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Comprehensive Smoking Cessation Policy for All Smokers: Systems Integration to Save Lives and Money

David B. Abrams

Office of Behavioral and Social Sciences Research

National Institutes of Health


Abstract In terms of the end points for cessation policy, three outcomes will reduce overall smoking prevalence: (1) reach and motivate more current smokers to make more frequent quit attempts, especially reaching the underserved; (2) ensure quitters know about and use appropriate evidence-based programs; and (3) enact policy that guarantees continuity of delivery of effective services via a comprehensive system of care management for all smokers. Policies that achieve these three goals will save millions of smokers from premature death and the burden of disease and will also save billions of dollars in excess cost to our nation.


Research provides evidence that effective smoking cessation interventions exist, including behavioral and pharmacological programs able to reach smokers through many delivery channels. Using evidence-based programs significantly increases success, from almost double to as much as fourfold the cessation rate of quitting on one’s own. Yet less than half of current smokers make serious quit attempts annually, and less than a quarter of those that do try will use proven interventions, and over 95 percent of self-quitters will relapse. Weak dissemination of unappealing cessation products relative to the tobacco industry’s marketing, results in many smokers harboring misinformation about the safety and efficacy of treatments with smokers tending to simultaneously believe that new cigarette products may be less harmful.


Having effective cessation programs and services is necessary but not sufficient to reduce population prevalence. The last decade has disproved the adage “if you build it, they will come.” Saving millions of lives and billions of dollars requires nothing short of aggressive, proactive, direct-to-consumer marketing of appealing cessation products. Strong political will is also critical; it is important to put into national policy what is known about effective ways to promote smoking cessation and to support the financial and other resources required to establish a unified delivery system of cessation care management for all smokers.

EXECUTIVE SUMMARY

For a smoker, it is long and arduous journey from starting to smoke to enjoying smoking in ones carefree youth to wanting to stop. For much of that journey, the smoker is not motivated to quit and does not make any quit attempts at all. Somewhere along the way the smoker may change, either suddenly or gradually over time. Smokers can move from being unmotivated and not making any quit attempts to wanting to quit (over 70 percent say they want to quit) and then



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Ending the Tobacco Problem: A Blueprint for the Nation A Comprehensive Smoking Cessation Policy for All Smokers: Systems Integration to Save Lives and Money David B. Abrams Office of Behavioral and Social Sciences Research National Institutes of Health Abstract In terms of the end points for cessation policy, three outcomes will reduce overall smoking prevalence: (1) reach and motivate more current smokers to make more frequent quit attempts, especially reaching the underserved; (2) ensure quitters know about and use appropriate evidence-based programs; and (3) enact policy that guarantees continuity of delivery of effective services via a comprehensive system of care management for all smokers. Policies that achieve these three goals will save millions of smokers from premature death and the burden of disease and will also save billions of dollars in excess cost to our nation. Research provides evidence that effective smoking cessation interventions exist, including behavioral and pharmacological programs able to reach smokers through many delivery channels. Using evidence-based programs significantly increases success, from almost double to as much as fourfold the cessation rate of quitting on one’s own. Yet less than half of current smokers make serious quit attempts annually, and less than a quarter of those that do try will use proven interventions, and over 95 percent of self-quitters will relapse. Weak dissemination of unappealing cessation products relative to the tobacco industry’s marketing, results in many smokers harboring misinformation about the safety and efficacy of treatments with smokers tending to simultaneously believe that new cigarette products may be less harmful. Having effective cessation programs and services is necessary but not sufficient to reduce population prevalence. The last decade has disproved the adage “if you build it, they will come.” Saving millions of lives and billions of dollars requires nothing short of aggressive, proactive, direct-to-consumer marketing of appealing cessation products. Strong political will is also critical; it is important to put into national policy what is known about effective ways to promote smoking cessation and to support the financial and other resources required to establish a unified delivery system of cessation care management for all smokers. EXECUTIVE SUMMARY For a smoker, it is long and arduous journey from starting to smoke to enjoying smoking in ones carefree youth to wanting to stop. For much of that journey, the smoker is not motivated to quit and does not make any quit attempts at all. Somewhere along the way the smoker may change, either suddenly or gradually over time. Smokers can move from being unmotivated and not making any quit attempts to wanting to quit (over 70 percent say they want to quit) and then

