Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ujpd20 Download by: [HSRL - Health Science Research Library] Date: 04 January 2018, At: 08:42 Journal of Psychoactive Drugs ISSN: 0279-1072 (Print) 2159-9777 (Online) Journal homepage: http://www.tandfonline.com/loi/ujpd20 Helping Smokers Quit: New Partners and New Strategies from the University of California, San Francisco Smoking Cessation Leadership Center Steven A. Schroeder, Brian Clark, Christine Cheng & Catherine B. Saucedo To cite this article: Steven A. Schroeder, Brian Clark, Christine Cheng & Catherine B. Saucedo (2017): Helping Smokers Quit: New Partners and New Strategies from the University of California, San Francisco Smoking Cessation Leadership Center, Journal of Psychoactive Drugs, DOI: 10.1080/02791072.2017.1412546 To link to this article: https://doi.org/10.1080/02791072.2017.1412546 Published online: 26 Dec 2017. Submit your article to this journal Article views: 5 View related articles View Crossmark data Citing articles: 1 View citing articles
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Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=ujpd20
Download by: [HSRL - Health Science Research Library] Date: 04 January 2018, At: 08:42
Helping Smokers Quit: New Partners and NewStrategies from the University of California, SanFrancisco Smoking Cessation Leadership Center
Steven A. Schroeder, Brian Clark, Christine Cheng & Catherine B. Saucedo
To cite this article: Steven A. Schroeder, Brian Clark, Christine Cheng & Catherine B. Saucedo(2017): Helping Smokers Quit: New Partners and New Strategies from the University of California,San Francisco Smoking Cessation Leadership Center, Journal of Psychoactive Drugs, DOI:10.1080/02791072.2017.1412546
To link to this article: https://doi.org/10.1080/02791072.2017.1412546
Helping Smokers Quit: New Partners and New Strategies from the University ofCalifornia, San Francisco Smoking Cessation Leadership CenterSteven A. Schroedera,b, Brian Clarkb, Christine Chengb, and Catherine B. Saucedob
aDepartment of Medicine, University of California, San Francisco, CA, USA; bSmoking Cessation Leadership Center, University of California,San Francisco, CA, USA
ABSTRACTThe Smoking Cessation Leadership Center (SCLC) was established in 2003 to increase the rate ofsmoking cessation attempts and the likelihood those efforts would succeed. Although smokingremains the number one cause of preventable death and disability, clinicians underperform insmoking cessation. Furthermore, many clinical organizations, governmental agencies, and advocacygroups put little effort into smoking cessation. Initially targeted at increasing the efforts of primarycare physicians, SCLC efforts expanded to include many other medical and non-physician disci-plines, ultimately engaging 21 separate specialties. Most clinicians and their organizations aredaunted by efforts required to become cessation experts. A compromise solution, Ask, Advise,Refer (to telephone quitlines), was crafted. SCLC also stimulated smoking cessation projects ingovernmental, not-for-profit, and industry groups, including the Veterans Administration, theHealth Resources Services Administration, Los Angeles County, and the Joint Commission. SCLChelped CVS pharmacies to stop selling tobacco products and other pharmacies to increase smokingcessation efforts, provided multiple educational offerings, and distributed $6.4 million in industry-supported smoking cessation grants to 55 organizations plus $4 million in direct SCLC grants.Nevertheless, smoking still causes 540,000 annual deaths in the US. SCLC’s work in the field ofbehavioral health is described in a companion article.
ARTICLE HISTORYReceived 8 September 2017Accepted 13 November 2017
Long recognized as the major preventable cause of deathand disability in the United States (US) and worldwide(McGinnis and Foege 2015), tobacco use has beendecreasing in the US since the 1964 Report of theSurgeon General (US Department of Health and HumanServices 2014). As shown in Figure 1 (National Center forHealth Statistics 2017; Jamal et al. 2016), adult cigarettesmoking prevalence in the US now stands at a modernlow of 15%. Furthermore, from 1995 on, the number ofcigarettes smoked by those who did not quit decreasedfrommore than 20 to the current level of about 14 per day(Figure 2) (National Center for Health Statistics 2017;Jamal et al. 2016; Schroeder 2012). Thus, not only wasthere a major decline in the proportion of people whosmoke, but even those who continued to smoke con-sumed fewer cigarettes.
