Reducing Tobacco Use &
Factors affecting Reach of the
Maine Tobacco HelpLine
Tim Cowan, MSPH
Director, MaineHealth Health Index Initiative
on behalf of the
Healthy Maine Partnerships,
and the Partnership For A Tobacco-Free Maine
March, 2012
Acknowledgements
• Partnership for A Tobacco-Free Maine
– Dorean Maines (Director)
• Center for Tobacco Independence
– Sandi Kazura, MD- Medical Director
– Ken Lewis- Executive Director
– Program Managers
– HelpLine Specialists
Topics Will Cover
• Prevalence of Smoking in Maine
• Review of PTM’s Comprehensive
Tobacco Treatment Program
• HelpLine Reach
– What is the level currently?
– What Factors Contribute to it?
Smoking Prevalence Decreasing,
but still lot of work to do
Percent Who Use Tobacco
40
30
Maine- % of HS Students Who Use Tobacco
US- % of HS Students Who Use Tobacco
Maine- % of Adults Who Use Tobaco
US- Median % of Adults Who Use Tobacco
20
10
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
% Adult Smokers: Maine vs. U.S.- ‘06/07
High Nicotine Dependence in Maine
• The maps on the next three slides present data
for variables that all indicate the level of nicotine
dependence in a state. Illustrates where the
hard-core smokers live.
• % smokers who have first cigarette within 30
minutes of waking
• Mean number of cigarettes per day
• % smokers who are daily smokers
• Patterns are similar in all three maps- Maine
among the highest, grouped with Appalachian
and tobacco growing states.
High Nicotine Dependence in Maine
High Nicotine Dependence in Maine
High Nicotine Dependence in Maine
% Adult Smokers- 2010
Partnership For A Tobacco-Free Maine’s
Comprehensive Tobacco Treatment Program
Maine Tobacco
HelpLine
Aug 2001-Current
Maine-CDC, DHHS:
Partnership
For A
Tobacco-Free
Maine
Estab 1997
Cessation
Medication Program
Sept 2002- Current
Tobacco
Treatment Training
2002 - Current
Maine Tobacco HelpLine
• Administered by MaineHealth, Center for
Tobacco Independence (CTI)
• Hybrid Service Delivery Model
– Free & Clear: registrations, initial counseling
sessions, some ad-hoc
– CTI: proactive, outbound counseling calls, full
service for fax referrals, most ad-hoc,
program evaluation
• Use Free & Clear protocol, data system,
and print materials
Maine Tobacco HelpLine, con’t
• Intended for tobacco users
– planning to quit in next 30 days, or
– currently in quit attempt
• Up to 4 scheduled counseling sessions,
plus unlimited ad-hoc (inbound) calls
• CTI HelpLine Specialists
– All trained in intensive tobacco treatment
– Ongoing training, case reviews, quality impr.
Medication Program: FREE NRT
• Eligible via HelpLine if…
–
–
–
–
18+ yrs age
Have no NRT-use exclusions
Uninsured OR insurance not cover cessation rxs
AND enroll in multi-call counseling program
• Patch, gum, lozenge
• 30-day supply per “authorization”
– 8 weeks NRT total- Sept 2002- Dec 2008
– Pilot of 12 weeks NRT total- _______ 2009
• “Authorization” process.
– HelpLine send auth. to pharmacy benefit manager (PBM)
– PBM coordinates with selected pharmacy
– HelpLine caller picks up at pharmacy they selected.
Definition Used in Presentation
Reach
Rate
(Percent)
Number
Adult Tobacco Users Registered
with Maine Tobacco HelpLine
in XYZ time period
=
(from HelpLine System)
Estimated Number
Adult Smokers in Maine
in XYZ time period
(based on Maine Behavioral Risk Factor
Surveillance System: % who report that
currently smoke cigarettes )
HelpLine Reach Consistently High
Next slide shows HelpLine Reach 2002-2009
In Fiscal Year 2010, Maine
One of Only Nine States
with Reach >3%
1.
2.
3.
4.
5.
6.
7.
8.
9.
Colorado
Iowa
Maine
Montana
New Mexico
New York
Oklahoma
South Dakota
Wyoming
Target for 2015=
6% Reach in U.S.
North American Quitline Consortium
(U.S. states & Canadian provinces)
Tobacco Users Calling HelpLine
8,000
HelpLine’s reach rate consistently one of highest for U.S. quitlines.
