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
Who we are 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
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 one-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
Scope of the problem 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
Evidence based treatments are widely underutilized 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
Highest quit rates are achieved by combining medications and intensive counselling • 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
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
Medicaid tobacco users • 28% smoking prevalence in Medicaid population • Unchanged between 1997-2013 Quit rates in Medicaid remain very low, despite brief • or 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
The Medicaid solution • 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
Declines in Smoking Prevalence Smoking Prevalence in Massachusetts Adults (18 - 64): MassHealth vs. No Insurance Smoking Prevalence (6-Month Annual Rolling Massachusetts Medicaid comprehensive 45.0% tobacco cessation benefit 40.0% Average) 35.0% 30.0% 25.0% 9 0 1 2 3 4 5 6 7 8 9 0 0 0 0 0 0 0 0 0 9 0 0 0 0 0 0 0 0 0 1 2 2 2 2 2 2 2 2 2 / / / / / / / / / / 1 1 1 1 1 1 1 1 1 1 / / / / / / / / / / 7 7 7 7 7 7 7 7 7 7 MassHealth (Point Estimates) No Insurance (Point Estimates) MassHealth (Model Estimates) No Insurance (Model Estimates) Annual percentage rate (APR) change for smoking prevalence among MassHealth uninsured adults in Massachusetts aged 18-64. Land & Warner, 2011
Return on investment of a Medicaid tobacco cessation program in Massachusetts • Program costs (medication, counseling, promotion) = $183/user • Hospital inpatient savings = $571/user • ROI $3.25 for every $1 spent for CV diseases Richard, 2012
Evidence of cost-effectiveness of tobacco treatment 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 of intensive, face-to face, individual/group 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 specialist 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
The role of biochemical confirmation in tobacco treatment Biochemical validation is a CTTS core standard of care practice intervention Expired breath carbon monoxide (CO) assessment is t he “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
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
Conclusions • 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.
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