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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
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o U
se
rs R
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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
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sers
Reg
iste
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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
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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 [email protected]
• Center for Tobacco Independence(Comprehensive Tobacco Treatment Programs) – Exec. Director: Ken Lewis [email protected]
– Med. Director: Sandi Kazura [email protected]
– HelpLine: David Spaulding [email protected]
– Clinical Outreach: Cori Holt [email protected]
– Training: Fred Wolff [email protected]
– Evaluation: Tim Cowan [email protected]
Contacts for more information