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The Big Picture:
An Overview of Major
Events Shaping
National, State,
Public and Private
Cessation Policy
Matt Barry
Director, Policy Research
Campaign for Tobacco Free Kids
Washington, DC
What’s on the Radar?
• What SHOULD We Be
Doing?
• Medicare
• Medicaid
• Other Federal Programs
• State Insurance Mandates
• DOJ
• Varenicline and Rimonabant
• Other
• X Factors
What SHOULD We Be Doing?
According to CDC’s Task Force on Community Preventive
Services, interventions should include restrictions on exposure to
secondhand smoke, increases in the unit cost of tobacco, mass
media campaigns, provider reminder systems, reducing out-ofpocket expenses, and telephone counseling/support.
Source – AJPM, 2001;20(2S), “Recommendations Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke”,
http://www.thecommunityguide.org/tobacco/tobac-AJPM-recs.pdf.
What SHOULD We Be Doing?
Strategies to Reduce Exposure to Secondhand Smoke
•
Smoking bans and restrictions: strongly recommended. “Strong scientific
evidence that they reduce exposure to ETS (1) in a wide range of workplace
settings and adult populations; (2) when applied at different levels of scale, from
individual businesses to entire communities; and (3) whether used alone or as part
of a multi-component community or workplace intervention.”
Strategies to Reduce Tobacco Use Initiation
•
Increasing the unit price for tobacco products: strongly recommended.
“Strong evidence of effectiveness in reducing tobacco use prevalence in study
populations of adolescents and young adults … In addition, increasing the price for
tobacco products is also effective in (1) reducing population consumption of tobacco
products, and (2) increasing tobacco use cessation.”
•
Mass media campaigns: strongly recommended (when combined with other
interventions). “Strong evidence of effectiveness in reducing tobacco use
prevalence among adolescents when implemented in combination with tobacco
price increases, school-based education, and/or other community education
programs.”
What SHOULD We Be Doing?
Strategies to Increase Tobacco Use Cessation
•
Increasing the unit price for tobacco products: strongly recommended.
“Strong evidence of effectiveness in (1) reducing population consumption of tobacco
products, (2) reducing tobacco use initiation …and (3) increasing tobacco
cessation. Excise tax increases demonstrated evidence of effectiveness in a variety
of populations and when implemented at both the national and state levels.”
Mass Media Education
•
Campaigns: strongly recommended (when combined with other
interventions). “Strong evidence of effectiveness in (1) reducing population
consumption of tobacco products, and (2) increasing cessation among tobacco
product users.”
What SHOULD We Be Doing?
Health Care System-Level Interventions
•
Provider reminders: recommended. “Provider reminders are recommended (1)
whether used alone or as part of a multi-component intervention … (2) across a
range of intervention characteristics (chart stickers, checklists, and flowcharts), and
(3) in a variety of clinical settings and populations.”
•
Provider reminder plus provider education, with or without patient education:
strongly recommended. “Strongly recommended on the basis of strong evidence
that this combination (1) increases provider delivery of advice to quit to tobacco
using patients, and (2) increases patient tobacco use cessation.”
•
Reducing patient out-of-pocket costs for effective cessation therapies:
recommended. “Recommended … on the basis of sufficient scientific evidence of
effectiveness in (1) increasing use of the effective therapy, and (2) increasing the
total number of tobacco-using patients who quit.”
•
Multicomponent patient telephone support: strongly recommended. “Strongly
recommended …on a strong body of evidence that this combination intervention (1)
increases patient tobacco cessation, and (2) is effective in both clinical settings and
when implemented community-wide.”
Nice Theory, But Does
It Work?
Ask New York City
What did they do?
•
Comprehensive Smoke Free Law
•
Highest Cigarette Excise Tax In the
U.S.
•
Well-Funded State Tobacco Control,
Prevention and Cessation Program
(including quitline and quit clinics)
The results?
•
In one-year, an 11% drop in adult
smoking rates between 2002-2003
(from 22% to 19%).
•
100,000 fewer smokers.
What are we
ACTUALLY doing?
Medicare
• March 22, 2005 - CMS issued a final
decision memo to cover tobacco
cessation counseling services under
Part B.
• Counseling services are now
available to all beneficiaries with a
disease or an adverse health effect
linked to tobacco use or who are
taking a therapeutic agent that is
affected by tobacco use.
• Medicare now covers 2 cessation
attempts per year - a maximum of 4
intermediate or intensive sessions,
with the total annual benefit up to 8
sessions.
Source: Decision Memo for Smoking & Tobacco Use Cessation Counseling (CAG-00241N), March 22, 2005, http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=130.
