HELP CURRENT USERS QUIT
More than 50 million Americans use tobacco products regularly, including 44 million who smoke cigarettes or cigars or who use spit and snuff tobacco.27 Approximately 70 percent of smokers express a desire to stop smoking (CDC, 1996). Half attempt to quit each year, but only 2.5 percent succeed (CDC, 1993). At present, approximately 3,000 children and youths start to smoke each day, contributing 1 million new smokers annually (Surgeon General, 1994; IOM, 1994). Even if prevention efforts reduce this figure by 60 percent, the goal stipulated in the settlement each year, the nation will have 400,000 new smokers each year, the majority of whom will become addicted and have difficulty stopping. On top of these compelling public health reasons, there is also a moral reason to intensify cessation efforts: Current tobacco users will be paying the increased prices, and some fraction of that revenue should redound to help them directly.
Dependence on tobacco, including smoking, is a pharmacologically based, behavioral disorder. Treatment is not uniformly integrated into medical practice, and coverage of cessation services is fragmented and incomplete. Addiction to tobacco is a chronic, relapsing disorder; multiple attempts to quit smoking are often required to attain permanent cessation. More than 45 million former smokers in the United States attest to the feasibility of cessation, but the process is difficult. It needs to be made easier, through research and routine integration of cessation services into medical practice.
Effective smoking cessation interventions, as identified by the AHCPR guidelines, should be widely disseminated and incorporated into the standard of practice.
The Agency for Health Care Policy and Research (AHCPR), with cofunding from CDC, has prepared a clinical practice guideline on smoking cessation for primary care physicians and other health professionals. This guideline is based on an exhaustive review of studies performed between 1978 and 1994.28 The American Medical Association used a grant from the Robert Wood Johnson Foundation to disseminate this guideline to 200,000 doctors and is working with the American Association of Health Plans on the guidelines to be used in managed care organizations. These are welcome steps, but implementing the recommendations of the AHCPR guideline will take time and will require sustained commitment until use of the guideline becomes routine. This requires educating physicians and other health professionals as well as incorporating coverage for cessation programs into insurance and health plans. Moreover, guidelines will need to be updated periodically.
Government health programs and private insurance and health plans should cover treatment programs for tobacco dependence.
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-