February 2005

Grant Results

SUMMARY

From April 2002 to March 2004, a research team, led by researchers at the University of Illinois at Chicago, developed a research agenda and funding proposals for studies of the economic consequences of smoking and the financial benefits of offering greater insurance coverage for smoking cessation treatment in U.S. managed health care plans.

Key Results
The researchers:

  • Submitted two proposals to the National Cancer Institute for funding for projects to address health services issues related to tobacco use and cessation.
  • Prepared an article that proposes a research agenda to support the business case for investments in smoking cessation programs.

Funding
The Robert Wood Johnson Foundation (RWJF) provided $128,753 to support this project.

 See Grant Detail & Contact Information
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THE PROBLEM

Despite the health and economic consequences of smoking and the availability of cost-effective evidence-based smoking cessation programs, many public and private insurance programs and health plans in the United States do not offer comprehensive coverage of smoking cessation services.

A 1997 survey by the American Association of Health Plans found that only 36 percent of health plans offered smoking cessation classes. Insurers' reluctance to cover their enrollees is due in part to the lack of health services and of economic research that effectively communicates the financial benefits of investing in these programs.

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RWJF STRATEGY

This planning grant complements the RWJF National Program, Addressing Tobacco in Managed Care, a research program that evaluates organization policy and practices to promote the provision of smoking cessation treatment to health plan members (for more information see Grant Results).

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THE PROJECT

The researchers originally proposed recruiting eight to 10 managed care organizations as partners in a multisite national study. Feedback gathered through outreach to the research and managed-care community indicated that this concept was not feasible due to:

  1. Declines in the managed-care market and health plans' reluctance to participate in research studies.
  2. A growing need for research into the economic benefits of tobacco treatment for specific populations rather than the U.S. population as a whole.
  3. Shrinking federal funding for major research studies.

Based on this input, the researchers designed a smaller study that focused more sharply on specific subgroups of smokers. They also conducted a literature review and prepared a manuscript identifying economic and health services barriers to health plan adoption of comprehensive smoking cessation benefits.

Susan Curry, Ph.D., co-director of Addressing Tobacco in Managed Care, led the research team, which included investigators from the University of Illinois at Chicago, the Center for Tobacco Research and Intervention at the University of Wisconsin, and the Center for Health Studies, a public-domain health services research center within the Group Health Cooperative, a Seattle-based nonprofit health system and insurer.

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RESULTS

  • In January 2004, the researchers submitted two proposals to the National Cancer Institute for funding for projects to address health services issues related to tobacco use and cessation.
    • The first proposed study will examine health care costs and utilization among middle-aged and older adults who never smoked, continue to smoke and stopped smoking. It will also compare the short- and long-term impact on health services of quitting smoking before age 50 and after age 50.
    • The second proposed study will assess the immediate and long-term patterns of health care utilization and costs of smokers who receive evidence-based tobacco cessation treatment from Aurora Healthcare (a large Wisconsin-based network of primary care clinics). This proposal was a component of the Center for Tobacco Research and Intervention's comprehensive application for funding renewal as a National Cancer Institute research center for the period 2004 to 2009.
  • The researchers prepared an article that proposes a research agenda to support the business case for investments in smoking cessation programs. The article — "Reducing Financial Barriers to Broader Coverage of Evidence-Based Tobacco Dependence Treatment Programs" — identifies seven key research questions, reviews the existing, often contradictory, evidence base for each, and points out opportunities for further research. (See Appendix, The Evidence Base and Opportunities for Further Research, for more details.)

    For example, in answer to the research question, "Does smoking increase the overall cost of health care?", the researchers' literature review found conflicting evidence that they say contributes to insurers' confusion and reluctance to provide coverage for tobacco cessation. Some researchers in the field suggest that smoking reduces overall health care costs because smokers, who are likely to die younger, avoid the expensive health care costs incurred by older people. This stands in contrast to a compelling body of literature that suggests that tobacco use increases the cost of providing health services on a population basis from 6 to 9 percent in the United States. More research is needed to resolve this conflict, according to the researchers.

Communications

In planning their proposals to the National Cancer Institute (see Results), the researchers presented their ideas at two conferences: the Ninth Annual Meeting of the Society for Research in Nicotine and Tobacco and the 2003 Annual Meeting of the RWJF National Program Addressing Tobacco in Managed Care, attended by representatives of the National Cancer Institute, the federal Centers for Disease Control and Prevention, state and local public health agencies, universities, and health plans. The researchers are revising their article, "Reducing Financial Barriers to Broader Coverage of Evidence-Based Tobacco Dependence Treatment Programs," for submission to a peer-reviewed journal.

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LESSONS LEARNED

  1. Researchers should communicate the benefits of smoking cessation in terms that are relevant to insurers. The continued lack of insurance coverage for evidence-based smoking cessation programs suggests that researchers need to adopt the language of business in order to "sell cessation" by focusing on "return on investment," for example, rather than on cost reduction. (Project Director)
  2. Strengthening the business case for coverage of smoking cessation programs will require collaboration among behavioral scientists, health services researchers and economists. To address gaps in the knowledge base about the costs of smoking and cessation treatment, multidisciplinary coordination of research is as important as the collection of new data. (Project Director)

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AFTER THE GRANT

The National Cancer Institute awarded a grant of approximately $750,000 for the study, "Health Care Costs and Utilization of Smoking and Quitting," which began in November 2004. The institute has invited the researchers to revise and resubmit their proposal to study the costs of smoking cessation among older adults.

