1. Public Health Goal is population-level change Use evidence-based interventions Emphasize changes in policy Note: policy exists at many levels

2. Public Health Perspective Based on Rose Curve 2011 estimate of adult smokers (363,000 Males and 273,850 Females): TOTAL = 636,850 Assumption: A small change in a large population will create more nonsmokers than a large change in a small population

3. Traditional Tobacco Control in KY Excise taxes: 3--30 cents (2005); 30--60 cents (2012) Smoke-Free: (26 cities, 10 counties, 2 merged city-county governments) Restrictions: advertising and promotion Media campaigns: promoting tobacco control Kentucky Quit Line: All have potential epidemiologic “reach” and “penetration”

4. Perspective Traditional PH Tobacco Control initiatives (excise taxes, smoke-free bans, promotion/advertising restrictions, media campaigns, KY QL) are necessary, but clearly not sufficient Two Problems: 1) Developmental pipeline (new users) 2) Those who don’t become nonsmokers because of Traditional PH Tobacco Control initiatives

5. Kentucky Quit Line: An Example Personal Communication from Andrew Waters (042814) 2011: 636,850 adults in KY were smokers 2013 KY Quit Line Data: 2,584 cigarette users at intake (0.004% of all adult smokers) 1,743 cig users with intake data that enrolled (67.5%) Coaching calls: 2 = 550 (31.6%) 3 = 271 (15.5%) 4 = 179 (10.3%) 5 = 119 ( 6.8%)

6. Kentucky Quit Line: An Example Personal Communication KDPH (Spring/Summer 2014) 2012 Data: Follow-up results 6 month follow-up:387 (24.1% of 1,606* (*est) EXTRAPOLATION TO POPULATION LEVEL 387 x 24.1 = 93.267 persons may have become nonsmokers using the Kentucky Quit Line in 2012 93/1,606 = 5.7% -- about same as spontaneous remission

7. Smoking Cessation: ALSO a Traditional Tobacco Control Approach Clinically oriented smoking cessation delivered to either individual smokers or groups of smokers Needed because many smokers don’t become nonsmokers because of other Tobacco Control approaches

8. Addiction A chronic, relapsing disease/condition Drug highjacks the brain and rational decision-making Highest lapse/relapse occurs in first several weeks to months

9. Why Do People Continue to Smoke? Cooper/Clayton Model Social Psychological Habit Addiction

10. Cooper/Clayton Method Long-term presence: C/C groups since June 1985, almost 30 years – brand recognition Training: avoids limitations of training-the-trainer: all facilitators “first generation” personally trained by C/C, >1,700 trained Implementation fidelity: C/C in every class via DVD and participant book Logistics: UK & UL KCP arrange training On-going/Upcoming Research: FMM, Louisville & Lexington, facilitators, oral pH (JAMA 1990)

11. Cooper/Clayton Method: Questions/Issues Spanish version Relapse/repeats Minimum number of participants Cost to participants Recruitment “New” Materials

12. Cooper/Clayton Method: Questions/Issues (Spanish version) Book has been translated into Spanish Voice-over on DVD has not been done Uncertain how many Anglos read/use book Uncertain reading ability of Latino participants Focus of C/C model on addiction, not sure there are sufficient race/ethnic differences in nicotine dependence to justify concern about Spanish version We are willing to be convinced of need

13. Cooper/Clayton Method: Questions/Issues (Repeats, Class Size, Cost) Dependence on nicotine difficult to treat; its use integrated into virtually every aspect of life – lapse and relapse to be expected Providing free NRT makes it easy to be a repeater, may be counter-productive except that it increases attendance and exposure Possible Solutions: 1) allow only one class free of charge – charge for anyone repeating and tell them up-front, 2) charge for the NRT and/or participation for everyone – repeat or first-time, 3) don’t allow any class under 10 participants – combine to insure there are enough participants to get most of group process

14. Cooper/Clayton Method: Questions/Issues (Recruitment into Smoking Cessation) Health Care Professionals NOT Answer: if they were we would have more referrals to QL (9,273 physicians, 1,180 PAs, 3,287 APRNs) Offering Lung Cancer Screening NOT answer Assign recruitment to smoking cessation to auxiliaries in physician offices Use smoking cessation classes for recruitment into screening

15. Cooper/Clayton Method: Questions/Issues (New DVD-Book) C/C has considerable reach and penetration in KY No smoking cessation of similar magnitude in KY Facilitators have received training essentially free Patients have received classes mostly for free C/C produced/paid for all previous versions to date C/C have not charged for their time or the C/C Method Production of “new” version (DVD, Book) requires resources

16. The Cooper/Clayton Method: Helping Change Lives (Letter Received May 15, 2014) Hello. My name is Katie and I completed your stop smoking class back in 2009. I attended all the meetings but the last one. The only reason I missed that one is because I was due to have surgery that day. I wanted to write to you and let you know that as of October 6, 2014 I will be smoke free for 5 years. Let me say that besides having my daughter, going through your program was the next best thing I have accomplished in my life. I had smoked for 27 years. I was born addicted to nicotine and I started smoking at age 9. I am truly blessed and grateful for your program.

17. Contact Information Thomas M. Cooper, DDS tmcdds@twc.com Richard R. Clayton, PhD clayton@uky.edu