Journal of the National Cancer Institute Monographs, No. 35, 2005 75
Relationship Between Tobacco Control Policies and
the Delivery of Smoking Cessation Services in
Nonprofi t HMOs
Victor J. Stevens , Leif I. Solberg , Virginia P. Quinn , Nancy A. Rigotti , Jack A.
Hollis , K. Sabina Smith , Jane G. Zapka , Eric France , Thomas Vogt , Nancy
Gordon , Paul Fishman , Raymond G. Boyle
Background: This project examined tobacco policies and de-
livery of cessation services in nonprofi t HMOs that collec-
tively provide comprehensive medical care to more than 8
million members. Methods: Three annual surveys with health
plan managers showed that all of these health plans had writ-
ten tobacco control guidelines that became more comprehen-
sive over the span of this study. We also surveyed a random
sample of 4207 current smokers who had attended a primary
care visit in the past year (399 – 528 at each of nine health
plans). Results: Of these smokers, 71% reported advice to
quit, 56% were asked about their willingness to quit, 49%
were provided some assistance in quitting (mostly self-help
material or information about classes or counseling), and
9% were offered some kind of follow-up. Smokers receiving
assistance in quitting reported higher satisfaction with their
care. Conclusions: In general, health plans with the most
comprehensive policies also showed higher rates of imple-
menting tobacco treatment programs in primary care. Com-
pared with tobacco control efforts of a decade or more ago,
considerable progress has been made. However, there is still
room for improvement in the proportion of smokers who re-
ceive the most effective forms of assistance in quitting. [J Natl
Cancer Inst Monogr 2005;35:75 – 80]
Tobacco smoking remains the leading preventable cause of
morbidity and mortality in the United States, accounting for more
than 440 000 deaths annually and a third of all cancer deaths
( 1 – 3 ) . Although the proportion of the population that smokes has
declined considerably in the past 25 years, overall smoking rates
have recently leveled off ( 2 ) .
Health care systems are in a particularly strong position to ad-
dress the tobacco epidemic. Many clinical trials have documented
the effectiveness of brief physician advice and counseling to stop
smoking, and the U.S. Public Health Service clinical guideline
has summarized the evidence behind its recommendations for
the “ 5 A’s ” , a fi ve-step sequential treatment program: (1) ASK
patients about smoking status at every visit, (2) ADVISE all
tobacco users to quit, (3) ASSESS a patient’s willingness to try to
quit, (4) ASSIST the patient’s quitting efforts (provide smoking-
cessation treatments or referrals), and (5) ARRANGE follow-up
(schedule supportive follow-up contacts) ( 4 , 5 ) . The fi ve A’s has
become the national model for tobacco treatment in medical care.
Since 60% – 70% of smokers at any given time express an interest
in quitting, and since 70% of them also report at least one
physician visit in the past year, there is ample opportunity for
clinicians to take effective action ( 2 , 6 – 8 ) .
Most Americans receive their health care from managed-care
organizations, and these health systems are in an excellent
position to encourage a variety of smoking cessation treatments
as a part of routine health care. HMOs can combine policy, orga-
nizational, health care provider, and individual-level initiatives
to integrate tobacco control into delivery systems, and they have
their own fi nancial incentive to reduce tobacco use in their de-
fi ned populations ( 9 – 13 ). Several HMOs have become nationally
known for their tobacco cessation research ( 7 , 14 – 20 ) .
Tobacco control policies in HMOs have been assessed by
three large-scale national surveys conducted in 1997, 2000, and
2002 by the Addressing Tobacco in Managed Care (ATMC) pro-
gram ( 21 – 23 ) . These policy surveys included 323, 85, and 152
managed care programs in 1997, 2000, and 2002, respectively.
