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Policy as a Driver of Cessation When trying to get smokers to quit, the focus often has been on treatments and services that reach the individual smoker. But there is a growing body of research that shows that tobacco control policies can increase tobacco cessation and treatment use at the population level. This article looks at five policies and their impact on cessation:
Policy changes are opportunities to create "breakthrough" increases in treatment use and quit rates. Identifying and capitalizing on policy has the potential to significantly improve the use and impact of current evidence-based treatments. Increasing Tobacco Prices/Taxes One policy that has been proven to have an impact on quit rates is increasing the cost of tobacco products. Higher cigarette prices induce smokers to quit. Research has shown that a mere 10 percent increase in cigarette prices reduces adult smoking prevalence by 2 percent, increases the probability of a quit attempt by 10-12 percent, and increases the probability of a successful quit by 1-2 percent. More than 43 states and several big cities, including New York City and Chicago, have raised their tobacco taxes in the last five years. There are signs that this trend will continue. Cost and tax increases also can boost treatment use when treatment options are widely available. When Illinois increased the state cigarette excise tax by 40 cents per pack in 2002, call volume to the state quitline more than doubled. One of the challenges of this policy is removing the barriers, such as access and cost, to cessation treatments. This is especially important to do at the time when these policies take effect to help to support the smokers who want to quit. Smoke-Free Air Laws Smoking bans may also play a role in demand for cessation products and services. There is growing evidence that bans appear to significantly boost desire to quit, quit attempts and treatment use. For instance, quitline calls increased significantly following the implementation of New Zealand's 2004 expanded smoke-free legislation - without any increase in quitline advertising. In 2002, New York City created the "perfect storm" in terms of policy. That year, they enacted a Smoke-Free Air Act requiring 100 percent smoke-free workplaces, restaurants and bars; increased tobacco taxes by a total of $1.81; implemented a media campaign; and launched a large, quitline-based NRT give-away program. As a result, from 2002 to 2004, the percent of adult New Yorkers who smoke declined from 21.6 percent to 18.4 percent, which was a 15 percent decrease and the fastest drop in smoking prevalence ever recorded in the U.S. As of early this month, a total of 35 states and the District of Columbia now have 100% smoke-free air laws at the local level, according to the most recent quarterly update from Americans for Nonsmokers Rights. This includes 8,276 municipalities that now have 100% smoke-free private workplaces/government buildings, restaurants, and/or bars, protecting 54.8% of the U.S. population. These numbers continue to grow with more smoke-free laws planned in other states and localities. Fully taking advantage of these policy changes requires being proactive. The goal is to be ready for the implementation of the policy and anticipate and accommodate increases in treatment demand. Several national groups and organizations, including NTCC, are working to develop policy "playbooks" to guide states/cities that pass smoke-free policies in ways to expand treatment access, capacity and promotion so they can take full advantage of the increase in quitting efforts and demand for treatment. Treatment Coverage Policies One barrier to the use of cessation services is cost. Reducing treatment costs by increasing insurance coverage and reimbursement can help boost treatment use and quitting. Fortunately, both public and private tobacco cessation treatment coverage has increased over the past decade. In 1995, only one state Medicaid program covered any tobacco dependence treatments. In 2005, 42 state Medicaid programs and 96 percent of U.S. health plans provided coverage for some form of evidence-based counseling or pharmacotherapy. Private health plans and employers also have a tremendous influence on which products and services are offered to smokers and are covered. Treatment coverage not only helps to improve the health of employees, but it is also good for business. Tobacco cessation products and services can help to improve employee productivity and performance. In Oregon, the "Make it Your Business Campaign" helped to clarifying the true business costs of tobacco use for employers, including the costs related to reduced smoker productivity. This campaign helped drive the Public Employees Benefits Board, the state's largest health care purchaser, to offer a barrier-free tobacco cessation benefit. There is still much progress to be made in the number and type of treatments covered, and the extent of coverage. There also is a great need to promote these benefits. Research shows that smokers unaware of treatment benefits are, not surprisingly, unlikely to use them. Allocating MSA Bonus Funds for Tobacco Control The 1998 state tobacco settlement, and the billions of dollars in revenue it provides each year, presented the states