Mr. Chairman and members of the Committee, thank you for asking me to appear before
you to talk about the critical issue of smoking cessation. I am very proud that the Agency for
Health Care Policy and Research (AHCPR) is part of the historic and important tobacco
legislation that is the subject of this hearing.
As you may know, on September 19, 1997, the President called for comprehensive
tobacco legislation with a goal of reducing the smoking rate among young people by 50 percent
within seven years. The President stressed that the following five key elements must be at the
heart of any tobacco legislation:
- A comprehensive plan to reduce teen smoking, including a combination of penalties and
price increases that raise cigarette prices up to $1.50 per pack over the next 10 years as
necessary to meet youth smoking targets;
- Express reaffirmation that the FDA has full authority to regulate tobacco products;
- Changes in the way the tobacco industry does business;
- Progress toward other critical public health goals, such as the expansion of smoking
cessation and prevention programs and the reduction of secondhand smoke; and
- Protection for tobacco farmers and their communities.
The primary focus of my testimony today will be on smoking cessation in general and
AHCPR's efforts in particular. AHCPR-sponsored research has found that most smokers want to
quit, and that clinicians -- in partnership with public and private payers -- can help them succeed.
However, I would like to take a few minutes to discuss with you additional research that is
needed to make the potential of effective and cost-effective smoking cessation a reality.
We should point out that our comments on the Committee's Discussion Draft are based
on a preliminary AHCPR review. The discussion draft has not been fully reviewed by all of the
other Executive branch agencies affected by the proposed legislation.
I don't need to tell you the human toll that smoking exacts or the serious financial impact
it has on health care costs. However, I would like to describe to you the statistics of smoking
cessation. There are currently some 50 million smokers in the United States, and according to
the Centers for Disease Control and Prevention (CDC), 70 percent have tried to quit, and
one-third of them try to quit at least once a year. Most are unsuccessful. Why? Evidence
that as many as 90 percent try to quit "cold turkey." The bottom line is that less than 3 percent of
smokers who try to quit succeed.
This is particularly tragic because research, some of it supported by AHCPR, clearly and
unequivocally shows that simple smoking cessation interventions can work.
What Works in Smoking Cessation
In 1996, AHCPR released an evidence-based clinical practice guideline on smoking
cessation developed by a private sector panel headed by Dr. Michael Fiore, Director of the
Center for Tobacco Research and Intervention at the University of Wisconsin Medical School.
This effort, for the first time, looked at what was then the total body of scientific data on
smoking cessation interventions to determine what works best. Dr. Fiore testified before the
Subcommittee on Public Health and Safety last fall. The panel concluded that:
- Clinicians can have a powerful impact in motivating patients who smoke to try to quit;
- As little as three minutes of a physician's time can about double the rate of quitting
among his or her patients and the more time spent with smokers, the higher their quit
- One simple, essentially no-cost intervention - expanding the vital signs to include
smoking status -- markedly enhances the rate at which physicians then go on to help their
- Every patient who tries to quit should be offered effective treatments including social
support, simple advice on how to quit successfully; and pharmacotherapies that have been
demonstrated to increase the likelihood that a smoker will quit successfully - nicotine
replacement therapies -- like the patch and the gum -- and the new non-nicotine medicine,
The panel found that this program can succeed only if the entire health care delivery team
-- including traditional fee-for-service insurers and managed care plans -- support and promote
smoking cessation programs. They can provide the financial incentives that will reinforce
clinicians' commitment to helping their patients quit smoking, and for them, smoking cessation
can help reduce health care costs.
AHCPR estimates that widespread implementation of the smoking cessation guideline
will, conservatively, double the annual quit rate, increasing the number of new nonsmokers by up
to an additional 1.3 million. This could save the health care system $2.6 billion in
smoking-related health care costs.
An AHCPR-supported analysis of the cost-effectiveness of smoking cessation, published
in the December 3, 1997, Journal of the American Medical Association, found that smoking
cessation treatments cost about $165 per smoker, and overall, cost $2,500 per year of life saved.
This compares to $50,000 per year of life saved for mammography screening and $100,000 per
year of life saved for cholesterol screening.
Other than immunization, smoking cessation is the most cost-effective prevention
intervention for adults. Leading authority on guidelines and cost-effectiveness analysis, David
Eddy, M.D., has referred to smoking cessation as the "gold standard" in prevention interventions,
and Dr. Tim McAffee, from Group Health Puget Sound in Washington State, called cessation
services "the health care bargain of the millennium" in testimony before your Subcommittee on
Public Health and Safety.
AHCPR's Smoking Cessation Programs and Partnerships
Over the past two years, AHCPR has been working with public and private sector
organizations to advance the implementation of smoking cessation programs. We have worked
with key clinician groups, such as the American Medical Association (AMA), National Medical
Association, American College of Obstetricians and Gynecologists, American Academy of
Pediatrics, and American College of Chest Physicians. These organizations are helping promote
use and adaptation of the AHCPR guideline by disseminating it to their members. For example,
the AMA mailed copies of the guideline physician pocket guide to 200,000 primary care
physicians across the country.
In addition, the American Cancer Society, following the recommendations of the AHCPR
guideline, has revamped its tobacco cessation program for pregnant women and mothers who
One of our most exciting initiatives is a partnership with the Robert Wood Johnson
Foundation and the American Association of Health Plans to promote the adoption of innovative
approaches to help Americans enrolled in managed care plans avoid the harm caused by tobacco.