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GRANT DETAILS & CONTACT INFORMATION

Project

Planning for a Study of Health Care Costs and Utilization Associated with Tobacco Use and Cessation in Managed Care

Grantee

University of Illinois at Chicago School of Public Health (Chicago,  IL)

  • Amount: $ 128,753
    Dates: April 2002 to March 2004
    ID#:  044580

Contact

Susan J. Curry, Ph.D.
(312) 355-4438
suecurry@uic.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.)

The Evidence Base and Opportunities for Further Research

(Excerpted from the article "Reducing Financial Barriers to Broader Coverage of Evidence-Based Tobacco Dependence Treatment Programs." Unpublished.)

Research QuestionEvidence from the Extant LiteratureFurther Questions/
Research Agenda

Does smoking increase the overall cost of health care?

No, from studies that use simulation modeling to study the question from a long-term social perspective.

Yes, from studies that focus on cross-section analyses examining direct health care costs associated with smokers' medical care needs.

What is the actual, long-term (lifetime) health care cost experience of actual smokers compared with nonsmokers?

What are the health care costs associated with smokers with smoking-related chronic diseases such as diabetes, hypertension, hypercholestoremia and COPD (Chronic Obstructive Pulmonary Disease)?

How do end-of-life costs compare for smokers and nonsmokers?

Does smoking increase costs for nonsmokers?

Yes, environmental tobacco increases morbidity and mortality among nonsmokers; babies born to mothers who smoke have significantly greater neonatal complications; children of smokers have greater respiratory disease; fires caused by smoking result in significant excess morbidity and mortality.

How do health care costs for children of smokers compare with those of children of nonsmokers?

How do health care costs compare for key subpopulations, e.g. children of smokers?

How do health care costs for nonsmokers who work in smoke-free environments compare with those of nonsmokers exposed to environmental smoke in the workplace?

Do smoking cessation efforts decrease health care costs?

Yes, former smokers have significantly greater health care costs than continuing smokers but this difference disappears within five years post quit.

How do health care costs among former smokers compare with their expected cost experience had they continued to smoke?

How do the costs of former smokers who quit with the assistance of an evidence-based tobacco dependence treatment program compare with smokers who quit through other means?

How do health care costs of smokers who quit in the midst of a major health care event compare to their projected health care costs if they had continued to smoke?

Will the rate at which former smokers change jobs or insurers affect the economic benefits of evidence-based tobacco dependence treatment programs for individual health plans or insurers?

Yes, simulations have demonstrated that health plans experience a positive return on investment in evidence-based tobacco dependence programs with an annual turnover rate of 10% or less.

There is no evidence regarding whether smokers and former smokers change jobs, health plans or providers at a greater rate than nonsmokers.

Do smokers and former smokers change jobs, insurers or health care providers at different rates than nonsmokers?

Are former smokers who quit through the aid of an evidence-based tobacco dependence treatment program more likely to change jobs, insurers or health care providers in the period after cessation than smokers, nonsmokers or former smokers who quit without the help of an evidence-based treatment program?

Does offering an evidence-based tobacco dependence treatment program as part of a comprehensive health promotion/health prevention benefit impact the degree to which smokers and former smokers change jobs, insurers or health care providers?

Do evidence-based tobacco dependence programs work well enough to justify the investment?

Yes, evidence-based tobacco dependence treatment programs are one of the most efficient ways of producing population-based health.

How does the return on investment in an evidence-based tobacco dependence treatment program compare with other routinely provided health benefits?

Do nonsmokers value the availability of treatment options for smokers?

Do health plans that offer a benefit for evidence-based tobacco dependence treatment programs attract more smokers?

There is no evidence showing that a benefit for evidence-based tobacco treatment programs attracts more smokers to a health plan or insurer.

Does a health plan or insurer that offers a benefit for an evidence-based tobacco dependence treatment experience adverse selection with respect to smokers relative to competitors that do not offer a benefit?

Will a smoking cessation benefit have an impact on whether smokers seek treatment?

Yes, smokers who are aware of an insurance benefit for evidence-based tobacco dependence treatment programs are more likely to use these services and make an attempt to quit.

How important is communicating an insurance benefit for evidence-based tobacco dependence treatment to smokers?

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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.)

Articles

Fishman PA, Curry SJ, Fiore MJ, Keller P, Mullahy J. "Reducing Financial Barriers to Broader Coverage of Evidence-Based Tobacco Dependence Treatment Programs: A Health Services Research Agenda." Unpublished.

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Report prepared by: Jayme Hannay
Reviewed by: Kelsey Menehan
Reviewed by: Molly McKaughan
Program Officer: C. Tracy Orleans