Prevention Matters

A new study published in the British Medical Journal states that smoking cessation offers a significant benefit to early-stage lung cancer patients by reducing the progression of the disease.
“The adjusted estimates suggest that the risk for death is halved in patients who stop smoking”, say the researchers, led by Amanda Parsons, research fellow at the UK Center for Tobacco Control Studies at the University of Birmingham, United Kingdom.

“The difference in survival between patients who stopped smoking and those who continued is striking", said H. Jack West, MD, medical oncologist at the Swedish Cancer Institute in Seattle, Washington, and author of the Blowing smoke blog on Medscape Oncology. “This effect is larger than that seen with postoperative chemotherapy”, he added.

This research is both fascinating and promising, but must be considered preliminary. Only a large-scale randomized controlled trial will permit researchers to confidently draw conclusions and make patient care recommendations.

David Zauche
Senior Program Officer
Partnership for Prevention

Two smoking-cessation groups want to make nicotine patches, lozenges and gum available for sale everywhere cigarettes are sold. They're petitioning the Food and Drug Administration to make that possible by relaxing current restrictions on those products.

The Association for the Treatment of Tobacco Use and Dependence and the Society for Research on Nicotine and Tobacco are also asking the FDA to tone down warnings on cessation products that say they shouldn’t be used when people continue to smoke or in those who have heart conditions.


“It sends the message that these products are dangerous and sends the message to the smoker to just continue smoking,” said Ken Wassum, former president of the Association for the Treatment of Tobacco Use and Dependence

Exellent piece in The Huffington Post on the health care system's failure to adequately tap the tobacco cessation resources that have been scientifically proven to be effective.

A new study in the American Journal of Preventive Medicine suggests that people respond well to free counseling programs on weight loss or smoking cessation, but participation falls dramatically when services are no longer free. The cost of counseling also appears to make a difference to the doctors or health-care providers who refer patients to the programs, according to the study.

The authors reviewed a program that used an electronic database system to suggest health-care counseling for adults with unhealthy behaviors. For a time, free counseling was provided until funding ran out. Under the free program, 1,860 of 5,679 people who were evaluated were determined to have at least one unhealthy habit, and 407 of them were given referrals for intensive counseling, the study reported.

After the funding ceased, 729 of 2,510 people who were evaluated were determined to have unhealthy habits and just five were referred for counseling -- a 97 percent decrease in the referral rate, according to the study. Even when clinicians did offer a referral, 81 percent fewer patients followed through and got counseling when the counseling was not free.

Smoking cessation significantly increases cardiac health later in life, says a new study from Tel Aviv University.

The research found that quitting smoking after a heart attack has about the same positive effect as other major interventions such as lipid-lowering agents like statins or more invasive procedures.

"We found that people who quit smoking after their first heart attack had a 37 percent lower risk of dying from another, compared to those who continued to smoke," said Dr. Yariv Gerber of TAU's Sackler School of Medicine.

Twenty-two institutions across the country are participating in a Phase III clinical trial to determine whether a new investigational "nicotine vaccine" is safe, effective and capable of stimulating an immune response. Approximately 1,000 male and female smokers aged 18 to 65 will take part in the 12-month study NicVAX, a vaccine developed by Nabi Biopharmaceuticals.

Nicotine molecules are so small that they can pass through the body's brain/blood barrier without triggering a reaction from the immune system. However, NicVAX stimulates the immune system to produce antibodies that bind to or capture nicotine
molecules in the bloodstream, making them too large to cross the blood-brain barrier. As a result, many of the expected rewards from smoking are blocked, making it easier for the smoker to become and remain abstinent.

“Smokers continue to smoke even when they know it’s harmful because of these ‘brain effects,’” explained David Gonzales, Ph.D., principal investigator and clinical investigator in medicine at the Oregon Health and Science University, one of the 22 test centers. “While a smoking cessation medication such as varenicline prevents nicotine from binding to receptors once it is in the brain, NicVAX is designed to block nicotine before it enters the brain.”

In the UK, the National Health Service is ramping up its support for people trying to give up smoking in a bid to halve the number of smokers from 21% to 10% of the population by 2020. According to a new government strategy, every smoker will be able to get help from the NHS to suit them if they want to give up, with new types of support available at their convenience. The government is also considering the case for plain packaging and will review legislation to decide whether to extend the smoking ban from enclosed public places and workplaces to areas like entrances to buildings.

The health benefits Americans have gained by reducing their tobacco use are becoming "outweighed" by the negative effects of our growing obesity epidemic, according to a new study. The study, led by Susan Stewart of Harvard University, forecasts the life expectancy for a nationally representative 18-year-old assuming that recent trends in smoking and weight gain continued for the next decade or so.

