NIH calls lack of tobacco treatment major problem

There is still a lot we don't know about why tobacco cessation treatment works and which approach works best, according to a 14-member consensus panel, which met under the auspices of the National Institutes of Health (NIH) recently. However, said the committee's draft statement, effective interventions "are available and could double or triple quit rates, but not enough smokers are being offered these interventions."

Indeed, the fact that most adult smokers want to quit, but only a few receive interventions, "represents a major national quality-of-care problem," stated the committee at the end of a three-day meeting, June 12-14, in Bethesda, Md.

Offering effective interventions is of immense importance because the tobacco epidemic may be approaching a critical moment in history, said speakers who addressed the committee. The decline in tobacco use has been astounding. Since the 1960s the proportion of men who smoke has dropped from more than 50% to under 24%. The rate for women has declined from close to 35% to 18.5%. But there is no guarantee the decline will continue, or even that the current lower levels will be sustained, said several experts.

The stakes are enormous, stressed Gary Giovino, Ph.D., M.S., of Roswell Park Cancer Institute in Buffalo. At 400,000 deaths annually, tobacco is still the No. 1 cause of preventable, premature mortality. And the United States has 8.6 million people living with serious disease attributed to tobacco, he said.

Another speaker who addressed the panel, C. Tracy Orleans, Ph.D., senior scientist, Robert Wood Johnson Foundation, emphasized that the nation knows a lot about intervention and could accelerate quit rates. She pointed to creative experiments that "go where the smokers are" with pharmacist-delivered counseling at NASCAR events and work in the new Wal-Mart "Minute Clinics," targeting smokers who have the least income and education and, often, no health insurance.

In discussing treatment in the community, the panel pointed to "one, good quality," randomized controlled trial, which showed that cessation services offered by pharmacies in the United Kingdom were effective. That study, published in Addiction 2001, looked at treatment that included an initial interview with a pharmacist; a cessation contract; an offer of nicotine replacement therapy, if appropriate; weekly follow-up for four weeks; and then monthly follow-up for three months. However, researchers still need to find out whether that experience can be generalized to other nonclinical community settings and to the United States, said the report.

Regarding efforts in healthcare systems, the consensus statement said there is fair-to-good evidence for strategies including "smoker identification, provider education, academic detailing, reminders, audit, and feedback." But it stressed that these approaches seem to work better when used in combination. Healthcare system studies have used both physicians and nonphysician providers, including pharmacists, and there is good evidence that systems that have staff dedicated to cessation services are better than those that do not.

The panel did not look specifically at the status of reimbursement for cessation counseling. But it stated that research shows that cutting out-of-pocket costs for effective cessation therapies, through insurance-based coverage and other means, increases their use when the benefit is apparent to consumers.

The committee also found that treatments, including nicotine replacement therapy and telephone quit lines, are powerful and even more effective in combination. It also cited evidence of effectiveness of media campaigns and increases in tobacco pricing/taxation.

Among the questions that should be researched, said the committee, are why strategies are not more widely adopted and how barriers to their adoption could be overcome.

The meeting tackled the controversy surrounding the contention by some health experts that use of smokeless tobacco, as an alternative to smoking, could reduce the harmful effects. The statement called for more research on smokeless tobacco, including the impact of marketing, the toxins and health risks, and the advantages and disadvantages of regulating it in a manner similar to tobacco and medicinal nicotine.