The ATMC surveys show a trend toward improved tobacco con-
trol policies and increasing insurance coverage for smoking-
cessation services between 1997 and 2002. For example, in 1997
less than half of the responding plans (47%) had written guide-
lines or had implemented any of the AHCPR guidelines for
managed-care organizations, whereas by 2004, 71% had written
guidelines for tobacco control. The ability of plans to identify
individual members who smoke increased from 15% of plans in
1997 to 72% in 2002. Full coverage for some form of pharmaco-
therapy for smoking cessation increased from 25% of plans in
1997 to 89% of plans in 2002. Overall, the results of the ATMC
surveys show a strong trend toward more aggressive tobacco
Affi liations of authors: Kaiser Permanente Center for Health Research North-
west, Portland, OR (VJS, JAH, KSS); HealthPartners Research Foundation,
Minneapolis, MN (LIS, RGB); Department of Research and Evaluation, Kaiser
Permanente Southern California, Pasadena, CA (VPQ); Harvard Medical School
and Massachusetts General Hospital, Boston, MA (NAR); University of Mas-
sachusetts Medical School, Worcester, MA (JGZ); Kaiser Permanente Colorado,
CO (EF); Kaiser Permanente Center for Health Research Hawaii, Honolulu, HI
(TV); Division of Research, Kaiser Permanente Northern California, Oakland, CA
(NG); Group Health Cooperative Center for Health Studies, Seattle, WA (PF).
Correspondence to: Victor J. Stevens, PhD, Kaiser Permanente Center for
Health Research, 3800 N. Interstate Ave., Portland, OR 97227 (e-mail: victor.
See “ Notes ” following “ References. ”
© The Author 2005. Published by Oxford University Press. All rights reserved.
For Permissions, please e-mail: firstname.lastname@example.org.
by guest on September 13, 2015
76 Journal of the National Cancer Institute Monographs, No. 35, 2005
control policies with increasing attention to identifying smokers
and providing them with advice and assistance in stopping smok-
ing. A similar survey of 34 California-based HMOs conducted in
1999 showed much the same results as the ATMC surveys ( 24 ).
This article examines the tobacco control policies in 11 non-
profi t HMOs and shows how those policies evolved over a 3-year
period. All of the HMOs in this study have been leaders in
developing and implementing tobacco control programs. Of
special interest is a patient survey conducted in nine of these
health plans immediately after the fi rst policy survey. The
combination of the policy and patient surveys allows examina-
tion of the relationships between organizational policies and the
actual delivery of tobacco cessation services to smokers. Relevant
data from a simultaneous survey of physicians in the nine health
plans are also presented. Although the study HMOs are not repre-
sentative of managed-care plans in general, the results from the
surveys show how well current national guidelines for tobacco
control are being implemented in nonprofi t health care systems
with long-standing, comprehensive tobacco control programs.
M ETHODS AND R ESULTS
This study was conducted within the Cancer Research Net-
work (CRN), a consortium of research organizations affi liated
with nonprofi t integrated health care delivery systems and the
National Cancer Institute. The CRN consists of the research pro-
grams, enrollee populations, and databases of 11 integrated
health care organizations that are members of the HMO Re-
search Network. The health care delivery systems participating
in the CRN are: Group Health Cooperative, Harvard Pilgrim
Health Care, Henry Ford Health System/Health Alliance Plan,
HealthPartners Research Foundation, the Meyers Primary Care
Institute of the Fallon Healthcare System/University of Massa-
chusetts, and Kaiser Permanente in six regions (Colorado,
Georgia, Hawaii, Northwest [Oregon and Washington], Northern
California, and Southern California). The 11 health plans have
nearly 10 million enrollees. The CRN conducts collaborative re-
search on variations in cancer prevention and treatment policies
The three components of this project included HMO policy
surveys, a patient survey, and a survey of primary care physi-
cians. The methods and results of each of these project compo-
nents are described below in series, followed by a description
of how fi ndings from these components relate to each other. The
results of the three components provide a comprehensive view of
the delivery of tobacco control services in these nonprofi t HMOs.
A few of the HMOs in this study included multiple health care
models. We limited our physician and patient surveys to those
portions of the health care systems were staff models or an exclu-
sive group practice model that closely resembled a staff model
(i.e., Kaiser Permanente).
