Sirgeon General's Report

Research Group 1995a,b). Declines in smoking preva-
lence were no greater in program communities than
in control communities (COMMIT Research Group
1995b). Although the overall populations in the pro-
gram communities became more aware of available
resources for smoking cessation, the prevalence of
smoking cessation among persons who smoked more
than 25 cigarettes per day did not differ between pro-
gram (18.0 percent) and control communities (18.7
percent). Persons who smoked fewer than 25 cigarettes
per day were significantly more likely to quit in pro-
gram communities than in control communities (30.6
vs. 27.5 percent), and that result was attributable to
success among light smokers with less than a college
education (COMMIT Research Group 1995a).

Statewide Programs

Recent statewide initiatives have integrated to-
bacco policy and smoking cessation programs. Al-
though Minnesota was the first state to implement a
statewide initiative to reduce tobacco use, California
has provided what is perhaps the most ambitious ex-
ample. Massachusetts has also conducted a similar
statewide effort based on a tax increase and incorpo-
rating a mass media campaign, policy initiatives, and
smoking cessation services. These initiatives and oth-
ers are discussed in detail in Chapter 7.

The state findings are promising. If this success
is replicated by other states that adopt a dedicated in-
crease in cigarette excise taxes, or that are able to use
resources from settlements with the tobacco industry,

statewide and nationwide initiatives may play an
important role in achieving the public health goal of
reducing smoking prevalence among U.S. adults to less
than 12 percent by the year 2010 (USDHHS 2000).

Summary of Large-Scale Public Health Programs

Community- and media-based programs have
the potential to reach large numbers of smokers who
are reluctant to seek formal treatment. Such programs
could greatly influence smoking prevalence in the
United States. The results from major randomized tri-
als and community-based efforts are thus especially

_disappointing. Though these projects have set new

standards for such research and have produced nu-
merous ancillary results of interest, the overall con-
clusions suggest that even large-scale, well-funded
programs may have difficulty promoting changes in
smoking behavior. Similarly, the results to date from
numerous worksite cessation projects suggest either
no impact or a small net effect. On the other hand,
results of the California and Massachusetts initiatives
(see Chapter 7) suggest that tobacco taxes may be an
effective means of funding efforts to reduce tobacco
use. The states that have devoted money obtained
from Medicaid settlements with the tobacco industry
have also had considerable success in implementing a
comprehensive approach (Chapter 7). Their results
suggest that the disappointing outcomes from research
programs may be related to the reach and penetration
of these programs and the isolated context in which
they were conducted.

Contemporary Issues in Research on Tobacco Addiction

 

Epidemiologic Concerns and
Clinical Issues

Because smoking cessation research has focused
more on improving standard paradigms than on in-
novative approaches (Shitfman 1993b), much of the
current energy is directed to pursuing well-trod paths.
But current directions have an internal logic, because
no new paradigms loom large. Established approaches
are perhaps unfairly criticized for lacking innovation.
As the foregoing discussion demonstrated, valid meth-
ods for treating nicotine addiction are available, but

{28 Chapter 4

they must be better understood and can be improved.
Despite considerable research on smoking cessation
during the past 40 years, the essential elements or com-
bination of elements necessary for successful programs
are difficult to extract. In a number of key areas, how-
ever, careful research can sharpen interpretation of
existing results and provide direction for future inves-
tigation and perhaps even innovation.
Nicotine Dependence

Dependence, a central construct in research on
drug abuse, has been defined as “self-administration
of a psychoactive drug in a manner that demonstrates
that the drug controls or strongly influences behav-
ior” (USDHHS 1988, p. 248). Evidence strongly sug-
gests that most smokers are dependent on nicotine
(USDHHS 1988). However, most researchers agree that
individual smokers differ in the degree to which they
are dependent (Fagerstrém 1978; McMorrow and Foxx
1983; Pomerleau et al. 1983; Shiffman 1989: Killen et
al. 1992; Niaura et al. 1994). Some occasional smokers
may not meet the criteria for physical dependence
(Shiffman et al. 1991). These differences in degree of
nicotine dependence have important implications for
treatment and research.

