Interagency Committee on Smoking and Health
Meeting Summary: August 14, 2001
Smoking Cessation: Facing the Challenges of Tobacco
Addiction
Planning for the Future
Michael C. Fiore, M.D., M.P.H., Professor, Department of Medicine, Director, Center for
Tobacco Research and Intervention, University of Wisconsin Medical School, Madison,
Wisconsin
Dr. Fiore began by summarizing some of the information that is already known about smoking
cessation that had been presented to the committee during the course of the meeting. Tobacco
is highly addictive, and approximately 50 million Americans currently smoke. Of those, 35
million would like to quit, and 20 million try every year. However, only one million of
those who try actually succeed. He emphasized that this low success rate could be markedly
increased if we effectively prompt more smokers to use evidence-based counseling and
medications in their quit attempts. Dr. Fiore further reiterated that there are effective
clinical and community interventions that exist and that these are described in two of the
guidelines described earlier in the day – the PHS Clinical Practice Guideline and the CDC's
Guide to Community Preventive Services. These guidelines tell us that not only do health
care providers have unique access to smokers and can be highly effective in promoting
cessation, but system level changes must also be institutionalized to maximize clinical
effectiveness. Furthermore, population-based interventions such as media campaigns, price
increases and reduced out-of-pocket costs for treatment are also important. During the
course of the meeting, committee members were told about some of the many populations that
are currently being targeted in cessation efforts; seniors, pregnant women,
socioeconomically disadvantaged, young people, rural and inner city smokers, and those who
visit health care facilities.
To conclude his remarks, Dr. Fiore offered several recommendations to the federal government
about ways that it could further promote cessation efforts. First, increase access to
effective treatments by Medicaid and Medicare recipients, federal employees, veterans, and
those in the military through universal (50 state) quitline access and mandated insurance
coverage for cessation services. Second, disseminate and implement evidence-based
interventions that we already know are effective. This can be done through increased
training for health care providers, and system-level changes that include provider reminder
systems and prompting of purchasers to require provision of cessation services. The PHS
Tobacco Guidelines Collaboration, a joint public and private initiative described by Ms.
Williams, is another way that evidence-based information can be disseminated. Third,
increase federal funding of research and increase coordination of current research efforts.
Although there are several examples of public/private research partnerships currently
underway (Treating Tobacco Use Research Centers [TTURC], a model NIH/RWJF initiative), more
of these alliances should be encouraged as should non profit and private sector initiatives
such as the American Legacy Foundation, Robert Wood Johnson Foundation, the Pharmaceutical
Industry and the Wisconsin Women's Health Initiative. Fourth, continue to promote
coordination and partnership development to address the needs of special populations and
increase access to treatment. Dr. Fiore believes that all of these four components should be
part of a new highly visible initiative led by Surgeon General Satcher and Secretary
Thompson, whose leadership in the area of prevention could enable us to make great progress
in our tobacco control efforts.
Dr. Satcher thanked all speakers and told the committee that it was his responsibility to
communicate the importance and urgency of these issues to HHS Secretary Thompson.
Dr. Satcher then asked Nancy Kaufman from the Robert Wood Johnson Foundation to announce an
exciting new public/private partnership between NCI, CDC, RWJ, and the Canadian Tobacco
Control Research Initiative. Ms. Kaufman described the new initiative, which will focus on
tobacco use treatment for youth smokers beginning with a survey of existing programs and a
review of best practices as well as ineffective interventions. Following the survey, the
collaborative will fund between 40 and 50 two-year evaluation studies of various
interventions. With the evidence from those evaluations, common measures will be designed
and meta-analyses will be conducted. During the fourth year of the initiative, the field
will be resurveyed to determine changes and improvements in youth tobacco use treatment.
Approximately 11.2 million dollars will be dedicated to this effort.
Dr. Satcher reacted to the announcement by telling the committee how encouraged he is by the
emphasis on youth, given that although black youth smoke less than their white counterparts,
this advantage disappears as they move into adulthood.