Human Subject Reviews
All of the data collection procedures described in this article
were reviewed and approved annually by each of the institutional
review boards of the HMOs listed in the following section. This
task was complicated by the widely various and occasionally
confl icting requirements of these review boards.
Survey methods. We surveyed key managers in 11 medium
and large HMOs to obtain descriptions of their policies and
practices regarding tobacco control. All 11 HMOs are well-
established nonprofi t managed-care organizations with a strong
research orientation, clear commitment to control of tobacco use,
award-winning tobacco control programs, and above-average
scores on the Health Plan Employer Data Information Set
(HEDIS) tobacco measure ( 25 ). Managers were surveyed by mail
and telephone using a standardized protocol ( 16 ). The fi rst policy
survey was conducted in the winter of 1999 – 2000, and the subse-
quent surveys were completed in 2001 and 2002.
The 11 HMOs surveyed included nine members of the CRN,
plus two more nonprofi t HMOs ( 27 ) . A description of the CRN
health plans may be found in Wagner et al. (in press). The two
non-CRN health plans were the Providence Health Plan in
Portland, Oregon, and Kaiser Permanente Georgia (Kaiser Per-
manente Georgia joined the CRN consortium after this study was
The structured survey used in this assessment covered the pro-
gram components recommended by the USPHS tobacco guide-
lines ( 5 ) and the Centers for Disease Control and Community
Preventive Services Task Force ( 28 , 29 ). Assessment included
questions about clinical guidelines for smoking cessation and pre-
vention, other tobacco-related policies, implementation of tobacco
control policies, monitoring and encouraging provider adherence
to tobacco guidelines, support for systems to address tobacco ces-
sation treatments, and health plan coverage of tobacco- cessation
treatments. Multiple informants with knowledge of each organiza-
tions tobacco-control policies, typically physician administrators
or health educators, were chosen to complete the survey in writing
and by telephone. Initial informants were selected by tobacco ces-
sation researchers in the local health plan, with additional infor-
mants identifi ed during the interviews. Interviews required an
average cumulative total of 8 hours per health plan. To ensure con-
sistency, one staff member conducted all of the policy interviews.
Policy survey results. Results of the fi rst policy survey, which
was completed in 2000, have been reported ( 26 ), but the results
of the 2001 and 2002 surveys are reported here for the fi rst time
and show the rapid evolution of tobacco control policies. The
fi rst survey found that all 11 HMOs had established many poli-
cies and programs for tobacco control. Ten of the 11 HMOs had
an overall written tobacco control policy, and all 11 had policies
and procedures to encourage delivery of the fi rst two of the fi ve
A’s ( ask about smoking status and advise patients to quit smok-
ing) as a part of routine medical care. Policies regarding the other
A’s were less consistent, as were policies concerning special
The second and third annual policy surveys showed that to-
bacco control policies in these health care organizations became
increasingly comprehensive over this short time span. There was
steadily increasing attention to systems to support the detection
of tobacco use in multiple populations and the delivery of a vari-
ety of tobacco cessation services to patients.
HMOs with the national treatment guidelines (5 A’s). Between 2000
and 2002 there was a change toward more comprehensive policies,
especially for the Assess and Assist steps. By 2002, all 11 HMOs
had policies calling for assessing tobacco use at every primary care
visit, providing advice to quit, and providing patients with assistance
fi g1 Figure 1 shows the concordance of tobacco policies of these
by guest on September 13, 2015
Journal of the National Cancer Institute Monographs, No. 35, 2005 77
in their smoking cessation efforts. However, only about half of the
HMOs had tobacco control policies in place for special populations
such as pregnant women, hospital patients, and adolescents, and
this changed little over this period (data not shown).