Flaws in the assessment of nicotine dependence
have impeded progress toward understanding its role
in smoking cessation. For example, nicotine depen-
dence consists of both physical and behavioral com-
ponents (USDHHS 1988). However, most smoking
cessation researchers have used the term to refer to
physical dependence exclusively. Although items in
two widely used nicotine-dependence assessment in-
struments (the Fagerstro6m Tolerance Questionnaire
and its successor, the Fagerstrom Test for Nicotine De-
pendence) assess the extent to which nicotine controls
behavior, the instruments are intended to measure
physical dependence (Fagerstrém 1983; Fagerstrom
and Schneider 1989; Heatherton et al. 1991). Other in-
vestigators have measured dependence by how much
nicotine smokers typically self-administer (Hurt et al.
1994) or by the severity of withdrawal symptoms
(Brigham et al. 1990-91); these two measures are typi-
cally not highly correlated with each other, and nei-
ther is highly correlated with the Fagerstrom
questionnaires (Kenford et al. 1994), Furthermore, the
scales themselves, especially the Fagerstrom Tolerance
Questionnaire, suffer from psychometric limitations
(Lichtenstein and Mermelstein 1986; Pomerleau et al.
1989; Tate and Schmitz 1993). In sum, tobacco research
is hampered by an inadequate conceptualization of
nicotine dependence and an inadequate assessment of
the nicotine dependence construct.

Because widely used dependence instruments
such as the Fagerstrém questionnaire are thought to
measure physical dependence, it has been hypothesized
that they can help identify patients who would benefit
from nicotine replacement therapies (Fagerstrom and
Schneider 1989) or from higher doses of these thera-
pies. The evidence for this assertion is mixed, with
support somewhat more consistent for the nicotine

Reducing Tobacco Use

gum than for the nicotine patch (Abelin et al. 1989;
Fagerstr6m and Schneider 1989; Transdermal Nicotine
Study Group 1991; Killen et al. 1992; Kenford et al.
1994; Niaura et al. 1994; Tang et al. 1994). To the ex-
tent that current measures capture variation in depen-
dence, they would be expected to predict outcome in
trials not using nicotine replacement and in groups of
subjects treated with placebo nicotine replacement.
Although this hypothesized correlation between de-
pendence measures and outcome has been found in
several studies (Fagerstrém and Schneider 1989), the
correlations have tended to be weak (Gritz et al. 1991;
Kozlowski et al. 1994) and have usually been signifi-
cant only at relatively short-term follow-up points
(Hall and Killen 1985; Pinto et al. 1987; Gritz et al. 1991;
Norregaard et al. 1993). Specialized assessments of
nicotine dependence are not recommended in current
treatment guidelines, and pharmacotherapy is recom-
mended for all tobacco users interested in quitting. The
one exception is that highly dependent smokers may
derive more benefit from 4-mg (as compared with
2-mg) nicotine gum (Fiore et al. 2000).

Other measures of nicotine dependence have been
developed, but these have fared no better than the
Fagerstr6m questionnaire. For example, the Heaviness
of Smoking Index, a derivative, offers no advantage in
predicting cessation (Kozlowski et al. 1994). Older mea-
sures of smoking motives, such as the Horn-Waingrow
Reasons for Smoking Scale (Horn and Waingrow 1966)
and McKennell’s occasion for smoking scales
(McKennell 1970), have good psychometric properties
but questionable construct validity (Shiffman 1993a).

Continued reconceptualization of nicotine de-
pendence and improved consensus on mechanisms for
measuring it are critical issues for future study. Stron-
ger ties to generic issues of substance abuse—already
begun but not discussed in detail here (see Orleans
and Slade 1993)—can facilitate such research and im-
prove recognition of behavioral mechanisms that are
common to the use of all addictive substances.

Stages of Change

Smokers differ in their motivation to quit smok-
ing, and these differences are thought to affect treat-
ment prognosis. The transtheoretical model, advanced
by Prochaska and DiClemente (1983), provides a theo-
retical structure for assessing these differences and has
greatly influenced smoking cessation research in re-
cent years. Briefly, the model proposes that smokers
go through a series of stages (not necessarily linearly)
on the way to achieving prolonged abstinence from
smoking: not thinking seriously about quitting in the

Management of Nicotine Addiction 129
Surgcolt General's Report

next six months, thinking seriously about quitting in
the next six months, planning to quit in the next month,
actually trying to quit, and trying to remain abstinent.
If relapse occurs, smokers return to an earlier stage in
the model. It is hypothesized that smokers in the ini-
tial stages are less ready to quit and thus less likely to
profit from traditional treatments (see Orleans 1993 for
a more detailed discussion).

