Tobacco Cessation: Guidance on Establishing Programs Designed to Help Employees Stop Using Tobacco
Table of Contents
Guidance on Establishing Programs Designed to Help Employees Stop Using Tobacco
Section I: Funding Tobacco Cessation Programs
- Introduction
- Use of Appropriated Funds for Tobacco Cessation Programs
- Nicotine Replacement Therapy as Part of an Agency's Program
- Relationship to Health Insurance Reimbursements
Section II: Guidelines for the Development of Effective Agency Tobacco Cessation Programs
Section III: Resources and Information on Tobacco Cessation Programs
Section I: Funding Tobacco Cessation Programs
Introduction
The U.S. Office of Personnel Management supports and encourages agency authorized programs aimed at health promotion and disease prevention, including smoking cessation programs. According to reports issued by the Surgeon General, smoking is the chief avoidable cause of death in our society. Programs designed to help employees stop using tobacco are not only in the best health interests of those Federal employees who are tobacco users, data from the Centers for Disease Control and Prevention (CDC) indicate that tobacco cessation may also contribute to improved organizational performance and productivity.
The purpose of these guidelines is to assist agencies in the development of tobacco cessation programs, including those which provide, as one element, pharmacotherapy (such as a nicotine replacement therapy (NRT), i.e., the nicotine patch or nicotine gum).
Use of Appropriated Funds for Tobacco Cessation Programs
A decision by the Comptroller General of the United States (B-231543 dated February 3, 1989) held that under 5 U.S.C. § 7901, Federal agencies have the authority to utilize appropriated funds to pay the costs incurred by employees participating in agency-sponsored smoking cessation programs. The decision held that because smoking is a major contributing cause of illnesses such as cancer, coronary disease and emphysema, smoking cessation programs are "preventive" in nature and authorized under 5 USC § 7901(c)(4).
Agencies may wish to develop their own in-house programs or contract with program providers (see section II, A Checklist for Assessing a Group Cessation Program). Such programs usually include: (1) educational materials; (2) classroom training; (3) individual and/or group counseling; and/or (4) pharmacologic therapy (such as nicotine replacement therapy).
Pharmacotherapy as a Part of an Agency's Program
Since appropriated funds may be used to pay for the provision of pharmacologic treatment and the costs of over-the-counter nicotine replacement therapy (such as the nicotine patch or nicotine gum), the following guidance is provided to assist program administrators:
Agency Purchase: Agencies that desire to provide their employees with nicotine replacement therapies, as part of an agency's smoking cessation program, should acquire those items in accordance with the regulatory and statutory provisions contained in the Federal Acquisition Regulation and all internal agency guidelines for the expenditure of appropriated funds. Agencies may also wish to contract with tobacco cessation program providers which include, as part of their program, nicotine replacement therapy.
Agencies may also purchase nicotine replacement therapy for employees who wish to quit using tobacco but who do not wish to attend formal classroom sessions sponsored by the agency. In this instance, agencies should offer employees on-site or telephone counseling services. Such counseling services, however, should not be made mandatory. Employees requesting agency purchase of nicotine replacement therapy in such circumstances should be considered as participating in the agency's smoking cessation program.
Employee Requests: When requesting the agency purchases a nicotine replacement therapy, as part of an agency's program, employees should provide program administrators (e.g., health unit physician, nurse, or Employee Assistance Program counselor) with a written request. Such a request would be appropriate regardless of whether the employee is participating in an on-site classroom program or in a self-initiated process.
Relationship to Health Insurance Reimbursements
The following information is provided for the benefit of employees who elect to participate in tobacco cessation programs other than agency-sponsored programs on-site. While agencies would not pay for the cost of registration for such programs, employees should be aware that they can seek insurance plan reimbursement (up to the amount covered in their health benefits plan). In these instances, however, employees may request agency purchase of pharmacologic treatment such as nicotine replacement therapy if such therapy were in addition to the program registration cost. These employees would be considered as participating in the agency's program.
