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Talking tobacco: a conversation about the past and future of smoking cessation research at group health

Volume 17 Issue 1
Winter 2005
Talking Tobacco:
A conversation about the past and future of smoking cessation research
at Group Health

By Katie Saunders
Cigarette smoking continues to be a blight on
between behavior and health, (2) make healthier the nation’s health. Despite substantial reduc- lifestyle choices, and (3) sustain these choices tions in U.S. smoking rates since the mid-1960s, over time. In the smoking arena, behavioral approximately one-quarter of adults still smoke. interventions are often designed to increase Comparable rates at Group Health Cooperative a person’s motivation to quit, facilitate the are substantially lower—more like 15 percent. development of an action plan for quitting, increase self-confidence, and help people since 1983, deserves partial credit for this cope with situations that “trigger” their urge to smoke. These interventions can take many forms, including written self-help materials, The Center’s first smoking cessation research group classes, and proactive telephone coun- study—Free & Clear—demonstrated the effec- seling in which the counselor contacts the tiveness of self-help written materials coupled smoker, instead of vice-versa. Because one with outreach via proactive telephone coun- size doesn’t fit all, behavioral interventions seling. This successful cessation strategy was are ideally tailored to smokers’ individual cir- modified and expanded to form the basis for cumstances, such as their readiness to quit, the Free & Clear program—implemented in barriers to quitting, and smoking-related con- 1989 and still offered as a covered benefit to Group Health enrollees through Free & Clear, Inc. A review of CHS tobacco research (see A Participants
Brief History of Tobacco-Related Interventions Terry Bush, PhD, research associate, is a at the end of this article) over the 20 years since psychologist who divides her time between the Free & Clear concept was first piloted illus- Free & Clear, Inc., (formerly the Group Health’s trates the Center’s continued commitment to Center for Health Promotion) and CHS. At Free & Clear, Terry conducts research related to Tobacco Cessation Helplines in Oregon Where are we now? That’s one of the ques- and Utah, two states that have contracted with tions posed to a group of experts (see below) Free & Clear to provide these cessation ser- during a conversation centered on a broad vices. At CHS, Terry has worked on health range of smoking-related topics, including behavior change interventions in the areas of current cessation strategies, pharmacological interventions, and comparisons of the war on tobacco with the battle against obesity. Evette Ludman, PhD, senior research associate, is a clinical psychologist who has developed The panel brings to the table extensive exper- behavior change interventions in the areas tise in health behavior change—the science of of smoking, mental health, breast cancer helping individuals: (1) understand the relation screening, and problem drinking. Evette has extensive experience with motivational inter- Terry Bush: I think you’re right that smoking
viewing, a form of counseling designed to rates vary in different populations. The tobacco trigger a decision and commitment to change companies have been putting so much money within a non-confrontational and empathic into targeted advertising toward gays and Latinos, college-aged people, and immigrants because there are not as many smoking restric- Jennifer McClure, PhD, assistant scientific tions or social constraints in these populations. investigator, is a clinical psychologist whose The tobacco industry is really hitting heavy in research has focused on changing smoking Europe, but people are standing up to it. Emi- and dietary behaviors. Jennifer has conducted grants from some of the Asian countries are several studies that have incorporated state- boosting the prevalence rates in this country. of-the-art technologies, such as using palm- And then there’s women—at one point they were taking up smoking as it was declining in Rob Reid, MD, PhD, is an assistant scientific Jennifer: I don’t know if women’s rates are
investigator at the Center for Health Studies. inordinately high compared to men, but they’ve Rob is also an associate director of preventive moved up to have a prevalence on par with men. care for Group Health’s medical group and In terms of why have the rates have plateaued, the other debatable theory that’s out there is The Conversation
that we’ve picked all the low-hanging fruit. In Katie Saunders: I've read that smoking rates
other words, the folks who could easily quit in the U.S. plummeted between 1965 and the have quit and a lot of the folks left out there— early ‘90s and since then the rates have leveled particularly the older smokers—are the more recalcitrant smokers. They need more inten- sive assistance than is readily available. Jennifer McClure: Smoking rates did decline
until about the early ‘90s when they were Katie: What's being done to provide this
about 25 percent. And they're about 22 per- cent nationally now, so they’ve been creeping down, but not at the same trajectory. They’re Evette: I think there are several approaches.