While continued declines in cigarette smoking would increase the life expectancy of the18-year-old by 0.31 years by 2020, continued increases in BMI would cut life expectancy by 1.02 years over the same period of time. That's an overall net loss in life expectancy 0.71 years.

USA TODAY's Rita Rubin reports that researchers are investigating whether the same approach used to prevent infectious diseases could treat addictions to such drugs as nicotine.

Nabi Pharmaceuticals has gotten a $10-million grant to study the effectiveness and to monitor the side effects of a smoking-cessation vaccine. Nabi, based in Rockville, Md., expects to begin enrolling patients in the NicVax study by year's end.

The success of a recent Massachusetts program hat provides virtually free access to tobacco cessation treatments has left CDC officials shocked and encouraged lawmakers to look at expanding the approach nationwide.

When the program was launched two years ago, about 38 percent of poor Massachusetts residents smoked. By 2008, the smoking rate for poor residents had dropped to about 28 percent, a decrease of about 30,000 people in two and a half years, or one in six smokers. There are also indications that the drop has lowered rates of hospitalization for heart attacks and emergency room visits for asthma attacks, she said.

Senators Richard J. Durbin of Illinois and Bernard Sanders of Vermont have introduced an amendment that would provide similar new Medicaid coverage for tobacco addiction as nationwide, and the Senate could vote on it by the weekend. If the amendment fails, Senator Tom Harkin of Iowa said he would try another avenue: seeking an expansion through a conference committee that will ultimately reconcile the House and Senate bills.

"We should be able to find an opening," Mr. Harkin said in an interview. "This is one demonstrable way we can actually bend the cost curve and keep people healthy."

Terry F. Pechacek, associate director for science for the CDC's Office on Smoking and Health, told the New York Times that he found the numbers “shocking,” since smoking rates around the nation have barely budged since 2004. He said the U.S. smoking rate has only decreased from 20.9 percent in 2004 to 20.6 percent in 2008, while smoking-related illnesses cost the Medicaid system more than $22 billion a year - or about 11 percent of overall Medicaid expenditures.

Pechacek says if the federal health care overhaul includes smoking-cessation coverage, publicizing it will be as crucial to its success as the cessation tools themselves.

"Even in the some of the states that offer wider coverage,” he said, “there’s been minimal promotion. People have to know about a benefit for it to have an effect.”

A “model” tobacco cessation benefit offered to Massachusetts’ Medicaid participants has produced an astounding 26% drop in smoking rates in only two and a half years, and has already been linked to decreases in heart attacks, hospitalizations for asthma and COPD, and a significant decrease in birth complications.


Researchers from the Massachusetts Tobacco Cessation and Prevention Program (MTCP) found that up to 38% fewer MassHealth cessation benefit users were hospitalized for heart attacks in the first year after using the benefit, and that 18% fewer benefit users visited the emergency room for asthma symptoms in the first year after using the benefit. Researchers also found that there were 12% fewer claims for adverse maternal birth complications since the benefit was implemented.

The Massachusetts Executive Office of Health and Human Services said more than 75,000 people – a full 40% of MassHealth members who smoke – have used the benefit to try to quit smoking. Cost savings are being studied, and all indications suggest they will be significant.

“As the nation debates the future of its health care system, the national significance of this research cannot be understated.” said Robert J. Gould, PhD, President and CEO of Partnership for Prevention. “These findings demonstrate that prudent investments in preventive health today will have a dramatic and positive effect on our health care system tomorrow.”

The American Lung Association is releasing its second annual "Helping Smokers Quit: State Cessation Coverage" report. The report addresses state coverage of cessation treatments through Medicaid, state employee health plans, private insurance, and quitlines in 2009. It shows that states are not doing enough to help smokers quit, when they could be saving lives and money by doing so.

Currently, only six states provide comprehensive coverage for Medicaid recipients: Indiana, Massachusetts, Minnesota, Nevada, Oregon and Pennsylvania. Just five states provide comprehensive cessation coverage for state employees: Illinois, Maine, Nevada, North Dakota and New Mexico.


The Lung Association recommends that private insurance plans also offer comprehensive cessation coverage and encourages states to require all insurance companies to cover these treatments. Currently, only seven states (Colorado, Maryland, New Jersey, New Mexico, North Dakota, Oregon and Rhode Island) have such requirements.

This lack of comprehensive cessation coverage in most states leaves smokers without clinically-proven treatment options when they want to quit.

The report makes recommendations on how to provide all smokers with access to cessation treatments in health care reform, and urges policymakers to provide this coverage. It also calls on each state to provide all Medicaid recipients and state employees with comprehensive, easily-accessible tobacco cessation medications and counseling. Finally, it recommends that private insurance plans offer comprehensive cessation coverage and encourages states to require all insurance companies to cover these treatments.