Under the Federal Employee Health Benefits (FEHB) programs, a number of insurance plans cover some costs associated with smoking cessation. Federal employees need to refer to their plan brochure for specific coverage information (by reviewing your plan's coverage and selecting "current plan brochures").
FEHB carriers are encouraged to provide benefits for smoking cessation that follow the Public Health Service's treatment guidelines. Consistent with these guidelines, primary care visits for tobacco cessation should be covered with the standard office visit co-payment. Individual or group counseling for tobacco cessation should be covered with no co-payment. Prescriptions for all Food and Drug Administration approved medications for treatment of tobacco use should be covered with the usual pharmacy co-payments.
Benefits vary by carrier. For example, a carrier might offer coverage for smoking cessation programs for either $100 lifetime maximum benefit per member or one course of treatment per member per calendar year. The Prescription Drugs Benefits section of each plan's brochure specifies whether drugs to aid in smoking cessation are covered or excluded.
Section II: Guidelines for the Development of Effective Agency Tobacco Cessation Programs
Background
The Public Health Service (PHS), of the U.S. Department of Health and Human Services is a leading entity addressing tobacco cessation. In 2000, the PHS released Treating Tobacco Use and Dependence , a PHS-sponsored Clinical Practice Guideline, an update of the 1996 Smoking Cessation Clinical Practice Guideline . A comparison of the findings of the year 2000 guideline with the earlier 1996 guideline indicates that considerable progress was made in tobacco research over the brief period separating these two publications. Among the myriad of important differences between the two documents, the following deserve special note:
The PHS Guideline has produced even stronger evidence of the association between counseling intensity and successful treatment outcomes, as well as identified additional evidence-based counseling strategies such as telephone quit lines.
The PHS Guideline offers the clinician many more efficacious pharmacological treatment strategies than its predecessor.
The PHS Guideline includes strong evidence that smoking cessation treatments shown to be efficacious (both pharmacotherapy and counseling) are relatively cost-effective.
Like its predecessor, the PHS Guideline includes a rigorous systematic review of the evidence performed by a private-sector panel of experts who employed an explicit, science-based methodology and expert clinical judgment to develop recommendations on the treatment of tobacco use and dependence.
The PHS Guideline was developed by a consortium of Federal Government and nonprofit organizations comprised of the Agency for Healthcare Research and Quality; Centers for Disease Control and Prevention; National Cancer Institute; National Heart, Lung, and Blood Institute; National Institute on Drug Abuse; Robert Wood Johnson Foundation; and University of Wisconsin Medical School's Center for Tobacco Research and Intervention.
Much of the following information can be found in the Clinician's Packet, a comprehensive PHS Guideline spin-off tool, featuring a wide array of evidence-based materials designed to encourage clinicians to help their patients quit using tobacco and adopt healthier lifestyles.
Whether agency-developed programs are administered internally (e.g., by a coordinated effort involving the agency's Health Unit and the Employee Assistance Program counselors) or externally (by contracting with tobacco cessation program providers), agencies are urged to follow these PHS Guideline recommendations in the development of their programs.
Program Development Recommendations
Assess the Smoker who has Entered a Program
Assess whether participants in tobacco cessation programs are motivated to quit using an intensive program. Specialists may also conduct other assessments that can provide information useful in counseling. For example, such assessments may reveal the presence of high stress levels caused by other issues in a tobacco user's life or may reveal the presence of other psychological or medical conditions that will affect success in quitting.
Use a Variety of Clinicians
Many different types of providers (physicians, nurses, dentists, psychologists, pharmacists, etc.) are effective in increasing rates of tobacco cessation, and involving multiple types of providers may enhance abstinence rates. Given that so many tobacco users visit a health care setting at some point, it is important that clinicians be prepared to intervene with tobacco users who are willing to quit.
The five major interventional steps (the "5As" ) to be used by providers in the health care setting are Ask, Advise, Assess, Assist , and Arrange . One strategy would be to have a medical/health care clinician deliver messages about health risks and benefits, and nonmedical clinicians deliver psychological or behavioral interventions.
