CHESTCHEST NewsSupplementing US framework for smoking cessation

Supplementing US framework for smoking cessation

With the goal of sustaining and strengthening our hard-won progress in reducing tobacco use through smoking cessation, the American College of Chest Physicians (CHEST) provided comments to the HHS 2023 Framework to Support and Accelerate Smoking Cessation.

CHEST comments include suggestions on specific benchmarks and metrics with an emphasis on those affecting populations and communities disproportionately impacted by smoking-related morbidity and mortality.

From the letter:

Smoking cessation is a patient-centered initiative, and metrics and benchmarks included should reflect this. CHEST proposes a list of various metrics and benchmarks that may be included to ensure framework progress:

  • evaluation of state and local programs and actions toward more comprehensive coverage;

  • evaluation of patient barriers and improvements in access;

  • quitline utilization and outcomes; and

  • lung cancer screening rates.

Read the full letter to the Department of Health and Human Services (HHS) within the Centers for Medicare & Medicaid Services (CMS) below.

August 18, 2023

VIA ELECTRONIC SUBMISSION

Honorable Xavier Becerra
Secretary
Department of Health and Human Services
200 Independence Ave SW
Washington, DC 20201

Re: Request for Information: Draft HHS 2023 Framework to Support and Accelerate Smoking Cessation

Dear Secretary Becerra:

The American College of Chest Physicians (CHEST) is pleased to submit these comments to the Centers for Medicare & Medicaid Services (CMS or “the Agency”) on the Request for Information (RFI): Draft Department of Health and Human Services (HHS or “the Department”) 2023 Framework to Support and Accelerate Smoking Cessation (“the Draft Framework”)1. CHEST commends the Administration on its various efforts, through the Biden Moonshot, Executive Order (EO) 13985, Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, and EO 14091, Further Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, to bring to the fore the goals of driving down cancer deaths and advancing health equity. We agree with the Department that smoking cessation is a key area in need of greater attention by the federal government in order to achieve those goals.

CHEST is the leading professional association in innovative and life-saving chest medicine. We support the advancement of improved health outcomes for patients with lung disease through education, advocacy, research, and philanthropy. CHEST is the professional home for more than 21,000 pulmonary, critical care, and sleep medicine professionals dedicated to the delivery of quality, evidence-based care for patients. Our mission is to champion the prevention, diagnosis, and treatment of chest diseases with a focus on ensuring and improving access for all patients, particularly underserved patients of highest need.

Addressing the issue of smoking cessation has been a long-standing priority for CHEST. We welcome the opportunity to respond to the five questions included in the RFI, as well as put forth overarching recommendations as the Department moves toward building and finalizing its Framework. A summary of our recommendations are as follows:

  • Understand the Patient Population of Need. The Department should set the goal of obtaining a more robust understanding of the social science affecting specific population-based behaviors, their barriers to access, and their engagement with available resources, in order to accurately target health disparities and improve cessation outcomes.

  • Coalesce Key Agencies and Programs. HHS should prioritize inter-agency and cross-program collaboration and cooperation as a key strategy within the Framework.

  • Expand Scope to Address E-Cigarettes. HHS should strongly consider expanding the Framework to include e-cigarettes at this initial juncture, recognizing that the harm profile of these products on at-risk populations has not been identified.

I. Responses to 5 Questions Included in the RFI

  • Question 1: Appropriateness and Relevance of Goals for Addressing the Needs of PopulationsDisparately Affected by Smoking and Question 2: Extent to Which the Broad Strategies Capture Key Components and Aspects Necessary to Drive Progress Toward Increasing Cessation

Overall, CHEST supports the Draft Framework vision stated, “to ensure that every person in America has access to comprehensive, evidence-based cessation treatment and can benefit from HHS cessation supports, programs, and policies”; however, to achieve this vision, the goals set through this Framework should be commensurately ambitious and forward-looking. In this RFI, the Department states its aim to both accelerate smoking cessation as well as reduce smoking-related health disparities. The Draft Framework identifies six goals that summarize activities and initiatives that are in existence today.2 Though the broad strategies laid out in the Draft Framework exhibit evidence-based strategies that are in effect at varying degrees today, these are necessary, but arguably not sufficient.

