What does a tobacco treatment clinic do?

Most people who try to quit smoking do so on their own with little or no outside assistance. This doesn’t mean it’s the best way to do it. Nowadays most people also have access to a telephone quitline and over-the-counter nicotine replacement therapy. These treatment components have been proven to increase your chances of success. Some people are fortunate enough to live near a specialist face-to-face tobacco treatment service (e.g. there are such services in Minnesota, Massachusetts, New Jersey, Ohio and Mississippi), but many do not and may wonder about what kind of services are provided by a tobacco treatment clinic. So to give an idea of the kind of work carried out by such services, I’ve summarized below the work carried out at the service I work at.

The Tobacco Dependence Clinic, part of the Tobacco Dependence Program (TDP) at the University of Medicine and Dentistry of New Jersey (UMDNJ)-School of Public Health, opened in January 2001 to provide specialist assessment and treatment for people who want help with tobacco dependence. A multidisciplinary team of specialists in tobacco dependence treatment, including psychologists, clinical social workers, and physicians, work closely with other staff and faculty to provide tobacco dependence treatment based on the evidence-based assessment and treatment procedures outlined in the US Public Health Service Clinical Practice Guideline on Treating Tobacco Use and Dependence (1) and the New Jersey Guidelines for Tobacco Dependence Treatment (2). The clinical staff is also involved in training and consulting to the network of tobacco dependence treatment clinics throughout New Jersey, known as New Jersey Quitcenters, and to other providers of tobacco treatment. Furthermore, the Clinic is involved with several ongoing projects that target special populations, including Latinos, young smokers, medically-ill smokers, and smokers with co-occurring mental health and/or addiction problems.

All patients receive a comprehensive individual assessment, with core information from that assessment being coded into a database. Around 95% of patients assessed select a Target Quit Date (TQD), and these patients are then followed up either in person or by telephone 4 weeks and 6 months after their initial TQD. At the end of the assessment a treatment plan is developed that includes a recommendation on medications and whether or not the patient will attend group or individual appointments or both.

More than half of the patients who attend beyond the assessment are treated in group. The most common group model used is a closed 6 (weekly) session group format, with the group’s quit day on the second session. Patients attending group have significantly better outcomes than those only attending individual treatment, even after controlling for baseline characterisitics3. The clinic provides on-site tobacco treatment groups at local employers (including Pfizer Corp, Firmenich, Clinphone, and Rutgers University) which have proven very successful (http://www.tobaccoclinic.org/ ). An open (daytime) group for people with disabilities (primarily serious mental illness), and an open weekly relapse prevention group (in the evening) are also provided. In addition to counseling, over 90% of our patients use tobacco treatment medication and of these most use more than one form of pharmacotherapy. Initial quit rates appear to relate to how many medications patients use4. Overall, around 45% of patients report abstinence (no tobacco use in previous week) at one month follow-up and 31% are abstinent at 6 month follow-up (3). These data count all patients lost to follow-up (30-40%) as continuing smokers.

The treatment philosophy at the Tobacco Dependence Clinic is that tobacco dependence is a life threatening chronic illness that warrants as intensive a treatment for as long a period as is required to enable the patient to quit and stay quit. Patients are advised to continue on the full prescribed medication dose until they have experienced 14 consecutive days without any cravings, withdrawal symptoms or near lapses. Over a quarter of patients followed up at 6 months are still using medication (4). Interestingly, around 20% of new patients are now smokers who have attended the Clinic in a previous year. These repeat patients tend to be more dependent and more have a history of mental health treatment, but they have reasonable six-month quit rates on repeat treatment (23%, 22% and 20% at first, 2nd and 3rd treatment episode) (5). When including repeat treatment episodes, the proportion of patients who achieve abstinence at 6 months follow-up is 33%. (5) Other notable findings are (a) African American (AA) and Latino smokers of regular cigarettes have the same quit rates as whites, but AAs and Latinos who smoke menthols have about half the quit rate, even after controlling for other predictors of outcome (3,6) and (b) 50% of patients awaken to smoke at night and this is predictive of poor treatment outcome (7).

In January, 2007 the TDP opened a new clinic in Newark, New Jersey, and by December 2007 over 3500 patients have been treated at the Clinics, which aim to treat over 500 new patients per year. Both clinics are fully integrated into the local healthcare systems, receiving referrals from community providers and hospitals via a Fax-to-Quit system, as well as linkages with the University and Hospitals’ electronic medical records system. The New Brunswick clinic serves Middlesex and adjacent New Jersey counties, and more than twice as many Middlesex county residents attend the clinic for tobacco treatment than engage in counseling on New Jersey’s excellent free Quitline (8). Also, with support from a grant from the Robert Wood Johnson Foundation, the proportion of Latino patients has increased from 3% in 2001 to 15% in 2006.