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Ending the Tobacco Problem: A Blueprint for the Nation to making serious quit attempts (about 45 percent try seriously to quit each year). If at first a smoker is not successful at quitting (over 90 percent are not), the arduous journey continues with cycles of trying to quit but relapsing to trying again. Some smokers may give up and feel too exhausted or perhaps even a bit ashamed to keep trying or to risk admission of repeated failure to their family, friends, and relatives. All too often a smoker may use unproven treatments or willpower to quit (over 75 percent do that). There are other barriers that a smoker needs to overcome, such as the cost of formal treatment or a lack of ability to discern ineffective from evidence-based treatments. There is no Consumer Reports or Good Housekeeping Award to guide one’s choice of cessation products and services. Perhaps a lucky smoker may eventually quit on his or her own or with the use of an effective cessation product or service. Finally, the journey ends when the smoker either quits for good or suffers and dies from a smoking related cause (about one third to one half of lifetime smokers will die of a smoking-related disease). Now that research has helped us understand so much of this journey, the challenge is to put what we know into practice and policy, and there is not a moment to lose as over 430,000 of our friends and fellow U.S. citizens die prematurely each year from their smoking addiction (that equals three fully loaded jumbo jets crashing with no survivors every single day, including weekends and holidays). There is substantial room to find more leverage points to improve the overall cessation outcome rate at every step of the way along a smoker’s journey to freedom from their addiction. This opportunity can only be fully realized with strong political will to do the right thing by designing cessation policies that support a comprehensive, systems approach to cessation intervention. This approach should provides aggressive, direct-to-consumer marketing and education campaigns to improve smoker’s health literacy about the dangers of smoking and the best tools for quitting. It should also cover the critical leverage points along the entire smokers’ journey, from being a slave to smoking to eventual freedom from tobacco addiction, and should provide interventions tailored to the smoker’s needs. This can be achieved through cessation policies that support a comprehensive care management network as well as cessation policies that ensure adequate resources and aligned financial incentives at federal, state, and local levels across both the delivery systems within the health care industry and across the broader public health system. Effective cessation programs are available but greatly underutilized, despite the social climate that is making it more difficult to smoke (e.g., bans in worksites, higher taxes). Decades of research, clinical practice guidelines, and meta-analyses provide solid evidence of the efficacy and cost effectiveness of smoking cessation interventions. Interventions include behavioral and pharmacological options ranging in intensity and cost from minimal (e.g., self-help) to maximal (e.g., inpatient treatment). Less than 50 percent of the over 45 million current U.S. smokers make a quit attempt each year. Of those that try to quit, over 75 percent do so on their own without evidence-based programs and, of those, over 95 percent relapse. Using even a minimal intensity/brief cessation program generally doubles the likelihood of success. There is also a dose-response relationship such that use of more intensive programs and use of combined pharmacological and behavioral programs can triple to quadruple the likelihood of success. As indicated by the available scientific evidence and computer simulation modeling (see work of Levy, Appendix J, and Mendez, Appendix K), even a conservative increase in the reach (number or percentage of smokers out of all current smokers who make a quit attempt each year) and a modest improvement in effectiveness (percent of smokers who use evidence-based programs and thereby increase their chances of maintenance of cessation) can play a very significant

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Ending the Tobacco Problem: A Blueprint for the Nation role in the mix of policy components that will reduce overall population prevalence. A more aggressive adoption and implementation of known best practices can make an even larger impact, using policies that reach those smokers who are not motivated to quit, those with the greatest health disparities, the highest smoking rates and those with comorbid complications that make treatment more difficult. In terms of policy, an integrated approach is needed at individual and at systems levels that can capitalize on all the proven cessation components and provide a continuum of care that will address the following three goals: (1) Proactively reach more smokers and create strong consumer knowledge, motivation and demand for cessation. Having effective treatment programs is necessary but not sufficient to reduce population prevalence. The last decade has disproved the assumption “if you build it, they will come.” Different smokers’ knowledge and needs must be targeted using social marketing and other behavioral principles and financial incentives. Smokers have misperceptions and gaps in their health literacy about tobacco product safety and about the value, safety, and efficacy of using proven cessation methods. Innovations must be found to specifically target smokers who are hard to reach and hard to motivate (i.e., smokers at disproportionate risk because they are from lower Socioeconomic Status (SES) groups or minorities, are under- or uninsured, have comorbid psychiatric/substance abuse disorders, or are adolescent or young adult smokers). Bio-behavioral vulnerability, cognitive expectations, and emotional and socio-demographic characteristics at individual and aggregate (e.g., community) levels are some of the critical elements that must be considered to ensure more smokers become: (1.a) more health literate about why and how to quit, (1.b) more motivated to make more frequent quit attempts, and (1.c) more likely to use their knowledge to choose and use the appropriate evidence-based treatments when quitting. (2) Make the full range of proven cessation treatments accessible and freely available in a coordinated, aligned delivery system of comprehensive care management. It is essential to: (2.a) establish and enforce policies for universal financial coverage of evidence-based cessation treatments; and (2.b) ensure service capacity is flexible, accessible, and meets the diverse needs of different smokers to use the appropriate type, intensity, and mode of treatment. A comprehensive care management system means that each smoker will receive continuity of care based on screening and triage into a level and type of treatment that meets their needs to enable smokers to receive the appropriate treatment (e.g., a Stepped Care approach; see Abrams et al. 1993;1996;2003, for details). Treatments can range from minimal/brief intensity (e.g., over the counter nicotine replacement, self help, or Internet-based interventions), to medium intensity (e.g., proactive telephone/brief primary care/managed care-based interventions), to maximum intensity (e.g., outpatient and inpatient multi-session clinical care delivered by specialists trained to treat severe nicotine addiction and comorbid psychiatric/substance abuse disorders). (3) Establish a coherent, unified national policy for the integration of all the effective components that enhance cessation into a comprehensive system of care management.

