Curbing the tobacco craving

Business & Health, Nov, 1998 by Janet Gemignani

Kicking the habit is no easy feat, but a combo consisting of pharmacological therapy, behavior modification and broad coverage is a smoker's - and employer's - best bet.

Cigarette smoking's link to a long list of debilitating conditions has been well-documented, with heart disease and stroke, cancer, and chronic bronchitis and other respiratory diseases foremost among them. While group health plans routinely cover the cost of treatment for these smoking-related illnesses, however, that's not the rule for programs to help smokers quit. In a 1996 survey of Fortune 100 firms, nearly a third did not cover smoking cessation activities of any kind. Another third offered limited coverage, paying for one or two components of a program that might include behavior modification classes, written material and nicotine replacement therapy, for example, while the remaining third covered the full range of services.

With ample evidence that smokers want to kick the habit but have a very hard time doing so, such an approach may be shortsighted indeed. In an American Lung Association survey this September, seven smokers in 10 said they hoped to quit and had tried repeatedly to give up tobacco. But the high recidivism rate has to do with the tactics employed, according to Alfred Munzer, an ALA physician. "Most people quit through the least effective way," he says: They go "cold turkey," a method that yields a mere 5 percent success rate.

The highest quit rates occur when pharmacological therapy is paired with behavioral modification, typically consisting of six- to eight-week one-hour sessions, Munzer says. There's an arsenal of nicotine replacement products and a non-nicotine drug on the market designed to ward off cravings and eliminate the harmful additives contained in cigarettes (see the box on page 46).

The American Lung Association, which helps employers design worksite programs, began its anti-smoking crusade in the '50s. In the decades since, the percentage of Americans who smoke has plummeted 56 percent. But that still leaves 25 percent of the adult population - some 46 million people nationwide - hooked on the deadly habit. Smoking directly causes an estimated 430,000 deaths per year and is believed to kill some 50,000 non-smokers through repeated exposure to second-hand smoke.

Financially, tobacco exacts a huge toll as well. Direct medical costs for smoking-related illnesses, according to the ALA, including hospital, physician, nursing home, Rx and home health care expenditures, come to about $50 billion a year. The tab doubles when you add up the indirect costs, primarily the result of lost productivity caused by increased absenteeism and smoking breaks. In comparison, the modest cost of smoking cessation programs - calculated by the Group Health Cooperative of Puget Sound in Seattle, which has been providing such services since 1993, to be about $328 a year per benefit user - is a bargain.

Lack of solid evidence on the use and effectiveness of anti-smoking interventions has been a barrier to widespread coverage, according to Susan Curry, a physician at Group Health Cooperative. To fill in the gap, she studied some 90,000 enrollees in a number of health plans in Washington State, 19 percent of whom smoked. Her findings: Reimbursement levels make a huge difference in participation rates.

About one smoker in 10 enrolled in smoking cessation programs in which behavior modification services and nicotine replacement therapy were fully covered. That's more than four times the participation rate (2.4 percent) of those with limited coverage. Those in the full coverage group had lower quit rates, possibly because people who have to foot part of the bill for a program are more likely to stick to it. But the difference was more than offset by the greater participation among those whose program activities were fully paid for, Curry asserts. In the final analysis, 2.8 percent of smokers with total reimbursement kicked the habit, four times more than those with limited program coverage.

Managed care's recognition of tobacco addiction as a serious health threat was spurred in part by the federal Agency for Health Care Policy and Research, which threw down the gauntlet with its 1996 release of clinical guidelines on smoking cessation. The provisions call for primary care providers to ask all patients if they smoke and to recommend treatment and offer encouragement to help smokers quit. Beginning in January 1997, the National Committee for Quality Assurance asked health plans to report on a HEDIS quality performance measure designed to gauge the percentage of adult smokers who received such advice.

A year later, the Robert Wood Johnson Foundation announced a $1.4 million grant to the American Association of Health Plans after research showed that only a third of the smokers who see a doctor every year actually get the help they need. The award was used to establish the National Technical Assistance Office, designed to help health plans implement smoking prevention and cessation programs.