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TED MARCY (Pulmonary physician, University of Vermont): I have been impressed that interventions that are aimed at current smokers are often based on behavioural theories. Are we working on using interventions aimed at other important targets such as physicians and administrators? And are those interventions also based on behavioural theories—such as social learning theory, and the stages of change?

SUSAN CURRY: That is an easy question to answer: yes. It’s important to go back to the individual level principles, those which pertain to getting providers to change their behaviour, as well as those which involve individuals. If you examine the methods we have described—one size does not fit all. It is important to tailor programmes to the clinics which they serve. It is also important in helping to change provider behaviour that we help them adopt the kind of perspective which we have with behavioural interventions. This is a process which unfolds over time. Attention must be paid to how people identify intermediate success markers which will keep them engaged in the process.

MICHAEL FIORE: In the AHCPR guideline, interventions at various levels are described, along with the research supporting them—at the provider level and at the system level. There are a variety of modalities to change and promote smoking cessation interventions.

ROB SIMMONS (Christiana Care, Wilmington, Delaware): Are there any differences in clinical practice guidelines or system changes related to smokeless tobaccovs cigarette smoking? Secondly, the directors and leaders in our managed care organisation are very supportive in building consensus around tobacco, but they raised the question: “If we did this in a real systematic way, wouldn’t we also have to address nutrition education, lipid management, stress reduction and physical activity as major health promotion components? Wouldn’t the cost be very significant?”

MICHAEL FIORE: Unfortunately, there is a paucity of data on clinical interventions to promote smokeless tobacco cessation. There are some studies, but a much smaller number than there are on promoting smoking cessation. What the AHCPR panel concluded and recommended is in the absence of a sufficient body of data to address smokeless tobacco, pipe and cigar smoking, use the recommendations for cigarettes and continue to encourage further research specifically on smokeless tobacco as well as these other forms.

In response to the cost significance of tobacco control programmes, you may want to examine the morbidity, the mortality, and the economic burden of the specific lifestyle issues to which your chief executive officer [CEO] was referring. There is a compelling body of data that nothing compares with tobacco addiction in terms of cost. If you have limited resources, you need to assign them where you will get the most “bang for the buck”.

JOACHIM ROSKI: I do not believe that CEOs are making decisions based solely on data. What we are finding is that it is important to show that tobacco control is more cost-effective than a lot of other common procedures that we routinely provide. Right now there is a managed care backlash going on, and organisations are clamouring for positive stories to tell. We at Allina have been somewhat successful in positioning the tobacco control initiative as a positive story to tell. We are getting a lot of recognition and a lot of organisational clout.

SUSAN CURRY: We do have to recognise that smoking interventions, particularly what we are asking providers to do with the patients, are being added to an already full plate. We do not want to get into the business of competing with other medical priorities. It is important to recognise that the intervention models and the kind of resources necessary for smoking cessation are often times very compatible with, and not vastly different from, the kinds of resources which should be available at the population level for programmes such as dietary or alcohol management, and exercise. The investment that an organisation makes in training providers around tobacco use generalises readily; you are training better clinicians.

BOB MURFORD (Health Plan of the Redwoods, Santa Rosa, California): Is there a process for revising the guideline? The introduction of non-nicotine pharmaceutical therapies has garnered a lot of attention recently, yet the guideline does not address these therapies.

MICHAEL FIORE: That is an excellent point, particularly as there may be a national settlement which may direct resources to smoking cessation services. We need to provide the most current, evidence-based set of recommendations for clinicians. The members of the AHCPR panel have indicated a willingness to update or reconsider some aspects of the guideline. It is my hope that by the end of 1998 we will be able to provide some additional information which builds upon the evidence-based work which has already begun.

TIM MCAFEE (Group Health Cooperative, Washington): We know that for individuals, cost is a barrier. We also know that for our organisations, cost is a barrier. Our first line of defence, as members in organisations, is to hold our own organisations accountable for spending the money necessary to provide smoking cessation programmes which are a vital medical service. The prospect of a possible “gravy train” in the near future (through settlements or increased taxes) may actually be slowing down some of the progress of plans’ commitment to allocate funds to cessation programmes. We cannot rely on increased funds through the goodwill of elected officials or the tobacco industry. We are going to need to work at the federal and state level to insure cessation programmes are included, and they are often at the bottom of the list of priorities. Finally, we as health plan organisations have to maintain our right to litigate. We have to protect what should be our members’ rights, which include coverage for cessation services and compensation for the damage they sustain from tobacco use. We are one of the primary groups that will be affected if we lose our right to litigate.

LARRY AN (University of Michigan, Ann Arbor, Michigan): The “Free & Clear” expansion of services at Group Health saw a 10-fold increase in the use of the programme in 1992. Yet there was a big divergence between the prevalence of smoking in the state of Washington and the prevalence of smoking within Group Health which clearly began before that. What would account for the disparity in rates prior to this big expansion in services? What was happening at Group Health?

SUSAN CURRY: That is an astute question. We had effective individual interventions available for smokers who wanted them which was part of a comprehensive strategy. There were a lot of organisational changes occurring. The drop in smoking prevalence cannot be attributed entirely to the introduction of the tobacco services benefit. It is an important part of it, but it is not the only part.

PETER BARNETT (Presbyterian Health Plan, Albuquerque, New Mexico): Global capitation passes the risk for expenditures on to the clinician, which is becoming a prevalent mode of physician compensation. This has been the object of some of the controversy surrounding managed care—you are compensated based on what you do not provide. Smoking cessation counselling presumes a rather long view of healthcare outcomes in a highly competitive market. We are very concerned that many of our capitated providers will choose not to assume this long view.

SUSAN CURRY: One of the assumptions pertaining to long-range processes, such as smoking cessation, is that it will be hard to get providers to provide it because patients change plans so often. Therefore, they are not going to see the benefits under the capitated plan. People change plans a lot more than they change providers—the incentive for the provider is the patient focus. There is probably more stability in the patients whom they are seeing than in the providers with whom their patients are contracting. The recommendation of what the provider does during the 15-minute clinical encounter is not particularly taxing—look your patient in the eye and say: “It’s important to me and it’s important to you and your family that you not smoke. I will be happy to hook you up with whatever kind of support I can. I would be happy to talk about this with you at any visit. We can arrange for phone follow up.” We are not talking about having providers take on very long or intensive intervention protocols. What we do need are backup resources when the providers plant the seed.

CHRISTINE WILLIAMS: We are promoting what we call the “two–three campaign”. It is for physicians, and it is two questions in three minutes. Do you smoke? Do you want to quit?

PARTICIPANT: Why are we emphasising physicians so much? What happened to the nurse in this whole process? It seems to me from the standpoint of effectiveness and cost-effectiveness they should be included.

MICHAEL FIORE: I should like to apologise for not conveying the importance of the entire team’s involvement. We go into that in detail in the guideline—from walking through the door and the encounter with the receptionist all the way to picking up the prescription from the pharmacist. Your point is well taken. The whole healthcare delivery team has to be involved. Frequently the individuals who are doing the bulk of the work are non-physicians.