Putting the Pieces Together for Statewide Tobacco Cessation

1
Putting the Pieces Together for Statewide Tobacco
Cessation

• State of the Movement
• Wendy Bjornson, MPH
• Pacific Center on Health and Tobacco

2
The Good News!!

• In 2002, 46 million adults were former smokers,
  50.1 of those who had ever smoked. For the first
  time, more adults have quit than are still
  smoking.
• In 2003, for the first time, the prevalence of
  cigarette smoking among adults in a state (Utah)
  has reached the Healthy People 2010 health
  objective of lt12.
• Smoking among 12th grade students dropped from a
  peak of 42.8 in 1999 to 26.2 in 2003.
• Lifetime (any smoking) among all high school
  students dropped from 70.4 in 1999 to 58.4 in
  2003.

• State Specific Prevalence of Current Cigarette
  Smoking Among Adults United States, 2003. MMWR,
  November 12, 2004/53(44)1035-1037
• Cigarette Use Among High School Students
  United States, 1992-2003. MMWR June 18,
  2004/53(23) 499-502.

3
The Worrisome News

• Decline in adult smoking prevalence is slowing
• From 1965 to 1990, adult prevalence dropped from
  42.4 to 25.5.
• From 1990 to 2003, adult prevalence only dropped
  from 25.5 to 22.1
• The median prevalence of adult smoking decreased
  only one percentage point from 2002 to 2003.
• The rate of decline is not rapid enough for the
  nation to achieve the 2010 national health
  objective of lt12 of adults smoking cigarettes.
• Only about 40 of adult smokers make a serious
  attempt to quit each year and only about 10
  succeed.

State Specific Prevalence of Current Cigarette
Smoking Among Adults United States, 2003. MMWR,
November 12, 2004/53(44)1035-1037 Priority
Areas for National Action Transforming Health
Care Quality, Institute of Medicine, 2003
4
What Works for Promoting Quitting?What are the
Tipping Points?

• Price increases
• Smoking bans
• Mass media campaigns
• Assistance/Treatment
• Reminder systems Provider intervention
  (5As)
• Individual, group, quitline counseling
• Medications
• Low or no out-of-pocket expenses

Public Health/Policy Approaches Increase Quit
Attempts
Healthcare Approaches Increase Quit Rates
5
How We Are Doing Taxes

• Tax increases
• State taxes have increased steadily from a year
  end average of .13 in 1980 to .84 in 2005.
• 39 states (78) have increased taxes in the last
  five years.
• 18 states have a tobacco tax of 1.00 or more.
• Three states have a tax of 2.00 or more.
• The average state tax has nearly doubled from
  2001 (.431) to January, 2005 (.84).

Campaign for Tobacco-Free Kids
6
How We Are Doing State Spending
Campaign for Tobacco-Free Kids
7
How We are Doing Second-hand Smoking Polices

• Since the 1970s, 1903 municipalities have passed
  laws that restrict where smoking is allowed.
• 201 by 1985 tripled to 689 in 1990 doubled to
  1275 in 1995 increased by 22 to 1556 in 2000
  increased by another 22 to 1903 by end of 2004.
• There are 30 states with local laws that require
  100 smokefree workplaces, bars, or restaurants.
• Across the US, 22 of the population is covered
  by a 100 smokefree provision in workplaces, 33
  in restaurants, 25 in bars.
• There are 10 states with state laws that require
  100 smokefree workplaces and/or restaurants
  California, Connecticut, Delaware, Florida,
  Idaho, Maine, Massachusetts, New York, South
  Dakota, Utah.

Americans for Non-Smokers Rights
8
How We Are Doing Treatment

• Quitlines
• Clinic services (5As)
• Benefits Coverage
• Medicaid
• Medicare
• Private health insurance
• Uninsured

9
How We are Doing Quitlines

• There are 36 state-managed quitlines, 5 states
  with CIS, 1 with the American Legacy Foundation,
  and 8 states and DC with no formal arrangements
  (using interim services from the NCI).
• More states are providing medications at low cost
  (4 states) or no cost (10 states) to all or some
  of their callers.
• The median level of funding in 2004 was 505,000
  with a range from 150,000 to 3.8 million. The
  funding for promotion is about the same as
  operations.
• Five states make the same level of services
  available to all callers, 21 states limit more
  intensive treatment services to callers who are
  ready to quit, and four states offer more
  intensive services to callers who are uninsured
  or who are a special population (e.g, pregnant
  women).

North American Quitline Consortium
10
How We are Doing Clinic Services

• About 50 of smokers report having received
  smoking cessation advice from their doctors in
  the past year.
• About 25 report receiving further counseling or
  assistance.

