What's the Best ROI for Dollars to Help Smokers Quit?

Under the pressure of stalled progress, the smoking cessation community is splintering into different and not always harmonious camps. They have competing visions for how best to spend scarce public health dollars allocated to encourage and help smokers quit.
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With the Supreme Court's ruling on the Affordable Care Act behind us, we will need to focus on its implementation and how our health care dollars are best used. The act promises to renew efforts to promote lifestyle and behavioral change and wellness programs like smoking cessation. When it comes to health care and smoking, however, we are facing a crossroads and need to carefully consider the best way to move forward.

The public health campaign against tobacco products reduced smoking rates by one-half over the 40 years between 1965 and 2004, from 42.4 percent of Americans over 18 years old to 20.9 percent. Since then, however, the smoking rate has held steady nationwide, at about 19 percent, proving more stubborn and resistant to decrease.

Under the pressure of stalled progress, the smoking cessation community is splintering into different and not always harmonious camps. These four approaches are: standard public health, harm reduction, cold turkey and clinical, and they have competing visions for how best to spend scarce public health dollars allocated to encourage and help smokers quit.

The current standard public health approach to help smokers is to provide free nicotine replacement therapy (NRT) through telephone call centers or "quitlines." However, recent studies have highlighted the limits of giving out nicotine patches and gum as a stand-alone approach, even when it includes minimal telephone counseling. NRT does what it does well: easing the physical symptoms of quitting when they are present. However, it was never designed to be a complete cure-all or to bear the entire burden of quitting, especially for hard-core smokers. Clearly, many smokers who struggle to quit need more than NRT alone, but what?

"Harm reductionists" assert that people who can't quit on their own, or with presumed "ineffective" methods such as NRT, should be encouraged to switch to less risky tobacco products like smokeless tobacco (ST) or other smokeless products such as e-cigarettes. Unlike NRT, these products are not subject to safety or quality control standards, which puts health care clinicians ("first do no harm") who might want to recommend them in an ethical bind.

The tobacco industry has been busy buying up smokeless tobacco and e-cigarette distributors and is finding a new lease on life by joining with the harm reduction camp. Unfortunately, smokeless tobacco products were found in a longitudinal U.S. study to not, in fact, promote smoking cessation. Instead, recent research shows, ST can serve as a "gateway" to smoking for many more people, especially young people, rather than serve as a withdrawal or "harm reduction" mechanism for cigarettes!

Harm reduction presents the taxpayer with an approach that is self-funded by smokers who also bear all the risks. It is outside the purview of the public health and health care delivery system and squarely in the private sector. The bad news is it will likely create many "dual users" who are cigarette smokers who also use ST.

The cold turkey camp, in contrast, is committed to freedom from all forms of nicotine, including cigarettes, e-cigarettes, smokeless tobacco and NRT. It believes that NRT has been oversold and can even have a harmful effect on smokers by convincing them that it is the patches and gum that are primarily responsible for their ability to quit, and not their own efforts and acts of self-agency. The cold turkey camp maintains, correctly, that most smokers quit on their own, without any medical or clinical help. Since the 45 million who smoke in the U.S. are now outnumbered by former smokers, there is reason for their optimism.

But clearly all smokers are not alike: Some quit on their own relatively easily and others struggle for years, further harming their health. Some say quitting was the hardest thing they have ever done, and others despair of quitting altogether.

Despite the struggles that hard-core smokers face, cold turkey advocates believe that scarce public health funding should be redirected away from clinical efforts for individual smokers. Instead, they maintain, funding should continue to be aimed at large-scale, counter-marketing efforts and other forms of motivational public health messaging such as graphic pack warnings and smoke-free public places to encourage more self-quitting. These strategies, which have always been part of a successful public health approach, create a demand for smoking cessation services, which economically hard-pressed health care systems are in no position to fulfill. Without designated funding for clinical services, some of those who are still smoking will be left struggling to quit on their own.

The last camp is composed of health care clinicians who want to help smokers with smoking-caused medical and dental problems quit. For clinicians, smoking dependence often presents as a significant problem which it makes no clinical sense to ignore.

As a smoking cessation treatment, cognitive behavioral therapy (CBT) has been shown to be far more effective than just offering NRT by itself or paired with brief structured or motivational interventions. However, struggling smokers are not routinely offered expert clinical services even in designated cancer centers, where patients who continue to smoke double their chance of having a second tumor.

From the viewpoint of the clinical camp, it especially makes sense to target medically- and psychiatrically-ill smokers, who are already high users of health care services. The effect is comparable to deploying extra police power in a high crime zone, which is likely to provide much greater returns in terms of public safety than keeping a smaller, more even police presence across all neighborhoods.

An advantage of the clinical approach is its targeted investment of health care dollars and its humane treatment of addicted smokers as individuals in need of expert outside help. The bad news is it requires an upfront investment. An investment in quitting smoking, however, has been shown to be a gift that keeps giving. For example, recent research has found quitting leads to greater levels of being physically active, greater levels of daily consumption of fruits and vegetables, and to reverse cognitive decline in middle age male smokers.

Quitting smoking, even later in life, is associated with greater independence, a longer active life span, less disability and fewer doctor's visits. Despite all the differences people may have about how to get there, one thing is clear: Quitting smoking produces a good return on investment indeed.

Dr. Daniel Seidman is director of smoking cessation services at Columbia University Medical Center, and author of Smoke-Free in 30 Days: The Pain-Free, Permanent Way to Quit, with a foreward by Dr. Mehmet Oz (Simon & Schuster 2010). For more details about the book, go to www.danielfseidman.com.

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