Under-use of tobacco dependence treatment among Wisconsin's fee-for-service Medicaid recipients.

BACKGROUND: Wisconsin Medicaid enrollees are eligible for treatment for tobacco dependence at minimal charge to the enrollee. This paper describes an evaluation of the use of this treatment within the Wisconsin fee-for-service Medicaid program. METHODS: Pharmaceutical claims data for Medicaid fee-for-service patients were analyzed for the year 1999 to determine rates of treatment use. RESULTS: Of 261,435 adults enrolled in fee-for-service Medicaid for 1 or more months, only 1131 adults received pharmacotherapy for tobacco dependence in 1999 at a modest cost of approximately $135 per treatment user. This represents less than 2% of the adult Medicaid fee-for-service patients who smoke. DISCUSSION: Few Medicaid fee-for-service enrollees are receiving evidence-based treatment for tobacco dependence, the leading preventable cause of illness and death in Wisconsin. The 16,000 Wisconsin physicians caring for these patients are urged to intervene with every Medicaid patient who smokes. To assist in this effort, the Wisconsin Medicaid program's coverage for tobacco dependence treatment is explained and a series of myths are corrected.

Helping Wisconsin women quit smoking: a successful collaboration.

The cost of treatments for tobacco dependence frequently presents a financial barrier to their use. To overcome such barriers, the Wisconsin Women's Health Foundation, the Wisconsin Bureau of Public Health, the McNeil Consumer Healthcare, and the University of Wisconsin Center for Tobacco Research and Intervention collaborated in an initiative to distribute nicotine patches to Wisconsin women at no cost. As a result of this collaborative effort, approximately 19,000 women received a 6-week course of Nicotrol Patches. To evaluate the effectiveness of this initiative, a sample of 500 recipients were contacted and surveyed by telephone 6 months after receiving their patches. Approximately 22% of these women reported total abstinence at 6 months, and another 77% reported they had reduced their smoking. At follow-up, women who had successfully quit rated their health status significantly better than women who were still smoking. More than 99% of respondents recommended that the program be repeated. Extrapolating the observed abstinence rate to the 19,000 patch recipients, an estimated 4000 Wisconsin women successfully quit smoking as a result of this program.

Cost-benefit analysis of sustained-release bupropion, nicotine patch, or both for smoking cessation.

BACKGROUND: The nicotine transdermal patch (NTP) has been shown previously to be a cost-effective smoking cessation intervention. This is the first economic analysis comparing the NTP with the only non-nicotine-containing pharmacological intervention, bupropion HCl. METHODS: Decision-tree analysis, based on a previously published cost-benefit smoking-cessation model, was used to determine the optimal treatment from the standpoint of costs versus benefits, from the employer's perspective. Base-case probabilities of successful quitting in our model came from clinical trial point-prevalence data at the end of a 1-year follow-up study (N = 893) comparing placebo, bupropion, NTP, and bupropion/NTP in combination, administered along with minimal counseling. Sensitivity analyses were performed to determine the effects of variations in base-case assumptions regarding the monetary benefits that would accrue if an intervention were successful, probabilities of quitting, drug costs, cost of lost work time for a health care provider visit, and cost of the visit itself. RESULTS: The analysis showed that bupropion is more cost-beneficial than either NTP or bupropion/NTP, with a net benefit in the first post-quit year of up to $338 per employee who attempts to quit compared with $26 for NTP, $178 for the two in combination, and $258 for placebo. These results were robust to most plausible variations in the assumptions used in the model. One exception was the monetary benefit of successful intervention (assumed in the base-case to be $1,654). If this benefit were actually less than $1, 112, placebo (i.e., minimal counseling with no pharmacological intervention) would be more cost-beneficial than any of the active treatments. CONCLUSION: From an employer's perspective, bupropion 300 mg/day for 9 weeks is a more cost-beneficial smoking cessation intervention than the nicotine patch, and under most scenarios, bupropion is also more cost-beneficial than placebo.

Smoking cessation services offered by health insurance plans for Wisconsin state employees.

Health insurance plans for state of Wisconsin employees were surveyed regarding the smoking cessation benefits offered to their members. Seven of the 25 plans (28%) cover some form of cessation treatment. Those plans that cover smoking cessation services differ substantially in the scope of benefits, and some have limitations and exclusions. These results suggest that smokers in Wisconsin are offered only limited insurance coverage for effective smoking cessation treatments.

