Article
Increasing the Demand for and Use of Effective Smoking-Cessation Treatments: Reaping the Full Health Benefits of Tobacco-Control Science and Policy Gains—In Our Lifetime

https://doi.org/10.1016/j.amepre.2007.09.003Get rights and content

Abstract

More adults in the United States have quit smoking than remain current smokers. But 45 million adults (20.9%) continue to smoke, with highest rates among low socioeconomic status (SES), blue-collar, and Native American populations. More than two thirds (70%) of adult smokers want to quit, and approximately 40% make a serious quit attempt each year, but only 20%–30% of quitters use an effective behavioral counseling or pharmacologic treatment. The lowest rates of treatment use are seen in the populations with the highest rates of tobacco use. Fully harvesting the last 4 decades of progress in tobacco-control science and policy to increase smokers’ demand for and use of cessation treatments represents an extraordinary opportunity to extend lives and reduce healthcare costs and burden in the next 30–40 years. This paper uses the “push–pull capacity” model as a framework for illustrating strategies to achieve this goal. This model recommends: (1) improving and communicating effective treatments for wide population use; (2) building the capacity of healthcare and other systems to deliver effective treatments; and (3) boosting consumer, health plan, and insurer demand for them through policy interventions shown to motivate and support quitting (e.g., clean indoor-air laws, tobacco tax increases, expanded insurance coverage/reimbursement) and efforts to improve treatment access and appeal, especially for smokers who use them least. Innovations recommended by the National Consumer Demand Roundtable for achieving “breakthrough” improvements in cessation treatment demand and use are described.

Introduction

Enormous progress has been made in reducing adult smoking prevalence from the time of the first Surgeon General’s Report on tobacco in 1964, when almost one of two adults in the United States were smokers, to 2005, when one of five adults were smokers (20.9%).1, 2 The number of ever-smokers who have quit now exceeds the number of current smokers in the U.S., and the proportion of current smokers who are heavy smokers (>25 cigarettes/day) has declined substantially over the past decade, from 19.1% in 1993 to 12.1% in 2004.2 In 2005, fewer cigarettes were sold in the U.S. than in any year since 1951, when the population was half its present size.3, 4 These changes are the result of four decades of comprehensive science- and policy-based tobacco control aimed at denormalizing tobacco use, preventing youth initiation, helping addicted smokers quit, and reducing secondhand-smoke exposure.1, 2, 5

These tobacco-control advances have been hailed as one of the greatest public health achievements of the past century. However, recent annual declines in adult smoking prevalence have stalled, making it virtually certain that the Healthy People 2010 goal of 12% adult smoking prevalence will not be reached.1, 2 An estimated 45.1 million American adults continue to smoke, with highest rates among working-class adults, those with least income and formal education, and American Indians/Native Alaskans.2, 4, 6 Tobacco use remains the nation’s leading cause of preventable death and disease, annually claiming 438,000 lives and accounting for $167 billion in preventable healthcare costs and lost productivity—with growing socioeconomic and racial/ethnic disparities in these health impacts.7 Tobacco-use cessation confers substantial and immediate health and economic benefits across the lifespan, even after 50 years of smoking.8, 9, 10 In fact, Levy et al.8 estimate that if youth initiation were eliminated, the nation’s smoking rate would change little in the near term; they project that the greatest declines in smoking-attributable death and disease in the U.S. over the next 30–40 years will come from adult tobacco-use cessation.

Many of the pieces are in place for substantial increases in annual cessation rates. Hard-won progress in comprehensive national, state, and local tobacco control (e.g., clean-air laws, tobacco tax increases, public education and counter-advertising, social denormalization) has moved us much closer to a world that seemed almost unimaginable 25 years ago—a world in which “nonsmoking cues and cessation information” would be “persistent and inescapable,”11 generating unprecedented support and motivation for smokers’ quitting efforts. Effective and cost-effective behavioral and pharmacologic treatments have been developed to help smokers quit and achieve long-term abstinence.9, 10 Moreover, these treatments are increasingly covered by insurers and accessible through primary care offices, provider organizations and health plans, pharmacies, telephone quitlines, and emerging online services.12, 13 Unfortunately, the hoped-for progress in national smoking and quitting rates has not occurred. While 70% of current adult smokers want to quit, only about 40% make a serious quit attempt each year, and the national annual quit rate has not changed much over the past 20 years.2, 4

