Reducing Tobacco Use & Factors affecting Reach of theMaine Tobacco HelpLine

Tim Cowan, MSPHDirector, MaineHealth Health Index Initiative

on behalf of the Healthy Maine Partnerships,

and the Partnership For A Tobacco-Free Maine

March, 2012

• Partnership for A Tobacco-Free Maine– Dorean Maines (Director)

• Center for Tobacco Independence– Sandi Kazura, MD- Medical Director

– Ken Lewis- Executive Director

– Program Managers

– HelpLine Specialists

Acknowledgements

• Prevalence of Smoking in Maine• Review of PTM’s Comprehensive

Tobacco Treatment Program• HelpLine Reach

–What is the level currently?–What Factors Contribute to it?

Topics Will Cover

0

10

20

30

40

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Per

cen

t W

ho

Use

To

bac

co

Maine- % of HS Students Who Use TobaccoUS- % of HS Students Who Use TobaccoMaine- % of Adults Who Use TobacoUS- Median % of Adults Who Use Tobacco

Smoking Prevalence Decreasing, but still lot of work to do

% Adult Smokers: Maine vs. U.S.- ‘06/07

• The maps on the next three slides present data for variables that all indicate the level of nicotine dependence in a state. Illustrates where the hard-core smokers live.

• % smokers who have first cigarette within 30 minutes of waking

• Mean number of cigarettes per day• % smokers who are daily smokers

• Patterns are similar in all three maps- Maine among the highest, grouped with Appalachian and tobacco growing states.

High Nicotine Dependence in Maine

High Nicotine Dependence in Maine

High Nicotine Dependence in Maine

High Nicotine Dependence in Maine

% Adult Smokers- 2010

Maine-CDC, DHHS:

Partnership For A

Tobacco-Free Maine

Estab 1997

Tobacco Treatment Training

2002 - Current

Cessation Medication Program

Sept 2002- Current

Maine Tobacco HelpLine

Aug 2001-Current

Partnership For A Tobacco-Free Maine’s

Comprehensive Tobacco Treatment Program

• Administered by MaineHealth, Center for Tobacco Independence (CTI)

• Hybrid Service Delivery Model– Free & Clear: registrations, initial counseling

sessions, some ad-hoc– CTI: proactive, outbound counseling calls, full

service for fax referrals, most ad-hoc, program evaluation

• Use Free & Clear protocol, data system, and print materials

Maine Tobacco HelpLine

• Intended for tobacco users

– planning to quit in next 30 days, or

– currently in quit attempt

• Up to 4 scheduled counseling sessions, plus unlimited ad-hoc (inbound) calls

• CTI HelpLine Specialists

– All trained in intensive tobacco treatment

– Ongoing training, case reviews, quality impr.

Maine Tobacco HelpLine, con’t

• Eligible via HelpLine if…– 18+ yrs age

– Have no NRT-use exclusions

– Uninsured OR insurance not cover cessation rxs

– AND enroll in multi-call counseling program

• Patch, gum, lozenge

• 30-day supply per “authorization”– 8 weeks NRT total- Sept 2002- Dec 2008

– Pilot of 12 weeks NRT total- _______ 2009

• “Authorization” process.– HelpLine send auth. to pharmacy benefit manager (PBM)

– PBM coordinates with selected pharmacy

– HelpLine caller picks up at pharmacy they selected.

Medication Program: FREE NRT

Number Adult Tobacco Users Registered with Maine Tobacco HelpLine

in XYZ time period(from HelpLine System)

Estimated Number Adult Smokers in Maine

in XYZ time period(based on Maine Behavioral Risk Factor

Surveillance System: % who report that currently smoke cigarettes )

Reach Rate

(Percent)=

Definition Used in Presentation

In Fiscal Year 2010, Maine One of Only Nine States

with Reach >3%

HelpLine Reach Consistently High

1. Colorado2. Iowa3. Maine4. Montana5. New Mexico6. New York7. Oklahoma8. South Dakota9. Wyoming

Target for 2015= 6% Reach in U.S.North American Quitline Consortium (U.S. states & Canadian provinces)