with an unprecedented opportunity to address tobacco use in the United States. Unfortunately, less than 4 percent of the original MSA funds awarded to the states have been allocated for tobacco control. Beginning in 2008, however, as MSA bonus funds become available, state-elected officials will get a second chance to adequately fund tobacco control programs. This represents a critical new policy initiative, and one with enormous potential impact on tobacco cessation treatment access, use and demand. Lack of Policy on Tobacco Industry PREPs The tobacco industry has been marketing modified tobacco products that they claim reduce the risk of smoking. These products, known as potential reduced exposure products, or PREPs, are marketed to smokers as having "reduced-risk" as compared to traditional tobacco products. Smokers are at risk of being misled by this new generation of so-called "reduced risk" products just as they were by light and low tar cigarettes. Studies have shown that smokers perceive these products to have lower health risks and carcinogens than regular or light cigarettes. In one study, despite the fact that none of the product ads explicitly stated that the products were healthier, 62 percent believed the ads for "reduced risk" cigarettes conveyed a message that the product was healthier or safer. These "reduced risk" products may deter smokers from quitting, encourage re-initiation by smokers who have quit, or even encourage others to begin smoking. New legislation is being considered to give the Food and Drug Administration the authority to assess the validity of claims made by tobacco companies. This authority to regulate tobacco products and protect the public health will help ensure that smokers are accurately informed about the health effects of tobacco products. Policy changes have the potential to significantly improve the use and impact of current evidence-based treatments. Identifying and taking advantage of these opportunities requires programs to support the smokers who make quit attempts as these policies are implemented. Policy changes have many beneficial effects, from reducing exposure to secondhand smoke and helping to prevent smoking initiation, to potentially creating "breakthrough" increases in treatment use and quit rates. For more information on this, please contact Jessica Nadeau at jnadeau@aed.org or visit http://www.tobacco-cessation.org. New Study Indicates Nicotine Patches May be Safe for Helping Patients with Coronary Artery Disease to Quit Smoking A new study presented at the American College of
Cardiology's 56th Annual Scientific Session indicates that nicotine
patches may be safe to use in patients with coronary artery disease.
The study evaluated patients with greater than nine percent ischemic
perfusion defect size (PDS, a measure of the amount of reduction
in myocardial tissue blood flow) and the effects of nicotine patches
on stress-induced myocardial ischemia. The people who smoked more
than 20 cigarettes per day were randomized to receive either 21mg
NicoDermCQ nicotine patches or placebo patches while continuing
to smoke. At week four, a scan showed that, despite an increase
in nicotine levels in the active patch group, no significant changes
in total or ischemic PDS were observed from baseline, when compared
to patients receiving the placebo patches. Rajesh Mishra, MD,
PhD, Director, Medical Affairs, GlaxoSmithKline Consumer Healthcare
says, "what many people and even physicians sometimes misunderstand
is that the cardiovascular risk associated with smoking is from
the components of burned tobacco smoke, not from the smoking cessation
aids that help smokers quit. These misperceptions in particular
may prevent more physicians from recommending and using these
proven safe and effective smoking cessation aids to help their
patients quit."
Global Surveys Reveal a Serious Communication Gap Between Doctors and Smokers There is a significant communication gap between
doctors and their smoking patients, according to combined results
from two of the largest international surveys of physicians' and
smokers' attitudes to smoking and smoking cessation. Results showed
that there are significant differences between doctors' smoking
cessation practices and smokers' experiences. Advice from a healthcare
professional, even when brief, is known to increase the success
of smokers wanting to quit. Despite this, the surveys highlight
a vast difference in the number of doctors (41%) who say they
discuss smoking with their patients at every visit, versus the
number of smokers (9%) who say they discuss smoking with their
doctor at every visit. Although 66% of doctors said they explain
various methods of quitting to their patients, only half of this
total of smokers who have talked to a doctor about smoking (33%)
said they received this advice. In addition, although 47% of doctors
stated that they develop quit plans for their patients to assist
them, only a quarter of this total of smokers who have talked
to a doctor about smoking (13%) said this was the case. The surveys
also highlighted that doctors need better support, resources and
improved training to engage patients. Data from the surveys showed
that doctors want effective smoking cessation medications (81%)
and additional coaching on motivating their patients to quit (78%).