Implementation of tobacco cessation programs in medical
care settings can be greatly facilitated by certain types of system
support. For those plans that have a unifi ed medical record, for
example, a systematic way to identify smoking status in the med-
ical record of every patient can provide a reminder to clinicians
to give advice and assistance, and such a way can facilitate con-
tinuity of care and follow-up treatment. In the fi rst survey, only
three HMOs reported having systematic ways to identify smok-
ers in their medical records systems, and this number rose to fi ve
by the third survey.
to medical offi ce systems to support tobacco control, for exam-
ple, the use of stickers, chart stamps, and other prompts for iden-
tifying tobacco use status to providers (tobacco use as a vital
sign) and to encourage delivery of tobacco cessation services.
Note that only half of the HMOs had current training programs
for staff in any given survey year.
overall policies and implementation supports for tobacco control.
Note that an increasing proportion of the health care systems
were setting specifi c tobacco reduction goals.
fi g2 Figure 2 shows the changes in policy related
fi g3 Figure 3 shows changes in
Patient survey methods. To assess the experience of smokers
in primary care, we surveyed a random sample of patients in each
of the nine HMOs in the CRN (see policy survey methods). That
is, we conducted patient surveys in nine of the 11 HMOs in which
we conducted policy surveys. Together, these nine HMOs provide
comprehensive medical care to more than eight million members
including a 30% minority enrollment.
To identify about 500 current smokers in each of these nine
HMOs, we mailed a 29-item survey to 64 764 adults who had a
primary care visit in the previous 12 months. Those who did not
respond were mailed a prompting letter and then a second survey.
Those who did not return the survey by mail were called and the
survey was completed as a telephone interview (a minimum of
three attempts were made to contact by telephone). The survey
started in late 1999 and was completed in the fall of 2000 ( 25 , 30 ).
The patient survey was intended to assess the general population of
adult smokers and did not attempt to identify individuals who were
parents of young children, had been hospitalized or were pregnant
in the past year, or other special populations of patients. The patient
survey was kept as brief as possible in an attempt to minimize
participant burden that thereby increase the response rate.
Patient survey results. After adjusting for the 7.5% that were
undeliverable or where respondents were found to be ineligible
(died, no longer members, or unable to communicate), there were
41 677 completed responses (70%). Of these, 80% had responded
by mail and 20% to telephone follow-up. The response rate from
all of those with attempted telephone follow-up was 33%. Com-
pared with those who responded, nonresponders were more
likely to be male (40% versus 33%; P ≤ .001) and younger (mean
age 44 versus 49 years; P ≤ .001).
Of those who provided survey responses (n = 41 677) 10%
were current smokers who had made at least one outpatient
visit in the previous 12 months (n = 4207). The number of smok-
ers identifi ed from each health plan ranged from 399 to 528.
Combining data from all nine health plans, 74% of the current
smokers reported being asked about tobacco use at their last
primary-care visit, with a range of 66% to 82% across the nine
health plans. This high rate of assessment of smoking status
shows that, in these health care systems, tobacco use has become
a vital sign assessed at most primary care visits.
When considering receipt of tobacco cessation advice and ser-
vices, we chose to ask about the patient’s experiences over the pre-
vious 12 months. Although the guidelines call for provision of
services at every visit, we chose to ask “ During the past 12 months,
did a doctor, nurse or other health care professional do any of the
following … ? ” With limited space on the questionnaire, we were
Number of Plans
Fig. 1. Comparison of HMOs’ tobacco cessation guidelines with the 2000 US
PHS Tobacco Guideline: the 5 A’s.
code nicotine dependence
train support staff
identify key person at site
use vital sign stamps/stickers
self-help materials on site
use of standard intake forms
Number of plans
Fig. 2. Medical offi ce systems to support tobacco cessation activities.
tobacco control a priority
tobacco control coordinator
dedicated tobacco counselors
tobacco training staff
trained physicians about policies
specific tobacco reduction target
distinct budget for tobacco control
Number of Plans
Fig. 3. Health plan policies supporting tobacco cessation.
by guest on September 13, 2015
78 Journal of the National Cancer Institute Monographs, No. 35, 2005
most interested in the overall pattern of services for patients
over time rather than by visit. Using this approach, 71% (range,
65% – 78%) of the smokers reported getting advice to quit at least
once in the past year, 56% (range, 47% – 68%) were asked about
their interest in quitting (Assess), 49% (range, 42% – 63%) received
some form of assistance in quitting, and 9% (range, 8% – 14%) were
scheduled for follow-up contacts to help in quitting (Arrange).