Tobacco Users Registering
7,000
In 2008- 75% of states reported quitline reach <2%.
6,000
5,000
4,000
3,000
2,000
1,000
1.5% 2.0% 2.9% 2.4% 3.3% 3.5% 5.4% 7.4% 4.5% 3.5% 4.2% 2.8% 4.2% 2.4% 5.3% 3.3%
0
2002
JanJun
2002
JulDec
2003
JanJun
2003
JulDec
2004
JanJun
2004
JulDec
2005
JanJun
2005
JulDec
2006
JanJun
2006
JulDec
2007
JanJun
2007
JulDec
2008
JanJun
2008
JulDec
2009
JanJun
Percents in Bars = Maine Tobacco HelpLine Reach Rate
2009
JulDec
Multi-pronged Approach = Success
for Reach of HelpLine
• Supportive Culture in Maine for
tobacco prevention, control & treatment
• Broad-based Promotion of HelpLine
• Medication Program Linked to Maine
Tobacco HelpLine
• Tobacco Treatment Training for
professionals interacting with tobacco users
• Surveillance and Evaluation
Supportive Culture
Tobacco Legislation in Maine
Cigarette Tax
ME Laws Banning Smoking
1981
1983
1985
1986
1989
State tax to $0.37
State tax to $0.74
State tax to $1.00
State tax to $2.00
Federal tax to $1.01
1991
1997
1999
2001
2003
2005
2007
2009
Public meetings
Court houses
Stores
Most workplaces
Hospitals, except psychiatric
patients and psych. hospitals
Restaurants
Bars
Most loopholes closed
School grounds
Public beaches, outdoor eating
Supportive Culture
Strong Advocacy Support
Many organizations and individuals





American Lung Association- Maine
American Cancer Society
American Heart Association
Health Policy Partners
Maine Public Health Association
Result: Continued legislative support &
funding for PTM comprehensive
programs, HMPs- 1998-Current.
Supportive Culture
Advancements in Tobacco Treatment
1996
Maine Medicaid began coverage of NRT medications
1997
Partnership For A Tobacco-Free Maine created
2000
Maine CDC, Fund For A Healthy Maine- tob settlement $
Maine Medicaid created add-on reimbursement for counseling
2001
June- PTM Comprehensive Tobacco Treatment Program began
Aug- Maine Tobacco HelpLine Launched
Basic Treatment Trainings (Conferences) began
2002
Sep- Free NRT available via HelpLine
Sep-Oct- 4900 Clinicians mailed tobacco treatment toolkits
Nov- Clinical Outreach full speed ahead
Supportive Culture
Clinician Support for Quitting
Among Maine smokers
with a clinical visit in the
past 12 months…
 For BOTH Physicians
& Dentists
 Percents advised in
Maine significantly higher
than US percents.
100
Percent Advised
% who reported clinician
advised them to quit
2nd highest in US.
Tobacco Use Supplement of
Current Population Survey
2006/2007
Maine
75
US Total
50
25
0
by Physician
by Dentist
High Nicotine Dependence in Maine
Yet one of highest % of quit attempts
And better success with abstinence
Supportive Culture: Tobacco Users Quitting
Maine 1 of only 8 states
where there was a significant increase
in the % of 30+ yr old “Ever Smokers”
who have quit (1992/93 vs. 2006/07)
(Tobacco Use Supplement, Current Population Surveys)
Ever= Both Current and Former Smokers
Stars on map on next slides indicate these 8 states
Eight states still leaders:
more smokers made quit attempts in 2006/2007
= significant
increase in
“Ever smokers”
who quit
92/93 vs. 06/07
% Ever smokers quit vs. dependence
= significant
increase in
“Ever smokers”
who quit
92/93 vs. 06/07
None of the
eight states
from the
Appalachian
region
Supportive Culture: Quitters Using HelpLine
Tax Increase = Calls
8,000
July-Aug 2005:
2457 Callers
Nov '08-Feb '09:
2124 Callers
Tobacco Users Registering
7,000
Sept 2005:
State Cig Tax $1.00 to $2.00
Mar: Industry raised prices
Apr: Fed Cig Tax $0.62 to $1.01
6,000
Sept-Oct 2005:
4571 Callers
Mar-Jun 2009:
3875 Callers
5,000
4,000
3,000
2,000
1,000
112
hrs/wk
HelpLine Operated 51 hrs per week
84 hrs per week
40 hrs/wk
0
2001
SepDec
2002
JanJun
2002
JulDec
2003
JanJun
2003
JulDec
2004
JanJun
2004
JulDec
2005
JanJun
2005
JulDec
2006
JanJun
2006
JulDec
6-month time periods
2007
JanJun
2007
JulDec
2008
JanJun
2008
JulDec
2009
JanJun
2009
JulDec
Broad-based promotion of HelpLine
Partnership
For A
Tobacco-Free
Maine
Health
District Tobacco
Coordinators
Community
Orgs.