Clearly, continued progress in reducing tobacco use and increasing cessation attempts and successes among U.S. adults will require comprehensive tobacco-control polices that address both initiation and cessation and will reach all smokers. However, to reap the fullest health benefits of the impressive tobacco-control science and policy gains achieved in the past 4 decades, over the next in 4 decades, tobacco-control efforts must focus more intentionally on increasing the demand for and use of effective smoking-cessation treatments among current smokers and quitters. Today, the vast majority of U.S. smokers who try to quit still are doing so “on their own,” without the benefit of treatments demonstrated to achieve quit rates substantially higher than current 5%–7% “unaided” quit rates.9, 14 In 2000, only 20%–30% of U.S. quitters reported using an evidence-based treatment, only a modest increase from the 15% reported in 1986.15 And, disparities in treatment use continue to compound disparities in tobacco use; smokers with the least income and education, who try as often to quit as others, are the least likely to use effective treatments, and the most likely to fail when they make a serious quit attempt.2, 4, 6, 13 Strategies that can increase the reach, appeal, and use of effective cessation treatments hold untapped potential to reduce overall adult smoking prevalence and growing disparities in tobacco use and tobacco-caused death and disease.

To realize this potential, six leading U.S. tobacco-control funders—the American Cancer Society (ACS), American Legacy Foundation (ALF), Centers for Disease Control and Prevention (CDC), National Cancer Institute (NCI), National Institute on Drug Abuse (NIDA), and Robert Wood Johnson Foundation (RWJF)—recently joined forces to organize and fund a multidisciplinary, multisector Consumer Demand Roundtable with the aim of identifying strategies and innovations that could lead to “breakthrough improvements” in treatment demand, use, and disparities in the next 5 years (www.consumer-demand.org). The Roundtable’s chief findings and recommendations will be released in a 2007 report.

This paper uses the model outlined in Figure 1, a model developed to help guide broader cancer control and health promotion research-to-practice efforts, to categorize the major challenges and opportunities addressed by the Roundtable.14, 15, 16, 17 It illustrates the need to work simultaneously on three fronts: (1) strengthening “science push” by proving, improving, and communicating effective treatments for wider population use; (2) building the capacity of relevant systems and institutions to deliver them; and (3) boosting demand, or market “pull,” for these treatments among consumers, healthcare purchasers, and policymakers. The next sections highlight selected accomplishments and innovations in each area with the potential, when combined, to bring about substantial reductions in adult smoking prevalence and in needless tobacco-caused death, disease, and healthcare burden in the next 30–40 years.

The science base for efforts to expand cessation-treatment use and reach is a strong one. Formal clinical practice guidelines based on over 6000 articles using well-established measures for assessing long-term effectiveness have identified efficacious and cost-effective interventions (behavioral and pharmacologic) that can be delivered at a population level in a variety of settings and modalities (e.g., healthcare, community, quitline, online), and in many cases individually tailored or targeted to the needs of priority populations.9 Table 1 summarizes the treatments that received a grade of “A” for strength of evidence based on a consistent pattern of findings from multiple, well-designed efficacy and effectiveness trials. The odds ratios (ORs) reported in the guidelines for these treatments range from 1.3 to 2.8, with most doubling quit rates compared to unaided quitting, usual care, placebo, no medication, or other controls, and with absolute long-term quit rates ranging from 10% to 30%.9, 18

