2009 NAQC Seminar Series
Sustaining Quitlines Now and in the Future: Topics to Build the Case
“Cessation Medications and Quitlines: Current Practice and the Evidence Base”
Seminar Summary
Chantix: Successes and Challenges in South Dakota
Jim McCord, Project Director, SD Tobacco Control Program
After a brief introduction to South Dakota’s tobacco program in general and the history of their quitline, the medications offered to quitline participants was described. The South Dakota quitline offers up to 8 weeks of the patch or gum to South Dakota residents who enroll in the program (“no counseling, no meds”). The participant receives a letter explaining how to pick up the NRT at a local participating pharmacy that also includes a member ID number. These participants are able to pick up 2 weeks of NRT at a time and their coach approves the NRT in 2 week increments.
South Dakota residents are also eligible for up to 12 weeks of Zyban and Chantix. Once enrolled in the program the participant goes to their healthcare provider and that provider determines if the medication is safe and appropriate. The provider then faxes a quitline prescription form to the South Dakota Central Pharmacy (a separate vendor from service provider). The quitline coach sends the Central Pharmacy notification of completion of the first, third and fifth coaching sessions in order for the participant to receive the medication. The medication is sent directly to the participant’s home address.
While still too early to report quit rates, South Dakota is seeing an increase in quit rates and an increase in reach since offering Chantix to callers. Challenges with offering Chantix seem to be mostly administrative including:
The provider sends the script to the pharmacy but client never calls the quitline to initiate cessation coaching.
Scripts are signed but incomplete, illegible or wrong medication amount prescribed.
Scripts are faxed to a local pharmacy rather than the central pharmacy.
Lack of follow through from provider (no fax sent).
Successes with the Chantix program include:
The prescription medications are mailed directly to participant’s home which alleviates barrier for those in rural areas.
Central pharmacy tracks amount of medication received by participant so as not to exceed 3-month supply.
Physician referrals increased to 44% of all quitline callers.
Quit Rates have significantly improved.
Chantix: Successes and Challenges in Arizona
Gowri Shetty, Research and Evaluation Director
Arizona Department of Health Services
Since 2003 the Arizona Smokers Helpline has offered some sort of NRT benefit. In 2006 they offered a 50% discount on NRT and medications like Zyban. Soon after an NRT workgroup was formed to address issues related to NRT and NRT+ (includes medications like Zyban, Welbutrin and Chantix) coverage. Based on recommendations of this workgroup, a pilot program in which all clients received 12 weeks of free NRT or NRT+ started in March 2008. The pilot was implemented for all clients enrolling in cessation services for the months of March and April.
The pilot was funded through the portion of the Arizonastate tobacco tax received by the state tobacco program. The estimated billing between March 1 and April 30 was between $200-250,000.
The purpose of the pilot was to assess the impact of offering 12 week free NRT and NRT+ on quitline service utilization and cessation outcomes. Specifically the program looked at:
–How effective is offering free medication in motivating people to call the quitline?
–Do free medications impact someone’s ability to quit for at least 7 days, 30 days or more? Does this vary by type of NRT/medication?
–Do people value the behavioral support offered through the quitline, and is there a difference if they do?
Evaluators compared quitline utilization for months before, during and after the pilot program and followed up with all clients enrolled during the pilot phase at 4 months to assess their smoking status. Up to ten attempts were made to contact eligible callers.
83.2% of callers during the pilot phase enrolled in the free NRT program and 80% of these callers said the offer of free quit medication was important in their decision to quit tobacco. Over 75% of those enrolled said that the offer of coaching was important in their decision to quit and over 55% said that the coaching was important in their efforts to quit. The pilot also showed very positive quit rates for those who received Chantix (see slides).
Online Registration for NRT: The New York Experience
Paula Celestino
Coordinator, NYS Smokers’ Quitline, Roswell Park Cancer Institute
The primary purpose of the online registration for NRT is to extend the reach of services. During high call volume periods clients are directed to the web, web registration is available 24/7 and the web tends to capture a different demographic than the phone.
Online NRT became available in July of 2006. Clients complete a web-based survey to determine eligibility and an in-house fulfillment service processes these orders. Online orders have grown every year since 2006.