The most commonly reported form of assistance was being
offered pharmacotherapy (38% of smokers), followed by 37%
receiving information about classes or counseling and 30%
receiving self-help materials (some smokers reported receiving
more than one type of assistance in the past 12 months).
Consistent with many other studies, we found that most smok-
ers wanted to quit within the next 6 months (69%) and that most
smokers (82%) reported that they wanted their physicians to ad-
dress smoking often or at every visit. Satisfaction with health
care services was lowest among smokers who did not receive
cessation services and was highest among those who reported
assistance or follow-up contacts ( 30 ) .
Survey methods. In early 2001 we conducted a survey of pri-
mary care physicians in each of the nine CRN HMOs participat-
ing in this study ( 31 ). We mailed a 19-item questionnaire (one
page) to 100 randomly selected physicians in each organization.
Eligibility criteria included adult primary care physicians (inter-
nists, family physicians, or obstetrician – gynecologists) who had
worked for the current group for at least 1 year and who worked
at least half time in a non – urgent care setting.
Physician survey results. After excluding 65 respondents
who did not meet the inclusion criteria (e.g., left the practice
group, not working at least half-time), the adjusted response rate
was 91% (761 of 835). Physician awareness of their health plan’s
clinical guidelines for tobacco cessation was highly variable. For
example, the proportion of physicians who reported receiving a
copy of their plan’s tobacco guidelines varied from 61% to 90%.
However, at least two-thirds of the physicians at each HMO
(range, 66% – 98%) reported “ yes ” to the questions “ Does your
plan’s guideline recommend identifying smokers at every visit? ”
“ … advising all smokers to quit? ” and “ … assisting smokers to
quit? ” Although many physicians at each plan were unaware of
the details, a large proportion understood the general aspects of
their plan’s tobacco policy.
Relationships Between Policy and Patient Reports
The overall fi nding from our study has been that the national
tobacco treatment guidelines, both for health care administrators
and insurers, as well as the 5 A’s, have been partially implemented.
All of the medium and large HMOs we studied had aggressive
policies focused on tobacco control, but the actual implementa-
tion of these policies was uneven. Whereas patient surveys at all
nine of the plans studied showed high rates of assessing tobacco
use, only about half of the patients reported receiving assistance
in quitting during that period. Most of those not receiving assis-
tance reported an interest in quitting smoking and an expectation
that their physician should help them stop smoking.
Using data from the year 2000 policy survey and the year
2000 patient survey, we found an association between health plan
policies and services received by patients. Five of the nine health
plans provided feedback to physicians regarding their delivery of
smoking cessation services and had incentive systems for deliv-
ering these services. Patients in HMOs providing feedback and
incentives to physicians reported higher levels of receiving
advice to quit, assessment of readiness to quit, receiving self-help
smoking cessation materials, and smoking cessation counseling
from their physician (
showed that organizations providing feedback and incentives to
physicians had higher levels of physician knowledge of the
HMOs tobacco policies, and higher rates of assistance for pa-
tients. Smokers in the four HMOs with physician training pro-
grams were also statistically signifi cantly more likely to report
receiving tobacco cessation advice and services than those in the
HMOs without training programs (
There were only minimal differences between the nine health
plans with regard to coverage for more intensive treatment pro-
grams. At the time of our survey, all nine plans provided coverage
for Bupropion and some form of nicotine replacement, and all
nine plans also provided coverage for group-based smoking ces-
sation counseling. Most also offered coverage for telephone coun-
seling, and/or referrals to non – health plan telephone counseling
programs. Since there were only minimal differences in coverage,
we were not able to see differences in service delivery related to
insurance coverage for pharmacotherapy or behavioral treatment.
tbl1 Table 1 ). Physician survey results also
tbl1 Table 1 ).