Susan Rossi from NIH followed this comment by asking speakers what they knew of research
linking cigarettes, as drug delivery devices, to self-medication for psychiatric conditions.
The response was that while the tobacco industry has researched this issue, we do not have
adequate research on ingredients and design of tobacco products to know their effect on
self-medication.
Dr. Satcher directed a question to all speakers concerning the extent to which they have
been able to segment their target populations. Dr. Richling from Union Pacific Railroad
responded that his organization has only segmented by geographic region, but is interested
in developing a better instrument to enable them to further segment the population. Sarah
Rosenberg from the Oregon Health Division responded that they are only able to monitor their
target population based on Medicaid enrollment and that they really do not have a good
answer to the issue of segmentation. Dr. Timothy McAfee from Group Health Cooperative of
Puget Sound confirmed that there are extreme measurement complexities, but added that in the
Medicaid population we know that the tobacco use rate is almost double that for the
non-Medicaid population. Dr. Lyndon Haviland from the American Legacy Foundation addressed
the segmentation issue by reporting that the American Legacy Foundation had conducted a
National Youth Tobacco Survey and had over- sampled for Asian Americans. Results indicated
that while Asian American youth have the second lowest rates of tobacco use in 6th grade, by
the time they reach 12th grade, they jump to the second highest use rate. The survey also
identified that Asian American youth are 65% more likely to smoke menthol than regular
cigarettes, but we do not yet understand the reason for this.
Before moving to public comments, Dr. Satcher gave committee members an opportunity to make
final comments. Nancy Kaufman from the Robert Wood Johnson Foundation mentioned the
Smokefree Families project and how it is an example of a low cost intervention with positive
outcomes achieved by providing incentives to pregnant women and their buddies to encourage
cessation. Dr. Scott Leischow from NCI addressed the issue of disparities by announcing a
plan to convene a national conference to focus on disparities and tobacco use to identify
key research directions. Dr. Leischow also remarked on the tremendous number of federally
funded efforts that are currently ongoing and how much data already exists that should
continue to be optimized and analyzed.
Following these remarks, Dr. Satcher invited public comments. A question was asked regarding
the effect of increasing excise taxes on reducing youth smoking prevalence, and Dr. Satcher
responded that a 10% increase in taxes has been found to reduce prevalence by 7%. In
response to an earlier question posed by the Surgeon General regarding the cost of covering
cessation services for all smokers currently enrolled in Medicare, Matt Barry from the
Campaign for Tobacco Free Kids said that the Campaign had studied the issue and estimated
that the benefit would cost between $120 million over 10 years (assuming a 2% utilization
rate) to $600 million over 10 years (assuming a 10% utilization rate). Mr. Barry also
mentioned a bill introduced by Senators Durbin and Brownback (S.854) that includes both a
counseling benefit for Medicare enrollees and a counseling and pharmaceutical benefit for
Medicaid enrollees.
Maris Bondi from Partnership for Prevention asked a question about the enormous influence of
tobacco use in the media on youth smoking rates. Dr. Satcher reported that he had been
involved in a meeting with Hollywood executives to talk about public health issues in the
media, including smoking, and that these talks would continue. Nancy Kaufman from the Robert
Wood Johnson Foundation added that Stan Glanz, a researcher from California, had received an
innovators award from the Robert Wood Johnson Foundation and was using the award for an
initiative to educate Hollywood executives about the negative consequences of the glamorous
portrayal of tobacco use in the media. Dr. Cathy Backinger from NCI added that NCI-supported
research has shown a strong link between young people who watch PG movies and above and
their smoking rates. Dr. Lyndon Haviland from the American Legacy Foundation mentioned that
Legacy had been working with the Entertainment Industry Foundation to better understand the
perception of smoking in movies and would be announcing a new initiative in this area
shortly.
Marcela Gaitan from the National Alliance of Hispanic Health requested comments from
speakers regarding the increasing prevalence among young Hispanic girls as well as differing
risk behaviors among first and second generation Hispanic Americans. Dr. Satcher responded
by saying that he had been involved in a meeting of editors of Latino magazines who
discussed the high rates of school dropout and teenage pregnancy among Latino youth and how
these youth were more likely to smoke.