The impressive decline in smoking prevalenceresulted from a set of tobacco control policies thatreduced both the numbers of new smokers as well ascontinuing smokers. These policies include: raisingtobacco taxes; enacting state and local clean indoor air
laws; developing counter-marketing programs featuringmessages highlighting the nefarious tactics of thetobacco industry; educating the public about the harmcaused by smoking, especially to those exposed to sec-ondhand smoke; and providing smoking cessation ser-vices, including counseling, medications, and access totoll-free telephone quitlines.
Despite these impressive gains, smoking still remainsthe number one cause of premature deaths in the UnitedStates. More than 40 million adults continue to smoke, halfof whom will die prematurely. Smoking causes 540,000deaths a year (Carter et al. 2015), and the earlier smokersquit, the bigger the benefit. Even at age 60, a smoker whoquits gains an extra four years of life (Jha et al. 2013).
The fastest way to reduce population smoking levels isto accelerate the rate at which smokers stop (Macioseket al. 2006). Quitting is a two-step function. First, thesmoker must decide to stop. Second, that attempt—orsubsequent ones—must succeed. But cessation is a strug-gle. The average person who quits does so after manyunsuccessful attempts—estimated from 10 to as many as30. The likelihood of a successful unaided quit attempt is
CONTACT Steven A. Schroeder [email protected] 3333 California St., Suite 430, San Francisco, CA 94143-1211Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/UJPD.
JOURNAL OF PSYCHOACTIVE DRUGShttps://doi.org/10.1080/02791072.2017.1412546
only about 4–7%.With counseling and smoking cessationmedications, those odds increase to as high as 20% or soin real world settings, and even higher in reported clinicaltrials (Tobacco Use and Dependence Guideline Panel2008). Many clinicians are discouraged by these low suc-cess rates, although they do not differ from the results oftreatments for conditions such as many cancers. Yet eventhe simple advice from clinicians to quit raises the odds ofquitting, with the increase being as high as two-fold forphysicians and somewhat less, but still substantial, forother clinicians.
Surprisingly, given the huge toll smoking exerts onhealth and the impressive benefits that occur with quit-ting, most clinicians do not place a high priority onhelping smokers quit. For example, in a 2003 survey ofseven health professional groups, although almost allclinicians reported asking about smoking, the percentreferring to smoking cessation programs ranged from ahigh of 46.7% for primary care physicians to a low of23.6% for dentists. The proportion arranging follow-upvisits was even lower, ranging from 1% to 23% amongthe clinician groups (Tong et al. 2010). Similar results
were found in a 2007 survey of physicians. Only 13% ofphysicians referred smokers to cessation services andonly 17% arranged for smoking cessation follow-up(Association of American Medical Colleges 2007). It isnot known whether there have been any recent changesin rates of smoking cessation interventions.
The creation of the Smoking CessationLeadership Center at UCSF
The combination of the known lethality of smoking andthe relative recalcitrance of clinicians to help smokersquit prompted the Robert Wood Johnson Foundation(RWJF) to establish the Smoking Cessation LeadershipCenter (SCLC) at the University of California, SanFrancisco, when the lead author (Schroeder) left hisposition as RWJF President and CEO at the end of theyear 2002. The smoking cessation theme made program-matic sense since, during his tenure at RWJF, the foun-dation was active in tobacco control. Indeed, RWJF’stobacco control programs were identified as one ofAmerican philanthropy’s 12 high impact programs of
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the twentieth century (Fleishman 2007). The decision tofocus on smoking cessation, rather than initiation oftobacco use, reflected the reality that two effective orga-nizations—the American Legacy Foundation (nowTruth Initiative) and the Campaign for Tobacco-FreeKids)—had strong programs on preventing youth smok-ing initiation. The SCLC grant was for $10 million toextend over five years; it contained $4 million to be usedfor re-granting to national organizations, presumablyclinical associations that would stimulate smoking cessa-tion efforts. Although there are multiple forms oftobacco, SCLC focused on cigarettes as by far the mostharmful and widely used tobacco product (Fiore,Schroeder, and Baker 2014).
