July 2002

Grant Results

SUMMARY

From August 1998 to September 2000, the University of Wisconsin-Madison Medical School updated Clinical Practice Guideline on Smoking Cessation (#18), a publication of the federal Agency for Health Care Policy and Research (AHCPR).

CTRI, coordinator of the project and located at the University of Wisconsin-Madison Medical School, reconvened the original Guideline's Smoking Cessation Panel to review and produce the update.

Key Results and Findings
In June 2000, the U.S. Public Health Service (USPHS) published the updated, 179-page guide, Treating Tobacco Use and Dependence, the only current evidence-based set of treatment guidelines available.

Findings include:

  • Effective treatments for tobacco dependence exist that can double or triple the likelihood of long-term cessation.
  • Many cessation treatments are appropriate for primary care settings.
  • A strong dose-response relationship exists between the intensity of tobacco treatment counseling and its effectiveness.
  • Treatments involving person-to-person contact (via individual, group, or telephone counseling) are consistently effective and their effectiveness increases with treatment intensity (e.g., minutes of contact).
  • Five first-line pharmacotherapies for tobacco dependence — nicotine gum, nicotine inhaler, nicotine nasal spray, nicotine patch, and sustained-release bupropin hydrocloride — are effective.

USPHS printed 55,000 copies of the book and has distributed 44,000 copies to date.

Surgeon General David Satcher announced the updated book's publication at a press conference, and several journals, including the Journal of the American Medical Association (JAMA) featured articles about it.

A panel discussed its findings at the World Conference on Tobacco OR Health in August 2000; the 4500 attendees received a copy of the book. The book and its affiliated products are available online in English and Spanish on the Web sites of the Surgeon General, and the AHRQ.

The grantee organization is developing a project to further disseminate the publication to increase its visibility and utilization.

Funding
RWJF provided partial funding for the project with a grant of $102,016. RWJF was a part of a consortium whose members supported the update: Agency for Health Care Research and Quality (AHRQ, formerly AHCPR); The Center for Tobacco Research and Intervention (CTRI); the National Cancer Institute (NCI); the National Heart, Lung, and Blood Institute (NHLBI); the National Institute on Drug Abuse (NIDA); and the Centers for Disease Control and Prevention (CDC).

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THE PROJECT

Recent research shows that having health care providers give advice regarding tobacco use has a significant impact on helping people quit smoking. In 1996, AHCPR (now AHRQ) released The Clinical Practice Guideline on Smoking Cessation (No. 18), which proved to be a valuable tool in encouraging health care providers to incorporate tobacco prevention and cessation interventions into routine primary care.

Since 1996, there have been significant research findings that are relevant to clinical practice on treatment for tobacco use. These include the efficacy of new pharmacotherapies approved by the Food and Drug Administration (FDA) as smoking cessation aids, and the effectiveness of the "stages of change" model as a strategy to guide the assessment and treatment of smokers.

These new findings made an update of the Guideline necessary if clinicians were to have the most current and accurate information to help patients quit tobacco use.

RWJF funded this project as part of a consortium of funders. The funding supported the University of Wisconsin-Madison Medical School to reconvene the original Smoking Cessation Panel (see the Appendix) to review new treatments for smoking cessation and to update the previous AHCPR publication.

In addition to RWJF, the consortium consisted of: AHRQ, CTRI, NCI, NHLBI, NIDA, and the CDC. CTRI, located at the University of Wisconsin-Madison Medical School, coordinated the project.

RWJF had funded numerous previous grants to help disseminate the original Guideline. These were: one to the University of Wisconsin-Madison Medical School, Center for Tobacco Research and Intervention, to develop strategies for the dissemination program and to provide oversight of the project (ID# 029389), and five others to health professional organizations to disseminate to their constituencies.

These included: the American Academy of Pediatrics (ID# 030329), which has an active national committee on substance abuse; American College of Chest Physicians (ID# 030525) — specialists in cardiopulmonary disease — administered through Creighton University; American Medical Women's Association (ID# 030375), which has targeted tobacco as a serious women's health issue; American College of Obstetricians and Gynecologists (ID# 030520), which also worked in concert with the American Medical Women's Association; American Nurses Foundation (ID# 030254), which has access to nurse-clinician members of the American Nurses Association.

It also made grants to the American Medical Association (AMA) for distributing a pocket version (ID# 029466); the Dana-Farber Cancer Institute to make the Guideline available to labor union leaders and members (ID# 029471); and Pitney Associates Inc. to prepare and publish conference proceedings on policy issues critical to disseminating the Guideline (ID#s 030465 and 027474).

