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Table of Contents

A Joint Message From NCQA and Pfizer 4

A Word About Tobacco Dependence and Smoking Cessation 6

Introduction 9

The Current State of Quality of Care for Tobacco Use and Dependence 15

An Integrated Health Systems Tobacco-Dependence Program 24

Employer EffortGet Ready...Get Set...Get Quit: An Employee Nicotine Cessation Program 30

Principles for Reducing the Burden of Tobacco Use 37

Health Plan: Yes, You Can! 39

State Collaborative Focused on Clinicians 45

Employer-Based Tobacco Policy 51

Smoke-Free Campuses: Policies to Change Social Norm Behavior 54

Special Populations: Pregnant Members & Youth 57

Barriers to Reducing the Burden of Tobacco Use 61

Using the Electronic Medical Record: Smoking as a Vital Sign 65

Tobacco-Use Treatment Training for Clinicians 72

Addressing the Quality Gaps in Reducing the Burden of Tobacco 79

Impacting a State: A Health Plans Multiple Strategies 82

The Value of Effective Tobacco Cessation Initiatives 101

A Look to the Future 107

Appendix 115


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| Q U A L I T Y P R O F I L E S4

A Joint Message From

NCQA and Pfizer

The National Committee for Quality Assurance (NCQA) and Pfizer Inc are pleased to present th

sixth edition of Quality Profiles: The Leadership SeriesFocus on Tobacco Dependence and Smoking

Cessation. Tobacco use and dependence has been a focus of national attention for more than

four decades, yet reducing tobacco-related morbidity and mortality is an ongoing challenge for

individuals, health care clinicians, health care systems, employers, and public health programs.

NCQA and Pfizer hope that this edition of Quality Profiles: The Leadership Series will provide the

reference and direction to implement effective, evidence-based interventions that deliver andsupport effective treatments in tobacco dependence, encourage smoking cessation, prevent

tobacco use initiation, and reduce exposure to environmental tobacco smoke, contributing to the

improved health of the American people.

Despite greater public awareness of the negative health effects of smoking, tobacco use is

still the nations leading preventable cause of disease and death. The list of diseases linked

to tobacco use is expanding well beyond the general health risks of coronary heart disease,

stroke, cancer, and chronic lung disease. As smoking is responsible for over 435,000 deaths and

more than $50 billion in direct medical costs per year, it is time to view tobacco dependence

as a chronic condition and treat it as sucha condition that requires ongoing assessment andrepeated intervention to support users in their extended efforts to quit. In spite of the knowledg

of the immediate and long-term benefits of cessation of tobacco use and the availability of

effective treatments, quality gaps still exist in the health care industry with treating tobacco use

and dependence. We believe treating tobacco use should be a requirement for an acceptable

standard of care.


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A J O I N T M E S S A G E F R O M N C Q A A N D P F I Z E R

By providing practical examples of successful initiatives to serve as models of smoking cessation

interventions, we hope to assist organizations in targeting appropriate individuals, establishing

interventions, changing patient and physician behavior, and evaluating the results of these

efforts. Implementing and maintaining tobacco control initiatives that work and are well matched

to the needs and capabilities of the community are essential to reducing tobacco use on a greater

scale. The purpose of Quality Profiles: The Leadership SeriesFocus on Tobacco Dependence and

Smoking Cessationis to present a single-source publication that summarizes the latest research,reviews barriers to success, addresses quality gaps in care advancement, and provides examples

of successful smoking cessation initiatives.

This issue of Quality Profiles highlights collaborative efforts among health plans, employers,

pharmaceutical companies, health care providers, and others that have launched successful

smoking cessation initiatives.

It is the sincere hope of NCQA and Pfizer that Quality Profiles: The Leadership SeriesFocus on

Tobacco Dependence and Smoking Cessationwill help health care organizations and payers address

the challenges to providing effective smoking cessation initiatives. Treating tobacco use anddependence and integrating smoking cessation into the continuum of health care offers the

opportunity to raise the quality of care in America, improve clinical outcomes, and reduce health

care expenditures.

Margaret E. OKane Joseph M. Feczko, M.D.

President Senior Vice President, Chief Medical Officer

National Committee for Quality Assurance Pfizer Inc


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A Word About Tobacco Dependence

and Smoking Cessation

Steven A. Schroeder, M.D.Department of MedicineUniversity of California at San Francisco

Tobacco use is devastating the health of this nation. Although the good news is we have made

progress in the last few years, the bad news is there are still over 435,000 people dying each year

from tobacco use, and up to eight million are disabled by its effects.1,2The toll is staggering.

Consider that more women today die from lung cancer than breast cancer.3In addition, smoking

among pregnant women is a major contributor to premature births and infant mortality.1We can

do better. We mustdo better.

Tobacco use may begin earlyas a teenage fascination. Adolescents discover smoking at an age

when they do not truly understand its destructive effects or comprehend their own mortality.

Once hooked on nicotine, teens continue smoking into adulthood.

Even when they recognize the need to stop, quitting may seem quite

difficult or even impossible.

Of the 44.5 million smokers in the United States, 70% would like to

quit.2However, each year fewer than 5% of smokers are able to quit

without assistance.2The odds of quitting successfully can be doubled

or tripled if clinicians can recognize and act to address smoking habits

in their patients. Employers and health plans should be included

in this smoking cessation discussion, too. Employer trends toward

smoke-free workplaces along with policies that prohibit smoking on company grounds send clea

messages that smoking is unacceptable. The creation of smoke-free areas has undermined the

social acceptability of smoking, while concern about secondhand smoke has served to counterthe tobacco industrys claims that smoking is a matter of choice. Health plan initiatives that

include financial support to enrollees for smoking cessation counseling and medications are

proving effective as well.

I would like to see smoking become more central to the way we look at health. Tobacco use

needs to be defined as a disease state. Clinicians need to elevate smoking and tobacco use

to the level of a true disease. Similar to diabetes, asthma, and the host of chronic illnesses, if

tobacco use hit the same radar screen as other chronic illnesses, clinicians would focus more

on its symptoms. Defining smoking as a chronic disease state may also negate the stigma that

The central message

for clinicians is that

you have a responsibility

to help your patients

who smoke.


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A W O R D A B O U T T O B A C C O D E P E N D E N C E A N D S M O K I N G C E S S A T I O N

surrounds tobacco use, allowing clinicians to take that first step toward

discussing tobacco cessation with their patients.

We have issues to combat in defining tobacco use as a chronic illness.

There is a staggering gap between the damage that smoking causes

and the amount of resources and attention paid to combat those ills. This edition of Quality

Profilesfurthers the national dialogue on smoking cessation, examining the necessary changes in

health care delivery and quality outcomes.

There are four well-documented strategies to prevent children from initiating smoking and/or

reduce its use among current tobacco users. These four strategies are:

Smokers are price sensitive, especially adolescents

The movement toward smoke-free

workplaces is proving to reduce the effects of secondhand smoke for nonsmokers. Additionally,

this creates a barrier for current tobacco users, many of whom are motivated to quit as smokingbecomes more burdensome socially

Although the tobacco industry spends $15 billion annually in

marketing, national and state resources devoted to counter-marketing are meager. Yet, there

is strong evidence that the counter-marketing efforts in several states as well as the American

Legacy Foundations truthcampaign have reduced the rates of smoking initiation. This

represents a wonderful opportunity for states and public health departments to truly promote

the antismoking message

Some will wish tobecome smoking cessation educators. But, unfortunately, most

will not. Yet there are successful tools available for the bulk of

cliniciansdoctors, nurses, dentists, dental hygienists, pharmacists,

physician assistants, respiratory therapists, and othersto help

smokers quit. They can establish systems in their clinical settings, as has occurred in the

Veterans Health Administration and Kaiser Permanente health care systems. Or, they can refer

smokers to a local quit line that will offer customized counseling to help them quit. A national

number1-800-QUIT NOWwill direct callers to their states quitline

It is tempting to be lulled

by current progress...

Telephone quitlines

work. Although the

number of smokers who

use these lines is small,

their success rates are high.


