Public Health Focus: Effectiveness of Smoking-Control Strategies -- United States

In 1990, approximately 46 million adults in the United States continued to smoke; however, more than 44 million persons were former smokers (1) who had reduced their risk for the leading causes of death in the United States (2). Smoking-cessation methods can be categorized as 1) self-help strategies (e.g., quitting abruptly and completely ("cold turkey"), using quitting manuals, or using nonprescription drugs) or 2) assisted strategies (e.g., smoking-cessation clinics, hypnosis, acupuncture, or nicotine gum or patch with counseling). This report summarizes information regarding the efficacy and cost-effectiveness of smoking-cessation strategies. Efficacy

Approximately 90% of successful quitters have used a self-help quitting strategy, most by quitting abruptly (3). Those who used an assisted method (8%) were more likely to be women, be aged 45-64 years, have more than a high school education, have made more previous attempts to quit smoking, and have been heavier smokers (3). Twelve-month abstinence rates for persons using self-help methods have ranged from 8% to 25% (4), while cessation rates for persons who used smoking-cessation clinics have ranged from 20% to 40% (5). Fewer smokers use smoking-cessation clinics than use self-help methods; however, clinics are more likely to attract heavy smokers (3).

Mass media campaigns also influence smoking behavior by changing awareness, knowledge, and attitudes of smokers (6). In addition, televised "self-help" clinics have been effective in changing behaviors of smokers, especially when coupled with a social support component (e.g., group discussion) (6). Effective mass media campaigns have been characterized by multiple and repeated messages (e.g., a series of public service announcements), widespread dissemination, and high saturation over a prolonged period.

Physician counseling is an important element in many smoking-cessation strategies. A brief and simple message from physician to patient can be effective in changing smoking behavior (7). Cost-Effectiveness

Assessment of the American Lung Association's (ALA) self-help smoking-cessation program indicated that, overall, 12-month cessation rates were higher (18%) among groups with a maintenance component (i.e., relapse prevention) than among groups without a maintenance component (12%-15%). The cost per current abstainer at 12 months ranged from $105 to $116 in groups with a maintenance component, compared with $126 to $135 per abstainer in groups without a maintenance component (8).

Smoking-cessation programs designed for the Stanford Five City Project included 1) a smoking-cessation clinic, 2) an incentive-based quit-smoking contest, and 3) a self-help quit-smoking kit (9). The self-help kit was the most cost-effective program, and the smoking-cessation clinic was the least cost-effective. Costs per abstainer for each program ranged from $235 to $399 for the clinic, from $129 to $236 for the contest, and from $22 to $144 for the self-help quit-smoking kit.

Modeling of the cost of brief physician counseling on smoking cessation during a routine office visit per life-year saved was at least as cost-effective as other preventive medical practices (e.g., the treatment of mild to moderate hypertension and cholesterolemia) (10,11). In addition, nicotine gum, when used with physician counseling, enhanced the effectiveness of the intervention; the cost per life-year saved with this intervention ranged from $4113 to $6465 for men and from $6880 to $9473 for women (11).

Reported by: Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings described in this report suggest that wider dissemination of self-help materials, such as smoking-cessation booklets, hold the potential for assisting a substantial number of smokers who might not seek help in quitting smoking through more formal methods. In addition, the cost-effectiveness of smoking-cessation programs may be enhanced by targeting specific populations (e.g., smoking-cessation manuals tailored to pregnant women) and developing programs with a follow-up or maintenance component that use a combination of multiple interventions (12).

Physician intervention can be an effective strategy for smoking prevention and cessation. Physicians can counsel persons in high-risk groups, including pregnant women and adolescents whose other behaviors (e.g., alcohol use and poor school performance) indicate they are more likely to use tobacco (7). In 1990, approximately half of current smokers reported that they had ever been advised by their physicians to quit or reduce their smoking (CDC, unpublished data, 1992). Counseling effectiveness can be increased by direct face-to-face advice and suggestions, setting of a target date for quitting, scheduled reinforcement, provision of self-help materials, referral to community programs, and drug therapy when used as an adjunct to other behavioral interventions. The U.S. Preventive Services Task Force concluded that smoking-cessation counseling should receive the highest priority as a preventive intervention (7) and recommended that physicians 1) obtain a complete history of tobacco use for all adolescent and adult patients and 2) offer counseling on a regular basis to all tobacco users.

