The Big Picture:

1
The Big Picture An Overview of Major Events
Shaping National, State, Public and Private
Cessation Policy Matt Barry Director, Policy
Research Campaign for Tobacco Free
Kids Washington, DC
2

• Whats on the Radar?
• What SHOULD We Be Doing?
• Medicare
• Medicaid
• Other Federal Programs
• State Insurance Mandates
• DOJ
• Varenicline and Rimonabant
• Other
• X Factors

3
What SHOULD We Be Doing?
According to CDCs Task Force on Community
Preventive Services, interventions should include
restrictions on exposure to secondhand smoke,
increases in the unit cost of tobacco, mass media
campaigns, provider reminder systems, reducing
out-of-pocket expenses, and telephone
counseling/support. Source AJPM, 200120(2S),
Recommendations Regarding Interventions to
Reduce Tobacco Use and Exposure to Environmental
Tobacco Smoke, http//www.thecommunityguide.org/t
obacco/tobac-AJPM-recs.pdf.
4
What SHOULD We Be Doing?

• Strategies to Reduce Exposure to Secondhand Smoke
• Smoking bans and restrictions strongly
  recommended. Strong scientific evidence that
  they reduce exposure to ETS (1) in a wide range
  of workplace settings and adult populations (2)
  when applied at different levels of scale, from
  individual businesses to entire communities and
  (3) whether used alone or as part of a
  multi-component community or workplace
  intervention.
• Strategies to Reduce Tobacco Use Initiation
• Increasing the unit price for tobacco products
  strongly recommended. Strong evidence of
  effectiveness in reducing tobacco use prevalence
  in study populations of adolescents and young
  adults In addition, increasing the price for
  tobacco products is also effective in (1)
  reducing population consumption of tobacco
  products, and (2) increasing tobacco use
  cessation.
• Mass media campaigns strongly recommended (when
  combined with other interventions). Strong
  evidence of effectiveness in reducing tobacco use
  prevalence among adolescents when implemented in
  combination with tobacco price increases,
  school-based education, and/or other community
  education programs.

5
What SHOULD We Be Doing?

• Strategies to Increase Tobacco Use Cessation
• Increasing the unit price for tobacco products
  strongly recommended. Strong evidence of
  effectiveness in (1) reducing population
  consumption of tobacco products, (2) reducing
  tobacco use initiation and (3) increasing
  tobacco cessation. Excise tax increases
  demonstrated evidence of effectiveness in a
  variety of populations and when implemented at
  both the national and state levels.
• Mass Media Education
• Campaigns strongly recommended (when combined
  with other interventions). Strong evidence of
  effectiveness in (1) reducing population
  consumption of tobacco products, and (2)
  increasing cessation among tobacco product
  users.

6
What SHOULD We Be Doing?

• Health Care System-Level Interventions
• Provider reminders recommended. Provider
  reminders are recommended (1) whether used alone
  or as part of a multi-component intervention
  (2) across a range of intervention
  characteristics (chart stickers, checklists, and
  flowcharts), and (3) in a variety of clinical
  settings and populations.
• Provider reminder plus provider education, with
  or without patient education strongly
  recommended. Strongly recommended on the basis
  of strong evidence that this combination (1)
  increases provider delivery of advice to quit to
  tobacco using patients, and (2) increases patient
  tobacco use cessation.
• Reducing patient out-of-pocket costs for
  effective cessation therapies recommended.
  Recommended on the basis of sufficient
  scientific evidence of effectiveness in (1)
  increasing use of the effective therapy, and (2)
  increasing the total number of tobacco-using
  patients who quit.
• Multicomponent patient telephone support
  strongly recommended. Strongly recommended on a
  strong body of evidence that this combination
  intervention (1) increases patient tobacco
  cessation, and (2) is effective in both clinical
  settings and when implemented community-wide.

7

• Nice Theory, But Does It Work?
• Ask New York City
• What did they do?
• Comprehensive Smoke Free Law
• Highest Cigarette Excise Tax In the U.S.
• Well-Funded State Tobacco Control, Prevention and
  Cessation Program (including quitline and quit
  clinics)
• The results?
• In one-year, an 11 drop in adult smoking rates
  between 2002-2003 (from 22 to 19).
• 100,000 fewer smokers.

8
What are we ACTUALLY doing?
9

• Medicare
• March 22, 2005 - CMS issued a final decision memo
  to cover tobacco cessation counseling services
  under Part B.
• Counseling services are now available to all
  beneficiaries with a disease or an adverse health
  effect linked to tobacco use or who are taking a
  therapeutic agent that is affected by tobacco
  use.
• Medicare now covers 2 cessation attempts per year
  - a maximum of 4 intermediate or intensive
  sessions, with the total annual benefit up to 8
  sessions.

