The AHCPR guideline notes that successful smoking cessation correlates with the intensity of the cessation regimen. In the short term, cessation is associated with lower rates of cardiovascular disease.29 In the long term, cancer risks are reduced dramatically, although some genetic damage does appear to be permanent.30 The Robert Wood Johnson Foundation recently called for proposals to address treatment for tobacco dependence in managed care.31 The Koop-Kessler report notes that ''coverage for tobacco use cessation programs and services should be required under all health insurance, managed care and employee benefit plans, as well as all Federal health financing programs (e.g., Medicare and Medicaid)." The board concurs. Many who quit do so only after repeated attempts, so effective coverage cannot be a one-time benefit but must recognize the cyclical nature of quitting, and health programs must provide coverage for repeat attempts at cessation.

Treatment programs for tobacco dependence should be incorporated into quality of care measures, "report cards" on health plans, and public health performance monitoring.

Assisting smokers with smoking cessation is a powerful intervention for promoting health and reducing dramatically the risk of cancer, heart disease, lung disorders, and other medical conditions. Instruments used to evaluate the quality of health plans and the adequacy of insurance coverage should include an indicator of whether tobacco cessation services are covered. When coverage is included, the effectiveness of the cessation methods needs to be continually measured and reported. This will require ongoing research to improve smoking cessation methods and to assess their cost-effectiveness. The HEDIS measures of health plan quality developed by the National Committee for Quality Analysis, for example, assess whether those enrolled in the plan are advised to quit smoking. Test indicators (provisional measures being evaluated for their usefulness) include how many smokers quit and what fraction of enrollees smoke. These are welcome initial steps, but there is a large gap between rendering advice and affecting quit rates. Access to treatments for tobacco dependence, beyond the general "chemical dependence" measure currently in place, would be a more specific and direct measure. A recent survey of those in health plans asked "Is smoking cessation a covered service in your plan?" and 40 percent of respondents said no; access was higher in staff model health maintenance organizations than in practice associations or network plans.32

Adolescent smokers have proven to be more resistant to treatment than adults, and in research trials they have exhibited higher failure rates than adults. This suggests that among research priorities, aspects of treatment for adolescents (motivation, recruitment, retention, adherence, and the long-term effectiveness of behavioral and pharmacological treatments) should rank high. A recently announced NIH program on prevention and cessation of tobacco use among youths should begin to fill this gap.33

Programs and norms outside the medical care system must also support prevention, cessation, and harm reduction.

Many tobacco users succeed in quitting without a cessation program and without formal care in the medical system. In recent years, nicotine gum and patches have been ap-



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