Comparison of Four Cessation Programs: What Works Best? For Whom?

1
Comparison of Four Cessation Programs What
Works Best?For Whom?
2
Comparison of Four Cessation ProgramsWhat Works
Best? For Whom?

• Presenters
• Ann H. Wendling, MD MPH
• Anne E. Betzner, MA
• Julie A. Rainey, BA
• Barbara A. Schillo, PhD
• Additional Contributors
• Michael G. Luxenberg, PhD
• Lawrence C. An, MD
• Annette Kavanaugh, MS
• Sharrilyn Evered, PhD

Acknowledgement of Collaborating
Vendors   Helpline Free Clear,
Inc.   Website QuitNet.com, Inc.   Treatment
Centers Affiliated Community Medical Center St.
Mary's Duluth Clinic Northwest Medical
Center     Work Sites Park Nicollet Institute
3
Learner Outcomes

• Understand key program components of MPAATs
  telephone helpline, website, treatment center,
  and workplace cessation programs.
• Understand cessation outcomes for each program in
  terms of the populations served and the degree to
  which clients utilized key services.
• Assess the effectiveness of four program types
  for their own populations, and have a standard of
  comparison for similar cessation programs.

4
Minnesota Partnership for Action Against Tobacco
(MPAAT)

• Established in 1998 as 501(c)3 as part of
  Minnesotas tobacco settlement
• Funded by Ramsey County District Court with 3 of
  settlement (202 million)
• MPAAT has awarded more than 20 million in
  program grants and contracts

5
How is Minnesota different from other states?

• MPAAT is not located within or funded by the
  State Department of Health
• MPAAT funds may not supplant benefits of other
  programs or health plans
• MPAAT maintains partnership with health plans to
  provide helpline service

6
MPAAT Resources
www.mpaat.org
7

• Cessation services provided by MPAAT
• QUITPLAN Helpline 1-888-354-PLAN
• quitplan.com
• QUITPLAN Centers
• QUITPLAN at Work
• QUITPLAN Community-tailored Programs

8
Helpline Goals

• Provide a multi-call proactive phone counseling
  program to uninsured or underinsured Minnesotans
• Connect Minnesotans who have access to telephone
  counseling to their health plans
• Create systems changes/sustainability

9
Uninsured and Underinsured

• Uninsured no insurance at all (not even state
  public programs)
• Underinsured insurance does not include tobacco
  cessation counseling and/or NRT

10
Health Plan Partners (7)

• Blue Cross Blue Shield of Minnesota
• HealthPartners
• Mayo Health Plan
• Medica
• Metropolitan Health Plan
• PreferredOne Community Health Plan
• UCare

11
Helpline Process
Paid media Targeted promotions Referrals
Calls to Helpline
MPAAT-funded phone number1-888-354-PLAN Is phone
counseling available through health
insurer? Yes No
Health plan helpline, possible NRT
MPAAT-funded phone counseling, possible NRT
12
Evolution of Helpline Services

• May 2001 - Began services
• Sept. 2002 - Initially provided NRT
• Allowed any Minnesotan to enroll with resulting
  duplication of services
• August 2003 - Changed scripting to improve triage
  and split NRT shipment

13
Evolution of Helpline Services

• June 2004 - Present
• Health plan systems changes initiated
• Began collecting health plan identification
  numbers
• Further adjusted scripting to triage clients

14
Helpline Volumes 2001-2005

• 34,970 calls requested some service
• 7,246 callers were triaged to health plans
• 16,306 enrolled in multi-call counseling
• 13,071 participants received nicotine patches or
  gum

15
Addressing Challenges

• Health plan members
• Copays, Rx requirements, deductibles
• Not all health plan members have NRT
• Self-report of NRT benefits

16
www.quitplan.com

• Provides interactive cessation advice and social
  support at all stages of readiness to quit
• Available to ALL Minnesotans, regardless of
  health plan coverage
• Over 11,000 Minnesotans have enrolled since
  August 2003
• No free NRT

17
QUITPLANSM Centers

• Provide face-to-face counseling services
• Located within existing health care facilities in
  the Twin Cities and greater Minnesota
• Health plans billed for services to members
• Focused on people making a quit attempt in the
  next 30 days
• NRT available to un- and underinsured