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Ending the Tobacco Problem: A Blueprint for the Nation Systems integration is arguably the single most critical missing ingredient needed to maximize the as yet unrealized potential to significantly increase population cessation rates. Systems integration includes: (3.a) putting what is known into widespread practice and policy and overcoming the barriers to implementation at every level (national, state, and local) of organizational systems structure, (3.b.) achieving continuity of care delivery via the alignment of the organizational infrastructure and the financial incentives within which health care and public health services are delivered, and (3.c) using quality indicators to ensure fidelity in the adoption and implementation of best cessation practices and continuous quality improvement based on measurable indicators. Key indicators for improving the fidelity of care include: surveillance; program, process and outcomes tracking measures as well as use of public access “report cards” to enhance consumer choice and to improve accountability across providers and their health service delivery organizations. Since smoking is an addiction (a chronic, refractory, relapsing condition), for many smokers effective intervention requires a proactive and coherent strategy of strong care management—the same kind of “chronic disease care management” model being adopted for other expensive life-threatening conditions like diabetes and hypertension. An integrated system of care management with appropriate and aligned financial incentives must become part of the fabric of health care, public health, and policy at local, state, and national levels. An adequately financed system of care must be put in place and must be sustained over decades to cumulatively accelerate the trajectory of smoking prevalence reduction in the entire population within our lifetime. While much is known about each of the successful components that will increase cessation rates, what is lacking is the integration of all the components to support a continuum of care management services. In many respects the single most critical issue for increasing population cessation rates lies in a lack of full “systems integration” of cessation tools and services that are already well known to be effective. Systems integration implies using the integrated knowledge base that we already have to inform the establishment of an overarching policy or set of policies. These policies must, in turn, support a comprehensive, seamless system of intervention care management at every level of societal structure (i.e., governmental, private sector, state and local public health, health care stakeholders, and delivery systems). A comprehensive system of care management will require policies that align incentives, resources and political will for the greater long range good of improving the nation’s health. Full implementation of a comprehensive, integrated “systems approach” to smoking cessation can significantly accelerate population prevalence reduction, saving lives and money. Policies are urgently needed that will result in increases in: (a) all smokers’ interest in and motivation to quit but particularly targetting the underserved and those with comorbid conditions; (b) smokers’ health literacy about the range of safe and effective treatments available and how best to use them; (c) smokers’ demand for and use of proven cessation interventions that are tailored and targeted to their specific profiles; (d) maintenance of cessation (reductions in relapse rates); and (e) access to affordable treatment by restructuring the health and health care delivery systems via aligned financial incentives and policies that support continuity of care as well as the screening and delivery of comprehensive services at federal, state, and local levels (a system of comprehensive care management). The major components of cessation treatment products and services are based on solid scientific evidence. Saving millions of lives and billions of dollars requires nothing short of strong political will to put into national policy what is known about effective ways to promote smoking