As initially conceived, the SCLC would concentrateon educating and motivating professional organizations—mainly those representing primary care clinicians,especially physicians—to stimulate their members todo better in helping smokers quit. It would achievethis by persuading organizational leadership of theworthiness of that effort, and then providing tools toenable clinicians to serve as more effective smokingcessation activists. But over time the approach to clin-icians changed, the list of clinicians who could serve assmoking cessation advocates expanded, and the sphereof organizations with the potential to createopportunities for better smoking cessation enlarged.Furthermore, because SCLC was able to attract moreresources and modify its grant-making approach, thelife of the Center surpassed the original expectationthat it would only survive for five years. Ultimately,the SCLC pursued five major strategies. The first fouraddressed general issues regarding smoking cessation.The fifth, “Engaging behavioral health professionals insmoking cessation: Challenging old myths and tradi-tions,” is the topic of a companion article (Schroederet al. 2017).
Strategy 1: Make it easier for clinicians to helppatients stop smoking
There are many reasons why clinicians do not counselpatients about stopping smoking or help them oncethey’ve decided to quit. They include being too busy,lacking smoking cessation expertise, lacking fiscal incen-tives, perceived unavailability of treatments and/or insur-ance coverage, the discouraging reality that most smokerscannot or will not quit, the stigma attached to smoking, arespect for privacy and the “right to smoke,” the fear thata negative message might scare away patients, and thecircumstance that the clinician himself is a smoker (com-mon for behavioral health clinicians, but not others)(Schroeder 2005).
Given these obstacles, the initial strategy involvedpersuading primary care clinicians to adopt the modelpractice embodied in the US Clinical Practice Guideline,Treating Tobacco Use and Dependence (Tobacco Use andDependence Guideline Panel 2000), which recommendsthat clinicians use the “Five As” with their patients whosmoked: “Ask (about tobacco use), Advise (to quit),Assess (willingness to make a quit attempt), Assist (inquit attempts), and Arrange” (follow-up). Under theoriginal plan, SCLC would persuade relevant profes-sional societies to educate their members about the“Five As,” and then provide support to embed theseGuideline components into routine clinical practice.But none of the professional organizations had heardof the Guideline, and when informed of its components,they protested that their members were simply too busyto spend the 20 minutes or so required to perform the“5As.” Therefore, the SCLC formulated a simplerapproach. At its first organizational meeting, held inSan Francisco in September 2003 and involving theAmerican Dental Hygienists’ Association (ADHA), analternative plan emerged. Instead of five As, the numberwas reduced to three: Ask, Advise, Refer (to a toll-freetelephone quitline, which offers free cessation services inevery state and has proven effectiveness).
The resultant relationship with the ADHAwas the inau-gural SCLC partnership, and it led to two phrases that havesince become mainstream in tobacco control: Ask, Advise,Refer, and Take 30 Seconds to Save a Life. Easier referral toquitlines was facilitated in 2004 with the establishment of anational routing number (1-800-QUITNOW), housed atthe National Cancer Institute of the National Institutes ofHealth. Because there was no budget to market the avail-ability of this service, the SCLC took the lead by designing awallet-size plastic card (Figure 3) that it made available atcost to anyone interested in stimulating quitline referrals(Saucedo and Schroeder 2010). In some instances, organi-zations modified the card and imprinted their own logo.Over 5 million cards have been distributed.
Strategy 2:Expand the network of practitionershelping people to stop smoking
Over time, SCLC formed partnerships with 21 separateclinical organizations. The sequence of engagement typi-cally began with a phone call or in-person meeting withorganizational leadership—either senior administrativestaff or members with a demonstrated interest in tobaccocontrol—explaining the goal of SCLC and exploringwhether the organization wished to become moreinvolved in smoking cessation. Unlike many founda-tion-sponsored programs, the request did not prescribea specific formula for organizational engagement. Rather,
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SCLC tried to tailor programs that met organizationalneeds and capabilities. Sometimes an alliance was quicklyforged, sometimes the “courtship” was prolonged and, insome instances, it proved impossible to come to anarrangement. In most cases, SCLC provided initial grants,often for assembling an organizational planning commit-tee that set goals, proposed ways to achieve those goals,and assigned responsibility for execution.