18
QUITPLANSM at Work

• Provide five session group counseling at
  worksites
• Provide service to at least 50 worksitesa year,
  five worksites in each region of the state, and
  multiple diverse sectors
• Employees ready to quit are eligible
• NRT available to un- and underinsured

19
Face-to-face Programs January 2004 Present

• QUITPLAN Centers
• Over 950 clients
• QUITPLAN at Work
• Over 650 clients
• Recent high demand post ordinance implementation

20
QUITPLAN Community-tailored Programs

• Culturally tailored cessation programs serving
  priority communities
• African-American
• Somali and Oromo
• Southeast Asian
• Chicano Latino
• GLBT
• Community participatory evaluation model

21
Numbers Served by QUITPLAN Programs
Helpline (4 years)
Website (18 months)
Centers (18 months)
Worksite (18 months)
(Community tailored programs are being evaluated
separately.)
22
Methodology
worksite
website
helpline
treatment center
23
Scope of the Evaluation

• Process
• Track services provided and to whom participant
  satisfaction
• Outcome evaluation
• Participant outcomes

24
Todays Presentation

• Who goes to each program?
• Demographics and tobacco use and quit history for
  each program
• Demographic user profiles or clusters
• Tobacco use and quit history user profiles or
  clusters

25
Todays Presentation

• Who goes to each program?
• Demographics and tobacco use and quit history for
  each program
• Demographic user profiles or clusters
• Tobacco use and quit history user profiles or
  clusters
• How effective is each program?
• For whom?

26
Evaluation Methods Intake

• Intake Form at Registration
• Demographic information, tobacco use and quit
  history, confidence quitting

27
Quit Survey Methodology

• Quit Survey administered 6 months after
  registration
• Tobacco use, pharmacotherapy use, utilization
• Telephone survey
• Dual methodology for Website

28
Consent Rates to Date

366/457
292/351
685/1139
296/301

• Helpline used a more passive, general consent
  process than the other interventions

29
Response Rates to Date
36.8 Phone
41.3 Online
257/366
230/292
535/685
219/296
30
Using MATS to Compare to Intervention Samples of
Smokers

• The Minnesota AdultTobacco Survey (MATS) used a
  sampleof 1,850 smokers.
• Survey data was collected collaboratively with
  MPAAT, Blue Cross Blue Shield of Minnesota, the
  Minnesota Department of Health, and the
  University of Minnesota.

Estimated 660,000 smokers in Minnesota
31
Who Uses the QUITPLAN Programs?
worksite
website
helpline
treatment center
32
Gender
Significantly different than MATS (p .05)
33
Mean Age
Significantly different than MATS (p .05)
34
Education
Significantly different than MATS (p .05)
35
Employment Status
Significantly different than MATS (p .05)
36
Insurance Status
Significantly different than MATS (p .05)
37
Are there demographic user profiles?

• K-Means Cluster analysis
• 6 groups emerged
• Determined by distance between and within
  clusters, meaningfulness of clusters, and
  parsimony
• All participants fall into one group only

38
Gen X - Gen Y

• 40 male
• Younger (18-40)
• Few college grads (15)
• All unemployed
• None married
• Highest rate of uninsured (1/3)
• Racially more diverse (12 nonwhite)

39
Ms. Executive

• All female
• 25 - 50 years old
• High proportion of college grads (59)
• All employed
• ½ married
• 90 white

40
Working Women

• All female
• 41 - 60 years old
• Almost no college grads (7)
• All employed
• ½ married
• 90 white

41
Hard Luck

• 36 men 64 women
• All 41 years old
• High proportion with HS or less ed (40)
• All unemployed
• ½ married
• More uninsured (¼)
• 90 white

42
Mr. Executive

• All male
• 31 - 60 years old
• High proportion of college grads (59)
• All employed
• 2/3 married
• 90 white

43
Blue Collar Workers

• Mostly male
• Broad age range (18-50)
• Lowest education of all groups (75 HS or less)
• All employed
• 1/3 married
• More uninsured (1/4)
• 90 white

