Operationalizing Tobacco Cessation Policy Efforts

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: working to reduce adult tobacco use in America; explaining why 2019 is the Year of Cessation.

LUCI LONGORIA:
State health departments have a very important role to play in creating an environment where being tobacco-free is the easy choice and that people that are ready to make that step to quit using tobacco have the support that they need to be successful.

DR. CORRINE GRAFFUNDER:
It's really through this Year of Cessation that we are hoping to then launch several new initiatives that will then give us plenty of work to do in 2020 and beyond to continue the drumbeat, essentially, on the significance and importance of cessation.

PATTI HENLEY:
And the results showed that, for every dollar spent on medication counseling or even the promotion of the benefits, it was associated with a reduction in a $3.12 in Mass Health expenditures.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, we're talking about the teamwork it takes to reach the 34 million American adults who smoke and the opportunities available to help them quit for good.

2019 has been proclaimed the Year of Cessation by the Centers for Disease Control and Prevention's office on smoking and health. Since January, CDC, states, and other partners have been focused on efforts to reduce the incidence of adult tobacco use that still plagues our nation's healthcare system, impacts lives, and drives up related healthcare costs.

Patti Henley is director of the Massachusetts Tobacco Cessation and Prevention Program. Luci Longoria is the chair of the Tobacco Control Network, addressing policy issues within the Oregon Health Authority. They'll be along shortly.

But first, Corinne Graffunder, director of the CDC office on smoking and health, reviews the fact of the cessation case.

GRAFFUNDER:
Well, what we know is that we've made a lot of progress with reducing the overall number of adults, as well as youth, who use cigarettes and also overall tobacco products.

But we also know that we've not made the same kind of progress with the number of people who continue to use tobacco or, again, use cigarettes. So, we're looking at, you know, well over 40 million that are using some form of tobacco and about 34 million that use cigarettes, adults that are cigarettes smokers today.

So, we still have quite a number of individuals who are putting their health at significant risk by continuing to use tobacco products.

JOHNSON:
That is a lot, but the numbers were bigger.

GRAFFUNDER:
Yes, and we think that's good news.

We know that, at one point in time, the numbers were bigger in terms of the number of people who were continuing to smoke and who were making a quit attempt and who were not being able to successfully quit. And then, we crossed a threshold where we saw for the first time that they were more former smokers who were current non-smokers than the reverse.

And so, that's a good news story because that means that of the 40 plus million tobacco users and 30 plus million who are still smoking cigarettes, the most dangerous form of tobacco, that those individuals, we know they want to quit—up to 70% report regularly that they want to quit. We know that they make a quit attempt—about 50% of current smokers try to quit each year. But we also know that their success rates can be pretty low.

And so, there's a mixed story here where we know that they want to quit, we've seen that smokers can be successful in quitting; and yet, at the same time, there's still plenty more than we can do to help the 30+ million who are continuing to smoke cigarettes.

JOHNSON:
The fight to reduce adult tobacco use has been going on for decades, but Graffunder said 2019 represented a special opportunity that could not be missed.

GRAFFUNDER:
We looked at the four quarters in the year and we thought that there was some really significant opportunities to, essentially, for each of the four quarters, have a focus, a priority, that we would be working toward and articulating, but then also have some anchor events and opportunities where those priorities could be expressed and elevated.

And this Year of Cessation really is the idea of shining a spotlight and emphasizing the kinds of things that need to be done and really trying to galvanize and kick off some exciting, either new tools and resources or new opportunities.

Smoking cessation is a challenging and time intensive activity in and of itself, and these kinds of systems changes don't happen overnight. So, we did not set the Year of Cessation up to be where we're going to accomplish everything that we are laying out. But rather, we say in each of these four quarters that there are some really important both science- and then also practice-based learning that needs to be taken advantage of so that we can really accelerate the progress in this area.

So, the first quarter at the beginning of the year, we really focused on the people who smoke and quit attempts. And we thought, of course that made a lot of sense because that's the time, at New Year's resolutions, when people who smoke often do try to make an attempt. They try to quit and they use a variety of different resources.