Effective community-based tobacco-control programs, such as the National Cancer Institute's (NCI) Community Intervention Trial for Smoking Cessation and NCI and the American Cancer Society's American Stop Smoking Intervention Study, stimulate community involvement by identifying major community groups and organizations that can support interventions. Smoking-control activities in communities should encompass health-care providers, worksites, cessation resources and services, and public education.

The proportion of smokers who have quit has been consistently higher for males than for females (although the difference becomes minimal after controlling for other forms of tobacco use), for whites than for blacks, for older smokers than for younger smokers, and for college graduates than for persons with less than a high school education (3). Therefore, to reduce overall tobacco use, the U.S. Department of Health and Human Services has targeted several high-risk populations, including women, black adults, and persons with a high school education or less, for smoking-cessation programs (13). For example, the national health objectives for the year 2000 includes increasing smoking-cessation efforts for pregnant women so that at least 60% of women who smoke cigarettes at the time they become pregnant quit smoking early and for the duration of their pregnancy (objective 3.7) (13).

The achievement of long-term health and economic benefits of reducing the nation's overall smoking rate also requires intensive smoking-prevention efforts. In particular, each year, more than 1 million young persons start to smoke, adding an estimated $10 billion during their lifetimes to the cost of health care in the United States (14). A multicomponent approach to prevent initiation among youths should be coupled with school-based tobacco-use prevention programs and include 1) mass media campaigns to target high-risk groups, 2) increased excise taxes on tobacco products, 3) increasing the minimum age for sale of tobacco products, 4) prohibiting the distribution of tobacco product samples to minors, 5) elimination or severe restriction of tobacco product advertising and promotion to which youth are likely to be exposed, 6) restricting the sale of tobacco products through vending machines, and 7) enforcing tobacco access laws for minors (13).

References

1. CDC. Cigarette smoking among adults--United States, 1990. MMWR 1992;41:354-5, 361-62.

2. CDC. The health benefits of smoking cessation: a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (CDC)90-8416.

3. Fiore MC, Novotny TE, Pierce JP, et al. Methods used to quit smoking in the United States: do cessation programs help? JAMA 1990;263:2760-5.

4. Cohen S, Lichtenstein E, Prochaska JO, et al. Debunking myths about self-quitting: evidence from 10 prospective studies of persons who attempt to quit smoking by themselves. Am Psychol 1989;44:1355-65.

5. Public Health Service. Review and evaluation of smoking cessation methods: the United States and Canada, 1978-1985. Washington, DC: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1987; DHHS publication no. (NIH)87-2940.

6. Flay BR. Mass media and smoking cessation: a critical review. Am J Public Health 1987;77:153-60.

7. US Preventive Services Task Force. Guide to clinic preventive services: an assessment of the effectiveness of 169 interventions -- report of the U.S. Preventive Services Task Force. Baltimore: Williams and Wilkins, 1989:99-105.

8. Davis AL, Faust R, Ordentlich M. Self-help smoking cessation and maintenance programs: a comparative study with 12-month follow-up by the American Lung Association. Am J Public Health 1984;74:1212-7.

9. Altman DG, Flora JA, Fortmann SP, Farquhar JW. The cost-effectiveness of three smoking cessation programs. Am J Public Health 1987;77:162-5.

10. Cummings SR, Rubin SM, Oster G. The cost-effectiveness of counseling smokers to quit. JAMA 1989;261:75-9.

11. Oster G, Huse DM, Delea TE, Colditz GA. Cost-effectiveness of nicotine gum as an adjunct to physician's advice against cigarette smoking. JAMA 1986;256:1315-8.

12. Elixhauser A. The costs of smoking and the cost effectiveness of smoking-cessation programs. J Public Health Policy 1990;11:218-37.

13. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

14. Hodgson TA. Cigarette smoking and lifetime medical expenditures. Milbank Q 1992;70:81-125.

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