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Policy initiatives have helped consumers understand the gravity of smoking. The 1998 Master

Tobacco Settlement between the attorney generals of 46 states and the tobacco industry was a

notable opportunity to reduce tobacco use. Unfortunately, little of

the $206 billion awarded to the states has been used for public health

efforts.2The settlement did prohibit advertising targeted to young

people, and made available tobacco industry documents that have

helped scholars understand how tobacco use became so prevalent.2

The United States is approaching a tobacco tipping pointa

state of greatly reduced smoking prevalence. Segments of the

population already show low rates of smoking, including physicians

(less than 2%) and people with postgraduate education (8%), along

with residents from Utah (11%) and California (14%).1

Increasingly,smoking is concentrated in the lower socioeconomic classes, begging for more public health

attention and governmental interventions. Two of the strongest evidence-based tobacco-control

measuressmoke-free public places and increases in cigarette taxeswere successfully driven

by state and community regulations and litigation.1

While reading this edition of Quality Profiles, you will be inspired by the numbers and types

of efforts being made in tobacco use and smoking cessation initiatives. This issue includes case

studies from employers, health plans, integrated health systems, university clinics, clinician

practices, and a clinical guidelines collaborative. Although many excellent programs and projects

are underway, so much more needs to be accomplished.

In 25 years, the damage from tobacco use

(even if everyone ceased using it today)

would still be enormous. As such, legislators,

practitioners, employers, health plans, and

consumers must continue to embrace all

available modes to reduce tobacco dependence

and encourage tobacco cessation.

References

1. Schroeder SA. We can do betterimproving the health of the American

people. N Engl J Med. 2007;357(12):1221-1228.

2. Schroeder SA. Tobacco control in the wake of the 1998 Master Settlement

Agreement. N Engl J Med. 2004;350(3):293-300.

3. Zeller JL. Lung cancer.JAMA. 2007;297:1022. http://www.jama.ama.assn.

org/cgi/content/full/297/9/1022. Accessed April 28, 2008.

Increasing the

baseline quit rate of

smokers to 10%

would prevent 1,170,000

premature deaths.1

Since smoking has been

around for so long and the

damages have been around

equally as long, people

may be blind to the

real tragic outcomes.


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I N T R O D U C T I O N

Supporting theHealth Care Industry

Quality Profiles: The Leadership Series is

the result of collaboration between two

organizationsNCQA and Pfizer Inc

that share a deep and profound interest in

promoting quality health care. This series

of publications is intended to help health

care organizations, clinicians, and other

stakeholders progress along the quality

continuum toward excellent patient care.

There is a national awareness of the health

risks associated with tobacco use and

dependence, yet it remains the leading

preventablecause of death among Americans.

The need to increase our efforts in tobacco

control and smoking cessation initiatives

for individuals, and reach beyond into more

population-based interventions, has never

been greater. This edition has been published

to increase dialogue about this epidemic by

exploring the latest research and trends

for treating tobacco use and dependence,

promoting smoking cessation, prevention

initiatives, and clinician efforts for creating

system-wide policy changes.

Introduction

Quality Profiles: The Leadership Series

The Evolution of Quality Profiles

1999

Quality Profiles summarizes quality improvement activities (QIAs) in

chronic illness, womens health, preventive care, behavioral health,

and service.

2000

Quality Profiles includes more in-depth QIA summaries across the same

health care areas as in 1999, and includes practical tools for quality

improvement.

2003 to 2005

The Leadership Series features expanded discussions, case studies,

and tools for improvement in selected disease states:

Cardiovascular disease (CVD) (2003)

Depression (2004)

Diabetes (2005)

2006

The 2006 edition of Quality Profiles: The Leadership SeriesFocus on

Enhancing Care for Older Adults was developed to address the health

care needs of older adults by exploring the changing portrait of illness in

the context of longer life expectancy, as well as the very nature of aging,

which presents unique challenges and barriers to effective care within thecurrent health care system.

2007

Quality Profiles: The Leadership SeriesFocus on Wellness and

Prevention addressed the growing awareness that promoting health and

preventing disease and disability are as important as providing quality

care after an illness is diagnosed. Decreasing obesity in adults and

children, controlling risk factors for CVD, cold and flu prevention, and

smoking cessation are the topics highlighted in this edition.


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Whats New?

This edition of Quality Profiles

: The LeadershipSeriesfocuses on an orientation in the provision

of wellness and prevention in health care

tobacco use and dependence. Its express

purpose, to provide evidence-based strategies

and practical support to reduce and prevent

tobacco use, departs from the earlier editions,

which focused on particular health conditions

cardiovascular disease, depression, and

diabetes. It also differs from an earlier edition,

which specifically focused on the older adult

population, with its unique challenges and

needs that cut across clinical conditions and

require a broader, more patient-centered

perspective.

This edition gives tobacco use and dependence

the much-needed attention it deserves. It

provides a greater emphasis on what steps

health plans and employers are taking

to promote initiatives that treat tobacco

use and dependence. By viewing tobacco

dependence as a chronic relapsing condition

and emphasizing smoking cessation in the

prevention and management of other major

chronic diseases, we can alter the current

mindset that tobacco use is a choice. In

addition, employers offer another avenue

to reducing tobacco use and dependence.

Employers that promote tobacco-relatedinitiatives realize that earlier identification

and intervention minimizes the likelihood of

expensive complications, and that a tobacco-free

workplace is a healthier, more productive one.

A Snapshot of the Profiles

In Quality Profiles: The Leadership Series

Focus on Tobacco Dependence and Smoking

Cessation, we provide comprehensive

descriptions of six case studies that demonstrat

best practices, along with summaries of

several additional activities. These case

studies address a variety of efforts associated

with tobacco use and dependence such as

smoke-free workplace policies; the role of

electronic medical records (EMR) in elevatin

tobacco use to a vital sign; creation of state-specific clinical guidelines for clinicians;

integrating pharmacist consulting and referral

to quitlines; the need for specialized clinicians

to serve as tobacco treatment specialists; along

with examples of employer, health plan, and

integrated health system initiatives. The case

studies represent successful approaches that

organizations have piloted or implemented

on a broad scale. The case study format

generally includes:

Unique to this years Quality Profiles: The

Leadership Series, each case study includes a

brief section that reflects on the contributors

impression from each contributor grounds the

case study in its effect on the contributing

organization and that organizations efforts to

produce real change in tobacco use.



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Methodology

The initiatives highlighted in this edition

of Quality Profiles: The Leadership Series were

selected based on a review process led by

NCQA staff. With the topic defined, NCQA

convened an advisory panel. This panel

advised NCQA on the current state of the art

in management of tobacco dependence and

provided direction regarding the content and

focus of this QualityProfiles.

in determining the specific content and direction

of this text. Through the advisory boards

recommendation, a methodology was created

to call for case submissions. This edition of

Quality Profiles used a four-step process:

1. Call for submissionorganizations

were encouraged to submit applications

in response to a posting on the NCQA

Web site.

2. Applicationresponding organizations

completed an extensive application.

3. Review and selectionapplicants

underwent a review process for scoring

purposes.

4. Interviewrepresentatives from chosen

organizations were interviewed for further

clarification and to obtain additional

information.

Initiatives selected for inclusion exemplify

quality improvement in reducing tobacco

use and dependence. Chosen organizations

were then interviewed to gather information

on the methodology, barriers, adjustments

to the intervention (if any), and current

status of the initiative. This information was

then integrated to develop the case studies

included in Quality Profiles: The Leadership

SeriesFocus on Tobacco Dependence and

Smoking Cessation.

I N T R O D U C T I O N


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NCQA and Pfizer:The Quality Profiles

Partnership

Quality Profiles: The Leadership Series has been

developed as a useful resource for organizations

undertaking quality improvement activities.

It provides both a clinical rationale for

improvement and examples of challenges

and successes of specific initiatives. The

series is the product of a partnership between

two organizations that share a deep commitment

to advancing quality in health care. The initial

draft of this edition was developed by The

Eden Communications Group, who were

funded by Pfizer Inc. Editorial oversight and

content decisions were the joint responsibility

of NCQA and Pfizer Inc.

NCQA is a private, nonprofit organization

dedicated to improving health care quality.

NCQA accredits and certifies a wide range

of health care organizations and recognizes

physicians in key clinical areas. NCQAs

) is the most widely

used performance measurement tool in

HEDIS is a registered trademark of NCQA.

health care. NCQA is committed to providin

health care quality information through the

Web, media, and data licensing agreements

in order to help consumers, employers, and

others make more informed health care

choices. For more information, visit http://

www.ncqa.org/.

NCQA has worked for 18 years to improve

health care delivery through its accreditation

certification, and physician recognition

programs and the ongoing development of

and

Pfizer Inc is the worlds leading research-base

pharmaceutical company, which partners

with health plans, medical groups, and other

health care organizations to facilitate clinical

excellence and improve patient outcomes.

Pfizer has also long been a supporter of

NCQA and its mission to improve the quality

of health care.



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Acknowledgments

We would like to thank the following people

and organizations, whose dedication to the

delivery of quality health care has made this

edition of Quality Profiles: The Leadership Series

possible.

Participating Organizations

Blue Cross and Blue Shield of Minnesota

Colorado Clinical Guidelines Collaborative

CSX Transportation, Florida

Kaiser Permanente Northern California

Contributing Organizations

Independence Blue Cross, Pennsylvania

University of Pittsburgh Medical Center

Advisory Panel

John Clymer

President

Partnership for Prevention

Washington, DC

Professor

UMDNJSchool of Public Health

New Brunswick, New Jersey

President

University of the Sciences in Philadelphia

Philadelphia, Pennsylvania

Kenneth Glover, M.S., R.C.E.P., C.S.C.S.

Director of Health and Wellness

CSX Transportation

Jacksonville, Florida

Chief of Epidemiology Branch Office

on Smoking and Health

National Center for Chronic Disease Prevention

Centers for Disease Control and Prevention

Atlanta, Georgia

A C K N O W L E D G M E N T S


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Advisory Panel (contd)

Vice President, Chief Medical OfficerQuality

Excellus

Syracuse, New York

Vice President, Chief Medical Officer

Horizon Blue Cross Blue Shield of New Jersey

Newark, New Jersey

Bruce ShermanDirector of Health and Wellness

Medical DirectorGlobal Services

Good Year Tire and Rubber Company

Washington, DC

NCQA Staff Members

Kathleen C. Mudd, M.B.A., R.N.

Vice President, Product Delivery

Executive Vice President

Richard Sorian

Vice President, Public Policy

and External Relations

Elizabeth M. UsherAssistant Vice President, Customer Resources

Pfizer Staff Members

Consultant to Pfizer

Clinical Director

Senior Medical Director


NCQA and Pfizer Inc would like to acknowledge and thank The Eden Communications

Group for assisting in the development of the publication through funding by Pfizer Inc.

Scavone, and Perianne Walter at Eden.


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These efforts are laudable and certainly

an improvement over the past. Yet, thecurrent use of tobacco abatement programs

is well below the goals set by numerous

governmental agencies and expert panels.

Screening for tobacco use, urged for all adults

by the Agency for Healthcare Research and

Quality (AHRQ), has yet to become consistent

clinical practice.5Interventions known to

be effective and recommended by leading

experts are not universally covered by health

plans and employers or implemented by

clinicians.6,7Tobacco prevention initiatives are

losing funding at the same time the tobacco

industry is stepping up marketing efforts

to attract potential smokers.8Aggressive

interventions to prevent and treat tobacco

addiction must continue to be implemented to

address the still-major health threats, as

millions of American smokers and tobacco

users face the damaging consequences of a

lifetime of tobacco addiction and use. For

those who are dependent on smoking, unless

they are helped to quit, half will die from the

consequences of their habit, and they will be

less productive and more disabled while they

are alive.9

T H E C U R R E N T S T A T E O F Q U A L I T Y O F C A R E F O R T O B A C C O U S E A N D D E P E N D E N C E

The Current State of Quality of Care

for Tobacco Use and Dependence

Cigarettes, once images of sophistication and elegance, are now recognized by many, but unfortunately not

everyone, as a cause of serious diseases that exact a high toll on smokers, employers, health plans, and society

as a whole. Employers are increasingly creating tobacco-free environments and offering smoking cessation

programs in benefits packages, and health care organizations are collaborating more than ever with government

agencies to affect larger populations and reinforce efficacy of programs.1,2 There is a general trend toward

expansion of smoking cessation efforts to include population-wide interventions that encompass prevention,

cessation, and reduction of exposure to environmental tobacco smoke (ETS) (Table 1).2At the broadest level,

19 states now have laws mandating 100% smoke-free air in bars, restaurants, and worksites, while all 50 states

prohibit the sale of tobacco to minors.2-4

Table 1.Components of Population-Based SmokingInterventions2

Prevention of smoking initiation

(e.g., implementation of school-based programs for adolescents)

Reduction of exposure to environmental tobacco smoke

(e.g., implementation of worksite restrictions on tobacco use)

Policy changes in health care systems to promote smoking cessation

(e.g., implementation of systems to identify and intervene with smokers

during every health care visit)


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Current understanding of the personal,

financial, and social costs of tobacco use has

spurred the U.S. Department of Health and

Human Services to call for an increase in

cessation efforts in theirHealthy People 2010

objectives.10NCQA supports this goal through

its HEDIS measures that evaluate quality of

care based on the latest research in this field.10

Further, NCQA efforts are also reflected in

its Physician Recognition Programs such as

the Heart/Stroke Recognition Program and

the Diabetes Recognition Program.11Each of

these programs includes criteria for physiciansto measure their performance.

Definition of TobaccoUse and Dependence

Tobacco addiction has been characterized

as the most common chronic disease in

the developed world.12Beginning with

the first puff, smoking disturbs the bodys

natural homeostasis.12Approximately

10 seconds after inhalation, a high-

concentration dose of nicotine reaches

the brain, generating a cascade of effects

in the central nervous system, as well as

exerting behavioral, neuromuscular, endocrine,

renal, metabolic, and cardiovascular changes.12,13

While it alters hormone levels, heart rate,blood pressure, and other bodily processes,

smoking also causes the release of dopamine,

ensuring a reward effect that encourages

continued use.13

Smokeless tobacco elicits similar responses.

While some forms of smokeless tobacco may

be sniffed or inhaled, most smokeless tobacco

users place the product against their cheek or

between their gum and cheek. Nicotine ente

the body directly through the mouth mucosa

lining.13,14

Nicotine is the addictive substance in all form

of tobacco, keeping smokers and those who

use smokeless tobacco in their habit long afte

they want to quit. It has been theorized that

initial motivation for using tobacco is based osocial and other nonpharmacologic rewards.

Over time, the physiologic effects of nicotine

exert increasing control so that later motivatin

factors become the drugs sedative and

stimulatory effects in the brain.13No clearly

defined threshold marks the point at which

tobacco dependency occurs; however, several

clinical measures are used to establish an

addiction (Table 2).12The presence of

withdrawal symptoms is a key measure,


Table 2.Clinical Measures of TobaccoDependency12

Daily tobacco use for several weeks or longer

Evidence of tolerance: increasing amount of

tobacco use with lack of adverse effects

(e.g., no dizziness or nausea from nicotine

inhalation)

Manifestation of symptoms upon withdrawal of

nicotine: cravings, anxiety, irritability, decreased

heart rate, increased blood pressure, difficulty

concentrating, increased appetite, weight gain,

restlessness, and mood changes


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and these make quitting especially difficult.

While some withdrawal symptoms begin

to decline after a few days of abstinence,

otherssuch as cravings, increased appetite,

and impaired concentrationmay persist

for more than a year.12Not surprisingly,

few smokers are able to quit on their own,

often making this dependency a lifelong

affliction.12,13

Rather than quit, some smokers may attempt

to smoke fewer cigarettes or switch to low-tar

products. However, research demonstratesthat there is no safe way to smoke. Even one

cigarette smoked a day causes damage, and

the risk of lung cancer is not reduced among

smokers who use low-tar cigarettes.15

Prevalence of TobaccoUse in the United States

Although most smokers in the United States

want to quit, fewer than 10% are able to

quit themselves, and more than 45 million

American adultsover 20% of the adult

populationcontinue to smoke or use

other forms of tobacco.16-18This is especially

concerning, as it reflects a lack of progress

in reducing the prevalence of tobacco use.

Between 1965 and 1990, early cessation effortssuccessfully reduced smoking rates by 40%.

Yet, over the past several years, rates have

remained virtually unchanged (Figure 1).18


40

45

30

35

*National Health Interview Survey (NHIS) redesigned in 1997; comparisons with prior years should be conducted with caution.

10

5

0

15

20

25

1965 1970 1974 1980 1985 1990 1997* 2000 2001 2002 2003 2004 2005

AdultsWhoWereCurrentSmokers(%)

Year

Figure 1.Adult Smokers in the United States: 1965-200518


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|18 Q U A L I T Y P R O F I L E S

Additionally, 2.2% of American adults smoke

cigars, and 2.3% use smokeless tobacco.19

Young people, who may carry their habits into

adulthood, are faring even worse. Approximately

23% of high school students smoke cigarettes,

14% smoke cigars, and 8% use smokeless

tobacco.20

Among adults, smoking is most prevalent in

those under age 45, individuals with lower

education and incomes, gay men, and some

ethnic minorities (Table 3).19,21The considerable

disparity between younger adults (24%prevalence) and older adults (9% prevalence)

may have many explanations. Over 80% of

adult smokers began using tobacco when they

were teenagers, and younger smokers may be

those who havent yet quit.22Unfortunately,

smokers tend to die much earlier than

nonsmokers, leaving fewer smokers to reach

elderly status.21

Of all ethnicities, American Indians and Alaska

natives have the highest rate of smoking

at 32%.19While African Americans are no

more likely to smoke than nonHispanic whites

(both 22%), they experience higher rates of

smoking-related illnesses, including lung

cancer and cardiovascular disease (CVD).19,21

Reasons for this disparity are not clear.

Table 3.U.S. Adult Smokers bySelected Demographics19,21

Demographic Smoking

Characteristic Prevalence (%)

Age

18-24 24

25-44 24

45-64 22

65 10

Education

GED* diploma 43

High school graduate 25

Undergraduate degree 11

Graduate degree 7

Poverty status

Below poverty level 30

At or above poverty level 21

Sexual orientation

Gay men 33

Lesbian women 25

Sex

Men 24

Women 19

Ethnicity

White, nonHispanic 22

African American, nonHispanic 22

Hispanic 16

American Indian/Alaska native,

nonHispanic 32

Asian, nonHispanic 13

* GED=General Educational Development.


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Although African Americans tend to smoke

cigarettes higher in tar and nicotine and

are less successful in their attempts to quit,

both African Americans and Hispanics tend

to smoke fewer cigarettes per day than

nonHispanic whites.

21

Across all ethnicities,

men are more likely to smoke than women

(Figure 2) and tend to smoke more cigarettes

per day.19,21In fact, the low rate of smoking

among Asians is due to the few numbers of

Asian women who smoke: 21% of Asian men

and only 6% of Asian women use tobacco.

19

40

30

35

10

5

0

15

20

25

White,NonHispanic

AfricanAmerican

Hispanic American

Indian/AlaskanNative

Asian Overall

CurrentSmokers(%)

Ethnicity

Men

Women

Figure 2. U.S. Adult Smokers According to Ethnicity and Sex19


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Morbidity and MortalityAssociated With

Tobacco Use

Cigarette smoke damages multiple organ systems,

making it the single most preventable cause

of disease, disability, and death in the United

States.23,24Beyond causing nearly 90% of all

lung cancers, smoking leads to numerous

other forms of cancer, CVD, aneurysms,

stroke, chronic obstructive pulmonary disease

(COPD), and other respiratory illnesses

(Table 4).15Asthmatic smokers experience a

worsening of symptoms and an accelerated

decline of lung function; further, tobacco use

reduces the efficacy of the corticosteroids used

to treat their condition.25

An estimated 8.6 million smokers currently

live with at least one smoking-related

illness, most commonly COPD (Figure 3).29

Its prevalence is growing. Even though it is

still underdiagnosed, COPD is the fourth

leading cause of death in the United States.30,31

The National Institutes of Health projects that

COPD will be the third most common cause

of death by the year 2020.31Smoking is the

primary cause of this progressive respiratory

disease, which includes chronic bronchitis and

emphysema.31,32There is no known cure for

COPD, and lung function inevitably worsensover time, especially if individuals continue

their tobacco use.31


Table 4.Diseases Caused by Tobacco Use

Smoking15Lung cancer

Cancers of the larynx, mouth, pharynx,

esophagus, bladder, pancreas, cervix, kidney,

and stomach

Some leukemias

COPD

CVD

Aneurysms

Bronchitis

Stroke

Severity of pneumonia and asthma

Emphysema

Smokeless tobacco26

Oral cancer

Leukoplakia (mouth lesions that may become

cancerous)

Periodontal degeneration

Environmental tobacco smoke

CVD27

Lung cancer27

Effects in children28

AsthmaSudden infant death syndrome

Middle ear disease

Pneumonia

Cough

Upper respiratory infections

Abnormal lipid levels

Increased risk of leukemia and lymphoma

as an adult


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Cancer, COPD, and heart disease account for

the majority of deaths related to tobacco use

(Figure 4).23Taken together, smoking-related

illnesses cause significant premature mortality:

every year18

in the United States15

than nonsmokers18

nonsmokers to die from COPD33

smoking triples the risk of dying from

heart disease34

Significant mortality also occurs in nonsmokers

who are exposed to the effects of tobacco.

Every year, ETS causes 3,000 deaths from

lung cancer and more than 35,000 deaths from

CVD in nonsmokers.23Also, over 900 infants

die each year because their mothers smoked

during pregnancy.23

Stroke

17,436 Infant Deaths910

SecondhandSmoke38,112

Other Cancers34,693

Other Diagnoses46,442

COPD90,582

Ischemic HeartDisease86,801

Lung Cancer

123,836

Figure 4.Annual Deaths Attributable to CigaretteSmoking Among U.S. Adults18,23

*COPD includes chronic bronchitis and emphysema.

Hispanic

Lung Cancer

Stroke

Other Cancers

Heart Attack

COPD*

Figure 3. Cigarette-Smoking Attributable ConditionsAmong Current Smokers29


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Economic Impact ofTobacco Use

The economic costs of tobacco use are

also devastating. On a personal level,

smokers spend nearly 10% of their medical

expenditures on smoking-related illnesses.15

Similar data is not available for users of

smokeless tobacco. Expenses for employers

due to death-related productivity losses

amount to $92 billion a year, and direct

medical costs account for more than $75billion annually, for a total cost to the econom

of $167 billion every year (Figure 5).15These

numbers do not account for diminished

on-the-job productivity of smokers, who

have more accidents and injuries, as well as

higher rates of turnover and absenteeism, tha

nonsmokers.35Because the most profound

health effects of tobacco use may manifest at

midlife, workers often become disabled at th

height of their productivity.9

It is important to note that while the

prevalence of smoking has remained relativel

stable in recent years, health care costs

associated with tobacco use continue to

escalate. In 1999, medical and productivity

costs were $7.18 for every pack of cigarettes

sold.17By 2004, these costs had grown

to $10.47 per pack (Figure 6).36

Withapproximately 47.5 million smokers in the

United States, it was recently estimated that

the average tobacco-related health care cost i

$3,400 annually per smoker.17

180

40

60

80

100

120

140

160

20

0

Medical Costs Death-RelatedProductivity Costs

Smoking-Attributable Health Costs

Total

$75

$92

$167

Expensesin

(Dollars)

Figure 5.Annual Smoking-Attributable Health Costs15

10

12

4

6

8

2

0Medical Care Lost Productivity Total

Expense

in

Dollars

Health Care Costs per Pack of Cigarettes

1999

2004

Figure 6. Escalating Health Care Costs Attributable toSmoking: 1999-200417,36


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Related HEDISMeasures and CAHPS

Questions

Reducing the morbidity and mortality of

tobacco use will require broad implementation

of health care protocols that address the

importance of smoking cessation. NCQA

recognized this need by incorporating

relevant quality-of-care standards in HEDIS

measures, both at the health plan and

physician practice level (see CAHPS).The most directly related measures are

within the part of HEDIS represented by

the Consumer Assessment of Healthcare

Providers and Systems (CAHPS). CAHPS

was developed by the AHRQ and has been

adapted by NCQA for use within HEDIS.

HEDIS measures set a standard of care for

health plans to follow across a broad range

of health care services, and CAHPS surveys

assess health care provider performance

from the patients perspective.10In this way,

health plans and providers are encouraged to

implement protocols that ensure quality of

care for everyone.

CAHPS is a registered trademark of the Agency for Healthcare Research

and Quality (AHRQ).



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Background

Steeped in a rich history of foundational

beliefs focusing on prevention and treatment,this large, integrated health system boasts a

comprehensive tobacco-dependence program.

This multifocal effort embraces the shortened

U.S. Public Health Service Best Practice

recommendations from its 2000 Clinical

Practice Guideline.

Similar to other case study efforts, this

program focused on elevating tobacco use

to a vital sign. Instead of an optional pieceof information gathered during a clinic visit,

patients are now routinely asked about their

tobacco use with the response documented in

their respective medical record.

Case Description

Implementing all of the Public Health

Service Best Practice recommendations meanthat multiple efforts had to be effectively

integrated and implemented across a large

segment of the health systems enrollees and

employees. Initiated in 1998 and still ongoing

today, the tobacco-dependence program

employs four main strategies:

1. For patients: routine tobacco use

assessment, counseling, and referrals during

clinic visits; for clinicians: training, audit, an

feedback linked to incentives

2. Enhanced health plan benefits ensuring

access to tobacco cessation medications at

the level of a members pharmacy copay

when the member is participating in any

one of the programs

3. Menu of no-cost tobacco cessation program

for members

4. Work site and community tobacco control

efforts

In addition to these strategies, member

satisfaction is considered an important

measure of program success. Since 2001,

routine member satisfaction surveys include

a question regarding whether the member

smokes and if the member was advised to qu


Case Study: An Integrated Health Systems

Tobacco-Dependence Program

Organization at a Glance:

Organization Type: Managed care organization

Target Population: All product lines

Enrollment: 3.2 million

Location: West coast


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U.S. Public Health Service Best Practice2000 Clinical Practice Guideline

The key recommendations of the 2000 Guideline Treating Tobacco Use and Dependence, based on literature

review and expert panel opinion, includes1:

1. Tobacco dependence is a chronic condition that often requires repeated intervention. However, effective

treatments exist that can produce long-term or even permanent abstinence.

2. Because effective tobacco-dependence treatments are available, every patient who uses tobacco should be

offered at least one of these treatments:

a. Patients willingto try to quit tobacco use should be provided with treatments identified as effective in this

guideline.

b. Patients unwillingto try to quit tobacco use should be provided with a brief intervention designed to increasetheir motivation to quit.

3. It is essential that clinicians and health care delivery systems (including administrators, insurers, and

purchasers) institutionalize the consistent identification, documentation, and treatment of every tobacco user

seen in a health care setting.

4. Brief tobacco-dependence treatment is effective, and every patient who uses tobacco should be offered at least

brief treatment.

5. There is a strong dose-response relationship between the intensity of tobacco-dependence counseling and

its effectiveness. Treatments involving person-to-person contact (via individual, group, or proactive telephone

counseling) are consistently effective, and their effectiveness increases with treatment intensity (e.g., minutes ofcontact).

6. Three types of counseling and behavioral therapies were found to be especially effective and should be used

with all patients attempting tobacco cessation:

a. Provision of practical counseling

b. Provision of social support as part of treatment

c. Help in securing social support outside of treatment

7. Numerous effective pharmacotherapies for smoking cessation exist. Except in the presence of contraindications,

these should be used with all patients attempting to quit smoking.

8. Tobacco-dependence treatments are both clinically effective and cost effective relative to other medical and

disease prevention interventions. As such, insurers and purchasers should ensure that:

a. All insurance plans include as a reimbursed benefit the counseling and pharmacotherapeutic treatments

identified as effective in this guideline, and

b. Clinicians are reimbursed for providing tobacco-dependence treatment just as they are reimbursed for treating

other chronic conditions.


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on his or her last clinician visit. This question

mirrors a CAHPS question regarding whether

a patient received advice to quit smoking

from his or her clinician during a visit in the

past year. Because this measure relies on

patient recall, it implicitly measures whether

the advice given was memorable and, thus,

effective.

Having a fully integrated health system allows

assessments and interventions to occur at

both primary care and specialty care visits.

The clinicians provide routine assessments oftobacco use status, advice to quit, and referrals

to cessation programs. The referrals are to

an array of in-house resources and programs

available to members on an unlimited basis

without charge. Participation in the programs

entitles members to receive tobacco cessation

medications at their copay amount.

Walking-the-talk has led the entire

integrated health system to work toward

smoke-free environments. By 2008, this entir

multicampus organization will be entirely

tobacco free.

Providing support to clinicians, the tobacco-

dependence program conducts quarterly

audits and provides feedback regarding the

clinicians performance in advising smokers

to quit. In the initial implementation years

of this program, it also included an incentive

for clinicians who counsel patients to quitsmoking. As part of a Quality Goal package,

clinicians were encouraged to advise their

patients to quit smoking through a pay-for-

performance model.


61.80%

57.20%

67.00%

68.90%

74.70%75.10%

81.19%

83.00%

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

%M

embersReportingAdviceReceived

1998 1999 2000 2002 2003 2004 2005 2006

Figure 1. HEDIS/CAHPS Performance: Advising Smokers to Quit


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Population

The target population of 3.2 million adult

patients is served by 20 medical centers (with

over 55 sites). Also, the integrated health

system is including its employees through

similar initiatives and campus-wide, smoke-

free environments.

Results

The tobacco-dependence program has

achieved a more than 33% reduction in

smoking prevalence in the adult patients.

Further, it reports a 25 percentage-point

increase in the HEDIS/CAHPS scores on

the advising smokers to quit measure and

a significant increase in tobacco cessation

program attendance and medications use

(Figure 1).

Sustainability

Sustainability is a key to success of any

population-based health program. The

ongoing efforts of this program are managed

through dedicated resources. This integrated

health system has dedicated one regional lead

manager, a health educator, and physician

champion at most of its 20 medical centers.

In Their Own Words

The system reports:

This long-term program has increased

awareness of the unique and powerful position

of medical staff and physicians in encouraging

cessation. Most of our clinicians now feel

empowered to take the step and discuss

tobacco use with their patients since they

know that, not only does their brief advice

statement have an impact, but also that they

are supported by proven programs to helptheir patients quit tobacco.

Future Thoughts

Going forward, the program is looking to

provide more clinician training on medication

management for smoking cessation. As the

population of patients who smoke declines,

the health system may be faced with patients

who are more heavily dependent on nicotine

and who need more intensive interventions to

be successful in quitting.

Conclusion

This integrated health system case study

highlights the multiple efforts underway

to decrease tobacco use. Integrated health

systems have opportunities to impact patients

and clinicians through program delivery

modes, incentives, and barrier reduction.

Please refer to Appendices 1-3 for tools and

resources used by this organization.


Reference

1. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence.

Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and

Human Services. Public Health Service. June 2000. http://www.ncbi.nlm.nih.

gov/books/bv.fcgi?rid=hstat2.chapter.7644. Accessed March 5, 2008.


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Two HEDIS measures focus specifically on

issues related to smoking: cessation efforts and

COPD diagnosis (Table 5). Related CAHPS

questions directly assess the components of

the HEDIS measure on Medical Assistance

With Smoking Cessation (Table 6).

Compared with results from 2005, commercial

plans on average showed slightly improved

performance on Medical Assistance With

Smoking Cessation in 2006 (Table 7). Yet,both detection and interventions still fall far

short of recommended levels. While about

75% of smokers were advised to quit, less than

half were counseled about medications and

other smoking cessation strategies available

to them.10Published guidelines from the

U.S. Preventive Services Task Force strongly

recommend that clinicians ask alladults about

tobacco use and give every smoker counseling

and pharmacotherapy to help them quit.5

Use of spirometry in the assessment

and diagnosis of COPD also improved

slightly from the previous year.10However,

performance is still far less than desirable.

Fewer than half of adults with COPD on

systematic health exams have been previousl

diagnosed by their physicians.30Lack of an

appropriate diagnosis prevents appropriate

treatment, including smoking cessation

counseling, for the majority of people

suffering from this progressive disease. As afirst-line measure, spirometry is essential for

an accurate diagnosis providing an objective

measure for evaluating disease severity.39

Spirometry is indicated for any patient with

persistent dyspnea, chronic cough, or ongoing

sputum productionespecially if the patient

has a history of smoking.39Since symptoms

of COPD may be confused with other

conditions, such as asthma or heart failure,

spirometry guides appropriate treatment.

Further, the simple act of spirometry testing

has been shown to motivate smokers to quit.4

Table 5.HEDIS Measures Related to Quality of Care for Smokers37

Measure Description

Medical Assistance With Smoking Cessation Evaluates three components of an effective smoking cessation program: advice

to quit, discussion of medication options, and recommendations for specific

cessation strategies

Use of Spirometry in the Assessment and Estimates the percentage of members, or at the physician level, patients with

Diagnosis of COPD visits, who are 40 years of age and older who received spirometry testing to

confirm a diagnosis of COPD


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Table 6.CAHPS Questions Regarding Performance on HEDIS Measure: Medical AssistanceWith Smoking Cessation38

Question Response Choices

Do you now smoke cigarettes every day, Every day

some days, or not at all? Some days

Not at all (skip next three questions)

Dont know (skip next three questions)

In the last 12 months, on how many visits were you None

advised to quit smoking by a doctor or other health care One visit

provider in your plan? Two to four visits

Five to nine visits

10 or more visits

I had no visits in the last 12 months

On how many visits was medication recommended or None

discussed to assist you with quitting smoking One visit

(e.g., nicotine gum, patch, nasal spray, inhaler, Two to four visits

prescription medicine)? Five to nine visits

10 or more visits


On how many visits did your doctor or health care None

provider recommend or discuss methods and strategies One visit

(other than medication) to assist you with quitting smoking? Two to four visits

Five to nine visits10 or more visits


Table 7.Commercial Plan Performance on HEDIS Measures Related to Quality of Carefor Smokers10

Measure Performance (%)

2005 2006

Medical Assistance With Smoking Cessation

Advising smokers to quit 71.2 73.8

Discussing medications 39.4 43.9

Discussing strategies 39.0 43.2

Use of Spirometry in the Assessment and Diagnosis of COPD 34.8 36.1


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Case Study: Employer Effort

Get Ready...Get Set...Get Quit: AnEmployee Nicotine Cessation Program

Background

With 33,500 union and nonunion employeesin 23 states, the District of Columbia, and

two Canadian provinces, this employer

implemented a tobacco cessation policy

and created a program to support its

implementation.

The tipping point for action occurred

in November 2004 when the company

introduced health and wellness into the

organizations culture. Beginning with top

leadership, pilot programs were launched to

assess employee health status. Tobacco use

was one measure of health status assessed.

Data from the pilots led to the development

and implementation of 12 health and wellness-

related programs, including placement of

onsite Wellness Centers in large employee-

based areas along with creation of 19 fitnesscenters.

Case Description

Investing in employee wellness made goodbusiness sense for this large employer. The

company created a comprehensive health

screening that incorporated biometric

screenings, pulmonary function testing, and

health risk assessments. The screenings

were designed to inform employees about

behavioral health issues. A multidisciplinary

team of American Dietetics Association

(ADA) Registered Dietitians and American

College of Sports Medicine (ACSM) Health

Fitness Instructors used the biometric

data to stratify employees disease risk and

developed individualized behavior change

programs. Through the data collected, this

company found that at least 34% of employee

used tobacco products and were at risk for

pulmonary disease.



Organization Type: Large employer

Target Population: 33,500 union and nonunion

employees

Location: Dispersed locations across

the United States & Canada


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Further, the company assessed the financial

impact of tobacco dependency on health

care and productivity costs. A cost model

was developed using comparative data from

national data sets. Using estimates that 9% of

smokers would maintain nicotine abstinence

for one year, the company concluded that

health care and productivity savings would

offset program costs. The pharmacoeconomic

analysis combined with the high prevalence

of tobacco users prompted the employer

senior leadership to invest in creating a

comprehensive nicotine cessation program.

A company-specific program was designed based

on identified best practices from the Centers for

Disease Control and Prevention (CDC) Guidelines

for Tobacco Dependency. Table 1 highlights the

six components of the program along with methods

used for program implementation.

Table 1.Employer Components for Nicotine Cessation Program

Component Methodology

1. Behavioral Health Self-Assessment Uses the Transtheoretical Behavior Change Model to

assess the smokers readiness for behavior change.

2. Nicotine Cessation Brochure Promotes the program and increases employee

awareness of the new benefit.

3. Nicotine Cessation Toolkit

Fagerstrom Test for Nicotine Dependence Assesses nicotine dependence level.

Nicotine Triggers Quiz Identifies triggers for nicotine use and assesses

associative reasons for nicotine use.

Are You Ready to Quit? Assesses motivation level.

The Craving Journal Provides a visual log for craving occurrences.

The Nicotine Trigger Plan Allows smokers the ability to identify nicotine coping

strategies, craving periods, and triggering cues.

Reimbursement Policy Provides smokers an incentive to attempt the

cessation program.

Initial Physician Cessation Visit Form Prompts physicians to review the toolkit with the

patient, facilitates the creation of the patients quit

plan, and is required for initial reimbursement.

Follow-Up Physician Cessation Visit Form Certifies successful completion of the nicotine

cessation program.

4. Medical Oversight Facilitates employees use of the physician communityto receive nicotine cessation advice and if needed,

pharmacotherapy.

5. Program Reimbursement Participants are reimbursed up to $250 for physician

office visit and copayments for nicotine cessation

prescriptions. Additionally, participants can receive

reimbursement for 100% of Nicotine Replacement

Therapy with a maximum of two attempts per year.

6. Behavioral Support Counseling Contracts services offered through a medical center.


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Recognizing the difficulty that employees

may have with quitting, the program provided

coverage for up to two quit attempts per year

with a lifetime maximum of six quit attempts.

Results

To determine the impact of the nicotine

cessation programs success, participation,

abstinence, and recidivism rates were

measured:

receipt of the Initial Physician Cessation

Visit Form

receipt of the Follow-Up Physician

Cessation Visit Form

follow-up telephone surveys at six and 12

months with the medical center contracted

to provide behavioral support counseling

In addition, the following variables are also

measured and tracked for ongoing program

enhancements and reporting:

residence, union/nonunion status, years of

smoking, and daily usage rate

determined from the Fagerstrom Test for

Nicotine Dependence

date, and relapse date

Based upon an ongoing pilot of initial

participants, the program has shown initial

success. The mean age of participants was

44.6 years; with a 24.4-year smoking history;

averaging 1.4 packs per day. Twenty-five

percent of those enrolled have completed

the program and remain smoke free. Of

the quit group, 80% received an average

reimbursement of $215 to cover physician

and pharmacy costs. An additional 5% of

participants have abstained from smoking,

but have yet to seek reimbursement.

Unfortunately, 10% abstained and have sincerelapsed. The remaining 5% were lost to data

collection.

Leadership/Sustainability

Company leadership supports the action

of the wellness program including the

nicotine cessation program. This support

is demonstrated through program policies,financial support, and staff assignments. Ten

dedicated field-based staff are responsible for

marketing program services and providing

nicotine coaching; one person is dedicated to

program tracking and participant follow-up

and reimbursement; and health counseling

continues to be offered through an outside

vendor.


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In Their Own Words

The company observes:

Prior to this, the company did not have a

comprehensive nicotine cessation program.

The previous program lacked sophistication

to address the complexity of nicotine

dependence and did not demonstrate the

companys commitment to overall employee

health and well being. Unique aspects of

this program are senior leadership support,

coverage for multiple quit attempts, significantstaff support, high reimbursement level, and

collaboration with the medical community.

Conclusion

This case represents a large employers efforts

to change tobacco use among employees.

Using a top-down, leadership-driven effort,

this company created a comprehensive

health and wellness program. This company

recognized financial barriers and issues with

chronic relapse of behaviors for nicotine users

and offered solutions for each barrier. This

effort is a work in progress with the company

continuing to hone its program investing

in employee wellness while continuouslyassessing the economic impacts that such

programs have on this company.

Please refer to Appendices 4-5 for tools and

resources used by this organization.

Successful program replication requires

having senior leadership support, obtaining financial resources,

dedicating professional resources, involving the employees

primary care physician, and understanding the organizational culture.


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Use of Health RiskAppraisals

Another widely used screening tool is

the Health Risk Appraisal (HRA). Both

health plans and employers rely on these

instruments to help identify risk factors and

provide interventions in the populations they

serve. A typical HRA gathers information

from individuals regarding demographic

characteristics (e.g., age, sex), lifestyle (e.g.,

smoking status), and personal and family

medical history.41HRAs also may include

feedback and intervention services.41

Numerous HRAs are commercially available,

including instruments designed specifically

to assess and manage lifestyle risk factors.41

While benefits can be significant, several

caveats accompany the use of HRAs,

including ethical considerations and reliability

of data (Table 8).


Table 8.Benefits and Caveats of Health Risk Appraisals41,42

Benefits Caveats

Widely available in numerous formats

Clarifies goals for interventions

Improves cost-effectiveness of resources

where need is greatest

Quantifies progress when HRA is givenat baseline and repeated posttreatment

Increases employee awareness

and motivation

Ethical Considerations:

Goals, methods, and requirements for participation

must be clearly communicated

Materials must be appropriate for population,

including cultural and ethnic sensitivity

Confidentiality must be maintained

Individuals must be free to decline participation

without consequences

Data must be secure

Results and their implications must be

clearly interpreted

Referrals or on-site interventions must

be provided to address tobacco use


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Conclusion

Nicotine dependency is a chronic condition

that harms nearly every organ in the body.23

Despite this well-known fact, the number

of smokers in the United States has not

decreased significantly in recent years.18Of

the more than 47 million current smokers,

nearly 20% live with a chronic smoking-related

illness, and all are at increased risk of dying

prematurely from cancer, heart disease, or a

respiratory condition.

19,23,29

Even to those whonever hold a cigarette, ETS expands the damage

These consequences cause considerable

personal suffering and escalating economic

costs that affect all of us. Smoking-related

HEDIS measures and CAHPSquestions,

as well as results from HRAs, should spur a

greater emphasis on quality care for these

populations. While health plans and employers

are taking notice, improved adherence to

smoking cessation protocols is required if

we are to stem the growing burden of tobacco

use and dependency.

References

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People/F/Freudenheim,%20Milt&oref=slogin. Accessed October 27, 2007.

2. U.S. Department of Health and Human Services. Healthy People 2010:

Volume II (second edition) Tobacco Use. http://www.healthypeople.gov/Document/HTML/volume21/27Tobacco.htm. Published November 2000.

Accessed October 9, 2007.

3. American Nonsmokers Rights Foundation. States, commonwealths, and

municipalities with 100% smoke-free laws in workplaces, restaurants, or

bars. http://www.no-smoke.org/pdf/100ordlist.pdf. Updated April 1, 2008.

Accessed April 28, 2008.

4. Centers for Disease Control and Prevention. State Tobacco Activities

Tracking and Evaluation (STATE) system: state smoke-free indoor air fact

sheet. http://www.cdc.gov/tobacco/statesystem. Accessed December 8,

2007.

5. Agency for Healthcare Research and Quality (AHRQ). U.S. PreventativeServices Task Force. Counseling to prevent tobacco use and tobacco-caused

disease: recommendation statement. Rockville, MD: AHRQ publication

04-0526; November 2003

6. Tokarski C. Smoking cessation treatment cost-effective for health plans.

Medscape Medical News. June 7, 2004. http://www.medscape.com/view-article/480313. Accessed April 30, 2008.

7. Holtrop JS, Malouin R, Weismantel D, Wadland WC. Clinician perceptions

of factors influencing referrals to a smoking cessation program. BMC Fam

Pract. 2008;9:18. http://www.biomedcentral.com/1471-2296/9/18.

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8. California Department of Health Services. Confronting a relentless adversary:

a plan for success. Toward a tobacco-free California 2006-2008. http://

www.dhs.ca.goc/tobacco/documents/pubs/MasterPlan05.pdf. Published

March 2006. Accessed April 30, 2008.


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www.who.int/tobacco/health_priority/en/index.html. Accessed October 6 ,

2007.

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2007: Industry Trends and Analysis. Washington, DC: National Committee

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11. National Committee for Quality Assurance. ProgramsAccreditation,

certification, and recognition. http://www.ncqa.org/tabid/58/Default.aspx.

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12. Mitrouska I, Bouloukaki I, Siafakas NM. Pharmacological approaches to

smoking cessation. Pulm Pharmacol Ther. 2007;20:220-232.

13. Frishman WH, Mitta W, Kupersmith A, Ky T. Nicotine and non-nicotine

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http://www.cdc.gov/tobacco/data_statistics/Factsheets/smokeless_

tobacco.htm. Updated April 2007. Accessed March 25, 2008.

15. American Cancer Society. Questions about smoking, tobacco, and health.

http://www.cancer.org/docroot/PED/content/PED_10_2x_Questions_

About_Smoking_Tobacco_and_Health.asp. Accessed October 2, 2006.

16. Schroeder SA. What to do with a patient who smokes.JAMA.

2005;294:482-487.

17. Balkstra CR, Fields M, Roesler L. Meeting Joint Commission on

Accreditation of Healthcare Organizations requirements for tobacco

cessation: the St. Josephs/Candler Health System approach to success.

Crit Care Nurs Clin North Am. 2006;18:105-111.

18. American Lung Association. Trends in tobacco use. http://www.lungusa

org/atf/cf/%7B7A8D42C2-FCCA-4604-8ADE-7F5D5E762256%7D/

TREND_TOBACCO_JUNE07.PDF. Published June 2007. Accessed October

6, 2007.

19. Centers for Disease Control and Prevention. Tobacco use among

adults-United States, 2005. MMWR Morb Mortal Wkly Rep.

2006;55(42):1145-1148. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5542a1.htm. Accessed May 19, 2008.

20. Centers for Disease Control and Prevention. Healthy Youth! Health

topics: tobacco use. http://www.cdc.gov/HealthyYouth/tobacco/index.htm.

Updated November 7, 2007. Accessed December 7, 2007.

21. Doolan DM, Froelicher ES. Efficacy of smoking cessation intervention

among special populations. Nurse Res.2006(suppl 4):S29-S37.

22. American Cancer Society. Cigarette use among teens inches downward:

rate is higher in rural areas. CA Cancer J Clin. 2002;52:3-4. http://www.

caonline.amcancersoc.org/cgi/content/full/52/1/3. Accessed May 1,

2008.

23. Centers for Disease Control and Prevention. Annual smoking-attributablmortality, years of potential life lost, and productivity lossesUnited States,

1997-2001. MMWR Morb Mortal Wkly Rep. 2005;54(25):625-628. http:/

www.cdc.gov/mmwr//preview/mmwrhtml/mm5525a1.htm. Accessed May

1, 2008.

24. Free & Clear. Why tobacco cessation for health plans? http://www.

freeclear.com/services/tobacco_cessation/health_plan/?nav_section=1.

Accessed May 9, 2006.

25. Chaudhuri R, Livingston E, McMahon AD, et al. Effects of smoking

cessation on lung function and airway inflammation in smokers with

asthma.Am J Respir Crit Care Med. 2006;174:127-133. http://www.

medscape.com/medline/abstract/16645173. Accessed May 19, 2008.

26. Centers for Disease Control and Prevention. Guidelines for school health

programs to prevent tobacco use and addiction. MMWR Morb Mortal Wkly

Rep. 1994;43(No. RR-2):1-19. ftp://ftp.cdc.gov/pub/Publications/mmwr/

rr/rr4302.pdf. Accessed December 18, 2007.

27. Centers for Disease Control and Prevention. Fact sheet: secondhand

smoke. http://www.cdc.gov/tobacco/data_statistics/Factsheets/

SecondhandSmoke.htm. Updated September 2004. Accessed Decembe

7, 2007.

28. American Academy of Pediatrics Committee on Substance

Abuse. Tobaccos toll: implications for the pediatrician. Pediatrics.

2001;107:794-798.

29. Centers for Disease Control and Prevention. Cigarette smoking-

attributable morbidityUnited States, 2000. MMWR Morb Mortal Wkly Re

2003;52(35):842-844.

30. Celli BR. Chronic obstructive pulmonary disease: from unjustified nihilism

evidence-based optimism. Proc Am Thorac Soc. 2006;3:58-65.

31. National Heart Lung and Blood Institute. National Institutes of Health. U.S

Department of Health and Human Services. Chronic obstructive pulmonadisease. http://www.nhlbi.nih.gov/health/public/lung/other/copd_fact.p

Published March 2003. Accessed October 6, 2007.

32. Hylkema MN, Sterk PJ, de Boer WI, Postma DS. Tobacco use in relation t

COPD and asthma. Eur Respir J. 2007;29:438-445.

33. Missouri Department of Health and Senior Services. Facts: health risks o

smokingfrom A to V. http://www.dhss.state.mo.us/SmokingAndTobacco

HealthRisks.pdf. Accessed May 1, 2008.

34. Centers for Disease Control and Prevention. Fact sheet: cigarette smokin

related mortality. http://www.cdc.gov/tobacco/data_statistics?factsheet

cig_smoking_mort.htm. Updated September 2006. Accesssed May 1,

2008.