Source Decision Memo for Smoking Tobacco Use
Cessation Counseling (CAG-00241N), March 22,
2005, http//www.cms.hhs.gov/mcd/viewdecisionmemo.
asp?id130.
10

• Medicare Next Steps
• Need to promote awareness of this benefit among
  beneficiaries and providers.
• Need to promote awareness of this decision by CMS
  among other public and private insurers.
• Need to work with CMS and/or Congress to allow
  access by beneficiaries to telephone quitline
  services quitlines are not eligible for
  reimbursement under the CMS decision.
• Need to coordinate this benefit with prescription
  drug benefit taking effect January 2006.
• Need to work with CMS on training/certification
  of providers.

Source Decision Memo for Smoking Tobacco Use
Cessation Counseling (CAG-00241N), March 22,
2005, http//www.cms.hhs.gov/mcd/viewdecisionmemo.
asp?id130.
11
Other Federal Activity Federal Employees Health
Benefit Plan - In an August 7, 2003 memo to Rep.
Meehan, former OPM Director Kay Cole James
stated I continue to encourage FEHBP plans to
provide benefits for programs aimed at health
promotion and disease prevention, including
smoking cessation programs While we urge plans
to cover special benefits and programs, we do not
mandate that they do so For more information
on FEHBP, see http//www.opm.gov/insure/health/ind
ex.asp Federal Bureau of Prisons Effective
July 15, 2004 1. PURPOSE AND SCOPE 551.160.
To advance towards becoming a clean air
environment and to protect the health and safety
of staff and inmates, the Bureau of Prisons will
restrict areas and circumstances where smoking is
permitted within its institutions and offices.
For more information on BOP no smoking policy,
see - http//www.bop.gov/ Department of Veterans
Affairs The VA published an interim final rule
in the Federal Register on May 2, 2005, to
amend its medical regulations concerning
co-payments for inpatient hospital care and
outpatient medical care. This rule designates
smoking cessation counseling (individual and
group sessions) as a service that is not subject
to co-payment requirements. The intended effect
of this interim final rule is to increase
participation in smoking cessation counseling by
removing the co-payment barrier. For more
information on VA cessation programs and
policies, see - http//www.publichealth.va.gov/smo
king/describe.htm and http//www.va.gov/smokingmh/
index.html
12

• Current CMS Federal/National Policy On Cessation
  for Medicaid
• General Policy -
• Smoking cessation benefits, such as counseling
  and drug therapy, are optional benefits under
  Medicaid (except for kids covered under EPSDT).
• Smoking cessation drugs are specifically
  classified as those drugs that may be excluded
  from coverage under Medicaid.
• Smoking cessation counseling services may be
  provided under a variety of Medicaid benefit
  categories.
• Pregnant Women - There are no mandatory smoking
  cessation benefits for pregnant women under
  Medicaid. A state may elect to provide smoking
  cessation services in a State plan.

13
Medicaid State Activity
Its ugly out there folks
14
Despite the crushing financial burden of Medicaid
on State budgets
Medicaid growth continues to outpace every
other functional category of state expenditure,
increasing by 8 percent in fiscal 2003 Medicaid
now totals 21.4 percent of all state
spending. Total Medicaid spending in fiscal
2003 excluding administrative costs was 243.6
billion ... Source National Association of
State Budget Officers, 2003 State Expenditure
Report, http//www.nasbo.org/Publications/PDFs/20
03ExpendReport.pdf.
15
there is hope!!!!!

• For Example
• The State of Kentucky had a projected 200
  million budget deficit for FY 2005 (Source
  Center for Budget and Policy Priorities, State
  Budget Deficits Projected For FY 2005,
  http//www.cbpp.org/10-22-03sfp2.htm).
• Despite this deficit, a NEW tobacco cessation
  benefit for pregnant women was added to the
  Medicaid program.
• Our message? It saves lives, it saves money and
  it works.
• How did this happen? Good luck, great facts, and
  great work by the state coalition, state
  officials and legislators.
• If it can happen in Kentucky, it can happen
  anywhere.