Objective assessment of ocular and respiratory alterations in employees in a sick building.

BACKGROUND: Sick building syndrome (SBS) is a constellation of diffuse, "irritative" symptoms predominantly involving the eyes and the respiratory tract. To date, the effects of working in a "sick building" have not been adequately assessed using objective measures. We undertook the present study to determine whether objective alterations could be found in the eyes and respiratory' tracts of employees working in an office building in which a high rate of SBS had been reported in the preceding year. METHODS: We studied 163 office workers: 87 workers from a modern, air-conditioned building (the sick building), and 76 employees employed in three traditional-style office buildings (the comparison buildings). After being surveyed for SBS symptoms, all subjects underwent a series of objective tests, including spirometry, a methacholine test, prick tests for aeroallergens, and submitted tear samples. In addition, Schirmer's test and the break-up time test were used to explore for potential ocular effects of sick building exposure. RESULTS: Employees in the sick building complained more frequently of ocular symptoms, upper-airway disturbances, and general and respiratory' symptoms than did employees in the comparison buildings; prick tests were positive in 20% and 17.4%, respectively. Groups did not differ significantly on spirometry measures. Bronchial hyperreactivity to methacholine (PD15 = 16.348 mumol) was present in 20.5% of the sick building workers and in 16.2% of comparison buildings workers. Methacholine dose-response slope values were similar. Stability of tear film was significantly reduced (P < 0.01) in the employees in the sick building compared with employees in the comparison buildings. CONCLUSIONS: Our results indicate that (1) atopy does not seem to influence the prevalence of SBS symptoms, and (2) the lower respiratory tract seems unaffected by exposure to a "sick building," but (3) alterations in tear film stability do exist after such exposure.

Does over-the-counter nicotine replacement therapy improve smokers' life expectancy?

OBJECTIVE: To determine the public health benefits of making nicotine replacement therapy available without prescription, in terms of number of quitters and life expectancy. DESIGN: A decision-analytic model was developed to compare the policy of over-the-counter (OTC) availability of nicotine replacement therapy with that of prescription ([symbol: see text]) availability for the adult smoking population in the United States. MAIN OUTCOME MEASURES: Long-term (six-month) quit rates, life expectancy, and smoking attributable mortality (SAM) rates. RESULTS: OTC availability of nicotine replacement therapy would result in 91,151 additional successful quitters over a six-month period, and a cumulative total of approximately 1.7 million additional quitters over 25 years. All-cause SAM would decrease by 348 deaths per year and 2940 deaths per year at six months and five years, respectively. Relative to [symbol: see text] nicotine replacement therapy availability, OTC availability would result in an average gain in life expectancy across the entire adult smoking population of 0.196 years per smoker. In sensitivity analyses, the benefits of OTC availability were evident across a wide range of changes in baseline parameters. CONCLUSIONS: Compared with [symbol: see text] availability of nicotine replacement therapy, OTC availability would result in more successful quitters, fewer smoking-attributable deaths, and increased life expectancy for current smokers.

Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. Agency for Health Care Policy and Research.

CONTEXT: The Agency for Health Care Policy and Research (AHCPR) published the Smoking Cessation: Clinical Practice Guideline in 1996. Based on the results of meta-analyses and expert opinion, the guideline identifies efficacious interventions for primary care clinicians and smoking cessation specialty providers. OBJECTIVE: To determine the cost-effectiveness of clinical recommendations in AHCPR's guideline. DESIGN: The guideline's 15 recommended smoking cessation interventions were analyzed to determine their relative cost-effectiveness. Then, using decision probabilities, the interventions were combined into a global model of the guideline's overall cost-effectiveness. PATIENTS: The analysis assumes that primary care clinicians screen all presenting adults for smoking status and advise and motivate all smokers to quit during the course of a routine office visit or hospitalization. Smoking cessation interventions are provided to 75% of US smokers 18 years and older who are assumed to be willing to make a quit attempt during a year's time. INTERVENTION: Three counseling interventions for primary care clinicians and 2 counseling interventions for smoking cessation specialists were modeled with and without transdermal nicotine and nicotine gum. MAIN OUTCOME MEASURE: Cost (1995 dollars) per life-year or quality-adjusted life-year (QALY) saved, at a discount of 3%. RESULTS: The guideline would cost $6.3 billion to implement in its first year. As a result, society could expect to gain 1.7 million new quitters at an average cost of $3779 per quitter, $2587 per life-year saved, and $1915 for every QALY saved. Costs per QALY saved ranged from $1108 to $4542, with more intensive interventions being more cost-effective. Group intensive cessation counseling exhibited the lowest cost per QALY saved, but only 5% of smokers appear willing to undertake this type of intervention. CONCLUSIONS: Compared with other preventive interventions, smoking cessation is extremely cost-effective. The more intensive the intervention, the lower the cost per QALY saved, which suggests that greater spending on interventions yields more net benefit. While all these clinically delivered interventions seem a reasonable societal investment, those involving more intensive counseling and the nicotine patch as adjuvant therapy are particularly meritorious.