Medicare – Next
Steps
• Need to promote awareness of
this benefit among beneficiaries
and providers.
• Need to promote awareness of
this decision by CMS among
other public and private insurers.
• Need to work with CMS and/or
Congress to allow access by
beneficiaries to telephone
quitline services – quitlines are
not eligible for reimbursement
under the CMS decision.
• Need to coordinate this benefit
with prescription drug benefit
taking effect January 2006.
• Need to work with CMS on
training/certification of providers.
Source: Decision Memo for Smoking & Tobacco Use Cessation Counseling (CAG-00241N), March 22, 2005, http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=130.
Other Federal Activity
Federal Employees Health Benefit Plan - In an August 7, 2003 memo to Rep.
Meehan, former OPM Director Kay Cole James stated: “I continue to encourage
FEHBP plans to provide benefits for programs aimed at health promotion and
disease prevention, including smoking cessation programs … While we urge plans
to cover special benefits and programs, we do not mandate that they do so …”
[For more information on FEHBP, see http://www.opm.gov/insure/health/index.asp]
Federal Bureau of Prisons – Effective July 15, 2004 – “1. [PURPOSE AND SCOPE
§551.160. To advance towards becoming a clean air environment and to protect
the health and safety of staff and inmates, the Bureau of Prisons will restrict areas
and circumstances where smoking is permitted within its institutions and offices.]”
[For more information on BOP no smoking policy, see - http://www.bop.gov/]
Department of Veterans Affairs – The VA published an interim final rule in the
Federal Register on May 2, 2005, to “… amend its medical regulations concerning
co-payments for inpatient hospital care and outpatient medical care. This rule
designates smoking cessation counseling (individual and group sessions) as a
service that is not subject to co-payment requirements. The intended effect of this
interim final rule is to increase participation in smoking cessation counseling by
removing the co-payment barrier.” [For more information on VA cessation programs and
policies, see - http://www.publichealth.va.gov/smoking/describe.htm and
http://www.va.gov/smokingmh/index.html]
Current CMS Federal/National Policy On Cessation
for Medicaid
General Policy •
Smoking cessation benefits, such as counseling and drug therapy,
are optional benefits under Medicaid (except for kids covered under
EPSDT).
•
Smoking cessation drugs are specifically classified as those drugs
that may be excluded from coverage under Medicaid.
•
Smoking cessation counseling services may be provided under a
variety of Medicaid benefit categories.
Pregnant Women - There are no mandatory smoking cessation
benefits for pregnant women under Medicaid. A state may elect to
provide smoking cessation services in a State plan.
Medicaid –
State Activity
It’s ugly out there folks …
Despite the crushing financial burden
of Medicaid on State budgets …
“… Medicaid growth continues to
outpace every other functional
category of state expenditure,
increasing by 8 percent in fiscal
2003; Medicaid now totals 21.4
percent of all state spending.”
“Total Medicaid spending in fiscal
2003 excluding administrative
costs was $243.6 billion ...”
Source: National Association of State Budget Officers, 2003 State
Expenditure Report,
http://www.nasbo.org/Publications/PDFs/2003ExpendReport.pdf.
… there is hope!!!!!
For Example
• The State of Kentucky had a projected
$200 million budget deficit for FY 2005
(Source: Center for Budget and Policy Priorities, State Budget
Deficits Projected For FY 2005, http://www.cbpp.org/10-2203sfp2.htm).
• Despite this deficit, a NEW tobacco
cessation benefit for pregnant women
was added to the Medicaid program.
• Our message? It saves lives, it saves
money and it works.
• How did this happen? Good luck, great
facts, and great work by the state
coalition, state officials and legislators.
• If it can happen in Kentucky, it can
happen anywhere.
Number of State Medicaid Programs
Covering Tobacco Dependence
Treatments (N=51), 2003
Tobacco Dependence Treatment
Zyban
2002
40
2003
36
Nasal Spray & Inhaler
28
27
Patch
Gum
Individual Counseling
Group Counseling
27
26
17
10
28
27
14
11
Telephone Counseling
5
4
Source: Halpin, HA, MMWR, January 30, 2004 / 53(03);54-57.
Source: Analysis by the Center for Health and Public Policy Studies, University of California at Berkeley of the State Medicaid Tobacco
Dependence Treatment Survey, 2003. http://statehealthfacts.org/cgibin/healthfacts.cgi?action=compare&category=Health+Status&subcategory=Smoking&topic=Cessation+Treatment+Under+Medicaid.