Priority Areas for National Action
Transforming Health Care Quality, Institute of
Medicine, 2003
11
How We are Doing Medicaid

• In 1994, one state Medicaid program covered some
  form of tobacco dependence treatment ( Rhode
  Island, counseling services).
• By 1999, 31 Medicaid programs covered some
  treatment services.
• By 2003, 40 Medicaid programs covered treatment
  services 4 are for pregnant women only.
• Only two state programs covered all
  pharmacotherapy and counseling treatments
  recommended in the PHS Guideline seven states
  covered all recommended pharmacotherapy and some
  form of counseling.

State Medicaid Coverage for Tobacco Dependence
Treatments United States, 1994 -2002. MMWR,
January 30, 2004/53(03)54-57
12
How We Are Doing Medicare

• Will provide some medication coverage in 2006.
• Is proposing to cover some counseling services by
  2006.

13
How We Are Doing Health Insurance Coverage
1997 Tobacco Cessation Service Coverage
14
How We Are Doing Health Insurance Coverage
2001 Tobacco Cessation Coverage
15
How We Are Doing Health Insurance Coverage
2001 Tobacco Cessation Service Coverage by Plans
16
How We Are Doing Uninsured

• Uninsured coverage through quitlines
• 36 states provide proactive counseling services
  through quitlines.
• 13 states provide counseling low-cost or
  no-cost medications.

North American Quitline Consortium
17
What is Working Overlapping Systems
Health Community Services
Purchasers Employers
Quitlines
Tailored and Community Development
18
What is Working Quitlines

• National Quitline program and phone number
• Supplemental funding from CDC
• North American Quitline Consortium
• Coordination
• Evaluation minimum data set
• Innovations
• Multi-cultural Multi-language
• Marketing strategies to reach target groups
• Dispensing of low or no cost medications
• Tailored programs youth, pregnancy
• Cost sharing e.g. Utah
• Partnerships with employers and health insurers

19
What is Working Health and Community Services

• Fax/quitline referral systems everyone! Some
  more complex than others.
• Outreach over time through agencies,
  professional networks - e.g. Pennsylvania, Ohio,
  New Jersey
• Clinic Detailing - e.g Wisconsin Maine
• Training programs e.g Massachusetts, Mayo, New
  Jersey
• Promotion of low cost or no cost medications
  through quitlines e.g. New York, Ohio,
  Minnesota, Utah, Arkansas, Arizona
• Pharmacy programs New Mexico, California

20
What is Working Insurers and Employers

• Partnerships with state programs especially
  quitlines - e.g. Ohio, Minnesota.
• Toolkits e.g. MIYB Medicaid
• How-tos
• Model benefits
• Increase in data
• Cost effectiveness/Return on investment
• Model programs from research studies
• Cost of benefits - actuarial studies
• Case studies
• Collaborations and working groups.

21
What is Working Community Programs for
Multi-cultural and Underserved Populations

• Multi-language, multicultural quitlines promoted
  with culturally appropriate media
  (e.g.California, Minnesota, Hawaii?)
• Outreach to low-income clinics (Wisconsin)
• Community-based programs developed within the
  culture of the community (Arizona, Alaska,
  barbers beauticians)
• Customized programs (Pathways to Freedom, Native
  American programs.)
• Low/no-cost medication programs

22
Summing Up

• Taxes have increased dramatically 2nd hand
  smoking restrictions are increasing steadily due
  to widespread policy initiatives.
• Smoking among high school students is down
  dramatically.Adult prevalence is down slightly.
• Treatment effectively helps smokers stop but
  policy strategies are lagging.
• Quitlines as a strategy are increasingly
  successful.
• Quitlines have increase access and availability
  provide program momentum
• Help coordinate services in the community and
  through health care.
• Help coordinate distribution of medications in
  some states.
• Help reach the uninsured.

23
Summing Up

• Quitline referral programs have helped increase
  participation of health care and helped build
  support in communities.
• Coverage through Medicaid programs is increasing
  gradually (but few states cover adequately).
• Outreach efforts have helped include tobacco
  cessation in more areas (e.g. pregnancy, mental
  health and addictions, dentistry, pharmacies,
  prison systems)

24
Summing Up

• Medicare program is poised to include benefits.
• National quitline program is underway.
• Good partnerships have been established.
• But..

25
Summing Up

• Public funds invested in tobacco control are
  declining. Programs are at risk.
• Private coverage (health insurers/employers) is
  not changing very much.
• Many tobacco users do not know how to access
  services.
• Many tobacco users still do not have access to
  affordable and culturally appropriate services.

26
Where are the Tipping Points?

• Medicare benefits will be available soon. Can
  Medicare help drive the standard of care for
  insurers?
• Two new medications will be on the market within
  the next 18 months can these provide a renewed
  focus on cessation and promote more cessation?
• Are there some new innovations with quitlines
  that can help tip the balance in favor of more
  service delivery?
• Can JCAHO requirements be effectively leveraged
  to increase service delivery?
• Are there strategic training opportunities that
  can help increase support among health care
  providers?

27
Where are the leverage points? What are the best
investments of limited time, resources, and
political realities to help take the next step?