Tobacco Researcher Moves Deeper Into Policy

    • July 23, 2009

Michael C. Fiore, MD, MPH
Director, University of Wisconsin Center for Tobacco Research and Intervention
Professor of Medicine
University of Wisconsin School of Medicine and Public Health
Madison, Wis.

The problem: While smoking-cessation interventions have made substantial progress in reducing smoking in the United States, too many people continue to smoke. Most smokers visit a health care setting each year, but clinicians do not consistently offer smoking cessation treatments to patients.

Programee background: Michael C. Fiore, MD, MPH, a professor of medicine at the University of Wisconsin School of Medicine and Public Health in Madison, has had a long and varied career as a tobacco researcher. He has led efforts to expand the vital signs clinicians collect on all patients to include an assessment of smoking status. He chaired a federal panel that developed the internationally used U.S. Public Health Service's Clinical Practice Guideline: Treating Tobacco Use and Dependence.

The award: In 2003, he got a chance to use his research to improve tobacco policies when he received an Innovators Combating Substance Abuse award. The Robert Wood Johnson Foundation (RWJF) created the Innovators program to nurture and promote innovation in combating substance abuse. Between 2000 and 2003, some 20 senior researchers, practitioners and policy-makers received Innovators awards. See Program Results Report for more information on the program.

Shortly before he received his Innovators award, Fiore had chaired a federal committee that developed the National Action Plan for Tobacco Cessation in 2003. The National Action Plan made six key recommendations to reduce tobacco use.

The award: Fiore used his Innovators award to help implement key components of the National Action Plan for Tobacco Cessation. The award freed up his time to work with federal, state and local policy-makers to strategize ways to implement aspects of the national plan and other tobacco-cessation activities.

C. Everett Koop, MD, provides mentorship. Fiore looked to mentors to help him learn how to implement policy change in health care. Among his key mentors was Koop, the former U.S. Surgeon General who helped shepherd many health policy changes including a greater attention to the dangers of smoking.

About every two months during his Innovators award, Fiore flew to Hanover, N.H. where Koop now lives, and spent a day with him, talking about their work and brainstorming strategies to secure policy changes.

"To see how [Koop] linked science to policy was invaluable to me," Fiore said. "To talk about it in the real world was invaluable. He advised me on the National Action Plan for Tobacco Cessation every step of the way as we moved along policy implications."

Results: Fiore undertook numerous activities to support the National Action Plan's recommendations. For example, he hosted a reception and press conference held at the National Press Club in Washington in February 2004 to release the National Action Plan. This event celebrated the plan, which also was released in the February 2004 issue of the American Journal of Public Health.

At the press conference, Tommy Thompson, then Secretary of the U.S. Department of Health and Human Services, announced the formation of a National Network of Tobacco Cessation Quitlines. This is a $25-million telephone-based smoking-cessation initiative funded and coordinated by the Centers for Disease Control and Prevention and the National Cancer Institute.

Quitlines provides grants to states to establish or enhance quitline services and a toll-free number, 1-800-QUITNOW. Fiore's University of Wisconsin Center for Tobacco Research and Intervention runs one of the quitlines. Between 2004 and 2007, more than 880,000 people called a quitline somewhere in the country.

Justice department asks for testimony. Fiore had another opportunity to advance the National Action Plan's recommendations in 2005 when the U.S. Department of Justice asked him and another Innovator, Jack Henningfield, to serve as expert consultants in the government's case against the tobacco industry.

As part of constructing its legal case, the Justice Department asked Fiore to testify about the public health gains that would be realized by implementing the National Action Plan recommendations. In his testimony, Fiore suggested that, as a penalty for past behavior and as one condition of settling the litigation, tobacco companies should fully fund the Nation Action Plan's recommendations. Fiore testified that, in its presentation before Judge Gladys Kessler of the U.S. District Court for the District of Columbia, the Justice Department should argue that tobacco companies be required to pay this penalty.

In its closing arguments, however, the Justice Department recommended only a scaled-down version of the penalty. In 2005, the New England Journal of Medicine published Fiore's article entitled "The Justice Department's Case against the Tobacco Companies." In this article, Fiore summarized the case, the controversy surrounding the change in the recommended penalty, and the likely lost opportunity to help millions of Americans to stop smoking.

New guidelines for physicians and others to help people quit smoking. To further promote the translation of research into practice, Fiore chaired the panel that updated the U.S. Public Health Service Clinical Practice Guideline entitled Treating Tobacco Use and Dependence. Fiore worked with staff from public health agencies, RWJF, the American Legacy Foundation and others to revise the guideline.

The guideline had not been updated since 2000 and publications regarding tobacco dependence had expanded from 5,000 articles on the subject in 2000 to more than 8,000 articles, Fiore said. "There was endless new analysis," he said. "It was dramatically different. The science had changed so much. Much of the 2000 edition was outdated."

Importance of the award: Prior clinical practice guidelines recommended that counseling by itself or medicine by itself would help smokers quit. But those guidelines hadn't looked at the effects of doing both.

"In 2008 for the first time we could say that if you added medicine to counseling you could get more bang for your buck," Fiore said. "You'll get more quitters. That became the new standard of care."

The updated guideline was completed and released in May 2008 in partnership with the American Medical Association, which organized a "call to action" to engage physicians across the United States to address tobacco use with all of their patients.

Since the Innovators award ended, Fiore and his colleagues have been working to create tools and other means to inform physicians and other health care providers about the new standards of care. Among other activities, Fiore is creating one-hour continuing medical education trainings and writing research articles that summarize the guideline.

RWJF perspective: "The Innovators Combating Substance Abuse program recognized the innovation and creativity of researchers, advocates and providers who have dedicated their professional careers to reducing the toll of substance use and abuse," said Michelle A. Larkin, JD, RN, MS, RWJF senior program officer. "These individuals have had an extraordinary impact on the prevention and treatment of substance abuse, promoting the science and advocating for positive and lasting change."

Michael C. Fiore, MD, MPH

Michael C. Fiore, MD, MPH
2003 Innovator Combating Substance Abuse