Compared with a few decades ago when health care workers
smoked on the job and it was common practice to sell cigarettes
in hospital gift shops, we can see great improvement in tobacco
policies in HMOs. Most patients in the systems we studied are
now being asked if they smoke, and this information is likely to
be recorded in the medical record as a vital sign. Most smokers
are also likely to receive advice to quit smoking. Although not
suffi cient, these improvements are an essential foundation for a
comprehensive tobacco control program. The other key elements,
Table 1. Relationships between HMO tobacco control policies and smoking cessation services reported by patients who smoke *
Feedback and incentives for physicians to
provide smoking cessation services Tobacco cessation training programs for physicians
Reported by patients
HMOs with incentives
(n = 5 HMOs)
HMOs without incentives
(n = 4 HMOs)
HMOs with training
(n = 4 HMOs)
HMOs without training
(n = 5 HMOs)
Advice to quit
Assessment of readiness to quit
Smoking cessation materials
Counseling by physician
* P <.01 for all comparisons, chi-square tests.
by guest on September 13, 2015
Journal of the National Cancer Institute Monographs, No. 35, 2005 79
assessing patient readiness to quit, providing assistance in quitting
to willing patients, and arranging follow-up contacts for patients
who are attempting to quit, are being provided less consistently,
but the overall trend appears to be toward providing more com-
prehensive services for smokers. The proportion of patients re-
ceiving assistance, particularly the more effective types of
assistance, is higher in health plans that provide feedback and
incentives about these actions to physicians.
A major limitation of this study is that the policies and smok-
ing cessation treatment patterns seen in these HMOs are not
representative of managed-care programs in the United States. In
comparison with the national policy surveys conducted by ATMC
( 23 ), the health plans included in our study have more aggressive
and comprehensive tobacco control programs. Study of these
vanguard plans helps to show which policies are most effective
and provides examples of effective policy implementation.
Given the relatively aggressive tobacco control policies of the
HMOs in our study, it is a bit disappointing that many smokers are
not receiving assistance in quitting or are receiving only minimal
assistance such as a smoking cessation brochure. To be specifi c,
our patient survey shows that only about half of the smokers with
insurance coverage for multiple smoking cessation treatments are
actually receiving treatment in any given year. Although this is
much better than several decades ago when treatment rates were in
the low single digits, there is still much room for improvement.
In our study, the programmatic supports for tobacco cessation
that appeared to have the most effect on increasing the proportion
of patients who receive treatment include detailed and specifi c
tobacco control policies, physician training programs, providing
feedback to physicians on their delivery of tobacco services to
patients, and using incentives for providing tobacco cessation
treatment. This level of commitment by health plans leads to
higher rates of delivering smoking cessation services to patients.
Areas still needing improvement include developing more effec-
tive supports for delivering high quality assistance to patients and
better systems for providing supportive follow-up for patients re-
ceiving initial smoking cessation treatment.
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80 Journal of the National Cancer Institute Monographs, No. 35, 2005 Download full-text
Supported by grant U19 CA79689 from the National Cancer Institute. Article
contents are solely the responsibility of the authors and do not necessarily repre-
sent the offi cial views of the National Cancer Institute or the National Institutes
This study would not have been possible without the active cooperation of the
researchers, staff, and leadership of the participating health plans: Group Health
Cooperative of Puget Sound, Harvard Pilgrim Health Care, HealthPartners,
Health Alliance Plan of Michigan, and the Kaiser Permanente plans of Colorado,
Northern California, Northwest, Southern California, and Hawaii. Special thanks
to Weiming Robert Hu for his help with the data analysis.
N.A. Rigotti has received research funding from GlaxoSmithKline, Pfi zer, and
Sanofi – Aventis to test smoking-cessation pharmacotherapies. She has consulted
for Pfi zer and Sanofi – Aventis.
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