  • Question 3: Additional Goals or Broad Strategies That Should Be Included in the Framework

At the center of smoking cessation services and initiatives are the patients, particularly the underserved patient population. It is well documented that low-income populations among other underserved populations are disproportionately affected by cigarette smoking and tobacco use3; however, there is much information yet to be obtained about the target population and what their needs are. Between 30% to 50% of smokers in the U.S. make a quit attempt in any given year, though the rate of success rate is only approximately 7.5%.4 CHEST recommends that HHS include in the final Framework an additional goal to obtain a more robust understanding of the social science affecting specific population-based behaviors, their barriers to access, and their engagement with available resources regarding smoking prevention and cessation.

As noted in the RFI, cigarette smoking is the single leading cause of preventable disease, disability, and death in the U.S., and in 2023, cigarette smoking will directly cause more than 80% of lung cancer deaths.5 Achieving positive health outcomes for the health and wellness of the patient population through smoking cessation is possible when supplemented by comprehensive services, such as lung cancer screening. Lung cancer screening and smoking cessation are strongly linked, with various associations putting forth best practice recommendations to incorporate cessation counseling with screening visits. Emphasizing lung cancer screening would bolster the Draft Framework and help provide a more comprehensive strategy.

  • Question 4: Targeted Actions HHS Should Take to Advance the Outlined Goals and Strategies

CHEST agrees with the Department that improving coverage of tobacco cessation treatment in Medicare, Medicaid, and private insurance (Goal 4) is a key priority. To ensure comprehensive coverage, HHS should put forth guidance and compile reports on the necessary elements of comprehensive state tobacco control programs. For example, in the 2020 Report to the Surgeon General, the Department stated successful elements of comprehensive smoking cessation programs to include: “state and community interventions; mass-reach health communication interventions; cessation interventions; surveillance and evaluation; and infrastructure, administration, and management”.7 Additionally, HHS should provide additional guidance to state programs on the need to cover all FDA-approved medications.

The support for the use of quitlines as an evidence-based, cost-effective tool for smoking cessation should be bolstered. Introduced in 1998, quitlines are effective tobacco cessation interventions that help tobacco users quit through tele-counseling, provision of practical information on how to quit, referral to other resources, and provision of additional self-help materials sent by mail. Data show that quitlines increase 6-month smoking cessation quit rates and prove to be cost-effective; however, quitlines reach approximately 1% of individuals who smoke in the U.S.6,7,8 Use of quitlines should be encouraged and bolstered through additional funding and educational efforts.

Health care system support is critical to ensure effective care coordination and care delivery and necessary provision of adequate treatment and support. The CDC’s recommended Best Practices state that the factors that have greatest impact on increasing success are (1) support for direct provision of treatment and (2) support for health systems and population-based tobacco control policies.7 Though education efforts for patients and providers are important and underway, medical professionals should be better equipped on a systems-level to approach smoking cessation. This includes methods of education through strengthened medical school curriculum, on-the-job training for all healthcare personnel, and stronger guidelines on care coordination across care teams.

  • Question 5: Metrics and Benchmarks That Should Be Included to Ensure That the Framework Drives Progress

Smoking cessation is a patient-centered initiative, and metrics and benchmarks included should reflect this. CHEST proposes a list of various metrics and benchmarks that may be included to ensure framework progress:

  • evaluation of state and local programs and actions toward more comprehensive coverage;

  • evaluation of patient barriers and improvements in access;

  • quitline utilization and outcomes; and

  • lung cancer screening rates.

II. Overall Recommendations 

Administration-wide efforts, like the Biden Cancer Moonshot, set ambitious goals for reducing the death rate from cancer, and CHEST commends these efforts. Though we have seen great strides in smoking cessation over the years, we know that in order to take leaps forward, it will require commitment and forward thinking across the federal government in concert with organizations like CHEST. In order to develop targeted and effective strategies for the future of smoking cessation, it is imperative to understand the patient population’s needs and access barriers. CHEST recommends that HHS take steps to gain a deeper understanding of the social science affecting specific population-based behaviors, their barriers to access, and their engagement with available resources. The Department should prioritize efforts to collect information and data on the smoking population throughout the U.S. and conduct a thorough evaluation of the modern barriers for smoking cessation access and root causes of disparities prevalent in care delivery. You cannot fully solve a problem without a clear understanding of every challenge that persists.

