1. Reducing Tobacco Use & Factors affecting Reach of the Maine Tobacco HelpLine Tim Cowan, MSPH Director, MaineHealth Health Index Initiative on behalf of the Healthy Maine Partnerships, and the Partnership For A Tobacco-Free Maine March, 2012

2. 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

3. 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

4. Smoking Prevalence Decreasing, but still lot of work to do

5. % Adult Smokers: Maine vs. U.S.- ‘06/07

6. 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

10. % Adult Smokers- 2010

11. 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

12. 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

13. 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

14. 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

15. 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

16. In Fiscal Year 2010, Maine One of Only Nine States with Reach >3% HelpLine Reach Consistently High 1.Colorado 2.Iowa 3.Maine 4.Montana 5.New Mexico 6.New York 7.Oklahoma 8.South Dakota 9.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

17. Tobacco Users Calling HelpLine HelpLine’s reach rate consistently one of highest for U.S. quitlines. In 2008- 75% of states reported quitline reach <2%.

18. 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

19. Tobacco Legislation in Maine 1981 Public meetings 1983 Court houses 1985 Stores 1986 Most workplaces 1989 Hospitals, except psychiatric patients and psych. hospitals 1991 1997 1999 Restaurants 2001 2003 Bars 2005 Most loopholes closed 2007 School grounds 2009 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

20. Strong Advocacy Support Many 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

21. 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

22. Clinician Support for Quitting 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 2 nd highest in US.  For BOTH Physicians & Dentists  Percents advised in Maine significantly higher than US percents.

23. High Nicotine Dependence in Maine

24. Yet one of highest % of quit attempts

25. And better success with abstinence

26. 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

27. Eight states still leaders: more smokers made quit attempts in 2006/2007 = significant increase in “Ever smokers” who quit 92/93 vs. 06/07

28. % 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

29. Tax Increase = Calls Supportive Culture: Quitters Using HelpLine

30. Broad-based promotion of HelpLine Healthy Maine Partnerships Health District Tobacco Coordinators Friends & Family Past Callers Community Orgs. Healthcare Orgs. Employers Insurance Companies Partnership For A Tobacco-Free Maine Direct Media

31. 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

32. Media: Impacts HelpLine Call Volume

34. 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

35. In 2005- Surveyed Tobacco Users who: enrolled in HelpLine counseling & were authorized, by HelpLine, to get free NRT. Medication Program Linked to HelpLine Knowledge of Free NRT Influenced Decision to Call the HelpLine

36. NRT Program: Increased Counseling

37. Webinars Begin 2009 Tobacco Intervention: Intensive Treatment Training Constellation of PTM Training Offerings Clinical Outreach Tobacco Intervention: Basic Skills Training Helpers Program (proposed)

38. 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

39. 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

40. Tobacco Treatment Training: Referrals

41. Reason #1: Reach different subgroups of smokers via proactive referrals Encouraging Proactive Referrals Compared Three Groups of Tobacco Users

44. 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

45. 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

46. 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

47. Partnership For A Tobacco Free Maine (NRT Program, Media, Community programs) –Director: Dorean Maines Dorean.E.Maines@maine.gov Center for Tobacco Independence (Comprehensive Tobacco Treatment Programs) –Exec. Director: Ken Lewis lewisk1@mainehealth.org –Med. Director: Sandi Kazura kazura@mmc.org –HelpLine: David Spaulding spauld@mainehealth.org –Clinical Outreach: Cori Holt holtc1@mainehealth.org –Training: Fred Wolff wolfff@mainehealth.org –Evaluation: Tim Cowan cowant@mainehealth.org Contacts for more information