1. Edward Anselm, MD Medical Director Public Health Perspectives of Accountable Care: Opportunities for Alignment

2. Program Outline Causes of death as markers for health care cost Opportunities for alignment Variation in the prevalence of tobacco use Variation in tobacco use taxes Variation in tobacco cessation services Health System Performance The opportunities in Texas Conclusions 1

3. Top ten causes of death in the USA 2

4. Align with the National Tobacco Control Strategy: An evidence based approach

5. Opportunities for alignment States that have the strongest policy interventions have shown the greatest improvements Population Health Levers Taxes Regulations State Funding of Tobacco Control Programs Public Relations Reimbursement Heath System Performance 4

6. Tobacco Tax varies from $0.17 to $4.35

7. Medicaid Coverage of Smoking Cessation Treatments 2014

8. 7

9. Reducing Tobacco Use: Interventions to Increase the Unit Price for Tobacco Products Prevalence of Tobacco Use A 20% increase in tobacco unit price would be associated with: 3.6% median reduction in the proportion of adults who use tobacco (26 studies, median elasticity of -0.18; IQI:-0.31 to -0.11) 7.2% median reduction in the proportion of young adults who use tobacco (22 studies, median elasticity of -0.36; IQI: -0.73 to -0.24) Cessation of Tobacco Use A 20% increase in tobacco unit price would be associated with: 6.5% increase in cessation among adults (1 study, elasticity=0.375) 18.6% median increase in cessation among young people (5 studies, median elasticity of 0.93; IQI: 0.37 to 1.00) 8

10. Estimation of the impact of intervention on a state-specific basis http://www.communityhealthadvisor.org/drupal/cha/SmokingInterventionsCosts 9

11. Reducing Tobacco Use and Secondhand Smoke Exposure: Smoke-Free Policies Prevalence of tobacco use: median absolute reduction of 2.7 percentage points Cessation of tobacco use: median absolute increase of 3.8 percentage points Cardiovascular events: median relative reduction in hospital admissions of 5.1% (IQI: -11.6% to -2.2%; 9 studies) 10

12. State Funding for Tobacco Control In Fiscal Year 2014, the states will collect $25 billion in revenue from the tobacco settlement and tobacco taxes, but will spend only 1.9 percent of it – $481.2 million – on programs to prevent kids from smoking and help smokers quit. This means the states are spending less than two cents of every dollar in tobacco revenue to fight tobacco use. https://www.tobaccofreekids.org/content/what_we_do/state_local_issue s/settlement/FY2014/2014_02_updates/FY2014%20Funding%20for%2 0State%20Tobacco%20Prevention%20Programs.pdfhttps://www.tobaccofreekids.org/content/what_we_do/state_local_issue s/settlement/FY2014/2014_02_updates/FY2014%20Funding%20for%2 0State%20Tobacco%20Prevention%20Programs.pdf

13. Health System Performance Benefit design meets or exceeds ALA recommendations Align with inpatient smoking cessation Optimal use of State Quitlines Measurement of physician performance on counseling and use of medication enhanced by incentives Member engagement through HRA, DM and CM, enhanced by incentives 12

14. Opportunities in Texas Adult Prevalence of Tobacco Use 15.9%, ranked 27 th in the USA, 3,000,000 smokers Annual health care cost attributed to tobacco $8.85B Annual Medicaid cost attributed to tobacco $1.6B Tobacco attributed death in Texas 28,000 Tobacco Tax $1.51 ranked 25 th in USA State Spending on Tobacco Control $11.2M Tobacco-generated revenue (Master settlement agreement plus taxes) $1.9B Percent of CDC Recommended Spending-4.2%. Ranked 34 th in USA 13

15. Tobacco Control in Texas The mission of DSHS Tobacco Prevention and Control is to reduce the health effects and economic toll tobacco has placed on the citizens of Texas. Major goals are: 1.Prevent tobacco use among young people. 2.Promote compliance and support adequate enforcement of federal, state and local tobacco laws. 3.Increase cessation among young people and adults. 4.Eliminate exposure to secondhand smoke. 5.Reduce tobacco use among populations with the highest burden of tobacco- related health disparities. 6.Develop and maintain statewide capacity for comprehensive tobacco prevention and control http://www.dshs.state.tx.us/tobacco/ 14

16. Conclusion Align with the National Tobacco Control Strategy Maximize state specific interventions Taxes Regulations State Funding of Tobacco Control Programs Optimize Heath System Performance Smoking Cessation Benefit Design Intervention strategies 15

17. Sources I Causes of Death http://www.cdc.gov/nchs/data/dvs/LCWK9_2012.pdf Detailed state by state coverage http://www.lung.org/assets/documents/publications/smoking- cessation/helping-smokers-quit-2014.pdfhttp://www.lung.org/assets/documents/publications/smoking- cessation/helping-smokers-quit-2014.pdf Campaign for Tobacco-free kids: Detailed state tax and tobacco control policy data http://www.tobaccofreekids.org/ State Specific Value Calculations http://www.communityhealthadvisor.org/drupal/cha/SmokingInterventions Costs 16

18. Sources II http://www.thecommunityguide.org/tobacco/increasingunitprice.html CDC: Detailed Sate by State data http://apps.nccd.cdc.gov/statesystem/Default/Default.aspx Health System Performance http://www.edwardanselmmd.com/ Community-based interventions http://www.thecommunityguide.org/tobacco/comprehensive.html 17