The MSSP is the first large-scale demonstration to test the effectiveness of three variations of a Medicare smoking cessation benefit in real-world settings. Each treatment significantly outperformed the Usual Care intervention by 12 months, and increasingly intensive treatments significantly outperformed less-intensive treatments, with the Quitline producing the highest quit rates. At the inception of the study, it was unclear whether any one evidence-based intervention would outperform another. The results here are somewhat mixed, with the Provider Counseling arm failing to outperform Usual Care at 6 months, but not at 12 months, and the Provider Counseling + Pharmacotherapy arm outperforming the Provider Counseling arm at 6 months but not 12 months. Unequivocally, however, the Quitline arm outperformed all other treatment arms at both follow-up intervals. Rates of confirmed smoking cessation in the MSSP compared favorably with quit rates in the general population and were higher than expected for older adults. Further, differences across treatment arms were robust to a broad set of covariates and survey nonresponse.
Although quit rates were highest in the Quitline, physician counseling alone or in conjunction with Pharmacotherapy was more cost-effective. The fact that Provider Counseling, which had the lowest quit rate among the three active interventions, was in some cases the most cost-effective treatment is not surprising. Interventions that are more resource intensive are typically more effective than less resource intensive programs, but the costs of the former tend to be proportionally higher than those of the latter (Warner 1997
). Different approaches to smoking cessation may be more or less effective (and cost-effective) for different groups or people. Seniors who successfully quit smoking while using high-intensity interventions such as physician counseling with NRT may not be successful with low-intensity interventions. The search for the single most effective or cost-effective intervention may be misguided, for it presumes that all smokers have similar preferences in choosing a cessation method.
An important question is how our results generalize to the Medicare population given that enrollees in the MSSP were more motivated to quit smoking than the average Medicare-eligible smoker. Absolute quit rates at 12 months were 10 percent in Usual Care, 14–16 percent in the physician counseling arms, and 19 percent in the telephone Quitline. This suggests that providing coverage for cessation services would increase quit rates by 50–100 percent among older smokers motivated to quit, depending on the type of service.
The majority of Quitline participants had five or more contacts with a counselor. The Quitline counselors delivered a structured intervention tailored to both senior smokers in general and to the individual smoker's circumstances in particular. In addition to greater frequency of counseling received in this arm compared with the Provider Counseling arms, the intervention included support in the proper use of the nicotine patch and dealing with side effects. Thus, it is not surprising that this highly structured, proactive, and individualized counseling experience, when combined with the opportunity to use low-cost nicotine patches, produced superior outcomes.
A larger increase in cessation was observed when participants were also given the opportunity to use Pharmacotherapy at minimal cost. This is consistent with meta-analytic studies, which have shown that use of the nicotine patch or bupropion significantly increases quit rates compared with placebo or minimal treatment (Fiore et al. 1996
; Hurt et al. 1997
; Jorenby et al. 1999
). This study is one of the few to directly manipulate the addition of Pharmacotherapy to behavioral treatment, and the results support the assertion that the addition is beneficial. Hughes et al. (2003)
proposed several hypotheses by which behavioral and pharmacologic treatments might combine to increase efficacy, including: (1) Pharmacologic treatment provides relief of withdrawal early on and provides the necessary bridge through the most difficult period, whereas behavioral treatment provides skills necessary to prevent relapse subsequently, (2) behavioral skills may be specifically helpful for a subset of smokers, whereas pharmacologic treatment helps another subset, and (3) one treatment may increase compliance with the other.
There are two justifications for offering cessation services through health care providers. First, the vast majority of older smokers have contact with a physician each year, with multiple occasions to provide cessation interventions (USDHHS 1994
). Second, smokers who receive even brief clinical interventions demonstrate significantly increased cessation rates compared with those who receive no advice, and there is a dose-dependent relationship between the intensity of person-to-person contact and successful cessation outcome (Fiore et al. 1996
). One disadvantage of a provider-based intervention is that clinicians do not take full advantage of opportunities to intervene with their patients who smoke. Only about half of current smokers report that their physicians have either asked them about smoking or advised them to quit (Goldstein et al. 1997
). Providing adequate reimbursement for counseling services would remove an important barrier, but can substantially increase the costs of the program (Niaura and Abrams 2002
A national telephone Quitline provides a single access point for smokers and has been shown to be effective. One disadvantage of a telephone Quitline is that treatment must be initiated by the beneficiary. One can, however, envision systems where health care providers refer their smoking patients to a free national Quitline while providing them with pharmacologic assistance, if warranted.
Our analysis has several limitations. Most prominent was low enrollment in southeast Florida. While enrollees differed across intervention arms in a statistical sense with regard to race, education, income, lifetime quit attempts, and stages of change, the differences were modest in absolute terms. Further, we controlled for these factors in multivariate models and included binary indicators for each state. The fact that the unadjusted and adjusted quit rates were nearly identical provides strong evidence that the randomization process worked despite the enrollment problem in southeast Florida. Second, we did not know the number of counseling sessions received in the Provider Counseling arms nor the quality of the advice. The initial 6-month survey asked participants about the number of Provider Counseling visits. However, to increase response rates, shortened versions of the follow-up surveys were sent to those who did not initially respond. The short-form surveys only asked participants whether they had tried any of the methods listed, and if they did, whether that particular quit method was offered as part of the MSSP.
Finally, self-reported measures were likely to underestimate actual use of counseling services as participants may not recall whether counseling occurred, how counseling was reimbursed, or what constitutes counseling. Thus, we may underestimate the costs of providing coverage for cessation counseling by providers.
In 2005, Medicare began covering cessation counseling for beneficiaries diagnosed with a smoking-related illness or who were taking medications complicated by tobacco use. Further, the Department of Health and Human Services recently launched a national telephone Quitline for all smokers in the Unites States. The results of this study suggest that a fully integrated benefit structured around low-cost Pharmacotherapy in conjunction with available free Quitline services would substantially reduce the prevalence of smoking and smoking-related illness among elderly beneficiaries motivated to quit, at a relatively modest cost. Future work should examine the reduction in medical costs associated with cessation among older smokers to assess how coverage of these services affects total Medicare outlays.