Statewide Comprehensive Tobacco Cessation Wendy Bjornson, MPH Pacific Center on Health and Tobacco

Why Hasn’t Cessation Been a Higher Priority? Tobacco control movement started with research and campaigns to help people stop. Effective clinical methods were developed.  Behavioral science - designed around a clinical behavioral model – “small group therapy”.  Effective medications were developed – initially prescriptions, medical supervision were required – added to clinical model.  Clinical model was too limiting; didn’t meet needs of broad populations.

Why Hasn’t Cessation Been a Higher Priority? Population based policy approaches were discovered and found to be effective.  Price increases  ETS restrictions  Advertising restrictions  Sales to minors enforcement Initial experiments with population based cessation approaches were ineffective – were not evidence-based. Clinical models too limiting; population approaches ineffective. Conclusion: “Cessation doesn’t work.”

Why is cessation becoming more of a priority? Despite ineffectiveness of first population based approaches, research has continued. Effective population based approaches have evolved: Now, “Cessation works.” Implementation strategies have been developing somewhat separately – beginning to come together. Momentum is building as effectiveness increases and as tobacco control movement changes – poised to coalesce into a “tobacco cessation movement.”

What are the changes in the tobacco control movement? Changes in policies restricting smoking in public places together with price increases are motivating more tobacco users to try to stop.  Tobacco control has been successful in stimulating more quit attempts.  Most of these tobacco users try to quit on their own and most fail.  Tobacco users are 2-3 times more likely to quit with help than on their own. Goal is to increase number of assisted quit attempts. New cessation strategies can work.

Why is funding for cessation becoming a priority? Assistance to stop smoking costs $300 - $500 (counseling and medications). Tobacco control advocacy for tax increases together with state economic problems have resulted in increased tobacco taxes in many states; almost none of these revenues are used to help people stop smoking. Nationally,about half of tobacco users are economically disadvantaged; can’t afford help.

What Do We Need to Do? Opportunity: Cessation approaches can now help reach public health goals. Challenge: Need programs and policies to set up, deliver, and finance evidence- based services with limited public funding. HOW? Partnership approach to statewide comprehensive tobacco cessation programs.

Comprehensive Tobacco Cessation Evidence-based, state funded quitlines Cessation services in conjunction with community and health care services. Benefit coverage through employers, public insurance programs and other health care purchasers. Innovative and culturally sensitive community development and population based approaches to reach disparate populations Quitlines Health & Community Services Purchasers & Employers Community Development

Quitlines Play a central role through:  Direct counseling  Central resource for materials, information and referrals – triage callers.  Easily accessible, convenient, economies of scale  Multi-language, culturally tailored services  Trained staff; quality assurance

Health Care and Community Services Need system that makes advice and referral from health care professionals routine – evidence based. Health and community services can make services integral part of clinic visits.  Give personal advice  Refer tobacco users who are ready for services (e.g.quitlines)  Prescribe medications  Record in charting systems Service delivery can be included in administrative and billing health information systems – monitor for quality improvement.

Benefit Coverage Benefits through:  Employers – both public and private  Publicly funded insurance programs – Medicaid, Medicare, HIS, FQHC’s, mental health and substance abuse programs. Need to build partnerships and demonstrate how effective tobacco cessation is a good investment in a health workforce.

Community Development/ Tailored Population-Based Approaches Key issue for reaching disparate populations is how access to health services is affected by SES. About half of tobacco users in US are economically disadvantaged – affects access and affordability of health services. Some economically disadvantaged also face cultural, language, geographic hurdles – often missed by existing health services. Community development using creative partnerships are needed– e.g.the health care “safety net” clinics. Tailored population-based approaches – e.g. multi- language quitlines.

Comprehensive Tobacco Cessation Strategy: Two Directions Develop service infrastructure.  Develop a network of that links and promotes a variety of affordable services, including services reaching disparate populations, and that use multi-service quitlines.  Develop partnerships that lead to increasing access to services through better coordination and systems changes. Conduct outreach campaigns: public opinion and health care policy changes.  Communication strategies that influence social norms for seeking and using services. “Getting help is good” vs.“Do it yourself.”  Promote health care policy changes that increase benefit coverage.

Comprehensive Tobacco Cessation Regardless of which strategic direction and projects are agreed on first, a central requirement is to make assistance to stop a higher priority among policy makers and funders, within health care, and among tobacco users.