Next slide shows HelpLine Reach 2002-2009

Tobacco Users Calling HelpLine

1.5% 2.0% 2.9% 2.4% 3.3% 3.5% 5.4% 7.4% 4.5% 3.5% 4.2% 2.8% 4.2% 2.4% 5.3% 3.3%0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

2002Jan-Jun

2002Jul-Dec

2003Jan-Jun

2003Jul-Dec

2004Jan-Jun

2004Jul-Dec

2005Jan-Jun

2005Jul-Dec

2006Jan-Jun

2006Jul-Dec

2007Jan-Jun

2007Jul-Dec

2008Jan-Jun

2008Jul-Dec

2009Jan-Jun

2009Jul-Dec

To

ba

cc

o U

se

rs R

eg

iste

rin

g

Percents in Bars = Maine Tobacco HelpLine Reach Rate

HelpLine’s reach rate consistently one of highest for U.S. quitlines.

In 2008- 75% of states reported quitline reach <2%.

Multi-pronged Approach = Success for Reach of HelpLine

• Supportive Culture in Maine for tobacco prevention, control & treatment

• Broad-based Promotion of HelpLine

• Medication Program Linked to Maine Tobacco HelpLine

• Tobacco Treatment Training for professionals interacting with tobacco users

• Surveillance and Evaluation

Tobacco Legislation in Maine

1981 Public meetings1983 Court houses1985 Stores1986 Most workplaces1989 Hospitals, except psychiatric

patients and psych. hospitals199119971999 Restaurants20012003 Bars2005 Most loopholes closed2007 School grounds2009 Public beaches, outdoor

eating

ME Laws Banning SmokingCigarette Tax

State tax to $0.37 State tax to $0.74

State tax to $1.00

State tax to $2.00

Federal tax to $1.01

Supportive Culture

Strong Advocacy SupportMany organizations and individuals

American Lung Association- Maine American Cancer Society American Heart Association Health Policy Partners Maine Public Health Association

Result: Continued legislative support & funding for PTM comprehensive programs, HMPs- 1998-Current.

Supportive Culture

Advancements in Tobacco Treatment

1996 Maine Medicaid began coverage of NRT medications

1997 Partnership For A Tobacco-Free Maine created

2000 Maine CDC, Fund For A Healthy Maine- tob settlement $

Maine Medicaid created add-on reimbursement for counseling

2001 June- PTM Comprehensive Tobacco Treatment Program began

Aug- Maine Tobacco HelpLine Launched

Basic Treatment Trainings (Conferences) began

2002 Sep- Free NRT available via HelpLine

Sep-Oct- 4900 Clinicians mailed tobacco treatment toolkits

Nov- Clinical Outreach full speed ahead

Supportive Culture

Supportive Culture

Clinician Support for Quitting

0

25

50

75

100

by Physician by Dentist

Pe

rce

nt

Ad

vis

ed

Maine

US Total

Tobacco Use Supplement of Current Population Survey

2006/2007

Among Maine smokers with a clinical visit in the past 12 months…

% who reported clinician advised them to quit

2nd highest in US.

For BOTH Physicians & Dentists

Percents advised in Maine significantly higher than US percents.

High Nicotine Dependence in Maine

Yet one of highest % of quit attempts

And better success with abstinence

Supportive Culture: Tobacco Users Quitting

Maine 1 of only 8 states where there was a significant increase in the % of 30+ yr old “Ever Smokers” who have quit (1992/93 vs. 2006/07)

(Tobacco Use Supplement, Current Population Surveys)