?
In 2008, the New York State Smokers’ Quitlineprovided free NRT kits (2 weeks of free NRT) and counseled 67,189 new clients over the phone and provided freeNRT kits to 57,845 new clients through on-lineregistration ( 46% of new clients access Quitline services through online NRT registration while 54% of
new clients access NRT & services via thephone.
Gender:
There is a slight increase of male utilization of online NRT registration (48%) compared to phone (46%).
Education Level:
Online clients tend to have higher education levels withthe majority (60%) having some college or were college graduates while the majority of phone clients (54%) are high school graduates or lower.
Age:
Online clients are younger with the majority (28%) between 25 and 34 years old and the majority (26%) of phoneclients are between the ages of 45 and 54 years old.
Race:
The majority of online clients (85%) were white compared to 66% of phone clients.
Insurance Status:
61% of online clients were privately insured compared to 42% of phone clients. Those who are uninsured or have Medicaid are more likely to call the quitline.
Amount of Cigarettes Smoked per Day:
Online clients tend to be lighter smokers, with 83.2%smoking less than 30 cigarettes a day compared to73.8% of phone clients.
Clients are tracked during the web session and are not allowed to apply again for at least 30 minutes after final web contact. This helpsto avoid people to apply using trial and errortechniques to beat the process.Qualified clients are compared against the quitline client database using several fieldsfor duplication or previous NRT awardsbefore they are considered eligible to receive NRT.
What NY has learned:
- Online ordering increases coincides with
increases in call volume.
- Email prompts generate increase in orders.
- Yields higher number of false email and phone number
information.
- Online clients are harder to reach via callback
than phone clients.
Advantages to offering online NRT registration:
- Increases access.
- Increases capacity to provide service.
- Attracts smokers who may not access
phone services.
- Can help alleviate phone congestion.
There are several important things to consider before implementing an online NRT registration program including the cost for increased NRT, fulfillment costs, the need for skilled staff and safety nets for distribution.
Currently NY is further analyzing historical data such as website registration and all phone sessions in order to:
- Identify patterns of utilization of quitline services and cessation attempts by both online and phone clients.
- Compare online and phone clients by looking at the frequency of contacts with the quitline and call center/web.
- Registration patterns based on the time-of-day and othercall center related factors (i.e. closed/open hours, highwait times, etc.).
- Investigate client cessation patterns with respect to their smoking history, utilization of NRT and access to additional quitline services.
Questions, Ideas & Concerns Noted from the Conference Call
What is the sequence for SD callers who want Chantix?
Theperson calls the quitline then goes to the doctor to get the script. The script is faxed to the central pharmacy and after the client starts counseling the first 2 weeks are shipped to their home.
When I look at 2005 to 2007 (SD PowerPoint last slide) it shows that quit rates are up and as you said, “no coaching, no meds.” Could this increase in quit rates be the result of a policy effect or is it a medication effect?
Coaching has always been a requirement to receive cessation medications in SD.
Any explanation for the increase?
Could be a little of both. Plus we did begin offering free Zyban in 2007 and expanded enrollment.
We have found in MN that there is a “Chantix effect” in increasing quit rates.
It is not surprising that you have higher quit rates with Chantix. I’m wondering why you are not using the generic name of the drug?
I guess we are using “Chantix” because that is all that is available and callers are familiar with that name.
We are just always conscious of not using a specific product name.
Is it available by generic name?
No it is not but this is a good reminder as I’m sure there will be additional brands available soon.
Back to NRT and local pharmacy participation in the voucher system. 164 pharmacies out of how many total are participating?
Not sure but it is likely the majority of pharmacies in SD.
If rural folks are having to go to the pharmacy for NRT but having Chantix mailed – why? This doesn’t alleviate the barrier for them.
It is the only way we could ensure that they were getting the coaching really.
When state quitlines provide a specific type of medication does it influence the way they talk to callers about cessation medications? If you offer a specific medication, do you mention that medication first? Can you comment on this? My question is whether quitlines that offer NRT only talk to callers aboutthe NRT that they provide and do not provide information related to all of the other cessation medications.