16
Number of State Medicaid Programs Covering
Tobacco Dependence Treatments (N51), 2003
Source Halpin, HA, MMWR, January 30, 2004 /
53(03)54-57.
Source Analysis by the Center for Health and
Public Policy Studies, University of California
at Berkeley of the State Medicaid Tobacco
Dependence Treatment Survey, 2003.
http//statehealthfacts.org/cgi-bin/healthfacts.cg
i?actioncomparecategoryHealthStatussubcategor
ySmokingtopicCessationTreatmentUnderMedicaid
.
17
Informing Medicaid Tobacco Users about Benefits,
2003
Methods for Informing Medicaid Recipients States 2002 States 2003
Inform tobacco users about benefits 9 18
Through primary care provider 5 8
Mailer 5 6
Newsletter/magazine 3 4
Television spots 3 3
Member services/information line 3 8
Website 2 3
New member packet 2 8
Source Analysis by the Center for Health and
Public Policy Studies, University of California
at Berkeley of the State Medicaid Tobacco
Dependence Treatment Survey, 2003.
http//statehealthfacts.org/cgi-bin/healthfacts.cg
i?actioncomparecategoryHealthStatussubcategor
ySmokingtopicCessationTreatmentUnderMedicaid
.
18
COVERAGE CONSISTENT WITH PHS GUIDELINES

• 9 States Offer Comprehensive Coverage
• California
• Indiana
• Maine
• Minnesota
• New Jersey
• New York
• Oregon
• Pennsylvania
• West Virginia

Zyban, NRT Gum, Patch, Nasal Spray, Inhaler,
and at least one type of counseling (individual,
group or proactive telephone).
Source Halpin, HA, MMWR, January 30, 2004 /
53(03)54-57.
19

• State Insurance Mandates
• New Mexico Is the first state to mandate
  comprehensive tobacco cessation benefits by all
  health care insurers (except Medicaid)
  effective 3/1/04. The benefit includes
• Diagnostic services Diagnostic services
  necessary to identify tobacco use, use-related
  conditions and dependence.
• Pharmacotherapy Two 90-day courses of
  prescription-only medications per calendar year.
• Cessation counseling A choice of cessation
  counseling of up to 90 minutes total provider
  contact time or two multi-session group programs
  per calendar year.
• California A bill (SB 576) was passed in the
  California legislature (Senate and Assembly), but
  vetoed by the Governor, that would have required
  health plans and insurers to cover the following
  tobacco cessation services
• Counseling (4 sessions of at least 30
  minutes each),
• All Rx and OTC cessation medications,
• Two quit attempts per year.
• Maryland New mandate (HB 303 signed by the
  Governor 5/10/05) requiring certain insurers to
  provide coverage for prescription-only cessation
  drugs (eff. 10/1/05).

20
Department of Justice Tobacco Trial
21

• Trial phase concluded in early June 2005.
• In light of major and unexplained changes to
  DOJs own cessation remedy, several public health
  groups (TFK, ACS, ALA, ANR, AHA, NAATPN) sought
  to intervene in the case.
• The Court granted the motion to intervene in July
  2005. Interveners have since filed their own
  proposed remedies with the Court (8/31/05) and a
  reply brief (9/26/05).
• The case brings with it an opportunity and the
  potential for significant funding for cessation
  services for all smokers in the U.S. Conversely,
  there exists substantial risk for a bad
  settlement.
• There remain several issues under appeal that
  could have a major impact on the potential
  financial and non-financial remedies available.
• If no settlement takes place, a ruling on
  liability is expected by late 2005, early 2006.

There Are Risks Opportunities
22
NEW DRUGS!!
Varenicline and Rimonabant
23

• Varenicline (Pfizer) and Rimonabant
  (Sanofi-Adventis) are two new drugs that FDA is
  expected to approve in the next 6 to 18 months.
• Both are in late stage clinical trials and
  publicly available data thus far suggests that
  quit rates are at least as high as currently
  available NRTs.
• The buzz around these drugs is block buster
  that could result in extensive, high profile
  media.
• Regardless of your views on pharmacotherapy/NRT,
  this will provide a unique opportunity to discuss
  cessation issues with a variety of audiences and
  we must be prepared to take advantage of this
  opportunity when it happens.

24
Other Activities National Quitline Network
1-800-QUITNOW Tax and Smokefree
Activity Increased Private Sector Interest in
Tobacco X Factors
25

• National Quitline Network
• 1-800-QUITNOW
• Has been in effect since November 2004 (approx.
  156,000 callers through October 2005).
• Very little for promotion or actual services.
• Has the potential to serve as the portal for a
  much more ambitious and comprehensive quitline
  network.
• Funding at the federal level has been nominal
  and, as a result, the potential impact limited.

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• Tax and Smokefree Activity
• ... they keep going, and going, and going ...
• 57 state tax increases since January 2002 (12 in
  2005)
• 25 of U.S. population covered by comprehensive
  smokefree laws.
• Sources Campaign for Tobacco Free Kids,
  Cigarette Tax Increases By State State Per Year
  2000-2005, http//www.tobaccofreekids.org/research
  /factsheets/pdf/0275.pdf Americans for
  Nonsmokers Rights Foundation, Summary of United
  States Population Protected by 100 Smokefree
  Laws, http//www.no-smoke.org/pdf/percentstatepops
  .pdf.