RWJF also funded a grant to the Allina Health System on evaluating the implementation of the Guideline (ID# 030499). This grant led to an RWJF national program, Addressing Tobacco in Managed Care, to promote adoption of innovative approaches for helping Americans enrolled in managed care organization to avoid the harm caused by tobacco.

Seventeen of the 18 panel members who developed the original Guideline reconvened to produce the update. They reviewed data of substantial new research from 6,000 English-language, peer-reviewed articles and abstracts to identify clinical interventions that promote successful tobacco cessation, and to modify clinical and health care delivery system behaviors to support cessation efforts.

On September 14–15, 1999, panel members met in Madison, Wis., where they evaluated their findings and prepared a draft of the new Guideline. Seventy experts provided external reviews for incorporation into the final document. The final version was sent to RWJF, and submitted to the USPHS for approval.

Additional funding for this project came from other consortium member contributions totaling $239,379. CTRI made in-kind contributions through office equipment and space, and some staff support. The University of Wisconsin Comprehensive Cancer Center paid the project director's salary during part of the project.

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RESULTS

In June 2000, USPHS published the updated, 179-page guideline, Treating Tobacco Use and Dependence, the only up-to-date evidence-based set of treatment guidelines available. The new Guideline contains recommendations based on evidence published through January 1, 1999 and is designed for three principle audiences: primary care clinicians; tobacco dependence treatment specialists; and health care administrators/insurers/purchasers. It is intended for use in a variety of clinical practice settings including: private practices, academic heath centers, managed care settings, public health department clinics, hospitals, schools, and work-site clinics.

Findings

  • According to the updated Guideline, effective treatments for tobacco dependence exist that can double or triple the likelihood of long-term cessation. It further reveals that: tobacco dependence often requires repeated intervention to achieve long-term or permanent abstinence; and that brief tobacco dependence treatment is effective.
  • Many cessation treatments are appropriate for primary care settings. Cessation treatments are more cost-effective than many other reimbursed interventions, and supportive health system policies (e.g., insurance coverage) could increase their utilization and impact.
  • A strong dose-response relationship exists between the intensity of tobacco treatment counseling and its effectiveness. Treatments involving person-to-person contact (via individual, group, or telephone counseling) are consistently effective and their effectiveness increases with treatment intensity (e.g., minutes of contact).
  • Five first-line pharmacotherapies for tobacco dependence — nicotine gum, nicotine inhaler, nicotine nasal spray, nicotine patch, and sustained-release bupropin hydrocloride — are effective. Over-the-counter nicotine patches are effective relative to placebo and their use should be encouraged.

Communications

PHS printed 55,000 copies of Treating Tobacco Use and Dependence, and has distributed approximately 44,000 to date. Surgeon General David Satcher announced the book's publication at a press conference in Washington, D.C. Three professional journals ran articles on the project, including one in JAMA, June 2000.

A panel discussed its findings at the World Conference on Tobacco OR Health in August 2000 (co-sponsored by RWJF [ID#s 029398, 029689, 036507, 039809]); all 4500 attendees received a copy of the book. The book and four ancillary products, produced as part of the project to aid its dissemination and implementation, are also available online in English and Spanish at www.surgeongeneral.gov/tobacco and www.ahrq.gov. (See the Bibliography for details.) CTRI also produced a slide show for presentation of the findings.

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LESSONS LEARNED

  1. Early consultation with experts in the field helped pave the way for wide dissemination of the project's findings. Consultations with panel members, outside experts, and members of the funding consortium helped prepare the field for receiving and using the revised Treating Tobacco Use and Dependence guideline's recommendations and findings. (Project Director)

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AFTER THE GRANT

The University of Wisconsin-Madison Medical School is seeking funding for a project to disseminate Treating Tobacco Use and Dependence findings to increase its visibility and utilization.

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GRANT DETAILS & CONTACT INFORMATION

Project

Updating the AHCPR Clinical Practice Guideline on Smoking Cessation

Grantee

University of Wisconsin-Madison Medical School (Madison,  WI)

  • Amount: $ 102,016
    Dates: August 1998 to September 2000
    ID#:  034068

Contact

Michael C. Fiore, M.D., M.P.H.
(608) 262-8673
mcf@ctri.medicine.wisc.edu

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Smoking Cessation Panel Members and Consultants

Panel Members
Michael Fiore, M.D., M.P.H.
University of Wisconsin Medical School
Madison, Wis.