Smoking status as the new vital sign: effect on assessment and intervention in patients who smoke.

OBJECTIVE: To assess the effect of expanding the vital signs to include smoking status. DESIGN: We prospectively conducted exit interviews with patients at a general internal medicine clinic in Madison, Wisconsin, during a 16-month period from 1991 to 1993. METHODS: Patients were surveyed briefly before (N = 870) and after (N = 994) the implementation of a simple institutional change in clinical practice. This change involved training the staff in how to use progress notepaper with a vital sign stamp that included smoking status (current, former, or never) along with the traditional vital signs. Included in the survey were questions about whether the patient smoked, whether the patient was asked that day about smoking status (by a clinician or other staff), and, for smokers, whether they were urged to quit smoking and given specific advice on how to do so. RESULTS: After expansion of the vital signs, patients were much more likely to report inquiries about their smoking status on the day of a clinic visit (an increase from approximately 58% at baseline to 81% at intervention; P < 0.0001). The vital sign intervention was associated with significant increases in the percentage of smokers who reported that their clinician advised them that day to quit smoking (from approximately 49% at baseline to 70% during the intervention; P < 0.01) and in the percentage who reported that their clinician gave them specific advice that day on how to stop smoking (from approximately 24% at baseline to 43% during the intervention; P < 0.01). CONCLUSION: Expanding the vital signs to include smoking status was associated with a dramatic increase in the rate of identifying patients who smoke and of intervening to encourage and assist with smoking cessation. This simple, low-cost intervention may effectively prompt clinicians to inquire about use of tobacco and offer recommendations to smokers.

Are clinicians intervening with their patients who smoke? A "real-world" assessment of 45 clinics in the upper Midwest.

OBJECTIVE: To determine the level of intervention provided by primary care physicians to individuals who smoke. SETTING: 45 primary care clinics throughout the upper Midwest. PATIENTS: 6,086 men and women (M:F = 1:2), ages 50 to 68, who sought medical care at any one of the 45 primary care clinics and completed two questionnaires regarding preventive medical services received during the previous 3 years (1990-1993). RESULTS: Of patients who smoke, 92% reported that their clinician had asked about their smoking status. Additionally, 86% reported being informed at their clinic of the dangers of tobacco use. A smaller percentage of individuals (60.1%) reported being explicitly advised on how to quit, and fewer still (27.2%) reported being referred to a stop smoking program. CONCLUSIONS: While most clinicians inquire about their patients' smoking status and recommend they quit, there currently exists a deficiency in the translation of these recommendations into concise, explicit instructions on how to quit. By increasing the frequency of clinicians giving specific advice about how to quit, the overall success rate of the public health campaign against tobacco use will be greatly enhanced.

Cigarette smoking prevalence by occupation in the United States. A comparison between 1978 to 1980 and 1987 to 1990.

