Massachusetts Department of Public Health, Tobacco Cessation and Prevention Program

Tobacco Cessation and Worksite Wellness

November 13, 2012

Context

• Massachusetts spends $4.3 billion on healthcare costs every year.

• 10% of all healthcare costs in the Commonwealth are attributable to smoking.

• In Massachusetts, 8,000 people die prematurely every year from smoking-related illnesses.

Smoking Prevalence (Age 18+): Massachusetts, 1986 to 2009

Source: Massachusetts Behavioral Risk Factor Surveillance System

22.9% 22.7%

20.2%

15.0%

18.5%

27.8%

0%

10%

20%

30%

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

-2.2% APC

Other Tobacco Product Use* Among High School Students: Massachusetts, 1999-2009

• Other Tobacco Products (OTP) are beginning to surpass cigarette consumption among adolescents in MA

17.6%

16.0%

0%

10%

20%

30%

40%

1999 2001 2003 2005 2007 2009

Per

cent

of

Stu

dent

s

.

Other Tobacco Products

Cigarettes

Source: Youth Risk Behavior Survey 1993-2009

* Used one or more days during the past 30 days.

565 547510

466 465 451

406 388369 361 346 355

297 280 274 282 277 278

225 222 224

$0

$100

$200

$300

$400

$500

$600

Fiscal Year

Mil

lio

ns

of

Sta

mp

sNumber of Cigarette Packs Sold:

Massachusetts, FY 1991 to FY 2011

Data Source: Massachusetts Department of Revenue

Adult Smoking Prevalence Among Subgroups: Massachusetts, 2010

More Likely to Smoke Less Likely to Smoke

14.1%

30.3%

25.7%23.1% 22.6%

19.0%

11.2%8.7%

7.0%

MA Adults MassHealth* <$25Khousehold

income

High schoolor less**

Disabled LGBT* Privatehealth

insurance*

$75K +household

income

Collegedegree**

Source: Massachusetts BRFSS, 2010. * Adults, age 18-64 ** Adults, age 25+

Adult Smoking Prevalence By Race/Ethnicity: Massachusetts, 2008-2010

15%

18%

15%

0%

20%

White Black Hispanic

Source: Behavioral Risk Factor Surveillance System

Who Smokes in Massachusetts?

2008 Estimate

Why address tobacco use as an employer?

• At least $96 billion per year in direct medical costs in US1

• Businesses pay an average of $2,189 in workers‘ compensation costs for smokers, compared with $176 for nonsmokers2

• An estimated $96.8 billion per year in lost productivity due to sickness and premature death in US3

• Cost analyses have shown that tobacco cessation benefits, from an employer's perspective, are cost-saving.4,5

1, 3 CDC, MMWR , September 30, 2011/60(38);1305-1309

2, 4 National Business Group on Health, November 2011

5 US DHHS, Treating Tobacco Use and Dependence- 2008 Update

Comprehensive Approach

• Tobacco Free Policies• Benefits/Insurance Coverage• Workplace programs that include

evidence-based treatment options

Approach 1: Worksite Policies

• MA state law since 2004 – Review of basic requirements of SFWL – Employers have the discretion to implement

additional or stricter policies.

• Common additions:– Smoke-free outdoor spaces/campuses – Buffer zones– Tobacco-Free campus (smokeless, alternative

products)

Statistics on Quitting Post SFWL

• A Cochrane review found evidence that community interventions using "multiple channels to provide reinforcement, support and norms for not smoking" had an effect on smoking cessation outcomes among adults, including:

• Policies making workplaces1 and public places smoke-free

• Estimated that "comprehensive clean indoor laws" can increase smoking cessation rates by 12%–38%2

1. Lee CW, Kahende J (2007). "Factors associated with successful smoking cessation in the United States, 2000". Am J Public Health 97 (8): 1503–9. doi:10.2105/AJPH.2005.0835272. Lemmens V, Oenema A, Knut IK, Brug J (2008). "Effectiveness of smoking cessation interventions among adults: a systematic review of reviews". Eur J Cancer Prev 17 (6): 535–44. doi:10.1097/CEJ.0b013e3282f75e48

Approach 2: Employee Benefits

• PPACA Law – Beginning in 2014, all new health plans

will be required to offer smoking cessation benefits (both medications and counseling) to members free of co-pays.

• MassHealth Benefit (2006)

• Commonwealth Care Benefit (2012)

Recommended benefit for smoking cessation

• All 7 FDA-approved medications are covered for 2 courses of treatment in a calendar year with a prescription

• Brief and intensive counseling are a covered service

• Four tobacco cessation counseling sessions of at least 30 minutes for at least two quit attempts per year. This includes proactive telephone counseling, group counseling and individual counseling.