So, we really ratcheted up our social media efforts. We engaged a number of partners to really make sure that the resources that were already out there, already available—including resources, the ones that are on our Tips from Former Smokers website where we have resources for smokers themselves, we have resources for concerned friends and family members, we also have resources for healthcare providers—there's a large array of resources that are available.

So, quarter one was really the kick-off to say, "We have resources. We know what works. We can do a better job of making those things available."

Then when we rolled into quarter two, we focused on the health conditions that are improved by quitting as well as, then, what health systems can do to be more meaningfully engaged in this work.

Our big launch event, or our big anchor event, in quarter two was the launch of our 2019 Tips from Former Smokers campaign. This is the eighth year that this campaign is in the field, on air, and we continue to see a remarkable response. So, again, it's an indication, it's a marker that helps us understand that: number one, we are reaching people with these messages—the ads are continuing to resonate with the people who smoke; but also, number two, when there is a specific action they can take, they will take that action.

We also track our web traffic and so we, you know, we know that in 2019 not everyone wants to call a phone line. So, when we say quit lines, it really is a more comprehensive service than that. It's not just the telephone line: there are web interfaces that people can access; there's texting—many of the states have texting available; there's also some apps that have been made available.

So, it really is with the idea that helping meet that individual where they are in their quit journey and try to help get them the resources and support that they need.

JOHNSON:
So, you're halfway through the year, you have two quarters left.

What should we look forward to?

What's coming up?

GRAFFUNDER:
So, moving forward for quarter three, we are really going to focus on quitlines and continue with the focus on cessation interventions, but we're also going to work to really link the significance of how we create a supportive environment for the smoker, or the person who smokes who's trying to quit.

So, we know—here are the things that we know. We know that tobacco-free environments matter—they matter both for non-smokers obviously, but they also actually matter a lot for people who smoke and who are trying to quit. Because you can imagine if you were a person who's addicted to nicotine, trying to quit and then—you're still in an environment, you're in a workplace, you're in the community setting—you're somewhere where you're still being exposed to tobacco smoke, that's a trigger. It makes it harder to quit.

And the same thing is true for work that's being done to restrict advertising within retail environments. There's work that's being done to really limit the distribution of certain tobacco products. So, we really want to use quarter three as an opportunity to make some of those links and connections. So, we're working on some new resources.

We have a national conference on tobacco and health that will happen in late August, in Minnesota, in Minneapolis, and that's going to be a platform where we'll be making announcements about some new products and resources that'll be made available.

We'd got a number of anniversaries also that we're excited to be able to showcase and really just highlight the good and important work, which includes the anniversary of our national network of quitlines—it's going to be the 15th anniversary of that network and where all 50 states have had quitline services available.

And so, we will be really pointing to best practices, pointing to success stories, talking to the partnerships that included the Tobacco Control Network, which is the network of our states who are also sharing that anniversary, the North American Quitline Consortium, which has been a backbone part of this work as well. So, we're trying to really drum up a lot of excitement.

And then in quarter four, we're going to focus on back to clinicians, to the people who smoke and who we want to help support quitting, but we're going to do that more in the context of what we're calling, like, real-world use of evidence-based interventions. And what we mean by that is it's not always easy for everyone to make an appointment, go see their doctor, get a prescription, have the medication prescribed, or get the counseling services. So, we know there's a lot of barriers. And we know that the more we can—as a collective, as a society—the more we can reduce those barriers and make it less of a challenge, the better off and the more success we have with helping support people who want to quit using their tobacco.

To do that, one of the things that we're working on right now is we're working on partnering with a number of organizations that have the ability to help support and reach a person who's smoking but not within the clinical setting. There's still pharmacists or, like, health centers, community health centers, where people are still engaging with the clinical setting in a way, but it's not going into a doctor's office. And so, we're looking at the opportunities and, again, hoping to be able to kick off some new and exciting partnerships.