There’s been a big push in the area of primary prevention (keeping people from starting to Evette Ludman: And my understanding is
that what accounts for some of the difference future-oriented perspective. And I think the other thing that’s going on right now is target- ing high-risk subgroups. Large foundations are Rob Reid: Yes, that’s absolutely right. It isn’t
targeting funds toward low-income, pregnant consistent across all populations that rates are plateauing. If you look at children and college- aged people, there is a fair amount of move- Jennifer: Another big thing that’s happening,
ment. There is good news for school-aged and hopefully will continue to happen on the children where rates in Washington state national level, is a lot of the states have put have decreased substantially since the late their tobacco settlement money into things 1990s. However, college-age rates are actu- like state quit lines, as well as education. ally increasing and that’s worrisome. Rates may have plateaued overall, but actually providing cessation resources. That’s at risk there’s a lot of movement beneath the surface. of disappearing so we don’t know what the long-term impact is really going to be. But might be more motivated and receptive to if it’s sustained it has great potential. thinking about quitting or receiving services. Pregnancy is the classic teachable moment. Rob: I don’t want to lose this thing about
We’ve also looked at visits for cervical abnor- primary prevention. More effort is being malities and visits to pediatricians and other focused on preventing children and adoles- receptive to giving weight to the health effects of their smoking. Some of our research has Terry: That also applies to college students.
shown that among these people who are not volunteers—who do not just walk into a treat- Katie: What’s being done to ensure that
ment program ready to quit—we’ve been ef- cessation interventions reach more smokers? fective in helping them be more ready to quit.
Jennifer: Most cessation treatments are tar-
I do think that we at Group Health are uniquely geted toward people who are ready to quit. positioned to identify smokers and to be able We know that that’s a fairly small percentage of the overall population of smokers—at most, about 20 percent at any given time. The Jennifer: And we’re trying to take that idea to
majority of smokers out there will say they the next level. You can couple an intervention want to quit some day, but not in the next month or six months. One of the areas I’m when you don’t have a readily available interested in is this: How do we go out to those people and reach them and deliver an that’s about to field where we’re going out intervention that will increase their motivation into the community and contacting smokers. and readiness for quitting. And at the same And we’re creating a teachable moment by time, how do we put them into contact with doing a health screening with them and using the appropriate resources so that when they that as the time to give them advice about are ready to quit they have access to the quitting. We’ll hook them up with access to Free & Clear if they choose to use that. In Rob: And that’s something that Group Health
beyond the confines of Group Health and our can potentially do very well. Because Group Health physicians often have long-term pro- fessional relationships with their patients, Terry: Group Health also has a huge poten-
they can help motivate smokers to consider tial with the electronic medical record (EMR). quitting over extended periods of time. So, if a Rob Reid, Bev Green (associate director of patient isn’t really interested in quitting right preventive care), and I have been struggling now, doctors can continue to bring the topic with whether EpicCare (Group Health’s new up and tell the patient that we are willing to EMR) has enough bells and whistles to make assist them. And, eventually, doctors can sure providers ask about things like patients' move many smokers into a place where they smoking status and whether patients smoke might be ready to change and put them in around their children. Are there those kind of touch with resources that can help them. built-in teachable moments? There’s a big potential to build those interventions and Evette: Group Health’s smoking research
agenda has really followed the sentiment of proactive, outreach interventions. I guess one Rob: You’re right. The electronic medical
way I would describe it is “looking for optimal record has really changed the way in which teachable moments”—times when a person Katie: Aren't providers always supposed to
Evette: And it’s well integrated into our
ask patients about their smoking status? Evette: They probably do it better here than
Jennifer: I think it’s a combination of things.