The brief primary care intervention known as the 5A’s (Ask every patient about tobacco use; Advise all smokers to quit; Assess quitting readiness; Assist those who are ready to quit with brief cessation counseling and appropriate medication and those who are not with brief motivational counseling; Arrange follow-up for continued support and intervention and more intensive treatment if needed) deserves special attention given that 70% of smokers see their physicians each year.9, 19, 20, 21 The National Commission on Prevention Priorities recently identified the 5A’s intervention as potentially the single most effective and cost effective of all clinical preventive services recommended for adults in the general population, with estimated cost savings of $500 per smoker.19, 20 Closing the gap between current rates of delivery of the 5A’s and ideal rates of delivery (i.e., 90% of eligible adults) was projected to save as many quality-adjusted life years as closing the similar “delivery gaps” for all the other clinical preventive services recommended for adults in the general population combined (e.g., breast, colon, and cervical cancer screening, cholesterol and blood pressure screening, screening/counseling for problem drinking, influenza vaccine). Given the magnitude of its potential to improve population health, and reduce healthcare costs, burden, and disparities, the Institute of Medicine (IOM) identified this intervention as one of the top 20 priorities for all national healthcare quality improvement efforts.21

As Table 1 shows, the 2000 guideline panel reviewed and did not recommend self-help materials alone, acupuncture, or hypnosis. The panel did not review combined counseling/pharmacologic treatments, emerging computer-tailored and online behavioral interventions, or two newly FDA-approved efficacious medications (nicotine lozenges, varenicline), and it recommended further research for adolescent smokers and for smokers with psychiatric comorbidity and/or chemical dependency.9, 10, 22 Several of these topics will be reviewed as part of the 2008 guideline update that is now underway. “A-rated” guideline treatments were recommended for wide population use, with appropriate precautions in medically high-risk groups, and with cultural tailoring for smokers in racial/ethnic minority populations.9, 23, 24 The guideline update will also review new data from population-level trials, such as those recently reviewed by Cummings and Hyland,25 exploring why increased use of over-the-counter nicotine replacement products has not influenced quit rates more substantially in the population at large (e.g., possible use by less motivated quitters and/or by nonquitters seeking short-term relief from nicotine withdrawal in smoke-free environments).

These science-based guidelines have been widely promoted to healthcare providers, health plans, policymakers, and advocates, and have furnished a powerful rationale for many healthcare practice, systems, and policy changes. These advances have included increases in: (1) the numbers of primary care providers routinely assessing tobacco-use status and advising smokers to quit, (2) the tracking and reporting provider quitting advice and assistance as core healthcare quality measures, and (3) healthcare benefits and coverage for tobacco-cessation treatments.9, 10, 12, 13, 14, 25, 27, 28, 29, 30 One of the chief “lessons learned” from these successes is that simply having strong scientific evidence and respected evidence-based guidelines is not enough. Strategic leadership, advocacy, and communications have been critical to translating this science base into policy and practice.5, 10, 13, 26, 27

These strong science-based guidelines have not, however, been widely communicated or promoted to consumers—to smokers and their families. Recent survey and focus-group data reveal wide public uncertainty about the value of these treatments, reflected in difficulties discriminating effective and ineffective aids and in wide misconceptions about the harms of nicotine replacement therapy (NRT) use. For instance, a 2006 RWJF national telephone survey of 1076 U.S. adults aged 18 and over (21% smokers, 47% with a high school education or less, 67% Caucasian) found limited public knowledge about effective versus ineffective treatments.31 This survey asked which of 13 different treatments (seven evidence-based, six non-evidence-based) they believed had been “proven effective” to help smokers quit, typically doubling a quitter’s chances of success.27 While more than half rated getting help from a doctor or other healthcare professional (77%), going to a stop-smoking clinic or class (73%), and nicotine patches (58%) as effective, fewer than half placed Zyban/Wellbutrin (47%), NRTs (37%–45%), and using a telephone quitline (24%) in this category. In fact, unproven acupuncture (32%), hypnosis (39%), and quit-smoking programs offered by tobacco companies (32%) were more often endorsed as “effective” than quitlines. McMenamin et al.32 documented similar misconceptions among Medicaid enrollees and found that the perceived effectiveness of varied tobacco-dependence treatments was significantly related to their use in this low-income population. There is growing evidence as well for public doubt and misconceptions about how over-the counter (OTC) NRT products work, with many smokers, particularly those in low socioeconomic status (SES) and racial/ethnic minority populations, concerned about their safety and addiction potential.25, 33 Bansal et al.34 recently surveyed adult smokers and found that only 60% agreed that nicotine patches and gum improved smokers’ chances of quitting, and that fewer than half believed that these products were less likely than cigarettes to cause a heart attack.