You can download the report here, and you can find detailed, state-specific information on cessation coverage through an online State Tobacco Cessation Coverage Database.

Forty-three states now cover some form of cessation treatment for Medicaid beneficiaries, up from 23 states in 1998, according to the Nov. 6 issue of Morbidity and Mortality Weekly Report (MMWR), which summarizes coverage of tobacco dependence treatment under the Medicaid program, reported that. However, only six states cover all of the effective pharmacotherapies and individual and group counseling.

Smoking rates among Medicaid enrollees are much higher than among the general population – 4.7 million smokers. This represents 33% of the total Medicaid population and adds to nearly $22 billion in annual Medicaid expenditures related to smoking. Numerous studies have found that tobacco cessation treatments are highly cost effective. Yet many barriers exist, preventing greater access to those who need and want help to quit tobacco use.

Partnership for Prevention and the Call for ACTTION initiative encourage the federal government and states to implement the updated 2008 Public Health Service Clinical Practice Guidelines which call for access to comprehensive coverage of all effective treatments – counseling and medication without barriers and limitations.

Diane M. Canova
Managing Senior Fellow
 & Senior Program Officer
Partnership for Prevention

A number of new tools have been added to The US Public Health Service's Clinical Practice Guidelines for Treating Tobacco Use and Dependence since it was released in June 2008. At the same time, some additional guideline-related information is now available online. As with all guideline materials and information, they are in the public domain and can be used without obtaining permission from the US PHS. These new materials and tools include:

1) A 20-page “quick reference guide” for clinicians that summarizes key guideline findings in a short, easy-to-use guide.

2) A PowerPoint presentation containing every data table and recommendation in the 2008 guideline to aid policymakers, researchers and others who may need this information for presentations.

3) A 30-40 minute PowerPoint presentation that summarizes key findings in the 2008 guideline for people who wish to give a presentation on the guideline.

4) A tool for health systems that are interested in incorporating the guideline recommendations into clinical practice, summarizing key strategies and opportunities.

5) An updated poster for clinician offices.

6) A new Guideline addition and corrections section. This new section now provides clinicians with a link to the recent update by the FDA on the use of bupropion and varenicline and a correction to Table 6.22 from page 102.

These new tools and other materials, including the full Guideline and references, are available online at: http://www.ahrq.gov/path/tobacco.htm#Clinic  and http://www.surgeongeneral.gov/tobacco/. While all of the materials are on the AHRQ website, some of these materials are still being added to the Surgeon General’s website.

Additionally, a free, one-hour CME program sponsored by the University of Wisconsin School of Medicine and Public Health on treating tobacco dependence has been updated based on the 2008 guideline. The program is currently accredited for physicians (up to Category 1 CME credit), nurses (one ANCC contact hour), and pharmacists (one ACPE contact hour). The CME program is available on Medscape at http://cme.medscape.com/viewprogram/17710 .

Finally, the Guideline panel wants to alert you to two recent publications. First, the U.S. Preventive Services Task Force recently reaffirmed its recommendation that using evidence-based cessation interventions in adults and pregnant women can lead many to quit using tobacco products and improve their health. The Task Force’s recommendations were published in the April 21, 2009 issue of the Annals of Internal Medicine and are available on the AHRQ Web site at http://www.preventiveservices.ahrq.gov/. Second, John Hughes has recently published an article in Addiction that describes the high rate of concordance between two independent entities that have examined the smoking cessation literature: the 2008 PHS Guideline and relevant Cochrane Collaboration analyses (Hughes JR. "How confident should we be that smoking cessation treatments work?" Addiction 2009; published online August 4, 2009 (http://www3.interscience.wiley.com/cgi-bin/fulltext/122538766/HTMLSTART  ).

A new Institute of Medicine report further clinches the case for linking second-hand tobacco smoke to cardiovascular disease.  An IOM committee found that data consistently demonstrates that secondhand-smoke exposure increases the risk of coronary heart disease and heart attacks and that smoking bans reduce this risk. Given the prevalence of heart attacks, and the resultant deaths, the committee found smoking bans can have a substantial impact on public health.

"The IOM study underscores the 2006 declaration by Surgeon General Richard Carmona that when it comes to second-hand smoke, 'the debate is over, the evidence is clear,'" said Partnership for Prevention President Robert J. Gould.

"Most importantly, the report clearly re-iterates that the damage from second-hand smoke does not require years of exposure," he continued. "The effects are immediate, and smokefree laws quickly reduce heart attacks among non-smokers.

