National Tobacco Cessation Collaborative

INNOVATIONS IN BUILDING

ConsumerDemand FOR TOBACCO CESSATION PRODUCTS AND SERVICES

6 Core Strategies for Increasing the Use of Evidence-Based Tobacco Cessation Treatments

September 2007

Academy for Educational DevelopmentWashington, DC

Published by the National Tobacco Cessation Collaborative, which is funded by:

The following organizations provided additional support for The Consumer Demand Roundtables:

Free & Clear®, GlaxoSmithKline, John Pinney Associates, Office of Behavioral and Social Sciences Research at the National Institutes of Health, Pfizer, Inc.

LEAD AUTHORS

C. Tracy OrleansRobert Wood Johnson Foundation

Todd PhillipsAcademy for Educational Development

CONTRIBUTING AUTHORS

David AbramsElaine ArkinPeter CoughlanCarlo DiClementeGary GiovinoKaren GutierrezKatie KemperTim McAfeeSaul ShiffmanKay Kahler Vose

OTHER CONTRIBUTORS

Katherine GarrettJessica NadeauMelisssa OteroStephanie Smith-SimoneStephanie Weiss

INNOVATIONS IN BUILDING

ConsumerDemand FOR TOBACCO CESSATION PRODUCTS AND SERVICES

6 Core Strategies for Increasing the Use of Evidence-Based Tobacco Cessation Treatments

September 2007

Academy for Educational DevelopmentWashington, DC

INNOVATIONS IN BUILDING CONSUMER DEMAND FOR TOBACCO CESSATION PRODUCTS AND SERVICES2

Consumer Demand:The degree to which smokers and other tobaccousers who are motivated or activated to quit know about, expect, seek, advocate for, demand, purchase, access and use tobacco cessation products and services that have been proven toincrease quitting success.

3INNOVATIONS IN BUILDING CONSUMER DEMAND FOR TOBACCO CESSATION PRODUCTS AND SERVICES

Viewing smokers as consumers and taking a fresh look at quitting from theirperspective.

Redesigning evidence-based products and services to better meet consumers'needs and wants.

Marketing and promoting cessation products and services in ways that reach smokers—especially underservedsmokers—where they are.

Seizing policy changes as opportunities for “breakthrough” increases in treatmentuse and quit rates.

Systematically measuring, tracking,reporting and studying quitting and treatment use—and their drivers and benefits—to identify opportunities andsuccesses.

Combining and integrating as many of these strategies as possible for maximumimpact.

Six core strategies for building demand among smokers for proven tobacco cessationproducts and services include:

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2

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Building Consumer Demand:


The premise of the ConsumerDemand Initiative is simple:

• 44.5 million Americans smoke,with the highest prevalence andgreatest health impact amonglow-income and racial/ethnicminority populations.

• There is no better way toimprove the nation’s health andreduce health disparities than tohelp these smokers quit.

• Most smokers who try to quitfail—especially those with theleast education and income.

A key reason: most smokers whotry to quit don’t use treatmentsthat could significantly improvetheir success rates.

Smokers with the least income andeducation try as often to quit, butuse treatments less often and failmore often.

While access to treatments can be a barrier, treatment use is low evenwhen they are available free ofcharge and are covered by healthinsurance.

Increasing demand for tobaccocessation products and servicesrepresents an extraordinary opportunity. But it is a challengethat will require bold thinking,innovation, changes in practicesand new approaches that start withthe consumer perspective.

Providing consumers with tobaccocessation products and services that they find both appealing andeffective could substantially boostthe nation’s quit rate. A higher quitrate would yield enormous benefits for our nation’s health, healthcaresystem and productivity, which is why the Institute of Medicine identified tobacco dependence treatment as one of the top prioritiesfor national improvement in its 2003report, Priority Areas for NationalAction: Transforming Health CareQuality.

Helping More Smokers Quit – An Extraordinary Opportunity

INNOVATIONS IN BUILDING CONSUMER DEMAND FOR TOBACCO CESSATION PRODUCTS AND SERVICES 5

“One of these days I know I’ll quit.”

Current smoker

The primary aim of theConsumer DemandRoundtable is to accelerateprogress toward freedomfrom tobacco-caused deathand disease—for individualsmokers (consumers) and for the nation as a whole.


The American Cancer Society,American Legacy Foundation,Centers for Disease Control andPrevention, National CancerInstitute, National Institute on DrugAbuse and Robert Wood JohnsonFoundation began to focus on theissue of building greater demandfor tobacco cessation products andservices as part of the NationalTobacco Cessation Collaborative(NTCC) in early 2005.

These national tobacco controlorganizations developed the visionof a Consumer Demand Initiativewith the goal of:

• Identifying innovative strategiesfor substantially increasing thedemand for, and use of, evidence-based tobacco cessation productsand services—particularly inunderserved low-income and

racial/ethnic minority populationswhere tobacco use is highest andtreatment use is lowest.

The Academy for EducationalDevelopment (AED) hosted threeConsumer Demand Roundtablemeetings in December 2005, February2006, June 2006, and The NationalConference in May 2007. TheseRoundtable meetings focused on:

• Generating new ways ofthinking about increasingdemand for evidence-basedtobacco cessation products and services.

• Identifying and catalyzingfeasible innovations in productdesign, promotion, researchfunding, practice and policy thatcould significantly improve theuse and impact of current evidence-based treatments.

Participants included leadingtobacco cessation researchers,providers, practitioners, policyadvocates, consumer productdesigners and marketing experts.

Individual meeting summaries can befound at www.consumer-demand.org.This report summarizes the overallkey concepts and ideas that emergedfrom the Roundtable meetings.

Each year about 40 percentof U.S. smokers make aserious quit attempt, but only4.7 percent succeed instaying smoke-free for atleast three months. Source: 2000 National Health Interview Survey,www.cdc.gov/mmwr/preview/mmwrhtml/mm5129a3.htm

Addressing the Challenge of Building Demand for and Use of Proven Cessation Treatments


U.S. PHS CLINICAL PRACTICE GUIDELINES LIST OF EFFECTIVE TREATMENTS1,2

The U.S. Public Health Service PHS Clinical Practice Guidelinesrecommend the following assessment of effective tobaccocessation treatments:

• Tobacco use screening and brief intervention in routinemedical care, provided by a variety of providers—including physicians, nurses and dentists—using the 5As:

• Ask all patients about tobacco use. • Advise all users to quit.• Assess quitting readiness. • Assist with brief counseling (1-3 minutes for most

smokers, 5-15 minutes for pregnant smokers) andFDA-approved pharmacotherapies if appropriate.

• Arrange follow-up assistance and referral ifneeded.

• Face-to-face and proactive telephone counselingshould be used.

• Three types of behavioral counseling: 1. Providing smokers with practical counseling

(behavioral problem solving skills/skills training). 2. Providing social support as part of treatment.3. Helping smokers obtain social support outside

of treatment.

• Intensive counseling interventions are more effectivethan less intensive interventions and should be usedwhenever possible – including face-to-face or telephone.

• Effective cessation pharmacotherapies except in thepresence of special circumstances (e.g. medicalcontraindications, pregnancy).

1. Recommended first-line FDA-approvedpharmacotherapies include bupropion SR(Zyban or Wellbutrin), nicotine gum, nicotineinhaler, nicotine nasal spray and nicotine patch.

2. Second-line pharmacotherapies includeclonidine and nortriptyline.

3. Combination nicotine replacement therapy(combining the nicotine patch with a self-administered form of nicotine replacementtherapy) is encouraged if patients are unable toquit using a single type of first-line pharmacotherapy.

