Smoke Free Environments and Tobacco Cessation


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  • Tobacco use remains the leading cause of death in the US and in Massachusetts. It is also the most preventable cause of death and disease, presenting an opportunity for cost savings.
  • Hourss= mean days x 8 hoursDays missed and Presenteeism ALL statistically signif from each other. Not absenteeismMean hours worked calculated on respondents estimation of average hours worked/week and weeks/year, including OT, but not paid time off.Mean hours worked current statistically significant difference from non and former, but non and former not statissignif dif from each other.The "mean" is the "average" you're used to, where you add up all the numbers and then divide by the number of numbers
  • If we’ve learned anything in public health, it’s that we need to employ multiple strategies at once in order to achieve meaningful outcomes. In tobacco prevention, we do this by making tobacco use more expensive, creating smoke-free environments and offering support to smokers who want to quit. Our approach has been to change the environment – the physical environment, the social environment and the policy environment, with a goal to make it harder to smoke, making it less normal to smoke and to provide all the supports available to facilitate smoking cessation.We also place a big emphasis on trying to prevent youth from using tobacco in the first place, through public awareness and through pricing, but for the purposes of this presentation, we will be focusing on tobacco-free policies and cessation benefits.
  • In Boston, we’ve slowly been adding to the list of the city’s smoke-free places. In 2003, before the state passed its smoke free workplace law, Boston went smoke free. In 2008, we expanded the definition of “workplace” to include some outdoor workspaces– such as loading docs and restaurant patios – to protect workers in those spaces. More recently, we designated the city’s 130 tot lots smoke-free and worked with hospitals across the city to designate their campuses smoke free. Finally, the city increased its stock of smoke-free market-rate, affordable and public housing through implementation of a smoke free policy at BHA and voluntary programs with developers and CDCs. The 125 Boston Public Schools have created a smoke free perimeter around their schools and do not allow staff to have tobacco products visible on school properties.
  • This is a map that shows the cumulative effect of Boston’s recent focus on creating smoke free environments. It does not cover all the workplaces that are covered by Boston’s Smoke Free Workplace regulation, which covers indoor environments and some outdoor environments.
  • Employees who work in smoke-free workplaces are twice as likely to quit smoking as those who work in smoking environmentsBauer JE, Hyland A, Li Q, Steger C, Cummings KM. A Longitudinal Assessment of the Impact of Smoke-Free Worksite Policies on Tobacco Use. American Journal of Public Health 2005;95(6):1024–9 [cited 2011 Mar 11].Also associated with smoke-free workplaces are reductions in the number of cigarettes smoked per day among employees who continue smoking.
  • Citation? Dr. Keithly presented data on the success of the MassHealth benefit that includes all these elements.
  • It’s important to provide coverage for all types of prescription and over-the-counter cessation aids, all with low co-pays. This will offer smokers a menu of options to try during their quit attempt and increase the likelihood that they will be successful.Doctors also prescribe bupropion (under the brand name Wellbutrin) to treat depression. Varenicline is an oral drug that is used to promote cessation of smoking. It competes with nicotine from cigarettes for binding to nicotine receptors in the brain. Although varenicline stimulates nicotine receptors like nicotine, it blocks the stronger stimulation by nicotine. Therefore, smokers do not experience the full effect of smoking while taking varenicline. The FDA approved varenicline in May 2006
  • Massachusetts has the free Smokers Help Line and QuitWorks that assures free telephone cessation counseling to any Massachusetts resident and health plans promote this. In addition:Gold Standard has adopted the MassHealth benefitMajor Insurer #1 is HPHC. #2 is BC/BS
  • We have four options, but the vast majority are under one plan.Pub Emp Committee is exclusive bargaining agent re: health care issues
  • Excludes BPHC and BPS; majority of city workers are men.
  • The average age of a city worker is 48; bulk are over 40 years old.
