The Impact of Smoking in Los Angeles County

Slide 1:The Impact of Smoking in Los Angeles CountyMarch 25, 2010

Jonathan Fielding, M.D., M.P.H., M.B.A Director of Public Health and Health Officer L.A. County Department of Public Health Professor of Health Services and Pediatrics Schools of Public Health and Medicine, UCLA

Slide 2:Los Angeles County Overview

Unique geographic and demographic characteristics of Los Angeles that impact tobacco control efforts: 4,300 square miles 88 incorporated cities, 2 islands, and large un-incorporated areas 10.3 million residents (more than 42 states) 46% Latino, 32% White, 13% Asian/Pacific Islander, 10% African American, 0.3% American Indian Over 100 different languages Source: Department of Public Health � Strategic Plan 2008-11 2

Slide 3:Tobacco Control Efforts in Los Angeles County

Tobacco control & prevention efforts in Los Angeles County focuses on four major areas: Preventing youth initiation Promoting cessation resources Reducing secondhand smoke exposure Countering pro-tobacco influences Approach designed to change the social norms of communities (create a social and legal climate where tobacco is less desirable, less acceptable, and less accessible). The Department of Public Health works with several partners, including community-based organizations, voluntaries (e.g., American Heart Association, American Lung Association, and American Cancer Society), universities, businesses (e.g., Ralph�s pharmacies), and community coalitions on several initiatives to reduce SHS exposure, prevent youth initiation, counter pro-tobacco influences, and increase access and utilization of effective smoking cessation services. Social norm changes indirectly influence current and potential future tobacco users by creating a social milieu and legal climate in which tobacco becomes less desirable, less acceptable, and less accessible The Department of Public Health works with several partners, including community-based organizations, voluntaries (e.g., American Heart Association, American Lung Association, and American Cancer Society), universities, businesses (e.g., Ralph�s pharmacies), and community coalitions on several initiatives to reduce SHS exposure, prevent youth initiation, counter pro-tobacco influences, and increase access and utilization of effective smoking cessation services. Social norm changes indirectly influence current and potential future tobacco users by creating a social milieu and legal climate in which tobacco becomes less desirable, less acceptable, and less accessible

Slide 4:Tobacco Use in Los Angeles County Among Adults

4 Source: 2007 LACHS Efforts highly successful--overall adult smoking prevalence in CA and LAC has declined approximately 30% since 1990. At 14.3 %, overall smoking prevalence in Los Angeles County is one of the lowest in the Country However, we are now seeing a flattening out and even a slight increase in smoking rates among both adults and youth in Los Angeles County. At this point, we do not know if this is just an anomaly or the beginnings of an upward trend. However, we do know that we are seeing the same phenomenon at the state level as well. The dash line represents the a change in the definition of smoking. (There was a similar decrease between 1999 and 2002 when we used the old definition so we know that the sharp decline was not the result of the new definition) Prevalence 1997 18.20% 1999 18.10% 2002 14.60% 2005 14.10% 2007 14.30% Dotted line: change of definitionEfforts highly successful--overall adult smoking prevalence in CA and LAC has declined approximately 30% since 1990. At 14.3 %, overall smoking prevalence in Los Angeles County is one of the lowest in the Country However, we are now seeing a flattening out and even a slight increase in smoking rates among both adults and youth in Los Angeles County. At this point, we do not know if this is just an anomaly or the beginnings of an upward trend. However, we do know that we are seeing the same phenomenon at the state level as well. The dash line represents the a change in the definition of smoking. (There was a similar decrease between 1999 and 2002 when we used the old definition so we know that the sharp decline was not the result of the new definition) Prevalence 1997 18.20% 1999 18.10% 2002 14.60% 2005 14.10% 2007 14.30% Dotted line: change of definition

Slide 5:Wide Variation in Tobacco Use Among Sub-populations

Source: 2007 LACHS 5 In addition, there is a wide variation in tobacco use among different racial/ethnic groups. In addition, there is a wide variation in tobacco use among different racial/ethnic groups.