4. Newly FDA-approved cessation nicotinelozenges (Commit) and varenicline (Chantix) maybe included in the 2008 USPHS Guideline update.

• Long-term smoking cessation pharmacotherapyshould be considered as a strategy to reduce thelikelihood of relapse.

INNOVATIONS IN BUILDING CONSUMER DEMAND FOR TOBACCO CESSATION PRODUCTS AND SERVICES

Note: This report focuses primarily on building consumer demand for products and services to quit cigarette smoking. However, many of the same strate-gies apply to cessation of other tobacco products. The focus is also on tobacco cessation among adults. Treatment evidence is strongest for adults, andguidelines currently recommend the same treatments for youth until more effective and appealing youth–tailored options can be developed.


When most companies develop aproduct or service, they begin theprocess by understanding whatconsumers need and want. Butsmokers have often been viewed as passive treatment beneficiariesrather than treatment consumers. The first step in building consumerdemand for proven cessation treatment products and servicesinvolves viewing smokers asconsumers, and going beyondtesting products for their efficacy to determining how they can bestmeet quitters’ wants and needs.

DEVELOPING A BETTERUNDERSTANDING OF QUITTERS’ PREFERENCES AND NEEDS

While focus groups and surveyresearch have provided tremen-dous insight into smokers’ lives

and preferences, the under-use ofevidence-based treatments showsthere is still much to be learned.

To build a deeper understanding of smokers, those wishing to boostconsumer demand for proven treatments need insight not onlyinto smokers’ expressed needs andpreferences, but also into theirlatent, unmet needs—needs thatthey often can’t articulate, but thatstill have a powerful influence ontheir behavior.

Such latent needs may include asmoker’s need to try a productbefore committing to a full package,or the desire to find cessation products that are aestheticallypleasing and compatible with theirlifestyles.

STRATEGY 1: Viewing smokers as consumers andtaking a fresh look at quitting from their perspective

“To build a deeper understanding of smokers,those wishing to boostconsumer demand forproven treatments needinsight not only into smokers’expressed needs and preferences, but also intotheir latent, unmet needs…”

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“I’ve only been smoking a year. Many of my friendssmoke—it’s a socialthing. It gives us time to be together.”

Current smoker


Increasing the use of researchmethods that produce deeperknowledge into smokers’ needs andwants may provide new insightsinto how to help smokers quit.

FOCUSING ON THE “CONSUMER EXPERIENCE”

The consumer experience is aboutmore than just proven product effi-cacy. The consumer experienceinvolves every aspect of a productor service—the advertising, packaging, product and servicefeatures, ease of use, and reliability—all the ways a consumer interactswith a product or service.

As part of the Consumer DemandRoundtable, the product designfirm IDEO discussed the need tofocus on improving the “consumerexperience.” IDEO has worked witha number of organizations oncreating new and more engagingconsumer experiences. Two exam-ples of this work follow.

Example 1: “Keep the Change”Account Service for Bank ofAmericaFacing the challenge of enticingpeople into opening new accounts,Bank of America came to IDEO insearch of ethnography-based innovation opportunities. To betterunderstand the target market, IDEOand members of Bank of America'sinnovation team conducted obser-vations in several cities. Theydiscovered that many individualswould often round up their finan-cial transactions for speed andconvenience. In addition, the teamfound that many had difficultysaving money, whether due to alack of resources or willpower.

After these observations, the teamarrived at a solution that usesexisting habits to resolve theproblem. Ultimately dubbed "Keepthe Change," the service rounds uppurchases made with a Bank ofAmerica debit card to the nearestdollar and transfers the differencefrom individuals' checking accounts

IDEO uses a number of research techniques to gain consumer insight. A few of these techniques include:

• Shadowing — observing smokerswhere and when they smoke, andwhere they go for help in quitting.

• Consumer Journey — keeping trackof all the interactions smokers havewith cessation products and services.

• Extreme Users — interviews withindividuals who really know a lot (or know nothing) about cessationproducts and services. From theseindividuals, researchers and product design experts can moreeasily elicit passions and emotionaldrivers related to the product,service or behavior of interest.IDEO’s experience indicates that theextreme users amplify what peoplein the middle are thinking or feelingand give greater clarity about oppor-tunities to design for everybody.

• Storytelling — prompting people totell personal stories about theirconsumer experiences, and usingthese stories to inspire the creationof relevant smoking cessation products and services.


into their savings accounts. Theconvenience and ease of roundingup now helps members save moneyover the long run.

After Bank of America's extensivetesting and refinement of prototypes,“Keep the Change” launched inOctober 2005. In less than one year,“Keep the Change” attracted 2.5million customers who haveopened more than 700,000 newchecking accounts and one millionnew savings accounts.

Example 2: Redesigning theHospital Experience IDEO worked with KaiserPermanente to improve the patientexperience in hospital settings.Kaiser staff, including nurses,doctors and facility managers, as wellas IDEO's social scientists,designers, architects and engineers,observed patients as they madetheir way through medical facilities.

IDEO and Kaiser concluded that thepatient experience can be awful,

even when people leave treated andcured. The observation revealed that:

• Patients and family often becomeannoyed and anxious becausechecking in was terrible, waitingrooms were uncomfortable, andpatients were often left alonebecause family and friends whocame with them were notallowed to stay.

• Patients hated examinationrooms because they often had towait alone for long periods oftime in gowns, with nothing todo, surrounded by threateningneedles and tools.

After this process with IDEO,Kaiser realized it needed to makepatients more at ease by offeringmore comfortable waiting rooms, alobby with clear instructions onwhere to go, and larger exam roomsthat have space for three or morepeople and curtains for privacy.

UNDERSTANDING THE QUITTINGJOURNEY AND ENGAGING SMOKERS ALLALONG THE WAY

To free themselves from nicotineaddiction, each smoker makes a verypersonal journey on the road tosuccessfully quitting smoking. Thatjourney can be long and arduous,often marked by ambivalence,desires, decisions, hopeful attempts,frustrating failures, persistence, planning, prioritizing, and finally,in the best case, both short- andlong-term success.

There are opportunities to buildconsumer demand for smokingcessation by engaging those whoare trying to quit throughout theirjourneys—not just during the firstfew days and weeks of their quitattempts.

The challenge of the journey forthose who might assist is to makesolid connections with smokers thatlast over time, to develop a betterunderstanding of the needs of theseconsumers at various points along


the journey, and to treat smokers andtheir quitting efforts with respect.Smokers benefit from different kindsof help and support at differentstages of their journeys as well.

Figure 1 shows one depiction of thequitter’s journey.

DISSATISFIEDBUT AMBIVALENTABOUT QUITTING

SATISFIEDDEPENDENT OR CASUAL

SMOKER

C

External Motivations:Social PressurePricePolicyProducts & ServicesSocial SupportPromotionTobacco AdvertisingSmoking Network

Internal Motivations:Quitting HistoryPersonal ConcernsSpecial EventsBeliefs & MythsPsychiatric Conditions & Other Life Problems

Figure 1.


CHOOSE AMETHOD: NRT, COLD TURKEY, QUITLINE, ETC.

QUIT ATTEMPT SHORT TERMSUCCESS

LONG TERMSUCCESS

RELAPSE &RECYCLING

DECIDE TOMAKE A

QUIT ATTEMPT

E THE QUITTER’S JOURNEYOnce smokers are triggered to quit, both external and internal motivations influence the quitting process as they learn about quitting, set quitting goals, choose a quittingprocess, and attempt to quit. As smokers succeed or fail, they continue to customize their approach and repeat attempts at quitting until they are successful.

