for their practice to start doing that. We ideally would have something to replace it with. Also, the office usually isn’t even set up to do it efficiently. Clearly a lot of counseling doesn’t have to be done by the physician. Participant: So how does the physician get the patient to those ancillary services? Dr. Len Lichtenfeld: Is the actionable item to change or influence the paradigm of care so that the physician and the healthcare system find other ways of empowering other people in the system to engage in this process, to help make it a reality? Is that going to be part of the solution, instead of the doctor having to do everything all the time? Dr. Ron Davis: I would agree with that. I think the strategy will be different, depending on what kind of medical practice you are talking about. The solo practitioner is in a different situation than a 400-physician group practice. More doctors are becoming part of group practices, and we have potentially much more leverage with them than with individual practitioners. For example, when I got to Henry Ford Health System in 1995, we had an 800-member Henry Ford Medical Group. At that time they got bonus pay determined by various performance indicators. Those indicators were mostly financial, like hospitalization rate and length of stay, and there were no quality-of-care indicators, much less preventive services indicators. I was pushing for those, and fairly soon we ended up having some, at least for pediatricians and family physicians. There was one for pediatric immunization rate, for example. With medical groups, if we can get these indicators into performance measurement, then people will pay attention to them. Physicians will often find someone else in the office to implement a preventive service. That’s easier with a large group practice, but with the solo practitioner, or with two or three docs in small offices, it is much more difficult to get these things done. Participant: You mentioned NCQA and HEDIS earlier. What opportunities do we have to partner with managed care organizations? What are they doing now in anticipation of HEDIS and colon cancer screening down the road in 2004? Dr. Ron Davis: I think there is a lot of truth to that—what gets measured, gets done. I have seen that in my own institution, and I have heard it from others. If a new measure is added to HEDIS and others rotated out, then that determines the priorities in the quality improvement program. So, there is a lot of opportunity, when you see a HEDIS measure like that one coming down the pike, to partner with managed care organizations in a par-

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium ticular community or at the national level with a large health plan such as UnitedHealth, which invests a lot of money in quality improvement. Dr. Sandra Reed: In our four-physician practice, for the last six months we have had a weight loss program that is performed by our two nurse practitioners. We identify patients and refer them to our nurses. They have more time than we do to spend on the counseling sessions and follow-up visits with these patients. So, I think physicians are willing to implement these things, but I don’t think we have done a good job in educating them in how to do it. Dr. Hal Sox: It is relatively easier to change a big practice like Henry Ford, because it can afford the support personnel to implement system change and the information systems to monitor practice. A small practice can’t afford any of these necessities of 21st century medicine. I see helping the small practice to make system changes as one of the great challenges for medicine. Dr. Sandra Reed: I think the biggest obstacle is helping them to identify the systems that need to be implemented and helping them to have a way to implement these systems. A lot of small practices are not computerized. Although they are going in that direction, they have not yet made the investment because it is costly. Our practice is undergoing right now a $250,000 upgrade in our computer system. We were able to do some of these things, but that was a big chunk of change for us. In five years the system will probably be antiquated. It is just extremely costly for small practices to be able to establish the kind of infrastructure within their practice to handle these data. Dr. Len Lichtenfeld: Let me share a personal observation, having been an oncologist and a primary care internist, in reverse. I had a little piece of paper on my chart. It cost me maybe a penny or two to Xerox the thing, and I would check off what I thought somebody should be having over time. Some of my patients had many pieces of paper. I knew when they had their Pap smear, their sigmoidoscopy, or when they had whatever exam they needed to have on a preventive basis over time. I think that every patient chart could have that piece of paper in there, checked off, and updated. Every time that person walks in the office, they should be checked. The problem is the people that don’t walk in the office, that is where we fail. We were not delivering preventive services then that we knew people should have. Reminder systems can get built in; I think there is that opportunity. But, right now, as things have transformed, there is no time. Time has become a very precious commodity. I commented this morning that 7.4 hours a day of a provider’s time would be taken to deliver all the preventive services that we think people should have. It is overwhelming.