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Recent Cigarette Tax Increases
WASHINGTON 202.5
MONTANA 170
MAINE 200
NORTH DAKOTA 44
VT119
MINNESOTA 123
OREGON 118
VT
IDAHO 57
NH 80
WISCONSIN 77
SOUTH DAKOTA 53
NEW YORK 150
MA
MA151
WYOMING 60
RI246
MICHIGAN 200
CT
CT151
IOWA 36
PENNSYLVANIA 135
NJ240
NEBRASKA 64
NEVADA 80
OHIO 125
DELAWARE55
UTAH 69.5
IN 55.5
ILLINOIS 98
WV 55
30 VIRGINIA
MARYLAND100
COLORADO 84
KANSAS 79
MISSOURI 17
DC100
87
KENTUCKY 30
CALIFORNIA
NORTH CAROLINA 30
TENNESSEE 20
OKLAHOMA 103
ARKANSAS 59
ARIZONA 118
NEW MEXICO 91
SOUTH CAROLINA 7
GEORGIA 37
ALABAMA 42.5
MS 18
TEXAS 41
36 LOUISIANA
ALASKA 160
FLORIDA 33.9
HAWAII 140
States that have recently passed or implemented a
cigarette tax increase (since 1/1/2002)
Oregon actually decreased its cigarette tax by 10
cents on 1/1/04. The second phase of the North
Carolina tax increase (an additional 5-cents)
will be effective 7/1/06, bringing the NC tax to
35 cents per pack.
November 1, 2005
30
Smoke-Free Laws
Restaurants and Bars
Restaurants
June 2005
31

• Increased Private Sector Interest in Tobacco
• There is an increasing recognition of the
  negative financial impact of tobacco on the
  corporate bottom line.
• Companies are tired of wasting scarce resources
  on spiraling health care costs and desperately
  want to do something about it.

32

• Increased Private Sector Interest in Tobacco
• There is a slow but growing realization of the
  positive impact of tobacco control policy changes
  (e.g., tax increases, smokefree laws) on
  corporate financial performance.
• Tobacco control can be part of the solution to
  their problem.
• By Jove, I think shes got it!

33
Increased Private Sector Interest in Tobacco Is
this good or bad?
the fact is, federal and state laws prohibit
employers from discriminating on the basis of
age, sex, race, weight, national origin and other
attributes -- and smoking is not a civil right.
It's just a poor personal choice. - Howard
Weyers, CEO, Weyco, Inc.
34
X factors
35

• Peter Jennings
• The recent death of ABC Nightly News Anchor Peter
  Jennings has generated a significant amount of
  coverage in the media about smoking, lung cancer
  and the importance of quitting.
• This is a teachable moment for many people and
  organizations consumers, the media, policy
  makers, health care professionals, health
  plans/insurers/organizations.
• We always need to be prepared for, and take
  advantage of, in a positive and respectful
  manner, the good that can come out of one
  individuals personal tragedy.

36

• In response to the death of Peter Jennings, ABC
  News launched a month-long series (November 2005)
  of stories on ABC World News Tonight and on Good
  Morning America about the harms associated with
  tobacco use, about how to quit using tobacco, and
  about lung cancer.
• The resources include on-air stories, a dedicated
  website, partnerships with major public health
  organizations, and publicizing of cessation
  resources, including the national quitline number
  1-800-QUIT NOW.
• This is unprecedented.

37

• Hurricane Katrina
• In a recent webcast to investors, U.S. Smokeless
  Tobacco Company cited Hurricane Katrina and its
  impact on higher gasoline prices for a
  substantial, negative impact on sales,
  particularly in the Gulf Coast region.
• According to UST, nearly 2/3 of its sales occur
  at retail convenience stores and nearly 4 out of
  every 5 of those stores sell gasoline. USTs
  customers are trying to save money on gasoline
  (like the rest of us) and are making fewer stops
  at these stores thereby resulting in fewer sales.
• Conversely, in the wake of 9/11 we saw an
  increase in the number of tobacco users (as well
  as alcohol and other substances of abuse).

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Dont Lose Sight Of Every Smokers Biggest Problem
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Domestic Cigarette Advertising and Promotional
Expenditures 1998 - 2003(Billions of dollars)
15.15 Billion
12.47 Billion
11.22 Billion
9.59 Billion
8.24 Billion
6.73 Billion
Source Federal Trade Commission Cigarette Report
for 2003
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Contact Information Matt Barry Campaign for
Tobacco Free Kids 1400 I Street, NW Suite
1200 Washington, DC 20005 [phone] (202)
296-5427 (fax) mbarry_at_tobaccofreekids.org www.toba
ccofreekids.org