Some evidence supports the notion that smok-
ers in earlier stages of change fare worse in smoking
cessation than do smokers in later stages (DiClemente
et al. 1991; Kristeller et al. 1992; Ockene et al. 1992;
Rohren et al. 1994). The finding of interactions between
treatment assignment and stage membership
(Prochaska et al. 1993) has led to the recommendation
that clinical protocols for smoking cessation be based
on stage assessments (Abrams 1993; Orleans 1993;
Velicer et al. 1993; Hughes 1994).

Evidence is not available, however, that linking
motivational stage to a stage-appropriate strategy
leads to better outcomes than do nontailored interven-
tions of equal intensity (see Prochaska et al. 1993; Fiore
et al. 2000), perhaps because motivation to change is
more a continuum than a set of discrete states
(Lichtenstein et al. 1994). Nonetheless, the stages-of-
change model has considerable theoretical and empiri-
cal appeal as a typology that is easy to use in
day-to-day decision making (Wiggins 1988). Further
refinement and clarification of this model, coupled
with continued assessment of its relationship to smok-
ers’ probability of quitting, is a potentially fruitful re-
search area.

Negative Affect

A negative affective reaction to quitting tobacco
use (Baker et al. 1987; Brandon 1994; Hall et al. 1994)
may be an important predictor of relapse (Shiffman
1982; Brandon et al. 1990; Piasecki et al. 1997). As
mentioned previously, depressed persons are less
likely to quit smoking successfully than persons with-
outa history of depression (Glassman et al. 1988; Anda
et al. 1990), and depressed persons suffer an increase
in symptoms after quitting (Covey et al. 1990; Hall et
al. 1991). These related findings have special impor-
tance because the frequency of clinical depression
among smokers may exceed that among nonsmokers
(Frederick et al. 1988; Hall et al. 1991; Brandon 1994).

The role of adverse psychological states—even
mild conditions—in prolonging smoking and imped-
ing cessation is an important avenue for further in-
vestigation. For example, depressed or otherwise
affectively disturbed persons may require special

130 Chapter 4

interventions to succeed in smoking cessation; at least
two studies have identified behavioral treatments that
have boosted success rates among such persons
(Zelman et al. 1992; Hall et al. 1994). As noted, antide-
pressants and anxiolytics have been proposed as smok-
ing cessation aids and are undergoing clinical trials
because of their ability to ameliorate negative affects.

Sex-Specific Differences

Some studies (Pomerleau et al. 1991; Kenford et
al. 1993; Swan et al. 1993), but not all (Derby et al. 1994;
Whitlock et al. 1997; Gritz et al. 1998), have suggested
that women find it more difficult than men to quit
smoking. The quit ratio (the proportion of persons who
have quit smoking out of those who ever smoked) has
increased at the same rate or at a faster rate among
women than men in recent years (Fiore et al. 1989;
Giovino et al. 1994; Husten et al. 1996). An extensive
review of difference in nicotine effects between men
and women (Perkins et al. 1999) cites complex differ-
ences in psychological and biologic aspects in the main-
tenance of nicotine self-administration. Women may
differ from men in the response to withdrawal, possi-
bly mediated by menstrual cycle phase (Perkins et al.
2000), as well as a variety of nonnicotine effects (Perkins
et al. 1999). For example, although the same treatments
benefit both women and men, some treatments (e.g.,
nicotine replacement therapies) may be less efficacious
in women (Perkins 1996; Wetter et al. 1999; Fiore et al.
2000). Other reviews of this phenomenon (Fant et al.
1996; Christen and Christen 1998) confirm the need
for further exploration of such differences.

A further difference between men and women
may be related to genetic factors, particularly differ-
ences by sex in the metabolism of nicotine (Messina et
al. 1997; Tyndale et al. 1999). These studies have fo-
cused on differences in the roles of enzymes involved
in the metabolism of nicotine to cotinine (enzymes
CYP2A6 and CYP2D6). The considerable variability
in nicotine metabolism appears to be due to variable
expression of CYP2A6 (Messina et al. 1997) and may
play a role, as yet undefined, in gender response to
therapeutic modalities. Other researchers, using stud-
ies of twins, have postulated that genetic factors may
play a role in predicting which cigarette smokers
progress to long-term addiction, an effect that may be
stronger for men than for women (Heath et al. 1998).

