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Case Studies

Comprehensive Treatment of Tobacco Dependence in Oregon

Overview

Policy/Program Objectives of the Intervention

Oregon's tobacco prevention program is a true collaborative effort among several organizations of the community. Both public and private entities joined together to implement one of the country's early comprehensive programs. The Tobacco-Free Coalition of Oregon (TOFCO) is an alliance of 51 voluntary, professional and government organizations, including the CDC-funded state tobacco program. This coalition first defined the challenge of tobacco prevention in its broadest sense, i.e., recognizing that the challenge to reduce the number of smokers requires addressing the issue from the policy perspective, e.g., clean indoor air ordinances, youth programs to prevent tobacco initiation, etc. Toward this end, TOFCO developed a state-wide tobacco prevention plan with the following goals:

• Decrease tobacco use by youth
• Treat tobacco dependence
• Protect children from exposure to tobacco
• Protect workers and the public from secondhand smoke
• Secure funding and implementation of state and local tobacco use prevention and education programs

The focus of this case study is on the treatment of tobacco dependence, the statewide program's second goal. Also known as "cessation," Oregon's program takes a multi-dimensional approach to this goal as well and includes the implementation of a telephone-based Quitline as but one aspect of their multi-faceted cessation intervention. The discussion that follows will focus on the cessation goal of Oregon's comprehensive tobacco prevention plan. In a general sense, the program's objectives are to create a public/private partnership to foster access to smoking cessation services. The specific objectives for this goal are as follows:

• To increase the percentage of health systems in Oregon that have adopted formal guidelines, policies and procedures to integrate systematic tobacco use assessment, documentation, and cessation intervention into the routine delivery of health care in outpatient, inpatient and dental care settings.
• To increase the percentage of health care systems that have integrated quality assurance monitoring of tobacco use encounters.
• To increase the percentage of health care providers in community-based and public health clinics that conduct routine assessment, intervention and follow-up for tobacco use.

Throughout the implementation, the priority for scarce state tobacco funds was to support and leverage resources within the health system to implement the Public Health Service guidelines.

Description of the Intervention

Using the Agency for Healthcare Research and Quality (AHRQ) national tobacco cessation guidelines as a starting point, the TOFCO task force made modifications to foster local understanding and ownership by addressing factors unique or relevant to Oregon. Because of the significant role played by managed care organizations in the delivery of health care in Oregon at that time, guidelines were adapted specifically for these organizations. Other plan components include implementation by clinicians of "the 5-A's –Ask, Advise, Assist, Arrange, Assess," implementation of coverage for tobacco use cessation services by the state Medicaid program and incorporation of provisions into the Oregon Patients' Rights Act for the mandatory reporting of "advice to quit" data for the commercially insured. Finally, in cooperation with commercial and Medicaid health care plans, the state implemented a cessation Quitline.

The Quitline is a single, statewide, no-charge telephone-based resource to provide screening, one-time counseling, support materials and referral for tobacco cessation assistance based on individuals' readiness to quit. It provides comprehensive pro-active follow-up counseling support for uninsured Oregonians who are ready to quit. For insured individuals ready to quit, the Quitline coordinates with Oregon's Medicaid and private health care delivery system to link the person attempting to quit with the appropriate resource for comprehensive support services, which in many cases is a seamless enrollment in the comprehensive program from the same Quitline vendor. The Quitline is also an information resource for health care providers regarding effective cessation methods.

Program implementation also included the development of training models for the various key players/program resources. The Medicaid agency's health plan forum for prevention was the primary vehicle for this training. The medical directors and quality improvement coordinators advised the state program and TOFCO on the audiences and content for training. They organized full-day sessions for health plan staff and half-day sessions for clinic managers/ coordinators. These sessions were conducted throughout the state.

Implementation also included the introduction of a comprehensive media campaign to promote program awareness throughout the state. The media program including development of materials that health plans could use with their physician networks and members to promote quitting and to advertise the Quit Line as the single resource that would connect potential quitters with the appropriate resources for which they were eligible.

Personnel/Key Players/Resources Required for Conducting the Intervention

To conduct the intervention, the Coalition developed a "health systems" task force that included managed care organizations, large health care delivery systems, Medicaid agency medical directors, 16 health plans participating in the state Medicaid program and private health plans. The Group Health Cooperative's Center for Health Promotion in Seattle was selected as the Quitline service provider for the initial front-door screening and one-time counseling for all callers and telephonic service delivery for those with no health insurance or commercially purchased service.

