Tobacco Use and Dependence A global non-profit organization of - - PowerPoint PPT Presentation

Association for the Treatment of Tobacco Use and Dependence A global non-profit organization of providers dedicated to the promotion of and increased access to evidence-based tobacco treatment for the tobacco user. www.attud.org

Tobacco treatment specialists are:

• trained in established core competencies
• enabling the delivery of evidence-based

treatment

• across a variety of settings and modalities
• including intensive individual, group, and

telephone/telehealth counseling

• And achieve higher quit rates than our

non-specialist clinical colleagues

Burke, 2015; Song, 2016

Who we are

Certified Tobacco Treatment Specialists (CTTS)

• Completed an accredited training program in tobacco treatment

(www.ctttp.org)

• Provide intensive counseling treatment and are well-versed in

working collaboratively with physicians for prescribing medications

• Part of an integrated team of physicians/APNs, etc. providing a
• ne-stop shop for tobacco dependent patients
• Composed of many professions including physicians, nurses,

master’s level counselors, psychologists, social work, respiratory care, pharmacists, etc.

• While there is currently no national certification, ATTUD is working

with NADDAC (Association of Addiction Professionals) and NCC AP (National Certification Commission for Addiction Professionals) to develop a National Certificate in Tobacco Treatment Practice launching Oct 15, 2017

Tobacco use is the leading cause of preventable death in the US

• Tobacco-caused illness accounts for 8.7% of

healthcare costs (2010 data)

• 60% of these costs were paid for by

Medicare/Medicaid and other federal programs

• Costs $170 billion/year, not including lost

productivity

Xu, 2015

Scope of the problem

• While 55% of adult smokers attempted to quit in the

past year, only 5% used both counseling and medication

• Best-practice treatments remain underutilized

because:

• Most clinicians have no advanced or specialized

training in tobacco cessation treatment

• Hospital systems/clinicians are not adequately

and consistently reimbursed for tobacco treatment

Babb, 2017; Nolan, 2017

Evidence based treatments are widely underutilized

• CTTSs can function as both treatment clinicians

and health care system navigators ensuring that tobacco users receive appropriate services

• CMS should ensure that all healthcare providers

(including CTTSs) are reimbursed for providing tobacco treatment

Siu, 2015

Highest quit rates are achieved by combining medications and intensive counselling

CTTSs should be fully reimbursed for the clinical treatment they deliver

• Dose response: more frequent & longer

sessions lead to higher quit rates

• Intensive counseling (20-60 min) provided by

CTTS results in higher quit rates than brief advice or minimal advice (3-19 min)

• The largest effect : > 8 visits
• Intensive treatment is highly cost-effective

Siu, 2015

Defining “Intensive” tobacco treatment

• 20-60 min per visit for individual counseling
• 45-90 min per visit for group counseling
• Visits 1-2x/week for at least 8 weeks, per

modality

• A number of existing CPT codes can be utilized

for CTTS services

Bars, 2016; Siu, 2015

• 28% smoking prevalence in Medicaid population
• Unchanged between 1997-2013
• Quit rates in Medicaid remain very low, despite brief
• r quit line treatment
• Medicaid population has very high levels of chronic

(mental & physical) diseases, costing an estimated $40.1-$75 billion (2016)

• Medicaid smokers try to quit but have less success, in

part possibly due to having more severe psychological distress

Zhu, 2017

Medicaid tobacco users

• California has had solid, sustained tobacco control for

decades

• Medicaid smoking prevalence rate is now only

14.7% (HALF the national rate)

• Massachusetts Medicaid comprehensive tobacco

cessation benefit (medications plus individual/group counseling)

• ROI of greater than $3 for every $1 spent while

reducing cardiovascular events 40-50% within 70 weeks

Richard, 2012; Zhu, 2017

The Medicaid solution

Declines in Smoking Prevalence

Annual percentage rate (APR) change for smoking prevalence among MassHealth uninsured adults in Massachusetts aged 18-64. Land & Warner, 2011

Smoking Prevalence in Massachusetts Adults (18 - 64):

MassHealth vs. No Insurance

25.0% 30.0% 35.0% 40.0% 45.0% 7 / 1 / 1 9 9 9 7 / 1 / 2 7 / 1 / 2 1 7 / 1 / 2 2 7 / 1 / 2 3 7 / 1 / 2 4 7 / 1 / 2 5 7 / 1 / 2 6 7 / 1 / 2 7 7 / 1 / 2 8 Smoking Prevalence (6-Month Annual Rolling Average) MassHealth (Point Estimates) No Insurance (Point Estimates) MassHealth (Model Estimates) No Insurance (Model Estimates)

Massachusetts Medicaid comprehensive tobacco cessation benefit

• Program costs (medication, counseling, promotion)

= $183/user

• Hospital inpatient savings = $571/user
• ROI $3.25 for every $1 spent for CV diseases

Return on investment of a Medicaid tobacco cessation program in Massachusetts

Richard, 2012

Tobacco cessation interventions are ranked as the most cost-effective preventive service for adults

• Health impact – clinically preventable health

burden and QALY gained

Maciosek, 2017

Evidence of cost-effectiveness

• f tobacco treatment

Combination of pharmacotherapy and intensive behavioral treatment is the most cost-effective intervention in the healthcare sector

Shahab, 2015

Evidence of cost-effectiveness of intensive, face-to face, individual/group tobacco treatment

Treatment specialists may be more effective re: quit rates than community practitioners Smoking cessation specialist have 2x quit rates compared with physician preventive care visits Specialists have increased quit rates and also reduced longer-term (one year) relapse

McDermott, 2012; Kotz, 2014; Song, 2016

Evidence of cost-effectiveness of specialist treatment

Biochemical validation is a CTTS core standard of care practice intervention Expired breath carbon monoxide (CO) assessment is the “stethoscope” of tobacco treatment & assesses efficacy. Better treatment matching could be accomplished with CO assessment and by measuring cotinine levels Analysis of 177,000 smokers treated at 144 Stop Smoking Service Centers in the UK found measuring CO correlated with abstinence CO testing & cotinine assays demonstrate clinical efficacy and are important medically appropriate services in specialist tobacco treatment settings (similar to HgbA1c for DM)

West, 2010; Goldstein, 2017; Lawson, 1998; Bittoun, 2008

The role of biochemical confirmation in tobacco treatment

Pairing tobacco cessation services with lung cancer screening

• Tobacco users at Lung Cancer Screening are highly motivated to

quit

• Smokers with positive lung cancer screening findings are more

likely to quit, but screening alone has little impact on quitting

• Intensive, comprehensive Tobacco Treatment is often needed

for this population

• Highly dependent
• Intensive treatment more effective than brief treatment
• Adding brief counseling, intensive counseling, and telephone

counseling to screening would make lung screening more cost effective

• Former smokers had an all cause mortality reduction of 39%

Fucito, 2016; Clark, 2015; Pastorino, 2016

• CTTSs have the training, clinical experience to assist the

nation in saving lives reducing morbidity and bending the cost curve

• CMS needs to reimburse the CTTSs as approved

Medicare/Medicaid clinicians

• Public health and economic gains from CTTSs may be much

greater than for chemical dependence counseling, wellness coaches or health educators

• A CMS initiative for CTTSs similar to DM educators/coaches

may be helpful. ATTUD is here to start a conversation.

Conclusions