Meeting the Tobacco Cessation Coverage Requirement of the Patient Protection and Affordable Care Act: State Smoking Cessation Quitlines and Cost Sharing

Access to effective smoking cessation medications in patients with medicare, medicaid and private insurance

Objectives

Compare financial barriers to the most effective smoking cessation medications - varenicline and combination nicotine replacement therapy (CNRT) across major insurance categories and determine whether these financial barriers impact smoking cessation outcomes.

Study design

Longitudinal retrospective observational cohort study.

Methods

Patients seen at Duke Smoking Cessation Program 05/2016 through 07/2021 were studied. Those prescribed varenicline or CNRT were determined to have financial barriers to access if they could not purchase the medication using insurance or their own funds. Outcomes were compared between Medicare, Medicaid, and private insurers. Abstinence was defined as self-reported 7-day smoking abstinence.

Results

Patients with Medicare were 5.08 times more likely to face a financial barrier to highly effective smoking cessation medications compared to patients with private insurance (p<0.00001) and 2.81 times more likely compared to Medicaid (p<0.00001). Patients able to access these highly effective medications achieved a smoking abstinence rate that was 1.58 times higher than those who could not (p = 0.01).

Conclusions

Findings suggest Medicare coverage of the most effective smoking cessation medications is considerably worse than Medicaid or private insurance; inability to access these medications may lead to lower rates of smoking abstinence.

Symptoms of depression and active smoking among survivors of stroke and myocardial infarction: An NHANES analysis

Historic concerns about the cardiovascular and neuropsychiatric side effects of smoking-cessation pharmacotherapy have in part limited their use. We sought to evaluate whether depressive symptoms are associated with active smoking among survivors of stroke and myocardial infarction (MI). To do this, we performed a cross-sectional analysis using data from the National Health and Nutrition Examination Survey (2005-2016). We included participants ≥20 years old with prior stroke or MI and any history of smoking. Symptoms of depression, at survey participation, were ascertained using the Patient Health Questionnaire-9. Active smoking was defined using self-report and, secondarily, with cotinine measures. We used logistic regression to evaluate the association between depression and active smoking after adjusting for demographics, smoking-related medical conditions, and health-related behaviors. We found that, among stroke and MI survivors with any history of smoking, 37.9% (95% CI, 34.5-41.3%) reported active smoking and 43.8% (95% CI, 40.3-47.3%) had biochemical evidence of smoking. Rates of active smoking were similar for stroke and MI survivors. Twenty-one percent screened positive for depression. In adjusted models, depression was associated with active smoking in the combined group of stroke and MI survivors (odds ratio, 2.28; 95% CI, 1.24-4.20) and in stroke survivors (odds ratio, 2.97; 95% CI, 1.20-7.38). Tests of heterogeneity by event type did not reveal an interaction. Findings were similar when using cotinine measures. We conclude that symptoms of depression were associated with active smoking among stroke and MI survivors. Stroke and MI survivors with symptoms of depression may require targeted smoking-cessation interventions.

Impact of Adding Telephone-Based Care Coordination to Standard Telephone-Based Smoking Cessation Counseling Post-hospital Discharge: a Randomized Controlled Trial

BACKGROUND

Cessation counseling and pharmacotherapy are recommended for hospitalized smokers, but better coordination between cessation counselors and providers might improve utilization of pharmacotherapy and enhance smoking cessation.

OBJECTIVE

To compare smoking cessation counseling combined with care coordination post-hospitalization to counseling alone on uptake of pharmacotherapy and smoking cessation.

DESIGN

Unblinded, randomized clinical trial PARTICIPANTS: Hospitalized smokers referred from primarily rural hospitals INTERVENTIONS: Counseling only (C) consisted of telephone counseling provided during the hospitalization and post-discharge. Counseling with care coordination (CCC) provided similar counseling supplemented by feedback to the smoker's health care team and help for the smoker in obtaining pharmacotherapy. At 6 months post-hospitalization, persistent smokers were re-engaged with either CCC or C.

MAIN MEASURES

Utilization of pharmacotherapy and smoking cessation at 3, 6, and 12 months post-discharge.

KEY RESULTS

Among 606 smokers randomized, 429 (70.8%) completed the 12-month assessment and 580 (95.7%) were included in the primary analysis. Use of any cessation pharmacotherapy between 0 and 6 months (55.2%) and between 6 and 12 months (47.1%) post-discharge was similar across treatment arms though use of prescription-only pharmacotherapy between months 6-12 was significantly higher in the CCC group (30.1%) compared with the C group (18.6%) (RR, 1.61 (95% CI, 1.08, 2.41)). Self-reported abstinence rates of 26.2%, 20.3%, and 23.4% at months 3, 6, and 12, respectively, were comparable across the two treatment arms. Of those smoking at month 6, 12.5% reported abstinence at month 12. Validated smoking cessation at 12 months was 19.3% versus 16.9% in the CCC and C groups, respectively (RR, 1.13 (95% CI, 0.80, 1.61)).

CONCLUSION

Supplemental care coordination, provided by counselors outside of the health care team, failed to improve smoking cessation beyond that achieved by cessation counseling alone. Re-engagement of smokers 6 months post-discharge can lead to new quitters, at which time care coordination might facilitate use of prescription medications.

TRIAL REGISTRATION

NCT01063972.

