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FROM "VITAL SIGNS" TO A NATIONAL ACTION PLAN: MOVING THE
NEEDLE ON SMOKING CESSATION
Michael C. Fiore, M.D., M.P.H. Named Robert Wood Johnson Foundation
Innovator
(Princeton, NJ, July 23, 2003) - Michael C. Fiore, M.D., M.P.H. can easily reel off numerous facts and figures on smoking. Just over 23 percent of adults in America smoke. Smoking adds $100 billion to the nation's health care bill each year and another $100 billion in lost productivity. The fact that touches him most deeply, however, is that one of every five deaths in the U.S. is caused by tobacco use. These deaths, he says, are preventable… and they disproportionately affect the most disadvantaged members of our society.
Fiore, a world-renowned scientist and practicing physician who put smoking status on the radar screen for the majority of his medical colleagues as a "vital sign" that they must monitor, wants to help at least five million Americans quit smoking each year, preventing approximately three million premature deaths. It's all part of a far-reaching national action plan he has developed and is trying to convince the federal government to adopt. The plan involves establishing a Smokers Health Fund through a tobacco excise tax increase, a national "quit line," a massive media campaign, counseling, research and many other elements. Fiore will use funds from a Robert Wood Johnson Foundation Innovators Combating Substance Abuse award he has just received to disseminate the recommendations of this national action plan.
Fiore and four others were recently named Innovators as part of a program that recognizes leaders in the fields of substance abuse prevention, treatment, and policy development, brings attention to their groundbreaking work and provides an opportunity for them to undertake projects they might not otherwise be able to complete.
"Unless the prevalence of tobacco use is cut dramatically," says Fiore, who is professor of medicine at the University of Wisconsin Medical School and founding director of the University of Wisconsin Center for Tobacco Research and Intervention, "about 24 million Americans - one out of two current smokers - will die prematurely of a disease directly caused by their dependence on tobacco." Many policy-makers may be inclined to listen to Fiore: he chaired the panel that produced the most influential guide on smoking cessation -- the Clinical Practice Guideline for Treating Tobacco Dependence. Almost two million copies of the guideline have been distributed and its recommendations have been widely adopted by the medical community.
Witnessing the Devastation of Addiction and Smoking at an Early Age
Raised in a poor neighborhood in Boston, Fiore lost two of his closest friends to substance abuse before high school graduation and watched how addiction devastated his neighborhood. He also saw how his mother, a smoker, suffered from heart disease. "These experiences helped drive my decision to become a physician," he says. "In the 1950s and 1960s we saw tobacco move to attack and kill the least advantaged members of society - the poorest, the least educated, and women, who were smoking at higher rates. Dedicating my medical career to this avoidable toll seemed to be a natural focus."
Fiore's experiences during his medical residency at Boston City Hospital strengthened his resolve to reduce the impact of tobacco. "The wards of Boston City, which provide care to those in greatest medical need, were filled with the deleterious effects of substance abuse, such as emphysema and cancer," he says. "We suffer an especially devastating burden from tobacco use, a very personal toll. Children are deprived of parents, individuals lose friends."
Smoking Status Becomes a "Vital Sign"
Because of Fiore's work, smoking status is now one of the vital signs America's medical community must monitor -- a move that has saved many lives. The development of the new vital sign was based on years of research and practical efforts in clinical settings by Fiore, first at the U.S. Office on Smoking and Health, and later at the University of Wisconsin. As early as 1992, Fiore developed strategies to prompt physicians to counsel patients to quit smoking. Realizing that clinicians and health delivery systems all view and accept the vital signs (blood pressure, pulse, respiratory rate, and temperature) as an essential component of every office or bedside visit, he proposed expanding these signs to include smoking status, publishing his proposal as a commentary in JAMA. Fiore then obtained National Institutes of Health funding to test the impact of this proposal, and documented in 1995 that this simple, no-cost institutional change more than doubled the rate of smoker identification and the rate at which clinicians counseled smokers to quit.
In 1994, Fiore published an editorial in JAMA: "Smoking Cessation Treatment and the Good Doctor Club." He emphasized the role of the clinician in confronting tobacco dependence and pointed out that 70 percent of smokers see a primary care clinician each year. Given that clinical intervention is associated with substantial increases in tobacco cessation rates, clinicians were losing a great opportunity to convince smokers to quit.
During the same year, Fiore, appointed chairman of a new expert federal expert panel charged with the task of writing the first evidence-based guideline for smoking cessation, led a review of more than 3,000 published articles and helped to conduct more than 50 meta-analyses of scientific papers on the topic. As a result, in 1996 the panel published Smoking Cessation Clinical Practice Guideline. The updated guideline, published by the United States Health Service in 2000 as Treating Tobacco Use and Dependence, is recognized as the standard of care for treating tobacco dependence.