Employers
Healthy Maine
Partnerships
Insurance
Companies
Friends
& Family
Direct
Media
Healthcare
Orgs.
Past
Callers
Broad Based Promotion:
• Health
Communications
Interventions
• Multiple types of media addressing tobacco use
– TV, Radio, Internet, Newspapers, Telephone Books,
Pamphlets, Posters
• HelpLine specific ads
• Other ads addressing tobacco have tagMaine Tobacco HelpLine number
• Motivational and Awareness Ads
Media: Impacts HelpLine Call Volume
Maine Tobacco HelpLine- # Registrations/ Month
Jan 2006- Feb 2009
1400
1200
1000
800
600
400
200
09-Jan
Jul
08-Jan
Jul
07-Jan
Jul
06-Jan
0
Media: Impacts HelpLine Call Volume
250
2009- regular media
2010- 10-week media campaign
HelpLine Registrations
200
150
100
50
0
week1
week2
week3
week4
week5
week6
week7
week8
Last week, July- 4th week, September
week9
Medication Program Linked to HelpLine
Began Authorizing free NRT via HelpLine
September 2002
NEVER advertised through traditional media.
Tell clinicians free NRT available

Clinical Outreach,

Basics and Intensive trainings,

Other programs advertise NRT via HelpLine
Word of mouth advertising.
Medication Program Linked to HelpLine
In 2005- Surveyed Tobacco Users who:
• enrolled in HelpLine counseling &
• were authorized, by HelpLine, to get free NRT.
Knowledge of Free NRT Influenced
Not Aware of Free NRT
Decision to Call the HelpLine
Before Calling
Knowledge "Very Much
Influenced" Decision
50%
Not Aware
50%
Aware
75%
20%
Knowledge "Influenced"
or "Somewhat
Influenced" Decision
Knowledge Did Not
Influence Decision
NRT Program: Increased Counseling
8,000
Tobacco Users Registering
7,000
6,000
NRT Access
via HelpLine
began
Sept 2002
Self Help
Requested Counseling
% Tobacco Users
Requesting Counseling
5,000
4,000
3,000
2,000
1,000
76% 52% 86% 91% 94% 96% 94% 96% 97% 99% 99% 99% 99% 99% 99% 99% 99%
0
2001 2002 2002 2003 2003 2004 2004 2005 2005 2006 2006 2007 2007 2008 2008 2009 2009
Sep- Jan- Jul- Jan- Jul- Jan- Jul- Jan- Jul- Jan- Jul- Jan- Jul- Jan- Jul- Jan- JulDec Jun Dec Jun Dec Jun Dec Jun Dec Jun Dec Jun Dec Jun Dec Jun Dec
6-month time periods
Constellation of PTM Training
Offerings
Tobacco Intervention:
Tobacco Intervention:
Basic Skills
Training
Intensive
Treatment
Training
Webinars
Begin
2009
Helpers
Program
(proposed)
Clinical
Outreach
Tobacco Intervention:
Basic Skills Training
 Targets all professionals interacting
with tobacco users
 Teaching Goals: How to conduct
Brief Tobacco Interventions
– Appreciate the importance of asking
about tobacco use for every
patient/client at every visit
– Learn basic assessment tools
– Acquire skills on how to
• Advise to quit
• Encourage patient/client change
– Learn how to assist with treatment
planning
– Achieve understanding of, and
comfort with, referring to the Maine
Tobacco HelpLine
Clinical Outreach
One-hour, onsite education
– Offered to medical and other
clinical practices
– Present tobacco dependence
as a chronic, relapsing but
treatable condition
– Increase self-efficacy about
effectiveness of their role in
increasing quit attempts and
quit success
– Promote referrals to the
Maine Tobacco HelpLine
Tobacco Treatment Training: Referrals
8,000
Tobacco Users Registering
7,000
Sept-Oct 2002
4900 Toolkits Mailed to
Medical and Dental
Providers
All Other: Media, Friends/Family, Past
Callers, Employers, Community Orgs,
Other
Healthcare Providers
6,000
Nov 2002
Clinical Outreach
Full Speed Ahead
5,000
4,000
3,000
2,000
1,000
25%
0
1
2
Sep '02Jun '02
28%
3
4
Jul '02Jun '03
28%
30%
5
6
Jul '03Jun '04
29%
29%
7
Jul '04-8
Jun '05
24%
36%
9
10
Jul '05Jun '06
37%
37%
11
12
Jul '06Jun '07
34%
25%
13
14
Jul '07Jun '08
37%
30%
15
16
Jul '08Jun '09
Practices Received
Clinical Outreach
18
162
191
128
34
141
153
201
Training Attendees
Basics
Intensive Tx
419
151
93
210
68
185
54
169
57
254
114
346
123
369
140
Encouraging Proactive Referrals
Reason #1: Reach different subgroups
of smokers via proactive referrals
Study Population:
Compared
Three Groups
of Tobacco
Users
Tobacco Users Using Quitline, 2007-2008
(Total N=9,440)
688
(7%)
2174
(23%)
6578
(70%)
Physician FaxReferrals, QL Staff
Proactively Called
Tobacco Users
Phoned Into QL,
Heard About from
Health Care
Professional
Phoned Into QL,
Heard About from
Other Sources
Demographic Characteristics
100%
11%
16%
28%
22%
28%
39%
80%
21%
19%
13%
33%
11%
42%
49%
13%
60%
46%
7%
43%
40%
45%
44%
32%
52%
47%
26%
40%
61%
58%
26%
51%
41%
20%
37%
27%
33%
23%
22%
12%
12%
15%
FR
HCP
SC
34%
20%
0%
FR
HCP
p<0.0001
Age
55+ yrs
35-54 yrs
LT 35 yrs
SC
FR
HCP
p<0.0001
Gender
Male
Female
SC
FR
HCP
SC
p<0.0001
Insurance
Uninsured
Medicaid
Medicare
Commercial
p<0.0001
Education
<High School
HS Grad/ GED
Some College
College Grad/
Graduate School
More In Fax-referred Group Had Chronic Dxs
(Chi-square p<0.0001)
100%
90%
80%
70%
60%
50%
40%
19%
13%
30%
20%
7%
32%
29%
FR (N=688)
HCP (N=2174)
10%
21%
0%
1 Chronic Dx
SC (N=6578)
2+ Chronic Dx
Encouraging Proactive Referrals
Reason #2: Reach & Help MORE smokers
If 1,000 Tobacco Users Fax-Referred to
Maine Tobacco HelpLine
50% of tobacco
vs.
Tobacco Users
users fax-referred
receive services
from HelpLine
1000
800
600
400
200
4% Calling into
HelpLine on own
460 More
240
More
0
Registered with
HelpLine
Counseled by MTH
Staff
Multi-pronged Approach = Success
for Reach of HelpLine
• Supportive Culture in Maine for
tobacco prevention, control & treatment
• Broad-based Promotion of HelpLine
• Medication Program Linked to Maine
Tobacco HelpLine
• Tobacco Treatment Training for
professionals interacting with tobacco users
• Surveillance and Evaluation
Sustaining & Expanding Volume
• Strong advocacy groups– to protect the Fund For A Healthy Maine
– Keep tobacco treatment $$ levels
• Continue work closely w/ PTM & Media
Contractor
• Expand provider referral systems
– electronic referral systems for EMRs
– Office system change interventionsmaximize on referral opportunities
– Referrals with discharge from hospitals
Contacts for more information
• Partnership For A Tobacco Free Maine
(NRT Program, Media, Community programs)
– Director: Dorean Maines
[email protected]
• Center for Tobacco Independence
(Comprehensive Tobacco Treatment Programs)
–
–
–
–
–
–
Exec. Director: Ken Lewis
Med. Director: Sandi Kazura
HelpLine: David Spaulding
Clinical Outreach: Cori Holt
Training: Fred Wolff
Evaluation: Tim Cowan
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]