Perceptions, Knowledge, and Use of Electronic Cigarettes: A Survey of Mental Health Patients

Tobacco smoking is the leading cause of preventable illness and death in the United States. Smoking and mental illness are often comorbid, yet little is known about mental health patients' perceptions, knowledge, and use of electronic nicotine delivery systems (ENDS). ENDS may be a beneficial short-term intervention to help this group quit smoking. A survey was administered to a sample of patients at an adult outpatient mental health office (N = 109, 45% male, mean age 33). The majority of participants had tried ENDS. Most used ENDS to quit smoking, and believed it was less harmful than smoking. Participants had variable knowledge about ENDS, but few had asked providers for recommendations. They reported providers were not very knowledgeable about ENDS, and were not asking providers for recommendations. ENDS may help mental health patients who have been unable to quit tobacco, but should not be recommended outside of smoking cessation. This survey provides needed information about how ENDS are being used by mental health patients to help guide future recommendations by their healthcare providers when screening for tobacco use.

Testing the feasibility of a guided imagery tobacco cessation intervention delivered by a telephone quitline: Study protocol for a randomized controlled feasibility trial

Background

Guided imagery (GI) is an evidence-based method that uses the imagination to practice and achieve a desired outcome. Little research has focused on how GI can be delivered to smokers using remote or virtual methods, such as a telephone-based intervention. Telephone-based services for tobacco cessation (quitlines) have emerged as standard of care for tobacco cessation. However, quitlines reach only a small fraction of smokers, and men and racial/ethnic minorities are less likely to use quitlines than majority women. GI has the potential to attract under-served minority groups as well as smokers who are looking for an alternative approach to cessation. The present study is designed to test the feasibility and potential impact of a GI tobacco cessation intervention delivered by telephone. This study compares the GI intervention with a standard behavioral (SB) intervention.

Methods

Participants (N = 100) are randomized to either the GI (intervention) or SB (control) condition. Each condition features a 6-week intervention in which participants work with coaches to quit tobacco. Primary outcomes are feasibility related (recruitment, retention, adherence), and secondary outcomes include cessation at 6 months post-intervention (7-day and 30-day abstinence).

Discussion

A GI intervention delivered via quitline would allow for scalability and dissemination, potentially reaching a more representative group of smokers. Results from this study will determine the feasibility of delivering the GI intervention, and describe the reach of the intervention to under-represented tobacco users. If successful, our study results will guide the design and conduct of a future efficacy trial.

Direct-to-Member Household or Targeted Mailings: Incentivizing Medicaid Calls for Quitline Services

INTRODUCTION

Innovative methods are needed to promote tobacco cessation services. The Medi-Cal Incentives to Quit Smoking project (2012-2015) promoted modest financial and medication incentives to encourage Medi-Cal smokers to utilize the California Smokers' Helpline (Helpline). This article describes the implementation and impact of two different direct-to-member mailing approaches.

METHODS

Medi-Cal Incentives to Quit Smoking promotional materials were mailed directly to members using two approaches: (1) household mailings: households identified through centralized membership divisions and (2) individually targeted mailings: smokers identified by medical codes from Medi-Cal managed care plans. Mailings included messaging on incentives, such as gift cards or nicotine patches. Number of calls per month, calls per unit mailed, and associated printing costs per call were compared during and 1 month after mailings. Activated caller response was based on reporting a household mailing promotional code or based on requesting financial incentives for individually targeted mailings. Analyses were conducted in 2018.

RESULTS

Direct-to-member mailings, particularly with incentive messaging, demonstrated an increase in call volumes during and 1 month after mailing, and increased Medi-Cal calls to the Helpline per unit mailed. Mailings with only counseling messages had the lowest percentage of activated calls per unit mailed, whereas the incentive messaging mailings were consistently higher. Although household mailings demonstrated lower printing costs per call, individually targeted mailings had a higher percentage of activated calls per unit mailed.

CONCLUSIONS

Household and individually targeted mailings are feasible approaches to increase Medi-Cal calls to the Helpline, particularly with incentive messaging. Choosing an approach and messaging depends on available resources, timing, and purpose.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Estimated Budget Impact of Adopting the Affordable Care Act's Required Smoking Cessation Coverage on United States Healthcare Payers

INTRODUCTION

Despite abundant information on the negative impacts of smoking, more than 40 million adult Americans continue to smoke. The Affordable Care Act (ACA) requires tobacco cessation as a preventive service with no patient cost share for all FDA-approved cessation medications. Health plans have a vital role in supporting smoking cessation by managing medication access, but uncertainty remains on the gaps between smoking cessation requirements and what is actually occurring in practice. This study presents current cessation patterns, real-world drug costs and plan benefit design data, and estimates the 1- to 5-year pharmacy budget impact of providing ACA-required coverage for smoking cessation products to understand the fiscal impact to a US healthcare plan.

METHODS

A closed cohort budget impact model was developed in Microsoft Excel^® to estimate current and projected costs for US payers (commercial, Medicare, Medicaid) covering smoking cessation medicines, with assumptions for coverage and smoking cessation product utilization based on current, real-world national and state-level trends for hypothetical commercial, Medicare, and Medicaid plans with 1 million covered lives. A Markov methodology with five health states captures quit attempt and relapse patterns. Results include the number of smokers attempting to quit, number of successful quitters, annual costs, and cost per-member per-month (PMPM).

RESULTS

The projected PMPM cost of providing coverage for smoking cessation medications is $0.10 for commercial, $0.06 for Medicare, and $0.07 for Medicaid plans, reflecting a low incremental PMPM impact of covering two attempts ranging from $0.01 for Medicaid to $0.02 for commercial and Medicare payers.

CONCLUSION

The projected PMPM impact of covering two quit attempts with access to all seven cessation medications at no patient cost share remains low. Results of this study reinforce that the impact of adopting the ACA requirements for smoking cessation coverage will have a limited near-term impact on health plan's budgets.

FUNDING

Pfizer Inc.