Compounding these misperceptions and uncertainties, evidence-based cessation products and services are facing growing competition from new tobacco products promoted for “harm reduction,”35, 36 from record-level tobacco industry spending ($15.15 billion/year) on cigarette advertising and promotion,37 and from a growing proliferation of untested and unproven “miracle cures” and remedies (e.g., laser therapy, herbal remedies) exempt from U.S. Food and Drug Administration (FDA) and Federal Trade Commission (FTC) labeling and advertising regulations.38, 39 These factors combine to make effective consumer-oriented marketing and communications for evidence-based treatments more important now than ever. Direct-to-consumer marketing has been shown to help “demystify” and enhance the appeal and use of quitline services40; to boost the use and perceived effectiveness of NRT41; to generate greater treatment use when targeted specifically to underserved priority populations, including racial/ethnic minority smokers42; and to boost quit attempts, quit rates, and treatment use.40, 41, 42 The introduction of new medications (i.e., nicotine lozenges, varenicline)10 and the direct-to-consumer marketing campaigns for them, and the release and promotion of 2008 U.S. Public Health Service (PHS) guideline update28 will create new opportunities to boost the awareness, appeal, and use of treatments that work and to help smokers discriminate effective and ineffective quitting aids. They also will provide the context for innovative theory-driven studies to explore consumer treatment perceptions, expectations, and decision-making processes.

Policymakers and healthcare, public health, and tobacco-control leaders and advocates have succeeded in greatly expanding the nation’s capacity to deliver effective treatments over the past decade. Remarkable changes have occurred in the healthcare system. An increasing number of national, state, and professional groups (medicine, nursing, pharmacy, dentistry, mental health, cessation specialists) offer cessation-related training and assistance to deliver brief cessation advice and treatment.10, 12, 13 Based on evidence that healthcare provider training alone is not sufficient in the absence of systems supports to increase cessation-treatment delivery,9, 43 the proportion of health plans using some system to identify smokers has risen from 15% in 1997 to 91% in 2003,38 and the majority (over 60%) of smokers currently report physician advice to quit—advice that is associated with increased use of effective smoking-cessation treatments (counseling, medication) and with greater patient healthcare satisfaction.12, 13, 19, 32, 44 Advances in health information technology are rapidly expanding capacity for computerized reminder systems that have been found to improve the delivery of advice, counseling and medication in 5A’s primary care interventions.11, 12, 13, 28, 44 There also has been considerable growth in understanding and implementing broad multicomponent healthcare systems changes to improve treatment delivery, approaches that typically combine provider training, computerized provider reminder and patient referral systems, patient self-management support programs, performance measurement, feedback, and incentives for evidence-based care.12, 13, 21, 26, 28 The fact that tobacco-cessation advice and treatment are now metrics in the nation’s leading national healthcare quality measurement systems means that pay-for-performance initiatives using these measures will bring new incentives for their delivery as part of routine primary care.12, 13

Complementing these healthcare system changes, telephone quitlines are now available in 50 states and the District of Columbia through a single toll-free access portal (1-800-QUIT-NOW) providing smokers and providers an unprecedented barrier-free conduit to effective counseling.10, 45, 46 A 2005 survey of state quitline directors found that 90% of quitlines offered materials and/or counseling in Spanish, 71% offered broader language translation services for counseling, and 35% provided free or low-cost nicotine medication to eligible adult callers, especially to low-income and uninsured smokers.47 In addition, OTC availability of NRT gum, patches, and lozenges has widened their use, and the growth in online services hold the potential for “24/7” access to individually tailored quit smoking counseling and valuable quitting peer networking and social support.32, 48, 49

