This past week, the Centers for Disease Control (CDC) reported that a new initiative to curtail smoking rates could reduce the 400,000 annual U.S. tobacco related deaths. The core of the new initiative is a recommendation that states adopt tougher “tobacco control” programs. Click here for the CDC press release touting the report.
One small problem – the same CDC reported in November 2009 that U.S. smoking rates remained unchanged over the five year period between 2003 and 2008 despite states having received over $200 billion in tobacco control funding over the past decade. Click here for the CDC press release regarding the success rates of recent tobacco control programs.
We don’t disagree that stopping smoking is highly beneficial in terms of improving a person’s health and lowering overall health care costs, but it does seem rather wasteful to us to keep throwing money down a hole that has previously shown little return.
The classic assortment of methods employed by states to control tobacco distribution/use include taxing cigarette sales at high enough rates that it makes smoking a financially uncomfortable habit to continue, enacting smoke-free laws that limit/eliminate smoking in public places, limiting where and how often cigarettes can be marketed, investing in anti-smoking public service advertisements, and subsidizing smoking cessation programs for those who can’t afford to pay for such programs on their own. All of these are noble efforts but one wonders how successful they’ve been in reducing the number of people who smoke or the health care costs associated with tobacco use.
The CDC’s new report suggests that tightening the screws across all 50 states through more aggressive tobacco control programs will yield a breakthrough in smoking rates. They point to California as a success story example. The state of California has been one of the most aggressive states in employing tobacco control programs and has seen smoking rates fall from 23% of the adult population in 1988 to 13% in 2006. As a consequence, the CDC indicates that California has seen lung cancer rates decline at a substantially higher rate than other states.
That is indeed impressive, but if the overall level of smoking in the U.S. has remained unchanged over the past five years, California’s progress in recent years has either stalled or other states are experiencing offsetting increases in smoking rates - despite a significant increase in new tobacco control programs enacted in many states during that time period.
The gist of CDC’s position is that there is wide variability of enacted laws and money spent on tobacco control programs across the 50 states. If all states employed a higher/more aggressive set of tobacco control programs, the CDC is convinced smoking rates would decline and thereby cut tobacco related deaths and reduce overall healthcare costs.
But one has to ask - how realistic is it to assume a broad swath of states can afford to beef up their tobacco control program investments? Significant budgetary constraints already exist in most states due to the tenuous state of the U.S. economy and the recently enacted federal healthcare reform legislation imposes significant new healthcare cost obligations on most states that will dominate state funding agendas for an extended period of time.
Not mentioned in the CDC press release is the additional fact that commercial smoking cessation programs have terribly low success rates – another confounding circumstance impacting the ability of the medical community to lower smoking rates. The low levels of success among commercial smoking cessation programs and most state-funded tobacco control programs to reduce smoking rates points out the obvious – nicotine is a powerfully addictive substance and the habit of smoking is awfully difficult to break.
So what’s the solution then? In our view, it’s reframing the problem and then attacking the reframed problem from a different angle. The problem isn’t reducing smoking rates…the problem is improving the health status of our smokers.
From our perspective, if one refocused a good portion of the money and other resources spent on tobacco control programs and smoking cessation programs on a “healthy living for smokers” program patterned after the clinically affirmed therapy known as pulmonary rehabilitation, it is our bet that we would see lower healthcare costs, improved health status, and ultimately increased smoking cessation success among the U.S. smoking population.
To that end we ask whether it is a better pursuit to spend another $200 billion over the next ten years to reduce smoking rates by 2% (a level we’re betting the CDC would declare as good progress) or invest that same amount of money in opening up smoker access to pulmonary rehabilitation style programs?
If our 46 million smokers better understood the dramatic health benefits (i.e. improving physical conditioning, reducing shortness of breath, reducing hospital admissions, and improving quality of life) that accrue from an exercise program of moderate intensity tailored for those who have compromised respiratory function - would more than 2% be inclined to try one especially if they weren’t required to give up smoking as a prerequisite? We think so. And beyond these immediate health benefits there is evidence in recent studies that an active exercise program boosts smoking cessation program success rates. As a case in point, we refer you to our recent blog posting about a new research study supporting smoker access to pulmonary rehab: http://breathebetterblog.blogspot.com/2010/04/new-study-demonstrates-pulmonary-rehab.html
Look at it this way – if you took the $200 billion spent over the past decade on tobacco control programs and divided it by 46 million active U.S. smokers, it means that state & federal governments have spent approximately $4,350 per active smoker over that time period and achieved zero improvement in smoking rates.
By way of contrast, under recently improved Medicare reimbursement provisions, hospitals can achieve $50/hour reimbursement for up to 72 1-hour pulmonary rehab sessions per patient (sadly, Medicare and insurance reimbursement for pulmonary rehab is limited to moderate to severe COPD patients, and only 1-2% of COPD patients are admitted to pulmonary rehab programs annually). If the combined state and federal governments offered every active U.S. smoker access to a 24 week pulmonary rehab program (3 days/week, 1 hour per day) and reimbursed health care professionals at the same $50/hour Medicare reimbursement rate, the subsidized cost per smoker would be $3,600 and the overall subsidy would be $166 billion – nearly 20% lower than what has been spent on tobacco control programs over the past decade (a level, by the way, the CDC acknowledges was inadequate to reduce smoking rates in its November 2009 report). Now realistically not every U.S. smoker would be interested in such a program but we’re guessing more than 2% would – and we’re confident there would be a greater than zero return for those who did opt for pulmonary rehab given the three decades worth of published studies demonstrating its efficacy.
If one polled pulmonary rehab professionals and asked the question – do you think overall smoker health status and tobacco related healthcare costs would improve more from $200 billion additional investment in tobacco control programs over the next decade or from a $166 billion investment in an extended subsidized pulmonary rehab program for every U.S. smoker, we think you’d find a dominant majority would favor pulmonary rehab’s chances of delivering a more meaningful societal benefit.
Our position is that in order to achieve a breakthrough in improving the health of our smoking population, physicians and policymakers will have to do more than just ratchet up the intensity of “same old, same old” approaches. We believe offering active smokers subsidized access to pulmonary rehab (whether they give up smoking or not) is a novel approach worthy of serious investigation as a means of achieving improved health status among active smokers while at the same time lowering healthcare costs. And with all due respect to the CDC, we think it would cost far less than $200 billion and take less than a decade to prove it.
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