Even when Minnesota health plans pay for products to help smokers quit, plan members don't usually take them up on it, according to a study published today in the journal Health Affairs.

Only one-fourth of Minnesota smokers used nicotine patches and gum and the drug Zyban whether their health plans paid for them or not, the study by a Minnesota researcher found. Smokers whose medications were covered by insurance were no more likely to quit than smokers who paid for the products themselves. The results were consistent across both groups -- about one-fourth in each used nicotine replacement products, and about 10 percent in each succeeded in quitting at least once for 30 days. But only 4 percent of each group quit for six months or longer. It is the latest study showing that the standard medications for tobacco addiction are not very effective alone. This study, based on two surveys of 2,700 Minnesota smokers conducted 12 months apart, showed that even providing the medications for free doesn't make them any more popular or effective, researchers said. "It does not appear to be the saving grace," said Raymond Boyle, a researcher with the HealthPartners Research Foundation and the lead author of the study. How to treat nicotine addiction has been controversial in Minnesota. Early this year, state Attorney General Mike Hatch sought a court ruling against the Minnesota Partnership for Action Against Tobacco (MPAAT) for not doing enough to help individual smokers quit. As a result, MPAAT now provides patches and gum to smokers who call its tobacco help line. Boyle said the latest study shows that health plans and doctors may have to do more to make such medications worthwhile. For example, only one-third of the Minnesotans in the survey even knew that their health plan will pay for the medications, he said. Those who did know and took advantage of it tried to quit more often than those who didn't know. That's important, experts said, because on average it takes five to seven tries before smokers successfully stay off cigarettes for at least a year. The smokers did not get much support or assistance in quitting from their doctors, the survey found. Other studies have shown that those who do get help from their doctors succeed in quitting two to five times more often than those who don't, researchers said. The study did not measure the effectiveness of counseling or other types of support, but other research has shown that counseling can increase quit rates, especially when used in combination with nicotine replacement products. "I'm not sure it makes sense to spend money on medicines alone," Boyle said. Health plan officials said that the results came as no surprise, but added that the findings would not change their policies of providing the coverage. Dr. George Isham, chief medical officer for HealthPartners, said that the health plan covers medications for the majority of its members if they see a doctor and get a prescription. But it also encourages smokers to use telephone counseling services as well. Making counseling a requirement for members who want the medications "could be desirable, but not practical," he said, because it would create administrative headaches for the health plan and barriers for smokers who try to stop. HealthPartners, which has 670,000 members, spends about $1.75 million annually on patches, gum and Zyban. MPAAT does require counseling for uninsured smokers who call requesting patches or gum. MPAAT officials said that counseling is an essential part of helping smokers quit. "If you link it [medication] to counseling, there is strong evidence that it's useful," said Dr. Stuart Hanson, vice chairman of MPAAT's board and expert on smoking cessation at Park Nicollet Clinic in St. Louis Park. The study was initiated in 1998, when Minnesota health plans began offering coverage for the nicotine medications, researchers said. At the time, tobacco experts believed that if health plans gave their members access to nicotine treatments then "cessation would be a cinch," said Dr. Sanne Magnan, a co-author of the study and medical director of the tobacco research arm of Blue Cross and Blue Shield of Minnesota. Clinical trials had shown that smokers who use the products quit 30 percent of the time. Experts now say that those high rates most likely were in part the result of the artificial circumstances of a clinical trial. Study participants may have had more incentive to quit, or may have received emotional and psychological support as a part of the study. "Making them [nicotine products] available over-the-counter was based on the idea that it would increase access," Boyle said. "We'd have the medicines in the hands of folks, and we'd have all this quitting going on." This year there have been several studies showing that in the real world, it hasn't worked that way. Separate studies of Massachusetts and California smokers published earlier this year showed that making nicotine products available over the counter has not increased long-term quit rates in either state. The study published today shows similar results. Starting in 1998, the researchers surveyed two groups -- one consisted of smokers who had health plans that did not cover the medications, and a second group had health plans that did. "At the very least, we ought to be having this conversation" about what works and what doesn't, said Boyle. "And where should we be spending the money?"

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