One of the most exciting possible by-products of the growth in each of these individual treatment delivery systems is the emergence of integrated multichannel, multimodality systems of care that can tailor treatment modalities and content for individuals and targeted populations, achieving higher reach, especially among low-income smokers, and possibly higher quit rates as well.13, 47, 49, 50, 51, 52, 53, 54, 55 Fiore et al.,46 Graham et al.,49 and Abrams50 have advocated for making the full range of cessation treatments (healthcare provider, medication, quitline, online, community-based clinics) accessible and freely available in a seamless, coordinated system of care management. For example, primary care practices increasingly are turning to telephone quitlines to provide the counseling assistance that is much less likely to be offered during brief quitting sessions by providers limited to 14-minute office visits.13 The “Ask-Advise-Refer” campaign of the American Dental Hygienists Association and the “Ask and Act” campaign of the American Academy of Family Physicians encourage providers to conduct the first two A’s of the 5A’s intervention (Ask and Advise) in their offices, and to refer patients to quitlines and other external services for additional help (Assess, Assist, Arrange). In 2005, 77% of state quitlines used faxed MD referrals to facilitate such primary care–quitline linkages.47 Under the best of these models, quitline counselors work with primary care clinicians in a team-based approach that includes follow-up collaboration.10, 13 Statewide programs in Maine, Minnesota, and New York are providing OTC NRT patches/gum to screened, eligible quitters.51, 52, 53 In studies conducted in three states, such efforts have greatly boosted quitline call volumes, have been particularly effective in reaching and assisting low-income and minority smokers, and have improved on the quit rates achieved in the same populations with quitline-only or NRT-only interventions.51, 52, 53 The integration of online services, particularly as the “digital divide” continues to erode, will further extend the reach, efficiencies, and social networking support of these multicomponent interventions—for both patients and providers.48, 49, 50

The inclusion of tobacco-use screening and treatment in the nation’s leading healthcare quality improvement agendas will spur new multisystem efforts to widen the delivery of proven treatments to the smokers who need them.13, 19, 20, 21 Public–private quitline service partnerships,45 pharmaceutical company investments in product promotion and in individually-tailored computer-based counseling programs for FDA-approved medications,54 and innovative minimal-contact NRT counseling and distribution strategies (such as brief pharmacist counseling in pharmacy-based health clinics serving low-income smokers)55 are examples of promising and potentially profitable (financially sustainable) delivery systems that work around the constraints of busy primary care office practices. However, as outlined in the National Cessation Action Plan,46 sustaining and expanding the nation’s quit-smoking treatment capacity and infrastructure ultimately depends on securing needed funding from federal, state, and local tobacco-control funds, excise tax revenues, as well as original (1998) and bonus (2008) Master Settlement Agreement (MSA) funds—only a small fraction of which are currently devoted to tobacco control.2, 56

While the supply of cessation products and services has grown enormously, especially over the past decade, demand for them has not caught up, either among smokers themselves or among the public and private health plans and employers who purchase cessation products and services on their behalf. Major strides in public-policy supports for cessation and treatment use over the past decade have substantially improved national prospects for higher consumer and market demand for effective quit-smoking treatments, but further efforts are needed to reap the full benefits of these policy advances.

As outlined below, population-based public health policies recommended by the CDC to increase quitting and/or treatment use (i.e., tobacco tax increases, clean indoor-air laws, reduced out-of-pocket treatment costs, cessation media campaigns),44 are currently reaching unprecedented numbers of smokers.

Since 1998, the combined average state and federal cigarette tax has increased from $0.59 to $1.33 per pack, with prospects for additional increases in the coming year.56 A positive change of 10% in cigarette prices increase the probability of a quit attempt by 10%–12% and of a successful quit by 1%–2%, with greatest effects on smokers with the least income.46, 57 State tobacco tax increases not only induce quitting and deter smoking, they also hold (mostly unrealized) potential for funding comprehensive tobacco-control initiatives.