Ever= Both Current and Former Smokers

Stars on map on next slides indicate these 8 states

Eight states still leaders: more smokers made quit attempts in 2006/2007

= significant increase in “Ever smokers” who quit 92/93 vs. 06/07

% Ever smokers quit vs. dependence

= significant increase in “Ever smokers” who quit 92/93 vs. 06/07

None of the eight states

from the Appalachian

region

Tax Increase = CallsSupportive Culture: Quitters Using HelpLine

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

2001Sep-Dec

2002Jan-Jun

2002Jul-Dec

2003Jan-Jun

2003Jul-Dec

2004Jan-Jun

2004Jul-Dec

2005Jan-Jun

2005Jul-Dec

2006Jan-Jun

2006Jul-Dec

2007Jan-Jun

2007Jul-Dec

2008Jan-Jun

2008Jul-Dec

2009Jan-Jun

2009Jul-Dec

6-month time periods

To

bac

co U

sers

Reg

iste

rin

g

HelpLine Operated 51 hrs per week

112 hrs/wk 40 hrs/wk 84 hrs per week

Nov '08-Feb '09: 2124 Callers

Mar: Industry raised pricesApr: Fed Cig Tax $0.62 to $1.01

Mar-Jun 2009: 3875 Callers

July-Aug 2005: 2457 Callers

Sept 2005: State Cig Tax $1.00 to $2.00

Sept-Oct 2005: 4571 Callers

Broad-based promotion of HelpLine

Healthy MainePartnerships

HealthDistrict Tobacco

Coordinators

Friends& Family

Past Callers

CommunityOrgs.

HealthcareOrgs.

Employers

InsuranceCompanies

PartnershipFor A

Tobacco-FreeMaine

DirectMedia

• Health Communications Interventions

Broad Based Promotion:

• Multiple types of media addressing tobacco use– TV, Radio, Internet, Newspapers, Telephone Books,

Pamphlets, Posters

• HelpLine specific ads• Other ads addressing tobacco have tag-

Maine Tobacco HelpLine number• Motivational and Awareness Ads

Media: Impacts HelpLine Call VolumeMaine Tobacco HelpLine- # Registrations/ Month

Jan 2006- Feb 2009

0

200

400

600

800

1000

1200

1400

06-J

an Jul

07-J

an Jul

08-J

an Jul

09-J

an

Media: Impacts HelpLine Call Volume

0

50

100

150

200

250

week1 week2 week3 week4 week5 week6 week7 week8 week9

Last week, July- 4th week, September

Hel

pL

ine

Reg

istr

atio

ns

2009- regular media

2010- 10-week media campaign

Began Authorizing free NRT via HelpLine September 2002

NEVER advertised through traditional media.

Tell clinicians free NRT available Clinical Outreach, Basics and Intensive trainings, Other programs advertise NRT via HelpLine

Word of mouth advertising.

Medication Program Linked to HelpLine

In 2005- Surveyed Tobacco Users who:

• enrolled in HelpLine counseling &

• were authorized, by HelpLine, to get free NRT.

Medication Program Linked to HelpLine

20%

75%50%Aware

50%Not Aware

Not Aware of Free NRTBefore Calling

Knowledge "Very MuchInfluenced" Decision

Knowledge "Influenced"or "SomewhatInfluenced" Decision

Knowledge Did NotInfluence Decision

Knowledge of Free NRT Influenced Decision to Call the HelpLine

NRT Program: Increased Counseling

99%99%99%99%99%99%99%99%97%96%94%96%94%91%86%52%76%0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

2001Sep-Dec

2002Jan-Jun

2002Jul-Dec

2003Jan-Jun

2003Jul-Dec

2004Jan-Jun

2004Jul-Dec

2005Jan-Jun

2005Jul-Dec

2006Jan-Jun

2006Jul-Dec

2007Jan-Jun

2007Jul-Dec

2008Jan-Jun

2008Jul-Dec

2009Jan-Jun

2009Jul-Dec

6-month time periods

To

bac

co

Use

rs R

egis

teri

ng

Self Help

Requested Counseling

% Tobacco Users Requesting Counseling

NRT Access via HelpLine

began Sept 2002

WebinarsBegin 2009

Tobacco Intervention:

Intensive Treatment

Training

Constellation of PTM Training Offerings

Clinical Outreach

Tobacco Intervention:

Basic Skills Training

Helpers Program

(proposed)

Tobacco Intervention:Basic Skills Training

Targets all professionals interacting with tobacco users

Teaching Goals: How to conduct Brief Tobacco Interventions

– Appreciate the importance of asking about tobacco use for every patient/client at every visit

– Learn basic assessment tools– Acquire skills on how to

• Advise to quit• Encourage patient/client change

– Learn how to assist with treatment planning

– Achieve understanding of, and comfort with, referring to the Maine Tobacco HelpLine

Clinical Outreach

One-hour, onsite education– Offered to medical and other

clinical practices

– Present tobacco dependence as a chronic, relapsing but treatable condition

– Increase self-efficacy about effectiveness of their role in increasing quit attempts and quit success