One is the environment we’re in, where Washington state rates are slightly lower than Rob: But the electronic medical record has
the national average, King County rates are slightly lower than the Washington state rates; and then on top of that, at Group Health you Jennifer: In addition to the clinical benefits
have people who are middle-class, educated, of the electronic medical record—being able and have access to a very well integrated, to prompt the collection of smoking status systematized, comprehensive resource for information and to prompt a discussion with smoking cessation which makes a difference. patients about smoking—it’s also an impor- tant research tool. It’s one of the things that Katie: Is it the norm among health plans to
sets us apart from most other places in that we provide coverage for smoking cessation ser- can identify who smokers are in our popula- tion, which allows us to proactively deliver Jennifer: No. I think most health plans now
offer some type of intervention but they’re Rob: And it may not be that we prompt and
very varied in what that is, and I’d say few, if remind doctors; it might be that we reach out any, offer as comprehensive and established a program as the Free & Clear program. Katie: Smoking rates at Group Health are
Terry: When other health plans do offer
about 15 percent compared to a national aver- coverage, they often charge very high copays, like $60. And, that might not even cover nico-
Rob: There are likely many reasons. One is
tine replacement therapy (e.g., nicotine gum, probably because of our demographics. Our enrollees are mainly insured through employer
Katie: Speaking of nicotine replacement
contracts or government programs. We don’t therapies, my understanding is that they’re have a large Medicaid population. The state of supposed to help smokers with physical with- Washington (with its higher smoking rates), on drawal symptoms. How important are these the other hand, has a significant uninsured pharmacological interventions to smoking cessation, and do they work in the absence of Katie: Are those the demographics with the
Rob: Yes, low income, uninsured, and disad-
Jennifer: The first question’s easy—they are
definitely important. The second question, Evette: I think regarding the Group Health
speaking as a behavioral scientist, is easy, too. smoking rates, we should also take some credit. We know that, out in the real world divorced from any behavior therapy, pharmacological Rob: Absolutely. We can also take some
treatments do not work as well. Partly be- credit for having a state-of-the-art smoking cause people don’t use them as directed, partly because people experience side effects and they decide it’s not worth it. And partly now are trying to partner with the food indus- because it’s only one portion of the equation try rather than fight them—to think about how in really preparing someone for the quitting we can work creatively with them in this area. process. It’s a very important part of the equa- It’s going to take a whole new way of thinking. tion, but you’ve got to have that other half of preparing them behaviorally and emotionally. Terry: I think Group Health’s role in this is
going to be key because the things that have Rob: I agree with you. I think the vast major-
helped in tobacco prevention and cessation ity of people do much better when behavioral are the same sorts of things that will help with programs are in place in addition—sort of a this problem. Primary care providers can talk two-pronged approach. But I was wondering about the health implications of not exercising how you would handle people who don’t want counseling—they just want the pharmacol- Evette: I think the assistance hasn’t been
there for patients and providers. Providers Jennifer: When using just the pharmacological
may be initiating these conversations but it’s therapy, many people find it’s not effective and hard for them to actually help people–to give they give up trying to quit because they think them self-management strategies and support. the drug is the magic bullet and the drug These are difficult changes because unlike didn’t work, so they can’t quit. I understand smoking, it’s more than one discrete behav- why [just using pharmacotherapy] is very ior—there are a bazillion behaviors involved. appealing to smokers and for some smokers it may be adequate. But it’s important to give a Terry: Plus, there are so many different diets
very clear message that this might not be and there’s so much confusion about how to enough, and if it’s not enough, it doesn’t lose weight, how to increase your exercise mean you can’t quit. It’s important to lay and maintain that. It’s a little bit narrower things out and really inform people of their with the cessation strategies for smoking. Jennifer: People understand that when you
Katie: Do you think we have the potential to
quit smoking, you don’t smoke anymore. But have the same success on the obesity/exercise to lose weight, it’s managing your physical front that we've seen on the smoking front? activity, it’s managing your diet. It’s an ongoing thing. Getting people into that mindset of “This Evette: In terms of smoking, we’ve been