Withdrawal Symptoms

The vast majority of smokers become physically
dependent on nicotine, and these persons commonly
display several withdrawal symptoms when deprived
of the substance (Shiffman and Jarvik 1976; USDHHS
1988; Hughes et al. 1991b). Conventional wisdom holds
that two persons who have different degrees of nico-
tine dependence will have different degrees of with-
drawal severity when they quit smoking (Fagerstrom
1978; Gritz et al. 1991; Hughes 1993). Withdrawal
symptoms are presumed to give a conflicting (and of-
ten canceling) motivation to people who have other-
wise been motivated to quit (West 1984; Hughes et al.
1991b). The severity of the withdrawal is thus expected
to be a strong predictor of eventual relapse (Gritz et al.
1991; West 1992; Hughes 1993). Some research sug-
gests that the various discomforts of abstinence are
valid indicators of eventual relapse (Baker et al. 1987;
Anda et al. 1990; Hughes 1992; Zelman et al. 1992).
Despite the intuitive appeal of this proposed associa-
tion, other studies have found an inconsistent relation-
ship between withdrawal severity and relapse (Hughes
et al. 1984; Hughes and Hatsukami 1986; Stitzer and
Gross 1988; West et al. 1989; Transdermal Nicotine
Study Group 1991; Prochazka et al. 1992; West 1992;
Hughes 1993). Interpretation of this literature remains
complicated because researchers use different instru-
ments to assess withdrawal, sometimes reporting total
withdrawal discomfort and other times reporting re-
sults on a symptom-by-symptom basis, and because
they assess symptomatology at different time points.
Improved assessment of withdrawal and consensual
definitions, coupled with epidemiologic assessment,
may better clarify the critical connection between the
withdrawal syndrome and the likelihood of relapse.
Recent studies demonstrate that there is considerable
between-subject variability in the time course of smok-
ing withdrawal and suggest that more consistent links
between withdrawal and relapse may be found if this
variability is systematically assessed (Piasecki et al.
1998).

Weight Gain

As noted earlier in the discussion of specific
modalities, weight gain is a common concomitant of
smoking cessation (Klesges et al. 1989). The average
smoker gains 5-10 pounds after cessation, and a small
percentage of smokers gain more than 25 pounds
(Klesges et al. 1989; Williamson et al. 1991). The con-
cern that smokers express about gaining weight may
be great enough to prevent them from attempting to
quit (Klesges et al. 1988; Gritz et al. 1989; French et al.
1992). Similarly, persons who quit smoking and who
do subsequently gain weight may be more likely to
relapse (Wack and Rodin 1982; Hall et al. 1986). Two

Reducing Tobacco Use

prospective studies, however, found that concern
about weight did not predict cessation success (French
et al. 1995; Jeffery et al. 1997). Innovative strategies
have failed to reduce weight gain or to improve absti-
nence rates among persons concerned about gaining
weight (Hall et al. 1992; Pirie et al. 1992). Because
weight change is a complex metabolic phenomenon
(about which there is a considerable epidemiologic and
biologic literature, not reviewed here) that is subject
to the interplay of behavioral and pharmacologic in-
fluences, further research on the behavior and physi-
ological mechanisms that produce postcessation
weight gain may suggest new strategies for dealing
with this problem and may provide insights into
mechanisms of addiction.

Early Relapse

Three recent reports from four trials of the nico-
tine patch have found that any smoking during the
first two weeks of using either the nicotine or the pla-
cebo patch is a strong predictor of relapse at long-term
follow-up (Hurt et al. 1994; Kenford et al. 1994;
Stapleton et al. 1995). For example, Kenford and col-
leagues (1994) analyzed data from two patch trials. In
both trials, large proportions (97.1 and 83.3 percent)
of patients treated with the nicotine patch who smoked
during the second week of treatment had relapsed by
the six-month follow-up. Early relapse may predict
longer-term failure—regardless of the cessation strat-
egy, if any—because physiological and behavioral
forces may present their most significant challenges
to smokers during the first two weeks they try to quit.
Strategies that could shepherd smokers through the
first two weeks without a single cigarette might be
expected to improve treatment outcome. According
to another view, most lapses during the first two weeks
of treatment merely identify those smokers who will
find it difficult to quit no matter what the interven-
tion. Even if given adjunctive interventions to help
them pass this two-week period without smoking,
these smokers would be expected to relapse soon af-
ter these adjuncts were withdrawn. Research on treat-
ments for persons who are strongly addicted and likely
to relapse early (should they attempt cessation at all)
is a great challenge for cessation research.