– Promote referrals to the Maine Tobacco HelpLine

Tobacco Treatment Training: Referrals

30%37%25%34%37%37%36%24%29%29%30%28%28%25%0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

To

ba

cc

o U

se

rs R

eg

iste

rin

gAll Other: Media, Friends/Family, PastCallers, Employers, Community Orgs,OtherHealthcare Providers

Sept-Oct 20024900 Toolkits Mailed to

Medical and Dental Providers

Nov 2002Clinical Outreach Full Speed Ahead

Practices Received Clinical Outreach

18 14134128191162 153 201

419 254169185210151 346 36911457546893 123 140Intensive Tx

BasicsTraining Attendees

Sep '02- Jun '02

Jul '06- Jun '07

Jul '05- Jun '06

Jul '04- Jun '05

Jul '03- Jun '04

Jul '02- Jun '03

Jul '07- Jun '08

Jul '08- Jun '09

Reason #1: Reach different subgroups of smokers via proactive referrals

Encouraging Proactive Referrals

Study Population: Tobacco Users Using Quitline, 2007-2008

(Total N=9,440)

6578(70%)

688 (7%)

2174(23%)

Physician Fax-Referrals, QL StaffProactively CalledTobacco Users

Phoned Into QL,Heard About fromHealth CareProfessional

Phoned Into QL,Heard About fromOther Sources

Compared Three Groups of Tobacco Users

Demographic Characteristics

41%

27%20%

43%

45%52%

16%

28%28%

51%58%61%

49%42%39%

12% 12% 15%

23% 22%26%

44% 47%

46%

21% 19%13%

37%33% 34%

40%

32% 26%

11%

13%

7%

11%

22%

33%

0%

20%

40%

60%

80%

100%

FR HCP SC FR HCP SC FR HCP SC FR HCP SC

MaleFemale

UninsuredMedicaidMedicareCommercial

55+ yrs35-54 yrsLT 35 yrs

<High SchoolHS Grad/ GEDSome CollegeCollege Grad/ Graduate School

GenderAge Insurance Education

p<0.0001p<0.0001 p<0.0001 p<0.0001

More In Fax-referred Group Had Chronic Dxs (Chi-square p<0.0001)

21%29%32%

7%

13%19%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FR (N=688) HCP (N=2174) SC (N=6578)

1 Chronic Dx 2+ Chronic Dx

Reason #2: Reach & Help MORE smokers

Encouraging Proactive Referrals

50% of tobacco users fax-referred receive services from HelpLine

vs.

4% Calling into HelpLine on own

If 1,000 Tobacco Users Fax-Referred to Maine Tobacco HelpLine

240More

460 More

0

200

400

600

800

1000

Registered withHelpLine

Counseled by MTHStaff

To

ba

cc

o U

se

rs

Multi-pronged Approach = Success for Reach of HelpLine

• Supportive Culture in Maine for tobacco prevention, control & treatment

• Broad-based Promotion of HelpLine

• Medication Program Linked to Maine Tobacco HelpLine

• Tobacco Treatment Training for professionals interacting with tobacco users

• Surveillance and Evaluation

• Strong advocacy groups- – to protect the Fund For A Healthy Maine– Keep tobacco treatment $$ levels

• Continue work closely w/ PTM & Media Contractor

• Expand provider referral systems– electronic referral systems for EMRs– Office system change interventions-

maximize on referral opportunities– Referrals with discharge from hospitals

Sustaining & Expanding Volume

• Partnership For A Tobacco Free Maine(NRT Program, Media, Community programs)– Director: Dorean Maines Dorean.E.Maines@maine.gov

• Center for Tobacco Independence(Comprehensive Tobacco Treatment Programs) – Exec. Director: Ken Lewis lewisk1@mainehealth.org

– Med. Director: Sandi Kazura kazura@mmc.org

– HelpLine: David Spaulding spauld@mainehealth.org

– Clinical Outreach: Cori Holt holtc1@mainehealth.org

– Training: Fred Wolff wolfff@mainehealth.org

– Evaluation: Tim Cowan cowant@mainehealth.org

Contacts for more information