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The American Journal of Accountable Care December 2016
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Tobacco Control in Accountable Care: Working Toward Optimal Performance
Edward Anselm, MD
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Tobacco Control in Accountable Care: Working Toward Optimal Performance

Edward Anselm, MD
Accountable care organizations are well positioned to leverage a significant impact on tobacco control. A review of the changing landscape of tobacco use can help optimize performance.

Objectives: Tobacco use remains the single greatest public health challenge in the United States, creating an extraordinary burden of death, disease, and healthcare cost. There is a strong scientific basis for tobacco control interventions, yet these interventions have not been applied consistently or systematically. The aim of this review was to explore the changing landscape of tobacco use, the results of which can be used to help optimize performance.

Study Design: Literature review.

Methods: The CDC updated their Best Practices in Comprehensive Tobacco Control in 2014. A PubMed literature review for key words “tobacco control” and “smoking cessation” from 2010 to June 2016 was reviewed for content not previously discussed in the document.

Results: The demographics of smoking have shifted: although the prevalence of smoking has declined overall, smoking has become increasingly concentrated among individuals with mental illness, the rural poor, and the community of lesbian, gay, bisexual, and transgender individuals. Self-medication with nicotine is increasingly apparent as new ways of delivering nicotine are increasingly available in the form of electronic cigarettes. The central paradigms of smoking cessation treatment based on the “readiness to change” model have been challenged, and many authors are recommending treatment or harm reduction for all smokers. The economic value generated by smoking cessation has been affirmed in large-scale studies.

Conclusions: New information on the epidemiology of smoking and cessation will lead to a change in focus for smoking cessation interventions. Tobacco use is a chronic illness and merits sustained interventions inclusive of harm-reduction strategies and a nuanced integration of the role of nicotine in behavioral health. Integrating these interventions in a coordinated manner requires leadership, structure, and a sustained effort that are only available when the cost reductions in healthcare utilization align with the business model of the system of care. Accountable care organizations are well positioned to leverage a significant impact on tobacco control and can help bridge gaps in the overall treatment of mental illness and tobacco use in this population.

The American Journal of Accountable Care. 2016;4(4):34-40
In the 50 years since the first Surgeon General’s Report on Smoking and Health,1 tremendous progress has been made in reducing tobacco use, with a 50% reduction in the prevalence of adult smoking. Yet, according to the most recent National Adult Tobacco Survey, 21.3 % of adults reported tobacco product use “every day” or “some days.”2

Current estimates of avoidable tobacco-related deaths are now thought to be over 460,000 per year, and on average, smokers live 10 years fewer than nonsmokers.3 Recent National Health Interview Survey data revealed that approximately 14 million US adults suffered from major medical conditions that were attributable to smoking.4 A recent evaluation of the cost of tobacco-related conditions estimated that 8.7% of the healthcare costs—as much as $170 billion per year—could be attributed to smoking.5 Projections indicate that the prevalence of adult smoking could likely still be above the Healthy People 2020 objective of 12%, even by mid-century, “if there is little change to current strategies and the burden of illness will persist well into the 21st century.”3 Progress in lowering the prevalence of smoking over the last 8 years has been substantial; however, there are many missed opportunities to improve even further.6

Managed care organizations (MCOs) have been at the forefront of tobacco control. Group Health of Puget Sound showed that an MCO could have a profound impact by reducing the adult prevalence of smoking from 25% to 17% from 1985 to 1994.7 Implementation of clinical practice guidelines by health plans was studied extensively.8 Insights from these and other studies were used to develop the CDC’s Best Practices for Tobacco Control Programs (2014).9  

In 2000, the National Commission for Quality Assurance added questions to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey regarding physician-based interventions.10 The 2014 data show substantial progress in the measure “Advising Smokers and Tobacco Users to Quit,” with 77% of commercial health maintenance organization (HMO) members reporting that their doctors had advised them to quit in the previous year. Performance on “discussing cessation medications” and “discussing cessation strategies” were reported by only 50% of the smokers. Performance for preferred provider organizations (PPOs) and Medicaid health plans was 5% lower, on average, than other plans. A close review of the data suggests that improvements in performance on these measures has reached a plateau. The landscape for tobacco control is changing: the demographics have shifted, and new treatment options are available. Accountable care organizations (ACOs) are well positioned to leverage emerging approaches to tobacco control over the populations they serve and their surrounding communities.11,12


A PubMed literature review for key words “tobacco control” and “smoking cessation” from 2010 to June 2016 was reviewed for content not previously discussed in the CDC’s Best Practices for Comprehensive Tobacco Control Programs (2014).9

Understanding the Evolving Demographics of Smoking

Although the overall prevalence of smoking has declined, the prevalence of smoking in many subgroups has not declined at the same rate. Tobacco use has become increasing concentrated in marginalized populations, such as the lesbian, gay, bisexual, and transgender communities13; those of low socioeconomic status14; and the rural poor.15

The greatest disparity is among those with mental illness. The prevalence of smoking among this group generally has been reported as double that of the general population,16 and the proportion of these smokers has remained constant over the last 15 years, even as the prevalence of smoking has declined overall.17 Addiction to nicotine by itself is not sufficient to explain the demography of tobacco use. The addictive properties of nicotine are well known, but young individuals start smoking for the same reasons that they experiment with other adult behaviors. A significant fraction of individuals will continue smoking in order to self-medicate.18