Americans for Nonsmokers’ Rights reports that there are now 22 states and hundreds of additional municipalities with 100% smoke-free laws in workplaces, restaurants, and/or bars, and that 54.8% of Americans are now protected from harmful secondhand smoke in one or more of these settings.58 These restrictions increase population quit attempts and successes, and when coupled with treatment promotions and cost reductions, appear to increase treatment use and demand.53, 59

In 1995, only one state Medicaid program covered tobacco-dependence treatment. In 2005, 42 state Medicaid programs and 96% of U.S. health plans provided coverage for some form of evidence-based counseling or pharmacotherapy.30, 60 Medicare now covers both counseling and medication, and the Veterans’ Affairs Health Administration now covers cessation counseling.12 Unfortunately, many, if not most, smokers eligible for these benefits are unaware they have them, making them essentially “stealth” benefits.13, 14, 29, 32, 60

Public health anti-tobacco advertising and cessation media campaigns and promotions have been shown to increase population quit rates, quitline calls, NRT use, and the utilization of treatment benefits.5, 11, 27, 32, 40, 41, 42, 46, 61, 62, 63 However, funding for these campaigns from MSA and state tobacco excise tax revenues is only a fraction of what it could or should be.1, 2

Demand is increased most when these public health strategies are combined. The New York City Department of Health paired a strong clean indoor-air law and recent state and local tobacco tax increases with a citywide cessation media campaign, primary care physician educational campaign, and the offer and promotion of free quitline counseling and NRT. The result was an 11% decline over 1 year in the citywide smoking rate from 2003 to 2004 (the fastest drop in U.S. smoking rates ever recorded) and a 15% decline over 2 years from 2003 to 2005, producing 200,000 new ex-smokers and averting an estimated 60,000 premature deaths.53, 59, 63 Citywide mass media and neighborhood-targeted promotions offering a free 6-week supply of NRT patches to the first 35,000 eligible adult quitline callers stimulated 400,000 calls, with disproportionate response from nonwhite, foreign-born smokers in the targeted low-income neighborhoods.53, 59

These results illustrate, at a local level, the potential synergistic effects that could be achieved nationally through the comprehensive strategies recommended by the National Cessation Action Plan (i.e., tax increases, physician training, free quitline counseling and NRT, effective treatment promotion). Replicating New York City’s success at the national, state, or local levels will require proactive efforts to assure that adequate cessation resources are in place to meet the demand generated by tobacco tax increases, clean indoor-air laws, and well-publicized cessation treatment benefits. The rapid spread of clean indoor-air laws and the presence of quitlines in 50 states and the District of Columbia offer unprecedented opportunities for such planning and coordination. However, the kind of alignment achieved by New York City is rare, and limited state and local tobacco-control funding is an obstacle. The enhanced surveillance system created by the New York City Department of Health to target and evaluate their efforts also is rare, providing much stronger epidemiologic surveillance of smokers’ quitting efforts and treatment use than now exists nationally or at the state and local levels.

Boosting market demand also requires marketing efforts aimed at employers, insurers, and health plans, the nation’s powerful intermediary “consumers.” New evidence and tools establishing the “business case” for tobacco-dependence treatment and the inclusion of tobacco-use screening and treatment in national pay-for-performance quality metrics will be helpful, although the full return on investment is delayed by 3–5 years.12, 13, 30, 45 Insurers and employers also place great weight on direct employee and enrollee request, an emphasis projected to increase with the growth of consumer-directed health insurance products.64 This places a premium on informing smokers of the cessation-treatment benefits that are available, and on discovering ways to design, package, promote, and deliver evidence-based treatments so that they are more appealing and more likely to inspire smoker demand for them as part of their basic health benefit packages.