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While many effective cessationproducts and services exist,consumers don’t always have positive experiences with them.Using consumer-centered designprinciples may help ensure thatsmokers find treatments appealingas well as effective.

USING CONSUMER-CENTERED DESIGN PRINCIPLES

The consumer experience withcessation products and servicescould be improved by applying aset of design principles identifiedby IDEO.

These design principles include thefollowing:

• Allowing smokers to “kick thetires” by giving them an

opportunity to test or experi-ment with a service/productbefore buying into it.

• “Lowering the bar” to make theinitial quit attempt less costly,both psychologically and finan-cially. This includes reducing thecosts of products for quittersand breaking the process ofquitting into manageable steps.

• Designing aestheticallypleasing products, tools andservices that create a positiveand compelling consumer experience for each smokertrying to quit.

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STRATEGY 2: Redesigning evidence-based products and services to better meet consumers'needs and wants

“Using consumer-centereddesign principles may helpensure that smokers findtreatments appealing aswell as effective.”

Opposite page: An example of what someonewho wants to quit with an NRT product mayencounter in a pharmacy.



Netflix completely redesigned the movie rental experience that for years centered around thelocal video rental store. Netflix incorporates many consumer-centered design principles, such asproviding a free two-week trial, having a user-friendly and appealing interface, tracking moviesthat have been viewed, allowing a personalized queue of movies, and offering a variety of plans.

• Facilitating transitions to ensurethat smokers get appropriatetools, as well as professional andsocial support, as they movefrom step to step through thestages and processes of smokingcessation. Helping quitters makeit from one step to the nextinvolves bridging activities andtools to assist in the transitionprocess while anticipating chal-lenges throughout each step ofthe smoker’s journey.

• Making progress tangible toallow smokers to see, acknowl-edge, and celebrate small stepsthat enable them to advancetoward their overall goal and toappreciate the nature of thejourney. Tracking progress andreceiving incentives and rewardsalong the way can help to reinforce smokers’ dedicationand commitment to quitting.


• Fostering community so thatsmokers and quitters areappropriately linked to a real or virtual social support networkto help them in their journeytowards sustained smoking cessation.

• “Connecting the dots” to linkproducts, services and deliverysystems/providers into a cohesive, accessible system so thatsmokers receive the best treatmentavailable and engage in a moreintegrated delivery system or“web” of support and assistance.This principle includes linkingproducts with promotions andpolicies that catalyze their use.

• Connecting to the rest ofsmokers’ lives by showing anunderstanding that, for manysmokers, quitting is a lifestyledecision—not exclusively a healthdecision—that affects them inmany ways.

• Allowing smokers to “make ittheir own” by tailoring productsand services to their needs andtheir lives.

Some existing products and servicesalready incorporate many of thesedesign principles. Many quitlines, forexample, lower the bar by offering atoll-free number, facilitate transitionsby working with callers throughouttheir quitting process, foster commu-nity by offering online forums, andconnect the dots by using fax refer-rals with providers.

When thinking about existingevidence-based cessation productsand services, are there opportunitiesto incorporate more of these designprinciples?

“Helping quitters make itfrom one step to the nextinvolves bridging activitiesand tools to assist in thetransition process whileanticipating challengesthroughout each step of the smoker’s journey.”


ENSURING PRODUCTS AND CESSATION MATERIALS FOLLOW HEALTH LITERACY PRINCIPLES

A product or service is more than the actual patch,gum or quitline call. A “product” includes everythingthe consumer comes into contact with: the productname, packaging, instructions and accompanyingcessation materials.

Recent data show that many Americans, especiallythose with the least income and education, havetrouble understanding and using health information.To create a better consumer experience with cessationproducts and services, especially for smokers in low-literacy and low-income groups (where smoking ratesare highest and treatment use rates are lowest), it ishelpful to ensure these other components of aproduct/service follow health literacy principles.

An initial review of tobacco cessation materials andproduct instructions shows that many may not beappropriate for smokers with lower health literacyskills, and may contribute to the under-use of evidence-based products/services. New FDAlabeling for over-the-counter and prescription medications may be needed to ensure most smokers can properly use these products.

Smoking by education level

Source: CDC, MMWR Tobacco Use Among Adults—United States, 2005.October 27, 2006.

GED HS diploma Some college Associates College Post grad

50

40

30

20

10

0

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tSm

oke

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Health literacy scores by education

Source: National Assessment of Adult Literacy 2003, The Health Literacyof American Adults, September 2006.

Some HS GED HS diploma Some Associates College Post grad college

268

184

100

5

The National Tobacco Cessation Collaborative (NTCC) is addressing health literacy and its role inlimiting cessation treatment use and demand by:

• Conducting an environmental scan of low-literacycessation materials to determine their appropriatenessfor under-served smoker populations—those withthe least income and education, including workingclass and blue-collar smokers. This environmentalscan will help NTCC assess how well the field ismeeting the needs of lower-literacy smokers whoare trying to quit.

• Comparing literacy levels of labeling and claims onevidence-based vs. non-approved quit smokingproducts.

• Developing a health literacy guide for organizations to follow in creating engaging and understandable low-literacy cessation materials and media.


How could this labeling be improved for low-literacy consumers?


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Compared to cigarettes, cessationproducts/services are not widelypromoted. Many smokers are notaware of quitline services, andmany in health plans that offer andeven subsidize proven treatmentsdo not know that these treatmentsare available.

Cessation media campaigns anddirect-to-consumer marketing ofquitting services and products cansignificantly boost quit attempts,treatment use and population quit rates.3 Even barrier-free treatments like quitlines depend onadequate promotion for their use.Effective ads and promotions canbe targeted to high-risk and under-served populations, includingthose in low-income groups and

racial/ethnic groups where treatment use is most limited.4

ENGAGING SMOKERS IN NEW WAYSAND IN NEW PLACES

Why not take a page from the bookof the tobacco industry when itcomes to going where smokers areto offer cessation products?

This means expanding cessationefforts beyond the doctor’s office,to the places that smokers work,socialize and play. The tobaccoindustry reaches their consumersand markets their products in manydifferent ways, from traditionalmass media advertising to buzzmarketing events that spur Internetchatter, promotional offers andgiveaways, and price promotions

STRATEGY 3: Marketing and promoting cessation products and services in ways that reach smokers—especially underserved smokers—where they are

GSK’s NASCAR program features brand signageon race cars and public relations with driversemphasizing the importance of being tobacco-free.

1


and direct mail. Philip Morris, forexample, has a database of morethan 26 million smokers to whom itsends everything from birthday cardsto free tickets for local concerts.5

Some in tobacco cessation arebeginning to take this approach. Forexample, GlaxoSmithKline (GSK)follows this strategy to promote itstherapeutic nicotine products andsupport programs. Katie Kemper,now with the Campaign forTobacco-Free Kids and previouslywith GSK, described its NASCARracing sponsorship to illustrate thisconcept—building a relationshipwith NASCAR fans by going towhere they go.

• NASCAR fans are a large audi-ence (75 million in the U.S.) thatis disproportionately likely tosmoke. The NASCAR followingalso skews to the lower incomebrackets.


Right: To make tobacco cessation products andservices more accessible, the “Winner’s Circle”onsite education center at NASCAR racesfeatures cessation counselors, interactive riskassessment kiosks, product samples, couponsand information. 21


• As Winston’s 25-year title sponsorship of NASCAR ended,GSK recognized the opportunity to reach an audience with a highpercentage of smokers and raiseawareness of cessation productsand programs.

• Now in its second year, GSK’sNASCAR program features brandsignage on race cars and publicrelations with drivers emphasizingthe importance of being tobacco-free. Tie-ins with major tradeaccounts (e.g., Target) include in-store NASCAR-themed displays.