Data from the surveys also showed 51% of doctors said they do
not have time to help their patients quit, 46% said they had higher
priorities and 38% said they were not appropriately trained to
help patients quit smoking.
Smoking Takes a Toll on Productivity As Well As on Health Two studies reported in the April issue of Tobacco
Control indicate that smoking takes a toll on productivity
as well as on health. In the first study, among the approximately
59,000 women serving in the U.S. Navy, smoking at the time of
enlistment was consistently associated with poor work performance,
as well as a higher risk for demotion, desertion, or a less-than-honorable
discharge, according to Terry L. Conway Ph.D., and colleagues
at San Diego State University Graduate School of Public Health.
In the second study, Petter Lundborg, Ph.D., an economist at the
Free University of Amsterdam in the Netherlands, reported that
Swedish smokers take an average of nearly eight more sick days
annually than their non-smoking co-workers, even after adjusting
for health status and for riskier occupations that seem to attract
smokers.
First-of-its-kind Tobacco Treatment Unveiled for Persons with Serious Mental Illness Nearly 70 percent of individuals with serious mental
illness (SMI), as compared with 23 percent of the general population,
smoke cigarettes. Smokers with SMI and addiction consume nearly
half of all cigarettes sold in the United States. However, smokers
with SMI have less access to cessation services and traditional
treatments are less effective on this population. A project conducted
by healthcare professionals at Clubhouse of Suffolk, Inc., a private,
not-for-profit, psychiatric rehabilitation agency in New York,
has found compelling evidence that these individuals respond to
tailored interventions which address their specific needs. The
Smoking Cessation Project at Clubhouse addressed the unique issues
of tobacco use within this population and developed and applied
a comprehensive approach addressing the biological, psychological
and social aspects of tobacco dependence in individuals with mental
illness. In a pilot study, this model had a significant impact
on the readiness of participants to quit smoking, the number of
cigarettes smoked per day (6.8cpd reduction), and the number of
participants who made a quit attempt (36%).
Research Finds Genes Which May Help Smoking Cessation Scientists supported by the National Institute on
Drug Abuse (NIDA) have for the first time identified genes that
might increase a person's ability to abstain from smoking. The
study, published in the journal BMC Genetics, brings researchers
a step closer toward tailoring individualized drug therapy for
addiction based on an individual's unique genetic makeup. "This
research marks the first time we've been able to identify genes
involved in the ability to quit smoking," says NIDA Director Dr.
Nora D. Volkow. Dr. George Uhl and his colleagues performed a
genome wide analysis on the DNA of two types of nicotine dependent
individuals, one that was able to successfully quit the cigarette
smoking behavior and one that was not. "We identified 221 genes
that distinguished successful quitters from those who were unsuccessful,"
says Dr. Uhl. "We know the functions of about 187 of these genes,
but 34 have functions that are unknown at present. We also found
that at least 62 of the genes that we had previously identified
as playing roles in dependence to other drugs also contribute
to nicotine dependence."
The Effects of Foods, Beverages, and Other Factors on Cigarette Palatability By making a few modifications to the diet one may
be able to make quitting smoking bit easier, according to a study
published in April 2007 issue of the journal Nicotine and Tobacco
Research. While smokers commonly report that various foods and
beverages worsen or enhance the taste of cigarettes, the prevalence
and diversity of these phenomena have not been studied. This study
administered an open-ended questionnaire to 209 smokers asking
for reports of foods or beverages that worsen or enhance the taste
of cigarettes. Commonly reported categories that worsen the taste
of cigarettes were dairy products (19%) non-caffeinated beverages
(14%) and fruits and vegetables (16%). Commonly reported categories
that enhance the taste of cigarettes were caffeinated beverages
(45%), alcoholic beverages (44%) and meat products (11%).
