Reports of tobacco services received by smokers in nine large HMOs from across the nation found that clinician compliance with the national tobacco control guideline varied across the 5-A treatment model. While the majority of smokers were offered Advice, most were not offered the most effective Assist treatments. Only 41% were offered cessation classes or counseling, and only a third was offered pharmacotherapy. At the time of the surveys, the published HEDIS quality measure for health plan performance on tobacco control was the percentage of smokers receiving advice from their physician in the previous year. This may help explain the higher frequency of clinicians advising their patients about smoking compared with offering other cessation treatments. Yet, more recent HEDIS quality reports that include measurement of physicians’ discussion of smoking cessation medications and cessation strategies have shown only modest improvements.13
In addition, while all the study health plans provided comprehensive coverage for classes/counseling and pharmacotherapy for smoking cessation,15
physicians’ lack of understanding of their health plan’s coverage for tobacco treatment may have contributed to under-provision of these benefits to patients who smoked.21
In contrast to the other 5-A treatments, only an offer of pharmacotherapy was independently associated with increased cessation at the time of the 12-month follow-up. Yet, when smokers attended classes or participated in counseling they were almost twice as likely to report quitting. The effect sizes we found for the Assist treatments are similar to those published from reviews of efficacy trials. For classes/counseling, the OR of 1.8 compares with the ORs reported in the USPHS tobacco clinical guideline review7
(ORs ranging from 1.2 to 2.3) and reviews from The Cochrane Collaboration22–24
(ORs ranging from 1.6–2.1). For pharmacotherapy consisting of the transdermal nicotine patch and bupropion, our OR of 2.2 compares with of the range of 1.9 to 2.0 from the national tobacco guideline7
and 1.8 to 2.7 from Cochrane reviews.25,26
The US Surgeon General’s report, Reducing Tobacco Use, concluded the lack of progress in tobacco control is attributable more to the failure to implement proven strategies than it is about what to do.27
Increasing smokers’ participation in existing cessation treatments should be a tobacco control priority. The National Institutes of Health’s recent conference on tobacco identified effective strategies for health plans to create a sustained demand for cessation services, including media campaigns using brief, recurring messages to inform and motivate smokers to quit; outreach to smokers such as proactive counseling; informing smokers about their covered benefits for tobacco treatments; and incentives to clinicians.28
The low frequency of smokers who reported receiving an offer of a follow-up contact and, consequently, the few smokers who used this service make it difficult to evaluate the effectiveness of the Arrange component of the 5-A model. However, the absence of follow-up contacts may indicate the need for better systems to support clinicians in their tobacco control efforts. The National Cancer Institute’s initiative to promote systems thinking about tobacco control acknowledges the complexity of the problem.29
It seeks an integrated systems-based approach that includes multiple stakeholders and environmental factors with the goal of having administrators, clinicians, and staff working together to develop effective strategies to provide smokers with cessation interventions they will use. Most recently, the updated national clinical guideline for treating tobacco use and dependence emphasized the increasing evidence that health-care systems significantly affect the likelihood that smokers receive effective tobacco-dependence treatment.8
Finally, these results also point to the need for more efficacious treatments to help smokers quit. Even when smokers used the more effective tobacco cessation services, less than a fifth reported 30-day abstinence at follow-up. Culturally tailored, gender-specific, and language-appropriate programs may improve outcomes, as well as interventions that target populations with co-occurring comorbidities.28
In addition, the potential of combined pharmacotherapies and behavioral treatments, including interventions to improve medication compliance, has yet to be fully explored.
Strengths of this study include the prospective assessment of respondents’ smoking-related characteristics, the geographic diversity of the health plans, and large size of the sample. In addition, these results are responsive to the recent call for assessment of the 5-A treatment model in real world settings.8,30
Our findings are subject to the limitations of observational studies, which make it difficult to prove the causality of relationships. To minimize these limitations, we assessed smokers’characteristics at baseline, followed smoking status for 12 months, and adjusted results for important potential confounders.
Other limitations include potential biases if respondents were more interested in quitting and, thus, more likely to respond, recall, and report receipt and use of services. However, smokers who were offered services, but did not use them, may be less likely to report receipt of offers. The percentage of baseline survey respondents who reported current smoking was lower than the prevalence of smokers in the health plans; thus, under-reporting did occur. Respondents to the baseline survey under-represented men and probably younger and minority smokers.18
Only 65% of the smokers identified in the baseline survey returned a follow-up survey, and this may help explain the higher overall cessation rated found in this study compared with national annual estimates (8.9% vs 2.5%, respectively).31
Further, these results are based on reports from patients and do not reflect the perspective of clinicians or notations from the medical record. Of note, however, Patrick and colleagues found the overall validity of smoking self-reports is high, with sensitivity and specificity estimates of close to 90%, especially in observational studies.32
Separate analyses conducted in the HIT study health plans found notations of offers of the 5-As treatments in the medical record were substantially lower than reports from patients.33
Analyses do not include unmeasured factors such as provider34,35
characteristics. Finally, these results may not apply in other health-care settings, especially where cessation treatments are not covered benefits.