Dose-Response

More intense interventions yield better outcomes
(Kottke et al. 1988; Lichtenstein and Glasgow 1992;
Fiore et al. 1994c, 2000). Although this general rela-
tionship has not been precisely explained, outcomes

Management of Nicotine Addiction 131
Surgeon General's Report

may be influenced by a host of structural factors, in-
cluding session length, session frequency, total num-
ber of sessions, and number and types of treatment
modalities (e.g., telephone contacts and individual vs.
group formats).

More specific issues must be clarified, such as
determining what level of adjuvant behavioral sup-
port is most cost-effective when used with pharmaco-
therapy. However, a central question surrounding the
use of intensive interventions is whether a greater pro-
portion of smokers can be motivated to enroll in such
treatment. Debate over whether program refinements
can improve outcomes may be moot, from a public
health perspective, if most smokers continue to shy
away from—or cannot afford to spend the time or
money needed for—intensive interventions (Fiore et
al. 1990; Lichtenstein and Hollis 1992). A final area for
dose-response research concerns the optimal dose for
nicotine replacement. Two recent studies (Jorenby et
al. 1995b; Hughes et al. 1999) have found that dou-
bling the normal patch dose does not improve cessa-
tion outcomes. There may be some benefit, however,
to combining different smoking cessation pharmaco-
therapies (Blondal et al. 1999; Jorenby et al. 1999), in-
cluding two different nicotine pharmacotherapies
(Fiore et al. 2000).

Treatment Components

Defining the individual impact of treatment com-
ponents will require controlled trials that systemati-
cally manipulate individual treatment components
against a background of constant treatment intensity.
As Lichtenstein and Glasgow (1992) have noted, smok-
ing cessation researchers have largely abandoned this
line of research because most comparison studies
(though not all; see Stevens and Hollis 1989) failed to
find significant treatment effects. Nonetheless, until
the combined effects of treatment components can be
determined, empirical design of multicomponent treat-
ments will be difficult.

Individualized Treatment

Investigators have become increasingly inter-
ested in seeking interactions between treatment con-
tent and smokers’ characteristics. Identifying such
interactions would allow individual smokers to be
given specific interventions to maximize their chances
of attaining long-term abstinence. Although subject-
by-treatment interactions have been obtained (Zelman

132 Chapter 4

et al. 1992; Niaura et al. 1994), these relationships re-
main too elusive to suggest an overall strategic theory.
Research that incorporates unconfounded compari-
sons of specific ingredients may suggest algorithms
for matching patient and treatment. In view of the
increasing presence of the computer in many people’s
lives, computer-assisted tailored treatments warrant
further exploration. Some tailoring and individual-
ization may be appropriate for older smokers whose
other medical problems and pharmacologic treatment
must be given special consideration (Rimer and Or-
leans 1993). Currently, however, there is insufficient
evidence to recommend individually tailored interven-
tions (Fiore et al. 2000).

Analternative to treatment matching is the strat-
egy of offering smokers increasingly more intensive
treatments as they continue to have trouble quitting
(Abrams 1993; Orleans 1993), despite the risk that this
strategy will reinforce failure. There is insufficient
evidence, however, to recommend sucha stepped-care
approach (Fiore et al. 2000). Research must first re-
veal hierarchies of treatment as well as determine when
patients should be given more intensive interventions.

Dissemination and the Role of the Clinician

Because self-help and minimal clinical interven-
tions are likely to continue to be the preferred method
of cessation for most smokers, innovative strategies
must be developed to improve efficacy and delivery
(Cohen et al. 1989b; Orleans et al. 1991; Fiore et al.
1995). Some of the most effective of the minimal clini-
cal interventions include the institutionalization of
system changes as core components of health care
(Glynn and Manley 1993; Fiore et al. 2000). For ex-
ample, having a screening system in place to identify
smokers triples clinician intervention (Fiore et al. 2000).