  • Majority white
  • The Boston Public Health Commission collects and reports on health data for city of Boston residents – and most CoB employees are required to live in the city.As you can see here, there has been no change in smoking prevalence among Boston residents and this is similar to the statewide smoking rate that Dr. Keithly reported.
  • As you noticed earlier, the largest demographic among city of Boston employees are White. This is statistically significant. Dr. Keithly showed different statewide demographic data. Could be reflective of subpopulations (education, income, ethnicity)… Not sure why
  • A number of circumstances lined up that helped facilitate our success in improving our cessation benefit:Boston Public Health Commission had received federal ARRA funds to address tobacco use and exposure through organizational systems and policy change and was actively promoting the expansion of smoke free environments in city of Boston owned properties and properties other properties (housing, hospitals). As part of promoting smoke free environments we were educating about the importance of a barrier free cessation benefits.BPHC is health department for the city, so attempt to model the health policies and behaviors we are promoting. We presented to our human resource department on the effectiveness of a comprehensive/barrier free benefit. CoB able to leverage being such a large employer in negotiations.During this same period, a human resources representative was conducting worksite visits on a tour of “10 things you don’t know” about your HI coverage. At these meetings, employees brought to her attention an interest in an improved cessation benefit.
  • In counseling, more options have proven better. Now have on-site, telephone and on-line options. In cessation, A Cochrane review of All of the commercially available forms of NRT (gum, transdermal patch, nasal spray, inhaler and sublingual tablets/lozenges) found NRTs increase the rate of quitting by 50-70%, regardless of setting. J Am Pharm Assoc (2003). 2008 Sep-Oct;48(5):659-65.Systematic review and meta-analysis of combination therapy for smoking cessation.Shah SD, Wilken LA, Winkler SR, Lin SJ.SourceHarvard School of Public Health, Boston, MA, USACurrent literature indicates that combination therapy is statistically better than monotherapy in smoking cessation treatment as assessed by 3-, 6-, and 12-month abstinence rates. Systematic review and meta-analysis of combination therapy for smoking cessation. J Am Pharm Assoc. 2008;48:659-664. doi:10.1331/JAPhA.2008.07063
  • Doing promotion between CoB human resources and BPHC, Probably do it again for New Years.
  • One insurer covers @ 80% of employees
  • Smoke Free Environments and Tobacco Cessation

    1. 1. Margaret Reid, RNDirector, Healthy Homes & Community Supports Boston Public Health Commission 11/13/2012
    2. 2.  Reasons to invest in tobacco policies and benefits Influence of tobacco-free policies Importance of tobacco cessation benefits Case study in Boston Questions
    3. 3. Nonsmokers Former Current Smokers SmokersMean days missed 4.4 days 4.9 days 6.7 daysfor work d/t healthconditions/yearMean hours lost d/t 35.2hours 39.2 53.6absenteeism/year hours hoursMean hours lost d/t 42.8 hours 56.0 76.5presenteeism/year hours hours Journal of Occupational and Environmental Health, Volume 48, Number 10, October 2006.
    4. 4.  Implement policies that discourage tobacco use ◦ Increase taxes on tobacco and packaging ◦ Create smoke-free public places Provide support for smokers who want to quit ◦ Offer high-quality cessation benefits Prevent youth tobacco use ◦ Disrupt tobacco marketing to youth
    5. 5. August 2003: 2011: September Smoke Smoke 2012: Smoke Free Free Tot Free BostonWorkplace Lots Public SchoolsLaw Passed Designated Policy in Effect 2008: April 2012: October 2012: Smoke Smoke Smoke Free Free Free Public Workplace Hospital Housing Policy Law Campuses in Effect Updated
    6. 6.  Smoke free policies are effective because ◦ They make smoking inconvenient; ◦ They change the norm around what is acceptable behavior; ◦ They convey the importance of protecting others from secondhand smoke. SF policies result in less secondhand smoke exposure and increase the likelihood that smokers quit.