And then the last thing I want to say about quarters three and four—and this is, you know, maybe one of the most significant reasons why this is the Year of Cessation for CDC—because this year the U.S. Surgeon General will be releasing a forthcoming Surgeon General's report on the topic of cessation. And it's the first time in—believe it or not—nearly 30 years that there's been a Surgeon General's report on cessation. So, you can imagine the accumulation of the evidence and science and the opportunity, again, to really then be reflective not only on where we have had progress, where we've made progress and had success, but also—importantly—where do we still have a gap and we still have a tremendous opportunity to really recognize this as an addiction, where we have opportunities to treat this addiction with evidence-based, known to be effective medications and support through counseling.

And yet, again, we're not doing everything we can to make that easily available to people, make it known to people that this is what works. And even with providers, making it easy for them to be able to offer the right kind of support to their clients, their patients. When they're busy, they've got a limited amount of time.

So, we're trying to address a variety of those kinds of challenges, but we are—essentially, this is almost the culmination of our Year of Cessation, will be this release of the Surgeon General's report, and we're really excited for that to come out and the opportunities that then that will create as well.

JOHNSON:
Patti Henley, along with the team at the Massachusetts Department of Public Health, approaches the challenge with a benefit not many have available: state-mandated tobacco cessation health coverage.

HENLEY:
In April of 2006, as part of our Massachusetts healthcare reform efforts, our recommendation was put forth to provide more comprehensive tobacco cessation benefits for the members of Mass Health—and that's our state Medicaid program, so it's part of that.

The state law, the original legislation, mandated a two-year smoking cessation pilot. They funded the Medicaid program $7 million per year for that pilot. And the legislation also required a report to the legislature each year reviewing the utilization of the benefits, clinical outcomes, including quit rates, and cost savings. And this was very important because it set us up for really taking a look at what would happen if we did increase availability and access to this type of benefit.

But another key to this tobacco position benefit was that we really needed to make sure that it will be generous and easy to use. So, it will set up to include all of the FDA-approved medications. It included a 90-day supply per treatment attempt twice per year of nicotine replacement therapies like the patches and gum and lozenge. Zyban and Chantix are also included. And if, they got prior authorization, folks could also use the nasal spray and the inhaler.

Another really important aspect of the benefit was that it had to include counseling. And so, we included up to 16 face-to-face counseling sessions, 45 minutes in-depth intake assessments twice per year, and 30-minute individual and 60-minute group counseling sessions were authorized.

The evidence shows us that coupling counseling with medications increases the chances of a smoker quitting by three times. And so, it was very important to us that we made sure that the comprehensive nature of this benefit was there for the people in Mass Health.

JOHNSON:
And this benefit is still available to people in your state.

So, the pilot went well?

HENLEY:
The pilot went very well. And one of the reasons why the pilot went so well is that we knew we had to let people know that they had that benefit. It wasn't gonna be effective if we just put a benefit in place and nobody knew about it.

So, we had a tremendous promotion effort, and the promotion was really of vital importance. The Department of Public Health and Mass Health collaborated to widely promote the availability of the cessation benefits, and Mass Health held statewide meetings, fact sheets mailed to all of its members. We conducted a mass media campaign that was really very well-received.

The target audience was adults 25 to 54; but at first, we focused on women. We used real women and real stories, unscripted, in their own voices about why they quit, how they quit, and their life after the cigarettes. We did an intensive eight-week radio and transit campaign in six markets in Massachusetts. And later, we also included messaging specifically to men in that target age group of 25 to 54.

It took a statewide effort to get this information out, and we worked with partners throughout the state producing materials and information that detailed how to quit. We worked with Mass Health community health centers, medical societies, cancer coalitions, tobacco coalitions. And we also had the materials translated into 10 different languages. It was available free of charge on our health promotion pages. But all of this promotion is one of the things that really increased the utilization of the benefit, and it helped so many more people.

The other side of the promotion was it wasn't just letting members of Mass Health know, but also working with providers so that they felt more effective providing this intervention. And we did consumer fact sheet and provider fact sheets, and we also provided detailed frequently asked questions about rates and billing code for providers and pharmacotherapy dosing pocket guides so that they would be able to hear it right on the spot, to be able to feel comfortable with their intake and assessment protocols and guiding people with the NRCs. In addition, they did an online program on intake and assessments.