The major challenge faced by the clinics is in the area of billing and reimbursement from health insurance. 53% of the patients have private health insurance, 13% Medicaid, 12% Medicare and 22% have no health insurance. Even for those with private health insurance most plans do not cover the counseling provided by the clinic and in many cases medications (e.g. NRT, Zyban, or Chantix) are not covered either. Lack of systematic and comprehensive insurance coverage for high quality tobacco dependence treatment is a major barrier to helping smokers quit.

The success of the Tobacco Dependence Clinic at UMDNJ-School of Public Health shows that there is a demand for high quality tobacco dependence treatment among smokers, even in a state that already provides free high-quality telephone and internet support for smoking cessation. The smoking cessation outcomes show that quit-rates comparable to or greater than those achieved in research studies can be achieved by a clinical service implementing the Guideline on Treating Tobacco Use and Dependence (1). Full details of all patient characteristics and outcomes are provided in Clinic Annual Reports (9) . Further details of this work and publications can be found at www.tobaccoprogram.org .


Acknowledgements:
The clinic is part of the Tobacco Dependence Program at UMDNJ-School of Public Health which is funded by New Jersey Department of Health and Senior Services, as part of New Jersey’s Comprehensive Tobacco Control Program (NJ CTCP). The Tobacco Dependence Program also receives funding from NJ CTCP for youth cessation in schools, training health professionals, and community education and outreach. The TDP is also supported by grants from Robert Wood Johnson Foundation, Rutgers Community Health Foundation, and the Cancer Institute of New Jersey.

References.
pdfs of many of these are available at: http://www.tobaccoprogram.org/staffarticles.htm

1. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, MD US Department of Health and Human Services. Public Health Service 2000.
2. Slade J, Zeidonis D, Foulds J, Lindberg D and Order-Conners B. New Jersey Guidelines for Tobacco Dependence Treatment. New Jersey Department of Health and Senior Services, 2001. http://www.tobaccoprogram.org/pdf/njguidelines.pdf
3. Foulds J, Gandhi KK, Steinberg MB, Richardson D, Williams J, Burke M, Rhoads GG. Factors associated with quitting smoking at a tobacco dependence treatment clinic. American Journal of Health Behavior 2006; 30:400-412
4. Steinberg MB, Foulds J, Richardson DL, Burke MV, Shah P. Pharmacotherapy and smoking cessation at a tobacco dependence clinic. Preventive Medicine 2006; 42:114-119.
5. Han ES, Foulds J, Steinberg MB, Gandhi KK, West B, Richardson D, Zelenetz S, Dasika J. Characteristics and smoking cessation outcomes of patients returning for repeat tobacco dependence treatment. International Journal of Clinical Practice 2006 September; 60(9): 1068-1074.
6. Gandhi KK, Foulds J, Steinberg MB, Lou SE, Williams J. Lower quit rates among menthol cigarette smokers at a tobacco treatment clinic. (Internal report submitted for publication).
7. Bover MT, Foulds J, Steinberg MB, Richardson D, Marcella SW. Waking at night to smoke as a marker for tobacco dependence: patient characteristics and relationship to treatment outcome. International Journal of Clinical Practice Feb 2008; 62(2): 182-190..
8. Foulds J, Steinberg MB, Williams JM, Ziedonis DM. Pharmacotherapy for tobacco dependence: past , present and future. Drug and Alcohol Review Jan 2006; 25:57-69
9. Tobacco Dependence Clinic Annual Reports available at: http://www.tobaccoprogram.org/clinic.htm

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Health insurance coverage for nicotine dependence treatment

Last night I went to see the Michael Moore movie “SiCKO” which is an expose of the problems with the U.S. healthcare system, focusing particularly on the problems with health insurance and so-called “Health Maintenance Organizations (HMOs)”. No matter what you think of Michael Moore, if you have any interest at all in your health or that of your family, and particularly if you have any interest in this nation’s health, then you should definitely see this movie.

The movie points out some of the worst aspects of the health insurance system and then compares it to the situation in countries like Canada, the UK, Cuba and France. As someone who has been both a patient and a provider in the UK and US healthcare systems I have to say I found the portrayal in the movie to be very accurate. The United States is a great country with tremendous wealth both financially and in terms of the resilience and hard work of its people. But to my mind its healthcare system is nothing short of a national disgrace. There are many areas of business in which the free market works best, but healthcare is just not one of them. A clear example of this is the existence of hundreds of doctors and other professionals employed by HMOs basically to devise reasons to deny coverage and save the company money. A number of ex HMO employees in the movie explained that they would receive bonuses based on the proportion of denials of care/coverage the achieved, setting up a bizarre situation where staff are given incentives to provide less care for sick patients.

