Putting the Pieces Together for Statewide

Tobacco Cessation

“State of the Movement”

Wendy Bjornson, MPHPacific Center on Health and Tobacco

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 <12%.*

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.

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 <12% 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

What Works for Promoting Quitting?What are the “Tipping Points?”

Price increases Smoking bans Mass media campaigns Assistance/Treatment

Reminder systems Provider intervention (5A’s) Individual, group, quitline counseling Medications Low or no out-of-pocket expenses

Public Health/Policy Approaches

Increase Quit Attempts

Healthcare Approaches

Increase Quit Rates

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

How We Are Doing: State Spending*

6(0)0%

15(2)< 25%

14(3)> 25% < 50%

4(1)> 50% < 75%

4 (2)> 75% < 100%

4 (0)> 100%

Number of States% CDC Minimum Recommendation

* Campaign for Tobacco-Free Kids

How We are Doing: Second-hand Smoking Polices* Since the 1970’s, 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

How We Are Doing: Treatment

Quitlines Clinic services (5A’s) Benefits Coverage

Medicaid Medicare Private health insurance Uninsured

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

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

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

How We Are Doing: Medicare

Will provide some medication coverage in 2006.

Is proposing to cover some counseling services by 2006.

How We Are Doing: Health Insurance Coverage

0

5

10

15

20

25

Devices and Drugs Counseling Both

PercentEmployersCoveringService

1997: Tobacco Cessation Service Coverage

How We Are Doing: Health Insurance Coverage

0

5

10

15

20

25

30

AnyCessation

Counseling Rx OTC Self-help

PercentEmployersCoveringService

2001: Tobacco Cessation Coverage

How We Are Doing: Health Insurance Coverage

0

5

10

15

20

25

30

35

AnyCessation

Counseling Rx OTC Self-help

PPO

POSHMO

2001: Tobacco Cessation Service Coverage by Plans

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

What is Working: Overlapping Systems

Quitlines

Health & Community

Services

Purchasers & Employers

Tailored and Community

Development

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

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

What is Working: Insurers and Employers Partnerships with state programs especially quitlines

- e.g. Ohio, Minnesota. Toolkits – e.g. MIYB; Medicaid

“How-to’s” 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.

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

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.

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)

Summing Up

Medicare program is poised to include benefits.

National quitline program is underway. Good partnerships have been established.

But…..

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.

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?

Where are the leverage points? What are the best

investments of limited time, resources, and

political realities to help take the next step?