Supplementing US framework for smoking cessation
August 18, 2023
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.
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.
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
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”.9 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
- 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
-
(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
-
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.
-
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
-
Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. Ca
Cancer J Clin. 2023 Jan 1;73(1):17-48.
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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
-
2012 Task Force on Community Preventive Services review on Quitline
Interventions.
https://www.thecommunityguide.org/sites/default/files/assets/Tobacco-Quitlines.pdf.
-
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.
-
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
-
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-.
- 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
- Gotts JE, Jordt SE, McConnell R, Tarran R. What are the respiratory
effects of e-cigarettes?. BMJ 2019 Sep 30;366.