44
Proportion of Participants in Each Demographic
Cluster
Demographic Clusters Gen X Gen Y Ms. Executive Working Women Hard Luck Mr. Executive Blue Collar Workers
of participants 11.9 22.3 18.7 16.0 17.3 13.8
Weighted so that each intervention is 25
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Who Uses the Helpline?
Demographic Clusters Helpline Gen X Gen Y Ms. Executive Working Women Hard Luck Mr. Executive Blue Collar Workers
of participants 18.2 9.5 14.2 34.8 7.4 15.9
46
Who Uses the Centers?
Demographic Clusters Centers Gen X Gen Y Ms. Executive Working Women Hard Luck Mr. Executive Blue Collar Workers
of participants 10.4 19.7 17.5 25.1 14.8 12.6
47
Who Uses QUITPLAN at Work?
Demographic Clusters Work Gen X Gen Y Ms. Executive Working Women Hard Luck Mr. Executive Blue Collar Workers
of participants 1.4 22.9 28.4 0.7 25.0 21.6
48
Who Uses the Website?
Demographic Clusters Web Gen X Gen Y Ms. Executive Working Women Hard Luck Mr. Executive Blue Collar Workers
of participants 14.5 29.1 17.1 9.5 19.6 10.4
49
Who Uses Each Program?

• Tobacco Use and Quit History

50
Time to First Cigarette
Significantly different than MATS (p .05)
51
Daily Smokers
Significantly different than MATS (p .05)
52
Smoking Intensity
Significantly different than MATS (p .05)
53
Quit Attempt in Last Year
Significantly different than MATS (p .05)
54
Ever Quit for a Year or More?
55
Are there tobacco use/quit history user
profiles?

• Six groups emerged
• Determined by distance between and within
  clusters, meaningfulness of clusters, and
  parsimony
• From lighter to heavier smokers

56
Lighter Smokers
Poised to Quit

• 1

2

• Light to moderate smokers (50/50)
• About ½ smoke daily
• About ½ highly addicted
• All recent quit for 30 days
• All 1-yr quit

• Light smokers (82)
• ½ are daily smokers (fewest of all clusters)
• Only 1/3 highly addicted
• All recent quit for 30 days
• None 1-yr quit

57
Lighter Smokers
Poised to Quit

• 1

2

• Light to moderate smokers (50/50)
• About ½ smoke daily
• About ½ highly addicted
• All recent quit for 30 days
• All 1-yr quit

• Light smokers (82)
• ½ smoke daily
• Only 1/3 highly addicted
• All recent quit for 30 days
• None 1-yr quit

58
Moderates

• Light to moderate smokers (50/30)
• Some heavy smokers (20)
• All daily smokers
• ¾ highly addicted
• None have recent quit
• All have 1-year quit

• 3

59
Rookie Quitters
Second Chance
4
5

• Moderate to heavy smokers (50/30)
• All smoke daily
• 85 highly addicted
• No recent quit
• No 1-year quit

• Moderate to heavy smokers (70/30)
• All smoke daily
• 90 highly addicted
• All recent quit, most lt30 days
• No 1-year quit

60
Rookie Quitters
Second Chance
4
5

• Moderate to heavy smokers (50/30)
• All smoke daily
• 85 highly addicted
• No recent quit
• No 1-year quit

• Moderate to heavy smokers (70/30)
• All smoke daily
• 90 highly addicted
• All recent quit, most lt30 days
• No 1-year quit

61
Heaviest

• Moderate to heavy (50/40)
• 80 daily smokers
• 93 highly addicted
• All recent quit, most for lt30 days
• Few 1-year quit