Informing Medicaid Tobacco Users
about Benefits, 2003
Methods for Informing Medicaid
Recipients
# States # States
2002
2003
Inform tobacco users about benefits
Through primary care provider
Mailer
9
5
5
18
8
6
Newsletter/magazine
3
4
Television spots
Member services/information line
Website
New member packet
3
3
2
2
3
8
3
8
Source: Analysis by the Center for Health and Public Policy Studies, University of California at Berkeley of the State Medicaid Tobacco
Dependence Treatment Survey, 2003. http://statehealthfacts.org/cgibin/healthfacts.cgi?action=compare&category=Health+Status&subcategory=Smoking&topic=Cessation+Treatment+Under+Medicaid.
COVERAGE CONSISTENT WITH PHS GUIDELINES
9 States Offer Comprehensive* Coverage:
• California
•
•
•
Indiana
Maine
Minnesota
•
•
•
•
•
New Jersey
New York
Oregon
Pennsylvania
West Virginia
* = Zyban, NRT Gum, Patch, Nasal Spray, Inhaler, and at least one type of
counseling (individual, group or proactive telephone).
Source: Halpin, HA, MMWR, January 30, 2004 / 53(03);54-57.
State Insurance Mandates
New Mexico – Is the first state to mandate
comprehensive tobacco cessation benefits by all health
care insurers (except Medicaid) – effective 3/1/04. The
benefit includes:
•
•
•
Diagnostic services: Diagnostic services necessary to
identify tobacco use, use-related conditions and
dependence.
Pharmacotherapy: Two 90-day courses of prescriptiononly medications per calendar year.
Cessation counseling: A choice of cessation counseling
of up to 90 minutes total provider contact time or two multisession group programs per calendar year.
California – A bill (SB 576) was passed in the California
legislature (Senate and Assembly), but vetoed by the
Governor, that would have required health plans and
insurers to cover the following tobacco cessation services:
•
•
•
Counseling (4 sessions of at least 30 minutes each),
All Rx and OTC cessation medications,
Two quit attempts per year.
Maryland – New mandate (HB 303 signed by the
Governor 5/10/05) requiring certain insurers to provide
coverage for prescription-only cessation drugs (eff.
10/1/05).
Department
of Justice
Tobacco Trial
•
Trial phase concluded in early June 2005.
•
In light of major and unexplained changes to
DOJ’s own cessation remedy, several public
health groups (TFK, ACS, ALA, ANR, AHA,
NAATPN) sought to intervene in the case.
•
The Court granted the motion to intervene in
July 2005. Interveners have since filed their
own proposed remedies with the Court
(8/31/05) and a reply brief (9/26/05).
•
The case brings with it an opportunity and
the potential for significant funding for
cessation services for all smokers in the U.S.
Conversely, there exists substantial risk for a
bad settlement.
•
There remain several issues under appeal
that could have a major impact on the
potential financial and non-financial remedies
available.
•
If no settlement takes place, a ruling on
liability is expected by late 2005, early 2006.
There Are Risks &
Opportunities …
NEW
DRUGS!!
Varenicline
and
Rimonabant
• Varenicline (Pfizer) and Rimonabant
(Sanofi-Adventis) are two new drugs
that FDA is expected to approve in
the next 6 to 18 months.
• Both are in late stage clinical trials
and publicly available data thus far
suggests that quit rates are at least
as high as currently available NRTs.
• The buzz around these drugs is
“block buster” that could result in
extensive, high profile media.
• Regardless of your views on
pharmacotherapy/NRT, this will
provide a unique opportunity to
discuss cessation issues with a
variety of audiences and we must be
prepared to take advantage of this
opportunity when it happens.
Other Activities
National Quitline
Network: 1-800QUITNOW
Tax and Smokefree
Activity
Increased Private
Sector Interest in
Tobacco
“X” Factors
National Quitline
Network:
1-800-QUITNOW
• Has been in effect since
November 2004 (approx.
156,000 callers through October
2005).
• Very little $$ for promotion or
actual services.
• Has the potential to serve as the
portal for a much more ambitious
and comprehensive quitline
network.
• Funding at the federal level has
been nominal and, as a result,
the potential impact limited.
Tax and Smokefree
Activity
... they keep going, and
going, and going ...
• 57 state tax increases since
January 2002 (12 in 2005)
• 25% of U.S. population
covered by comprehensive
smokefree laws.
Sources: Campaign for Tobacco Free Kids, Cigarette Tax Increases By State State Per Year
2000-2005, http://www.tobaccofreekids.org/research/factsheets/pdf/0275.pdf; Americans for
Nonsmokers Rights Foundation, Summary of United States Population Protected by 100%
Smokefree Laws, http://www.no-smoke.org/pdf/percentstatepops.pdf.