An exciting new frontier in tobacco-cessation research and practice involves applying design principles and processes used to build demand for other consumer products to meet this challenge. The need to “design for demand” was given a high priority by the Consumer Demand Roundtable, which reached out to IDEO, a top global consumer product design firm, for help to identify possible “breakthrough innovations” in product design and delivery. The initial design principles proposed for tobacco-cessation treatments are based on: (1) IDEO’s similar work redesigning other consumer products, including lifestyle and behavior-change products, to better meet their users’ latent unmet needs65; and (2) the view that current cessation treatments and delivery systems will need to engage and support quitters all along their “quitting journeys,” not just during the initial active quit attempt.66 The following initial IDEO design principles propose strategies for building cessation product appeal, use and demand by:

  • (1)

    allowing smokers to kick the tires by giving them an opportunity to test or experiment with a service/product before buying into it (e.g., pharmacy-administered “trial” packages of multiple forms of NRT);

  • (2)

    lowering the bar to make the initial quit attempt less costly, both psychologically and financially (e.g., short-term “practice” quit attempts);

  • (3)

    designing aesthetically pleasing products, tools, and services that create a positive experience for consumers, especially for smokers in underserved populations;

  • (4)

    facilitating transitions by giving smokers appropriate tools and professional and social support as they move through the multiple stages of quitting;

  • (5)

    making progress tangible by allowing smokers to see and celebrate the small steps that are bringing them closer to their goal (e.g., cutting back before quitting);

  • (6)

    integrating multiple often disparate treatment elements in a unified system of care (e.g., integrated multimodality treatment and support systems);

  • (7)

    fostering community by linking smokers and quitters to real or virtual social support networks that prevent stigmatization and help smokers/quitters succeed; and

  • (8)

    connecting to the rest of smokers’ lives by showing an understanding that, for many smokers, quitting is a lifestyle decision—not exclusively a health decision—that affects them in many ways and by linking them to services and supports in other arenas (e.g., exercise, weight control, appearance, and stress and mood management).

These preliminary design principles will be applied and refined through a series of pilot design projects conducted by IDEO and Roundtable members to discover innovations that will increase the appeal and use of proven cessation products, especially among the low-income and racial/ethnic minority smokers who currently use them least. While not yet formally tested, these principles are congruent with several promising innovations already in the field, including: (1) pre-quitting use of NRT to facilitate smoking cessation67; (2) 6-month “re-cycling” treatments for smokers who do not succeed in quitting68; (3) combination treatments that offer multiple medications as well as face-to-face and phone counseling over a 12-month period69; (4) the ALF’s “Become an Ex” cessation campaign that is being designed to draw quitters and ex-smokers into an ongoing “brand community” using the same kinds of marketing techniques that the tobacco industry uses to maintain relationships with its customers70; and (5) programs that successfully integrate tobacco-cessation treatment into multiple-risk behavioral interventions, including diet, physical activity, and cancer screening.71 Innovations that address smokers’ obesity- and weight-related concerns may be especially appealing: Quitters in a recent study of consumer demand expressed willingness to pay more for cessation products that would help them to quit and to minimize quitting-related weight gain.72 Innovations such as these, if found to be effective, could help guide the next generation of smoking-cessation treatment studies to discover treatments that are both effective and appealing.

In sum, the push–pull capacity model outlines the need for efforts that: (1) strengthen and better communicate the strong evidence for treatments that help smokers overcome tobacco use and addiction; (2) capitalize on progress in building the nation’s capacity to deliver these treatments especially through multichannel, multimodality systems of care that relieve some of the burden on primary care practices; and (3) increase market and consumer demand for them by harnessing public policy changes that motivate and support smokers’ quitting efforts and by designing more appealing cessation products and services. These efforts must especially target the low-SES and racial/ethnic minority populations with the highest rates of tobacco use and lowest rates of treatment use. In combination, these strategies present an extraordinary opportunity to reap the full health benefits of the past four decades of tobacco-control science and policy gains, translating these gains into longer, healthier lives and reduced healthcare costs for the 45 million American adults who continue to smoke, and addressing the nation’s widening disparities in tobacco use and tobacco-caused death and disease. Combining these strategies, as demonstrated in New York City and recommended by the National Cessation Action Plan and the National Consumer Demand Roundtable, holds great promise for breakthrough reductions in tobacco use among current adult smokers and among current adolescents who do not escape future tobacco addiction. This is an opportunity that cannot be missed.

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