Getting Started First step: create a state working group with dedicated staff. Role of the working group is to:  provide leadership.  determine the initial strategic direction that is most suited to the resources and environment of the state.  serve as a catalyst.

Assessment Assess current needs including:  Quality and availability of cessation services.  Funding and funding possibilities.  Who is served and who is not.  Policy environment. Determine strategic direction.

Infrastructure Development: Quitlines Fund and set up a quitline.  Quitlines provide economy of scale and can serve as a centralized resource for services and information. (CDC Quitline Resource Guide.) Advocate for funding if not in place.

Infrastructure Development: Networks Reach out to health care and communities to link and/or expand existing services. Develop systems that promote referrals into health system services (and quitlines). Make services more available within health systems Make services available to uninsured.

Networks: Examples of Projects Massachusetts: Quitworks referral project Arizona: Helpline Client Referral Program and Provider Training Maine: Medication Voucher Program and Provider Training Minnesota: Health care referral partnerships Oregon: Quitting Connection referral project

Changing Health Care Systems and Policies Promote tobacco treatment as part of standard benefit for health insurers. Promote increased demand from employers for tobacco treatment in contracts with health insurers. Promote changes in public opinion leading to increased consumer demand. Advocate for tobacco treatment in government health care policies directed to priority populations.

Changing Health Care Systems and Benefits Policies: Examples of Projects California: Consortium of health care purchasers, insurers and providers collaborating on strategies and polices to make cessation a standard health care benefit. Oregon: Make It Your Business – outreach to employers and media advocacy campaign. (tobaccofreeoregon.org) North Carolina: Prevention Partners outreach to businesses Federal legislation: Medicaid, Medicare, MCHB

Infrastructure + Policy Changes to Reach Disparate Populations Provide services for all tobacco users:  Includes specialized strategies for reaching and covering services for the uninsured and other disparate populations.  Advocating for publicly funded services to include tobacco cessation assistance.  Uses community development approaches to reach tobacco users who are not part of regular health care system.  Uses tailored population based approaches such as multi-language quit lines.

Disparities: Examples of Projects California Help Line provides services in multiple languages. Washington quitline provides services and medications for the uninsured. Arizona community outreach to Hispanic and Native Americans. Alameda County “smoking as a vital sign” project in community health clinics.

Strategies: “It Depends” What is possible depends on what is happening and who is involved. Take advantage of opportunities.  Include cessation focus in tobacco control campaigns e.g. part of enforcement of workplace restrictions; earmarking of tobacco tax increases; highlighting cessation services and quitline to help defend budgets.  Partnerships with other health initiatives e.g. maternity and chronic disease case management.  Business, union benefit contract negotiations.

Strategies: “It Depends” Leaders and partners can develop longer-term strategies for phasing-in cessation initiatives. Develop new messages.  Polling to reframe “smokers are bad” messages to “smokers have a right to treatment to help them quit.” Note: reframed messages are essential for working with new partners (e.g. employers, unions)

PCHT Reports and Resources Available or coming soon on PCHT Website:

Pacific Center on Health and Tobacco Consortium of representatives from health departments, researchers, advocacy coalitions, health plans, and business from five western states: California, Arizona, Oregon, Washington, Hawaii. National partners – CDC, CTC, CTFK, SmokeLess States. Develop strategies for statewide tobacco cessation cessation approaches. Goal: Promote widespread adoption of evidence-based methods for improving the availability and accessibility of tobacco cessation services.

PCHT Members Arizona  Dept of Health Services, TEPP  Arizona Smokers Helpline  University of Arizona California  Bay Area Community Resources  Integrated Healthcare Association  Next Generation Tobacco Control Alliance  California Department of Health Services  California Smokers’ Helpline

PCHT Members Hawaii  Coalition for a Tobacco-Free Hawaii  Hawaii Community Foundation  Kalhi Palama Health Center Oregon  Tobacco-Free Coalition of Oregon  Oregon Department of Human Services, Health Services  Oregon Research Institute

PCHT Members Washington  GHC Center for Health Promotion  Department of Health Centers for Disease Control Center for Tobacco Cessation National Center for Tobacco-Free Kids SmokeLess States Project

PCHT Contact Information Wendy Bjornson, MPH, Director Pacific Center on Health and Tobacco 1200 Naito Pkwy. #220 Portland, OR (503) (phone) (503) (fax)