is a new lifestyle I have to adopt.” And “This talking mainly about the contributions at has got to be a multi-faceted lifestyle change.” Group Health. But, we have to acknowledge That’s going to be hard. But I agree with eve- that this success has happened within the context rything Evette said about there needing to be of tobacco settlements and within the context a culture shift. The progress we’ve made with of big money in counter-advertising. There’s tobacco is only because it’s been a multi- been a cultural shift; for example, taxation of pronged effort that’s had the backing of the cigarettes has made a big difference. Economic government and the public. We’re seeing and cultural things have to shift for individual signs of that around weight management now. interventions about weight and physical activ- The test will be whether it is the fad of the ity to work as well. I believe the potential is day or whether people are really committed to there but it’s going to be harder (than smok- ing). If we think the tobacco industry has a lot of money and power behind it, think about the food industry! I know a lot of researchers right
A Brief History of Tobacco-Related Interventions at CHS and Group Health
—Ed Wagner, MD, MPH, assumed the
among a random sample of smokers instead directorship of the Center for Health Studies of volunteers. The largest effect on quit rates (CHS), bringing the Free & Clear grant with
ported at the trial’s outset that they weren’t ready to even think about quitting smoking. 1985Free & Clear (Ed Wagner, CHS Prin-
cipal Investigator [PI]) tested minimal self- 1992—Group Health leadership made decreas-
help smoking cessation interventions among ing the prevalence of tobacco use its number- 2,000 Group Health volunteer smokers. After one prevention priority for the 1990s. To one year, 23 percent of the group that re- achieve this goal, leadership endorsed a series ceived outreach telephone counseling calls, in addition to written self-help materials, had Group Health Committee on Prevention that quit smoking. This quit rate was significantly included identification of tobacco status at all higher than that of the other intervention clinical encounters, physician brief advice, coverage for counseling and medications, and support for community and legislative initia- 1987Breaking Away I (Susan Curry, PhD,
PI) enrolled 1,200 Group Health volunteer smokers in a second trial of self-help interven- 1993Project HOPP (Susan Curry and
tions. One year post-randomization, smokers who received computerized feedback that was first example of a CHS cessation study targeting personalized or tailored to their individual a demographic subgroup, in this case pregnant situations were twice as likely to have quit women, who might be particularly receptive smoking than were smokers who received a to cessation and relapse prevention messages. Hoping to capitalize on the “teachable moment” offered by pregnancy, the researchers’ main Late 1980s—Group Health added nicotine
goal was to reduce the high rates (80 percent gum to its formulary, but not as a covered to 90 percent) of postpartum relapse to smok- ing. Twelve months post-delivery there were no differences in smoking rates among women 1989—Group Health, through its Center for
who received the relapse-prevention interven- enrollees the phone-based Free & Clear pro- gram for a fee that covered program cost. This 1995SALONS (CHS PIs Susan Curry and
program utilizes the successful proactive tele- Colleen McBride) attempted to capitalize on phone counseling component of the Free & another potential “teachable moment”—a Pap Clear research trial. During the mid-1990s, test. The thinking was that an intervention other cessation aids such as nicotine replacement pointing out the link between smoking and an therapy (e.g., gum, patches) and bupropion were increased risk of cervical cancer and severe cervical abnormalities might be particularly salient in the context of a recent Pap test. 1990Breaking Away II (Susan Curry, PI)
However, smoking rates did not differ between deviated from CHS’ previous cessation trials the control and intervention groups at six and by testing minimal self-help interventions 1998—Group Health decided to offer full
tively new technology of palm-sized computers coverage for smoking cessation services after into CHS’ smoking cessation arsenal. Project a CHS evaluation (PI Susan Curry) examined WIN evaluated a relapse prevention interven- four different coverage approaches. Results tion specifically tailored for women; Project showed that use of services quadrupled when STOP tested a self-help smoking cessation enrollees were offered full coverage for both intervention in the general population of counseling and medication (vs. a $42.50 fee smokers. Both trials featured tailored interven- for each). Program participation increased 20- tions based on real-time, real-world responses collected via the computers in a pre-assessment 1998-2003—Group Health won first-place
feasibility of using portable electronics to awards six years in a row from the American Association of Health Plans for its pioneering work in tobacco, including efforts with adults, 1998Project EZ (CHS PI Sue Curry)
youth, benefit design, and public-private part- compared the effect on smoking cessation nerships. Group Health received high marks rates of different dosages (150 mg vs. 300 mg) from NCQA and national recognition for its of sustained-release bupropion (bupropion improvements in provider charting of tobacco status, program enrollment, and collaborations ferent levels of telephone counseling. The with state health departments to address lower dosage of ZYBAN in combination with minimal or moderate phone counseling resulted in one-year quit rates of 24 percent and 33 1998Project Fresh Start (CHS PI Susan
