1. Use of Pharmacotherapy in Conjunction with Quitlines Tim McAfee Tracey Strader (OK) Paula Celestino (NY) Heidi Grossman (OR) Susan Swartz (ME) Mary Hartman (BCBS-MN)

2. Even Mount St. Helens Relapsed….

3. Format  Overview of Issues and Opportunities  Detailed studies from Oklahoma, New York, Oregon, and Maine  Case reports from other states & health systems  Discussion & share experiences

4. Issues & Opportunities  Briefly review evidence base  Pros & cons of NRT with quit lines  NRT as alternative or adjunct to media  Discuss operations & quality issues  Explore challenges, controversy & uncertainty  Mature the science/business together

5. NRT Evidence Base  Many large, well-designed randomized trials showing 1.5 x 2 – fold increase in quit rates  Improved outcomes with counseling  Uncertainty around low-intervention effectiveness (i.e. OTC with NO counseling)  Several trials show phone adds Quit Rate value to pharmacotherapy, but still early.. Swan et al – Group Health bupropion Hollis et al – Oregon quitline

6. Pros for Inclusion of NRT into QL services  May increase effectiveness  May increase popularity  May increase volume cost-effectively  May increase health provider interest Synergistic effects around 5-A adoption may create population quit attempts beyond callers  May recruit people for counseling who otherwise would not use

7. Cons for Inclusion of NRT into QL services  Full course of therapy is expensive  May divert $$$ and attention from counseling  May divert $$$ from paid media Which may decrease synergistic quit attempts by non-callers who saw ads  Some liability issues  Full course to all WILL dis-incent healthplan coverage

8. Issues Around NRT Role Should QLs function as fulfillment houses (i.e. connect people with patches?) -- OR -- Should NRT be incorporated as an adjunctive aid and/or inducement to accept and use behavioral support?

9. Operational Issues  What to offer and how long  Eligibility and screening  How to deliver medication Voucher vs. direct mail  ‘Full course’ vs. split dose delivery  How to integrate with counseling  What about prescription meds?

10. Safety & Quality Issues  Decision-making on type of Rx Participant decision input?  Appropriate dosing protocols FDA # of cigarettes sufficient?  ‘Right’ level of screening Medical oversight/over-ride role? Exclusions/over-ride (i.e. pregnancy, CAD)  Continuing education of counselors

11. How much?  8 weeks is a lot  How much do people really use?  Will people buy more if we get them started?  If 1-2 weeks works for promotion effect, why send more?  Different approaches to insured vs. uninsured?

12. How to hold back the sea?  Awareness of free NRT via media creates tsunamis of call volume  Can we: Handle the volume so as not to lose the promotional impact Learn to create predictable, sustained increased demand leveraging NRT  Healthcare system integration  Targeted outreach