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium Dr. Joseph Lipscomb, NCI: I think there was some mention this morning of evolution towards a consensus statement on preventive activity. I think I heard it involved the ACS, the American Diabetes Association and maybe the American Heart Association. How is that consensus going to be arrived at? Are you thinking about this as a small concise set of guideline statements that people can take in quickly and support the provider’s decision making process in the practice, and be time efficient? I assume that is what this is guiding us toward. Dr. Robert Smith: When you look at commonly recommended preventive health behaviors and guidance related to physical activity, maintaining a healthy weight, and nutrition, these recommendations are associated with lower risk for a number of chronic conditions, and therefore organizations focused on cancer, heart disease, and diabetes clearly have an opportunity to promote a broader benefit than may be apparent to the public if we focus on just one disease at a time. Also, each of these organizations represents conditions for which periodic testing for early signs of disease is recommended. I think the three organizations have come together, recognizing that they have common interests, and they ought not to be competing for physician and individual’s time and attention. They should have a simple message to the public about maintaining healthy weight, engaging in physical activity, and getting various tests for early detection of chronic conditions at whatever periodicity the evidence justifies. That seems pretty straightforward, but on the other hand, there is going to be a demand for the underlying evidence-based logic for what happens in those encounters with physicians, their periodicity, and, most important, evidence of cost-effectiveness. Therefore, we are pulling a group together to work through the literature on recommended preventive health measures and model age-specific periodicity and potential findings that could support a return to a model for periodic checkups, since we abandoned the every-year check-up, and haven’t replaced it with anything. Right now, it’s pretty much what we and the doctor decide, so some people get regular checkups and other people never get checkups. I believe that it is likely that encounters for the purpose of preventive medicine could be supported at some age and gender-specific periodicity, but it is important to determine whether or not there is evidence to support an alternative model for periodic health encounters. Dr. Joseph Lipscomb: What’s the time frame for this evidence review? Dr. Robert Smith: The game plan right now is to try to get going as quickly as possible, making calls to the experts in the field that have been thinking about his issue, in particular some representatives from the USPSTF. Rather than come out and say this is the right thing to do, we would say here is the evidence for what is the most cost-effective thing to do, provided, of course, that the evidence is there. In the discussion this morning, people frequently talked about helping people to lose weight. But

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium normally you don’t get counseled about obesity until you are obese. We first need to have those messages when you’re a young adult and have gained five pounds beyond your weight when you graduated from high school. Participant: I spent the last four years building a suite of software programs ready to use in the physician’s office, or for that matter in the corporate environment, which empower the individual to retrain and also provide the physician with a quick way of directing someone into a program that they can follow and which could be individually modified. Furthermore, the programs incorporate tracking systems so you can remotely monitor whether a person has been using a program, what their weight is doing, on a graphic display. They allow for the empowerment of both the patient and the physician and permit a continued exchange so you could follow whether patients are doing what’s been assigned. If they are making progress, they could be encouraged or if not, challenged in some other way. I think the use of the internet to interact with the patient in ways much of which are automated, is something interesting, and something I’ve thought a lot about over the last four years. Dr. Ron Davis: Dentists and veterinarians have done a better job than we have in medicine in utilizing recall and reminder notices, although in some instances, like childhood immunization, we are starting to improve. Our goal should be to do recall for all those who miss an appointment and to send reminders to patients for all upcoming appointments. But short of that, whenever patients contact the health care system, we ought to check to see what they are due for or what they are overdue for. Here is where informatics strategies are key. If someone calls the doctor’s office because he or she has abdominal pain, or if a patient goes to the emergency room, at that point the provider ought to pull up the patient’s medical record on the computer which will use software intelligence to indicate whether the patient hasn’t had a mammogram in so many years or is due for this or that check. Some health systems are moving toward that, but we still have a long way to go. That is something we should work toward. Dr. Robert Smith: I agree. Also, it seems to me there is the additional problem of role ambivalence. We talked a lot this morning about patient demand. Maybe in many settings physicians are waiting for patients to ask for something; in other settings—in almost all settings perhaps—the patients look to physicians to advise them what to do and what not to do. What we want to do is create a model for what each group can expect from the other. The demand side can really bring about a lot of change. We have very good examples of that. So the more patients start asking for something, the more physicians are revising their standard of care, the more they start initiating care they perceive patients desire. We are seeing this in colorectal cancer, a very good example. The likelihood that an individual has been screened is highly associated with having had a checkup. If patients haven’t