• The “Winner’s Circle” onsiteeducation center at NASCAR racesfeatures cessation counselors (oftenGSK sales representatives trainedin cessation counseling), interactiverisk assessment kiosks, productsamples, coupons and information.This removes NRT cost barriersand allows smokers to “kick thetires” before they commit to quitting or to a particular product.

Free & Clear® created videos that show potential program participants how an evidence-based program works by telling others’ stories of success. View athttp://www.freeclear.com.


“Personal, emotional storiesengage smokers and makethem reflect upon theimpact of smoking on themand/or their loved ones.”

• The “Quit Crew” programprovides cessation support (NRTand counseling) to NASCAR pitcrews/mechanics. Public relationsactivities reinforce the concept ofquitting as a team.

• The NASCAR program has beenfound effective in raising aware-ness of GSK’s cessation brandsand increasing product sales inNASCAR-themed displays. Of the over 200,000 smokerscounseled, 33 percent made aserious quit attempt.

TELLING A STORY IS MORE POWERFULTHAN SIMPLY SHARING FACTS ANDINFORMATION

Personal, emotional stories engagesmokers and make them reflectupon the impact of smoking onthem and/or their loved ones.Programs have had success usingthese types of testimonials toconvince smokers of the importantreasons to quit (J. Webb, personal

communication, June 2006 and 6, 7, 8,

9). Testimonials have also been usedto give smokers hope that they canquit by showing others’ stories ofsuccess. These ads focus on how toapproach quitting, includingproviding information about avail-able services and resources. 10, 11, 12

Free & Clear®, a tobacco treatmentprogram, created three videos that invited successful program participants to talk about their challenges in quitting, how theyworked with their Quit Coaches™

and how they relied on otherelements of the program to finallysucceed where they had failedbefore. The videos have been anexcellent way to show potentialparticipants how an evidence-basedprogram works without relying onvast amounts of text or a lot ofscientific study citations.


USING EVIDENCE-BASED PROMOTION PRINCIPLES

There are several efforts underway to distill key principles for cessation media campaigns, tobaccocounter-advertising and cessation treatmentmarketing.

For example, staff at the Institute for Global TobaccoControl at Johns Hopkins Bloomberg School ofPublic Health and the Global Dialogue for Effective Stop Smoking Campaigns conducted aninternational review of published literature onsmoking cessation campaigns and then combinedthose data with key unpublished data from cessation campaigns around the world.

They grouped lessons learned and recommendationsfrom the review into four main topics:

• Advertising• Promotion of Cessation Services• Media Planning and Placement• Collateral Support (i.e.,

non-mass media marketing elements and news media coverage).

The recommended evidence-based principles for promotion are available online at www.stopsmokingcampaigns.org.

The Global Dialogue for Effective Stop Smoking Campaigns’ lessons learned andrecommendations for effective smoking cessation campaigns are available ontheir website.


USING NEW FORMS OF MARKETING TO REACH SMOKERS

Technology-based marketing is becoming increasingly important to reach Internet-connectedconsumers, such as many young adult smokers. It isno mystery that the landscape of communications ischanging rapidly. Several years ago, no one reallyknew what a blog was—because they didn’t exist.Technorati, a blog search engine, now estimates that a new blog is created every second of every day, and that the size of the “blogosphere” isdoubling every five months.

The world is witnessing the rise of a generation that has never known life without TiVo, iPods,mobile phones, Google, instant messaging, broadband, Wi-Fi, and, of course, blogs. This generation is more adept at receiving and sharinginformation than adults over age 35 will ever be.

Social networking sites, such as Facebook, MySpaceand Friendster, now offer people ways to share information with large networks of people. Manysites that feature user-generated content, such asYouTube and Wikipedia, are having a major impacton people’s lives, influencing everything from political races to movie popularity.

“Technology-based marketing is becomingincreasingly important to reach Internet-connected consumers, such as many youngadult smokers.”

Michelle Vandever’s MySpace page promoting tobacco cessation.


Many mainstream websites nowallow users to rate products orprovide feedback on them.

The implications of user-generatedcontent for tobacco cessation aregreat: Many people give greatercredence to first-person accountsthan to paid media messages. But user-generated content is notalways accurate.

The field of tobacco cessation mustfind ways to engage in these formsof dialog to ensure that correctinformation about quitting smokingis provided.

CORRECTING MISPERCEPTIONS ABOUTWHAT WORKS AND WHAT DOESN’T ANDABOUT NICOTINE REPLACEMENT THERAPIES (NRTs)

One of the barriers to treatment useis consumer perceptions of theeffectiveness of products and services, both proven and unproven.In a 2006 nationally representativetelephone survey, evidence-based

smoking cessation methodsperceived as most effective included:

• Help from a doctor (77 percent).• Help from clinics or support

groups (73 percent).• Using a nicotine patch (58

percent).

However, fewer than half of respondents perceived that otherevidence-based treatments wereeffective, including:

• Prescription (cessation) medication (47 percent).

• Nicotine gum (45 percent).• Nicotine tablets, lozenges or

inhalers (37 percent).

Also, fewer than a quarter of respondents thought that using atelephone quitline (24 percent) wasan effective cessation strategy.Methods without evidence likeacupuncture, hypnosis, self-helpaids and even quit smokingprograms offered by tobaccocompanies were perceived as moreeffective than telephone quitlines. 13

There are many misconceptionsabout the safety of nicotine andNRT as well. Some smokers falselybelieve that nicotine and NRTs are acause of cancer and heart attacks.Some providers report similarbeliefs. These misperceptions helpto explain the under-use of FDA-approved NRTs.

More specifically, several studieshave documented wide misconcep-tions about the safety and efficacyof NRT, especially among smokerswith the least education.14 In anationally representative random-digit-dialed telephone survey ofcurrent smokers:

• Only one-third correctly reportedthat nicotine patches were lesslikely to cause a heart attack thansmoking cigarettes.

• 67 percent incorrectly believedthat nicotine causes cancer.

• Fewer than half reported thatnicotine gum and patches wereless addictive than cigarettes. 14,

15, 16


Weighted estimates from the 2004-2005 Assessing the Hard Core SmokerSurvey of U.S. adult smokers foundthat 36 percent falsely believed thatstop smoking medications mightharm their health.17

To address some of these concerns, the National TobaccoCessation Collaborative (NTCC) has developed a factsheet on themisperceptions about nicotine andnicotine replacement therapies anddistributed it to the tobacco cessation community.

Organizations that produce cessation materials were asked toreview their materials to ensure theyincluded accurate information aboutnicotine. The factsheet is available onthe NTCC website at www.tobacco-cessation.org.

“Nicotine replacementtherapy helped memanage the cravings for cigarettes and finally quit.”

Former smoker


Along with effective cessationmedia campaigns and treatmentpromotions, the CDC Guide forCommunity Preventive Servicesrecommends two tobacco controlpolicy interventions that increasecessation and treatment use anddemand at the population level. 3

They are:

• Increasing tobacco prices/taxes.• Reducing out-of-pocket cessation

treatment costs through coverageexpansions.

In addition, there is growingevidence that smoking bans andrestrictions may increase quitattempts, quitting and treatmentuse. Pairing these public healthpolicy changes with efforts toimprove treatment access holds

great promise for major break-throughs in treatment use and quit rates.

STIMULATING AND HARNESSING THETREATMENT DEMAND THAT IS GENER-ATED BY TOBACCO CONTROL POLICYCHANGES

Increasing Tobacco Prices/Taxes

Higher cigarette prices inducesmokers to quit, with the greatesteffects on smokers in low-incomeand blue-collar populations wheresmoking rates are highest and treatment use is lowest. 18

A 10 percent increase in cigaretteprices reduces adult smoking prevalence by 2 percent, and itincreases the probability of a quitattempt by 10-12 percent and of a

STRATEGY 4: Seizing policy changes as opportunities for “breakthrough” increases in treatment use and quit rates

4 5 632

“Pairing...public healthpolicy changes with effortsto improve treatmentaccess holds great promisefor major breakthroughs in treatment use and quit rates.”


successful quit by 1-2 percent. 3, 19

More than 43 states and severalcities (e.g., New York City, Chicago)have raised their tobacco taxes inthe last five years, and there aresigns that this trend will continue.Cost and tax increases also canboost treatment use when treatmentoptions are widely available.

For instance, Frank Chaloupka andcolleagues found that a 40-cent per pack increase in Illinois’ statecigarette excise tax in 2002 morethan doubled state quitline callvolumes. Other studies have linkedcigarette price increases to higherNRT sales. 20 Providing andpromoting barrier-free cessationtreatments at the time when tobaccoprices or taxes take effect could helpto convert more smokers tosuccessful quitters.

Reducing Out-of-Pocket Treatment Costs

Reducing treatment costs byincreasing insurance coverage andreimbursement also boosts the

population quit rate. 3 The markedincreases in public and privatetobacco cessation treatmentcoverage over the past decadeprovide another key venue forboosting treatment use and quitting.

In 1995, only one state Medicaidprogram covered any tobaccodependence treatments. In 2005, 42state Medicaid programs and 96percent of U.S. health plansprovided coverage for some form ofevidence-based counseling or phar-macotherapy. 21, 22

There is still much progress to bemade in the number and type oftreatments covered, and the extentof coverage. There is also a greatneed to promote these benefits.

One study found that only about1/3 of smokers, and fewer than 2/3of providers, in two states withgenerous Medicaid benefits wereaware of these benefits. 23 There aresimilar findings for health plans. 24

Several studies have now shownthat smokers who are unaware oftheir treatment benefits are, notsurprisingly, unlikely to use them!

Reaping the full quitting and healthbenefits of expanded coveragerequires promoting the coverageand reducing non-financial treatment access barriers.

Free quitlines have gone a long waytowards eliminating such barriers.An increasing number of quitlinesare even mailing free NRT samplesto quitline callers, following strategies pioneered by MichaelCummings and colleaguesthroughout New York State. 25



“There is growing evidencethat smoking bans andrestrictions not only reduceharmful secondhand smoke exposure but alsoconsistently improverevenue streams for bars and restaurants byattracting more businessfrom nonsmokers.”

Smoke-Free Air Laws

As of April 2007, 35 states,Washington D.C., Puerto Rico andhundreds of municipalities hadimplemented or enacted 100 percentsmoke-free provisions in work-places and/or restaurants and/orbars—representing 54.8 percent ofthe U.S. population.

There is growing evidence thatsmoking bans and restrictions notonly reduce harmful secondhandsmoke exposure but also consis-tently improve revenue streams forbars and restaurants by attractingmore business from nonsmokers.And they appear to significantlyboost quitting motivation, quitattempts and treatment use.

For instance, quitline calls increasedsignificantly following the imple-mentation of New Zealand’s 2004expanded smoke-free legislation—without any increase in quitline advertising. 26

Fully seizing these policy “pushes”requires being proactive—gettingout ahead of the policy implementa-tion to anticipate and accommodateincreases in treatment demand.

For instance, in preparing forJanuary 1, 2008, when Baltimore’snew comprehensive smoking banwill take effect, Mayor Sheila Dixonhas organized an NRT Initiativethrough which smokers can qualifyfor free nicotine patches or gum.

Similarly, several national groupsand organizations—the NationalTobacco Cessation Collaborative,North American QuitlineConsortium, and Campaign forTobacco-Free Kids—are working todevelop policy “playbooks” toguide states/cities that pass smoke-free policies in ways toexpand treatment access, capacityand promotion so they can take full advantage of the increase inquitting efforts and demand fortreatment.


CLARIFYING AND HEIGHTENING THEINCENTIVES FOR PURCHASERS, HEALTHINSURERS, AND BUSINESSES TO EXPANDTOBACCO CESSATION TREATMENTACCESS AND COVERAGE

So called “meta-consumers”—health plans, employers and thegovernment—have a tremendousinfluence on which products andservices are offered to smokers andwhich are covered in part or in full.

Making the business case for tobaccodependence treatment is important.In addition to improving the healthof employees, tobacco cessationproducts and services can improveemployee productivity and perform-ance. Good examples discussed atthe Consumer Demand Roundtablemeetings include:

• Oregon’s “Make it Your BusinessCampaign,” led by DawnRobbins, starts by clarifying thetrue business costs of tobacco use,including the costs related toreduced smoker productivity.This campaign helped drive the

With a new understanding of the business and human tolls of tobacco use from Oregon’s“Make it Your Business” campaign, Ed Wallace Jr. decided to invest in tobacco cessationafter a mechanic suffered a heart attack while fixing a motorcycle at his Harley dealership.


Public Employees BenefitsBoard, the state’s largest healthcare purchaser, to offer a barrier-free tobacco cessation benefit.

• Partnership for Prevention, basedin Washington, D.C., is devel-oping a Workplace ProgramGuide as a tool to provideemployers with guidance toimplement the most effectiveand cost-effective health promo-tion interventions. Tobacco usescreening and treatment top thelist. The Guide will educateemployers about the total costsof tobacco use, the total value oftobacco cessation activities (poli-cies and treatments) and theirimpact on business success.

• Beginning in 1996, the NationalCommittee on Quality Assurance(NCQA) added measures oftobacco cessation advice andassistance to its core HEDIS“report card” for managed careplans, and has promoted the use

of these measures in federal(Medicare) pay-for–quality initia-tives (e.g., the Doctors OfficeQuality initiative). Includingtobacco cessation treatmentmetrics in new pay-for-perform-ance initiatives will provideenduring incentives for theirdelivery.

• Similarly, the CEO Roundtable on Cancer has developedemployer guidelines for companies to be Gold Standard-certified. Requirements forpromoting healthy lifestyles and cancer prevention includeimplementing a full indoor andoutdoor smoking ban at theworkplace, and providingevidence-based counseling andprescription and non-prescriptionmedications for smoking cessation at no cost to employees.The CEO Roundtable on Cancerwas convened to support a C-Change initiative, which isfocused on demonstrating the

value and ultimate cost-savingsassociated with cancer preventionand early detection services andincreasing coverage throughemployee benefit programs.

• The Healthy Workforce Act of2007 proposed by Senator TomHarkin (D-Iowa) and his staffincludes a tax credit of $200.00per employee to businesses thatoffer comprehensive healthpromotion programs, includingevidence-based preventivescreenings, behavior changeprograms (including tobaccocessation treatments) and workenvironment and policy changes.To boost employee participation,companies would be encouragedto offer meaningful incentives,like reduced health insurancepremiums.

• America’s Health Insurance Plans(AHIP), the advocacy organizationfor U.S. health plans and insurers,promotes findings from health econ-omists at the Center for HealthResearch at Kaiser PermanenteNorthwest. The research shows thatthe return on investment (ROI) fortobacco cessation services yieldssavings in as little as two years, andsooner for pregnant smokers. Inaddition to providing details on thebusiness case, the website(http://www.businesscaseroi.org/roi/default.aspx) includes an interactive online “ROI calculator” that healthplans can use to estimate their owncost savings. 27

• Many employers cite the lack ofinformation about the cost of cessa-tion benefits as a barrier to coverage.Now that quitlines provide freecounseling to smokers across theU.S., their concerns focus increasinglyon pharmacotherapy. MargueriteBurns and colleagues examined


To encourage businesses to offer cessation coverage, this guide provides informationfor businesses and government agencies on health insurance coverage for tobaccouse cessation treatments.

pharmacotherapy costs amongWisconsin state employees andfound that they averaged only13-cents per member per month. 28

• To encourage businesses to offercessation coverage, the CDCcreated “Coverage for TobaccoUse Cessation Treatments," aguide that provides informationfor businesses and governmentagencies on health insurancecoverage for tobacco use cessa-tion treatments. This documentexplains why insurance coveragefor tobacco cessation is impor-tant, what treatments are avail-able to help employees, and howto design the treatment benefits.It is available online atwww.cdc.gov/tobacco/quit_smoking/cessation/00_pdfs/ReimbursementBrochureFull.pdf.

ALLOCATING MSA BONUS FUNDS FORTOBACCO CONTROL: A “TWICE IN A LIFETIME” OPPORTUNITY

Unfortunately, less than 4 percent ofthe original Master SettlementAgreement (MSA) funds awardedto the states have been allocated fortobacco control. However, beginningin 2008, the states that have notsecuritized their MSA funds willhave a second chance as MSA bonusfunds become available. In thecoming year, efforts to help states allocate sufficient dollars forcomprehensive tobacco control fromthe final 2008-2018 MSA bonuspayments represent a critical policylever, and one with enormouspotential impact on tobacco cessa-tion treatment access, use anddemand. In addition, creating business incentives for corporateinvestment in publicly funded services, such as quitlines, also holdspromise. For more information onthe use of MSA funds by states, visit the Campaign for Tobacco-Free Kids’ website at http://tobac-cofreekids.org/reports/settlements.


“Efforts to help states allocate sufficient dollarsfor effective comprehensivetobacco control ... representa critical policy lever, and one with enormouspotential impact on tobaccocessation treatmentaccess, use and demand.”


In the United States, tobacco use ismonitored via a series of annualcross-sectional surveys. Thesesurveys inform the field aboutusage trends over time and aboutpatterns of use among variousdemographic sub-groups in thepopulation.

But they do not explain much aboutthe natural history of quittingamong individuals, how smokersquit, or about the treatments thatthey try and find helpful. The cross-sectional surveys providesnapshots—pictures of the popula-tion at one point in time—and donot systematically track quittingefforts, methods and successes.

The single most basic need is toembed more quitting questions inmajor U.S. tobacco use surveysso that quit attempts, methods and successes can be trackedsystematically.

USING A LONGITUDINAL COHORT STUDYOF QUITTING MOTIVATION ANDBEHAVIOR, TREATMENT BELIEFS,DEMAND, USE, COST AND BENEFITS ASA TOOL FOR ADVOCACY AND RESEARCH

Having data from longitudinalstudies is like having a video taperather than just snapshots of thequitting process. Researchers can seewhat happens to a representativegroup of people as they cycle in andout of the quitting process.

STRATEGY 5: Systematically measuring, tracking,reporting and studying quitting and treatment use—and their drivers and benefits—to identify opportunities and successes

“Having data from longitudinal studies is likehaving a video tape ratherthan just snapshots of thequitting process.”

5 643


“I think the new smoke-free laws aregreat! Now I can go out and not have that urge to smoke.”

Former smoker


To better help people stop smoking,we need to better understand howthey go about quitting in the realworld. A two- to three-year longi-tudinal study would enhanceunderstanding of the processes U.S.smokers use to quit, the choicesthey make, their successes andpredictors of each.

For example, there is a need tobetter understand what individual-and policy-level factors influencemaking a quit attempt, the choice oftreatment strategies (e.g., PublicHealth Service-recommended, othertreatment strategies and quittingwithout treatment), and theoutcomes that follow the use ofeach approach.

There is also a need to understandwhich individual-level factors (e.g.,dependence, motivation) canmoderate these relationships.Repeating such a study every fiveyears would help to understand ifany changes in the process haveoccurred and, if so, to better

understand factors influencingthose changes.

For example, some researchers areconcerned that smokers arebecoming more resistant to treat-ment over time. Rolling cohortstudies of representative samples ofthe U.S. population could test thishypothesis.

These studies can also be used toassess how broader tobacco controlprogramming affects quit attemptsand the use and efficacy of proventreatments.

Multi-level research could bestinform how prices of tobacco prod-ucts and pharmaceutical treatments,along with the strength of localsmoke-free laws and the use ofeffective counter-advertising strate-gies, can influence quit attemptsand success among attempters.There is also a need to better understand how potential reduced-exposure products (PREPs) mightundermine quitting, by reducing

“To better help people stop smoking, we need tobetter understand how they go about quitting in the real world.”


the number of quit attempts andincreasing relapse among those whotry to quit.

FUNDING CONSUMER DEMAND RESEARCH

The NIH State-of-the-ScienceConference Statement on Tobacco Use:Prevention, Cessation, and Controlmeeting on June 12–14, 2006, identi-fied research to boost consumerdemand for and use of evidence-basedtreatments as a top priority. Thewritten statement prepared by theExpert Panel issuing recommenda-tions, based on two days of expertpublic testimony and a comprehensivecommissioned evidence review,included the following as “priorityaims for future research and publichealth action”: 29

-

The NIH State-of-the-Science Conference Statement on Tobacco Use: Prevention,Cessation, and Control identified research into building consumer demandfor evidence-based treatments as a top priority. Copies can be obtained athttp://consensus.gov/2006/TobaccoStatementfinal090506.pdf.

Improve and Implement EffectiveInterventions

• Understand the role of differentmedia in increasing consumerdemand for and use of effective,tobacco cessation treatments fordiverse populations.

• Identify and reduce barriersfaced by providers, insurers,policymakers and others toimplementing effective strategiesto increase and sustain demandfor smoking cessation treatment.

• Examine the effectiveness ofdifferent components of tele-phone-based counselingprograms (e.g., population quit-lines vs. provider-associatedprograms; self-referral vs.provider referral to telephone-based counseling; bundling ofservices within programs).

• Develop and enhance pharmaco-logic and non-pharmacologictreatments.


“I need to quit formy health, but Ilike smoking.When I quit, I’lluse the patch—that will be it.”

Current smoker

Improve and Implement EffectivePolicies

• Increase policymakers’ and thepublic’s awareness of effectivestrategies for preventing tobaccouse, promoting tobacco cessa-tion, and decreasing harm fromenvironmental tobacco smokeexposure.

• Identify and overcome barriersto implementing comprehensivestatewide tobacco controlprograms, such as those used inCalifornia and Florida.

• Develop effective policies forreimbursing health careproviders for offering tobacco-cessation interventions.

Develop New Population- andCommunity-Based Interventions

• Determine the effectiveness ofimplementing interventions insettings other than schools andhealth care facilities, such as

homes, community organizations,religious institutions, pharmacies,stores, bars, workplaces, militaryinstitutions and correctionalinstitutions.

• Determine the effectiveness ofincorporating social context (e.g., culture, neighborhoods andsocial networks) in interventionsto prevent or stop tobacco use.

• Evaluate the long-term effects ofsocial marketing strategies ontobacco use, particularly media-based programs to promotecessation and counter tobaccoadvertising.

• Learn from “natural experiments”that result from implementationof new policies on pricing/taxa-tion, smoke-free environments,or restrictions on the availabilityof tobacco products.

• Evaluate the effectiveness ofpublic (health care) performancemeasures (e.g., publicly reportedquality-of-care report cards) and financial incentives forincreasing smoking cessation.

Infrastructure

• Promote surveillance programsthat track tobacco use (e.g., initiation, quitting, intensity ofsmoking, use of smokelesstobacco); use of treatment; motivation to quit; new products;and marketing, policy andsystems changes.

• Educate providers, includingphysicians, dentists, nurses andallied health professionals aboutthe importance of tobacco-related diseases and the avail-ability and delivery of effectiveinterventions.



The best way to build consumerdemand for tobacco cessation prod-ucts and services is to combine andintegrate as many of these strategiesas possible. When this has beenachieved, real "breakthroughs" intreatment demand, delivery, reachand use have occurred, leading tosubstantial reductions in popula-tion-level smoking prevalence.

ALIGNING MULTIPLE POLICY AND TREATMENT STRATEGIES: THE NEW YORK CITY EXAMPLE

New York City (NYC) providesproof that a comprehensive tobaccocontrol plan can substantiallyreduce adult smoking prevalence.NYC’s efforts made it harder tosmoke and easier to quit. Keyelements included:

1. Implementing a 2002 baselinesurvey to assess adult smokingand quitting at the neighborhoodlevel and identify high-riskpopulations.

2. Increasing state and city tobaccotaxes by a total of $1.81 in 2002.

3. Disseminating cessation-treatmentrecommendations to NYC’s60,000 medical providers in 2002-2003.

4. Enacting a Smoke-Free Air Act in2002 requiring almost all work-places, restaurants and bars to besmoke-free.

STRATEGY 6: Combining and integrating as many ofthese strategies as possible for maximum impact

“The best way to build consumer demand for tobacco cessation products and services is to combine and integrate as many of these strategies as possible.”

654


5. Promoting and launching a largequitline-based NRT give-awayprogram in collaboration withthe Roswell Park CancerInstitute in April/May 2003 —providing free six-week nicotinepatch supplies with brief quitlinecounseling to the first 35,000eligible adult smokers to call theState Smoker’s Quitline.

6. Conducting city-wide assess-ments of program impact onsmokers and city-wide NRTsales. 30

The impact was immediate anddramatic:

• Over 400,000 calls were made tothe state quitline within the firstfew days of the cessationprogram launch.

From 2002 to 2003, the percent of adult New Yorkers who smoke declined from 21.6 percent to19.2 percent— the fastest drop in smoking prevalence ever recorded.


• 35,000 New Yorkers received freesix-week supplies of nicotinepatches with an over-representa-tion of smokers who were non-white, foreign-born or residing inlow-income neighborhoods —11,000 of whom are now ex-smokers. 31

• City-wide nicotine patch salesincreased 31 percent in the sameweek the free patch program waslaunched.32

• From 2002 to 2003, the percent ofadult New Yorkers who smokedeclined from 21.6 percent to19.2 percent, an 11 percentdecrease — the fastest drop insmoking prevalence everrecorded nationally.

• This decline continued in 2004,when 18.4 percent of NewYorkers reported smoking — a15 percent decrease from 2002. 33

• As a result, by 2005, there were200,000 fewer smokers and morethan 50,000 premature deaths averted. 33

According to Thomas R. Frieden,Commissioner of the NYCDepartment of Health and MentalHygiene and chief architect ofNYC’s comprehensive five pointplan, “Fewer New Yorkers aresmoking today than at any point inat least 50 years. Most smokerswant to quit and, for the first timeever, there are more former smokersthan there are smokers in New YorkCity.” 30

Michael Fiore, nationally recog-nized expert on smoking cessationand Chair of the InteragencyCommittee on Smoking and Health,which released the 2004 NationalCessation Action Plan that includedmany of the same elementscombined so successfully in NYC,has declared the city’s success amodel for other states and commu-nities and for the nation.

Dr. Thomas Frieden, Commissioner of the NYCDepartment of Health and Mental Hygiene.

45INNOVATIONS IN BUILDING CONSUMER DEMAND FOR TOBACCO CESSATION PRODUCTS AND SERVICESINNOVATIONS IN BUILDING CONSUMER DEMAND FOR TOBACCO CESSATION PRODUCTS AND SERVICES

It was the National Cessation ActionPlan that led to the organization ofthe national state quitline network,which now includes quitlines in all50 states, the District of Columbiaand Puerto Rico—providingunprecedented access to free cessa-tion counseling for all U.S. smokers.

“New York City has done all theright things—reducing exposure tosecondhand smoke, increasing theexcise tax, and helping currentsmokers quit. As a result, rates ofsmoking have declined and need-less illness and death has beenprevented. New York City is amodel for what we need to doacross America,” Fiore stated. 30

In fact, there is important potentialfor replicating this model through:

• Continued efforts to seek fundingto implement additional compo-nents of the National CessationAction Plan (e.g., providereducation, free medication,strategic cessation research andsurveillance). 18

• Efforts launched by NTCC andConsumer Demand Roundtablemembers and participants todevelop "playbooks" that willprepare states and communitiesto harness multi-strategy policychanges in a proactive way, tobuild consumer treatmentdemand and use.

Danny McGoldrick, director ofresearch for the Campaign forTobacco-Free Kids, notes that thereare at least five states in which a“trifecta” of state issues (sales tax,smoke-free laws and funding forprevention and cessation programs)is being actively proposed andconsidered by governors and statelegislatures in the year 2007 —including Wisconsin, Oregon, NewMexico, Iowa and Maryland.

ALIGNING MULTIPLE HEALTHCAREPOLICY AND SYSTEMS CHANGES:HEALTH PLAN EXAMPLES

Federal, state and communitypolicy and environmental changes(e.g., clean indoor air laws, tobacco

tax increases, treatment coverageexpansions, counter-advertising andcessation media campaigns)provide powerful motivation,incentives and support for quittingat the population level.

Similar policy and environmentalsupports can be harnessed at thehealth plan or provider organiza-tion level (e.g., coverage expan-sions; computerized remindersystems and communicationcampaigns aimed at providers andpatients; pay-for-performanceincentives to reward HEDIS report-card scores for tobacco usescreening and intervention).

Several leading health plans haveimplemented these kinds of healthcare systems and policy changes toachieve breakthroughs in theproportion of their enrollees whoare screened and treated for tobaccouse and dependence. These planshave drawn on internal andexternal quitting resources toincrease treatment delivery and


reduce the burden on busy officestaff. In some cases, plans workedto promote effective state tobaccocontrol policies (tax increases,smoke-free airs laws), and createdsystems to prompt, monitor andimprove their progress. Forexample:

• Over a 10-year period, asmoking cessation initiative atGroup Health Cooperative inSeattle reduced the prevalence ofadult smoking from 25 percent to15 percent, 5 percentage pointsbelow the Washington stateaverage. 34, 35, 36

• Kaiser Permanente of NorthernCalifornia achieved enrolleeadult tobacco use rates of 12percent, the 2010 national preva-lence goal and 4.5 percent lowerthan California’s 16.5 percentsmoking prevalence, by identi-fying smokers and referringthem to effective health plan andexternal quitting programs. 36

• Two federally qualified healthcenters serving predominantlylow-income African-Americansmokers used participatoryapproaches to change multiplesystems of care. 37 Within twoyears, provider quit advice andoffers of cessation assistancereached impressive levels of80 percent and 64 percent,respectively.

These case studies show what couldbe achieved by aligning health caresystems and policy changes inhealth plans and provider organiza-tions across the country. One of theunexpected benefits is that smokerswho are offered help to quit reporthigher satisfaction with their overallcare. 38

The New York City experience andthe health plan examples showwhat is achievable by combiningand integrating multiple strategiesthat build consumer demand.

