Smoke-Free Environments and Tobacco CessationThe Boston Experience

Margaret Reid, RNDirector, Healthy Homes & Community Supports

Boston Public Health Commission 11/13/2012

Reasons to invest in tobacco policies and benefits

Influence of tobacco-free policies Importance of tobacco cessation benefits

Case study in Boston Questions

Overview

Why invest in tobacco prevention?

Smoking Impacts Productivity

Nonsmokers

Former Smokers

Current Smokers

Mean days missed for work d/t health conditions/year

4.4 days 4.9 days 6.7 days

Mean hours lost d/t absenteeism/year

35.2hours 39.2hours

53.6hours

Mean hours lost d/t presenteeism/year

42.8 hours 56.0 hours

76.5 hours

Journal of Occupational and Environmental Health, Volume 48, Number 10, October 2006.

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

Strategies to reduce tobacco use

2003:Smoke Free

Workplace Law

Passed

2008: Smoke Free

Workplace Law

Updated

August 2011:Smoke Free Tot

Lots Designate

d

April 2012: Smoke Free

Hospital Campuses

September 2012: Smoke Free Boston

Public Schools Policy in Effect

October 2012: Smoke Free

Public Housing Policy in Effect

Creating Smoke-Free Places in Boston

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.

Smoke Free Policies Are Effective

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

Importance of Cessation Support

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

Barrier Free Cessation Benefits

Prescription Medications

Nicotine Replacement Therapy (OTC)

Zyban (bupropion hydrochloride)

Nicorette (Gum)

Chantix (varenicline) Nicoderm CQ, Nicotrol (Patch)

Nicotrol NS (Spray)

Nicotrol Inhaler (Inhaler)

Cessation Aids

Case Study: Cessation Benefits in for Boston Employees

Insurance Plan Cessation Counseling Benefit Cessation Pharmacy Benefit

Gold Standard Offers bi-lingual telephone counselingWill reimburse for 16 counseling sessions every 12 months, PA for counseling beyond this limit

Covers NRT and prescription medications;$1-3 co-pay

Major Insurer #1 Promotes Smokers Help Line and online support.Offers reduced rate for QuitSmart program

No coverage for NRT;$10 co-pay for generic drugs, $25 co-pay Chantix and Wellbutrin

Major Insurer #2 Promotes Smokers Help Line and online support.

Covers NRT and prescription medications;$10 co-pay for generics ; $25 for Chantix and Wellbutrin

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.

Case Study

Men64%

Women35%

Unidentified1%

City of Boston Workforce: Gender

Under 20 yrs0% 20-29 yrs

10%

30-39 yrs19%

40-49 yrs26%

50-59 yrs27%

60-69 yrs

12%

70+ yrs6%

City of Boston Workforce: Age

White57%

Black21%

Hispanic8%

Asian3%

Amer-ican

Indian0%

Not Indicated10%

City of Boston Workforce: Race/Ethnicity

Adult Current Smoking, 2010

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.

Case Study: Setting the Table

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.

Case Study: Negotiations

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.

Case Study: Negotiations

Major Insurer #1 Before AfterCessation Counseling Benefit

Reduced rate for QuitSmart program.

Added on-site cessation groups.Continues to promote Smokers Help Line and online support and reduced rate for QuitSmart program

Cessation Pharmacy Benefit

No coverage for NRT;$10 co-pay for generic drugs, $25 co-pay Chantix and Wellbutrin

Added coverage for NRT, most at Tier 1 co-pay level of $10.Continues coverage for prescription medications

Case Study: New Benefit

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

Case Study: Next Steps

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

Case Study: Next Steps

Questions?