Initially, SCLC anticipated awarding a relatively smallnumber of grants, ranging from $100,000 to $250,000. Itbecame apparent, however, that the more enthusiasticorganizations felt about partnering, the less funds theyrequired to participate. By contrast, some prominentand large national organizations stipulated a very highprice—such as $1 million—for engagement. Often, thosefunds would be earmarked to develop a separate curri-culum, even though the comprehensive Rx for Changecurriculum was available for free as a well-tested andfrequently updated resource (UCSF 2014. Rx for Change,as described in a following section, is a comprehensivetobacco control curriculum that focuses on smokingcessation and is available free of charge for all to use.Consequently, SCLC limited its support to organizationsappearing to have a genuine interest in smoking cessa-tion, and which usually had identified smoking cessationchampions within their midst. This strategy expandedthe types of clinicians beyond the primary care fieldsoriginally envisioned.
For most organizations, SCLC provided infrastructuregrants of about $25,000 to begin the process. Sample activ-ities included: creating regional smoking cessation expertswho could stimulate state and local activity (AmericanAssociation of Family Physicians/AAFP and ADHA); con-ducting pilot studies of Ask, Advise, Refer in hospital emer-gency rooms (American College of Emergency Physicians),as well as in pre-operative surgery suites (American Societyof Anesthesiologists/ASA) (Warner 2009); providing edu-cational content via society newsletters, webinars, articlesin professional journals, and sessions at annual and regio-nal meetings (all partners, to various extent); creating theirown version of the blue card (AAFP, ASA, and ADHA);adopting a national policy urging members to either
become smoking cessation experts themselves or refer allpre-operative smokers to a quitline (ASA); and creatingpermanent infrastructure mechanisms to ensure thattobacco control would remain an organizational priority(most partners). Notably absent from these partnershipswere organizations representing clinical subspecialtiesfacing the greatest burden from smoking: those dealingwith cancer, lung disease, and heart disease. These “down-stream” specialties were so involved with treating the con-sequences of smoking that they did not see it as their role toengage vigorously in smoking cessation activities.However, after a decades-long courtship, in 2015 theAmerican College of Cardiology formally affiliated withthe SCLC and established a task force on smoking cessa-tion, with the goal of devising strategies that would moti-vate and educate members.
Strategy 3: Stimulating governmental and not-for-profit agencies to become more invested insmoking cessation
Governmental agencies provide opportunities to promotesmoking cessation. In 2003, leaders of the Department ofVeteran’s Affairs (VA) central health office asked SCLC toorganize a national conference to help the VA drive downthe historically high smoking rates of veterans treated atVA health facilities. In September 2004, a meeting orga-nized by SCLC was held in San Francisco that assembled90 national experts in smoking cessation, includingnational and local VA officials. The published proceed-ings were widely disseminated across all VA facilities anda set of recommendations was created that includedincreasing the priority of smoking cessation, better inte-gration of smoking cessation activities into chronic dis-ease and mental health treatment settings, more researchinto smoking cessation activities, and better marketing oftelephone quitlines (Isaacs, Schroeder, and Simon 2005).A follow-up application process allowing VA facilities toreceive free quitline posters and cards resulted in 100 ofthe 158 VA institutions installing quitline promotionalmaterials in patient waiting rooms and clinics.
Figure 3. National quitline card.
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Another federal agency with great potential to reachsmokers is the Health Resources Services Administration(HRSA), which administers almost 10,000 clinical sitesserving 24 million people. Since most HRSA clinic patientscome from low-income settings that have higher rates ofsmoking, this provides an opportunity to reach manysmokers. But although SCLC was able to present somelectures on smoking cessation topics at HRSA-sponsorednational and regional meetings, and to participate in somewebinars, the engagement was relatively minimal, despitemany attempts at deeper engagement. However, asdescribed in the companion article, lower-income popula-tions were reached through involvement with other orga-nizations, especially those serving persons with behavioralhealth conditions (Schroeder et al. 2017) Regional govern-mental partnerships arose on an ad-hoc basis. One of thestrongest resulted when Los Angeles (LA) County HealthCommissioner Jonathan Fielding, MD, invited SCLC tohelp administer a county-wide program: LA Quits. SCLCinitially donated its services, and then was supported byCDC subcontracts from LA County. SCLC servicesbetween 2011 and 2014 included webinars plus in-servicetraining at over 75 community mental health and sub-stance abuse treatment centers to integrate cessation ser-vices and become tobacco-free campuses. Results includedan almost two-fold increase in calls from county residentsto the state telephone quitline and a decrease in adultsmoking prevalence from 15% in 2011 to 12% by 2014.SCLC staff also participated in place-based smoking cessa-tion efforts in Chicago and the states of Oregon andWashington.