The "Addressing Tobacco in Managed Care" Initiative, which was developed in collaboration
with AHCPR, CDC, The National Institutes of Health, and the American Association of Health
Plans, will promote the adoption of innovative approaches by managed care organizations to
identify enrollees who smoke and to help them quit, and to evaluate scientifically the
effectiveness of these approaches. This initiative was launched last week at a conference here in
AHCPR also is addressing smoking cessation through the renewed activities of the U.S.
Preventive Services Task Force, and its updated report. Its 1995 report provides clinicians with
information on the effectiveness and appropriateness of the full range of preventive care services,
including advising patients to reduce risky health-related behaviors such as tobacco use. AHCPR
also will work on implementing the recommendations of the Task Force through the Put
Prevention into Practice Program, the U.S. Public Health Service national campaign to provide
practical tools for patients, clinicians, and health care systems to improve the delivery of
AHCPR Comments on the Committee's Discussion Draft
Mr. Chairman, the discussion draft recognizes that the implementation of smoking
cessation is a team effort, by ensuring that funds are used to train health care professionals and
health plans in cessation interventions methods. It also ensures that funds are used to encourage
insurers and health plans to provide coverage for science-based cessation programs. Finally, I
want to thank you for endorsing AHCPR's smoking cessation guideline in your proposal as the
basis for cessation treatment programs.
The AHCPR guideline already is being used in states and by states to reduce health care
costs. For example, it is at the center of a smoking cessation project supported by the Maine
Medical Assessment Foundation and the Maine Medical Health Management Association, which
represents the state's largest employers, including L.L. Bean, Bath Iron Works, and the Maine
state government. The project, which will have an impact on 10 percent of the state's population
-- about 120,000 people -- will address the barriers to successful implementation of smoking
cessation programs associated with the physician community.
I want to stress that AHCPR's mission doesn't stop with building the evidence about
smoking cessation. We feel it is critical that we translate the knowledge we gain through
research into clinical practice. To do this, AHCPR disseminates science-based information and
supports the development of tools for use by clinicians, patients, and health care systems.
For example, AHCPR has developed educational materials to educate clinicians about
smoking cessation interventions. While most clinicians understand the of benefits that smoking
cessation, few make a serious effort to help their patients quit. Studies have found that while 70
percent of smokers see a physician each year, only about half are urged to quit, and less than 20
percent are given advice on how to quit and information on effective interventions.
Many physicians and other clinicians operate under misconceptions about smokers and
the cessation process. For example, many believe that if a smoker wants to quit, he or she will
bring the issue up; others feel that they don't have enough time during their encounters with
patients who smoke to make an impact. Better education could dispel these myths and provide
clinicians with scientific information on smoking cessation.
AHCPR's educational materials, entitled the "Two - Three" Initiative, are based on the
AHCPR guideline. It recommends that clinicians ask their patients two questions "Do you
Smoke?" and "Do you Want to Quit?" as part of every medical evaluation. Clinicians should
follow this with an intervention, as brief as three minutes, recommending smoking cessation
treatments proven to work.
Health Services Research Is Critical
Before I conclude, I also want to mention the research component which you cover in
Subtitle E of your bill. There is general agreement among all the agencies of the U.S. Public
Health Service on the critical importance of expanded research on tobacco, its impact on the
human body, and the impact of its use on the health care system.
My colleagues at the NIH and CDC can comment on the importance of basic biomedical,
clinical, and epidemiological research on smoking and smoking cessation. I would like to
emphasize the importance of health services research, which consists of three components.
First, we build the science base by conducting clinical research, such as outcomes and
effectiveness research and cost-effectiveness analysis, that serves as the foundation for improved
care. Second, we conduct and support research to develop strategies to improve the delivery of
health care services. Third, we help improve the quality of health care services delivered in this
country by translating and disseminating the findings of our research to the relevant audiences
and evaluating ways to ensure that the research is used appropriately.
Health services research can help us answer questions such as: How do smokers use the
health care system and how can smoking cessation services be organized to be most effective for
all smokers? How do we change the behavior of doctors and health systems to deliver needed
cessation services? What are the functional changes caused by long term tobacco use? How
does tobacco use affect nonsmokers?
For example, AHCPR's Peter Gergen found that passive cigarette smoke can be blamed
for causing about half of all asthma, chronic bronchitis, and frequent wheezing in children age
two months to two years. His study, which was reported last week in the Washington Post and
USA Today, found that the risk of illness is highest when adults smoke at least a pack of
cigarettes a day.
A critical issue that should be answered by research, both biomedical and health services
research, is what smoking cessation interventions are effective for younger smokers and
teenagers. The National Cancer Institute is currently funding biomedical research on tobacco
and youth, and how to help them quit using medical interventions.
Health services research can determine how to get the interventions to them. It has
always been assumed that young smokers don't want to quit, but research indicates that this is a
myth. We should determine how to capitalize on younger smokers' desire to quit and how we
can get them the information they need.
Mr. Chairman, and members of the Committee, I want to thank you for providing me
with the opportunity to comment on your proposal to curb smoking in this Nation. You have
taken a significant step in your proposal by recognizing that in order for smoking cessation
efforts to be effective, we must empower clinicians -- and ultimately patients -- with
evidence-based information on smoking cessation programs that work. This is the premise of
smoking cessation guideline. From a physician's perspective, I know the importance of
evidence-based information plays by dispelling misconceptions about courses of treatments, and
helping to make sound, safe medical decisions.
Mr. Chairman, I look forward to working with you and the Committee as you continue
your deliberations on this critical issue. Thank you.