Dissemination is intimately tied to the willing-
ness of clinicians to advise their patients about smok-
ing. An important area for ongoing research is the
investigation of strategies that foster this behavioral
role not only among physicians but also among a broad
range of health care providers, including dentists,
nurses, pharmacists, chiropractors, psychologists, phy-
sician assistants, and pulmonary technicians. But it is
unlikely that behavioral modification for clinicians
would be sufficient to produce the required dissemi-
nation. Reimbursement policies, financial incentives,
and underlying institutional support are all critical for
the effective management of tobacco addiction through
clinical interventions (Kaplan et al. 1995; Rothenberg
et al. 1998).
Cost-Effectiveness

Ultimately, the test of clinical modalities for treat-
ment of nicotine addiction will be their survival in the
current environment of cost containment and managed
care. Private insurers are unlikely to embrace such treat-
ment unless “they are convinced that there is a market
for such a product and that it is viable financially”
(Schauffler and Parkinson 1993, p. 189). For public in-
surers, demonstration of cost-effectiveness has become
the de facto standard for adoption of new technology
(G. Wilensky, cited in Schauffler and Parkinson 1993,
reference 17), though some may insist on cost-savings,
a strict standard of proof, for preventive practices.

Smoking cessation has been called the “gold stan-
dard” of cost-effective interventions (Eddy 1992). A
number of studies (and several reviews [Elixhauser
1990; CDC 1992; Tsevat 1992]) have addressed issues
of cost-effectiveness in behavioral counseling.
Cummings and colleagues (1989c) calculated that the
cost-effectiveness of brief office counseling during a
routine visit ranges from $705 to $988 per year of life
saved for men and from $1,204 to $2,058 for women.
The use of nicotine gum increases the cost-effectiveness
fourfold. Oster and colleagues (1986) performed a
similar study incorporating nicotine gum with brief
office counseling. The costs per year of life saved
ranged from $4,113 to $6,465 for men and from $6,880
to $9,473 for women. Both studies noted that these costs
compare favorably with those derived for other widely
accepted preventive practices. Altman and colleagues
(1987) found that self-help materials cost $22-144 per
person who quit, a cessation contest costs $129-239, and
a cessation class costs $235-399. In the setting of acute
myocardial infarction, Krumholtz and colleagues
(1993) concluded that a nurse-managed smoking
cessation program after myocardial infarction was
cost-effective, particularly when compared with other
modalities. (These studies are not necessarily reported
in standardized dollars.and are then only roughly com-
parable.)

An analysis of the cost-effectiveness of imple-
menting the 1996 Agency for Health Care Policy and
Research-sponsored Clinical Practice Guideline Smok-
ing Cessation reported that cost per quality-adjusted-
life-year saved ranged from $1,108 to $4,542. This
compares very favorably with $61,744 for annual mam-
mography for women aged 40-49 years and $23,335
for hypertension screening in 40-year-old men (Crom-
well et al. 1997).

Because smoking during pregnancy is associated
with lower birth weight, which in turn has been linked
to various adverse outcomes of pregnancy, cessation of

Reducing Tobacco Use

smoking in pregnancy has been the subject of a num-
ber of economic analyses. Several of these have been
performed in a managed care setting. Using patients
in a study performed by the Maxicare Research and
Educational Foundation, Ershoff and colleagues (1990)
weighed the intervention’s programmatic costs against
the smoking-related increased costs of medical care in-
curred by mothers who continue smoking and by their
infants. The program consisted of an initial interview,
smoking counseling by a health educator, and a series
of self-help books mailed to participants. The nonsmok-
ing message was reinforced at prenatal care visits. The
investigators concluded that in a health maintenance
organization of 100,000 members, the cost savings from
the cessation program was $13,432, the net benefit was
$9,202, and the benefit-to-cost ratio was 3.17:1.

