Make it Your Business: Comprehensive Tobacco Control

Transcription

1 Make it Your Business: Comprehensive Tobacco Control Charles J. Bentz, MD, FACP Medical Director: Tobacco Cessation and Prevention Providence Health & Services: Oregon

2 Providence Health & Services Number of facilities (acute care) Number of employees Acute admissions Long term care patient days Home health visits / hospice days Primary care visits Acute outpatient visits Housing and assisted living days Health Plan members University of Great Falls (students) Providence High School (students) St. Thomas Child & Family Centers (number licensed to serve) Charity care and community benefits (in thousands) 27 46, , , ,009 1,293,846 4,748, , , $ 465,736

3 Making It Your Business Why business should address tobacco What works in treating tobacco dependence Define comprehensive tobacco control Examples of systems that address tobacco Implications for business

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5 Costs of Smoking Business Costs: Greater absenteeism Time spent on smoking rituals Higher health care costs Higher life insurance premiums Higher risk of occupational injury Higher disability costs More disciplinary actions

6 Direct vs. Indirect Costs Direct Cost: $1600 each year per smoker 50% increase in utilization of health services 19% of health care expenses for employees children is related to second-hand smoke Double rate of on-the-job accidents Indirect Cost: $1700 each year per smoker Absent an average of 6.5 days more per year 8% of time in smoking-related activities Total Cost: $3300 each year per smoker Source: Centers for Disease Control and Prevention, Atlanta

7 Quitting saves lives Study of 34,439 male British doctors Smokers died 10 years younger Cessation improved life expectancy Age quit Years gained Doll R. et al. Mortality in relation to smoking: 50 years observations on male British doctors BMJ, doi: /bmj ae (June 2004)

8 High Benefit in High Risk Randomized clinical trail of intensive cessation CCU patients Creighton University Improved quit rates Fewer hospitalizations (NNT of 6) Lower mortality (NNT of 11) Several aspects deserve comment Systematic identification of smokers Intensive outpatient counseling Low barrier to medication (free) Multiple opportunities for re-treatment Mohiuddin SM, et al. Chest 2007;131:

9 Adding Mortality-Related Lost Productivity to the Estimate Raises the Total Cost to $5,606 per smoker per year $341 $1,623 $1,882 $1,760 Smoking Breaks Excess Medical Expenditures Mortality-Related Lost Productivity Missed Work Days Due to Sickness Sources: Mercer Human Resource Consulting / Smoking Cessation Leadership Center

10 Relative Cost-Effectiveness Quist-Paulsen P, et al. Eur J Cardiovasc Prev Rehabil, 2006, 13(2):

11 Cost of workplace tobacco dependence $ 7,000,000 $ 6,000,000 $ 5,000,000 $ 4,000,000 $ 3,000,000 $ 2,000,000 Blue collar (36%) Mixed workforce (26%) White collar (15%) $ 1,000,000 1,000 2,000 3,000 4,000 5,000 6,000 Number of employees Source: Mercer Human Resources Consulting, New York, NY

12 Return on Investment: ROI COST: comprehensive tobacco benefit: $1.20 to $4.80 per employee Direct ROI: Three years: Break-even Five years: Positive cost benefit Exceptions: (Pregnancy and High Risk employees) Indirect ROI: Demonstrate commitment to employee health Improve employee healthy lifestyle choices Provide tools to support consumerism strategy Sources: Mercer (NY) / Smoking Cessation Leadership Center (UCSF) Center for Disease Control and Prevention (Atlanta)

13 It is Very Hard to Quit Actor Bill Talman of TV's Perry Mason, died of lung cancer at the age of 53, shortly after this antismoking advertisement in His widow, Peggy Talman died from lung cancer at the age of 73 in 2002 in a Providence Hospital, after years of continued smoking.