6
62
Proportion of Participants in Each Tobacco Use /
Quit History Cluster
Tobacco Use / Quit History Clusters 1 2 3 4 5 6
of participants 17.8 9.0 10.5 29.8 20.4 12.5
Lighter Smokers
Poised to Quit
Mod-erates
Rookie Quitters
Second Chance
Heaviest
Weighted so that each intervention is 25
63
Who Used the Helpline?
Tobacco Use / Quit History Clusters Helpline 1 2 3 4 5 6
of participants 13.1 7.6 12.8 23.8 27.9 14.8
Lighter Smokers
Poised to Quit
Mod-erates
Rookie Quitters
Second Chance
Heaviest
64
Who Used the Centers?
Tobacco Use / Quit History Clusters Centers 1 2 3 4 5 6
of participants 11.2 7.7 15.6 35.5 19.1 10.9
Lighter Smokers
Poised to Quit
Mod-erates
Rookie Quitters
Second Chance
Heaviest
65
Who Used QUITPLAN at Work?
Tobacco Use / Quit History Clusters Work 1 2 3 4 5 6
of participants 15.1 10.3 15.4 33.6 16.1 9.6
Lighter Smokers
Poised to Quit
Mod-erates
Rookie Quitters
Second Chance
Heaviest
66
Who Used the Website?
Tobacco Use / Quit History Clusters Web 1 2 3 4 5 6
of participants 24.4 9.8 4.8 27.7 19.7 13.6
Lighter Smokers
Poised to Quit
Mod-erates
Rookie Quitters
Second Chance
Heaviest Smokers
67
Programs Serve Different Tobacco / Quit Groups
Tobacco Use / Quit History Clusters 1 2 3 4 5 6
Helpline
Centers
Work
Web
Lighter Smokers
Poised to Quit
Mod-erates
Rookie Quitters
Second Chance
Heaviest
68
Summary

• QUITPLAN participants can be described by
  clusters based on demographics and tobacco use.
• QUITPLAN programs serve demographic and tobacco
  use groups that differ in important ways.

69
Summary
The Helpline serves the Hard Luck demographic
group and the Second Chance tobacco use group
most frequently.

• The Centers serve the Hard Luck demographic group
  and the Rookie Quitter tobacco use group most
  frequently.

70
Summary
QUITPLAN at Work serves all employed demographic
groups and the Rookie Quitter tobacco use group
most frequently

• The Website serves Ms. Executive and Rookie
  Quitters most frequently.

71
Results at Six Months

• How effective is each cessation program?

72
Desired Outcomes at Six Months

• Quit attempt of at least 24 hours
• 7-day point prevalence
• 30-day point prevalence

73
Cautions in Interpreting Results

• Evaluation, not a clinical trial
• Participants not randomly assigned
• No comparison or control group
• Observations of what occurred in these real-life
  programs
• Caution in generalizing results to other
  populations

74
Calculating Quit Rates

• Artificially high quit rate
• Quitters / Respondents Quit rate
• Intention to treat rate
• Quitters / (Respondents Nonrespondents)
• ITT Rate

75
The majority of participants successfully quit
for at least 24 hours
24-Hour Abstinence during Past Six Months for
Each Program (Intent to Treat Rate)
76
Used No Tobacco in Past 7 Days
 
7 Day Point Prevalence at Six Months,
Intent-to-Treat Rates
77
Used No Tobacco in Past 30 Days
 
                                           
 

30-Day Point Prevalence at Six Months,
Intent-to-Treat Rates
78

• Which programs work best for whom?
• Is there a relationship between cessation and

• Tobacco use/quit history
• Demographics
• Program utilization
• Pharmacotherapy use