I suspect that unless you or your family have never been sick, or you are fortunate to have good coverage through your employer, and not to have suffered from one of the numerous illnesses that are not covered, then you won’t need any further evidence from Michael Moore or myself to know that the U.S. system is entirely broken. But you may be living under the false impression that despite its problems, the U.S. system is better than most other comparable places. As the movie shows, citizens in many other (poorer) countries have access to high quality medical care 24-7 at no (or minimal) direct cost. Doctors are able to provide healthcare according to need rather than according to individual ability to pay. Moore’s portrayal is supported by cross-national surveys on the satisfaction of citizens with their health system, in which Canada and the European nations have consistently earned higher marks than has the U.S. system. Part of the problem is that U.S. healthcare is more expensive, it treats patients more intensively (overtreats?), and it is very inefficient. So the very things that a free market is supposed to be good at (achieving lower prices and higher efficiencies via competition) do not work for healthcare. Why is this? Well part of the problem (in my humble opinion) is that some rather dim-witted people have continued to base their design of the system on ideology rather than a careful but common-sense analysis of how healthcare actually works. Take the example of a medium-sized city, - say 100,000 adults with another 100,000 in a 50-mile radius. Such a city will typically have one medium sized hospital, and just about enough medical personnel to cover most (but maybe not all) specialties. The idea of letting the market compete for best value healthcare in that (fairly typical) city is clearly ridiculous. The provider has a monopoly. In some places the health insurance company may also have a virtual monopoly. Add to the mix you as an individual developing a life-threatening illness and you really do not have a situation in which the free market system is likely to work well. So you don’t have many of the most important potential advantages of a market-based system, but you do have the disadvantages of businesses (including the doctors, hospitals, insurance companies etc) seeking to maximize profit. In the end it’s the patient that suffers.

In addition to the disadvantages of the U.S. system described above and shown in the movie, to me there is one very basic thing about the psychology of illness that makes this system bad. If ever there was a time in your life that you really don’t want to have financial worries, it’s when you or a loved one is sick. The system we have in the United States is designed to maximize financial stress whenever we get sick. Everyone in this country, except perhaps the very rich, has to live with the concern that if we are unlucky enough to get a serious illness that is expensive to treat, then everything we have built for our family is at risk, not just because of the illness but because of the cost of getting it treated. In most other comparable countries of the world, the people just have to worry about the illness, not the cost of treating it.

As you may have gathered, this is one of those topics (like global warming) that is much bigger and more important than my specific area of interest: tobacco and health. But I see on a daily basis how the U.S. system does not work well with smoking cessation. Counseling smokers and providing them with an effective smoking cessation medicine is one of the most cost-effective healthcare interventions available. But most healthcare providers cannot get paid by the insurance systems for providing such interventions and most patients cannot get the costs of their treatment covered by their insurance. If you are lucky, your health insurance will pay for your coronary artery bypass operation caused by your smoking, or for your operation and chemotherapy to treat your lung cancer. Most likely this could all have been avoided if your insurance had covered your smoking cessation treatment(s) in the first place. Instead your insurer is employing staff whose job it is to think up ways to deny you coverage: “we don’t cover over-the-counter treatments like the patch”, “we don’t cover preventive interventions”, “you have $200 per year for preventive care, but having your blood pressure measured at your last visit used that up”, “there are no tobacco treatment specialists in our network”, “your policy has a $500 deductible for preventive or behavioral interventions and smoking cessation is valued at $499”, “we don’t have a diagnosis or procedure code for smoking cessation” etc etc…” but we CAN send you a leaflet that tells you how bad smoking is for your health”!

So I’d recommend that you check out the movie and let me know what you think. If you managed to get help to quit smoking provided or paid by your health insurance, I’d love to hear about it. It’s always nice to hear about the times/places where the system works well. When you are considering who to vote for in the forthcoming elections, please check out the detail of their policy on health insurance, and also find out how big a contribution they accepted from (a) Big Pharma (b) Big Managed Care and (c) Big Tobacco. By doing that and voting for candidates who appear likely to do the best job on healthcare, we might get some much-needed change.

Labels: cessation, health-insurance, HMO, michael moore, nicotine addiction cigarette smoking tobacco, sicko, treatment

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