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“One sure way to break the cycle”
  1. Phil Nudelman
  1. Kaiser/Group Health, 1730 Minor Avenue, Suite 1500, Seattle, Washington 98101, USA;nudelman.p{at}ghc.org

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    My name is Phil Nudelman, and I am a quitter. Now, normally I would not brag about being a quitter, but in this case I am really proud of that fact. Over 25 years ago, I was driving in my car, with a Parliament cigarette in hand, and my youngest son in the back seat. He was five years old at the time, and he just blurted out, “Daddy, I want you to quit smoking!” I was a bit astonished, because no one had ever asked me to quit before. I thought, “Why not?” So I put my cigarette out and threw the pack into the trash bag, and I have not had a cigarette since. It has been a pleasure for me to be a member of the rank of smoking quitters. It is also a pleasure for me to be included at the starting point of a major initiative sponsored by the Robert Wood Johnson Foundation.

    The foundation’s foresight and generosity will allow managed care organisations to do what they can do so very well—integrate preventive techniques, in this case tobacco intervention, into the basic health care of their populations. I want to add my gratitude to the foundation for the opportunities and the hope they are giving to the people served by managed care. I also want to acknowledge the contributions of the other major sponsors to the cause of decreasing tobacco use in managed care—the American Association of Health Plans, The HMO Group, the Agency for Health Care Policy and Research (AHCPR), and the US Centers for Disease Control and Prevention.

    As healthcare officials and administrators, we have an obligation to do all we can to free our communities of tobacco use. I am proud that we are together today to forge our commitment to action. At this conference are the leading lights in the academic, governmental, and managed care tobacco control world. What do I have to offer you? I am certainly not an expert, or part of any of the tobacco control movements per se, but I have two stories, and the experience of one healthcare organisation to share with you.

    Here is the first story. There was a woman who worked for me for several years. By the time she was 35, her father had been a smoker for some 40 years—and no matter how ill he became, he kept smoking. Not only did he have lung cancer, but the disease had taken root in him and had spread tumours all through his body. At an advanced stage of his disease, the cancer had spread to his brain, and he began to have seizures and small strokes. He was being cared for at home, and after one of these seizures, he was partly paralysed and could hardly see. But one of his hands kept reaching and reaching; his family wondered why. He could not talk and he could barely move, but he kept reaching. They watched his hand roam over the bed table and finally he found a pen—a ballpoint pen—which he pulled to his mouth and began to puff on, as if it were a cigarette. His wife and daughter stood there aghast, knowing all too well what was killing him; they were furious at the tobacco companies.

    As this man’s experience, and the experience of millions of other smokers shows, smoking leads to disease, addiction, degeneration of the spirit, loss of humanity, and finally death. Family members are left with feelings of helplessness and fury at the addiction that took their loved one.

    Here is the second story. Charles Dean is a father of five and a Seattle [Washington, United States] native. Now 53 years old, he’s been in the longshoremen’s union all of his working life. He had his first cigarette at age 16, a year after he got his first Harley-Davidson; he was a biker and smoker from then on. He says it did not take long for him to be smoking three packs of Marlboro 100s a day—regulars, not lights. He continued at that rate for over 30 years.

    He says, “When I would get up to go to work, the first thing I’d do is take a cigarette, slap it in my mouth, and light ’er up before I’d do anything else. The more I smoked, the more I increased my smoking.”

    In December of 1991, Charles developed what he thought was another bad cold. After several weeks and two trips to the emergency room, he was diagnosed with pneumonia, and wound up paying a visit to Dr Tim McAfee, Group Health Cooperative’s foremost anti-smoking expert. This crossing of paths proved to be one of the best things that ever happened to Charles Dean. He went through a regimen of nicotine patches and now says he believes he will never smoke again. He finds that he is not short of breath anymore—even climbing cranes which are 150 feet (46 metres) in the air. Charles is a quitter—and very proud of that fact.

