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“This
very night I’m going to leave off tobacco! Surely
there must be some other world in which this unconquerable
purpose shall be realized.”
Charles Lamb (1815)
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TABLE
OF CONTENTS
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The public health community has many successes to celebrate in
cessation—working together we have made great progress through
the passage of smoking bans, clean indoor air ordinances, and the
increase of excise taxes on tobacco—helping to support an
environment ripe for changing social norms about tobacco use.
We direct this issue of extra!
to those of you working on cessation at the local level, bringing
you the latest figures from cessation research, what the literature
says about the success and failure of community-based cessation
programs and suggesting more effective ways communities can contribute
to cessation.
In the end, we hope this issue gets you thinking about your role
in cessation a little differently. In the words of Michael Fiore,
“We’re in a very positive position now with a powerful
evidence base that cessation works. It’s time to insure that
every smoker is offered the services it takes to quit.”
Together let’s give cessation the priority it demands.
Dearell Niemeyer, MPH
Director, Tobacco Technical Assistance Consortium
And what about the smokers you know and love in your
community . . . the people you face everyday? Although 41% of smokers
try to quit smoking each year, only about 4% succeed (Centers for
Disease Control and Prevention. Cigarette Smoking Among Adults—United
States—2000. Morbidity and Mortality Weekly Report 2002; 51(29).
This means that the death rate from tobacco use will continue, even
if no more young people begin smoking.
Although most smokers want to quit, the majority fail in the attempt
because they try to go it alone. According to the American Cancer
Society, over 70% of smokers who tried to quit in 2000 sought no
help, and only 15% used aids like nicotine replacement therapy (NRT).
However, would-be quitters are two to three times more successful
when they receive the help they need. In fact, research indicates
that with effective counseling and medication, success rates could
go up to 30% (Fiore, Bailey, Cohen. 2000).
So how do we overcome these facts? Often our first response has
been to offer cessation programs. But this is not the best use of
resources, according to the US Surgeon General (Reducing Tobacco
Use: A Report of the Surgeon General. MMWR December 22/49(RR);1-27).
Let’s look at the pros and cons of building your effort around
cessation programs:
On the plus side:
- Cessation programs do work when they are based on effective
content and participants have access to medications.
But the negative side far outweighs the positive:
- It’s tough to recruit smokers, and even tougher to get
them to complete the program.
- Many smokers don’t like a group format.
- Cessation programs don’t reach economically disadvantaged
groups, who are about half of all smokers (U.S. 2000 census data
combining proportion of smokers on Medicaid, Medicare, and those
who are uninsured).
So, cessation programs are a hit or miss solution. Instead, Wendy
Bjornson of the Pacific Center on Health and Tobacco suggests that
we think in terms of a whole network—a statewide system in
which advocates at all levels are working together.
A new report
from the Center for Tobacco Cessation explores what must happen
at the state level to ensure that as a nation we are able
to increase the number
of successful quitters to reach or surpass 30%. The report
outlines four action
areas that combined are the basis for a comprehensive effort
at the state level.
Look for this report to be available in early 2004. The Executive
Summary of this
report will be available on December 10, 2003 on the CTC
web site. |
Back to Table of Contents
“Smokers are
shoring up the state’s income with thousands of dollars each
year
in excise taxes, yet very little of that money is devoted to helping
smokers quit.”
Michael Fiore, Director, Center for Tobacco Research,
University of Wisconsin Medical School
The literature says that we can reach more smokers through a comprehensive
approach. This means passing excise taxes and clean indoor air/smoking
bans, funding comprehensive tobacco control programs, increasing
access to medications, and advocating for policies that change the
social landscape. For
more information...
Before creating and/or offering new cessation programs,
communities must ask themselves—How is our work part of
the statewide system? Are we building a local environment that promotes
quitting, helps maintain quitting, and utilizes existing services?
“Find out what’s happening in your community,”
says Wendy Bjornson, of the Pacific Center on Health and Tobacco.
“What services are available? What benefits do people have?
Is there a quitline available? How can you link services in a better
way? Rather than a cessation program, use your public resources
as a catalyst to get things moving.”
To find answers to the questions Wendy Bjornson poses and more,
take a look at these resources:
Back to Table of Contents
“What works?