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium been screened, it’s usually not for a lot of personal reasons; it’s just because their doctor hasn’t brought it up. Dr. Hal Sox: I would note the research opportunity. I don’t remember seeing a study in which somebody asked patients right after they left the doctor’s office, did you ask the doctor about doing a breast cancer screening? Did the doctor bring up the subject of screening? If not, did you ask about it? It is clear that the public is intensely interested in screening policy. But I don’t think we have a good handle on just how truly activated they are, how willing they are to go and say to a doctor—what about a Pap test? Dr. William Dietz: I’d like to come back to counseling for nutrition and physical activity. I think there are four critical elements in the disease care system—effectiveness, efficacy, bias, and system change. We don’t have proven effective strategies in primary care to counsel on nutrition, physical activity, and some other clinical preventive services. So we can’t very well expect a physician to do something without proven effectiveness, and we can’t expect a physician to do something that that physician doesn’t feel will be effective; there is no self-efficacy. Another problem, once somebody becomes overweight, is that in many quarters obesity is still considered a personal failing. The patients are responsible for this problem, let them solve it. I think that is a pervasive bias throughout society. Finally there is the issue of systems. How can physicians provide sensible nutrition advice? I’m not sure I see that as the physician’s role. I think the role of physicians in obesity care is to initiate and oversee it, but not to deliver it, for all the reasons that we’ve discussed, reimbursement, time, and so on. For example, I don’t even know whether the recommendation for smoking cessation is being commonly implemented in physicians’ offices, and whose responsibility it is and how often it is done. That might be a useful model to think about as an indicator for how far we go to start something for which there is evidence of efficacy and effectiveness, as opposed to obesity, for which we have none. Dr. Nancy Lee: I spend most of my time promoting screening, but I would like to go on record as saying that the really hard work is in primary prevention. Our problem with cervical cancer screening is that at the population level, we may actually over screen. We are getting pretty good at mammography screening. There are disparities, but we are getting there. Colorectal cancer screening, we have a long way to go, but we know what to do. We have got a lot further to go in the tobacco, nutrition and physical activity. I think that should be something that the IOM could spend a lot of time on, rather than tweaking around the edges of something we already know something about, like screening. We need to improve on that, but we actually know those systems, and I think we have a lot more that we don’t know about.

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium Dr. Len Lichtenfeld: I don’t think we do anywhere near the job we should be doing in colorectal cancer screening, given the potential return on investment we have, which is literally right in front of us. Dr. Nancy Lee: We know how to do it, because we have done it. To me, those systems are not too much different than what we have already got in place for breast and cervical cancer screening, but we’ve got really different systems that you are going to need for primary prevention. Dr. Len Lichtenfeld: What is the role of medical schools, what is the role of medical organizations, how do you get the information out there, how do you change the pattern, how do you provide the backup? The IOM report, while perhaps not an indictment, is clearly not an endorsement of our medical educational system. Who fixes it? How does it happen? Dr. Hal Sox: Well, part of the problem is acquiring knowledge, but I would argue that that is probably the smaller part. The larger part is figuring out how to institute system changes in your own workplace, so that the right actions are taken with every patient. Dr. Sandra Reed: I talk to my patients about stopping smoking. They see me once a year and walk out the door, and the next year they come back, and they are still smoking. We need some type of implementable system that can start the ball rolling in your office when you have got them there. Then somebody else has got to do the legwork and follow-up, because I don’t have time. I’ve got the smoke line, the number. You give it to them, and they come back the next year, and they are still smoking. First of all, the patient has to want to stop smoking. We can tell them they need to, but if they are not ready internally, we can send them out the door every year with that 1–800 number, and it is going to go in the trash can. So you’ve got to get the patient ready, and then have the information and the system set up so they can access it and have success. I have written prescriptions for Zyban, and they come back next year, and they are still smoking. It’s the same thing with weight loss. I have talked to my patients over and over about weight loss. We are starting a program now in our office; we have a dietician there who counsels the patient on diet and exercise. But that patient has to be ready to make a lifestyle change. Our environment does not allow that very easily. Our lifestyle—everybody’s lifestyle—is counterproductive to weight loss. It is a bigger thing than just bringing the patients in and getting them set up in a system. When they go into the real world, they have to fight to do the right thing with diet and exercise and activity, because the American lifestyle is not set up for that. Dr. Len Lichtenfeld: So, you would like to see more emphasis on what we discussed earlier, public education, mass media approaches to try to set the stage to make it happen. Dr. Hal Sox: I think Dr. Reed is also talking about implementing effective systems for supporting smoking cessation in a small practice. For exam-

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Fulfilling the Potential of Cancer Prevention and Early Detection: An American Cancer Society and Institute of Medicine Symposium ple, one person in the practice should have the job of talking with a patient who has decided to quit smoking and setting in place a reasonable treatment program and arranging for follow-up care. Dr. Sandra Reed: We need an inplementable plan for follow-up, whether that’s calling every two weeks to ask how is the smoking cessation going, what can we do to help you, or have you used the 1–800 number. We need something that works, that is proven to work, or we are wasting our time, and it’s expensive to have our staff call the patients, especially if you’re not getting reimbursed for it. Dr. Ron Davis: I think accountability gives us the best chance to effect change, but it has to be realistic. We can’t ask for accountability to administer all the services recommended by the U.S. Preventive Services Task Force guidelines, because that could take seven hours a day of a physician’s time (Yarnell et al., 2003). So pick the most important ones from the Partnership for Prevention, working with CDC and others, where they rank the three or four most important preventive services (Coffield et al., 2001), and then hold people accountable for those. Dr. Robert Smith: NCI, CDC, and ACS are working on a book about lessons learned from screening which would define a range of interventions of varying intensity. A practice could decide what’s the least that could be done to improve delivery of preventive care, and what benefits could they expect from the implementation of that new policy or tool.