Government Relations Update
With the Obama administration poised to dramatically overhaul the U.S. health-care system, psychology is moving assertively to demonstrate its capacity to improve public health. Arguably one piece of that campaign should be reducing tobacco use—and opinion leaders agree. Most recently, a much anticipated report from the Robert Wood Johnson Foundation's Commission to Build a Healthier America called for the United States to become a smoke-free nation as one of its six priorities.
Consider the context: Tobacco use is the leading cause of preventable death in the United States. Each year, according to the Centers for Disease Control and Prevention, an estimated 438,000 Americans die prematurely from smoking or exposure to secondhand smoke, and another 8.6 million have serious illnesses caused by smoking. For every person who dies from smoking, 20 more people suffer from at least one serious tobacco-related illness.
Despite these risks, 45.3 million U.S. adults smoke cigarettes. Coupled with this enormous health toll is the significant economic burden of tobacco use—more than $96 billion a year in medical expenditures and another $97 billion a year in lost productivity.
Glimmers of hope
Politically, the stars may be aligning to raise awareness of tobacco use as the most pressing public health problem and build support for effective prevention and treatment strategies. President Barack Obama admits to being an on-and-off smoker and to using nicotine replacement therapies. Industry was dealt a blow late last year with the U.S. Supreme Court decision on "light" cigarettes—ruling that smokers can use state consumer protection laws to sue tobacco companies for deceptive marketing of "light" and "low-tar" cigarettes. Rep. Henry Waxman (D-Calif.), chair of the Energy and Commerce Committee, has ushered legislation through the House of Representatives that would give the Food and Drug Administration regulatory authority over tobacco. That law, among other things, would restrict tobacco advertising and promotions, especially to children, and require larger, more effective health warnings on tobacco packages and advertising. Joshua Sharfstein, MD, who authored the rationale for FDA regulatory authority as a Waxman staffer, has been nominated to serve as FDA Deputy Commissioner. William Corr, the former executive director of the Campaign for Tobacco Free Kids, has been nominated to serve as the deputy secretary for the Department of Health and Human Services. Psychologist and world renowned treatment researcher Tom McLellan, PhD, has been nominated to serve as deputy director of the White House Office of National Drug Control Policy, and there are hints that office will take a more aggressive approach to tobacco control as part of its demand reduction strategy.
Meanwhile, the National Institute on Drug Abuse is devoting significant research funding to achieve breakthroughs in smoking cessation.
"Our rationale is simple," says NIDA Director Nora Volkow, MD. "Tobacco addiction causes more morbidity and mortality than any other single disease. Reduction or elimination of smoking would yield tremendous health and economic benefits."
Psychologists making the difference
Psychological researchers, practitioners and APA, as the organization representing both, are uniquely positioned to reduce the public health burden of tobacco dependence. APA scientists took their seat at the table decades ago, evaluating the etiology of nicotine addiction; establishing effective prevention programs to reduce the initiation of tobacco use; developing effective psychosocial/behavioral therapies for those wanting to quit; and evaluating a range of pharmacotherapies as treatment adjuncts.
For the practice community, that last point is paramount. In the absence of prescription privileges, psychologists have at their disposal three formulations of a remarkably effective over-the-counter adjunctive pharmacotherapy: the nicotine patch, gum and lozenge. We know that most patients want to quit, that brief interventions can increase quit attempts and that it may take multiple quit attempts for patients to succeed. While many APA psychologists have contributed to that research and many psychologists already ask their patients about a range of unhealthy behaviors, what if every psychologist with tobacco-using patients engaged his or her clients in a discussion about the health benefits of discontinuing tobacco use? This past summer, with leadership and input from a who's who of the psychological science community, the Agency for Healthcare Research and Quality published "Treating Tobacco Use and Dependence: 2008 Update." Among the recommendations included in the guidelines:
• Clinicians, in their offices and in the hospital, should ask their patients if they smoke and offer counseling and other treatments to help them quit.
• If tobacco users are unwilling to attempt to quit, clinicians should use the motivational treatments that have been shown effective in promoting future attempts to quit.
• Individual, group and telephone counseling are effective, and their effectiveness increases with treatment intensity.
• Tobacco cessation treatments also are highly cost-effective relative to other clinical interventions. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication treatments that have been found to be effective.
• Counseling treatments have been shown to be effective for adolescent smokers and are now recommended.
Discussions about health-care reform in Washington will be focused on complex payment plans and implementation of health-information technology. But it may be that psychologists across the country can make the most valuable contribution to health-care reform by asking their patients two simple questions: 1) Do you use tobacco products? 2) Would you like to quit? (To learn how to continue that conversation, go to the Office of the Surgeon General.)
"With the spread of 'clean indoor' laws and the recent increases in tobacco taxes at the federal and state level, we know that there has been a surge of interest in quitting among smokers," says Robert Croyle, PhD, of the National Cancer Institute Division of Cancer Control and Population Sciences. "Practitioners can play a critical role in ensuring that a smoker's motivation to quit is supported by evidence-based treatments that will increase the probability of a successful quit attempt."
Geoff Mumford, PhD, directs APA's science government relations office.