Optimizing Smoking Cessation within HUD s Proposed Smoke-Free Rule

Optimizing Smoking Cessation within HUD s Proposed Smoke-Free Rule Alan Geller, Harvard School of Public Health November15, 2016

Outline 1. Smoking and smoking cessation in public housing 2. HUD rule and smoking cessation

Rate of Smoking in Public Housing No accurate national estimate of rate of smoking among public housing residents Based on local surveys, rates among public housing residents likely exceeds rate among low SES populations, 26% (compared with US rate of 17%) Medicaid recipients: 29% Need to document current smoking rates among public housing residents in advance of new rule?

Boston Housing Authority (BHA) Intervention: Rationale Low-income smokers face additional obstacles to a successful quit attempt Low-intensity, high-reach interventions may not be well-suited

Boston Housing Authority (BHA) Intervention: Rationale Low-income smokers face additional obstacles to a successful quit attempt Low-intensity, high-reach interventions may not be wellsuited Ongoing engagement with a health advocate could reduce obstacles Advocate from same environment might be more effective Advocate to complement, not replace, existing smoking cessation resources

BHA Intervention: Design Test whether use of lay health advocates (Tobacco Treatment Advocate, TTA) can: Increase utilization of smoking cessation resources (SQL, clinic programs, MDs) Increase quit rates among smokers

BHA Intervention: Design Test whether use of lay health advocates (Tobacco Treatment Advocate, TTA) can: Increase utilization of smoking cessation resources (SQL, clinic programs, MDs) Increase quit rates among smokers TTAs trained in: Motivational interviewing (MI) Basic skills in smoking cessation Basic Community Health Worker skills, inc. navigation

BHA Intervention: Design Test whether use of lay health advocates (Tobacco Treatment Advocate, TTA) can: Increase utilization of smoking cessation resources (SQL, clinic programs, MDs) Increase quit rates among smokers TTAs trained in: Motivational interviewing (MI) Basic skills in smoking cessation Basic Community Health Worker skills, inc. navigation Intervention arm (n=163): eligible for multiple visits by TTA over 6 months Control arm (n=170): one visit, non-mi

BHA Intervention: Baseline Data 46% had made a quit attempt in past 12 months

BHA Intervention: Baseline Data 46% had made a quit attempt in past 12 months Among persons who made a quit attempt in past 12 months: 54% Black, 26% Hispanic, 18% White 77% had high school education or less 57% smoked <10 cigarettes per day 91% saw regular health care provider, 79% advised to quit smoking 59% knew of Medicaid coverage for NRT and counseling 11% had used Quitline (45% aware), 7% had used clinic-based programs (67% aware) 29% had used NRT

BHA Intervention: Baseline Data 46% had made a quit attempt in past 12 months Among persons who made a quit attempt in past 12 months: 54% Black, 26% Hispanic, 18% White 77% had high school education or less 57% smoked <10 cigarettes per day 91% saw regular health care provider, 79% advised to quit smoking 59% knew of Medicaid coverage for NRT and counseling 11% had used Quitline (45% aware), 7% had used clinic-based programs (67% aware) 29% had used NRT NRT more common among: Older, female, and White smokers Heavier smokers Asked provider about ways to quit smoking Knew someone who had a positive (39%) or neutral (17%) experience with NRT

BHA Intervention: Baseline Data 46% had made a quit attempt in past 12 months Among persons who made a quit attempt in past 12 months: 54% Black, 26% Hispanic, 18% White 77% had high school education or less 57% smoked <10 cigarettes per day 91% saw regular health care provider, 79% advised to quit smoking 59% knew of Medicaid coverage for NRT and counseling 11% had used Quitline (45% aware), 7% had used clinic-based programs (67% aware) 29% had used NRT NRT more common among: Older, female, and White smokers Heavier smokers Asked provider about ways to quit smoking Knew someone who had a positive (39%) or neutral (17%) experience with NRT Additional data on knowledge and attitudes toward NRT

BHA Intervention: 3-mo Results Utilization Utilization Outcomes (n=234) All participants Called Quitline or Used Local Clinic- Based Programs Intervention Control 21.6% 9.9% 3.52 (2.28 5.43) * OR: Odds Ratio; All results adjusted for language, race/ethnicity, health status, depression, enrollment time and cigarettes per day; accounting for group randomization

BHA Intervention: 3-mo Results Cessation Cessation Outcomes (n=234) Int. Control 7-day PPA** 14.6% 9.9% 30-day PPA** 13.6% 6.9% * OR: Odds Ratio; All results adjusted for language, race/ethnicity, health status, depression, enrollment time and cigarettes per day; accounting for group randomization **CO-verified

BHA Intervention: 3-mo Results Cessation Cessation Outcomes (n=234) All participants Int. Control 7-day PPA** 14.6% 9.9% 1.99 (1.05 3.76) 30-day PPA** 13.6% 6.9% 2.73 (1.41 5.32) * OR: Odds Ratio; All results adjusted for language, race/ethnicity, health status, depression, enrollment time and cigarettes per day; accounting for group randomization **CO-verified

BHA Intervention: 3-mo Results Cessation Cessation Outcomes (n=234) All participants Treatment Received Int. Control OR* (95% CI) 1 Visit 2+ Visits 7-day PPA** 14.6% 9.9% 1.99 (1.05 3.76) 0.69 (0.17 2.83) 2.72 (1.48 4.99) 30-day PPA** 13.6% 6.9% 2.73 (1.41 5.32) 1.05 (0.22 5.03) 3.75 (1.60 8.83) * OR: Odds Ratio; All results adjusted for language, race/ethnicity, health status, depression, enrollment time and cigarettes per day; accounting for group randomization **CO-verified

BHA Intervention: 3-mo Results Cessation Cessation Outcomes (n=234) 7-day PPA** 30-day PPA** TTA- MI TTA- SC All participants 14.6% 9.9% 1.99 (1.05 3.76) 13.6% 6.9% 2.73 (1.41 5.32) Treatment Received 1 Visit 2+ Visits OR* (95% CI) 0.69 (0.17 2.83) 1.05 (0.22 5.03) 2.72 (1.48 4.99) 3.75 (1.60 8.83) * OR: Odds Ratio; All results adjusted for language, race/ethnicity, health status, depression, enrollment time and cigarettes per day; accounting for group randomization **CO-verified

BHA Intervention: 12-mo Results Cessation * OR: Odds Ratio; All results adjusted for language, race/ethnicity, health status, depression, enrollment time and cigarettes per day; accounting for group randomization **CO-verified

HUD POLICY AND SMOKING CESSATION

The Breadth of the Proposed Rule An estimated 2 million individuals 954,000 homes 775,000 children 300,000 smokers (assuming 25% smoking rate)

Why must we include a robust smoking cessation effort? It s the right thing to do! Unparalleled opportunity to help lowincome smokers quit! Smoking cessation interventions that are supplemented by a smoke-free home policy may increase the likelihood of long term cessation Lower smoking rates less need for enforcement, change norms Synergy between smoke-free policies and cessation interventions may serve to protect the health of non-smokers A mechanism to reduce SHS (& THS) exposure Increased acceptability and support from residents and potential critics in public health

New opportunities for smoking cessation with HUD rule Geographically-defined small communities Resources frequently available Resident Service Coordinators American Lung Association Centralized oversight and coordination (HUD) Actual and potential relationships with other health partners Health departments Medical facilities Other organizations

Menu of Options for Cessation Programs Options to be considered for distribution to all public housing residents Smokers Quitline Smokefree.gov (national text messaging program) Ask Your Doctor

Current Work: Voluntary Adopters (VA) More than 600 PHAs (of 3,400 total) have voluntarily adopted some type of smoke-free rule (as of 9/30/15) 72% have 100% adoption, including the entire state of Maine Many PHAs have gone smoke-free between 9/30/15 and date of issuance of proposed rule

Main Goal of VA Evaluation Provide guidance to the more than 2600 PHAs that will adopt the new rule via evaluation of Executive Directors, staff, and residents at 150 randomly selected sites and critique of written policies Funded by American Cancer Society, Robert Wood Johnson Foundation, Harvard Catalyst, and Boston University Clinical and Translational Science Institute

VA Sample 612 PHAs (Voluntary Smoke-free Policy) 439 PHAs (100% Smoke-free Policy) 150 PHAs Web Surveys (From Random Sample of 200) 40 PHAs Telephone Interviews 15 PHAs Site Visits Staff Key Informant Interviews Resident Focus Groups

Survey of PHA Executive Directors or Staff Currently in field Time periods covered: Planning and preparation and ongoing implementation Description of policy Resident Engagement Smoking Cessation Staff support and training, community partnerships, enforcement

Survey Questions on Smoking Cessation D.1. Please check all of the smoking cessation support activities you offered at any point during the planning and preparation phase or after implementation. Was mechanism offered? On-site smoking cessation counselling Yes No DK Referrals to smoking cessation counselling Yes No DK Quit line number or information about other resources Yes No DK Nicotine replacement therapy (e.g. patches, gum, lozenges) Yes No DK Quit smoking information (e.g., booklet, brochure, video, etc.) Yes No DK Suggestions to contact primary care provider Yes No DK Other (specify below) Yes No DK

Research Partners: HUD and PHPC HUD s offices of Resident Opportunities for Self- Sufficiency (ROSS) and Family Self-Sufficiency (FSS) More than 800 HUD PHAs have received HUD funding to spur education (ROSS) and job advancement (FSS) Engage residents to motivate fellow residents to support/comply with smoke-free rules and engage in smoking cessation

Medical Settings 100 + HRSA Funded Community Health Centers part of Public Housing National Primary Care Program (PHPCs) serving public housing residents Many sites employ Electronic Health Records (EHRs) central to plan to increase counseling and provision of NRT

The Public Housing Primary Care Program (PHPC) Responsible for providing residents of public housing with increased access to comprehensive primary health care services through direct provision of health promotion and disease prevention activities and primary health care services. Services are provided on the premises of public housing developments or at other locations immediately accessible to residents of public housing.

Key Questions How can Federal agencies and their partners work together to provide optimal smoking cessation services to residents? How can we learn more about baseline behaviors among smokers ahead of the national policy? Help shape interventions Evaluation of success