percent, respectively. The take home message Curry) targeted low-income women of repro- was that ZYBAN works better in conjunction with a behavioral program and that 150 mg smoking rates are twice the national average. was as effective as the 300 mg. As a result of The trial recruited women when they brought this research, Group Health has changed its their children to a pediatric clinic—a “teach- able setting” that provided an opportunity for health care providers to link both the child’s 1999—The Center for Health Promotion
and woman’s health to smoking. After one launched the Oregon Quit Line, soon to be fol- year, women who received the cessation inter- lowed by quit lines in Washington, Minnesota, vention, which also included outreach counsel- ing calls, were twice as likely to have quit 2003, more than 100,000 people were receiving 1998Steering Clear (CHS PI Susan Curry)
1999Project Tobacco Status (PI Tim
represented CHS’ first effort at preventing McAfee) encouraged Group Health practitioners people from starting to smoke (primary pre- to record tobacco status using the automated vention). The trial, conducted among children aged 10 to 12, delivered interventions through parents and health care providers. After one year, children receiving the intervention appeared no less likely to take up smoking 2000Project WISE (PI Jennifer McClure)
(according to a measure of smoking suscepti- was similar to SALONS in that it took advan- tage of the “teachable moment” offered by a Pap test, but unlike SALONS, WISE focused 1998Projects STOP and WIN (CHS PI
specifically on women who had had an abnor- Jennifer McClure, PhD) introduced the rela- mal pap result or colposcopy. Since the majority of smokers are not ready to quit at any given tions. The study will evaluate the use of 150 point in time, the intervention featured four mg bupropion SR with each of the following telephone counseling calls whose timing and behavioral treatments: (1) proactive tele- phone-based Free & Clear; (2) a Web-based readiness to quit. Even though the vast ma- cessation program derived from Free & Clear; jority of women (83 percent) at the trial’s and (3) an integrated phone-Web program. outset were not interested in quitting smok- The researchers hypothesize that the com- ing in the next six months, they were very bined telephone-web program will be most receptive to the counseling calls, with 90 per- effective because it offers both the personal cent completing at least three of the four calls. Compared to controls, counseling participants were also more likely to enroll in Free & Clear 2004Project QUIT (Jennifer McClure, PI)
and had a higher abstinence rate at 6 month fol- is one of three studies funded through the University of Michigan Center for Health 2000National Cancer Institute Oregon
The goal of this program project is to develop Quitline (Group Health site PI Tim McAfee)
an efficient, theory-driven model for generat- recruited 4,500 smokers through the Oregon ing tailored health behavior interventions that Quitline to participate in a randomized trial is generalizable across health behaviors and examining three levels of phone counseling, sociodemographic populations. The goal of with or without an offer of nicotine patches. Project Quit is to identify and specify the active The trial found a dose-response relationship psychosocial and communication components between intensity of counseling and abstinence, of internet-based smoking cessation interven- with cost-effectiveness analysis indicating tions. Smokers are currently being recruited for this study, which is being conducted in collaboration with the University of Michigan 2003—Due to rapid expansion of its services
to a national market, The Center for Health 2004Get PHIT! (Jennifer McClure, PI)
Promotion (CHP) separated from Group Health ventures into the community to proactively to become a separate company. Renamed Free & Clear in late 2004, the organization continues hope to create a “teachable moment” by having to deliver smoking cessation services for Group Health. It also continues to contract shopping malls, work places, etc. All partici- with states to operate their telephone tobacco pants will have access to Free & Clear. Half help lines and with employers (e.g., Boeing, will receive generic information about smok- Microsoft) and other health care systems ing’s risks while the other half will receive (e.g., Minnesota Blue Cross, HIP New York) individualized feedback about their carbon to offer the Free & Clear smoking cessation monoxide exposure, lung functioning, and program. Free & Clear also offers weight other smoking-related symptoms and condi- management services to Group Health enrol- tions. The goal is to determine whether the lees. The company continues to be engaged in personalized health feedback increases smokers’ research on telephone-based cessation services. motivation to quit, use of cessation treatment, or likelihood of quitting. Recruitment for this 2004Son of EZ (Jennifer McClure, CHS
PI) follows up on Project EZ’s aim to find the optimal combination of a behavioral treatment program and bupropion SR (aka, Zyban), this time concentrating on technological innova-


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