At least 10 percent of U.S. smokers would quit and 3 million premature deaths would be prevented if 10 policy changes were instituted nationwide.

So says a federally appointed panel that culled available scientific evidence on tobacco addiction and how to curb it. The panel's report, "A National Action Plan for Tobacco Cessation," includes six recommendations from the Department of Health and Human Services, and four recommendations to achieve the end through public-private partnerships.

The panel, established by Department of Health and Human Services Secretary Tommy Thompson, was a subcommittee of the department's Interagency Committee on Smoking and Health (ICSH). It was led by Michael C. Fiore, M.D., M.P.H., director of the University of Wisconsin Medical School's Center for Tobacco Research and Intervention, and a director of the Foundation-funded national programAddressing Tobacco in Managed Care . The group's task was to craft a set of bold, evidence-based recommendations to promote tobacco cessation.

The group met five times between October 2002 and January 2003. In February 2003, the group's report was unanimously endorsed by the ICSH and was sent to Secretary Thompson. The report appears in the Feb. 9, 2004, issue of the American Journal of Public Health.

Recommendations from the Department of Health and Human Services

The federal recommendations, which the panel suggests should go into effect by fiscal year 2005, would cost more than $5 billion each year. Funding would come from the $2-per-pack tax. Half of the estimated $28 billion in annual revenue generated by the tax will be earmarked for programs that help people to quit smoking or prevent them from starting.

By comparison, in 2001, the six largest tobacco companies spent $11.2 billion on advertising and promotions.

Here are the federal recommendations:

1. A federally funded national tobacco quit line: a toll-free number, accessible 24 hours a day, and seven days a week, providing universal access to evidence-based counseling and medications for tobacco cessation. Calls would be forwarded to the appropriate state or regional quit line where appropriate.

Cost: Approximately $3.2 billion annually.

Evidence: Quit-line counseling increases the chances of long-term abstinence by about 30 percent. A study of 3,200 smokers in California found that compared to self-help materials alone, a quit line was more effective in promoting new efforts to quit and preventing relapse. One study suggested that smokers are four times more likely to use a quit line than to seek face-to-face counseling. An optimal quit-line service would reach up to 16 percent of smokers per year and result in 1 million people quitting smoking per year.

2. An ongoing, extensive media campaign to help Americans quit using tobacco. The campaign would encourage tobacco users to call the national toll-free quit line to learn about the health risks of smoking.

Cost: About $1 billion annually.

Evidence: Comprehensive media campaigns have been effective in the past. A program introduced in California in 1988 has led to a 57-percent decline in cigarette consumption in that state, compared with a nationwide decline of 27 percent. Analyses suggest that a significant portion of California's decrease can be attributed to the media campaign. Similar findings have been found in Massachusetts, Maine and Florida.

3. Include evidence-based counseling and medications for tobacco cessation in benefits provided to all federal beneficiaries and in all federally funded health-care programs (Medicare, Medicaid, Veterans Administration, federal employees, etc.).

Cost: Not estimated.

Evidence: Only 15 percent of smokers who saw a doctor in the past year were offered assistance in quitting, the study suggests, and only 3 percent were given a follow-up appointment to address the problem. Lack of insurance coverage and lack of availability are barriers. Extending coverage to federal beneficiaries would cover 100 million people and their families.

4. Invest in a new, broad and balanced research agenda to achieve future improvements in the reach, effectiveness and adoption of tobacco-dependence interventions among individuals and across populations.

Cost: About $500 million annually.

Evidence: With current treatments, only 10 percent to 30 percent of smokers who try to quit will actually succeed in the long term, according to research. Within 10 years, interventions should be developed that increase this percentage to more than 50. In addition, tailored treatments should be developed for subgroups such as users with psychiatric conditions, individuals with other addictions, pregnant women, minorities, adolescents, and people with very high levels of nicotine dependence.

