Putting the Pieces Together for Statewide Tobacco Cessation

1. Putting the Pieces Together for Statewide Tobacco Cessation “State of the Movement” Wendy Bjornson, MPH Pacific Center on Health and Tobacco

2. 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.

3. 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

4. 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

5. 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

6. How We Are Doing: State Spending* * Campaign for Tobacco-Free Kids

7. 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

8. How We Are Doing: Treatment • Quitlines • Clinic services (5A’s) • Benefits Coverage • Medicaid • Medicare • Private health insurance • Uninsured

9. 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

10. 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

11. 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

12. How We Are Doing: Medicare • Will provide some medication coverage in 2006. • Is proposing to cover some counseling services by 2006.

13. How We Are Doing: Health Insurance Coverage 1997: Tobacco Cessation Service Coverage

14. How We Are Doing: Health Insurance Coverage 2001: Tobacco Cessation Coverage

15. How We Are Doing: Health Insurance Coverage 2001: Tobacco Cessation Service Coverage by Plans

16. 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

17. What is Working: Overlapping Systems Health & Community Services Purchasers & Employers Quitlines Tailored and Community Development

18. 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

19. 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

20. 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.

21. 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

22. 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.

23. 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)

24. Summing Up • Medicare program is poised to include benefits. • National quitline program is underway. • Good partnerships have been established. But…..

25. 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.

26. 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?

27. Where are the leverage points? What are the best investments of limited time, resources, and political realities to help take the next step?