Place Where the Intervention was Conducted

The intervention to incorporate clinical guidelines into everyday medical practice occurred in health plans, health care clinics, hospitals, doctors' and dentists' offices throughout the state. The Quitline intervention is pro-active, conducted by telephone and supported by written materials mailed to program participants. The media campaign to promote the Quitline is conducted on a statewide basis with television, radio and print advertising as well as with promotional/education materials provided to physician and dentist offices and at professional meetings.

Approximate Time Frame for Conducting the Intervention

The overall Oregon program, including the implementation of strategies toward achievement of comprehensive prevention goals, began in 1997 and is ongoing. These components include conducting training sessions for members of the health care delivery system to promote utilization of common clinical guidelines as well as efforts to modify insurer coverage and data reporting regarding tobacco cessation services.

The Oregon Quitline (OQL) was implemented in 1998. The actual timeframe for the Quitline intervention is dependent on the caller's eligibility for services. All callers receive one intervention and encouragement to call back for additional help. Those that are uninsured, as well as teenagers and members of the six participating health care plans (some of which are Medicaid plans) get 3 months to 1 year of proactive follow-up depending on the particular contracted service. Others receive the services offered by their health plan, including other phone programs as well as classes. Callers who have health insurance that excludes comprehensive cessation assistance as a covered benefit are referred to programs available within the community.

Note: Oregon's program has not allocated settlement funding to the tobacco cessation program. Primary program funding has been from the cigarette excise tax. Due to the serious budget shortfalls in Oregon, the state has recently reduced available funding from tax dollars by more than 50%. The future of the program is currently under study.

Summary of Implementation of the Intervention

Oregon's Statewide Tobacco Cessation Project was implemented in a comprehensive and multi-faceted manner. The Tobacco-Free Coalition of Oregon Health Systems Task Force provided the theoretical framework, cessation expertise and planning and coordination functions for all participating health plans, especially for the large commercial plans. The first step in implementation was to develop the Oregon-based guidelines for tobacco cessation in health care systems that were adapted from the Public Health Service and Task Force on Community Prevention Service's guidelines. Because of their capabilities and requirements, the Oregon Health Plan, the state's Medicaid program, provided much of the hands-on input that was essential for widespread implementation of the initiative. With guidance from the state tobacco program and the Tobacco-Free Coalition, the Oregon Health Plan established evaluation measures and data collection and reporting requirements.

Among major implementation activities was the development of a communication plan for health care providers. Plans were developed to effectively communicate the clinical practice guidelines and to conduct "academic detailing" sessions to assist with office practice implementation.

The Tobacco Prevention & Education program (TPEP) within the Oregon Health Division issued a request-for-proposals from qualified agencies to offer a single, state-wide telephone-based resource to provide screening, counseling, support materials and referrals for cessation assistance. The selected "Quitline" administrator is also responsible for the distribution of non-prescription nicotine replacement therapies (NRT) to eligible callers.

Summary of Evaluation/Outcome of Intervention

The Oregon initiative has produced measurable, successful results. There has been a significant increase in the percentage of smokers who have been advised to quit and offered assistance to do so by their physician. Also, the percentage of smokers who think that cessation assistance would help has increased from 56% to 62%. Other improvements include measurable declines in the percent of the Oregon population that smoke and in annual per capita cigarette sales.

The Oregon Quitline has also proven to be a success as indicated by both process and outcome evaluations. Satisfaction with services is extremely high and, using the "intent to treat" analysis methodology at 6-months after the first call, 13% have been smoke-free for at least 7 days. This percentage is significant when compared to the rate of 4.1% of the general population who have been successful when quitting on their own.

Intervention's Applicability/Replicability/Recommendations for Other Sites

Oregon was fortunate to be implementing its public/private partnership for tobacco cessation in the late 1990's. The economy was thriving, high penetrations of managed care were containing health care costs, and uninsurance rates were low. Using a voluntary partnership approach to ask the health systems to step up to the plate to provide treatment for nicotine addiction was easier than it is in 2004. In light of large fluctuations in the state legislature's funding for the program, the partnership approach appears wise; private sector components of the program survive even in times when the state's program is diminished.

Models to assure cessation services other than a public/private partnership, such as state-directed services or legislative mandates, may be more appropriate in other states. The important learning from Oregon's experience is that these approaches cannot be mutually exclusive. A state needs to have a consistent over-arching framework about responsibilities for tobacco quitting assistance, and assure that all of the components work together.

Overview Notes

This case study was written by Jane Freedman, an Office on Smoking and Health Consultant, November 2003.

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