    I don’t know about you, but I like the ending of the second story a lot more than the ending of the first. And the second story, the story of a quitter, ties in with the experience of one healthcare organisation which I promised to relate to you.

    I am currently chairman and president of Kaiser/Group Health, but for seven years prior to this time, I was president and chief executive officer of Group Health Cooperative of Puget Sound. Group Health Cooperative is the nation’s largest consumer-governed, not-for-profit health maintenance organisation, with over 700 000 enrollees. Group Health’s founding principles include prevention and health promotion. We are also dedicated to a population-based, evidence-based approach to care.

    Ten years ago, Group Health took part in a National Cancer Institute clinical trial. It was for an inexpensive smoking cessation programme called “Free & Clear”. We learned from this study that participation in “Free & Clear” doubled a person’s chances of successfully quitting smoking and staying off tobacco over a year later. This was a fantastic result.

    Five years after the study, we discovered that only 180 smokers a year were using this proven service. We worked hard to understand why, because at about that same time, in 1992, decreasing tobacco use was identified as Group Health’s number one prevention priority, as it is the number one cause of preventable death.

    A few relatively simple changes resulted in a 15-fold increase in participation in the “Free & Clear” programme. The results are shown in figure 1. The first change we made was to offer people a choice of how to participate—through group meetings or over the telephone. Given a choice, about two-thirds chose the telephone calls. After registration in the programme, the telephone intervention begins. During the first call, the telephone specialist determines the smoker’s nicotine dependence, readiness to quit, and motivation to use behavioural techniques. With the smoker, the specialist develops a quitting plan that may include nicotine fading. Follow up by telephone is scheduled throughout one full year. In the group format a similar approach is used, with a series of eight classes in a six-week period, plus the year-long telephone follow up. In each case, throughout the process, the participant is linked and in contact with the specialist and a physician.

    Figure 1

    Increase in participation in the “Free & Clear” smoking cessation programme.

    The second change was that we experimented with removing financial barriers to participation. We know that the “Free & Clear” programme costs about $220 per person, including telephone or group support and nicotine patches. If you do the mathematics on that number, it turns out that 1000 people can successfully quit smoking for less than the cost of two lung transplants, not to mention the increased life expectancy for each of the smokers who quit.

    When we started out, the “Free & Clear” programme was not a covered benefit, so we were charging people the full $220 to participate. As I mentioned earlier, very few people came forward. So, in 1992, we provided coverage for “Free & Clear” with a co-pay (where they would pay just a small percentage of the cost). Right away, there was a 10-fold increase in participation that year. Four years later, during 1996, we reviewed the effects of various benefit structures on use, satisfaction, and outcomes. We found that a $42 co-pay resulted in 30% of registrants not showing up. In groups with no co-pay, only 1% of registrants failed to appear. We watched the behaviour of our Medicare population as well. In the first five months of 1997, we had only one Medicare person participate!

    Given all these findings, in May 1997, Group Health began providing full coverage for tobacco cessation services. We knew by then that eliminating co-pays would dramatically increase participation. Evidence was suggesting that removing co-pays, within the context of a comprehensive organisational effort to reduce tobacco use, may make it possible to increase programme enrolment by as much as 8–10% per year. In the overall Group Health population, nearly 3000 people went through the “Free & Clear” programme last year.

    You may be wondering about the Medicare population that I mentioned. In the second half of 1997, after the co-pays were lifted, “Free & Clear” enrolment increased from one to 110.

    We found that the programme changes we made were critical: allowing smokers to quit at their own pace, with telephone or group support from a trained specialist, with access to aids such as nicotine patches, and with financial barriers removed. Before, with co-pays, we enrolled one smoker in 200. With co-pays removed, we reach one in every 15, and we have seen a tripling of individual one-year success rates. We have also seen how this population-based, patient-centred approach to smoking cessation has contributed to a dramatic decrease in smoking in the overall Group Health Cooperative adult population—from 25% to 15% over the past 10 years. We are very proud of our success.

    I absolutely love it when someone asks me, “What can one organisation do about a huge, society-wide problem like smoking?” My answer is: “Both a little, and a lot”. At Group Health, we have counted on the small things adding up to something very significant.

    What can one organisation do?

    There are a variety of approaches to the problem.

    • Counselling

    • Education

    • “Muscle”

    • Participation

    • Commitment

    • Pressure

    COUNSELLING

    We distributed to every primary care team a guideline on giving brief, supportive, repetitive messages to the smokers on their panels. The guideline was based on the National Cancer Institute’s “Ask, Advise, Assist, and Arrange follow up” model, and is similar to the AHCPR guideline recommendations.1 The primary care teams also received an implementation manual, tools, training, and ongoing support for guideline integration.

    EDUCATION

    Group Health also provided broad-based consumer and community-based education through its distribution ofNorthwest Health magazine to all households of Group Health consumers. Northwest Healthis the third most widely distributed magazine or newspaper in the state of Washington. As part of our population-based approach, the magazine has run a major tobacco-related story in several issues, including a story by Garrison Keillor describing his experiences in quitting smoking, pictorial essays of anti-smoking advertisements, several analyses of tobacco industry attempts to ensnare children, and profiles of successful quitters, such as Charles Dean, whom I described. The magazine also runs large ads for the “Free & Clear” programme.

    “MUSCLE”

    Group Health has applied its organisational weight—its bully pulpit—to numerous community and legislative initiatives in Washington state, with physicians and administrative leaders testifying for policy changes on tobacco. The organisation’s officers, physicians, staff, and lobbyists have successfully fought a “smokers’ rights” bill and successfully supported a bill that eliminated vending machines. The bill also requires licensing fees and penalties for merchants selling tobacco to minors, with the money raised being devoted to enforcement and prevention programmes among the young.

    PARTICIPATION

    We remain active in several coalitions that support regulatory change and legislation directed at decreasing access by young people to tobacco products, increasing counter-advertising and tobacco education, obtaining a dedicated tobacco excise tax to support prevention activities, and strengthening clean indoor air regulations.

    COMMITMENT

    Group Health has co-sponsored a children’s art counter-advertising poster contest, provided free office space and grant support to a state-based tobacco control organisation, provided seed grants to the American Heart Association for tobacco control, provided testimony in support of a ban on smoking in offices, and encouraged staff participation in the Tobacco-Free Washington coalition.

    PRESSURE

    Group Health staff members were instrumental in establishing a large coalition of community groups that helped convince theSeattle Times newspaper in 1993 to stop accepting tobacco advertisements. Washington state has now banned smoking in all public (government and private) office buildings. The state also has one of the highest tobacco taxes in the nation.

    Conclusions

    These six categories show multiple, parallel tracks aimed at systemic change. We’re learning as we go along, building on prior lessons, and these activities are supported from the highest levels of the organisation, both clinical and administrative. As I mentioned, Group Health’s smoking rate has fallen from 25% to 15% over the past decade, whereas the Washington state rate went from 25% to 23% (figure 2).

    Figure 2

    Smoking prevalence in Washington state and at Group Health Cooperative.

    The more dramatic decrease at Group Health is due, at least in part, to our systematic efforts to address tobacco use with the same level of seriousness that we use to address other serious medical conditions. All segments of the healthcare system needed to work together using quality improvement principles for this effort to be successful.

    Components of this effort included the education of physicians and nurses, and the measurement of key performance indicators such as appropriate charting and patient exit interviews. Certainly, this is a complex strategy, in the sense that it requires hard data, determination, broad organisational support, integration of administrative support with clinical activities, and empowered healthcare teams. I am here to offer you proof that such customised efforts can succeed.

