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Case Studies

Comprehensive Treatment of Tobacco Dependence in Maine

Overview

Policy/Program Objectives of the Intervention

The Tobacco Treatment Initiative was launched in 2001 by the Partnership for a Tobacco-Free Maine (PTM), Bureau of Health, Department of Human Services. The Initiative’s objective is to provide evidence-based treatment for tobacco dependence based on the U.S. Public Health Service Practice Guidelines.

Description of the Intervention

The mission of Maine’s Treatment Initiative is to enhance access to effective treatments for tobacco dependence. The program is also based on the belief that tobacco treatment interventions are most effective when delivered in the context of a comprehensive program. The Initiative includes several components including the Maine Tobacco HelpLine, nicotine replacement provided through the Medication Voucher program and Tobacco Treatment Training to educate health professionals about tobacco dependence and training for Tobacco Specialists.

The Maine Tobacco HelpLine (the HelpLine) provides information, written materials and multiple-session behavioral counseling to any Maine resident. Beginning in August 2002, PTM began the Tobacco Medication Voucher Program, providing access through the HelpLine to vouchers for up to 8 weeks of nicotine gum or patch therapy. Smokers are eligible for the voucher program if they are aged 18 or older, interested in quitting, agree to speak to a HelpLine specialist and have no insurance or pharmacy benefit coverage for nicotine replacement therapy. Smokers authorized for a medication identify a Maine pharmacy of preference where the medication is dispensed. The Voucher program is an electronic process, implemented through collaboration with a pharmacy benefit management (PBM) company. The medication information is forwarded to the PBM who provides the information to the designated local Pharmacist.

Personnel/Key Players/Resources Required for Conducting the Intervention

The program was implemented by the Center for Tobacco Independence (CTI), under contract with the Partnership for a Tobacco-Free Maine (PTM), Bureau of Health, Department of Human Services. Telephone support is provided by Intellicare, South Portland, Maine. A specialized software program is licensed to CTI by the Center for Health Promotion, Tukwila, Washington. The Voucher Program is implemented by CTI through a partnership with Gould Health Services, Augusta, Maine, a pharmacy benefit management company.

Place Where the Intervention was Conducted

The HelpLine is housed at Maine Medical Center, Portland, Maine. All residents of Maine have access to the HelpLine through use of a toll-free number. Eligible individuals have access to the Voucher Program through the HelpLine but may receive medications at any pharmacy throughout the state.

Approximate Time Frame for Conducting the Intervention

All HelpLine callers who are interested in quitting in the next 30 days are encouraged to be counseled by a Tobacco Specialist. All callers are mailed Quit Kits that are appropriate to their intention to quit. Three follow-up calls are scheduled to support the client’s effort to quit. The timing of subsequent calls is arranged around the caller’s quit date using a relapse-related protocol. If a caller is not ready to quit within 30 days, they are mailed appropriate materials and encouraged to call back in the future.

Callers participating in the Medication Voucher program receive a 4-week supply of nicotine replacement therapy–either nicotine patch or gum. One additional 4-week supply is authorized if a smoker has follow-up contact with a HelpLine Specialist. Maine residents are eligible for a course of therapy every six months.

Summary of Implementation of the Intervention

The Maine program is somewhat unique in that a single contractor was sought to implement multiple elements of a comprehensive tobacco treatment initiative. Implementation components corresponded to five goals. The program selected the Center for Tobacco Independence (CTI), a new entity that brought together leading individuals across the state in a collaborative, coordinated structure. Other CTI collaborators include the American Lung Association of Maine, the Center for Outcomes Research and Evaluation at the Maine Medical Center (CORE), and Intellicare.

While CTI was responsible for overall program implementation, each phase occurred individually and in succession. The HelpLine was implemented first, followed a year later by the Tobacco Medication Voucher program. The other major program components include the Tobacco Treatment Training program—educating health professionals about tobacco dependence, and training Tobacco Specialists across the state.

Summary of Evaluation/Outcome of Intervention

The evaluation of the HelpLine includes an examination of the use (“reach”) of services, the impact on long-term quitting, and customer satisfaction with services. Quit surveys are conducted by telephone on a sample of callers six months following HelpLine use. Surveys are on a random sample of callers each month, using an independent subcontractor. Based on combined results of the first two surveys completed, 21.5% of smokers were not smoking 6 months after receiving any counseling by a HelpLine Specialist. The Maine Tobacco HelpLine concludes that services significantly impact quitting, because only about 5 to 10% of smokers quit on their own without help (from the US Public Health Service’s 2000 Clinical Practice Guideline for the Treatment of Tobacco Use and Dependence).

Utilization evaluation includes the volume of calls received by the Helpline over time (e.g., day, time of call, number of calls), and the demographic characteristics and county of residence of callers (i.e., age, sex, race, information collected at intake when the caller makes the initial call). To assess customer satisfaction with HelpLine services, surveys are conducted with customers 3 months after receiving assistance. Almost 90% of HelpLine callers were satisfied with counseling, self-help materials and overall service. Of those surveyed, 86% would recommend the HelpLine to a friend or family member.

Intervention's Applicability/Replicability/Recommendations for Other Sites

A primary recommendation for other sites is that, while multifaceted, a comprehensive program is possible and can be successful. However, it is best to develop program components carefully and in succession rather than to implement multiple components simultaneously but less effectively. Program implementations of this complexity require very clearly defined goals and timelines for each component, with specific roles and responsibilities of staff. Benefits of a comprehensive program include access to wide-ranging services that affect tobacco cessation, and the potential to coordinate program elements efficiently.

This program is replicable in other locations. However, in smaller states such as Maine, a smaller number of individuals in influential positions may successfully effect change.

One lesson learned, which was not unexpected, is that it is challenging to integrate programs such as these into health care systems.

Overview Notes

This case study was written by Jane Freedman, a consultant for the CDC Office on Smoking and Health, July 2005.

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