Ensure that the Program is Intensive Enough
Individual or group counseling programs are helpful. The PHS guidelines expert panel found a strong dose-response relationship between counseling intensity and cessation success. The following elements are recommended:
Session length - longer than 10 minutes
Number of sessions - 4 or more sessions
Total contact time - longer than 30 minutes
Use a Variety of Program Formats
While individual or group counseling is effective, proactive telephone counseling is also effective and tobacco users are more likely to use this format. Use of educational or self-help materials is an option for employees who don't wish to participate in counseling but this intervention may not be as effective as counseling. Follow-up assessment procedures should be used in any intervention.
Include Effective Counseling Techniques
Interventions should include problem solving/skill training content as well as clinician-delivered social support for quitting. For example, common elements of problem solving/skills-training treatments would be:
- recognition of danger situations (e.g., being around other smokers, being under time pressure, getting into an argument, experiencing urges or negative moods, or drinking alcohol);
- development of coping skills (e.g., learning to anticipate and avoid danger situations, learning cognitive strategies that will reduce negative moods, accomplishing lifestyle changes that reduce stress, improve quality of life, or produce pleasure); and
- understanding basic information about quitting (e.g., the nature/timeframe of withdrawal, the addictive nature of smoking, or the fact that any smoking, even a single puff, increases the likelihood of full relapse).
Common elements of supportive smoking cessation treatments would be:
- encourage the participant in the quit attempt;
- communicate caring and concern;
- encourage the participant to talk about the quitting process; and
- provide basic information about smoking and successful quitting. Social support during treatment can also be effective.
Provide Relapse Prevention Intervention
Most relapses occur soon after a person quits, although some people relapse months or years after the quit date. Therefore, specialists should work to prevent long-term risks of relapse. These interventions can occur during treatment sessions or during follow-up contacts and should:
- reinforce the employee's decision to quit;
- review the benefits of quitting; and
- assist in resolving any problems related to quitting.
Include Pharmacotherapy (Medications)
The use of pharmacotherapy is a key part of a multicomponent approach to assisting patients with their tobacco dependence.
All tobacco users trying to quit should receive pharmacotherapy, except in the presence of special medical circumstances. The guideline panel identified six first-line medications, including the five nicotine replacement therapies: the nicotine patch, nicotine gum, nicotine lozenge, nicotine nasal spray, and the nicotine inhaler; and one non-nicotine medication: bupropion SR. Each has been shown to significantly increase the rates of long-term abstinence.
A Checklist for Assessing a Group Cessation Program
NOTE: Providers should be carefully screened before contracting for their services or referring employees. The following checklist, provided by the Office on Smoking and Health of the U.S. Department of Health and Human Services, can be used for screening such services.
- How long has the organization been in existence? How long has it been providing tobacco cessation programs?
- How many people have gone through the program?
- Will the approach be appropriate for the employee?
- What methods are used to help tobacco users quit?
- How is maintaining abstinence addressed?
- What resources are provided to help promote the program among agency employees and stimulate participation?
- Have others been satisfied with the program?
- Will they provide a list of clients, especially other Federal agencies?
- Will they provide references so that satisfaction and success rates can be checked?
- What are the qualifications of the instructors? What training have they received? What is their cessation counseling experience?
- Are printed materials appropriate for the educational level of the employees? Are they attractive and motivational?
- Will the structure of the program accommodate the needs of employees? That is, can they:
- accommodate all shifts?
- provide on-site and off-site programs?
- structure flexible program formats?
- provide audio or visual equipment?
- Is the program provider willing to provide ongoing assistance and follow-up once the formal program ends?
- Does the program incorporate participants' support systems? For example, peers and family members?
- Does the program offer any form of guarantee? For example, can employees repeat the program for free or at a lower cost?
- Can the program provider provide evidence of six-month and one-year success rates of previous clients? (A range of 20-40% success rate is realistic.) Remember: if it sounds too good to be true, it probably is.
- How much does the program cost per employee? Are group discounts available?