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Ending the Tobacco Problem: A Blueprint for the Nation cessation and to make the financial investment required to support a unified system of cessation care management for all smokers. REVIEW OF EVIDENCE This appendix is structured into five sections, which focus selectively on the following areas: Overview and rationale for investing in smoking cessation. Understanding of smoker characteristics to reach more smokers and increase demand for cessation. Evidence for efficacy and effectiveness of cessation interventions. Future directions in cessation research and implementation. Systems integration to increase the cessation rate and the trajectory of reduced prevalence. SECTION 1 OVERVIEW AND RATIONALE FOR INVESTING IN SMOKING CESSATION There are still over 45 million smokers in the US, comprising about 23 percent of the population (CDC 2004b). It is estimated that as many as half the current smokers, over 20 million human beings, will die prematurely of a smoking caused disease (Camenga and Klein 2004). Among the possible investments in preventive or palliative health care services available and reimbursed (e.g., treatment for diabetes, hypertension, cancer), smoking cessation remains one of the most cost-effective interventions per quality-adjusted life year saved (Cromwell et al. 1997; Fiore et al. 2004). Tobacco related diseases are costing over $150 billion each year (CDC 2002) and reduce life expectancy by about 14 years (CDC 2002). While primary prevention of smoking initiation among future generations will have a long term societal benefit, for the immediate future an urgent, aggressive, and vigorous effort directed at helping all current smokers to achieve lifelong cessation will save many lives and much money. Levy and colleagues (2000b), using a simulation model, projected that even if 100 percent of smoking initiation by all youth under 18 years of age was prevented, it would still take decades to reduce smoking prevalence by 50 percent if cessation rates remained at current levels. In another simulation model, Mendez and colleagues (1998) reported that if adoption of smoking at age 18 years remained constant at rates of 20, 25, 30 or 35 percent, then overall population prevalence of smoking would reach a steady state by 2045 of 12.2 percent, 15 percent, 18.4 percent, and 21.5 percent respectively. Another reason to increase cessation is that it will save millions from premature disability and save money. As already demonstrated in California, cancer rates, heart disease, and savings in health care expenditures can be achieved by reducing smoking prevalence (Fichtenberg and Glanz, 2000: Warner et al. 1995; 1999). Nationwide, the overall cancer death rate in the United States has begun to fall for the first time in recorded history, primarily because of reductions in incidence and prevalence of lung cancer. These reductions are a direct result of smoking rates having declined from over 45 percent in the 1960s to under 23 percent in 2003 (CDC 2004a; Cole and Rodu 1996). In fact, Thun and colleagues (2006) reported that about 40 percent of the contribution to overall cancer deaths comes from the dramatic reduction in smoking prevalence since the 1960s. There are other direct and indirect benefits to increasing the cessation rate at the population level. The following benefits are briefly noted. Accelerating smoking cessation among adults

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Ending the Tobacco Problem: A Blueprint for the Nation will, in turn, reduce the number of role models who smoke, the number of children at risk for taking up smoking, the damage to the unborn fetus from maternal smoking during pregnancy (Buka et al. 2003), the amount of second hand smoke exposure to nonsmokers of all ages but especially to children, the risks and damage caused by fires from cigarettes, losses in productivity and absenteeism at work, and other direct and indirect costs of smoking and of passive exposure in terms of health and well being. SECTION 1 SUMMARY Increasing cessation rates to dramatically reduce population prevalence of smoking is possible but challenging. If an aggressive and immediate investment is not made in cessation interventions and policy, the consequences are devastating in terms of lives lost prematurely, reduced quality of life, and hundreds of billions of dollars in unnecessary expenses. Thus much more must be done to increase cessation among current smokers if a dramatic reduction in population smoking prevalence is desired and if millions of current smokers’ lives are to be saved. Failing to act now to implement a nationwide comprehensive smoking cessation system of care is an extraordinary opportunity lost, with devastating consequences. SECTION 2 UNDERSTANDING OF SMOKER CHARACTERISTICS TO REACH MORE SMOKERS AND INCREASE DEMAND FOR CESSATION As outlined above, from a systems perspective, full impact of cessation interventions on the intended target population is a product of the proportion of the population reached and the efficacy of the intervention delivered to them (Impact = Reach × Efficacy; see Abrams et al. 1993; 1996; 2003 for details). There are several ways to improve reach and efficacy from both individual and systems levels of intervention. Glasgow and colleagues (1999; 2003; 2006a) have expanded the concept of impact in their RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) model to include the individual and systems level considerations that reflect the need to measure and improve the fidelity of adoption and implementation of interventions, using measures of key indicators of quality and integrity of program, process, and outcomes evaluation at both the individual level and the delivery system level (see Abrams et al. 1993; 1996; 2003; Dzewaltowski et al. 2004; Glasgow at al. 1999; 2003; 2006a for more details). This section is focused primarily on the issue of reaching diverse groups of smokers, designing programs and services that can anticipate their needs, and planning for the increased demand for resources assuming that we are able to reach more of them and increase their motivation to make quit attempts. Individual Bio-Behavioral Vulnerabilities and Demographics There are a number of important individual and aggregate (i.e., group or population level) smoker characteristics associated with differences in smoking prevalence, motivation to quit, and with some cessation outcomes. Some of these factors are important in considering how best to reach more smokers, motivate them to try to stop smoking—and encourage them to use the best interventions available to ensure success—such as to reduce the high rates of relapse after quit attempts. Selected factors are briefly reviewed here to support the major recommendations of this appendix. A comprehensive critical review is beyond the scope and space limitations of this report. Factors include gender, education, income, SES, racial and ethnic background, and age.