William C. Bailey, M.D.
University of Alabama Lung Health Center
Birmingham, Ala.

Stuart J. Cohen, Ed.D.
Wake Forest School of Medicine
Tucson, Ariz.

Sally Faith Dorfman, M.D., M.S.H.S.A.
Medical Society of the State of New York
Lake Success, N.Y.

Michael G. Goldstein, M.D.
Bayer Institute for Health Care Communication
West Haven, Conn.

Ellen R. Gritz, Ph.D.
University of Texas, M.D. Anderson Cancer Center
Houston, Texas

Richard B. Heyman, M.D.
American Academy of Pediatrics
Elk Grove Village, Ill.

Carlos Roberto Jaén, M.D., Ph.D.
Center for Urban Research in Primary Care
State University of New York at Buffalo
Buffalo, N.Y.

Thomas E. Kottke, M.D., M.S.P.H.
Mayo Clinic Department of Internal Medicine
Rochester, Minn.

Harry A. Lando, Ph.D.
University of Minnesota School of Public Health
Minneapolis, Minn.

Robert E. Mecklenburg, D.D.S., M.P.H.
National Cancer Institute's Tobacco Control Research Branch
Potomac, Md.

Patricia Dolan Mullen, Dr.P.H.
University of Texas School of Public Health
Houston, Texas

Louise M. Nett, R.N., R.R.T.
National Lung Health Education Program
Denver, Colo.

Lawrence Robinson, M.D., M.P.H.
Philadelphia Department of Public Health
Philadelphia, Pa.

Maxine L. Stitzer, Ph.D.
Johns Hopkins/Bayview Medical Center
Baltimore, Md.

Anthony C. Tommasello, M.S.
University of Maryland School of Pharmacy
Baltimore, Md.

Louise Villejo, M.P.H., C.H.E.S.
University of Texas, M.D. Anderson Cancer Center
Houston, Texas

Mary Ellen Wewers, Ph.D., M.P.H., R.N.
Ohio State University Nursing College
Columbus, Ohio

Consultants
Victor Hasselblad
Duke Clinical Research Institute
Durham, N.C.

David Schriger
UCLA School for Medicine
Los Angeles, Calif.

David Wetter
University of Texas, M.D. Anderson Cancer Center
Houston, Texas

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Books

Fiore MC, Bailey WC, Cohen SJ, et. al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, Md.: US Department of Health and Human Services, Public Health Service, 2000. Also appears online.

Articles

Fiore MC. "Treating Tobacco Use and Dependence: An Introduction to the US Public Health Service Clinical Practice Guideline." Respiratory Care, 45(10): 1196–1199, 2000.

Morgan GD and Fox BJ. "Promoting Tobacco Cessation." The Physician and Sports Medicine, 28(12): 59–60, 2000.

Reports

Quick Reference Guide for Clinicians: Treating Tobacco Use and Dependence. Washington, D.C.: US Department for Health and Human Services. 2000. Also appears online.

You Can Quit Smoking. Washington, D.C.: US Department of Health and Human Services, 2000. Also appears online.

You Can Quit Smoking: Support and Advice from Your Physician. Washington, D.C.: US Department of Health and Human Services, 2000. Also appears online.

Treating Tobacco Use and Dependence: A Systems Approach. Washington, D.C.: US Department of Health and Human Services, 2001. Also appears online.

World Wide Web Sites

www.surgeongeneral.gov/tobacco. The Web site of the Surgeon General of the United States. Treating Tobacco Use and Dependence and its supporting materials are available through this site. Washington D.C.: Office of the Surgeon General of the United States.

www.ahrq.gov. The Web site of the Agency for Health Care Research and Quality (AHRQ) is linked to the Surgeon General's Web site. Rockville, Md.

Presentations and Testimony

Brion Fox, "Treating Tobacco Use and Dependence: The United States Public Health Service Guideline;" and Brion Fox and Timothy Baker, "Disseminating the Findings of the United States Public Health Service Guideline: Treating Tobacco Use and Dependence," at the World Conference on Tobacco OR Health, American Cancer Society, The Robert Wood Johnson Foundation, and the American Medical Association, August 2000, Chicago, Ill.

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Report prepared by: Eric Love
Reviewed by: Janet Spencer King
Reviewed by: Molly McKaughan
Program Officer: C. Tracy Orleans