SCLC also engaged in a variety of not-for-profitagencies. Five examples are provided:
● The Joint Commission. In 2011, after pilot testing in 24hospitals and undergoing a period of public comment,the Joint Commission followed the recommendationsof an advisory panel that included the SCLC directorto create a new tobacco cessation performance mea-sure set for hospitalized patients to replace a previousset that had proved meaningless because hospitalswere “gaming it” by reporting performance scores at100%. The new set had four components: (1) docu-ment tobacco use status on admission; (2) delivercessation counseling and medications during hospitalstay; (3) arrange for counseling and medication post-discharge; and (4) check smoking status one monthpost-discharge. These components were designed by atechnical advisory panel appointed by the JointCommission; SCLC was represented on that panel(Fiore, Goplerud, and Schroeder 2012). The tobaccocessation measure set was one of 14 from whichhospitals had to select four for reporting purposes.
Subsequently, the Joint Commission suspended com-ponent 4, responding to criticisms that it was undulyburdensome and lacked an evidence base. To date, 754acute care hospitals and 503 inpatient psychiatric facil-ities have chosen to use the tobacco measure set, withmost representing the governmental sector (VA andDepartment of Defense). Anecdotally, two reasonswhy more hospitals did not choose the tobacco mea-sure set were greater familiarity with alternativechoices and the concern that the tobacco measureswere more labor-intensive. In 2016, the Centers forMedicare andMedicaid Services ruled that psychiatrichospitals would be required to implement and reportthe first three components of the Joint Commissiontobacco measure set or risk financial penalties.
● The Association of Tobacco Treatment Use Disorders(ATTUD). In 2011, SCLC accepted a request fromATTUD to maintain a listserv for its over 600 mem-bers. This service connects interdisciplinary smokingcessation specialists, providing opportunities to dis-seminate educational material, as well as serving as avehicle for interchange among members.
● Beginning in 2004, Kaiser Permanente NorthernCalifornia (KPNC) engaged SCLC in a number ofeducational offerings, including two webinars withits providers, the endorsement of Kaiser’s tobaccocontrol strategy, and ad hoc consultation regardingspecific medication issues, as well as approaches topatients with behavioral health conditions. KPNCwas able to lower its already impressive adult smok-ing rate from 13.9% in 2002 to 8.1% in 2017.(Although it is likely that SCLC played a role in thatoutcome, its impact was probably relatively minor).
● The American Legacy Foundation, now known asTruth Initiative, co-hosted a series of webinarsaddressing various smoking cessation topics.
● The Gay and Lesbian American Medical Association.SCLC provided technical assistance to a lesbian, gay,bisexual, and transgender (LGBT)-oriented smok-ing cessation curriculum for clinicians, worked withits Healthlink network, and accredited a virtualconference.
Strategy 4: Forging smoking cessationpartnerships with pharmaceutical companies
The tobacco control movement has traditionally avoidedcorporate partners. In part, this is a legacy of the tobaccoindustry’s role as the vector in the smoking epidemic,which created a general suspicion of other industrymotives. Nevertheless, SCLC felt it was strategic to engagewith corporate partners whose ostensible business is to
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promote health, notably Pfizer and CVS Health. The Pfizerrelationship evolved from invitations to join the Pfizerspeaker circuit, a mechanism whereby academic expertsreceive funds to lecture on their subject of expertise, oftenusing educational materials supplied by a pharmaceuticalcompany that produces a relevant product. Based on thedesire to avoid perceived conflicts of interest that mightcompromise its role as a broker among organizations thatcould foster smoking cessation efforts, SCLC declined thisrole. In 2012, however, a senior Pfizer officer catalyzeddiscussions between SCLC and Pfizer’s IndependentGrants for Learning and Change program about a possibleunique partnership that would delegate administration of aPfizer-supported smoking cessation grants program toSCLC. The incentive for Pfizer was that increased smokingcessation would stimulate sales of its products—varenicline(Chantix®), and nicotine gum and inhalers. For the SCLC,the incentive was to enlist more health professional groupsinto smoking cessation efforts. SCLC’s strategy to avoidappearances of conflict of interest was three-fold. First, itrefused payment for the effort, offering its services gratisbecause the project was so aligned with its core mission.Second, SCLC sought tomake the relationship transparent,both in the conduct of the grants program and by publish-ing the results (Jensen et al. 2017). Third, paying for cessa-tion medications was not an allowable budgetary expensefor the grants. The program proved satisfactory to bothPfizer and SCLC. There was such interest in applying for agrant (201 letters of intent versus the 50 or so expected)that Pfizer raised its funding pool from $2 million to $4.6million. A total of 40 organizations received grants rangingfrom $50,000 to $200,000. In addition to the expectedgrantees representing hospitals and medical groups, therewere novel recipients: pharmacists in the Giant Eaglesupermarket chain in fourMid-Atlantic states; anesthesiol-ogy residency programs; retail clinics; substance abusetreatment programs in Texas; and parolees fromColorado prisons. Based on this experience, in 2015Pfizer authorized a second round of funding for a similareffort that yielded 154 applications, resulting in 15 grantstotaling $2 million.