"The science cannot and must not be ignored," Gould said. "We hope policymakers and employers across the country will take immediate action to protect the public from detrimental effects of second-hand smoke in all public spaces and workplaces. We also hope that citizens wll take this science 'to heart' and make their homes tobacco free."

Partnership for Prevention is a membership organization of business, nonprofit and government leaders working to make evidence-based disease prevention and health promotion a national priority.  A year ago, Partnership assembled a naitonal working group that issued a call to action (www.acttiontoquit.org) to provide smokers who want to quit with accress to a comprehensive range of evidence-based cessation treatment.

"Since smokefree policies encourage tobacco users to make quit attempts, it is important for such policies to be accompanied by improved access to a wide range of evidence-based treatments," Gould said. "Quitting smoking is very difficult for most people, and not all treatments work the same for all people,"

Recent commentary in the Journal of the American Medical Association (JAMA) highlights U.S. progress on addressing the disease and death caused by tobacco products, but notes that significant unfinished business remains. The article underscores the critical and unmet need for greater availability of cessation treatments, higher cigarette taxes and expanded smoke-free policies.

While we can feel good about the decline in the prevalence of smoking and the recent congressional action to give the U.S Food and Drug Administration (FDA) authority over tobacco products (finally), complacence has no place in the tobacco control world.

As the article states, “[s]moking cessation is critical for reducing the tragic and predicable burden of disease caused by smoking.” Tragically, although cessation is a medical treatment with proven efficacy, it remains woefully underfunded and underutilized. The major problem is lack of coverage in private insurance plans and employer-provided health benefits. Barriers, like co-pays and arbitrary limits on cessation treatments, further restrict access and affect quitting success. To address these obstacles, Partnership for Prevention convened the National Working Group for ACTTION (Access to Cessation Treatment of Tobacco in Our Nation), which seeks to change this dynamic by promoting collaboration among health providers, business, insurers and the tobacco control community to implement strategies to increase access and utilization of tobacco cessation treatments.

The JAMA Commentary states the obvious…the recently-enacted law giving FDA authority over tobacco products “represents a critical step in tobacco control.” While the FDA law won’t solve all tobacco control issues, it provides a tremendous opportunity to rein in a rogue industry and to communicate more truthful information to the public about tobacco products. But FDA is not authorized to mandate an expansion in insurance coverage, develop new therapies to help youth seeking to quit or provide workplace incentives that encourage cessation. That important work requires our continue vigilance and advocacy…especially with Congress as they debate health reform.

Be warned. We advocates of tobacco control must stay on high alert for actions that would undermine current tobacco prevention and cessation efforts. There will continue to be a need to demand attention and sufficient resources from government (state and federal) to reduce further tobacco product consumption and to provide those who want to quit with real, comprehensive support and effective treatments to do so.


Diane Canova
Managing Senior Fellow

The CDC released results from the national Youth Risk Behavioral Study (YRBS) that suggest it may be important to target tobacco cessation counseling to young smokers, where the likelihood of success in quitting is greatest.

The study showed that nearly two-thirds (60.9%) of students who ever smoked cigarettes daily tried to quit smoking cigarettes. However, among those who tried to quit, only 12.2% were successful. While the prevalence of success in quitting did not vary by sex or race/ethnicity, more students in 9th grade (22.9%) than in 10th grade (10.7%), 11th grade (8.8%) and 12th grade (10.0%) were successful at quitting.

The 2008 Public Health Service Guidelines – Treating Tobacco Use and Dependence agree that counseling has been shown to be effective in treating adolescent smokers, and recommend that adolescent smokers be provided with counseling interventions to help them quit smoking.

These findings also reinforce the need to fully implement and sustain comprehensive tobacco prevention and control programs that increase excise taxes, promote smoke-free air policies, and conduct media campaigns in conjunction with other community-based interventions, such as tobacco-use prevention programs in schools that include school policy and education components. These proven interventions are effective in reducing smoking among youth and adults.

Diane M. Canova
Managing Senior Fellow and Senior Program Officer

The U.S. Preventive Services Task Force reaffirmed its 2003 recommendation that clinicians ask all adults about their tobacco use and provide cessation interventions for those who use tobacco products. The Task Force also recommended that all pregnant women who use tobacco be provided pregnancy-tailored counseling. These reaffirmations, which were published in the April 21 issue of Annals of Internal Medicine, are based on information found in the 2008 Update of the Public Health Service Clinical Practice Guidelines.

The US Preventive Services Task Force is the leading independent panel of experts in prevention and primary care. Copies of the recommendations are available at http://ahrq.gov/clinic/uspstf/uspstbac2.htm.

Diane M. Canova
Managing Senior Fellow