Promoting Effective
Tobacco-dependence Treatments
in Health Systems
Amanda Lee Johnson
Master of Health Science Student
(‘14)
JHSPH PHASE Intern
May 10th, 2013
Alison Vadnais
Master of Health Science Student
(‘14)
JHSPH PHASE Intern
Co-Preceptors
Dawn Berkowitz, MPH, CHES
Director for the Center for Tobacco Prevention and Control
Sara Wolfe, MS, CWWS Maryland Quitline Coordinator
Today’s Objectives:
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Introduction and Internship Goals
Methods/Approaches
Results
Limitations and Challenges
Lessons Learned
Policy and Practice Implications
References
Questions and Comments
Introduction
• Tobacco use is the leading cause of preventable disease, disability, and
death in the US
• Maryland:
• the highest percentage (66.0%) of adult smokers who have made a quit
attempt in the past year
• For every $1.00 spent on tobacco cessation treatment, there is an average
potential return on investment of $1.34
• 11th highest adult cigarette prevalence (19.1%)
• 4th highest youth cigarette prevalence (12.5%)
• Annual costs of smoking-caused health problems: $1.96 Billion
• The Clinical Practice Guidelines support the use of seven medications and
three types of counseling for tobacco addiction.
• Having sufficient resources to fund and promote the Quitline and local
programming is important to continue to serve Marylanders, especially
those in vulnerable populations, including youth and pregnant smokers.
http://www.cdc.gov/tobacco/data_statistics/state_data/state_highlights/2012/sections/index.htm
Center for Tobacco Prevention and
Control, Department of Mental Health &
Hygiene
• Organization Goal to create a tobacco free Maryland
• Brings together community partners, state agencies, and local
health departments to implement evidence-based strategies
to prevent and reduce tobacco use in the state of Maryland.
• Programs and Projects
• Youth Risk Behavior Survey / Youth Tobacco Survey
• Maryland Tobacco Quitline
• Statewide & Local Tobacco Control Initiatives
• Oversees local and statewide initiatives modeled on the “best
practices” recommendation from the Centers for Disease
Control and Prevention (CDC).
Introduction to Quitline:
• An evidence-based telephone tobacco treatment service, available free to
all Maryland residents and accessible 24/7
• Standard service consists of four treatment sessions
• Five specialized treatment sessions and protocol for youth (ages 13 to
17)
• Ten specialized treatment sessions and protocol for pregnant women
• Highly trained, professional Quit Coaches©
• Provides callers with the opportunity to have NRT mailed directly to their
home* and access to the interactive web-based tobacco treatment
community*
• *Callers must be 18 years of age and older for these services
Introduction to NAQC:
• Maryland is one of 11 states participating in the North
American Quitline Consortium (NAQC) public-private
partnership initiative
• NAQC Public-Private Partnership aims to:
• provide resources and knowledge for the establishment
of cost-sharing partnerships between state Quitlines and
health insurance providers
Internship Goals
Alison’s Goals
• Create an online survey to
assess current tobacco
cessation coverage among
commercial health plans.
• Synthesize data from
disparate sources
concerning Quitline
utilization and health plan
quality
• Write an original report
highlighting opportunities,
challenges and making
recommendations
Amanda’s Goals
• Evaluate and update current
promotional and communication
materials
• Integrate updated statistics on
Quitline’s outreach effectiveness
and success rates into
presentations and promotional
materials
• Create original presentations to
health and insurance providers
on integrating Quitline, Fax to
Assist, and e-referral services
within their practices
Methods and Approach
Advertising
Campaigns
Data
Collection
Progress and
Evaluation
Reports
Needs
Assessments
Webinars
Results
Preliminary
Cessation
Coverage
Assessment
Report
bringing together Quitline
utilization data and HEDIS
health plan quality data
Quitline Utilization By Plan
Type 2012
Uninsured
25%
Medicare
16%
Don’t Know
2%
Private
Insurance
28%
Medicaid
29%
Commercially Insured Consumers Calling
Quitline: Most Prevalent Plans
Percentage of Private Insurance Call Volume
2012
8.52%
Aetna
42.25%
24.27%
6.65%
BCBS
Kaiser
10.09%
United
Health
Private
Ins.
“Other”
Results
Maryland Department of Health and
Mental Hygiene: Survey of Health Plan
Tobacco Cessation Benefits
Provider Reimbursement & Member
Incentives
Survey: Assessing Coverage of Nicotine
Replacement Therapy (NRT) and Cessation
Medications
• NRT and Cessation
Medications
• Which products are
covered?
• Are there barriers to
use?
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Cost Sharing
Service Limits
Requiring referrals
Age Limits
Coverage of Cessation
Counseling Types
Measures & Outcomes
• Are plans aware of the
prevalence of tobacco use
among plan members?
• Tracking quit rates due to
cessation benefits?
• Measuring outcomes of a
member quitting smoking
on that members use of
other benefits?
Amanda’s Results
• Assisted with the development of fact sheets for pregnant
women, youth, and web/text-based services
• Updated Quitline website with page for Spanish speakers,
event calendar, and county-specific resources
• Created presentations to target insurance providers and
medical providers and to promote Quitline’s new services
targeting pregnant women, youth, and web and text-based
programs.