So, we'd work to make sure that all of those who needed the benefits knew about the benefits, and all those who could help people connect to the benefits knew about the benefits.

JOHNSON:
In the first two years, what sort of drop in tobacco use did you realize in your state?

HENLEY:
In the first two years of our benefit, the evaluation found that 41% of all Mass Health smokers had used the benefits and the smoking rate among members dropped to 28.8%. When we first started in 2006, the smoking rate among Mass Health members was 38.3%, and that was a significant drop.

And then, we also did part of the legislation requires that we look at the cost. And so, we did do a return-on-investment analysis on the expanded Medicaid benefit and, from 2007 to 2009, we looked at inpatient hospital admissions for cardiovascular conditions among Mass Health members.

And the analysis showed that our comprehensive tobacco cessation program was successful in reducing smoking prevalence, and those who receive the tobacco cessation benefit had lower rates of inpatient admission for cardiovascular condition—including heart attack and nonspecific chest pain, coronary arterial sclerosis. In a relatively short period of time, we saw improvement of health outcomes related to that benefit.

And so, when they looked at all of that, the results showed that for every dollar spent on medications, counseling, or even the promotion of the benefits, it was associated with reduction $3.12 in Mass Health expenditures for cardiovascular hospital admissions. That was a net saving of $2.05.

JOHNSON:
Is the benefit now a sure thing?

Is it a permanent benefit or does it have to be renewed every few years?

HENLEY:
No, this is a permanent benefit.

And, in fact, recently we've worked with our partners over in Mass Health to reduce the barrier of the copays. The copays in this benefit are very low—a dollar or $3 depending on your plan—but what we've been working with Mass Health to do is to reduce that co-pay to zero. We think that eliminating as many barriers as possible will help increase the utilization.

We did continue to evaluate and we've looked at the utilization rate over the years. We've also gone back and did a survey of Mass Health smokers and claims data from 2006 to 2013. And then, we found, controlling for demographic and health characteristics, there was a significant reduction of over 16 percentage points in smoking rates between 2008 and 2014 among those Mass Health members.

So, we can't really attribute this directly to the tobacco cessation benefit availability, but we find that these are very encouraging statistics.

JOHNSON:
The point is you're fairly confident that your benefit is still generating an impact, or having an impact, on the overall amount of tobacco use in Massachusetts.

HENLEY:
Yes, we are.

We have seen a lower rate of utilization of the benefit in the recent past, and we've worked to develop—more recently, we did a media campaign that reached out to the smokers who had made more than one quit attempt, and the campaign was called Keep Trying. And we really did actually focus in on the Mass Health demographic. And we saw an increase in the number of calls to our quitline of people who had made multiple attempts in the past.

And so, it is just a continuation. We need to make sure that people know about the benefits and then people will use the benefits.

JOHNSON:
For states that don't offer this opportunity, is the argument for it really focused just on those bare-knuckled results?

The numbers? The decrease? The very measurable impact?

HENLEY:
The measurable impact of health outcomes is the most compelling, and the impact in terms of cost savings is also compelling.

I think that, for other states to take a look at both and to see that this is an option where we can reach a much wider audience of people who have, for a whole host of reasons, who still smoke at a much higher rate than our general population.

Using this opportunity to take a benefit that is provided to most people of lower income is an incredibly important investment. And we can see from Massachusetts, and other states as well, there are a very strong outcomes when you do this.

JOHNSON:
Compared to the other cessation tools that you have available, how does the Medicaid benefit rank?

Is it the best tool you have? Is it second?

Where does it fall on the list?

HENLEY:
Well, that's really hard to decide because I think that all of the tools work together.

We provide technical assistance to healthcare providers so that they can make sure that they have systems in place for addressing tobacco use with their patients and referring patients to tobacco cessation. In our state, we provide tobacco treatment training to clinicians and behavioral health providers.

And so, I think that all of the tools to put in place systems that work, they all contribute, and it's hard to pull one over another.

We also work very much in promoting smoke-free environments and smoke free multi-unit housing. That's a tool that motivates folks to try quit. And we have, as long as we have, those resources available to help them.

But I think it's a combination that makes a comprehensive program pull together, and it all works together.