Pharmacists have long been on record as opposing thesale of cigarettes in pharmacies, because promoting smok-ing stands in direct conflict with the pro-health mission ofthe pharmacy profession (Hudmon et al. 2006). Severalstudies over the past four decades documented that whileindependent pharmacies tend not to sell tobacco products,all chain pharmacies do (Eule et al. 2004; Schroeder andShowstack 1978). CVS Health, in order to strengthen itsposition as a pro-health organization, reached out to SCLCthrough its chief medical officer, Troyen Brennan, MD. Herequested advice concerning how to end sales of tobacco
products in the CVS chain of pharmacy retail outlets. Thatban was announced in early 2014, and the rationale for thedecision was published in JAMAwith joint CVS and SCLCauthorship (Brennan and Schroeder 2014). SCLC alsoworked with other chains containing pharmacy outlets,including Safeway and two large regional chains—GiantEagle and Ralphs—to help pharmacists become strongersmoking cessation advocates.
Lessons learned while employing the smokingcessation strategies
No single formula exists for engaging relevant clinicalorganizations in smoking cessation activities. A crucialelement for many partnerships involved identifying exist-ing champions, either in the organizational membershipor in the executive leadership (ideally both). Particularlyhelpful were the late Peggy Walsh in dental hygiene,DavidWarner in anesthesiology, Steve Bernstein in emer-gency medicine, and the three pharmacists—KarenHudmon, Robin Corelli, and Lisa Kroon—who developedRx for Change. Other important ingredients were theexistence of a strong science base on the harm fromusing combustible tobacco and the associated secondhandsmoke exposure, as well as evidence that smoking cessa-tion interventions can improve the chances of quitting;flexibility concerning terms of engagement; patience; andwillingness to be a background partner rather than adominant one.
Although onemight assume that working with govern-mental, non-governmental but not-for-profit, and corpo-rate entities entail vastly different negotiating styles andreporting relationships, that was not the case. In allinstances, establishing and maintaining a partnershiprequired identifying mutual interests, establishing trust,clarifying roles, and maintaining credibility. In all sectors,a challenge was the frequent turnover of staff, with theconsequent need to review the rationale for the activityand to establish trust with the new staff contacts.Budgetary cuts and changes in leadership were particu-larly common in state governments.
Major accomplishments of SCLC in 2003–2017(excluding behavioral health)
SCLC has engaged in many activities and worked withmultiple partners. Although there has been no formalevaluation of its work, this section presents highlights.
● Contributing to decreased smoking prevalence. Sincethe inception of the SCLC, three key indicators havetrended favorably. Overall, adult smoking prevalence
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declined, with the 2015 figure at a modern low of15% (Figure 1), and those who continue to smokeconsume fewer daily cigarettes (Figure 2). Finally, theproportion of smokers able to quit more than tripledduring the past two decades (Mendez et al. 2016). It islikely that many factors contributed to this progress.Obvious components include increased tobaccotaxation, both nationally in 2009 and at the statelevel, clean indoor air laws, and counter-marketingcampaigns. Other factors specifically focused on ces-sation are new medications such as varenicline, theuse of alternative nicotine delivery devices such aselectronic cigarettes, expanded health insuranceenrollment and mandating coverage of cessation ser-vices under the 2010 Affordable Care Act, and thefact that clinicians, especially in behavioral healthspecialties, have become more aggressive in urgingtheir patients to quit smoking. It is likely that SCLCcontributed to these trends.