Recent Cigarette Tax Increases
WASHINGTON
202.5
OREGON
118
MONTANA
170
NORTH DAKOTA
44
123
IDAHO
57
NEBRASKA
64
UTAH
69.5
87
118
77
COLORADO
84
200
36
MISSOURI
79
17
NEW MEXICO
103
91
98
ALASKA
41
160
IN
125
55.5
55
30
18
MARYLAND:100
VIRGINIA
DC:100
SOUTH
CAROLINA
ALABAMA GEORGIA
42.5
CT:151
30
20
59
36
NJ:240
MA:151
RI:246
NORTH CAROLINA
TENNESSEE
ARKANSAS
MA
DELAWARE:55
30
WV
KENTUCKY
MS
TEXAS
135
NH: 80
CT
PENNSYLVANIA
OHIO
KANSAS
OKLAHOMA
150
MICHIGAN
ILLINOIS
CALIFORNIA
ARIZONA
NEW YORK
IOWA
NEVADA
80
WISCONSIN
53
60
200
VT
SOUTH DAKOTA
WYOMING
MAINE
VT:119
MINNESOTA
7
37
LOUISIANA
HAWAII
140
FLORIDA
33.9
States that have recently passed or implemented a
cigarette tax increase (since 1/1/2002)
Oregon actually decreased its cigarette tax by 10 cents on 1/1/04. The second phase of the North Carolina tax increase (an
additional 5-cents) will be effective 7/1/06, bringing the NC tax to 35 cents per pack.
November 1, 2005
Smoke-Free Laws
Restaurants and Bars
Restaurants
June 2005
Increased Private Sector
Interest in Tobacco
• There is an increasing recognition
of the negative financial impact of
tobacco on the corporate bottom
line.
• Companies are tired of wasting
scarce resources on spiraling
health care costs and desperately
want to do something about it.
Increased Private Sector
Interest in Tobacco
• There is a slow but growing
realization of the positive impact
of tobacco control policy changes
(e.g., tax increases, smokefree
laws) on corporate financial
performance.
• Tobacco control can be part of the
solution to their problem.
• “By Jove, I think she’s got it!”
Increased Private Sector
Interest in Tobacco
Is this good or bad?
“… the fact is, federal and state laws
prohibit employers from discriminating
on the basis of age, sex, race, weight,
national origin and other attributes -and smoking is not a civil right. It's just a
poor personal choice.”
- Howard Weyers, CEO, Weyco, Inc.
X factors
Peter Jennings
•
The recent death of ABC Nightly
News Anchor Peter Jennings has
generated a significant amount of
coverage in the media about smoking,
lung cancer and the importance of
quitting.
•
This is a “teachable moment” for
many people and organizations –
consumers, the media, policy makers,
health care professionals, health
plans/insurers/organizations.
•
We always need to be prepared for,
and “take advantage” of, in a positive
and respectful manner, the good that
can come out of one individual’s
personal tragedy.
•
In response to the death of Peter Jennings, ABC News
launched a month-long series (November 2005) of stories
on ABC World News Tonight and on Good Morning America
about the harms associated with tobacco use, about how to
quit using tobacco, and about lung cancer.
•
The resources include on-air stories, a dedicated website,
partnerships with major public health organizations, and
publicizing of cessation resources, including the national
quitline number 1-800-QUIT NOW.
•
This is unprecedented.
Hurricane Katrina
•
In a recent webcast to investors, U.S.
Smokeless Tobacco Company cited
Hurricane Katrina and its impact on
higher gasoline prices for a
substantial, negative impact on sales,
particularly in the Gulf Coast region.
•
According to UST, nearly 2/3 of its
sales occur at retail convenience
stores and nearly 4 out of every 5 of
those stores sell gasoline. UST’s
customers are trying to save money
on gasoline (like the rest of us) and
are making fewer stops at these
stores thereby resulting in fewer
sales.
•
Conversely, in the wake of 9/11 we
saw an increase in the number of
tobacco users (as well as alcohol and
other substances of abuse).
Don’t Lose Sight Of Every Smoker’s Biggest
Problem
Domestic Cigarette Advertising and
Promotional Expenditures 1998 - 2003
(Billions of dollars)
18
$15.15 Billion
16
$12.47 Billion
14
$11.22 Billion
12
$9.59 Billion
10
$8.24 Billion
8
$6.73 Billion
6
4
2
0
1998
1999
2000
2001
Source: Federal Trade Commission Cigarette Report for 2003
2002
2003
Contact Information
Matt Barry
Campaign for Tobacco Free Kids
1400 I Street, NW – Suite 1200
Washington, DC 20005
(202) 296-5469
(202) 296-5427 (fax)
[email protected]
www.tobaccofreekids.org