Nicotine is also an antidepressant, so it should not be surprising that some antidepressant medications (eg, bupropion [Zyban] and nortryptiline)19 are effective in smoking cessation. Cigarette smoke also contains compounds that inhibit monoamine oxidase, an important enzyme that reduces brain dopamine. Monoamine oxidase inhibitors are a unique class of antidepressants, and some smokers may be self-medicating to attain this effect.20 There is growing literature showing that subpopulations of individuals with mental illness derive more specific benefits from nicotine; for example, schizophrenics reportedly self-medicate to reduce hallucinations,21 and those with anxiety or substance abuse appear to be self-medicating as well.22 Nicotine also has significant effects on concentration and cognition in individuals with attention deficit disorder and schizophrenia.23

A natural conclusion of this literature may be that those with mental illness need additional diagnosis and treatment to optimize symptom management. Providing them with a less harmful source of nicotine or alternative medications may have a profound impact on the future health of this population. Another conclusion might be that smokers should be evaluated for the presence of a mental illness for which they are self-medicating. The standard treatment model does not address the issue of self-medication.


New Approaches to Treatment

The US Public Health Service first detailed the evidence-based approach to smoking cessation in 1996 and updated its clinical practice guideline, “Treating Tobacco Use and Dependence,” in 2008.24 At the core of this guideline is a structured approach to a physician’s counseling of a patient. The clinical practice guideline also states that medications approved for smoking cessation are to be offered to every patient making a quit attempt. Beyond the additional 7 medications outlined by the US Preventive Services Task Force, many combinations of medications and new additional agents are being used to treat craving in smoking cessation.25

The basic approach to smokers is to prompt quit attempts during clinical encounters. Physicians now routinely inquire about the smoking status of all of their patients and ask about “readiness to change.” Patients who say that they “believe that they will be able to quit smoking in the next 6 months” are described as being in a state of contemplation and are provided progressive interventions as they advance toward being able to set a quit date. Although approximately 70% of US daily cigarette smokers say they want to quit, fewer than 50% will attempt to quit in a given year. The long-term success of these quit attempts is about 6%.26 Drummond has estimated at least 36 million US adults are unwilling or unable to completely abstain from combustible cigarettes.27 

There has been considerable criticism of the standard model of smoking cessation, which rejects smokers that are not ready to change. Steinberg has proposed that given the chronic relapsing nature of tobacco dependence, tobacco use, should be approached as a chronic disease28 and extended medication with nicotine be used as a way of treating this condition. Richter and Ellerbeck have argued for an opt-in treatment approach, wherein every smoker seen by a clinician is provided with an intervention regardless of their readiness to change.29 There is substantial evidence that interventions for smokers not ready to change impacts behaviors in one of 2 ways: by promoting quitting and by reducing the amount smoked. Positive outcomes for this type of proactive approach have been reported by many authors.30 Fu et al randomized 5000 smokers under care by the Veterans Administration into a comparison of usual care, based on the standard model, versus proactive care.31 At 1 year, the proactive group had a sustained 6-month abstinence rate of 13.5% compared with 10.9% in usual care.

Vidrene et al evaluated an alternative approach to smoking cessation quit-line referrals.32 It was observed that primary care referrals to quit lines were low and that most smokers who were passively referred did not call to utilize the service. After shifting to an “Ask-Advise-Connect” protocol,33 a 10-fold increase in smokers enrollment was observed.

Tobacco Harm Reduction: Medication

Many study authors have advocated the use of smoking cessation products for tobacco harm reduction.34,35 This literature has recently been summarized by the British National Health Service Institute for Care Excellence (NICE).35 NICE advocates the use of nicotine-containing medications for smoking cessation for as long as needed in order to assist patients to stop smoking, cut down prior to stopping smoking (cutting down to quit), reduce the amount they smoke (smoking reduction with no intention to quit), and temporarily abstain from smoking.

Another proactive approach is the use of practice quit attempts with medications for smoking cessation. Carpenter et al showed that nicotine therapy sampling during a practice quit attempt among patients who were unmotivated to cease smoking creates additional quit attempts.36 Ebert examined the impact of varenicline on smokers not ready to quit, and after 8 weeks, 26.3% of the patients had quit smoking or had reduced smoking by 75% compared with 15.1% of those on placebo.37 Thus, smokers can significantly reduce their exposure to combusted smoke by prolonged use of these medications.

Tobacco Harm Reduction: Electronic Cigarettes

Recently, Public Health England published a systematic review of the available literature on the health and safety implications of electronic cigarettes (e-cigarettes) concluding that their use is about 95% safer than smoking. The authors recommend that smokers who have tried other methods of quitting without success should be encouraged to switch to e-cigarettes.38 The FDA has rejected the harm-reduction approach implemented in England and has taken a more precautionary approach toward e-cigarettes.39 The case for tobacco harm reduction with e-cigarettes has been made by Polosa et al,40 who point out that besides delivery of nicotine vapor without the combustion products—which are responsible for nearly all of smoking’s damaging effect—they also replace some of the rituals associated with smoking behavior.

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