14 Neurobiology of Nicotine Addiction Nicotine binds to receptors in the brain This cause release of a neurotransmitter: dopamine Reward: Pleasure Center Long term exposure creates more receptors Withdrawal of nicotine causes symptoms which can last for several weeks. Coe JW et al. SRNT Prague, Czech Republic Picciotto MR et al. Nicotine Tob Res. 1999; Suppl 2:S Paifai:Drugs in Human Behavior, 2nd ed. Landry, Sci Am, 1997:42-45

15 Nicotine Withdrawal Symptoms Anxiety Irritability, frustration Decreased heart rate Difficulty Concentrating Increased appetite, wt gain Restlessness Cigarette cravings Depression, dysphoria No prior history Prior history 87% 87% 80% 73% 73% 71% 62% 31% 75% Data from Hughes JR, Hatsukami DK: Signs and symptoms of tobacco withdrawal. Arch Gen Psych 43: , 1986; Hughes JR, Hatsukami DK, Pickens RW, et al: Effect of nicotine on the tobacco withdrawal syndrome. Psychopharmacology 83:82-87, 1984.

16 Medications Can Help. First Line Medications: Nicotine Replacement Therapy (5 forms) Bupropion SR (anti-depressant) Varenicline (Chantix ) (new: affects nicotine receptor) Second Line Medications: Nortriptyline (anti-depressant) Clonidine (anti-hypertensive) Near Future: Rimonabant (cannabinoid receptor) Vaccine (antibody to nicotine)

17 BUT THEY DON T WORK ALONE Medications can double the quit rates Work best when used in the setting of a behavioral modification program Most smokers have to unlearn smoking It takes practice to become a non-smoker Social support really works

18 Medication with and without counseling Medication Status Minimal Therapy* Behavioral Therapy Status Brief Therapy* Intense Therapy* Medication 10% 20% 30% No Medication 5% 10% 15% *Data from NRT and bupropion trials Hughes JR. CA Cancer J Clin. 2000;50: Fiore MC et al. U.S. DHHS, U.S. Public Health Service, 2000 Hornbrook MC, et al. ATMC 2000

19 Medication vs. Behavior * Behavioral change for triggers, stressors, coping mechanisms, habit patterns, etc

20 What is Success? Spontaneous Quit Rates 2-3% 1 year Office-based (dose-response) Minimal Counseling: 4% Brief Counseling: 5% Counseling: 8-10% Interactive internet 5-10% Interactive telephone 10-25% Group classes 15-25% Classes with medication 25-35% Inpatient residential 45-50% Public Health Service Guideline 2000, Hughes et al, CA cancer journal clinic, :143, Providence Tobacco Cessation & Prevention Program, Mayo Clinic Residential Cessation Program

21 How do we do a better job. treating tobacco use and dependence?

22 It takes a clearly identified goal At every point where patients come into contact with our health system, tobacco use will be assessed and addressed. Providence Tobacco Task Force, 1994

23 Treating Tobacco Dependence : 2007 Community Tobacco Tax State Quit Line MIYB and Step Up! Target Groups Disease Management Clinical Programs Women & Children PHS employees Web-Based Hospital-Based Inpatient Program Behavioral Health/CD SMOKER (who wants to quit) Health System National Recognition AHIP (AAHP), RWJF SCLC, NCQA, LA AMA (CPT), CMS Cessation Group Classes Free Medications Telephone Support Self-Help Materials Nurse Help Line Providers Education Reimbursement Leadership Evaluation Research Tobacco as QI CMS, JCAHO Clinics Staff Training 5 A s of Tobacco Electronic Health Record Quit Line Connection

24 Smoking Prevalence in PHP vs. Oregon 24% 23% 22% 21% 20% 19% 18% 17% 16% 15% '88 '89 '90 '91 '92 '93 '94 '95 '96 State of Oregon (BRFS) '97 '98 ' Providence Health Plan: Oregon

25 The program at Providence is the platinum standard for tobacco cessation in health systems Steve Schroeder MD Chair and CEO of Robert Wood Johnson Foundation (90-02) Distinguished Professor of Health and Health Care Division of General Internal Medicine, UCSF Director: Smoking Cessation Leadership Center September 24, 2004

26 Resource: Tobacco Quit Lines Talk to an intake person (informational) Most have referral to trained counselors Develop a customized quit plan Information about medications Information / referral to cessation services A tailored Quit Kit is mailed Proactive Calls to the smoker (one to five) 14.8% one-year quit rates (Tobacco Control 2003;12:45-51)