And who should I go to for help? These are the key issues for a
smoker who wants to quit.”
Linda Bailey, Director, Center for Tobacco Cessation
Let’s take a closer look at three areas where
local advocates can play a key role in making cessation a core component
of tobacco control.
Quitlines
You can start by letting people know what happens when they call
a quitline. Many of the smokers in your community may not have a
clue—they may expect only a scolding and a brochure. Instead,
the quitline can be the hub of services in your community, offering
ongoing counseling, referral to other services, access to medication,
and even a link back to a health care provider. Most quitlines are
actually underused, according to Wendy Bjornson.
| What the literature says about success rates
of quitlines |
- Quitlines have proved their effectiveness in the real
world (Zhu S, Anderson C.M., Tedeschi G.J., et al. “Evidence
of Real-World Effectiveness of a Telephone Quitline for
Smokers.” In NEJM vol. 347:1087-1093 October 3, 2002
Number 14)
- Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco
Use and Dependence. Clinical Practice Guidelines. Rockville,
MD: U.S. Department of Health and Human Services; June 2000.
Read
full report.
- Lichtenstein E, Glasgow RE, Lando HA, Ossip-Klein DJ,
et al. Telephone counseling for smoking cessation: rationales
and meta-analytic review of evidence. Health Education Research:
Theory and Practice 1996;1:243-257
- Hopkins DP, Briss PA, Ricard CJ, et al. Reviews of evidence
regarding interventions to reduce tobacco use and exposure
to environmental tobacco smoke. American Journal of Preventive
Medicine 2001;20(2S):16–66.
Read
full article.
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| Hot button issues |
- Funding for quitlines is endangered because revenues from
tobacco excise taxes are frequently diverted to balance
state budgets.
- Quitlines offer an excellent means to improve access
to cessation services for the population as a whole.
- Presently, the demand for quitlines is directly tied to
the amount of media push they receive, and that requires
a budget commitment from legislators, not only for the media
campaign, but also for adequate quitline staffing.
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| What local advocates can do |
- Get more callers to use the service—Develop an outreach
program to clinics, dentists, physician groups in your community.
Spread the word to Women, Infants and Children (WIC) clinics,
maternal and prenatal clinics.
- Advocate for funding— If revenues from tobacco tax
are coming in, advocate for money to be dedicated for cessation.
- Make sure the quitline represents the needs of your community—Invite
a representative of the quitline to talk with your local
group. Offer them feedback about service. Develop a relationship
with the quitline.
- Make sure your community’s programs are in the
quitline database.
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| Key quitline resources |
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Coverage
for treatment
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| What the literature says about coverage for
treatment |
- The better the coverage, the better the results. Smokers
who have full coverage of both medications and counseling
are four times as likely to quit smoking. For
more information . . .
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| Hot button issues |
- Full coverage of counseling and pharmacotherapies by Medicaid
is significant because people who can’t afford these
aids are likely doomed to fail in their quit attempts.
- Comprehensive cessation treatment is available to Medicaid
beneficiaries in only one state.
- While 35 states offer varying levels of coverage for tobacco
dependence treatments, most smokers may never benefit because
of extremely low levels of awareness of coverage availability
and misperceptions about such coverage by pharmacists and
physicians.
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| What local advocates can do: Start the drumbeat |
- Work with the major employers in your community to make
sure health care plans cover both counseling and pharmacotherapies—
Ask employers in your community about coverage—learn
who is covered, and who is not. Publicize the results of
your research. Encourage employers to learn how to use the
benefits they already have. Make a business case for coverage
of cessation treatment. Show employers why it is cost effective
to cover cessation treatment.
- Advocate for changes in Medicaid coverage in your state.
Raise the importance of cessation by making the case for
cessation with Medicaid programs legislators. The process
for changing coverage varies from state to state. In some
states it is an administrative decision, and in others it
requires an act of the legislature. Find out the process
for influencing change in your state.
- Dispel the myths around state Medicaid coverage—Publish
an article with an accurate summary of Medicaid coverage
in the state medical journal; work through professional
organizations to educate pharmacists.
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| Key coverage resources |
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Working
with the local medical community
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| What the literature says |
- The Center for Tobacco Cessation Roundtable Report indicates
that when physicians advise their patients to stop smoking,
cessation rates increase about 30%. When they offer even
a brief, three minute intervention, cessation rates can
double (Fiore, Bailey, Cohen. Treating tobacco use and dependence.
PHS. 2000).
- Providers can easily recommend that their patients quit
by using the 5 As: Ask about smoking, Advise to quit, Assess
readiness, Assist with pharmacotherapy and counseling, Arrange
follow-up, , see the Clinical Practice Guideline available
at http://www.surgeongeneral.gov/tobacco/
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| Hot button issues |
- Providers generally don’t provide assistance and
follow-up because these are the most technical and time
consuming parts of the 5A’s. Then, because they aren’t
prepared to provide assistance and follow-up, they may not
even start the process. The solution is to have a referral
system in place so providers can ask and advise and then
refer motivated tobacco users on for treatment.
- The most popular referral systems are those that work
with quitlines – such as fax referral systems.
- Providers are not always convinced that offering cessation
messages works.
- Training for providers has limited effectiveness unless
changes in the office procedures/systems are made as well.
- Few providers are aware of the Clinical Services Guidelines
for Smoking Cessation.
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| What local advocates can do |
- Make sure local health care providers are talking to their
patients about smoking and are recommending their patients
quit—Again, develop an outreach program.
- Work with clinic managers to help put a system in place
that prompts providers to ask and advise and then helps
refer to services. This is a systems solution not just a
provider education solution.
- Find and engage a provider that will champion the issue.
- Target providers that serve those at greatest risk of
using tobacco.
- Increase providers awareness of research and effectiveness.
- Promote not only education of provider but changes in
office procedure/systems.
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| Key medical community resources |
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Back to Table of Contents
The Center for Tobacco Research and Intervention in
Wisconsin has devised a unique approach to working with physicians
to build quitline use through aggressive promotion of their statewide
quitline at the grassroots level and “Fax to Quit” referrals.
To insure that they reach every clinic and every smoker in Wisconsin,
six outreach specialists have gone clinic by clinic throughout the
state to change the health care system for working with smokers.
When a smoker visits a physician, the physician faxes a referral
to the quitline, which follows up with the smoker. Thus far, the
program has reached 150 clinics, and the quitline has received over
30,000 calls.
To learn more about how they are building this systems change in
the practice of medicine, check out education and outreach on the
Web site: http://www.ctri.wisc.edu/main_dept/outreach/out_main.html.
“Cessation has
to be a core component of your tobacco control activities.
If you don’t have cessation, you don’t have a comprehensive
plan.”
Michael Fiore, Director, Center for Tobacco Research, University
of Wisconsin Medical School
Back to Table of Contents
This issue of extra! brings to the forefront the Center
for Tobacco Cessation (CTC) Web site — an outstanding
resource that brings you the latest in what works in cessation.
Read on for just a few of the great resources you
can find at this site . . .
| Looking for the best
in what works in cessation? |
- Check out What
Works for a summary of the effective cessation treatments
and strategies.
- Read the latest Research
demonstrating what works.
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| Wondering how to
apply research to practice? |
- Access the resources in Tools
which include step-by-step approaches and good ideas on
cessation, such as
- Toolkits and guides for employers, clinicians,
insurers, and local programs
- Case studies that demonstrate what others
are doing to implement cessation activities
- Tobacco Cessation Blueprints that
include guidance on taking action to implement cessation
strategies for adults,
young people, and pregnant women.
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| Trying to stay current
on the happenings of cessation? |
- Sign up for the Center's
e-newsletter! The latest trends in cessation research,
media, and policy will be e-mailed to you twice month.
Back to Table of Contents
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Let ttac
help you strengthen the role of cessation in your community.
Consider the following services specific to cessation, available
to you through ttac:
- Help you develop a plan for building the cessation infrastructure
in your local community and state
- Help you think through how you can build cessation activities
into a comprehensive tobacco control program
- Work with you to figure out the “how-to” for making
a quitline the hub of cessation services and the link between
public health services and health care providers in your community
- Provide information on a “how-to” for advocacy
to maintain dollars for quitlines in your community
- Collaborate to convene coalition leadership in states
ttac
is committed to equipping the tobacco
control community with the
information and tools necessary to effectively reduce tobacco
use.
Click
here for more information on how to request technical
assistance from ttac. |
Back to Table of Contents
Cessation
for Priority Populations
Bibliography
of Tobacco Use and Health Disparities
This bibliography of research compiled by the National
Cancer Institute (NCI) includes cessation among specific populations.
Evaluation
of a culturally appropriate smoking cessation intervention for Latinos
Woodruff SI, Talavera GA, Elder JP. Tob Control. 2002
Dec;11(4):361-7.
This article reports on a culturally appropriate intervention for
Latinos.
The GAINS project: outcome of smoking
cessation strategies in four urban Native American clinics. Giving
American Indians No-smoking Strategies
Johnson KM, Lando HA, Schmid LS, Solberg LI. Addict Behav. 1997
Mar-Apr;22(2):207-18.
This study was designed to assess the capability of the Doctors
Helping Smokers (DHS) model to produce an increase in smoking cessation
within four urban Indian Health clinics.
Guía
para Dejar de Fumar
A Spanish-language guide to quitting smoking developed
by the National Cancer Institute.
National
Partnership to Help Pregnant Smokers Quit
This national partnership has developed an action plan
to help pregnant smokers quit smoking. The site also includes other
resources such as presentations and links.
Pathways
to Freedom: Winning the Fight Against Tobacco
The Centers for Disease Control and Prevention has
recently updated its well-known guide for promoting tobacco cessation
in the African American community.
Smoking cessation
among African Americans: what we know and do not know about interventions
and self-quitting
Pederson LL, Ahluwalia JS, Harris KJ, McGrady GA.
Prev Med. 2000 Jul;31(1):23-38.
The purpose of this review was to critically evaluate the available
studies on cessation interventions for African Americans.
Smoking cessation interventions in
U.S. racial/ethnic minority populations: an assessment of the literature
Lawrence D, Graber JE, Mills SL, Meissner HI, Warnecke
R. Prev Med. 2003 Feb;36(2):204-16.
This article reviews published studies that examine effects of smoking
cessation interventions relevant to racial ethnic minority populations.
The status of tobacco cessation research
for Asian Americans and Pacific Islanders
Chen MS Jr. Asian Am Pac Isl J Health. 2001 Winter-Spring;9(1):61-5.
This article reviews the status of tobacco cessation research among
Asian Americans and Pacific Islanders.
Working
with Hispanic Populations
This section from the Tobacco Cessation Online Library
developed by the Arizona Tobacco Education and Prevention Program
includes background information on smoking and Hispanic population.
For Professionals
Association
for the Treatment of Tobacco Use and Dependence
This new association for providers is dedicated to the promotion
of and increased access to evidence-based tobacco treatment for
the tobacco user. Learn about the association’s Inaugural
Meeting to be held December 13, 2003 in Boston after the 2003
National Conference on Tobacco or Health.
Center
for Tobacco Cessation Web Site
See Resource Spotlight for information on this
comprehensive web site. The site includes blueprints for adult and
youth tobacco cessation and research articles on effective cessation
activities.
Cessation:
Helping Smokers and Other Tobacco Users Quit
This series of fact sheets prepared by the Campaign for Tobacco-Free
Kids (CTFK) covers many cessation issues, such as the benefits of
cessation and cost savings of cessation.
First
5 Community Guide for Supporting Effective Tobacco Cessation Services
Based on best practices, this guide from the Center for Health Improvement
includes recommendations, case studies, and sample documents to
assist commissions in their efforts to help pregnant women and parents
quit smoking.
Tobacco
Cessation Guideline
Find the clinical practice guideline developed by the U.S. Public
Health Service and supporting research on treating tobacco use and
dependence. Web page also includes consumer materials.
Health
Insurance and Medicaid Coverage of Cessation
Addressing
Tobacco in Managed Care: A Resource Guide to Health Plans
This guide provides information, examples and other resources for
health plans interested in developing effective interventions aimed
at reducing tobacco use.
Build
a Financial Infrastructure: Health Plan Benefits and Provider Reimbursement
This guide by the Pacific Center on Health and Tobacco (PCHT) combines
recommendations with experiences concerning tobacco cessation benefits
and provider reimbursement.
