In 1995, 27.4 percent of American adults, 33.5 percent of high school students and 13.6 percent of pregnant women (average of 1995 and 1996 data), smoked cigarettes.
The health effects of smoking were well known by then. Physicians and experts agreed that smoking was bad for your health. The Surgeon General's warning about the dangers of cigarette smoking had adorned every pack of cigarettes for 29 years. Laws restricting sales of cigarettes to minors were on the books in virtually every state. (As of 1992, all states but Montana and New Mexico had laws banning the sale of cigarettes to minors.)
Most smokers wanted to quit, more than half of them tried to quit, but most tried to quit on their own, with fewer than 10 percent using a formal quit smoking treatment. And 90 percent to 95 percent of them failed.
This was the year that RWJF stepped into the field of tobacco cessation, with the specific goal of increasing the use of clinically proven tobacco-dependence treatments as one part of its broader policy-based efforts to prevent and reduce population tobacco use. Over the next 15 years, RWJF invested more than $77 million in major programs (see Appendix), grants and national leadership to increase access to, and use of, effective tobacco-cessation treatments that help smokers quit.
RWJF's investment in tobacco-cessation treatment and policy advances were critical in catalyzing and supporting the following accomplishments; strategic partnerships were formed with the nation's leading tobacco-control funders and advocates to bring about each of these accomplishments:
- Researchers identified effective new tobacco-cessation interventions (both policies and medical treatments) for youth and pregnant smokers and these interventions have been included in the U.S. Public Health Service (USPHS) Clinical Practice Guideline.
- The 1996 and 2000 the practice guidelines were widely disseminated to a variety of health care providers (e.g., physicians, nurses, dentists) and to smokers themselves. This effort placed special emphasis on reaching the providers who serve underserved low-income and minority smokers and those with co-occurring psychiatric and substance use disorders.
- The Foundation also co-funded the 2008 USPHS guideline update and its dissemination; the guideline has a greater emphasis on reaching the guideline's ultimate audience—smokers and their families.
- Provider tools and training modules, including interactive computer-based continuing medical education programs, were developed and disseminated to help translate the guideline recommendations into everyday practice.
- The national managed care "report card" on health care quality was expanded to include measures of the provider quit-smoking advice and assistance, including counseling and medications. These measures have been included in major national public "pay for performance" measurement sets.
- The Joint Commission for Accreditation of Healthcare Organizations added hospital-based tobacco use screening and intervention as requirements for hospital accreditation.
- Researchers identified practice—and broader level-health care systems changes to better integrate tobacco use screening and intervention into routine care. Effective interventions included: office- and health plan-level reminder systems, routine tobacco intervention measurement feedback and pay-for-performance incentives; expanding insurance coverage and promoting it widely among providers and smokers.
- Managed care and government (Medicaid, Medicare and Veteran's Health Administration) coverage for tobacco-dependence treatments increased substantially. Between 1990 and 2009 the number of states whose Medicaid programs cover at least some cessation aids increased from one to 45. Coverage of at least some cessation treatments was available in up to 97.5 percent of managed care plans in 2003 compared to 75 percent in 1997. Furthermore, 88 percent of plans provided full coverage of pharmacotherapy in 2003, up from 25 percent in 1997.
- Tobacco use cessation is now seen as a standard of care by physicians treating pregnant smokers. The proportion of smokers receiving advice and help to quit from their primary care health care rose steadily from 1995 to 2007, reaching 61.5 percent in 2006–07.
- All 50 states now have quitlines accessible through a single national portal (1-800-QUITNOW). Some 66 percent of these quitlines dispense free counseling and free medication to adult callers, and 34 (68 percent) provide counseling tailored to youth.
- Critical studies were funded showing that tobacco tax increases, smoke-free air laws, tobacco-cessation treatment coverage expansions, the switch from prescription to over-the-counter (OTC) nicotine replacement therapies (NRTs), tobacco counter-advertising, and expanded state tobacco-control funding are effective population-level cessation strategies, boosting smokers' quitting efforts and successes.
- Equally critical research was funded examining causes for smokers' under-use of effective treatments and documenting wide socio-demographic disparities in treatment use.
- The following policy changes resulted from focused RWJF-funded national state and local advocacy efforts:
- State tobacco taxes increased 173 times between 1994 and 2009, with the average tax more than quadrupled from $0.29 a pack in 1993 to $1.27 a pack in 2009. The Federal excise tax increased from $0.24 per pack in 1993 to $1.06 in 2009.