• No copayments or coinsurance and not subject to deductibles, annual or life time dollar limits.

Federal Employees Health Benefits (FEHB) as of 2011

0

2,000

4,000

6,000

8,000

10,000

Apr-06 Jul-06 Oct-06 Jan-07 Apr-07 Jul-07 Oct-07 Jan-08 Apr-08 Jul-08 Oct-08 Jan-09 Apr-09

Num

ber

of C

laim

s

Promotion and Utilization

31%Consumer Awarenes

s

75%ConsumerAwareness

40% of all MassHealth

smokers

Total People Using Benefit 75,810

MTCP Promotions

Began

MTCP Promotions

Ended

Announcement to 20,000 providers 6/06. Announcement to all MassHealth subscribers 6/06. Additional outreach to health centers, hospitals, community agencies, and providers beginning 8/06. Articles placed in over 15 professional and MCO newsletters beginning 9/06. MTCP radio and transit campaign 12/06 – 5/07. MassHealth wellness brochures 7/07. MTCP cessation television campaign 11/07 – 1/08. Consumer awareness surveyed by MTCP in 10/06 and by University of Massachusetts in 1/08.

Declines in Smoking Prevalence

Annual percentage rate (APR) change for smoking prevalence among MassHealth uninsured adults in Massachusetts aged 18-64.Source: Massachusetts Behavioral Risk Factor Surveillance System, 1998 to 2008

Smoking Prevalence in Massachusetts Adults (18 - 64):MassHealth vs. No Insurance

25.0%

30.0%

35.0%

40.0%

45.0%

7/1/

1999

7/1/

2000

7/1/

2001

7/1/

2002

7/1/

2003

7/1/

2004

7/1/

2005

7/1/

2006

7/1/

2007

7/1/

2008

Sm

oki

ng

Pre

vale

nce

(6-

Mo

nth

An

nu

al R

olli

ng

A

vera

ge)

MassHealth (Point Estimates) No Insurance (Point Estimates)

MassHealth (Model Estimates) No Insurance (Model Estimates)

Over 33,000 MassHealth

smokers quit

26% drop in smoking

prevalence

Near-term health impact

• Study finds health impact within one year

– 46% decrease in probability of hospitalization for heart attack

– 49% decrease in probability of hospitalization for acute coronary heart disease

– Controlled for demographics, prior health risks, seasonality, statewide influenza rates, and the implementation date of the Massachusetts Smoke-Free Workplace Law

Actual costs of benefit

• Actual costs only exceeded $7 million allocation in one fiscal year

• Costs were primarily for medication; counseling had only a 1% utilization rate

• FY07 $3.9 million

• FY08 $7.023 million

• FY09 $5.9 million

• Costs decreased as use of Chantix decreased

Source: MassHealth encounter data

Return on Investment

• Studies of the MassHealth benefit found that a positive return on investment happens within one year.

• A study by George Washington University shows a $2.21 net gain for every $1.00 spent on the MassHealth smoking cessation benefit.

Building on the MassHealth experience

• Coverage for all FDA-approved medications

• Coverage for behavioral counseling• Low co-pays• Allow for repeated quit attempts• Consistency of benefit across plans• Promotion of available benefit

Supporting tobacco treatment in workplace

• Develop clear and concise communications• Frame communication as goal of better health

for employees, not cost saving• Create a "brand" around the cessation program• Use a variety of communication methods such

as: – Employer's intranet, Home mailings, Mass e-mails,

Posters, Employee newsletters

• Recruit employees to assist with support and encouragement for employees trying to quit

• Be patient — recognize that this kind of culture change can take time

http://www.businessgrouphealth.org/tobacco/casestudies/index.cfm

Massachusetts Department of Public Health, Tobacco Cessation and Prevention Program

• At least $96 billion per year in direct medical costs in US1

• Businesses pay an average of $2,189 in workers‘ compensation costs for smokers, compared with $176 for nonsmokers2

• An estimated $96.8 billion per year in lost productivity due to sickness and premature death in US3

• Cost analyses have shown that tobacco cessation benefits, from an employer's perspective, are cost-saving.4,5

1, 3 CDC, MMWR , September 30, 2011/60(38);1305-1309

2, 4 National Business Group on Health, November 2011

5 US DHHS, Treating Tobacco Use and Dependence- 2008 Update