    7. 7.  Policy change alone is not sufficient to achieve the goal of reducing tobacco use. A robust, barrier-free cessation benefit is a proven way to help people quit ◦ Education and outreach to promote benefit is important
    8. 8.  Cessation benefits work best when they: ◦ Cover the cost of counseling, including telephone, individual and/or group counseling ◦ Offer counseling sessions over a period of several weeks and have high or no limit on sessions ◦ Cover all FDA-approved cessation aids, including prescription and over-the-counter drugs ◦ Limit out-of-pocket expenses for those making a quit-attempt ◦ Do not require preauthorization
    9. 9. Prescription Medications Nicotine Replacement Therapy (OTC)Zyban (bupropion Nicorette (Gum)hydrochloride)Chantix (varenicline) Nicoderm CQ, Nicotrol (Patch) Nicotrol NS (Spray) Nicotrol Inhaler (Inhaler)
    10. 10. Insurance Plan Cessation Counseling Benefit Cessation Pharmacy BenefitGold Standard Offers bi-lingual telephone Covers NRT and prescription counseling medications; Will reimburse for 16 counseling $1-3 co-pay sessions every 12 months, PA for counseling beyond this limitMajor Insurer #1 Promotes Smokers Help Line and No coverage for NRT; online support. $10 co-pay for generic drugs, Offers reduced rate for QuitSmart $25 co-pay Chantix and program WellbutrinMajor Insurer #2 Promotes Smokers Help Line and Covers NRT and prescription online support. medications; $10 co-pay for generics ; $25 for Chantix and Wellbutrin
    11. 11.  The City of Boston has about 18,000 employees, including the schools, public health, fire, police and other municipal departments Employee benefits are negotiated between the Public Employee Committee and city management The city is self-insured Boston currently contracts with Neighborhood Health Plan, Blue Cross/Blue Shield, Harvard Pilgrim, and BMC HealthNet to offer insurance.
    12. 12. Unidentified 1% Women 35% Men 64%
    13. 13. 70+ yrs Under 20 yrs 60-69 yrs 6% 0% 12% 20-29 yrs 10% 30-39 yrs 19%50-59 yrs 27% 40-49 yrs 26%
    14. 14. American Not Indicated Indian Asian 10% 0% 3% Hispanic 8% White Black 57% 22%
    15. 15. Adult Current Smoking, 2010
    16. 16.  The City was in a contract negotiation year. Management understood the ROI on offering a cessation benefit. Outside forces – municipal health reform, interest in cost containment – contributed to readiness on both sides to negotiate.
    17. 17.  Public Employee Committee and Management agreed to look at a 4-year health benefit design, with a focus on reducing costs Reducing costs = improving preventive care and increasing wellness benefits and chronic disease management Improved cessation aligned with these goals.
    18. 18.  Once PEC and Management agreed on cessation benefit, negotiations began with Insurer For Insurer, big hurdle was whether they would have to file with the Division of Insurance to offer the change in benefit Since Boston was self-insured, the insurer did not have to file, so the change was easier to make.
    19. 19. Major Insurer #1 Before AfterCessation Reduced rate for Added on-site cessationCounseling QuitSmart program. groups.Benefit Continues to promote Smokers Help Line and online support and reduced rate for QuitSmart programCessation No coverage for NRT; Added coverage for NRT,Pharmacy Benefit $10 co-pay for most at Tier 1 co-pay level of $10. generic drugs, $25 Continues coverage for co-pay Chantix and prescription medications Wellbutrin
    20. 20.  Outreach: Outreach to employees so they are aware of the new benefit and know how to utilize ◦ Postcards to homes, city intranet sites ◦ Department Human Resource Directors educated ◦ Letter from Mayor Menino to every employee ◦ Promotion for Great American Smoke Out
    21. 21.  Evaluation: Will be asking the insurer for data to assess uptake of the benefit by employees. ◦ Monitor adoption among other large Boston employers ◦ Continue to monitor smoking rates among residents of Boston