● Expanding the types of clinicians invested in smokingcessation. At its inception, SCLC assumed that pro-moting smoking cessation would concentrate on pri-mary care clinicians, especially physicians. But thereality is that smokers encounter many differenttypes of clinicians, and each encounter presents anew opportunity to encourage and assist smokers toquit. To that end, SCLC has helped to create newsmoking cessation actors across a wide variety ofclinical disciplines, often enabled by existing cham-pions within those specialties.
● Devising and marketing Ask, Advise, Refer as anacceptable strategy for busy clinicians to refer smokersto toll-free telephone quitlines. SCLC developed thisapproach when confronted with the reality that,because of perceived time constraints, most clinicalorganizations were reluctant to exhort their membersto become full-fledged smoking cessation experts. But,recognizing the need to address smoking, they werecomfortable with the strategy of referral. To facilitatethose referrals, SCLC also developed the referral “bluecard” (Figure 3) and made it available at cost.
● Helping CVS stop selling tobacco products. Althoughthis seemed a counterintuitive business move, forfeit-ing about $2 billion in annual sales, it was consistentwith CVS’ desire to position itself as a pro-healthcorporation. SCLC was privileged to be a small partof the execution of the tobacco-free policy, and also tohelp other pharmacy outlets do better at providingsmoking cessation services.
● Distributing more than $10 million in smoking cessa-tion grants to organizations throughout the country.
Initially with RWJF funds of $4 million, and laterwith $6.4 of Pfizer funds, SCLC identified and sup-ported multiple smoking cessation efforts at thenational and state levels. Hopefully, these grants willleave lasting legacies in the form of enhanced voicesof organizational champions, persistence of systemchanges such as electronic health record referral sys-tems to quitlines, and educational exposures that willendure long after grants end.
● Developing curricula, webinars, and tool kits to educateand accredit clinicians. Rx for Change is a comprehen-sive tobacco control curriculum created in 1999 bythree faculty members of the UCSF School ofPharmacy, who generously made Rx available to allwithout charge. SCLCmarketed this resource throughits website, as well as supported tailored variants foruse in psychiatry, for peer counselors of mental healthpopulations, for cardiology, and for respiratory care,among others. In addition, between 2007 and 2017,SCLC provided 70 free webinars. SCLC maintains anactive listserv with 1229 subscribers, plus Twitter andFacebook accounts.
● Publishing articles in the scientific literature. Between2003 and 2017, SCLC published 55 tobacco-relatedpapers in the medical literature—including nine inthe New England Journal of Medicine and seven inthe Journal of the American Medical Association (themedical journals with the two highest impact factors)—plus three op-eds in metropolitan newspapers,including theWashington Post. These scientific articlesthen stimulate coverage in the lay press, on radio, andin television spots. In addition to motivating andeducating clinicians, by keeping cigarette smoking inthe public eye they help to combat the view that thebattle against smoking has been won and it is nowtime to move on to other issues.
Discussion
During its 14 years, the SCLC has learned many lessons.A key one is that opportunities arise that were not part ofthe original strategic map. In SCLC’s case, it envisioned arelatively narrow playing field, limited to specific clinicalorganizations. But its scope enlarged over time toinclude governmental agencies, advocacy organizations,the prison system, the homeless, pharmacies, retailclinics, and the retail pharmacy industry. The overallgoal—increasing the frequency of quit attempts and theodds of those attempts succeeding—never wavered, butas SCLC became entrenched in the field and developed
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its own reputation, unanticipated opportunities arose.This expansion of SCLC activities would not have beenpossible without sustained funding, as well as permissionfrom the funders to avoid getting locked into an inflex-ible strategic plan. SCLC’s efforts in behavioral health, afield that encompasses so many persons who smoke, isdescribed in a companion article (Schroeder et al. 2017).Since almost 40 million persons still smoke cigarettes,there is much more to do. Immediate tasks for the SCLCinclude securing resources to enable it to plan for thefuture, and focusing on those vulnerable populationsthat have higher rates of smoking.
Acknowledgments
We acknowledge the core support of the Robert Wood JohnsonFoundation and the American Legacy Foundation (now knownas Truth Initiative), the work of present and former SmokingCessation Leadership staff—Jennifer Matekuare, Roxana Said,Connie Revell, Margaret Meriwether, and Reason Reyes—andthe editorial comments of Stephen L. Isaacs.
Funding
This work was supported by the Truth Initiative111933 andthe Robert Wood Johnson Foundation [72763].
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