    My challenge to you is to take this proof, take this success, make it your own, and then go one better—in your healthcare organisation, in your government agency, or in your public health programmes. We have inexpensive and proven means to break the cycle of addiction. This approach does not have to break the bank. We can achieve impressive rates of success with a minimal investment.

    Let me be more specific: at Group Health last year, we spent about $400 000 for behaviour services (the “Free & Clear” programme) and administration, and $500 000 for nicotine replacement therapy, for a total of $900 000 to treat 3000 people. That’s a very small percentage of our $1 billion budget, especially considering that we spent close to $20 million on treatment of tobacco-related diseases.

    Coverage for tobacco cessation is an opportunity for managed care organisations to behave like health improvement organisations, instead of people’s worst ideas of managed care meaning only managed cost. It’s an opportunity for public health to live up to its name. It is an opportunity for government agencies to do the right thing.

    You may encounter people telling you that such legislative or community-based activities are not appropriate for your organisation. You will certainly encounter scepticism that long-standing addictions can be broken. And there will be the need to work cooperatively with quite an array of organisations working on tobacco control—from state bureaucracies to ad hoc advisory groups—all with their own styles, beliefs, and favoured approaches.

    There will be resource competition, for sure. A potential concern about funding adult smoking cessation programmes is that they decrease funding for programmes aimed, for instance, at keeping kids from starting to smoke. But consider the situation of a woman with two children. She is trying to quit smoking. Her successful quitting is far and away the best thing that can happen in terms of keeping her two children from starting to smoke. That is because the children of smokers are twice as likely to start smoking as the children of non-smokers. By helping her to quit, we are helping her children.

    Group Health tobacco activists succeeded in promoting their goals to the organisation by pointing to the evidence. You and your organisations can point to the evidence gathered by Group Health Cooperative when you seek support for your tobacco cessation programme. Imagine what we could achieve if we all worked in concert. Picture the united effort of managed care and public health organisations, foundations such as the Robert Wood Johnson, and the legal challenges we could present to the tobacco companies.

    Tobacco use is a serious medical condition with proven effective treatment. Health plans need to take action and provide covered, easily accessible treatment for tobacco dependencenow. We have demonstrated that it can be accomplished. There is no excuse not to provide it because it may cost us money. We cannot refuse to provide cancer treatment just because it is costly. Smoking cessation programmes are a core service of a health improvement organisation.

    Ultimately, as cigarette taxes and tobacco settlement dollars increasingly provide support for social and healthcare programmes, it is morally imperative for us as a society to use a portion of this money to ensure that motivated tobacco users have easy access to proven help for quitting. For the tobacco industry, helping people to quit smoking should be a built-in cost of doing business—period.

    Let me close by saying that this is an impressive moment of convergence—with the researchers, legal community, healthcare providers, and government leaders all moving in the same direction. We are fortunate to be involved at this exciting time.

    My youngest son, Mark, is now 30 years old with children of his own. He never started smoking. He is the one who asked me to be a quitter and to stop smoking 25 years ago. He and I together set the stage for him and now for my grandchildren, all six of them, to be regarded as smoking non-starters. What more can a father or grandfather ask?

    References

    PARTICIPANT: The experience of Group Health is really wonderful and very impressive. Those of us who are working in other areas are trying to convince people like you, the chief executive officers (CEOs), of our plans to have the vision that you have. Can you help us? You have given us some information, but can you tell us what I can say to my CEO who has a much shorter vision and who views the world as very competitive?

    PHIL NUDELMAN: I think that what the CEOs of this industry and of the world have to answer is: What are you going to do tomorrow? How about tomorrow? Let’s stop thinking about the short term, and let’s stop thinking about quarterly profits, and let’s look at what is now irrefutable evidence about the cost of not treating smoking. We at Group Health have a long history, a 50-year history, of sharing our data. Data which is irrefutable. By showing that data, it is not a tough job to convince the thinking CEO that, in the long term, we are going to be much better off financially and health-wise when we implement smoking cessation programmes.

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