35. Free & Clear. Economic impact of tobacco use. http://www.freeclear.com

case_for_cessation/econ_impact.aspx?nav_section=2. Accessed May 9

2006.

36. Centers for Disease Control and Prevention. Department of Health and

Human Services. Sustaining state programs for tobacco control: data

highlights 2006. http://www.cdc.gov/tobacco/data_statistics/state_dat

data_highlights/2006/00_pdfs/DataHighlights06rev.pdf. Accessed May

19, 2008.

37. Fallon Community Health Plan. 2008 HEDISmeasures. http://fchp.

org/NR/rdonlyres/7793DFDF-5308-41D1-8A0D-CBA7F16918E3/0/

HEDIS_2008MeasuresForFCHPWeb.pdf. Accessed May 14, 2008.

38. National Committee for Quality Assurance. CAHPS 3.0H, 4.0H Survey

Crosswalk. http://web.ncqa.org/Portals/O/PolicyUpdates/HEDIS%20

Technical%20Updates/CAHPS_Crosswalk_30H_to_40H.pdf. Published

2006. Accessed October 7, 2007.

39. Rabe KF, Hurd S, Anzueto A, et al. Global strategy for the diagnosis,

management, and prevention of chronic obstructive pulmonary disease.

Am J Respir Crit Care Med. 2007;176:532-555.

40. Johansson S, Johansson G, Green Y. Screening with spirometry reducessmoking [abstract]. http://www.thepcrj/journ/vol15/15_3_213_c.pdf.

Accessed December 17, 2007.

41. Centers for Disease Control and Prevention. Health risk appraisals. http:/

www.cdc.gov/nccdphp/dnpa/hwi/program_design/health_risk_appraisa

htm. Accessed December 8, 2007.

42. Centers for Disease Control and Prevention. Ethics guidelines for developm

and use of health assessments. http://www.cdc.gov./nccdphp/dnpa/hw

program_design/ethical_guidelines.htm. Updated May 22, 2007. Access

December 6, 2007.


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P R I N C I P L E S F O R R E D U C I N G T H E B U R D E N O F T O B A C C O U S E

Principles for Reducing the

Burden of Tobacco Use

The health and economic burdens of tobacco use call for aggressive interventions to reduce its initiation,

improve cessation rates, and decrease exposure to environmental tobacco smoke (ETS). Along with Healthy

People 2010, the U.S. Public Health Service Best Practice recommendations offer health plans, employers, and

clinicians a structure to develop effective services to address these goals. Repeatedly, these recommendations

emphasize the value of combined interventions and collaborative efforts to improve smoking cessation rates. As

the most widespread form of addiction, this chapter focuses primarily on smoking cessation.

Self-Help/Cold Turkey

Nicotine Patch

Nicotine Inhaler

Nicotine Gum

Nicotine Nasal Spray

Medications

Behavioral Support/Counseling

Combining Physiologicaland Psychological Support

Success Rates (%)

0 10 20 30 40 50 60 70

*Success rates for single approaches are based on studies with at least five months of follow-up after target quit date.

Figure 1. Success Rates for Smoking Cessation Methods1,5*

Principles for SuccessfulSmoking CessationInitiatives

Most smokers attempt to stop using tobacco

on their own by quitting cold turkey, yet

this is the least successful method of smoking

cessation (Figure 1).1Withdrawal symptoms

are often intense and persistent, and

psychological, behavioral, and social factors

also make cessation difficult.2,3Consequently,

although 70% of smokers want to quit, just 5%

of them are able to quit without assistance.4

Increasing the odds of success requires a

multifaceted approach that accounts for the

various temptations smokers face as they

attempt to quit. Underlying this approach is

an awareness of the factors that encourage

smoking cessation and the clinical approaches

that motivate smokers to quit. Building on

this base are pharmacologic interventions,

counseling approaches, and incorporation of

repeat treatment for smokers who relapseafter an initial quit attempt.


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Factors That Encourage

Smoking Cessation

Effective smoking cessation initiatives

incorporate numerous factors that encourage

success. Outside assistance in various forms is

pivotal. For example, consistent support from

a health care clinician can more than double

the likelihood of quitting compared with

self-help methods.6Tailored to individual

needs, pharmacotherapy may double or

triple success rates.7Environmental factors

also significantly influence cessation efforts.No-smoking policies at work sites and other

locations lead to increased cessation rates, and

social support from friends and coworkers

provide the same effect.8The number of

smokers who attempt to quit is greatly

increased when the cost of cessation programs

is covered by their health plans. In one study

it was estimated that 50% more

smokers would quit every year under

full coverage, compared with partial

reimbursement.9Thus, the odds of smokers

quitting successfully are greatly increased

when interventions address physiologic,

psychological, social, and economic factors.10

Further, raising the cost of tobacco products

may also be a successful solution for

assisting smokers to quit. Increasing tobacco

taxes by 10% has been found to decrease

tobacco consumption by 4% in high-incomecountries and by 8% in low- and middle-

income countries. A 70% increase in the

price of tobacco could prevent up to 25%

of all tobacco-related deaths among todays

smokers.11



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T H E V A L U E O F E F F E C T I V E W E L L N E S S A N D P R E V E N T I O N I N I T I A T I V E SP R I N C I P L E S F O R R E D U C I N G T H E B U R D E N O F T O B A C C O U S E

Background

Located within a tobacco-growing state, this

NCQA-accredited Medicaid health plan

created a pilot program to address smoking

cessation. This state is noteworthy as having

the highest rate of smokers at 28.7%. Each

year more than 8,000 residents die from

illnesses caused by tobacco use.

This effort is the plans first attempt to

address smoking within its membership. The

health plans Quality Medical Management

Committee was involved in guiding the initialpilot portion of the program. This committee

formed a multidisciplinary workgroup that

provided input into the smoking cessation

program development.

The workgroup defined the smoking cessation

program objectives:

associated with tobacco use and secondhandsmoke

deaths attributed to tobacco use

types of cancer

to quit by assisting them in becoming and

remaining smoke-free

The workgroup also identified cost for

cessation programs and cessation medications

as significant barriers to members. Thus,

the health plans first step was to provide

100% coverage for the cost of services and

medications for members enrolled in its

smoking cessation pilot program.

Case Study:

Health Plan: Yes, You Can!


Organization Type: Medicaid health plan

Target Population: State Medicaid enrollees

Location:Tobacco state


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Case Description

Called theYes, You Can! program, this

initiative used behavioral and pharmacological

approaches to smoking cessation. The health

plan used an internal system of care managers

specifically trained in smoking cessation

techniques. The behavioral approach was

modeled using the Cooper Clayton smoking

cessation behavioral techniques (Table 1).

According to the plans research, the Cooper

Clayton method has a 20-year history of

success as a comprehensive behavioral

smoking cessation program. This method

was created by two faculty members at the

University of Kentucky. Thomas Cooper,

D.D.S., a dentist and former heavy smoker,

developed the program with Richard

Clayton, Ph.D., a clinician working in the

field of drug addiction.

Yes, You Can! is a specialized disease-management model created to address

tobacco use.

The plan initially piloted this program with

200 tobacco-using members who went through

the 12-week program. In the pilot group,

37% (74) of the 200 members were smoke-

free at 12 weeks. Considered a success, the

pilot project was rolled out to an additional 80

adult health plan members as a second-phase

pilot. TheYes, You Can!program is now

available to all adult health plan members.

Key pieces ofYes, You Can!include:

and clinicians

centers flyers

The program focused on individual success.

Each participant went through an interview

process to identify readiness and a

willingness to change. The member was

also asked to sign an agreement detailing

his or her own responsibility in smoking

cessation. To encourage members, services

were provided free as a covered benefit for

those members in the pilot program. Membe

also received refrigerator magnets, targetededucational materials, and phone numbers to

access support.


Table 1.Cooper Clayton Method to Stop Smoking1

Principle #1 Success is nothing more than a plan that is

adhered to.

Principle #2 A major problem can be solved when cut up

into a series of smaller problems.


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P R I N C I P L E S F O R R E D U C I N G T H E B U R D E N O F T O B A C C O U S E

Population

The health plan directed this effort at

Medicaid members 18 years of age or

older who were not pregnant. (The plan

had other initiatives that specifically

targeted health behaviors in pregnant

women.) Total membership in the p

ncqa - quality profiles-smoking

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