Slide 6:Impact of Tobacco Use in Los Angeles County 

Over 1 million adults still smoke.* 1 out of every 7 deaths is caused by cigarette smoking.** Top 5 causes of death are associated with tobacco use: lung cancer, coronary heart disease, chronic airway obstruction, cardiovascular disease, other cancers.** Approximately 336,000 children and 585,000 non-smoking adults in the County are regularly exposed in their homes.* *Source: LACHS, 2007 **Source: OHAE: Smoking Prevalence Among Los Angeles County Adults, LA Health Trends; August 2006 Despite tremendous progress in reducing the prevalence of smoking over the past generation , we still have more work to do. Tobacco use remains the leading preventable cause of death in the United States and is associated with the top five leading causes of death in Los Angeles County. These leading causes are responsible for nearly half of all deaths in the County, and cigarette smoking is a major risk factor for four of the five leading causes (heart disease, stroke, lung cancer, and emphysema/COPD). � Additionally, exposure to secondhand smoke also causes lung cancer and heart disease among non-smokers. Among children, secondhand smoke exposure causes lower respiratory tract infections, asthma, and middle ear infections. Secondhand smoke exposure among infants and fetuses is a risk factor for Sudden Infant Death Syndrome, low birth weight, and pre-term delivery. � Despite tremendous progress in reducing the prevalence of smoking over the past generation , we still have more work to do. Tobacco use remains the leading preventable cause of death in the United States and is associated with the top five leading causes of death in Los Angeles County. These leading causes are responsible for nearly half of all deaths in the County, and cigarette smoking is a major risk factor for four of the five leading causes (heart disease, stroke, lung cancer, and emphysema/COPD). � Additionally, exposure to secondhand smoke also causes lung cancer and heart disease among non-smokers. Among children, secondhand smoke exposure causes lower respiratory tract infections, asthma, and middle ear infections. Secondhand smoke exposure among infants and fetuses is a risk factor for Sudden Infant Death Syndrome, low birth weight, and pre-term delivery. �

Slide 7:Impact of Tobacco Use in Los Angels County

Source: TCPP, 2006 The next two slides show the health impact of disparities in smoking prevalence. Overall smoking-attributable mortality represents the number of deaths due to smoking across 19 disease categories, expressed as rates per 100,000. Smoking-attributable mortality was higher among African American females and males compared to the other race/ethnic groups. The next two slides show the health impact of disparities in smoking prevalence. Overall smoking-attributable mortality represents the number of deaths due to smoking across 19 disease categories, expressed as rates per 100,000. Smoking-attributable mortality was higher among African American females and males compared to the other race/ethnic groups.

Slide 8:Impact of Tobacco Use in Los Angels County

Source: TCPP, 2006 Overall smoking-attributable years of potential life lost is summed across 19 disease categories, and expressed as a rate per 100,000. Smoking-attributable YPLLs were higher among African American females and males compared to the other race/ethnic groups. Overall smoking-attributable years of potential life lost is summed across 19 disease categories, and expressed as a rate per 100,000. Smoking-attributable YPLLs were higher among African American females and males compared to the other race/ethnic groups.

Slide 9:Cost to Employers

Reduced Productivity On average male smokers miss 4 days and female smokers miss 2 more days of work a year than non-smokers.* The average smoker spends a total of 18 days a year on smoking breaks.* In Los Angeles County, total costs in lost productivity from tobacco use is more than $2.0 billion dollars per year.** Adult smokers cost employers at least $1,760 per year in lost productivity.* *Source: Pacific Business Group on Health: Tobacco Cessation Benefit Coverage and Consumer Engagement Strategies , 2008 ** Source: Max et al, 2002 9

Slide 10:Cost to Employers

Increased Medical Expenditures Smoking costs Los Angeles County more than $2.3 billion in direct medical costs.** Adult smokers cost employers $1,623 per year in excess medical expenses.* Neonatal health care costs related to smoking are equivalent to $704 for each maternal smoker.* On average, tobacco users cost company drug plans twice as much as non-tobacco users.* *Source: Pacific Business Group on Health: Tobacco Cessation Benefit Coverage and Consumer Engagement Strategies , 2008 ** Source: Max et al, 2002 10

