Affiliations: City of Hope National Medical Center
The Cardiac Center of Creighton University
Correspondence to: Frederic W. Grannis, Jr, MD, FCCP, Head, Section of Thoracic Surgery, City of Hope National Medical Center, Duarte, CA 91010; e-mail: firstname.lastname@example.org
To the Editor:
In the November issue of CHEST, Hilleman et
al1 published valuable information on the direct financial
costs of providing care for patients with COPD. Although the authors
provide the valuable information that the annual health-care cost of
stage III COPD is much higher ($10,812) than stage I COPD ($1,681), and
itemize direct costs, there is important information in their article
that goes without comment.
For example, although 26% of patients with stage I COPD are current
smokers, there is no mention of costs for nicotine replacement,
bupropion, or smoking-cessation counseling. Presumably, the data
accurately reflect the fact that COPD patients were not helped with
smoking-cessation interventions proven effective in prospective
randomized clinical trials. This is not surprising given the current
schizophrenic state of the art.
Although the National Institutes of Health, Agency for Healthcare
Policy and Research guidelines clearly mandate that all smokers should
have nicotine replacement or bupropion prescribed, neither Medicare,
nor Medicaid, nor private insurers pay for such
treatment.2 The data of Hilleman et al1
suggest that this is a costly frugality. Spending $250 to $500 for
nicotine replacement and/or bupropion in stage I COPD patients might
reasonably be expected to achieve smoking cessation in 30 to
40%.3We know from the results of the Lung Health Study
that decrements in pulmonary function parallel those in nonsmokers
following smoking cessation.4 It is therefore possible
that spending a few dollars on smoking cessation in early stage COPD
may prevent or delay progression to advanced COPD, with enormous
potential cost savings.
It is time to quit paying “lip service” to preventive medicine, and
to provide funding for effective smoking-cessation interventions that
will prevent morbidity, mortality, and expense secondary to COPD,
cardiovascular disease, neoplasms, and other diseases caused by tobacco
products. The money to pay for these treatments is already available in
the > $280 billion Tobacco Master Settlement Agreement, the lion’s
share of which is now allocated by politicians to such mundane purposes
as paving the sidewalks of Los Angeles. More financing can be obtained
through a United States Department of Justice lawsuit against the
tobacco industry to recover > $22 billion annual Medicare costs
attributable to diseases caused by tobacco products.5
We wholeheartedly agree with the recommendations offered by Dr.
Grannis. Smoking cessation is clearly a cost-effective approach to
reducing the medical consequences and costs of COPD as well as a host
of other disease states. Smoking-cessation efforts are underutilized
not only in patients with COPD but in other high-risk patient groups,
such as those with myocardial infarction.1 Following
Agency for Health Care Policy and Research recommendations to fund
smoking-cessation treatment programs and reimbursing providers who
offer smoking-cessation treatments should go a long way to stimulate
more widespread use of these treatments.
Specific to our study, we clearly were not able to document what
percentage of patients had treatment for smoking cessation and, hence,
could not identify the costs or cost-effectiveness of such
interventions. The most commonly used forms of nicotine replacement
therapy (patch and gum) are available over the counter, which limited
our ability to capture utilization rates for these products. In
addition, bupropion was not generally used for smoking cessation until
1997-1998. Our data collection period extended from 1993-1994 through
1997-1998. This may be the reason we were unable to document use of
We concur with Dr. Grannis that a significant percentage of the tobacco
settlement dollars be used to cover the medical expenses of patients
suffering from smoking-related illnesses and for the implementation of
both preventative treatment and smoking-cessation interventions.
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