JOHNSON:
When you're talking to colleagues elsewhere in the country, how do you portray the benefit to them?

And what kind of encouragement can you offer if they're thinking about it, or would like to do it, but haven't made that leap yet?

HENLEY:
Looking at the outcome, looking at just how much this benefit was used by people who needed it, and what an immediate impact it had on health, on hospitalization rate, on asthma emergency department visits, and there are a number of different health outcomes—you know, that would definitely be my argument.

There are certainly things that people would need to put in place. I think Massachusetts did it very well. They did it well because they were focused on the comprehensive nature of the benefits. They were be focused on the needs to bring in partners, and to educate providers and educate members of Mass Health to make sure that they knew the benefit was available. The mass media campaign to get that information out there and promotion was critical. And I think that all of those components together is what made this a successful benefit.

I also think that setting and making sure that there was an evaluation plan in place, that we did do that work on what was the return on investment, we did do that discovery of medical claims to really match up what was happening with the members who used the benefits—all of those things were very important about the Mass Health benefits that we put in place.

And I think that, you know, looking at the success of Massachusetts, it can be replicated. These are very straightforward pillars that we built the benefit on and that we saw success on.

JOHNSON:
ASTHO's Tobacco Control Network, also known as the TCN, gives states and territories access to the tools and resources they need to address tobacco use according to specific challenges and populations.

Luci Longoria is TCN chair.

LONGORIA:
The Tobacco Control Network is a peer network of the Association of State and Territorial Health Officials. We support state and territorial tobacco control programs across the nation and territories.

And so, we work closely with the Centers for Disease Control and Prevention. We have a network that has regional conference calls and discussions. We've got a website with information on our members. We've got information that we've collected. We've got a newsletter. We have podcasts, such as this one. We've got lots of information and ways to broker connection and support with people that are working in the important practice of helping people quit tobacco and in tobacco prevention practice all across the country.

And so, it's a great resource. Our purpose is to help each other be more successful. And so, I highly encourage people to reach out to Tobacco Control Network dot org to get more information on the Tobacco Control Network and support.

JOHNSON:
Through the TCN, members looking to improve or enhance their own programs can learn about initiatives working in other states and territories.

LONGORIA:
New York State has a tobacco control program funds a center of excellence for health systems improvement. So, what they are working on is helping support regional contractors and they're changing cessation practices in large health systems. It's a key piece of their strategy to reduce tobacco use among groups where the tobacco use rates haven't really decreased in recent years. So, they're doing some important work to make sure that everybody, all people, have the opportunity to have that support needed to quit tobacco for good.

Some work that's happening in Minnesota and Oklahoma. They, together with their quitline contractor, developed and implemented a quitline designed to serve American Indians and Alaska natives with culturally appropriate services. So, in that instance, councilors for this quitline are trained in working with native populations. They are familiar with tribal history and the key differences between traditional tobacco use in those communities—that spiritual, historical, ceremonial tobacco use—and what they call commercial tobacco use, which is that which we're most familiar with—tobacco cigarette smoking, those kinds of things.

So, they have really drilled down to how can they better make sure that those services support those communities that need that kind of support and that it's communicated to them in a way that makes sense. And so, as the purpose of the Tobacco Control Network, we've learned about that great work that's happening in Minnesota and Oklahoma.

We're really grateful to them here in Oregon because we are borrowing from their examples and we're going to be piloting that important service in Oregon in the coming year.

JOHNSON:
Longoria says the TCN's aim is to help public health professionals fulfill a key role on behalf of their affected populations.

LONGORIA:
State health departments have a very important role to play in creating an environment where being tobacco-free is the easy choice and that people are ready to quit using tobacco have the support that they need to be successful, and they need to get that support from a number of places.

Of course, get that in their doctor's office, and also in their communities so that they have the support that they need to help make sure that they can be successful with that good advice they've gotten from their physician on how to stay quit.

JOHNSON:
The information about the CDC's Year of Cessation plans, the Medicaid benefit in Massachusetts, and the programs and services offered through the Tobacco Control Network all can be found in the show notes for this episode.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.