Following publication of the guidelines, The Robert Wood Johnson Foundation asked Fiore to direct a new national program office, Addressing Tobacco in Managed Care. The office is designed to stimulate managed care organizations to adopt innovative evidence-based institutional changes that will increase the rates of smoking cessation among enrollees. Since the program began, it has awarded more than 25 grants to managed care organization-researcher partnerships, resulting in some of the most innovative systems-level substance abuse research conducted to date.
A National Plan for Smoking Cessation
Fiore plans to use his Innovators award to promulgate the recommendations of the National Action Plan for Tobacco Cessation, which he recently helped develop as chair of the Subcommittee on Cessation of the Interagency Committee on Smoking and Health. The plan calls for the establishment of a federally funded National Tobacco Quitline, an ongoing media campaign to help Americans quit, evidence-based counseling and medications for tobacco cessation, research on the effectiveness of tobacco treatment programs, and training and education for clinicians. A Smokers Health Fund, established through a $2 per pack excise tax increase would pay for this ambitious initiative.
As an Innovator, Fiore will convene a series of meetings in partnership with federal agencies, nongovernmental organizations and others to begin to effect the policy changes. He will also create and update a report card to monitor the progress of the federal government and other partners in implementing these policy changes.
Innovators Combating Substance Abuse is a national program of The Robert Wood Johnson Foundation that recognizes and rewards those who have made substantial, innovative contributions of national significance in the field of substance abuse. Each award includes a grant of $300,000, which is used to conduct a project over a period of up to three years that advances the field. The program addresses problems related to alcohol, tobacco and illicit drugs, through education advocacy, treatment and policy research and reform at the national, state and local levels. The Innovators program is run by a national program office at The Johns Hopkins University School of Medicine.
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NOTE TO LOCAL EDITORS: Michael Fiore is a resident of Madison, Wisconsin.
For additional information on the Innovators Combating Substance Abuse program, please visit the Web site: www.SAInnovators.org.
MICHAEL
C. FIORE, M.D., M.P.H.Innovator Combating Substance Abuse
Michael C. Fiore, M.D., M.P.H., is Professor of Medicine at the University of Wisconsin Medical School and director of the University of Wisconsin Center for Tobacco Research and Intervention, which he founded in 1992.
Fiore is chairperson of the Subcommittee on Cessation of the U.S. Department of Health and Human Services Interagency Committee on Smoking and Health, which was charged with developing an action plan for promoting tobacco cessation throughout the United States. He is principal investigator of "Relapse: Linking Science to Practice," a Transdisciplinary Tobacco Use Research Center grant funded by the National Institutes of Health.
Among his many accomplishments, Fiore has helped physicians across America to understand tobacco dependence as a chronic disease. He spearheaded a campaign to establish smoking status as a vital sign in patients' charts and to develop real-world strategies for treatment that doctors can incorporate in their day-to-day practice.
Fiore was a contributing author on a series of articles published in the Journal of the American Medical Association in 1989 that served as the first comprehensive assessment of population-based patterns of tobacco use and cessation.
In 1996, he chaired the federal panel that developed the internationally recognized Smoking Cessation Clinical Practice Guideline, now considered the single most important document ever produced to set standards of care for treatment of tobacco dependence. Fiore also took a lead role with other national panels and was the coauthor of the 1989 report of the Surgeon General summarizing 25 years of progress on addressing tobacco use and treatment needs.
In 1997, Fiore was named director of The Robert Wood Johnson Foundation National Program Office for Addressing Tobacco in Managed Care, which promotes the institution of evidence-based smoking cessation practices in healthcare systems.
In 2000, Fiore chaired the panel that undertook a major revision of the previous clinical practice guideline under the auspices of the United States Public Health Service. This Clinical Practice Guideline: Treating Tobacco Use and Dependence is based on a review of 6,000 articles and is considered the gold standard for healthcare providers for tobacco use treatment.
Most recently, Fiore was awarded a training contract to conduct a Medicare Stop Smoking Program Continuing Medical Education program.
Fiore received his bachelor's degree from Bowdoin College, graduating magna cum laude. He earned a medical degree from Northwestern University Medical School and did pre-doctoral research in pulmonary medicine and occupational health at the University of Perugia in Italy. He did residency training in internal medicine at Boston City Hospital and earned a master's in public health in epidemiology from Harvard University School of Public Health. He worked as an epidemic intelligence service officer for the Centers for Disease Control, then became a medical epidemiologist for the U.S. Office on Smoking and Health.
Fiore saw active duty from 1990 to 1991 during the Persian Gulf War, serving as a major in the U.S. Army.
Among Fiore's many honors are The U.S. Surgeon General's Certificate of Appreciation, which he received in 2002 for exceptional leadership in disseminating the first and second Clinical Practice Guidelines on Tobacco Cessation. That same year, Fiore received the Champion of Women's Health Award from the Wisconsin Women's Health Foundation.
Fiore is one of five individuals selected to receive The Robert Wood Johnson Foundation's Innovators Combating Substance Abuse award in 2003.
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A national program supported by The Robert Wood Johnson Foundation with direction and technical assistance provided by the Department of Psychiatry and Behavioral Sciences at The Johns Hopkins University School of Medicine.