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Briefings | ActionToQuit – Advancing Tobacco Control Policy

Obtener Adobe Flash Player

(Access to Coverage of Tobacco Treatment In Our Nation)

Partnership for Prevention

Shaping Policies | Improving Health


Office on Smoking and Health Director Sees Opportunities for Advancing Cessation

(Full monthly briefing)

March 28, 2011

Last fall a new director took charge of the Office on Smoking and Health (OSH) at the Centers for Disease Control and Prevention.  Tim McAfee, M.D., M.P.H., joined OSH following a distinguished career in tobacco control as a clinician, researcher, and public health evaluator. He worked for 20 years in population-based and clinical preventive health, with a strong focus on tobacco control. Since 2003, he served as the Chief Medical Officer for Free & Clear, a company providing quitline services to 26 states, as well as many health plans and individuals. He helped found and served on the Board of Directors of the North American Quitline Consortium, as well as numerous state and national tobacco policy advisory groups, and is an adjunct faculty member in the University of Washington School of Public Health.

ActionToQuit recently spoke with Dr. McAfee to learn about his vision for the Office on Smoking and Health and tobacco control in general.

ActionToQuit:

What is your vision for the Office on Smoking and Health?

Dr. McAfee:

I find it hard to separate my vision for OSH and my vision for what needs to happen to tobacco control in the country.  The Office on Smoking and Health is a catalyst, convener, and leader in all the efforts to make tobacco use a minor public health nuisance.  This is no small task.  Our efforts build on more than a half century of work, starting with the first epidemiological work on smoking and the first Surgeon General’s Report published in 1964.  The good news is that we have valuable resources at our disposal, including a strong evidence base on effective interventions, a network of state and local tobacco control programs nationwide, and new tools like FDA’s authority to regulate tobacco products.  As a result, we have it in our capacity to make tobacco use a minor public health nuisance as opposed to its current status as the number one cause of preventable death and disease in this country (and potentially soon in the world if trends in developing countries are not reversed).

ActionToQuit:

How can we reach that point?

Dr. McAfee:

At OSH, we see three key elements in reducing the problem of tobacco use.  In the last 50 years, we have driven smoking prevalence in this country down by half through public and private activity in these elements.

• Comprehensive smoke-free policies are the first element.  About half the states have implemented comprehensive smoke-free laws, and just under half the population is covered by smoke-free policies at the state or community level.  Many of the remaining areas are moving in the right direction.  But this activity has stalled in the last year.  Covering the remaining population must be a major pillar for future activity.  It will require societal movement and support, including the help of health professionals across the spectrum, from administrators to nurse’s aides.

• Price increases are the second element.  They have been shown to result in declines in consumption and initiation.  The impact of price increases can be further enhanced if a portion of the revenue is used to fund comprehensive state tobacco control programs, including services to help smokers quit.  Most of the first, highly successful state tobacco control programs, including the California, Massachusetts, and Oregon programs, were funded in this way.  However, in recent years most states have used tobacco excise tax revenue to plug budget holes, and it has been increasingly rare for states to dedicate any of this revenue to tobacco control.  In fact, a number of states facing budget shortfalls have drastically cut funding for their tobacco control programs at the same time that they substantially increased tobacco taxes.  I find this very disturbing.

One reason I took this position as director of OSH is to deal with this issue.  If we raise taxes on an addictive substance like tobacco, we incur an obligation to offer help in the broadest sense of the word to smokers who are paying the tax. While raising the price of tobacco is a powerful tool, it is not a silver bullet that will singlehandedly do the job of reducing tobacco use.  Like other tobacco control interventions, price increases are most effective when implemented as part of a comprehensive approach that includes eliminating second-hand smoke exposure, mass media campaigns to correct the information disparity created by the tobacco industry’s 12 billion dollar/year promotion of tobacco products, while also making assistance available to smokers who want to quit.  It is critically important to ensure that state tobacco control programs have adequate resources to fully implement the interventions that have been shown to drive down tobacco use.  Taxing tobacco products without concurrently funding programs that encourage and help smokers quit as well as discouraging kids from starting is unfair to the public—smokers and non-smokers alike.  We need to raise awareness about this issue.

