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  • ACOEM Comments on DoD Proposed Smoking Cessation Rule

    November 21, 2011

    The Honorable Leon E. Panetta
    Secretary, U.S. Department of Defense
    1400 Defense Pentagon
    Washington, DC 20301-1400

    Re: File Code DOD-2011-HA-0038

    Dear Secretary Panetta:

    The undersigned leading health and medical organizations appreciate the opportunity to comment on the Department of Defense’s (DOD) proposed rule regarding the Smoking Cessation Program Under TRICARE. Congress passed the provision requiring coverage in 2008, and we are pleased that DoD is implementing this equirement to help members of the military and their families quit smoking. We congratulate DoD on the comprehensive approach taken in interpreting this requirement, but we have specific concerns about some of the access limitations in the proposed rule.

    Tobacco Use in the Military

    Tobacco use remains the leading cause of preventable death in the United States and not surprisingly, is a significant problem within the military as well. The 2008 Department of Defense Survey of Health Behaviors among Active Duty Personnel found that while smoking rates among active duty personnel have essentially remained steady since 2002, smoking rates among deployed personnel are significantlyhigher. Alarmingly, more than one in seven (15 percent) of active duty personnel begin smoking after joining the service.1 

    Currently, the smoking rate for active duty military is 30.5 percent, with smoking rates highest among personnel ages 18 to 25. Smoking rates are especially high among soldiers and Marines. The Department of Veterans Affairs estimates that more than 50 percent of all active duty personnel stationed in Iraq smoke,2 an indication of the need for tobacco cessation services under TRICARE when they leave Iraq.  The use of tobacco compromises military readiness and the performance of our men and women in the armed forces. Studies have found that smoking is one of the best predictors of training failure, and it has also been shown to increase soldiers’ chances of physical injury and hospitalization.Tobacco use not only costs the DoD in troop readiness and health – it also costs the DoD money. The Pentagon spends over $1.6 billion on tobacco-related medical care, increased hospitalization and lost days of work.4 

    These reasons make it crucial that DoD take steps to help smokers in the military and their families quit smoking. This proposed rule instituting smoking cessation coverage in TRICARE is an important step in this direction.

    Tobacco Cessation Treatment

    The U.S. Public Health Service details the most current science on tobacco cessation treatment in the Treating Tobacco Use and Dependence Guideline. The most recent edition of the Guideline recommends seven medications (Nicotine gum, patch, lozenge, nasal spray and inhaler; and bupropion and varenicline) and three types of counseling (individual, group and phone counseling) as evidence- based treatments to help tobacco users quit.

    Treatment for smoking cessation is not one-size-fits-all. Just like other medical conditions, patients respond to treatment differently. It is normal for patients to try more than one treatment before finding the right one.  For all these reasons, it is important that cessation benefits offered to smokers be comprehensive – meaning they include all treatments proven effective.

    Quitting tobacco is very hard to do, and takes a large amount of motivation. Therefore, tobacco cessation treatment should be as easy to access as possible.  Tobacco cessation benefits must be publicized in ways appropriate for relevant target populations. Clinicians must also be made aware of available benefits and trained in tobacco cessation counseling. Treatment should be offered free or at as low of a cost as possible, and should not be subject to arbitrary limits on amount or duration as most smokers require multiple quit attempts to be successful.5 Any provision that makes it harder for a tobacco user to get treatment will potentially discourage them from quitting or cause failure.6 

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    1Department of Defense. Military Health System. 2008 Department of Defense Survey of Health Behaviors among Active Duty
    Personnel. December 2009. Available at:  http://www.tricare.mil/tma/studiesEval.aspx
    2Hamlett-Berry, KW, as cited in Beckham, JC et al. Preliminary findings from a clinical demonstration project for veterans
    returning from Iraq or Afghanistan. Military Medicine. May 2008; 173(5):448-51.
    3Institute of Medicine. Combating Tobacco Use in Military and Veteran Populations. 2009; 3-4.
    4 Institute of Medicine. Combating Tobacco Use in Military and Veteran Populations. 2009; 56.
    5 Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. A Clinical Practice Guideline. US Department of Health and Human Services. Public Health Service, 2008. Available at http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf.
    6 See pages 139-141. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. A Clinical Practice Guideline. US Department of Health and Human Services. Public Health Service, 2008. Available at  http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf

    TRICARE Smoking Cessation Program

    We applaud DoD for proposing a robust tobacco cessation benefit in this rule.  Individual and group counseling are both specifically covered, and a toll-free quitline is available. The proposed rule requires that medications are covered, including over-the-counter medications. We recognize that the DoD Pharmacy and Therapeutics Committee will decide specifically which medications to place on the formulary and make available. We strongly urge the Committee to include all the FDA-approved tobacco cessation medications. 

    The proposed rule includes some limitations on the smoking cessation program. The limit on number of counseling sessions covered per quit attempt is consistent with the Public Health Service Guideline. The limit of 120 days of medications treatment per quit attempt accommodates the typical duration of most tobacco cessation medications.  The proposed smoking cessation program is covered for two quit attempts per year, and a third is available with prior authorization. The Public Health Service Guideline does not specify the number of quit attempts that should be covered, but it does note that “tobacco dependence is a chronic disease that often equires repeated intervention and multiple attempts to quit” and recommends the removal of barriers to tobacco cessation services, including utilization restrictions.  Ideally, TRICARE members should have access to tobacco cessation services throughout the year even if they require more than two quit attempts.

    The proposed rule contains two other limitations that the undersigned groups strongly urge DoD to change: (1) the overseas exemption, and (2) the limit on where TRICARE members can obtain tobacco cessation medications.

    In Section III and elsewhere, the proposed rule specifies the TRICARE smoking cessation program will not be made available to personnel residing overseas unless the Assistant Secretary of Defense for Health Affairs [ASD(HA)] determines it can be “reasonably provided” overseas.  While we understand the unique challenges DoD faces with military families stationed across the globe, we are concerned this provision will result in too few military personnel having access to this benefit while overseas.

    We believe it is necessary and possible to make cessation counseling and medications available to many TRICARE members overseas. We urge DoD to change the rule to require the TRICARE smoking cessation program be available to all TRICARE beneficiaries, unless the ASD(HA) determines it not ossible to provide the program in specific  overseas locations or situations. This approach still allows DoD flexibility, but begins with the important resumption that all personnel have access to the benefit.

    The proposed rule also states that smoking cessation medications will only be available through the mail-order pharmacy program or military treatment facilities (MTF). We recognize that the Act providing the authority to establish a smoking cessation program in TRICARE states that the availability of pharmaceuticals should be limited to the national mail-order pharmacy program “if appropriate.” The proposed rule does not indicate that DoD conducted an evaluation to determine if this limitation is appropriate and limiting pharmaceuticals to mail-order and MTF-only could be a significant barrier for some TRICARE members. Our organizations urge DoD to implement access through the mail-order program and military treatment facilities immediately and then further expand TRICARE members’ access to these medications through other appropriate methods as soon as possible. 

    Almost three years have passed since Congress enacted the TRICARE Smoking Cessation Program, and DoD has yet to implement this benefit. We urge DoD to make these changes to the proposed rule and finalize it without delay, giving military members and their families the best chance to quit and be healthier. DoD will also reap the benefits of lower healthcare costs and a more productive, combat- ready military.

    Thank you for your consideration.

    Sincerely,

    American Cancer Society Cancer Action Network
    American Heart Association American Lung Association Campaign for Tobacco-Free Kids Partnership for Prevention Academy of General Dentistry
    American Academy of Family Physicians
    American Association for Respiratory Care
    American College of Occupational and Environmental Medicine
    American College of Preventive Medicine
    American Medical Association American Psychological Association Association of Black Cardiologists
    Association of Women's Health, Obstetric and Neonatal Nurses
    Legacy
    Lung Cancer Alliance
    National Association of County and City Health Officials
    National Association of Local Boards of Health
    National Latino Tobacco Control Network
    Society for Cardiovascular Angiography and Interventions
    United Methodist Church – The General Board of Church and Society