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Ending the Tobacco Problem: A Blueprint for the Nation There are also differences among subgroups of smokers in bio-behavioral variables such as their susceptibility to and their level of dependence on nicotine; the pattern of smoking over the years that they smoked; their motivation to quit; and their knowledge about the risks and benefits of smoking, the value of using smoking cessation programs, as well as the types of treatments available and how best to use them. Dependence is defined by the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM IV-R) (APA 1994) using a fixed set of symptoms. Depending on the number of symptoms used to define dependence (Piper et al. 2006) and the response bias in the population of smokers surveyed, the percentage of dependent smokers can be as high as 87 percent (Hale et al. 1993). Withdrawal symptoms are also related to severity of dependence, and these symptoms may increase temptations to smoke to alleviate the withdrawa,l especially in the first 30 days after cessation. Although a “cut point” for dependent versus not dependent is useful for some purposes, it is widely accepted now that there is an underlying continuum of dependence, from mild to severe (Shiffman et al. 1998) among all smokers. Greater nicotine dependence is related to lower motivation to quit; increased difficulty in trying to quit smoking; failure to quit; increase in prevalence of psychiatric of substance abuse comorbidity (e.g., depression, alcoholism) and, in some studies, to better treatment outcome with nicotine replacement therapy (Hughes 1996; Shiffman et al. 1998). However, it is important to note that nicotine replacement, evidence-based behavioral treatments, and now other pharmacological aids (see later in this appendix) increase all smokers’ chances of quitting, regardless of level of dependence. The PHS (public health service) guideline therefore recommends that all smokers be advised to use nicotine replacement therapy (NRT) and other evidence-based treatments when trying to quit, except when nicotine replacement is contraindicated, such as during pregnancy or immediately post myocardial infarction (Fiore et al. 2000). A detailed review of gender and smoking is beyond the scope of this chapter. The U.S. Surgeon General (DHHS 2004b) reported that since 1980, 3 million women have died prematurely from smoking related disease. Women differ from men in their biological responses to nicotine (Perkins et al. 1999). Some studies support the hypothesis that women have more difficulty quitting than men while others do not (Killen et al. 2002; Wetter et al. 1999). Sex-specific variables such as concerns about weight gain, stress reduction, and the need for social support may also underlie differences between men and women smokers. Some research suggests physical activity may help women smokers quit (Marcus et al. 1999). A recent report calls for more research to clarify the differences between men and women to improve treatment of women smokers (DHHS 2004). Differences in demographic characteristics are most evident in smoking rates among those at disproportionate risk due to comorbidity (e.g., psychiatric, alcohol/substance abuse), disparities in SES, and among some racial and ethnic minorities. Smoking is over four times more prevalent (43 percent) in adults with lower educational attainment such as a GED than in those with a graduate degree (8.9 percent). Smoking rates are 17.0 percent for Asian Pacific islanders versus 34.0 percent for Alaskan American natives; 11.6 percent for those with more than 16 years of education versus 35.4 percent for those who did not complete high school; 12 percent for those older than 65 versus 29 percent for those 44 years of age or younger (CDC 1998). Augustson and Marcus (2003) defined hardcore smokers as established smokers over age 25 years, smoking 15 or more cigarettes per day and reporting no recorded history of quit attempts. Hardcore smokers make up 17.6 percent of all smokers, are more likely to be male, unmarried, unemployed, and

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Ending the Tobacco Problem: A Blueprint for the Nation have a lower level of education. This hardcore subgroup may be a significant public health challenge in terms of reaching and treating them (Augustson and Marcus 2003). At the state level of aggregation, Utah has the lowest prevalence (12.7 percent) and Kentucky the highest (32.6 percent) an almost threefold difference. Smoking prevalence is also lower than the national average (23 percent) in those states with strong, visible, comprehensive, and sustained antismoking programs (e.g., 16.4 percent in California and 19 percent in Massachusetts) (CDC 2004a). One population-based study suggests that higher smoking prevalence within a state may be associated with lower motivational levels of readiness to quit, fewer quit attempts, and heavier smoking (Etter 2004). Generally, over 80 percent of adult smokers become regular users before the age of 18 years (CDC 1998). There has been a 32 percent increase in youth adoption of smoking between 1991 and 1997 in the United States (CDC 1998) and a 28 percent increase among college students (Rigotti et al. 2000). A unique window of opportunity exists for early cessation intervention among youth and young adults. This younger cohort of smokers has not received attention. Young smokers are a target population that has “slipped through the cracks” between the prevention and the treatment models of intervention (see Appendix D by Flay and Appendixes by E through H by Halpern-Felsher). The past decade has seen numerous studies document strong relationships between smoking and psychiatric comorbidities. Depression, alcohol and other substance abuse disorders, adult attention deficit/hyperactivity problems, psychotic disorders, and anxiety disorders are associated with increased prevalence of smoking (Hughes 1993). One recent population-based study estimated that 44 percent of persons suffering from current mental illness were smokers (Lasser et al. 2000). Smokers with a history of depression are more likely to be diagnosed as nicotine dependent and to progress to more severe levels of dependence than persons without a history, and are less likely to quit smoking (Glassman 1997; Patten et al. 1998). Smoking rates of over 85 percent are observed in alcoholics, opiate addicts, and poly-drug users (Fertig and Allen 1995). More alcoholics die of tobacco-related causes than from their alcoholism (Hurt et al. 1994). Smokers with a history of alcoholism are more likely to be nicotine dependent. Moreover, psychiatric comorbidities, whether historical or current, appear to significantly impede efforts at smoking cessation (Hughes et al. 1995;1996); conversely, quitting smoking may significantly increase risk of relapse to major depressive disorder, at least among those with such a prior history (Glassman et al. 2001). Studies have been conducted on some populations at disproportionate risk, including racial and ethnic minorities, women, older Americans and a limited number on adolescents and young adults (see Appendix P by Wallace). Preventing relapse among smokers who currently make quit attempts will have a very important impact on reducing population prevalence, along with reaching more smokers and motivating them to try to quit. Those smokers with comorbid complications and bio-behavioral vulnerabilities, such as increased dependence, do tend to relapse more often whether they quit on their own or even in formal evidence-based treatment. Although use of evidence-based interventions improves cessation outcomes for all smokers across the board, smokers who do have comorbidity and smoke more heavily generally do not achieve cessation at the same rates as smokers without such additional risks. While there is little evidence in support of treatment “matching” of smoker characteristics to specific treatment components (e.g., depressed smokers do not generally benefit more from cognitive behavioral treatment for depression (Brown et al. 2001), smokers who are at higher risk due to certain bio-behavioral or socioeconomic vulnerabilities may in-

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Ending the Tobacco Problem: A Blueprint for the Nation deed benefit from more intensive, longer, or specialized clinical interventions (see review below of treatment efficacy). In summary, the full impact of cessation interventions on the intended target population is a product of the proportion of the population reached and the efficacy and fidelity of implementation of the intervention delivered (Impact = Reach × Efficacy; see Abrams et al. 1993; 1996; 2003; Glasgow et al. 2003; 2006a,b for details). Thus, in addition to trying to motivate more smokers to make quit attempts, there is an enormous opportunity to further increase cessation outcomes. The vast majority of smokers who do make quit attempts, as many as 85–98 percent in studies of brief and self-help interventions, will relapse. As reviewed below and in subsequent sections, few smokers know about treatment efficacy, few use any treatments at all, and those who do use an evidence-based program may not use or have access to the best programs to address their individual vulnerabilities. Consequently, overall cessation can be improved by increasing the interest and motivation of smokers to make more quit attempts and to use evidence-based interventions when quitting to improve the likelihood of cessation and to reduce the likelihood of relapse. Increasing Demand for Cessation One way to increase the overall impact of cessation at the population level is to increase the reach of current interventions using social marketing and other behavioral principles to enhance smokers’ motivation and interest in cessation. The following material reviews some of the factors that, in concert with the socio-demographic and bio-behavioral characteristics of smokers presented above, might be considered in making a case for increasing consumer demand for smoking cessation products and services. Characteristics of smokers and patterns of smoking at individual and group levels need to be considered in any plan for marketing and communications strategies to reach more smokers and to increase their motivation to quit and their demand for use of evidence-based cessation. There is an enormous opportunity for improvement in cessation outcomes by reaching and motivating many more smokers to make quit attempts each year, by encouraging the use of proven cessation programs when trying to quit, and by targeting those with disparities in smoking rates and comorbidities. Increasing smoker motivation to make more quit attempts requires a multi-pronged set of intervention strategies targeted at multiple levels: (1) at all nonsmoking individuals and at smokers (e.g., increasing their health literacy, correcting misperceptions about smoking, and disseminating the facts about the safety and efficacy of cessation programs); and (2) at multiple systems levels of social and environmental structures and policies that can make smoking behavior more difficult and quitting easier at the peer, neighborhood, community, state and national levels (e.g., homes, schools, workplace bans; mass media campaigns and free OTC-NRT [over-the-counter nictotine replacement therapy]; tax disincentives). Individual Level Social marketing principles include the tailoring and targeting of campaigns to specific audience characteristics. Social marketing approaches would conceptualize smoking cessation programs as an attractive line of “products” that must be appropriately priced, packaged, positioned, and promoted in a competitive marketplace. In addition to the socio-demographic and bio-behavioral characteristics of smokers reviewed above, a number of other considerations may be

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Ending the Tobacco Problem: A Blueprint for the Nation useful to improve the marketing and the reach of existing smoking cessation programs and services. Effective social marketing to increase consumer demand must be driven by solid and appropriate social marketing principles, theories, and evidence. The marketing approach includes a number of elements such as understanding of each target audience’s needs, characteristics, and perceptions including, for example, the accuracies and inaccuracies in smokers’ knowledge of tobacco use and cessation and various approaches to risk perception, motivational enhancement (see Emmons 2003), and economic incentives. About 43 percent of smokers make a quit attempt per year (Hughes et al. 2003). Thus, although over 70 percent of smokers say they intend to quit, 57 percent do not do so in a given year. Of those that make a quit attempt, some studies report that less than 20 percent of quitters use proven treatments, and relapse after an unaided quit attempt is more than twice as high as when a proven treatment is used (Zhu et al. 2000). Moreover, of smokers motivated to quit, 78 percent believed they were just as likely to quit on their own as with cessation intervention assistance (Zhu et al. 2000). Those participants who did believe cessation methods were effective were more likely to intend to quit (OR 1.8), make a quit attempt (OR 1.8), and to use intervention assistance when quitting (OR 3.62). Zhu and colleagues (2000) also reported that smokers who used an intervention (self-help, counseling and/or NRT versus those who quit on their own were twice as likely to succeed (7 percent vs. 15.2 percent), abstinent at 12-month follow up) and that heavy smokers were more likely to use assistance than light smokers, women more than men, and older more than younger smokers. Thus, there is an enormous opportunity to increase population prevalence of smoking cessation by reaching and motivating the 57 percent of smokers who currently make no quit attempts per year. Among those who do make a quit attempt, their success rate could at least be doubled for those 80 percent who quit on their own if only they used an evidence-based intervention. Reaching and motivating more smokers to make quit attempts each year and having them use proven treatments when they do quit would dramatically increase population cessation rates nationwide. Some smokers come into treatment due to pressure from others. Motivation is best when it is intrinsic (comes from the smoker him/herself) and is tied to a realistic evaluation of the benefits of stopping versus the benefits of continuing to smoke (Curry et al. 1991; Curry et al. 1997). When a smoker is not really ready to quit and lacks self-confidence to try, then it is neither surprising that he or she will fail to quit when asked to try nor that the treatment provider will become discouraged from advising him/her to quit again in the future. Both smokers and their providers often have unrealistic expectations (Abrams et al. 1991; 1993; 1996; 2003). The mismatch between smoker readiness (not ready) and provider enthusiasm (you should quit today) is most evident in settings that require a provider to proactively reach out to smokers who are not seeking treatment for their smoking. Such settings include non-volunteer populations such as all the smoking members of a managed care organization, a worksite, a hospital, or in a substance abuse rehabilitation program (Abrams and Biener 1992; Abrams et al. 1993; 1996; 2003). The Stages of Change (SOC) model (Prochaska and Velicer 2004) lends itself to the development of interventions that are tailored to the smoker’s motivational readiness to change. The SOC model also provide a useful roadmap for smokers in that it provides milestones (pre-contemplation, contemplation, preparation, action, maintenance) and guidelines for processes used at every phase of the journey from smoking initiation to various patterns of use to various efforts at cessation, relapse, and recycling to the ultimate success of permanent maintenance of cessation. Both smokers and the health delivery systems (public health and health care) can