Section III: Resources and Information on Tobacco Cessation Programs
Federal Government Organizations
Agency for Health Care Research and Quality(AHRQ)
Public Health Service
540 Gaither Road
Rockville, MD 20850
301-427-1364
Visit Website
1-800-358-9295 (to request materials on all AHRQ Smoking Cessation Guidelines)
AHRQ is the lead agency charged with supporting research designed to improve the quality of health care, reduce its cost, and broaden access to essential services. AHRQ's broad programs of research, clinical guideline development, and technology assessment bring practical, science-based information to medical practitioners and to consumers and other health care purchasers.
Office on Smoking and Health
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention
Mail Stop K-50, 4770 Buford Highway, NE Atlanta, GA 30341-3724
770-488-5705
Visit Website
1-800-CDC-1311
The Office on Smoking and Health serves as the Federal focal point for activities on smoking and health and as the national and world center for scientific and technical information. The Office produces the Surgeon General's annual report related to smoking and health, and carries out a public education and a tobacco epidemiology program.
Regulations Management Division
Office of Real Property Management
p>General Services Administration (GSA)
18th and F Streets, N.W., Rm. 6203
Washington, DC 20405
202-501-1737
Visit Website
The GSA Office of Real Property is responsible for regulations on smoking in GSA-controlled Federal buildings and facilities. Each Federal agency head is responsible for implementing and enforcing the GSA regulations and establishing designated smoking areas.
U.S. Office of Personnel Management
1900 E Street, N.W., Rm. 7H24
Washington, DC 20415
202-606-1858
Email: worklife@opm.gov
OPM is responsible for Federal employee health and assistance-related personnel policy guidance and technical assistance.
Cancer Information Service (CIS)
National Cancer Institute (NCI)
31 Center Drive MSC2580
Building 31, Room 10A31
Bethesda, MD 20892-2580
1-800-4-CANCER (1-800-422-6237)
1-800-332-8615 - TTY
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The Cancer Information Service provides information on cancer to patients and their families, health professionals, and the general public. The CIS is a resource for state and regional organizations by providing expertise in program planning, use of NCI materials, media relations, networking and coalition building.
Other Organizations
American Cancer Society (ACS)
National Headquarters
1599 Clifton Road, N.E.
Atlanta , GA 30329-4251
404-320-3333 or call the local number listed in the telephone directory.
Visit Website
The ACS is dedicated to eliminating cancer through research, education, advocacy and service. ACS offers the "Fresh Start" program designed to help participants stop smoking. The program offers a variety of brochures, videos and other resources on smoking cessation. The information on tobacco cessation counseling can be found on the ACS website by typing in �cancer AND counseling� in the search box located in the upper right corner of the home page.
American Heart Association (AHA)
National Center
7320 Greenville Avenue
Dallas , TX 75231
214-750-5300 or call the local number listed in the telephone directory
Visit Website
AHA provides research support, public and professional education, and community programs in the fight against cardiovascular diseases and stroke. AHA also offers The Heart At Work health promotion program, including a module on smoking cessation. The program can be implemented with program support provided by a local AHA representative.
American Lung Association ( ALA )
Headquarters
61 Broadway
New York, NY 10006
212-315-8700 or call the local number listed in the telephone directory.
Visit Website
The ALA supports research and other efforts to better understand why smokers are addicted and how to help them. Programs include a stop-smoking program, Freedom From Smoking, which is also available online as well as self-help options including guidebooks, videotapes and audiotapes.
Resources
Employers' Smoking Cessation Guide: Practical Approaches to a Costly Workplace Problem is a guide published by the Professional Assisted Cessation Therapy (PACT) consortium for large and small employers interested in enacting an affordable, effective smoking cessation program.
Make Your Workplace Smokefree: A Decisionmaker's Guide provides information on the costs of tobacco use to employers.
Tobacco Information and Prevention Source (TIPS) sponsored by CDC's Office on Smoking and Health, provides a comprehensive array of information and resources, including publications on stopping the use of tobacco.