Creating Community-Clinical Linkages to Treatment Cessation pathways: Creating Community-Clinical Linkages to Treatment

Session Objectives Highlight the burden of tobacco use in Colorado Review Colorado QuitLine program fundamentals, including access, eligibility and service delivery Understand the critical role of providers on impacting quit attempts and cessation success

Smokers who are advised to quit attempt quitting at higher rates Colorado Data Story In 2016, nearly 68% of smokers attempted to quit Among smokers who saw a health provider in the past year, advice to quit increased from 68.0% to 76.9% and referral to cessation treatment increased from 38.6% to 51.1%. Adult smoking prevalence* in 2015 was unchanged from 2012, but not uniformly across population groups. Compared with 2001, prevalence has declined significantly, although the number of smokers has increased with the increasing population.As of 2015, there were approximately 600,000 adult Coloradans who currently smoke cigarettes. Smokers who are advised to quit attempt quitting at higher rates

Colorado Data Story Adult smoking prevalence* in 2015 was unchanged from 2012, but not uniformly across population groups. Compared with 2001, prevalence has declined significantly, although the number of smokers has increased with the increasing population.As of 2015, there were approximately 600,000 adult Coloradans who currently smoke cigarettes.

Statement on Structural Inequity The Colorado Department of Public Health and Environment acknowledges that social, economic and environmental inequities result in adverse health outcomes and have a greater impact than individual choices. Reducing health disparities through systems change can help improve opportunities for all Coloradans. What else do we know about current smokers? Less likely to have a regular provider ● Less likely to have annual wellness visit and be up-to-date on preventive services

Disparities Snapshot Low SES Uninsured and Medicaid members Adults <65 years Native American & Black LGBT Unemployed & unable to work Persons with behavioral health conditions Pregnant women Access VISION: www.colorado.gov/pacific/cdphe/vision-data-tool Smoking prevalence rates across demographic groups (Table 1) include several groups with continued significant declines since 2001, but little significant change occurred after 2012. Little or no progress occurred toward closing prevalence gaps between low- vs. non-low-SES populations and young adult students vs. non-students. In the past 15 years, prevalence remained basically unchanged among men, adults aged 25+, and the state’s largest nonwhite populations. SES patterns of smoking were recognized during a period when Colorado's population was growing through migration but losing socioeconomic ground, with 32.2% classified as low SES in 2001 compared with 51.0% in 2015. The SES population trend converged with a lack of meaningful cessation progress among low SES smokers. As a result, while roughly half (52.5%) of Colorado smokers had low SES in 2001, three-fourths (75.1%) did in 2015. Smoking in Colorado is now fundamentally a low-SES problem.

Disparities: LSES Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

Disparities: Insurance Data Source: Behavioral Risk Factor Surveillance System (BRFSS)

Disparities: Mental Health Data Source: Behavioral Risk Factor Surveillance Survey (BRFSS)

Disparities: Cessation Success Data Source: The Attitudes & Behaviors Survey (TABS)

Portrait of a Current Smoker Less likely to have a regular provider Less likely to have annual wellness visit and be up-to- date on preventive services Less likely to meet nutrition and physical activity recommendations More likely to be diagnosed with COPD, arthritis, cancer, cardiovascular disease, and depression Likely to have attempted to quit smoking in the past year What else do we know about current smokers?

The Impact of Provider Advice Compared to people who smoke who do not get help from a clinician, those who get help are 1.7–2.2 times as likely to successfully quit for 5 or more months1. 1Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.

Tobacco Use Standard of Care All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis  All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates Every tobacco user should be offered at least a minimal intervention and referral to evidence-based treatment, such as the Colorado QuitLine

Service Delivery Basics This section will highlight current QuitLine benefits and accessibility options for Colorado residents. QuitLine Service Delivery Basics

Why QuitLine? Quality Access Coordination QL can provide the treatment intensity that often cannot be offered in a clinical setting due to time constraints QL works in conjunction with physician intervention and provides feedback on client progress QL increases access & reduces barriers, including those related to: cost, travel, language & business hours

QuitLine: At a Glance How To Reach Us Features 1-800-QUIT-NOW 1-800-652-3455 (CO direct) 1-855-DEJELO-YA 1-800-659-2656 (TTS) www.coquitline.org Features Intensive, client-centered coaching Confidential Non-judgmental Free NRT Self-help materials Text-messaging and email support

Eligibility To enroll, caller must be: a Colorado Resident 15 years of age for the coaching program 18 years of age to receive cessation medication* Insurance status and nicotine dependence levels are not eligibility criteria *Provider consent is required for individuals self-reporting uncontrolled hypertension, heart attack or stroke occurrence within the past calendar year; and for pregnant and breastfeeding women

Access & Enrollment Participants can enroll by Phone (1-800-QUIT-NOW) Provider Referral (fax, web or e-referral) Online (COQuitLine.org)www.coquitline.org 7 day per week, Multilingual Call Center 5 am to 11 pm MST Voicemail available 24 hours 5 Call Program Up to 5 Coaching Calls (Outbound at scheduled times) Unlimited inbound calls for support

Referral Program QuitLine receives referral Patient receives call from QL within 48 hours Up to 3 attempts are made to reach client over a 10 day period Fax back to HIPAA covered provider: When referral is received When patient enrolls, is unreachable or declines When patient receives NRT When patient completes the program

Pharmacotherapy Benefit Every CO participant (18 or older) enrolled in coaching is eligible for 2 quit attempts and 2 courses of nicotine replacement therapy (NRT) or 1 course of Chantix per 12 months* Products shipped direct to client’s residence Clients must maintain enrollment in the coaching program to receive additional medication shipments *A client's calendar year begins on the date of their first QuitLine medication order.

NRT Options Monotherapy Patch, gum, or lozenge offered (one product) Course of therapy delivered in two, four week shipments Combination Therapy   6 weeks of patch plus short acting NRT (gum or lozenge) and one additional 2 week course of monotherapy (client choice of product).

Chantix® (varenicline) Benefit Standard course of Therapy Clients are eligible to receive one* 12 week course annually Provider prescription is required and faxed direct to Ridgeway mail order pharmacy   *For clients who cannot tolerate Chantix, or who choose to discontinue the product after one month, a full 8 week course of NRT may be offered as a replacement to support the first quit attempt. 

Chantix® (varenicline) Process Flow

Ridgeway Pharmacy Accepts prescriptions via fax, e-script and mail Licensed to sell prescriptions in all 50 states 2824 US Hwy 93 North Victor, MT 59875 Phone: 1-800-630-3214 Fax: 406-642-6050 https://ridgeway.pharmacy/

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Colorado Medicaid All FDA-approved cessation medications are covered* at low or no cost for up to two 90 day courses of treatment *Prior Authorization and cessation counseling required Individual and group behavioral counseling are offered by qualified providers at no cost

Thanks for all you do to support tobacco cessation in Colorado. Contact Michelle Lynch Cessation and Health Systems Supervisor, CDPHE 303.692.2519 michelle.lynch@state.co.us Thanks for all you do to support tobacco cessation in Colorado.