79
Tobacco Use/Quit History
Do people with different tobacco use patterns
quit at different rates at each of the programs?
80
Helpline produces high quit rates for a variety
of smoking types, from light to heavy, with and
without a quit history. Participants in the
heaviest use group do not fare as well.
Lightest Poised to Quit Mod Rookie quitters Second chance Heaviest
28.9 40.9 43.2 26.1 21.0 14.0
7-Day Abstinence Rates (ITT) at Six Months for
Each Cluster
81
Helpline produces high quit rates for a variety
of smoking types, from light to heavy, with and
without a quit history. Helpline users in the
heaviest use group do not fare as well.
Lightest Light -Mod Mod Rookie quitters Second chance Heaviest
28.9 40.9 43.2 26.1 21.0 14.0
Includes 50 of all Helpline participants
7-Day Abstinence Rates (ITT) at Six Months for
Each Cluster
82
Centers show the highest quit rates in the light
and moderate tobacco use clusters.
Lightest Light-Mod Mod Rookie quitters Second chance Heaviest
34.1 35.7 29.8 18.5 18.6 7.5
7-Day Abstinence Rates (ITT) at Six Months for
Each Cluster
83
Centers show the highest quit rates in the light
and moderate tobacco use clusters.
Lightest Light-Mod Mod Rookie quitters Second chance Heaviest
34.1 35.7 29.8 18.5 18.6 7.5
1/3 of all Center participants fall within these
clusters.
1/3 of Center participants are rookie quitters
7-Day Abstinence Rates (ITT) at Six Months for
Each Cluster
84
Work program shows strong results with three
clusters, one light, one moderate and the
heaviest group.
Social smokers Light-Mod Mod Rookie quitters Second chance Heaviest
18.2 26.7 31.1 12.2 10.6 25.0
7-Day Abstinence Rates (ITT) at Six Months for
Each Cluster
85
Work program shows strong results with three
clusters, one light, one moderate and the
heaviest group.
Social smokers Light-Mod Mod Rookie quitters Second chance Heaviest
18.2 26.7 31.1 12.2 10.6 25.0
Only 10 of Work participants are the heaviest
users.
Rookie quitters are the largest cluster (1/3 of
all Work participants)
7-Day Abstinence Rates (ITT) at Six Months for
Each Cluster
86
Website participants did not have statistically
significant differences in the quit rates of
tobacco use groups. Quit rates ranged from 10
to 22.
87
Programs have success with different tobacco use
groups.
Social smokers Light-Mod Mod Rookie quitters Second chance Heaviest
Helpline
Centers
Work
Web NS
Quit rates 30 or higher
Quit rates20 - 29.9
88
Demographics
Do different demographic groups quit at
different rates at each of the programs?
89
Demographic Clusters
Centers highest rates are seen in the demographic
clusters with older age groups.
Gen X Gen Y Ms. Executive Working Women Hard Luck Mr. Executive Blue Collar Workers
5.3 19.4 28.1 20.7 33.3 21.7
7-Day Abstinence Rates (ITT) at Six Months for
Each Cluster
90
Demographic Clusters
Centers highest rates are seen in the demographic
clusters with older age groups.
Gen X Gen Y Ms. Executive Working Women Hard Luck Mr. Executive Blue Collar Workers
5.3 19.4 28.1 20.7 33.3 21.7
10
20
70 of all Center participants
7-Day Abstinence Rates (ITT) at Six Months for
Each Cluster
91
Helpline, Work and Website
These QUITPLAN programs did not have significant
differences in quit rates for different
demographic clusters. The conclusion is that
the programs have about equal success with all
demographic groups. However, the smoking and
quit history clusters have varying levels of
success, depending on the program.
92
Utilization
How do participants make use of available program
services? How is level of use related to
cessation at each of the programs?
93
Programs have mixed patterns of utilization
94
Participants Using More Program Services Have
Higher Quit Rates
p lt .05
95
Pharmacotherapy Use
How is pharmacotherapy used by QUITPLAN
participants? How is use of medications related
to cessation?
96
Used Meds to Help Quit?

• Vast majority of Helpline and Center participants
  used meds
• Over half of QUITPLAN at Work and quitplan.com
  did

Includes use of one or more medication
Zyban/Wellbutrin/buproprion, nicotine patch, gum,
inhaler, lozenge or nasal spray.
97
Type of Medications Used
98
Pharmacotherapy Users have Higher Quit Rates
99
Tobacco Use Clusters
NRT Alone Is Helpful for all except the heaviest
users.
NRT Use? Social Smokers Light-Mod Moderates Rookie Quitters Second Chance Heaviest
No 25.0 22.6 26.1 11.5 12.5 20.4
Yes 37.5 43.1 45.2 29.0 24.4 19.6
Diff. 12.5 20.5 19.1 17.5 11.9 -0.8
7-Day Abstinence Rates (respondents only) at Six
Months for Each Cluster
100
Demographic Clusters
NRT Use is helpful to all demographic groups,
especially Hard Luck group.
NRT Use? Gen X Gen Y Ms. Executive Working Women Hard Luck Mr. Executive Blue Collar Workers
No 18.5 19.5 18.5 9.6 16.1 22.9
Yes 26.4 27.0 32.0 37.2 34.8 27.5
Diff. 7.9 7.5 13.5 27.6 18.7 4.6
! ! !
7-Day Abstinence Rates (respondents only) at Six
Months for Each Cluster
101
Putting it all together.. What is the unique
contribution of each of these factors to
cessation?
Demographic profiles
Tobacco use profiles
Confidence in successful quit
Program type
Utilization
Pharmacotherapy use
102
Logistic Regression Results
Demographic profiles Not significant Tobacc
o use profiles Moderates 1.7 times and
Light-Moderates 1.4 times more likely to quit
Heaviest 1.7 times more likely to be
smoking Confidence in Those with highest
confidence are 2.2 times successful quit more
likely to quit Program type Not
significant Utilization High utilization 2.6
times more likely to quit Medium utilization
1.9 times more likely to quit Pharmacotherapy
use NRT users 1.8 times more likely to quit
than non-usersZyban users 1.4 more likely than
non-users
103
Summary of Results