• The third element is implementing state and federal media campaigns.  State media campaigns have played an important role in educating the public, changing social norms, and reducing tobacco use.  California is one prime example of this.  Research shows that effective campaigns need 1200 gross rating points (a term used in advertising to measure the size of an audience reached by a specific media vehicle and the frequency with which they are reached) per quarter.  Currently, state tobacco control campaigns average about 138 gross rating points, about one tenth of the recommended intensity. Traditional mass media, as well as the new social media channels, represent an incredibly important and powerful vehicle to counteract the ongoing multi-billion dollar marketing campaigns of the tobacco industry.

ActionToQuit:

All of these things help move people to stop smoking.  What do you see coming up specifically to help people with quitting?

Dr. McAfee:

The next two or three years are a time of great opportunity for cessation and tobacco control in general.  We have a limited window of time to take advantage of specific opportunities to mainstream the delivery and financing of help for tobacco users interested in quitting. We need to take full advantage of these opportunities.

• The Patient Protection and Affordable Care Act contains several provisions encouraging expansion of smoking cessation coverage for Medicaid enrollees with no cost sharing.  A provision requiring state Medicaid programs to provide comprehensive cessation coverage for pregnant women is already in effect.  The Centers for Medicare and Medicaid Services (CMS) is working on plans for implementing similar provisions for other Medicaid enrollees.

• The Affordable Care Act provisions also require private health insurance plans, with certain exceptions, to cover evidence-based items or services that have a rating of ‘A’ or ‘B’ in the current recommendations of the U.S. Preventive Services Task Force.  This includes tobacco-use counseling and evidence-based tobacco-cessation interventions. This also implies coverage for FDA-approved cessation medications, but the details of coverage and promotion of the benefit have yet to be decided.  These decisions will be made in various ways at the federal and state levels, as well as by individual health plans where they have leeway.

• Several initiatives are in the works or under consideration that could increase smokers’ motivation to quit and lead them to call state quitlines in greater numbers.  These include national and regional media campaigns that OSH will be launching in the near future, as well as the possibility that FDA could put the national quitline portal number, 1-800-QUIT-NOW, on new graphic cigarette warning labels.  If the FDA were to do this, it would mean that every smoker would carry around an evidence-based cessation resource which they would be exposed to more than 7,000 times a year.  OSH plans to use resources from the Affordable Care Act’s Prevention and Public Health Fund to work with states to expand quitline services and to promote these services.  This will likely also require integration and cooperation with public and private insurers and providers.

• In addition to the changes in cigarette labeling, the FDA has regulatory authority over many other aspects of tobacco products. For instance, it has authority to require the tobacco industry to markedly decrease the nicotine content in cigarettes, as well as other harmful constituents. It can allow or dis-allow marketing claims of decreased harm for tobacco products, such as smokeless and the new dissolvables, based on evidence of their impact on individual and public health. The FDA has already banned flavoring agents in cigarettes, and may consider removal of menthol cigarettes from the marketplace, based on recent recommendations from its scientific advisory committee that this would benefit public health.

Also, the FDA can further restrict tobacco industry marketing practices, beyond its ban of terms like “light”, “ultra-light”, and “mild”. Although currently limited to cigarettes and smokeless products, the FDA can potentially assert jurisdiction over cigars and new products such as e-cigarettes, and could also loosen restrictions on nicotine replacement therapy. Actually creating rules to exercise its authority, and then upholding and implementing these rules against the inevitable litigation and political assaults of the tobacco industry, will be an incredibly important and complex task.  How far the FDA is able to go in its quest to markedly diminish the harms caused by tobacco products will have a profound impact on how easy or difficult it is for tobacco users to quit using deadly products, and for clinicians and public health practitioners to help them.

ActionToQuit:

In addition to these federal initiatives, what other policies do you foresee that will impact cessation?

Dr. McAfee:

Policies that affect health systems such as electronic medical records and enforceable quality improvement targets can be very important.  Making routine the collection of information about tobacco use is a practice well positioned for mainstreaming.  These policies will help providers to offer assistance to smokers.  New reward systems in CMS can help by providing extra reimbursement to practices that routinely identify tobacco users, and provide appropriate services.