5. Invest in training and education to ensure that all clinicians in the United States have the knowledge, skills and support systems necessary to help their patients quit tobacco use.

Cost: About $500 million annually.

Evidence: Research shows that clinicians feel inadequately prepared to intervene with patients who smoke, and medical schools provide little training in tobacco-intervention strategies. Potential ways to overcome this challenge include grants to medical schools and other health care-professional schools to develop curricula; partnerships with professional organizations and licensing bodies to ensure that licensing exams assess the knowledge of tobacco dependence and treatment; and the establishment of a group of experts to ensure that competency in tobacco-dependence interventions is a core graduation requirement.

6. Establish a Smoker's Health Fund by increasing the federal excise tax on cigarettes by $2 per pack (the current tax is $0.39) with a similar increase in the excise tax on other tobacco products. At least 50 percent of the revenue generated by this tax increase should be earmarked to pay for the components of this plan.

Cost: Would generate approximately $28 billion.

Evidence: A $2-per-pack tax increase is estimated to reduce cigarette sales by more than 4 billion packs each year, the report indicates, which would achieve a 10-percent reduction in smoking. An estimated 4.7 million smokers would quit in response to such an increase, and 3 million premature deaths would be prevented.

The tax increase would enhance quit rates disproportionately among lower-income smokers (including teenagers). According to research, it also would deter about 6 million youths from becoming regular smokers as adults.

Survey data show that the public supports such a tax. A 2002 survey found that 61 percent of Americans would favor such a tax increase if the revenue is used to help smokers quit and prevent children from starting to smoke. A 2003 survey of African Americans found that 47 percent would support a tax increase on tobacco products.

Recommendations to Curb Tobacco Addiction through Public-Private Partnership

1. Mobilize insurers, employers, and others to foster evidence-based tobacco dependence coverage for everyone.
2. Mobilize health systems to implement system-level changes to foster effective utilization of tobacco-dependence treatments.
3. Mobilize national quality-assurance and accreditation organizations, clinicians, health systems, and others to establish and measure the treatment of tobacco dependence as part of the standard of care.
4. Mobilize communities to ensure that policies and programs are in place to increase demand for services and to ensure access to such services.

Researcher Michael C. Fiore, M.D., M.P.H., Comments on 'A National Action Plan for Tobacco Cessation'

What we did was to come up with an integrated action plan that pays for itself, that will guarantee the outcomes it proposes, and that is eminently "do-able" today. I'm an optimist by nature—and I think this is an incredible opportunity. Who would have believed that we could have come up with a set of recommendations that would translate into more than 3 million premature deaths prevented and 5 million Americans quitting within a year? Those are big-picture, population-wide results that are within our power to implement. It's uncommon to have even the potential to have that kind of public impact, and I'm honored and thrilled to be a part of the enterprise that brought these recommendations together.

That said, I'm also a realist, and I know that until [the recommendations are] implemented by policy-makers, they're just a set of recommendations. But, to me, a line has been drawn in the sand when we say what we need to do and say it in such a powerful way. These recommendations will be a guidepost for smoking cessation in America, today and tomorrow.

I really appreciate the fact that Tommy Thompson empowered this panel to do what it did. It's uncommon for a leader to say, I want you to review the evidence, make recommendations and not consider the politics of it. I commend him and respect him for that opportunity.

In terms of how [the recommendations will] be received, we'll have to see. The Secretary announced in February the creation of a National Tobacco Quitline Network. This is an important first step, but several questions remain about the design and funding of the initiative. Also, there's already been some reaction from the Bush administration that the tax increase in particular is one that they will not endorse. The plan was designed such that each piece by itself would have impact. Together it would have the greatest impact, but each one of these recommendations would also have impact on its own.

The tax is a way to fund these recommendations and a way that the public supports. People support the idea of raising the tax, especially if the money is put toward helping people quit and helping kids not to start. When a tax increase will translate into specific action, there's widespread support for it.