• All four QUITPLAN programs are effective at
  helping participants quit tobacco.
• Tobacco use profiles The four programs have
  differing levels of success depending on tobacco
  use profiles.
• Demographic profiles For Centers, quit rates are
  high for all groups except Gen X Gen Y. In all
  other programs, quit rates for demographic groups
  do not differ.
• Participants who use more of the available
  program services are more likely to quit.

104
Summary of Results

• Participants who use medications are more likely
  to quit.
• NRT has a differential benefit depending on the
  demographic profile (all groups benefit from NRT
  especially the Hard Luck group)
• NRT is beneficial for all tobacco use profiles
  except the heaviest smokers.
• Tobacco/Quit history, Confidence, Utilization
  and Pharmacotherapy contribute to cessation
  holding all other variables constant.

105
Why conduct a synthesis evaluation?

• MPAAT invests significant resources in cessation
  services
• These is a need to synthesize
• Answer overall questions about the initiative
• Answer common questions asked about each
  individual intervention
• This allows MPAAT
• Conduct continuous quality improvement of each
  program
• Assess overall return on investment
• Make information decisions about future resource
  allocation

106
Why conduct a synthesis evaluation?

• Allows MPAAT to assess the degree to which the
  services delivered meet cessation goals
• Ensure assistance to all tobacco users in
  Minnesota
• Provide a full range of evidence-based cessation
  services
• Ensure access to counseling and NRT without
  regard to ability to pay
• Reach populations and communities with the
  highest tobacco use rates and poor access to
  health care

107
Limitations in Using Synthesis Evaluation Results

• Limits in comparing services
• Each component delivers cessation counseling
  differently (face to face or remotely, and by
  group or individual)
• These methods vary in intensity for the
  participants
• Findings do not equate to results from clinical
  trials
• Self selection of services and intensity of use
• Real world, real services, real time

108
What do we know about the initiative based on the
synthesis evaluation?

• Who is using MPAATs intervention services?
• We are serving a wide range of Minnesota tobacco
  users
• Each demographic and clinical cluster is
  well-served by one or more program
• Collectively across programs, we are serving MN
  tobacco users
• How are they using these services?
• Participants are using the services with varying
  levels of intensity

109
What do we know about the initiative based on the
synthesis evaluation?

• How effective are our services?
• Using QUITPLAN services increases the chance of a
  successful quit
• Need to examine why the four programs have
  differing levels of success depending on tobacco
  use profiles
• Participants using more program services have
  higher quit rates
• Need to examine ways to increase program
  intensity
• Pharmacotherapy users have higher quit rates
• Need to examine ways to further reduce barriers
  to NRT
• Need to consider where targeting resources to
  make NRT more accessible will have the greatest
  impact

110
What do we know about each individual evaluation
based on the synthesis evaluation?

• Helpline
• Serves the greatest number of demographic and
  clinical clusters
• Good reach - over 16,000 served in 4 year period
  
• Highest quit rates
• Website
• Serves younger, lighter smokers
• Highest reach over 11,000 served in 18 month
  period
• Quit rates lower but still effective

111
What do we know about each individual evaluation
based on the synthesis evaluation?

• Treatment Centers
• Appeals to heavier smokers broad reach across
  the demographic clusters
• Relatively fewer served
• Quit rates high
• Worksites
• Though numbers are few, serves well the heaviest
  smokers
• Overall, higher level of intensity of use of
  services
• Relatively fewer served
• Quit rates high

112
Future Directions

• Interpret findings as they relate to program
  goals
• Refine services expand where necessary
• Continue to evaluate and assess resource
  allocations
• Conduct additional research to enhance the use of
  services and improve outcomes
• Enhance utilization rates
• Increase access to and use of NRT

113
For Additional Information

• Dr. Ann Wendling
• MPAAT
• 952-767-1411
• awendling_at_mpaat.org