Under its regulatory authority, the FDA has the potential to make profound changes.  One almost stealth change, already in place, has been to remove misleading labels such as “light,” “mild” or “low tar.”  This change has received little media attention.  Unfortunately, cigarette packs for many brands still contain other cues, such as colors, which help smokers find the brands they were used to choosing and which may perpetuate smokers’ false beliefs that certain cigarettes are safer than others.  There has not been enough education on why the misleading descriptors were removed, and also on how to use these changes to help smokers quit.

Another extremely important policy change has been implemented by Massachusetts in their Medicaid benefit.  As part of its health care reform initiative, Massachusetts provided Medicaid enrollees with comprehensive evidence-based smoking cessation coverage in line with the 2008 Public Health Service guideline and heavily promoted this coverage to Medicaid enrollees.  The results were remarkable.  More than one third of smokers in Medicaid took advantage of the cessation benefit, the smoking rate in this population fell by one fourth, and hospitalizations for heart attacks and heart disease decreased significantly.  This is a powerful example which shows the importance of coverage and a comprehensive campaign approach, including making sure that smokers and providers are aware of the benefit, especially in a disadvantaged population. We are most effective in helping tobacco users quit when our efforts encourage quit attempts, as well as ensuring access to proven treatments that increase the odds of success for motivated quitters.

The benefits of comprehensive tobacco control programs are showing up in states which have implemented evidence-based tobacco control programs with adequate funding and have sustained these programs over time.  For example, California, the home of the longest-running comprehensive state tobacco control program, has reported dramatic decreases in lung cancer mortality and rates of other tobacco-related cancers.   Heart disease deaths and lung cancer rates have fallen at accelerated rates in California compared to the rest of the country.  In fact, California has the potential to be the first state in which lung cancer is no longer the leading cancer cause of death.  A recent analysis reported that California’s Tobacco Control Program has been associated with savings of $86 billion in health care expenditures, representing a 50 to 1 return on the investment in the program. Similar findings are beginning to materialize for well-funded programs started later, such as Washington State’s.

ActionToQuit:

What advice do you have for cessation advocates functioning in this time of reduced resources?

Dr. McAfee:

We are on the verge of having much broader availability of cessation services for tobacco users, in an environment that will encourage quit attempts, because of the changes we have talked about.  If these changes come to pass —more tools, referral services, broader coverage by public and private insurers, quitline promotion on packs and in mass media campaigns—resources will have actually opened up.

The concern is that these changes are at risk because of the economic downturn, and perhaps from a misplaced perception that the fight against tobacco has already been won.  Conditions exist—both in terms of regulatory authority and supportive, visionary leadership—to support efforts at the state and insurer level.  People who want to increase cessation should seize the opportunities available and take full advantage of them, while fighting to maintain existing programs. For clinicians and advocates specifically interested in cessation, it is also very important to support and insist on the broader pillars of the public health struggle enumerated earlier, instead of focusing solely on access to cessation support.

People working in the states on tobacco control have seen a disturbing 30% overall decline in funding from 2008 to 2011, with funding now at its lowest level since 1999.  At the same time tobacco excise taxes have increased by about 30%.  Some states have been left with only the funding from OSH for their programs, which is not even close to adequate to do what needs to be done. 

However, this situation does not need to be permanent.  Public opinion surveys show strong bipartisan support for funding comprehensive tobacco control programs, helping smokers quit, implementing smoke-free policies, increasing tobacco excise taxes, and regulating tobacco products.  We need to rededicate support for tobacco control approaches that have been demonstrated time and again to be effective but have only been partially and intermittently implemented.

At the same time, as I have mentioned, we have a golden opportunity to take advantage of provisions in the Affordable Care Act, upcoming national and regional media campaigns, changes in health care systems, FDA regulation, and other developments to motivate and help smokers to quit. 

Working together, we can take advantage of the unprecedented opportunities that are open to us while protecting state tobacco control programs from the threats posed by state budget woes. 

The next couple of years will be crucial.  If we act strategically, setting our priorities based on the strong evidence that is available to us, we can potentially turn the corner on this country’s tobacco use epidemic once and for all.


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