I can say for our program that we only talk about the medications that we provide via the quitline.
Where is the funding coming from for the SD Chantix program?
Our funding is a result of a state tax increase on tobacco.
Did you face any liability issues with the Chantix and coaches providing information on side effects?
No we did not.
Were you able to get a bulkdiscount for Chantix for the AZ pilot? Yes were were. I don’t know the specific price but there was a cost different between the NRT and Chantix. I will say that there was not a huge difference though between the lozenge and Chantix.
What can you tell us about compliance with Chantix use?
At follow up we matched with how much was shipped vs. how much used and the results were all over the map. Most people did not use the full 12 weeks. After the first 2 shipments there were very few shipments of Chantix.
How about patch and lozenge?
These clients used over 50% of what was shipped.
Results show a very small percentage of AZ callers are uninsured…is this typical?
No. We were surprised by this. Remember, there wasn’t any marketing going on at the time and so almost everyone who came in came in from health care fax referrals.
What were the mean number of counseling calls for callers receiving medication (AZ)?
We haven’t done those numbers yet but the protocol is 8 counseling calls.
Would you use a mail-order pharmacy again?
Yes, for the NRT portion we had not trouble. I would probably recommend not do it again for prescription medications.
What is your reach at now and have you computed impact of online services (NY)?
Reach in terms of number of smokers in NY – hard to answer – and includes new and recycled clients – we are close to 5% although that number comes and goes.
You mentioned individuals giving wrong phone numbers…have you considered online surveys to follow up with clients?
I would love to do this and it only makes sense to follow up with the same way they initially contacted you. Oddly enough if we send no-reach letters many clients typically reach out to contact us.
The NRT NY offers – is it primarily the patch?
Patch, gum or lozenge. When online they get 2-week starter kit. For uninsured and Medicaid callers, they may be eligible for 4 weeks of additional NRT. This requires a phone conversation though…
How many times can a person enroll?
Just once a year. In the past this policy was change to twice a year, but it is now back to just once a year.
Is the online program only in English?
No it is also available in Spanish.
How did Arizona promote the availability of NRT/Prescribed Meds and the quitline? What was the approach and why? What did it cost?
We did nothing new to promote the medication benefit. The benefit was incorporated into the current model of outreach. The focus was to encourage healthcare providers to make referrals to the program with the message that we are a tobacco cessation program that includes medication assistance. Primary message was never to include “free medication.”
Before piloting the service, what preparation was involved (i.e. negotiations, stakeholders, training, etc.)? What length of time and at what cost? (approximates are fine!)
A workgroup was established 8 months prior to the launch that included several stakeholders. The original time frame was three months, but due to contracting difficulties, the launch had to be postponed. Since most of the stakeholders were already funded by the Bureau of Tobacco Education and Prevention, the cost of travel to monthly meetings was the only increase. Most of the stakeholders used travel budgets already approved. An RFP for a medication distribution was used to identify the provider. The provider included all the costs of development of an ordering interface into their contract.
Did AZ use a new form for the healthcare referrals for the pilot? What did the “prescription form” look like and how did they distribute it to providers?
No new referral forms were developed. We did nothing in regards to prescribing. Pfizer chose to create a formulated script for physicians that was later pulled to due legal concerns. That script also created a great deal of confusion with the pharmacy and physicians. The fax referral forms were distributed by our usual method of getting them out to providers, plus Pfizer included them in their office visit packets for the two months of the pilot.
What type of legal challenges (eg, litigation concerns), if any, did your state have in launching online medications or prescription medications? Did you have to include additional screening mechanisms to gain approval?
AZ – Since the quitline was not directly prescribing medications, the legal concerns fell on the physicians that wrote the scripts. The NRT products are OTC and were not seen as a risk. The mail distribution company carries liability insurance to cover any issues related to product shipping mishaps.
NY – considering the costs, is an online registration program worth it?
Although we have not done a statistical cost analysis yet, the short answer is yes. With the online process we have been able to increase the number of clients we serve, which we would have not been able tosupport through the traditional phone method. Additionally, the increased number of clients served brings down the cost per client served through the quitline.