27 Diagram of Quit Line Connection in Primary Care ASK Clinic ADVISE ASSESS Program Free & Clear or Local Programs Tobacco Use Documented in Chart Clinic Advice to quit and Stage of readiness to quit Documented in Chart Provider refers to Quit Line ARRANGE Oregon Quit Line After initial smoking cessation intervention, QuitLine staff refer patients to appropriate resources and return fax form to clinic Patient Patient completes Form. Form faxed to Quit Line. Quit Line contacts patient. Two Options for Connection with Quitline Patient Brochure given Patient contacts quitline at their convenience. ASSIST Bentz CJ, et al. American Journal of Preventive Medicine, (1):

28 Resource: Pharmacist-Assisted Cessation Classes Counselor lead, 11-sessions over 8-weeks Patients can self-refer Medications at no out-of-pocket expense Pharmacist leads first class, remains available Pharmacist dispenses medication Only 2 week supply at a time Nicotine Replacement, Bupropion, or Varenicline Single $15 copay for everything Onsite at each hospital Worksite classes offered 33-35% 1-year quit rates How to Syllabus available fall 2007

29 Resource: Hospitals STEP UP! a collaborative effort to promote Cessation benefits for all hospital employees Intensive intervention for all patients Pharmacist-assisted cessation classes Hospital tobacco-free campus policies Hospital efforts to step up and lead local businesses to curb tobacco use Oregon Tobacco Prevention & Education Program, Oregon Association of Hospitals & Health Systems, Acumentra Health, Oregon Nurses Association, Make It Your Business, Smoking Cessation Leadership Center, many hospitals, health systems, and professional associations in Oregon

30 Definition: Comprehensive Tobacco Control All patients have tobacco use status documented All tobacco users receive brief provider advice to quit All smokers have access to intensive counseling and medication All smokers have coverage for tobacco cessation services All smokers are aware of their tobacco cessation benefit Health System cessation intervention is a quality measure Health System Quality Assurance sets goals, monitors interventions, and provides feedback to frontline staff Health System policies, training, and financial incentives support the delivery of quality cessation efforts

31 How do we get there from here? Evaluate and utilize resources Programs available from your medical or dental carriers Investigate Quit Line Connection (1-800-QUIT NOW) Review the Make It Your Business Employer s Toolkit Cover effective tobacco cessation Cover a range of options (medication & counseling) Waive fees, co-pays, and other barriers Opportunity for re-treatment (no benefit limits) Offer to employee spouses and dependents

32 How do we get there from here? Tobacco-Free Worksite Policy Understand legal implications Local smoke-free ordinances No legal ground for the claim that smoking is a right Secondhand smoke is classified a group-a carcinogen HIPAA non-discrimination rules apply to smoking Any cash incentive reward is taxable to employee Understand premium differentials (DOL website)

33 How do we get there from here? Communicate (Promote it!) Clearly state benefits that are offered Use consistent messaging Use multiple modes: Face-to-face during organizational meetings (if possible) Memos mailed to employee s home written by CEO s at work, inserts in pay envelopes Posters and flyers advertising the program HR/manager education and training Inserts in open-enrollment communications

34 How do we get there from here? Incentives? Average life insurance premium differential $10 - $30 /month Up to $500/year in benefit credits for people who meet goals Discounted life insurance premiums for nonsmokers Nonsmokers receive a $100 credit toward insurance premiums $50 for pledging to avoid tobacco, misuse alcohol, or drugs People who quit smoking get $600 in cash over 18 months Health System Incentives

35 Conclusions: There is return on investment (ROI) Most employees do not have access or coverage for effective tobacco cessation Employers need to cover cessation Employers need to promote cessation Collaborate with Health Systems Make It Your Business to have a Tobacco-free Workplace

36 Employer Resources Charles J. Bentz MD, FACP Addressing Tobacco in Healthcare Systems, Connecting to state-level Quit Lines, Pharmacist-assisted cessation classes Dr. Steven Schroeder: Dawn Robbins: