A systems approach to treating tobacco use and dependence Ann Wendland, MSL Policy Analyst & Cessation Programs Manager NYSDOH Bureau of Tobacco Control ann.wendland@health.ny.gov
A systems approach to treating tobacco use and dependence Presentation Overview NYS approach to tobacco control Tobacco use landscape in NYS Health Systems Change Overview Tobacco Dependence Treatment practical approaches Clinical Consumer Cessation Advice and medications
The Health Impact Pyramid NYS Smokers Quitline Paid Media/ Health Systems Change Community Action/Policy Change Health Systems Change Frieden, T. R. Am J Public Health 2010;100:590-595 Copyright 2010 American Public Health Association
Implementation of the Health Impact Pyramid Policydriven, populationbased approach designed to prevent youth from smoking and to motivate adult smokers to quit. Community Action Educate communities of the continuing need and potential policy solutions that reinforce the tobacco-free norm. Health Systems Change Work with health care systems to increase provision of and coverage for tobacco dependence treatment. Public Health Communications Mass media, PR and media advocacy to motivate users to quit, promote policy agenda and reduce acceptability of tobacco use.
Current Tobacco Use in NY Cigarettes 16.2% of adults 11.9% of H.S. students 3.1% of M.S. students Behavioral Risk Factor Surveillance System, 2012 Youth Tobacco Survey, 2012
Youth: Current Cigarette Use, 2000-2012 50% 40% 30% 20% 10% 27.1% 10.2% 20.4% 18.5% 16.3% 14.7% 12.6% 11.9% 6.1% 5.1% 4.0% 3.5% 3.2% 3.1% 0% 2000 2002 2004 2006 2008 2010 2012 Middle School High School
Youth: Current Other Tobacco Use, 2000-2012 50% 40% 30% 20% 10% 0% 14.1% 11.9% 16.7% 13.9% 14.0% 11.0% 9.7% 4.8% 5.5% 4.8% 3.3% 3.9% 4.1% 4.5% 2000 2002 2004 2006 2008 2010 2012 Middle School High School
Youth: Current Any Tobacco Use, 2000-2012 50% 40% 32.5% 30% 20% 10% 12.2% 25.3% 9.7% 23.2% 8.0% 21.2% 22.3% 20.8% 21.8% 6.0% 5.7% 5.6% 6.1% 0% 2000 2002 2004 2006 2008 2010 2012 Middle School High School
Adults: Current Cigarette Use, 2003-2012 30% 25% 20% 15% 21.6% 21.6% 20.9% 20.9% 20.8% 19.9% 20.5% 18.2% 19.7% 18.9% 20.5% 20.6% 21.1% 18.0% 16.8% 19.4% 18.9% 15.5% 18.9% 18.1% 18.0% 16.2% 10% 5% 0% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 National Health Interview Survey New York Behavioral Risk Factor Surveillance System New York Behavioral Risk Factor Surveillance System with Raked Weights
Tobacco Use Percentage of New York Adults Who Currently Smoke by Demographics Category 2011 2012 Overall 18.1% [16.9, 19.4] 16.2% [14.8, 17.6] Age 18 24 21.6% [16.5, 26.7] 17.4% [12.8, 21.9] 25 39 22.2% [19.3, 25.1] 19.7% [16.5, 22.9] 40 64 19.0% [17.3, 20.7] 17.6% [15.7, 19.6] 65 or older 8.3% [6.8, 9.7] 8.1% [5.9, 10.2] Race/Ethnicity White 18.0% [16.5, 19.6] 18.0% [16.3, 19.6] African American 21.3% [17.6, 25.0] 16.7% [12.1, 21.3] Hispanic 17.4% [14.0, 20.7] 14.9% [11.3, 18.5] Gender Female 16.8% [15.3, 18.4] 13.2% [11.7, 14.8] Male 19.5% [17.5, 21.5] 19.5% [17.2, 21.8] Education Less than high school 25.7% [21.6, 29.8] 23.9% [18.8, 29.1] High school diploma or GED 24.0% [21.2, 26.8] 21.8% [19.0, 24.7] Some college 17.7% [15.3, 20.1] 16.4% [14.0, 18.9] College degree or higher 9.2% [8.0, 10.4] 7.3% [6.0, 8.5] Income Less than $25,000 27.8% [24.9, 30.8] 23.4% [20.2, 26.6] $25,000 $49,999 18.4% [15.8, 21.1] 16.9% [13.9, 19.9] $50,000 $74,999 14.1% [11.2, 16.9] 15.4% [12.0, 18.8] $75,000 and more 10.1% [8.4, 11.7] 10.0% [7.9, 12.2] Employment Employed 16.6% [15.0, 18.2] 15.6% [13.9, 17.3] Not employed 27.7% [22.5, 33.0] 31.2% [24.1, 38.3] Not in the labor force a 17.8% [15.7, 20.0] 13.4% [11.4, 15.4] Legend: Estimate [95% Confidence Interval] a Not in the labor force includes students, homemakers, retirees, and those who are unable to work. New York has reduced the number of adult smokers by 664,000, prevented 305,000 kids from becoming smokers, prevented 265,000 smoking-caused deaths and saved $11.6 billion in long-term tobacco-related health care costs. Although high cigarette taxes are effective at reducing cigarette smoking, they disproportionally burden low-income smokers. Low-income smokers in New York, which has the nation s highest state cigarette tax at $4.35 per pack, spent nearly a quarter of their household income on cigarettes. Nationally, those with the lowest incomes spend just over 14 percent. Smokers in the highest income group, both nationally and in New York, spend just 2 percent of their income on cigarettes. Because they smoke more, lower-income smokers suffer disproportionately from smoking-caused disease. It is not high cigarette taxes that burden low-income households, but smoking itself because low-income people smoke more, suffer more, spend more and die more from tobacco use.