Drafts of
New Promotional Materials
Draft of
Promotional
Advertisement
Front and Back Covers
of Brochure
Inside of Brochure
Quitline Annual Enrollments
18590
15310
17122
14132
12617
11734
Target Reach: 12,354
Tobacco Users
4897
2007
6468
2008
7782
6404
7126
8407
Number of Callers
Number of Interventions
2009
2010
2011
2012
High Quality and Highly Effective
30 Day Quit Rates
Quitline***
10.0%
Physician Advice Alone**
Quitting Alone*
30.5%
5.5%
0.0% 5.0% 10.0%15.0%20.0%25.0%30.0%35.0%
All based on 1 month comparisons:
* Average of 4% to 7%. American Cancer Society. 2011-01-31. Retrieved 2011-0217.
** Fiore, Treating Tobacco Use and Dependence, Clinical Practice Guidelines 2008
Update
***Alere Wellbeing, Maryland Tobacco Quitline Comprehensive Evaluation Report
averages, 2007-2012 Responder rates at 30 days point prevalence
Amanda’s Recommendations for
Policy/Practice
• If I had another semester, I would:
• Place greater emphasis on targeting individuals who smoke and
who have psychological or behavioral health issues
• Emphasize the development of an e-referral program with
medical providers, build teaching materials and webinars
• Continue the development of smokingstopshere.com
• Ongoing evaluation of quitting methods including web and textbased services for youth and pregnant women will aid in targeting
our services to fit the needs of underserved populations
• Supporting health communications efforts for targeted populations
will increase Quitline reach and quit attempts of Maryland
residents.
Alison’s Recommendations for
Policy/Practice
• Ongoing partnership with Medicaid provides continued funding
for Quitline and the Center for Tobacco Prevention and Control
and helps to assist more smokers with quitting tobacco.
• Pursue cost sharing with Medicare similar to Medicaid
• Continue to work with Blue Cross Blue Shield to explore cost
sharing partnership options. Approach United, Aetna and Kaiser
to explore cost sharing partnership options.
• Consider new strategies for self-identification of health insurance
plan on Quitline before pursuing transfer strategy
• Continue to dedicate resources to integrate the Quitline and
other tobacco control efforts into health systems
Challenges and Limitations
• Much background knowledge to acquire before feeling able to
create survey and complete report
• Short time period – limited our ability to complete all
internship goals
• Survey tool created, however, not yet administered and analyzed
data
Lessons Learned
• The importance of inter-state and inter-agency collaboration
for sharing of knowledge and benefit of consumers
• Complexities of health insurance cessation benefit
• Gained knowledge and further developed interest in future
research involving future tobacco cessation
• The importance of language, visuals, and media in
communicating effective and affordable health programs and
addressing specific populations
Alison’s References
• Alere Wellbeing. (2013). Maryland Tobacco Quitline: Tobacco
Users By Health Plan Report 1/1/2012 to 12/31/2012.
• American Lung Association. (2012). Factsheet: Essential
Health Benefits.
• Kaiser Family Foundation. Maryland: Health Insurance Status
2010-2011 Retrieved April 22, 2013
• MHCC. (2011). 2011 Comprehensive Performance Report:
Commercial HMO, POS, and PPO Health Benefit Plans in
Maryland.
• Michael C. Fiore, et al., Treating Tobacco Use and Dependence:
2008 Update, U.S. Dept. Health and Human Human Services
(May 2008)
• North American Quitline Consortium "NAQC Public-Private
Partnership Initiative." Retrieved 02/17/2013, 2013.
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Amanda’s References
Alere. FY12 Annual Operations Summary Report for the Maryland Tobacco Quitline. Rep.
Seattle: Alere, 2012. Print.
Center for Tobacco Prevention and Control. Overview: Center for Tobacco Prevention and
Control. N.p.: n.p., 2013. Print.
Center for Tobacco Prevention and Control. Patient Protection and Affordable Care Act,
State Supplemental Funding for Healthy Communities, Tobacco Prevention and Control,
Diabetes Prevention and Control, and BRFSS. N.p.: n.p., n.d. Print.
Finley, Cara, MPH, Jeremy Braithwaite, MA, Ami Lynch, PhD, and Susanna Nemes,
PhD. Maryland Tobacco Quitline CDC-CPPW Stimulus Funding 7-Month Evaluation
Report. Publication. N.p.: Social Solutions International, 2012. Print.
MDQuit Best Practices Conference. 2012. PPT.
Monitoring Changing Tobacco Use Behaviors 2000-2010: Legislative Report. Publication.
2010. Print.
PATCH Draft Action Plan. Working paper. 25 Jan. 2013 Print.
Tobacco Program Activities. Rep. N.p.: n.p., n.d. Print.
"Tobacco Use." Centers for Disease Control and Prevention. Centers for Disease Control
and Prevention, 16 Nov. 2012. Web. 19 Feb. 2013.
Treating Tobacco Use and Dependence: Clinical Practice Guidelines 2008 Update.
Publication. 2008. Print.
Questions/Comments?
Special Thanks to:
Dawn Berkowitz, MPH, CHES
Sara Wolfe, MS, CWWS
Jennifer X. Le, MPH
Beth A. Resnick, MPH
JHU and the PHASE Internship Course