We analyzed data from 1987 to 1990 National Health Interview Surveys and compared them with 1978 to 1980 National Health Interview Surveys data to determine changes in cigarette smoking prevalence by occupation. During this period, cigarette smoking prevalence declined from 31.7% to 24.2% among white-collar workers, from 43.7% to 39.2% among blue-collar workers, and from 37.2% to 34.5% among service workers. For occupational groups, the largest significant declines in smoking prevalence occurred among male sales workers (10.5 percentage points), female and male managers and administrators (9.9 and 8.7 percentage points), female professional and technical workers (8.0 percentage points), and male transportation equipment operatives (7.5 percentage points). Analyses of 1987 to 1990 detailed occupation codes revealed that roofers (57.8%) and crane and tower operators (57.6%) had the highest prevalences of cigarette smoking, whereas physicians (5.4%) and clergy (6.5%) had the lowest smoking prevalences. Since 1978 to 1980, the differences in smoking prevalence by occupation have widened, providing further evidence that smoking has moved from a relatively common behavior practiced by most segment of society to one that has become more concentrated among selected subpopulations. Health professionals need to play an important role in encouraging smoking cessation among workers and in advising management and labor about the benefits of strong work-site smoking policies.

Tobacco dependence and the nicotine patch. Clinical guidelines for effective use.

OBJECTIVE: A comprehensive review of transdermal nicotine treatment for tobacco dependence, with recommendations derived from the research literature. DATA SOURCES: English-language clinical trials. STUDY SELECTION: Clinical trials using placebo-controlled, double-blind methodology (11 studies) with at least 6 months of follow-up after treatment (eight studies) and biochemical verification of smoking status. DATA SYNTHESIS: Nicotine patches produce end-of-treatment smoking cessation rates that range from 18% to 77%; these rates are about twice those of placebo-treated subjects. Nicotine patches produced 6-month abstinence rates of 22% to 42%, while placebo patches produced quit rates of 5% to 28%. Nicotine patches appear to reduce some, but not all, nicotine withdrawal symptoms. For instance, while the patch reduces craving for cigarettes and negative moods, it does not appear to reduce hunger or weight gain. The clinical trials literature suggests that proper adjuvant smoking cessation counseling is crucial in determining successful long-term outcome with the nicotine patch, and suggests that 6 to 8 weeks of patch therapy may be an adequate duration for most patients. CONCLUSIONS: Nicotine patches are an effective aid to tobacco dependence treatment. However, success rates vary greatly across research studies and may be influenced highly by the nature and intensity of adjuvant smoking cessation counseling. More research is needed to identify optimal duration, dosage, and individualization of patch therapy. The impact of nicotine patches (more than 5 million users with $1 billion in sales for 1992) also raises important ethical and public health issues.

The reliability of self-reported cigarette consumption in the United States.

To investigate the possibility that self-reported smoking is not a valid measure for assessing trends in smoking prevalence, we compared total self-reported cigarette consumption with the adjusted consumption data from cigarette excise taxes as reported by the US Department of Agriculture (USDA) for the period 1974 through 1985. Self-reported consumption was calculated by using data from the National Health Interview Surveys (NHIS) for adults and from the National Household Surveys on Drug Abuse for adolescents. For this period, the average ratio of self-reported cigarette consumption to the USDA estimate of consumption was 0.72 (range = 0.69 to 0.78). There was no statistical difference in this consumption ratio from year to year, indicating no apparent increase in the underreporting of cigarette smoking in these surveys. We conclude that cross-sectional surveys of self-reported smoking status remain a reliable surveillance tool for monitoring changes in population smoking behavior.

Trends in cigarette smoking in the United States. Projections to the year 2000.

Data from National Health Interview Surveys from 1974 through 1985 are used to project cigarette smoking prevalence to the year 2000. Smoking prevalence in the United States has declined at a linear rate since 1974. If this trend continues, in the year 2000, 22% of the adult population (40 million Americans) will be smokers. By the year 2000, the major inequalities in prevalence will occur among educational categories. At least 30% of those who have not proceeded beyond a high school education will be smokers, whereas less than 10% of college graduates will smoke. Among the other sociodemographic subgroups, smoking prevalence is expected to decrease by the year 2000 to 20% among men, to 23% among women, to 25% among blacks, and to 21% among whites. Between 1974 and 1985, approximately 1.3 million persons per year became former smokers, indicating considerable success in public health efforts to encourage people to stop smoking. However, in the early 1980s, approximately 1 million new young persons per year were recruited to the ranks of regular smokers. This is equivalent to about 3000 new smokers each day. Public health efforts need to focus more on preventing young people from starting to smoke, and such prevention efforts should particularly target less educated socioeconomic groups.