Windsor and colleagues (1988) compared three
cessation protocols for women in public health mater-
nity clinics: standard care, standard care combined
with use of a cessation manual developed by the Ameri-
can Lung Association, and standard care combined
with the use of that manual and a pregnancy-specific
manual. At the end of pregnancy, smoking cessation
had been achieved by 2 percent, 6 percent, and 14 per-
cent, respectively, of women in the three groups. The
investigators calculated cost-effectiveness as the cost
per patient divided by the percentage who quit. The
respective values were $104.00, $118.83, and $50.93. In
a second study (Windsor et al. 1993), the treatment
group in a multicomponent intervention involving
counseling and support had a cessation rate of 14.3
percent, and the control group had a rate of 8.5 per-
cent. Under varying assumptions, the economic analy-
sis found that benefit-to-cost ratios ranged from 6.72:1
to 17.18:1 and that estimated savings from statewide
use of the program ranged from $247,296 to $699,240.

Marks and colleagues (1990) estimated the ben-
efits that would accrue from shifting low-birth-weight
infants into the normal-birth-weight category, from
averting deaths attributable to prematurity, and from
avoiding the long-term costs associated with the care
of premature infants. They concluded that the ratio of
savings to costs would be as high as 6:1. If long-term
costs were omitted, the ratio would still be $3.31 for
each $1 spent. Finally, in a somewhat different ap-
proach to the problem, Shipp and colleagues (1992)
tried to identify the break-even point for the cost of a
smoking cessation program. Under general circum-
stances, the break-even cost was $32 per pregnant
woman, but this cost varied from $10 to $237, depend-
ing on the probability of adverse outcomes in various
populations.

Management of Nicotine Addiction 133
Surgeon General's Report

As Schauffler and Parkinson (1993) point out,
economic analyses of smoking cessation are often
based on hypothetical populations, start with differ-
ent assumptions about prevalence and intervention
effectiveness, and differ in their estimation of out-
comes. Although initial results are encouraging, con-
siderable work is needed to codify the results and make
them appealing to insurers and employers. In a re-
cent survey, only 8.6 percent of large corporations in
California had even considered using smoking status
in their risk ratings, and only 2.2 percent had imple-
mented such a rating. About 20 percent of companies
offered plans that covered smoking cessation services
(Schauffler and Parkinson 1993). Perhaps observations
comparing long-term hospitalized care of smokers and
nonsmokers will alter this policy. A recent study esti-
mated that helping one smoker to quit reduces antici-
pated medical costs associated with acute myocardial
infarction and stroke by $893 over seven years
(Lightwood and Glantz 1997). Wagner and colleagues
(1995) point out that smokers have consistently

Conclusions

increasing rates of hospitalization over five to six
years of follow-up. In contrast, smokers who quit
have increased hospitalization during the year in
which they quit (probably associated with the medi-
cal reason—e.g., emphysema—for quitting in many
cases); this rate declines thereafter. The authors note
that the cost savings that accrue from reduced utili-
zation would more than pay for effective cessation
interventions within three to four years.

The alteration of terminology—from “smoking
cessation” to “treatment of nicotine dependence” —
acknowledges the need to make cessation activity con-
sonant both with modern medical practice and with
the current climate for health care delivery. The cur-
rent body of evidence suggests that efficacious and
cost-effective therapeutic modalities are available and
that such consonance can be achieved. Further inves-
tigation not only of theoretical cost-effectiveness but
also of actual use-effectiveness will have considerable
impact on institutionalizing the treatment of nicotine
addiction.

 

1. Tobacco dependence is best viewed as a chronic
disease with remission and relapse. Even though
both minimal and intensive interventions in-
crease smoking cessation, most people who quit
smoking with the aid of such interventions will
eventually relapse and may require repeated at-
tempts before achieving long-term abstinence.
Moreover, there is little understanding of how
such treatments produce their therapeutic effects.

2. There is mixed evidence that self-help manuals
are an efficacious aid to smoking cessation. Be-
cause these materials can be widely distributed,
such strategies may have a significant public
health impact and warrant further investigation.

13-4 Chapter 4

3. Programs using advice and counseling—whether
minimal or more intensive—have helped a sub-
stantial proportion of people quit smoking.

4. The success of counseling and advice increases
with the intensity of the program and may be im-
proved by increasing the frequency and duration
of contact.

5. The evidence is strong and consistent that phar-
macologic treatments for smoking cessation
(nicotine replacement therapies and bupropion,
in particular) can help people quit smoking.
Clonidine and nortriptylene may have some util-
ity as second-line treatments for smoking cessa-
tion, although they have not been approved by
the FDA for this indication.
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