Slide 11:Smokers Want to Quit

Approximately 70% of smokers reported wanting to quit smoking.* Overall, 56.7% of smokers attempted to quit smoking in 2007.* Of those who made a quit attempt, 81% reported trying to quit �cold turkey� or without using a cessation aid.* Only 5% or fewer are successful with each attempt because most try without tobacco counseling or medications.** *Source: LACHS, 2007 ** Source: Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Clinical Practice Guideline 11 �According to the Los Angeles County Health Survey, a majority of smokers want to quit smoking Of those wanting to quit more than half (56.7%) of smokers attempted to quit smoking in 2007. Among those who tried to quit smoking, 81.2% reported quitting �cold turkey,� or without a cessation aid, 24.7% sought help or support from friends and family, 15.6% used anti-smoking literatures (including books, pamphlets, videos or other materials), and 8.6% consulted anti-smoking material on the Internet �According to the Los Angeles County Health Survey, a majority of smokers want to quit smoking Of those wanting to quit more than half (56.7%) of smokers attempted to quit smoking in 2007. Among those who tried to quit smoking, 81.2% reported quitting �cold turkey,� or without a cessation aid, 24.7% sought help or support from friends and family, 15.6% used anti-smoking literatures (including books, pamphlets, videos or other materials), and 8.6% consulted anti-smoking material on the Internet

Slide 12:Employers Can Help Further Reduce Tobacco Use

Nearly 1.8 million smokers in California receive their health insurance benefits through their employer. 57% of workers in private businesses offered employer-sponsored health insurance were offered benefits that included at least one form of tobacco-dependence treatment: nicotine replacement therapy Zyban� smoking-cessation counseling Only 22% of these employees have coverage for all three types of treatment. Source: McMenamin SB, et al: Trends in Employer-Sponsored Health Insurance Coverage for Tobacco-Dependence Treatments, Am J Prev Med 2008;35(4) 12 57% of workers in private businesses offered employer-sponsored health insurance were offered benefits that included at least one form of tobacco-dependence treatment: Specifically, 47% or workers had coverage for nicotine replacement therapy, 36% had coverage for Zyban� and 40% had coverage for smoking-cessation counseling. 57% of workers in private businesses offered employer-sponsored health insurance were offered benefits that included at least one form of tobacco-dependence treatment: Specifically, 47% or workers had coverage for nicotine replacement therapy, 36% had coverage for Zyban� and 40% had coverage for smoking-cessation counseling.

Slide 13:Effective Treatments

Tobacco-dependence treatment is more cost effective than most other common and covered disease prevention interventions, such as the treatment for hypertension and high blood cholesterol.* Proven cessation strategies � such as counseling, telephone quitlines, and FDA-approved smoking medications (nicotine gum, inhaler, lozenge, nasal spray, patch, Zyban, and Chantix) � can double or even triple a smoker�s chance of quitting.** Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit.** *Source: Cummings SR, et al. The cost-effectiveness of counseling smokers to quit. JAMA 1989;261(1):75�79. **Source: Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Clinical Practice Guideline, 2008 13 Paying for tobacco use cessation treatments is the single most cost-effective health insurance benefit for adults that can be provided to employees. Studies show that the success rate of quitting is dramatically improved when people are assisted by drug and/or behavior modification therapy. According to some estimates, intensive treatment that combines pharmacological interventions and behavioral counseling more than doubles quitting success rates. Paying for tobacco use cessation treatments is the single most cost-effective health insurance benefit for adults that can be provided to employees. Studies show that the success rate of quitting is dramatically improved when people are assisted by drug and/or behavior modification therapy. According to some estimates, intensive treatment that combines pharmacological interventions and behavioral counseling more than doubles quitting success rates.

Slide 14:Coverage Recommendations

Tobacco-use screening is covered at every clinical encounter. Eligible patients may access two courses of six counseling sessions per calendar year, for a total of 12 sessions per calendar year. . FDA-approved nicotine replacement products and tobacco cessation medications are covered as prescribed by a clinician and are not subject to copayments or deductible. Counseling sessions should last at least 30 minutes each. A course of treatment should support up to 300 minutes of counseling. Source: Purchaser�s Guide to Clinical Preventive Services: Moving Science to Coverage , 2008 14 Gold standard of coverage. Gold standard of coverage.

Slide 15:What Can Employers Do?