The Burden of tobacco use
Cessation: % adult smokers who intend to make quit attempt in next 30 days
Cessation: % of adult smokers who made a quit attempt in past 12 months
Cessation: % of adult smokers ASKED by health care provider if they smoked
Cessation: % of adult smokers ADVISED by health care provider(s) to quit smoking
Cessation: % of adult smokers ASSISTED by health care provider with cessation
A Systems Approach to Tobacco Dependence Treatment Should result in an increase in: health care providers use of evidence-based tobacco dependence counseling and medication treatments with patients who use tobacco and higher rates of cessation It should also make effective treatments more widely available in health systems that serve disparate populations.
A Systems Approach to Tobacco Dependence Treatment Systems Change Strategies Specific clinical strategies will help ensure that tobacco interventions are consistently integrated into health care delivery: Implement a tobacco-user identification system [integrated into electronic medical records] in every clinic Provide training, cessation resources/materials, and feedback to providers that promotes effective intervention Dedicate staff with clearly delineated responsibilities to provide tobacco dependence treatment and assess its delivery in staff performance
A Systems Approach to Tobacco Dependence Treatment Healthcare Providers Primary facilitator of tobacco dependence treatment Initiates tobacco dependence treatment intervention with all tobacco using patients Can be reimbursed by Medicaid for providing smoking cessation counseling to tobacco users Can prescribe medication to assist with the quit attempt
A Systems Approach to Tobacco Dependence Treatment Peer Advocates Support tobacco dependence treatment offered by healthcare providers Can raise awareness of the importance of engaging in healthy lifestyles and encourage a tobacco free life among peers Can refer tobacco users to their healthcare provider for treatment Can be trained to provide group or motivational interventions to help peers make positive life changes Can create a positive social network that provides a supportive, safe, and non-judgmental environment for peers making a quit attempt Can teach peers the skills they need to maintain a tobacco free life
Tobacco Cessation Treatment Evidence-based Recommendations Available at: http://www.ahrq.gov/path/tobacco.htm Or call the AHRQ Clearinghouse toll-free 800-358-9295.
The FIT initiative helps programs implement integrated treatment for co-occurring mental health and substance use disorders (COD), a proven strategy for helping people sustain and maintain recovery. The treatment emphasizes the importance of people setting their own recovery goals (such as education, employment, re-connecting with children and families) and underscores the key role of peers in the recovery process. Tobacco dependence treatment specific modules developed by NYC DOHMH tobacco control and NYS Office of Mental Health staff http://practiceinnovations.org
Consumers and Families Becoming Tobacco Free FIT module http://practiceinnovations.org/consumersandfamilies/tobacco/tabid/246/default.aspx
Tobacco dependence treatment minimum criteria to be effective Ask - Centralized system, preferably within electronic medical records, that identifies tobacco-use status with the collection of vital signs and features clinician reminder elements Advise & Assist - Provision of counseling and medication to assist all individuals making a quit attempt; Promote utilization of the NYS Medicaid cessation medication benefit Refer - Refer tobacco users to the NYS Smokers Quitline to support treatment intervention and follow-up tobacco users enrolled in Opt to Quit program (unless actively refuses enrollment)
A Systems Approach to Tobacco Dependence Treatment Effective treatments now exist, and every patient should receive at least minimal treatment every time he or she visits a clinician. The first step in the process identification and assessment of tobacco use status separates patients into three treatment categories: tobacco users who are willing to quit should receive intervention to help in their quit attempt; those who are unwilling to quit now should receive interventions to increase their motivation to quit; and those who recently quit using tobacco should be provided relapse prevention treatment.
ASSIST Provide appropriate tobacco dependence treatments YES ADVISE to quit ASSESS Are you willing to quit now? YES NO ASSIST Intervene to increase motivation to quit ASK Do you currently use tobacco? Arrange Follow Up NO ASK Have you ever used tobacco? ASSESS Have you recently quit? Any challenges? YES ASSIST Provide relapse prevention counseling YES NO ASSIST Encourage continued abstinence
Tobacco Cessation Strategies: Cessation Medications The only medications approved by the Food and Drug Administration (FDA) for tobacco cessation are: Nicotine Gum Nicotine Lozenge Why use medication for quitting? Medications: Make people more comfortable while quitting by reducing withdrawal symptoms Nicotine Patch Nicotine nasal spray Nicotine Inhaler Buproprion SR (Zyban) Varenicline (Chantix) Allows people to focus on changing their behavior Improves chances of a successful quit attempt In combination therapy (use of two or more forms of tobacco cessation medication) can improve cessation rates for highly addicted tobacco users
Tobacco Dependence is a twopart problem Physical The addiction to nicotine requires medication for cessation Behavioral The habit of using tobacco requires counseling and support
In summary, the treatment of tobacco use and dependence presents the best and most cost-effective opportunity for clinicians to improve the lives of millions of New Yorkers