“The New York City experience and the healthplan examples show what is achievable by combiningand integrating multiplestrategies that buildconsumer demand.”


MAKE VARIED CESSATION TREATMENTSAND MODALITIES AVAILABLE IN A SEAMLESS SYSTEM OF CARE

All of the examples above involvedtaking a “systems approach” inmaking a range of proven cessationtreatments accessible and freelyavailable in a coordinated system of care management. This is theapproach recommended byConsumer Demand Roundtablemembers David Abrams, director ofthe NIH Office of Behavioral andSocial Sciences Research, andAmanda Graham, GeorgetownUniversity School of Medicine.They point to the need for “second-generation” delivery systems thatintegrate multiple treatment modal-ities (e.g., telephone, web-based,face-to-face counseling, medicationsupport, physician brief counseling,etc.) into a seamless system ofsupport and assistance that can betailored to meet the needs ofvarious consumers throughout theirquitting journey. Such systemsallow for flexible self-tailoring andcan harness the power ofsupportive tobacco control policies.

Many efforts are starting to take thisapproach:

• The North American QuitlineConsortium reports that statequitlines are increasingly estab-lishing links to and from physi-cian offices (via fax referrals),directly dispensing NRT toeligible quitters, and connectingcallers to integrated websites for24/7 support.

• EX, a new cessation programdeveloped by the AmericanLegacy Foundation, providessmokers who want to quit withthe information and resourcesthey need to be successful. Thismulti-component program isdesigned to work in partnershipwith existing state and localorganizations. EX employs mediacampaigns that drive smokers to1-800-QUIT-NOW telephonecounseling services (which canlink callers to local providersand clinics for face-to-face counseling) and to the

BecomeAnEX.org website forfurther information and assistancein developing a personalizedquit plan. EX messaging focuseson building smoker confidencebefore they begin the quitprocess both via advertising andonline exercises. The program ispilot-testing in multiple marketsin early 2007 and—based onevaluation results—could launchnationally in late 2007 or early2008 with the backing of analliance of public and privatepartners. In preparation for anational launch, Legacy iscurrently developing EXmaterials for Latino and low-literacy populations.


Increasing interest in, demand forand use of proven tobacco cessationproducts and services represents anextraordinary opportunity to reduceadult tobacco use—the nation’ssingle greatest cause of preventabledeath and disease, and a majorsource of healthcare burden anddisparities.

Providing more smokers withtobacco cessation products andservices that they find bothappealing and effective could lead toa significant increase in the nation’soverall quit rate and help to eliminategrowing disparities in healthoutcomes. But it is a challenge thatwill require bold thinking; innova-tion; comprehensive, integratedchanges in policy and practice; andinnovations that result from takinga “consumer perspective.”

Use the checklist to see if you andyour organization are doing all youcan to build demand for cessationproducts and services.

CONSUMER DEMAND CHECKLIST

Are you and your organization:

Viewing smokers as consumers and taking a fresh look at quitting from their perspective?

• Developing a better understanding of quitters’ preferencesand needs?

• Focusing on the “consumer experience”?• Understanding the quitting journey and engaging smokers

all along the way?

Redesigning evidence-based products and services to bettermeet consumers' needs and wants?

• Using consumer-centered design principles?• Ensuring products and services materials follow health

literacy principles?

Marketing and promoting cessation products and services in ways that reach smokers—especially underserved smokers—where they are?

• Engaging smokers in new ways and in new places?• Telling stories instead of simply sharing facts and

information?• Using evidence-based promotion principles to help guide

the development and targeting of smoking cessationcampaigns?

• Using new forms of marketing to reach smokers?• Correcting the misperceptions about what works and what

doesn’t about nicotine and nicotine replacement therapies(NRTs)?

Conclusion


Seizing policy changes as opportunities for "breakthrough"increases in treatment use and quit rates?

• Stimulating and harnessing the treatment demand thatis generated by tobacco control policy changes?

• Clarifying and heightening the incentives for purchasers,health insurers, and businesses to expand tobacco cessa-tion treatment access and coverage?

• Allocating new MSA “bonus funds” for tobacco control?

Systematically measuring, tracking, reporting, and studyingquitting and treatment use — and their drivers and benefits— to identify opportunities and successes?

• Using a longitudinal cohort study of quitting motivationand behavior, treatment beliefs, demand, use, cost andbenefits as a tool for advocacy and research?

• Funding consumer demand research?

Combining and integrating as many of these strategies aspossible for maximum impact?

• Aligning multiple policy and treatment strategies, such as New York City officials did?

• Aligning multiple healthcare policy and systems changes,such as some health plans have done effectively?

• Making varied cessation treatments and modalities available in a seamless system of care?

The NTCC website provides the best available information on tobaccocessation from the many agencies and organizations working to increasetobacco cessation.

To participate in the Consumer Demand and NTCC activities described in this document, please contactTodd Phillips of AED at 202-884-8313 or [email protected].

For more information about NTCC, please visitwww.tobacco-cessation.org.



Consumer Demand Roundtable Members

David Abrams, Ph.D.National Institutes of Health

Linda Bailey, J.D., M.H.S.North American Quitline Consortium

Matt Barry, M.P.A.Campaign for Tobacco-Free Kids

Tim McAfee, M.D., M.P.H.Free & Clear

Carlo DiClemente, Ph.D. (Chair)University of Maryland

Amanda Graham, Ph.D.Brown Medical School

David Graham, M.P.A.Pfizer, Inc. (Now Johnson & Johnson)

Karen GutierrezGlobal Dialogue for Effective Stop Smoking Campaigns

Pablo Izquierdo, M.A.Elevacion Ltd.

Katie Kemper, M.B.A.GlaxoSmithKline Consumer Healthcare(Now Campaign for Tobacco-Free Kids)

Myra Muramoto, M.D., M.P.H.University of Arizona

C. Tracy Orleans, Ph.D. (Co-Chair)The Robert Wood Johnson Foundation

Joachim Roski, Ph.D., M.P.HNational Committee for QualityAssurance

Saul Shiffman, Ph.D.University of Pittsburgh

Victor Strecher, Ph.D., M.P.H.University of Michigan

Susan Swartz, M.D., M.P.H.Center for Tobacco Independence Maine Medical Center

Frank Vocci, Ph.D.National Institute on Drug Abuse

Dianne WilsonSouth Carolina African AmericanTobacco Control Network

Consumer Demand Roundtable andConference Planning Committee

Elaine ArkinThe Robert Wood Johnson Foundation

Carlo DiClemente, Ph.D.University of Maryland

Rajni Sood Laurent, M.A.Academy for Educational Development

Jessica Nadeau, M.A.Academy for Educational Development

C. Tracy Orleans, Ph.D.The Robert Wood Johnson Foundation

Todd Phillips, M.S.Academy for Educational Development

Stephanie Smith-Simone, Ph.D., M.P.H.

The Robert Wood Johnson Foundationand Princeton University

Kay Kahler Vose, M.A.Porter Novelli, Inc. (Now an independent consultant)

Stephanie Weiss, Sc.M.The Robert Wood Johnson Foundation

THE NTCC CONSUMER DEMAND ROUNDTABLES AND CONFERENCE


For more information about the Consumer Demand Roundtable, please visit www.consumer-demand.org.

Many other individuals participated in the Consumer Demand Roundtables and Conference. To view a list of theseparticipants, please visit www.consumer-demand.org.


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INNOVATIONS IN BUILDING CONSUMER DEMAND FOR TOBACCO CESSATION PRODUCTS AND SERVICES58www.tobacco-cessation.org

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National Tobacco Cessation Collaborative