- As a result of these higher taxes and tobacco price increases from the tobacco companies as a result of the Master Settlement Agreement, the number of smokers was reduced by 3.7 million and 38,000 smoking-related deaths were avoided.
- Between December 31, 1991, and September 30, 2008, the number of states providing strong protection from tobacco smoke pollution in private worksites, restaurants, and/or bars increased from 0 to 32. As of 2009, the percent of Americans covered by state smoking bans increased from less than 0.5 percent in 1990 to 57 percent in workplaces, 65 percent in restaurants and 54 percent in bars. The percent covered by both local and state laws in at least one of these setting rose to 71 percent as of October 2009.
- As a result of the smoke-free indoor air policies, the number of smokers was reduced by 1.7 million and 19,000 smoking-related deaths were avoided. The combined outcome was 5.3 million fewer smokers and 60,000 fewer smoking-related deaths.
- In 2006, a multidisciplinary panel was convened to discover new approaches for boosting demand and use of proven cessation treatments, especially among under-served low-income smokers. Promising efforts include aligning cessation services and promotions with the introduction of tobacco tax increases and smoke-free air laws, re-designing treatment and treatment delivery systems to make them more appealing for users.
From 2007 to 2010, RWJF awarded a series of grants to help form and support the North American Quitline Consortium (NAQC) to deliver high-quality cost-free services through a network of quitlines reaching all 50 states, the District of Columbia and Puerto Rico. In 2009, state quitlines assisted more than 480,000 people, representing 1.2 percent of U.S. smokers.
And, most importantly, 15+ years into RWJF's tobacco-cessation efforts and partnerships, the number of former smokers exceeded the number of current smokers, and fewer Americans smoke. Adult smoking prevalence fell from 24.7 percent in 1995 to 20.5 percent in 2008; youth smoking prevalence declined from 33.5 percent in 1995 to 20 percent in 2007.
A Three-Pronged Strategy
RWJF's efforts to help people quit smoking used a three-pronged strategy: "science push" (proving, improving and disseminating evidence-based cessation treatments), "capacity building" (increasing the capacity of providers, health care systems and community services to deliver effective treatments), and "market pull" (increasing policy-maker and consumer demand for proven treatment options).
- Science push. By the mid-1990s, scientists had been studying tobacco addiction for more than 20 years, and had identified effective ways to treat it, forming the basis for the first-ever USPHS Clinical Practice Guideline. Unfortunately, few doctors routinely asked about smoking or offered their patients proven help to quit. Most smokers wanted to quit, but very few used effective treatments and the vast majority were unsuccessful when they tried. In addition, effective treatments had not yet been identified for two important high-risk populations—pregnant smokers and adolescents. RWJF sought to bridge the gap between what the scientific evidence was showing and what medical practitioners were doing. That meant getting the evidence into the hands of practitioners—in a way they could implement it in their practices. And special emphasis was given to research and research partnerships to discover effective treatments for pregnant smokers and teens. The key goals in this aspect of the strategy were:
- Broadly communicating the science and clinical guideline recommendations to practitioners, health plan leaders, insurers and health care and government policy-makers, with an emphasis on reaching underserved populations.
- Testing, adapting and disseminating novel interventions for two specific populations—pregnant women and youth.
- Capacity building. Pushing the scientific evidence for tobacco-cessation treatments out to providers could only be effective if the health care system had the capacity to implement those treatments. The second aspect of RWJF's strategy was to increase the capacity of health care providers and the offices and health care systems in which they worked to be able to integrate evidence-based tobacco-cessation treatments into routine care. Efforts included:
- Identifying methods to increase providers' capacity to address smoking by their patients as an integral part of quality health care and then getting health plans and providers to implement these methods:
- Implementing systems to remind physicians to advise and assist their patients to quit smoking, and to monitor and incentivize their performance.
- Developing and disseminating provider training materials and tools, such as computer-based training and continuing medical education programs.
- Market pull and consumer demand. The third aspect of RWJF's strategy was to increase market incentives and consumer demand for proven treatment methods. Efforts included:
- Advocacy, action and communications to promote higher tobacco taxes, smoke-free air laws, expansion of treatment insurance coverage and other policies proven to boost smoker quit attempts, quit rates and treatment use.
- Research documenting the health and economic impacts and cost-effectiveness of tobacco cessation for employers and purchasers.
- Working to embed tobacco use screening and treatment into the leading national health care quality improvement metrics and pay-for-performance standards.
- Finding ways to redesign treatments and delivery systems and to promote them to make them more appealing to smokers, especially to reach underserved low-income smokers.