Employers’
Smoking Cessation Guide: Practical Approaches to a Costly Workplace
Problem
This tool developed by the Professional Assisted Cessation Therapy
(PACT) consortium helps employers enact affordable, effective smoking
cessation programs in their companies.
Reimbursement
for Smoking Cessation: A Healthcare Practitioner's Guide
The PACT consortium developed this guide for health care providers
on how to obtain reimbursement for cessation services.
State
Medicaid coverage for tobacco dependence treatments-United States,
1998 and 2000
This 2001 MMWR reports the extent of coverage for tobacco-use treatments
in state Medicaid programs.
Quitlines
Arizona
Smoker’s Helpline (ASH)
Find information about Arizona’s quitline, including research
on quitline activity and promotion.
California
Smokers' Helpline: A Case Study
This case study describes the California Smokers' Helpline and how
it supplements and compliments other state-funded tobacco programs.
See also the 2002 New England Journal of Medicine article, Evidence
of real-world effectiveness of a telephone quitline for smokers
for evaluation of the Helpline.
Linking
a Network: Integrate Quitlines with Health Systems
This PCHT report describes a model for quit lines as a centralized
state resource for proving quitting information, linking callers
with health plans and community programs. The report includes examples
from eight states.
Presentations
from the North American Conference of Smoking Cessation Quitlines
The North American Conference on Smoking Cessation Quitlines brought
together quit line providers, researchers and funders of quit lines.
Presentations include Survey of Quitlines in North America, A Review
of the Efficacy of Quitlines, Intervention Methods, Evaluation:
What Is Needed In The Field and How It Can Be Done, and Special
Populations.
States
with Tobacco Quitlines
This Center for Tobacco Cessation fact sheet outlines states with
tobacco quit lines. Includes how long they have been in service
and contact information.
State
Cessation Programs
Comprehensive
Statewide Tobacco Cessation
PCHT outlines a comprehensive approach to developing a comprehensive
statewide tobacco cessation program. Watch for an update of this
guide in December 2003.
Center
for Tobacco Research and Intervention
Research and information about Wisconsin’s cessation activities,
including its quit line and community outreach program.
State
Cessation Activities Table
See the Center for Tobacco Cessation’s overview of state cessation
activities.
Tobacco
Cessation Works: An Overview Of Best Practices And State Experiences
This CTFK fact sheet compiles evidence of effectiveness of state
cessation programs, including Arizona, California, Oregon, and Maine.
Research
Articles
See the Center for Tobacco Cessation web site for:
To Help
Smokers Quit
C.H.A.M.P.S.S.
CTFK has recently launched this new campaign called C.H.A.M.P.S.S.,
or Children Helping And Motivating Parents to Stop Smoking. The
web site provides children with the information and resources they
need to help their parents quit smoking.
Complete
Guide to Quitting
Guide developed by the American Cancer Society for
smokers. Includes tips, links, and information on quitting smokeless
tobacco.
Resources
For Quitting Smoking
This CTFK fact sheet provides a comprehensive list of web sites
and brochures for smokers who want to quit.
Smokefree.gov
The National Cancer Institute has developed this comprehensive,
research-based web site to help smokers quit. The site includes
an interactive U.S. map with information on cessation services in
each state, quit tips, and quit smoking manuals for many different
populations groups, including older smokers and Spanish-speaking
smokers.
Back to Resources and Links Table of Contents
Back to Table of Contents
Linda A. Bailey
Director, Center for Tobacco Cessation
Linda.A.Bailey@cancer.org
Wendy Bjornson
Director, Pacific Center on Health and Tobacco
wendy_bjornson@qwest.net
Michael Fiore
Director, Center for Tobacco Research and Intervention
University of Wisconsin Medical School
Mcf@ctri.medicine.wisc.edu
William Furmanski
Deputy Director, Center for Tobacco Cessation
William.Furmanski@cancer.org
Kathleen C. Harty
Technical Assistance Specialist/Consultant
Tobacco Technical Assistance Consortium
hartykc@msn.com
Robert Leischow
Statewide Projects Administrator
Tobacco Education and Prevention Program
Arizona Department of Health Services
bleisch@hs.state.az.us
Aliki P. Weakland, MPH, MSW
Editor-in-Chief
Madeline H. Barrow, MEd
Writer/Researcher
Samantha Helfert, MLS
Information Specialist
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