Learn more about smoking behavior among employees. Know what tobacco-use treatments your current health plan provides. Ask for coverage that provides effective treatments, including counseling and all FDA-approved medications. Promote effective tobacco cessation services, including the California Smokers� Helpline (1-800 NO BUTTS). Include tobacco cessation services in worksite wellness programs. Strengthen existing smoke-free work policies. 15 The first step is to identify smoking behavior among employees to determine a baseline of smoking prevalence. Most employers under-estimate the number of employees who smoke. Many employers rely of HRAs to identify smokers and tobacco users. Others extrapolate from national and statewide figures using the demographic characteristics of their workforce to estimate smoking prevalence. Others use life insurance enrollment forms, and analysis of prescription drug use data to determine worker tobacco use. Recognizing the challenge of managing different coverage levels from different health plans, most employers rely on health plans to manage delivery of smoking cessation services. Essential for employers to know the benefits being offered to their employees and to work with health plans to determine the most efficacious and cost-effective ways to cover smoking cessation services, including all FDA-approved medications. Also, it is essential for employers to know what benefits are available to employees, and to effectively communicate this information to employees using user-friendly communications. Because of California�s strict laws that govern smoking in indoor and outdoor public places, by definition, employers already have formal policies that prohibit smoking in indoor work buildings. However, a 1/3 of employers go a step further and have extended their smoke-free policies to include both indoor and outdoor areas or entire work campuses. And about one-quarter have policies that prohibit smoking in company vehicles at anytime. The first step is to identify smoking behavior among employees to determine a baseline of smoking prevalence. Most employers under-estimate the number of employees who smoke. Many employers rely of HRAs to identify smokers and tobacco users. Others extrapolate from national and statewide figures using the demographic characteristics of their workforce to estimate smoking prevalence. Others use life insurance enrollment forms, and analysis of prescription drug use data to determine worker tobacco use. Recognizing the challenge of managing different coverage levels from different health plans, most employers rely on health plans to manage delivery of smoking cessation services. Essential for employers to know the benefits being offered to their employees and to work with health plans to determine the most efficacious and cost-effective ways to cover smoking cessation services, including all FDA-approved medications. Also, it is essential for employers to know what benefits are available to employees, and to effectively communicate this information to employees using user-friendly communications. Because of California�s strict laws that govern smoking in indoor and outdoor public places, by definition, employers already have formal policies that prohibit smoking in indoor work buildings. However, a 1/3 of employers go a step further and have extended their smoke-free policies to include both indoor and outdoor areas or entire work campuses. And about one-quarter have policies that prohibit smoking in company vehicles at anytime.

Slide 16:Benefits of Tobacco-Use Cessation

Over time, tobacco-use cessation benefits generate financial returns for employers in four ways: Reduced health care costs Reduced absenteeism Increased on�the�job productivity Reduced life insurance costs Benefits realized more immediately include: Increases in employee productivity Reductions in smoking�attributed neonatal health care costs Smoke-free workplace policies may also realize savings on fire insurance and costs related to property repair and upkeep. Source: CDC. Coverage for Tobacco Use Cessation Treatments, 2008 16 Tobacco cessation is more cost-effective than other common and covered disease prevention interventions, such as the treatment of hypertension and high blood cholesterol. Cost analyses have shown tobacco cessation benefits to be either cost�saving or cost�neutral. Overall, cost/expenditure to employers equalizes at 3 years; benefits exceed costs by 5 years. Employers that have included a tobacco cessation benefit report that this coverage has increased the number of smokers willing to undergo treatment and increased the percentage that successfully quit.Tobacco cessation is more cost-effective than other common and covered disease prevention interventions, such as the treatment of hypertension and high blood cholesterol. Cost analyses have shown tobacco cessation benefits to be either cost�saving or cost�neutral. Overall, cost/expenditure to employers equalizes at 3 years; benefits exceed costs by 5 years. Employers that have included a tobacco cessation benefit report that this coverage has increased the number of smokers willing to undergo treatment and increased the percentage that successfully quit.

Slide 17:Resources

Centers for Disease Control and Prevention http://www.cdc.gov/tobacco/ A Purchaser's Guide to Clinical Preventive Services: Translating Science into Coverage http://www.businessgrouphealth.org/benefitstopics/topics/purchasers/fullguide.pdf America�s Health Insurance Plans-Online ROI Calculator www.businesscaseroi.org 17 There are many toolkits available for employers making benefit design decisions and other preventive coverage policies The calculator provides information for determining the cost of not addressing tobacco as well as the cost of initiating a tobacco treatment benefit. It is useful for benefit managers as well as health plan product managers. There are many toolkits available for employers making benefit design decisions and other preventive coverage policies The calculator provides information for determining the cost of not addressing tobacco as well as the cost of initiating a tobacco treatment benefit. It is useful for benefit managers as well as health plan product managers.