Smoking Cessation Rates in California Are Up Since the advent of the California Tobacco Control
Program in 1989, the state's young adult smokers are quitting
the habit in record numbers and older smokers are consuming far
fewer cigarettes, according to a new series of studies from the
Moores Cancer Center at University of California, San Diego (UCSD).
Studies published in the journal Tobacco Control found that cessation
rates were much higher among young adults ages 20 to 34 in California
compared to those of the same age in New York or New Jersey, which
have similar population size and high prices on tobacco, but no
focus on "de-normalizing" smoking. Cessation rates among young
adults in the tobacco-growing states, which have low tobacco prices
and no comprehensive tobacco control program, were significantly
lower than California, New York or New Jersey.
Indiana Receives National Smokefree Workplace Award Americans for Nonsmokers' Rights (ANR) has given
Indiana a national award recognizing the state as a leader for
protection from secondhand smoke in the workplace. In 2006, 15
Hoosier cities and counties enacted smokefree workplace laws,
making Indiana a national leader in protection from secondhand
smoke in the workplace. Indiana health groups are receiving a
national award for their leadership. "We are proud to present
Indiana with the ANR Smokefree Indoor Air Challenge Award for
its success in protecting the right to breathe smokefree air in
the workplace in a growing number of cities," said Cynthia Hallett,
executive director of ANR.
ANR Foundation Releases April 2007 Quarterly Update to the Lists and Maps On April 2nd, Americans for Nonsmokers' Rights released its updates to lists and maps of U.S. municipalities and states with 100% smokefree laws now in effect. This year is on track to be the biggest year ever for the smokefree movement. Nearly 55% of U.S. population now lives in a city or state with a strong smokefree law. This year also marks the 30 year anniversary of the landmark 1977 Berkeley, CA smokefree ordinance that helped spark the national movement. Altogether, as a result of both local and statewide smokefree laws, 8,276 municipalities now have 100% smokefree private workplaces/government buildings, and/or restaurants, and/or bars, protecting 54.8% of the U.S. population. There are now 2,572 U.S. municipalities with some sort of local clean indoor air law, 591 of which provide 100% smokefree protection for private workplaces/government buildings, and/or restaurants, and/or bars. Twenty two states/commonwealths have strong laws now in effect that qualify for at least one of the 100% smokefree list categories. A total of 35 states and the District of Columbia now have 100% smokefree air laws at the local level. A total of 198 municipalities have ordinances in effect that provide for 100% smokefree workplaces, restaurants, AND bars. For more information, see web link:
Kick Butts Day 2007 Activities Held Across the Country The 12th Annual Kick Butts Day, sponsored by the
Campaign for Tobacco-Free Kids, was held on March 28, 2007 More
than 2,000 events took place across the county. This year, Kick
Butts Day focused on raising awareness about the thousands of
chemicals in each puff of cigarette smoke and the need for elected
officials at all levels to step up the fight to reduce smoking
and other tobacco use. Cigarette smoke contains more than 4,000
chemicals, including at least 69 that cause cancer and many more
that are hazardous. But a new poll released by the Campaign for
Tobacco-Free Kids finds that most Americans are not aware of the
dangerous chemicals in cigarettes and cigarette smoke. The poll,
conducted March 7-11, found that 71 percent of adults and 79 percent
of teens could not name any of the chemicals found in cigarette
smoke, other than tar and nicotine. Health advocates are urging
Congress to pass legislation granting the U.S. Food and Drug Administration
(FDA) authority to regulate tobacco products. Among other things,
the FDA could require that tobacco companies disclose the contents
of tobacco products and remove harmful ingredients; crack down
on tobacco marketing and sales to kids; and stop tobacco companies
from misleading the public about the health risks of their products.
Legacy Releases New Milliman Report In March, the American Legacy Foundation released
a Milliman Report titled Covering Smoking Cessation as a Health
Benefit: A Case for Employers. The report contains actuarial data
related to the health consequences of smoking. The report provides
information so employers can make informed choices based on the
costs and benefits of smoking cessation programs and compare those
to other routinely provided benefits.
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