Katherine Pruitt from the American Lung Association asked for some comments regarding the
efficacy of group approaches to smoking cessation. She briefly mentioned her organization's
evidence-based cessation program for young people called "Not On Tobacco." Dr. Michael Fiore
from the University of Wisconsin responded that the PHS Clinical Practice Guideline
identifies that group counseling can be effective, but many smokers self-select away from
group approaches to cessation. He said that many professionals see group counseling as an
option, but one that is infrequently selected by smokers. Dr. Corinne Husten from CDC
confirmed that evidence supports the efficacy of group counseling, but that the reach of
these groups is often limited and more emphasis is often placed on trying to engage smokers
in more intensive cessation efforts. Dr. Timothy McAfee from Group Health Cooperative of
Puget Sound added that as more people attempt to quit, the telephone counseling approach
appears to be gaining favor. Dr. Scott Leischow from NCI reminded the committee that in the
1990s the public health community had great hopes for the power of new pharmacotherapy to
assist in cessation efforts but we now acknowledge that there is no panacea and we must
remain vigilant in our efforts to address behavioral change approaches.
Tom Glynn from the American Cancer Society asked for Dr. Gerald Keusch of the NIH's Fogarty
International Center to talk a bit more about the recent RFA focused on international
tobacco control. Dr. Keusch talked about the working group that had convened for a year that
led to developing the recently released RFA, cosponsored by the World Health Organization,
entitled "International Tobacco and Health Research and Capacity Building Program." Dr.
Keusch also talked about efforts to network applicants and link them to other efforts
currently underway. Dr. Anthony So of the Rockefeller Foundation praised NIH's work,
emphasizing how important international efforts are given the globalization of health
threats such as tobacco use. Dr. Satcher reported that he had an opportunity to meet with
China's Minister of Health and talk about the high rates of smoking among men in China,
including many physicians.
Matt Barry from the Campaign for Tobacco Free Kids asked for comments about how the tobacco
control field viewed recent harm reduction activities and whether they should be seen as a
threat or an opportunity. Dr. Scott Leischow from NCI responded by talking about the recent
NCI-sponsored meeting on the issue and how the intention of the meeting was to consider both
the opportunities and challenges. Acknowledging that the tobacco industry has already moved
ahead on new developments in this area, Dr. Leischow believes that it is still too early to
tell where we should go and what additional research is required in this area. Dr. Jack
Henningfield from Pinney Associates agreed that it is still premature to say that harm
reduction is a good thing because we currently have no surveillance system in place to
determine whether harm reduction approaches will undermine our goal of preventing initiation
and helping people quit. Dr. Timothy McAfee from Group Health Cooperative of Puget Sound
agreed with this assessment, encouraged more research in this area, and cautioned that both
the tobacco and pharmaceutical industries have a lot more to gain with harm reduction then
they do in promoting cessation. Dr. Tom Glynn from the American Cancer Society encouraged
the field to continue to work together in this area and not to become splintered. Dr.
Satcher then announced that the issue of harm reduction would be the likely topic for the
next meeting of the Interagency Committee on Smoking and Health.
Without further comments, Dr. Satcher offered his closing remarks. He thanked the committee
members, speakers, participants, and staff for their many contributions to what he called an
"outstanding" meeting. Dr. Satcher told participants that he thought it had been a very
productive day of learning about the current status of smoking cessation research and
program activities and ways in which we can advance our knowledge and program
implementation. As chair of the committee, he reported that he would transmit the ideas to
the Secretary "in a very enthusiastic manner" and confirmed his commitment to achieving the
Healthy People 2010 objectives in tobacco control that could only happen with significant
investment in cessation. Dr. Satcher encouraged all meeting participants to take the
messages back to their organizations and to work with him on a smoking cessation agenda. The
Surgeon General adjourned the meeting and told the participants that a meeting summary would
be available on CDC's Web site in the fall.
Page last modified 04/25/2008
= Link to a PDF document
= Link to nonfederal Web site