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Ending the Tobacco Problem: A Blueprint for the Nation therefore use metaphors such as the journey from smoking to cessation to develop interventions that take into account continuity of care and the need for a systematic and dynamic approach to management of the cessation process (chronic disease management model; see further in this appendix as well as Abrams et al. 2003). Population surveys show that only a small minority of current smokers (14–28 percent) is motivated to quit in the next 30 days (Abrams and Biener 1992; Velicer et al. 1995). Members of managed care groups such as Health Maintenance Organizations (HMOs) have higher levels of motivational readiness than the general population, with as many as 70 percent planning to quit within 6 months (Hollis et al. 1993). Wewers and colleagues (2003) measured the distributions by readiness to change. Desire or intention to quit, using the Stages of Change measure, was examined from data collected in 3 Tobacco Use Surveys (1992–1993, 1995–1996, and 1998–1999). Results indicated a similar distribution across all three time points indicating very little movement in the stages of readiness to change in the U.S. population during the 1990s. The percent in each stage was 59.1 percent in pre-contemplation (not seriously thinking of stopping within the next 6 months), 33.2 percent in contemplation (planning to stop in the next 6 months but not in the next 30 days or planning to stop in the next 30 days but made no quit attempts in the past 12 months), and 7.7 percent in preparation (planning to stop in the next 30 days and made a quit attempt of at least 24 hours duration in the past 12 months) (Wewers et al. 2003). However, Etter (2004) reported that there was an association between smoking prevalence and stages of change in the United States across the 50 states, such that a higher prevalence of smoking was associated with lower motivation to quit, fewer quit attempts, and higher cigarette consumption. Among youth 55 percent of middle school students and 61 percent of high school students said they wanted to stop smoking, and overall 59 percent of current smokers reported they had tried to stop smoking in the 12 months preceding a national Behavior Risk Factor Survey (CDC 2001). Among middle school students, 80 percent thought secondhand smoke was harmful to them while 89.8 percent of high school students thought secondhand smoke was harmful to them. Research also indicates that 24 percent of young girls aged 12–18 years believed that they could stop smoking whenever they wanted to even if they smoked regularly, and this myth was even more prevalent among girls who were already smokers (41 percent) (Portor Novelli Communication styles 2002). The PHS clinical guide (Fiore et al. 2000) does recommend motivational enhancement interventions for individual smokers who are not motivated to quit (for more details on motivational factors see Emmons 2003). Moreover, the PHS guide (Fiore 2000) recommends that smoking status and then intervention (the five A’s) be made a “vital sign” along with temperature and blood pressure in all encounters between patients and any aspect of the health care delivery system. Evidence is presented that such a system can increase identification of smokers from 38 percent to over 65 percent in a health care setting and that this, in turn, can also double the cessation rate among smokers from 3 to 6.4 percent. If these PHS guidelines were implemented nationwide by all health care providers and all health care organizations, it alone would dramatically increase the number of smokers reached and provide an opportunity to motivate them, educate them about the best ways to stop smoking, and provide them with evidence-based cessation interventions. Smoking prevalence and patterns of uptake, use, and cessation are also strongly influenced by the advertising and targeted marketing of the tobacco industry. The tobacco industry in the United States spent over $15.15 billion in 2003 on marketing its lethal products (FTC 2005). The tobacco industry continues to aggressively promote smoking with attractive new products, novel

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Ending the Tobacco Problem: A Blueprint for the Nation tire smoker’s journey and provides interventions tailored to the smokers’ needs. This can be achieved through cessation policies that support a comprehensive care management network with aligned financial incentives at federal state and local levels across both the health care industry and the public health system.

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Ending the Tobacco Problem: A Blueprint for the Nation Table A-1 Odds Ratios (95 percent Confidence Intervals) for Efficacious Smoking Treatments Relative to Placebo Gum Patch Spray Inhaler Bupropion Clonidine 1.5 (1.3–1.8) 1.9 (1.7–2.2) 2.7 (1.8–4.1) 2.5 (1.7–3.6) 2.1 (1.5–3.0) 2.1 (1.4–3.2)

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