Supplementing US framework for smoking cessation

CHEST is the leading professional association in innovative and life-saving chest medicine. We support the advancement of improved health outcomes for patients with lung disease through education, advocacy, research, and philanthropy. CHEST is the professional home for more than 21,000 pulmonary, critical care, and sleep medicine professionals dedicated to the delivery of quality, evidence-based care for patients. Our mission is to champion the prevention, diagnosis, and treatment of chest diseases with a focus on ensuring and improving access for all patients, particularly underserved patients of highest need.

Addressing the issue of smoking cessation has been a long-standing priority for CHEST. We welcome the opportunity to respond to the five questions included in the RFI, as well as put forth overarching recommendations as the Department moves toward building and finalizing its Framework. A summary of our recommendations are as follows:

• Understand the Patient Population of Need. The Department should set the goal of obtaining a more robust understanding of the social science affecting specific population-based behaviors, their barriers to access, and their engagement with available resources, in order to accurately target health disparities and improve cessation outcomes.

• Coalesce Key Agencies and Programs. HHS should prioritize inter-agency and cross-program collaboration and cooperation as a key strategy within the Framework.

• Expand Scope to Address E-Cigarettes. HHS should strongly consider expanding the Framework to include e-cigarettes at this initial juncture, recognizing that the harm profile of these products on at-risk populations has not been identified.

I. Responses to 5 Questions Included in the RFI

• Question 1: Appropriateness and Relevance of Goals for Addressing the Needs of PopulationsDisparately Affected by Smoking and Question 2: Extent to Which the Broad Strategies Capture Key Components and Aspects Necessary to Drive Progress Toward Increasing Cessation

Overall, CHEST supports the Draft Framework vision stated, “to ensure that every person in America has access to comprehensive, evidence-based cessation treatment and can benefit from HHS cessation supports, programs, and policies”; however, to achieve this vision, the goals set through this Framework should be commensurately ambitious and forward-looking. In this RFI, the Department states its aim to both accelerate smoking cessation as well as reduce smoking-related health disparities. The Draft Framework identifies six goals that summarize activities and initiatives that are in existence today.² Though the broad strategies laid out in the Draft Framework exhibit evidence-based strategies that are in effect at varying degrees today, these are necessary, but arguably not sufficient.

• Question 3: Additional Goals or Broad Strategies That Should Be Included in the Framework

At the center of smoking cessation services and initiatives are the patients, particularly the underserved patient population. It is well documented that low-income populations among other underserved populations are disproportionately affected by cigarette smoking and tobacco use³; however, there is much information yet to be obtained about the target population and what their needs are. Between 30% to 50% of smokers in the U.S. make a quit attempt in any given year, though the rate of success rate is only approximately 7.5%.⁴ CHEST recommends that HHS include in the final Framework an additional goal to obtain a more robust understanding of the social science affecting specific population-based behaviors, their barriers to access, and their engagement with available resources regarding smoking prevention and cessation.

As noted in the RFI, cigarette smoking is the single leading cause of preventable disease, disability, and death in the U.S., and in 2023, cigarette smoking will directly cause more than 80% of lung cancer deaths.⁵ Achieving positive health outcomes for the health and wellness of the patient population through smoking cessation is possible when supplemented by comprehensive services, such as lung cancer screening. Lung cancer screening and smoking cessation are strongly linked, with various associations putting forth best practice recommendations to incorporate cessation counseling with screening visits. Emphasizing lung cancer screening would bolster the Draft Framework and help provide a more comprehensive strategy.

• Question 4: Targeted Actions HHS Should Take to Advance the Outlined Goals and Strategies

CHEST agrees with the Department that improving coverage of tobacco cessation treatment in Medicare, Medicaid, and private insurance (Goal 4) is a key priority. To ensure comprehensive coverage, HHS should put forth guidance and compile reports on the necessary elements of comprehensive state tobacco control programs. For example, in the 2020 Report to the Surgeon General, the Department stated successful elements of comprehensive smoking cessation programs to include: “state and community interventions; mass-reach health communication interventions; cessation interventions; surveillance and evaluation; and infrastructure, administration, and management”.⁷ Additionally, HHS should provide additional guidance to state programs on the need to cover all FDA-approved medications.

• evaluation of state and local programs and actions toward more comprehensive coverage;

• evaluation of patient barriers and improvements in access;

• quitline utilization and outcomes; and

• lung cancer screening rates.

II. Overall Recommendations 

Administration-wide efforts, like the Biden Cancer Moonshot, set ambitious goals for reducing the death rate from cancer, and CHEST commends these efforts. Though we have seen great strides in smoking cessation over the years, we know that in order to take leaps forward, it will require commitment and forward thinking across the federal government in concert with organizations like CHEST. In order to develop targeted and effective strategies for the future of smoking cessation, it is imperative to understand the patient population’s needs and access barriers. CHEST recommends that HHS take steps to gain a deeper understanding of the social science affecting specific population-based behaviors, their barriers to access, and their engagement with available resources. The Department should prioritize efforts to collect information and data on the smoking population throughout the U.S. and conduct a thorough evaluation of the modern barriers for smoking cessation access and root causes of disparities prevalent in care delivery. You cannot fully solve a problem without a clear understanding of every challenge that persists.

The Department includes “Coordination, Collaboration, and Integration” as a Cross-Cutting Principle. CHEST agrees that coalescing various agencies and programs would strengthen the initiative. For example, in February 2023, the Food and Drug Administration (FDA) Center for Tobacco Products (CTP) outlined steps the CTP would take to strengthen its tobacco program. These steps include the reinvigoration of the Tobacco Products Scientific Advisory Committee (TPSAC) as well as the development and implementation of a 5-year strategic plan. The CTP states that it “must pivot from a reactive mode to a proactive mode”.⁹ Additionally, to further the previous recommendation of evaluating a more robust understanding of the patient population of greatest need, CHEST recommends collaboration, such as cooperation between the NIH and CDC to increase research funding to evaluate population-wide social determinants for smoking cessation. CHEST believes that HHS should promote coordination, collaboration, and integration of programs and activities across the Department to support the implementation and sustainability of effective cessation practices, programs, and policies, which should be reflected in the final Framework.

Included in the RFI is the stated intention to focus on “cessation of the use of commercial cigarettes, cigars, and cigarillos, for people of all ages across the lifespan” by omitting stances on e-cigarettes. CHEST acknowledges that there is more research to be done on the impact and outcomes of e-cigarette use; however, the significant increase in e-cigarette use in the U.S. population, especially among the population that has never used combustible cigarettes signals a need to address an increasingly prevalent mode of smoking.¹⁰ In the 2020 Report to the Surgeon General, the Department stated the importance of “monitoring the findings of research on the potential of e-cigarettes as a smoking cessation aid” and “evaluating the positive and negative impacts that these products could have at the individual and population levels”.¹¹ Though research is underway on the causal relationship between e-cigarette use and cancer, there is compelling evidence that associations exist.¹² Excluding monitoring and evaluating e-cigarette effects as a goal in the final Framework would represent a missed opportunity to addressing a key factor in the future of smoking cessation efforts.

III. Conclusion

CHEST greatly appreciates the Administration’s efforts and the opportunity to comment on the Draft Framework targeting smoking cessation, an issue of key significance to the patients we serve and physicians we represent. We would be pleased to answer any questions about these comments and look forward to continuing to work with HHS on ensuring uniform and equitable access to tobacco use prevention and cessation services.