The Department includes “Coordination, Collaboration, and Integration” as a Cross-Cutting Principle. CHEST agrees that coalescing various agencies and programs would strengthen the initiative. For example, in February 2023, the Food and Drug Administration (FDA) Center for Tobacco Products (CTP) outlined steps the CTP would take to strengthen its tobacco program. These steps include the reinvigoration of the Tobacco Products Scientific Advisory Committee (TPSAC) as well as the development and implementation of a 5-year strategic plan. The CTP states that it “must pivot from a reactive mode to a proactive mode”.Additionally, to further the previous recommendation of evaluating a more robust understanding of the patient population of greatest need, CHEST recommends collaboration, such as cooperation between the NIH and CDC to increase research funding to evaluate population-wide social determinants for smoking cessation. CHEST believes that HHS should promote coordination, collaboration, and integration of programs and activities across the Department to support the implementation and sustainability of effective cessation practices, programs, and policies, which should be reflected in the final Framework.

Included in the RFI is the stated intention to focus on “cessation of the use of commercial cigarettes, cigars, and cigarillos, for people of all ages across the lifespan” by omitting stances on e-cigarettes. CHEST acknowledges that there is more research to be done on the impact and outcomes of e-cigarette use; however, the significant increase in e-cigarette use in the U.S. population, especially among the population that has never used combustible cigarettes signals a need to address an increasingly prevalent mode of smoking.10 In the 2020 Report to the Surgeon General, the Department stated the importance of “monitoring the findings of research on the potential of e-cigarettes as a smoking cessation aid” and “evaluating the positive and negative impacts that these products could have at the individual and population levels”.11 Though research is underway on the causal relationship between e-cigarette use and cancer, there is compelling evidence that associations exist.12 Excluding monitoring and evaluating e-cigarette effects as a goal in the final Framework would represent a missed opportunity to addressing a key factor in the future of smoking cessation efforts.

III. Conclusion

CHEST greatly appreciates the Administration’s efforts and the opportunity to comment on the Draft Framework targeting smoking cessation, an issue of key significance to the patients we serve and physicians we represent. We would be pleased to answer any questions about these comments and look forward to continuing to work with HHS on ensuring uniform and equitable access to tobacco use prevention and cessation services.


References

  1. U.S. Department of Health and Human Services. Request for Information: Draft HHS 2023 Framework To Support and Accelerate Smoking Cessation (88 FR 42377). Published on June 30, 2023. Accessed from: https://www.govinfo.gov/content/pkg/FR-2023-06-30/pdf/2023-13928.pdf
  2. (1) Eliminate smoking- and cessation-related disparities; (2) Increase awareness and knowledge related to smoking and cessation; (3) Strengthen and sustain cessation services and supports; (4) Increase access to and coverage of comprehensive, evidence-based cessation treatment; (5) Expand surveillance of smoking and cessation behaviors and strengthen performance measurement and evaluation; (6) Promote ongoing and innovative research to support and accelerate smoking cessation
  3. Cornelius ME, Loretan CG, Wang TW, Jamal A, Homa DM. Tobacco Product Use Among Adults — United States, 2020. MMWR Morb Mortal Wkly Rep 2022;71:397–405.
  4. Centers for Disease Control (CDC). Smoking Cessation: Fast Facts. March 21, 2022. Accessed at https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/smoking-cessation-fast-facts/index.html
  5. Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. Ca Cancer J Clin. 2023 Jan 1;73(1):17-48.
  6. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, 2008. https://www.ahrq.gov/prevention/guidelines/tobacco/clinicians/update/index.html
  7. 2012 Task Force on Community Preventive Services review on Quitline Interventions. https://www.thecommunityguide.org/sites/default/files/assets/Tobacco-Quitlines.pdf.
  8. Fiore MC, Baker TB. Ten million calls and counting: progress and promise of tobacco quitlines in the US. American journal of preventive medicine. 2021 Mar 1;60(3):S103-6.
  9. Food and Drug Administration (FDA). Actions to Address Recommendations from the Reagan-Udall Evaluation of CTP. Updated July 21, 2023. Accessed from: https://www.fda.gov/tobacco-products/about-center-tobacco-products-ctp/actions-address-recommendations-reagan-udall-evaluation-ctp
  10. Boakye E, Osuji N, Erhabor J, Obisesan O, Osei AD, Mirbolouk M, Stokes AC, Dzaye O, El Shahawy O, Hirsch GA, Benjamin EJ. Assessment of patterns in e-cigarette use among adults in the US, 2017-2020. JAMA Network Open. 2022 Jul 1;5(7):e2223266-.
  11. U.S. Department of Health and Human Services. Smoking Cessation: A Report to the Surgeon General. 2020. Accessed at https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf
  12. Gotts JE, Jordt SE, McConnell R, Tarran R. What are the respiratory effects of e-cigarettes?. BMJ 2019 Sep 30;366.

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