H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment

2. Tobacco Prevention And Treatment: States Putting It All Together H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration U.S. Department of Health & Human Services SAMHSA’s Inaugural State Policy Academy on Tobacco Control in Behavioral Health Rockville, MD  June 20, 2014

3. Policy Academy: Looking Forward States are at the forefront of tobacco cessation efforts, and are essential hubs for public health efforts in their own communities and in communities across the U.S. Your participation today builds on state successes over the last several decades, which have greatly reduced tobacco use in this country; but the most challenging reductions remain, especially for vulnerable, high risk populations such as those suffering from MH/SUDs, young adults, the unemployed, homeless, uninsured, underinsured, and many minority communities.

4. States Putting It All Together Closing Thoughts • Affordable Care Act • Synar • SAMHSA Snapshot

5. The Affordable Care Act: Tobacco Screening and Cessation States play a pivotal role in ensuring that ACA tobacco measures are enacted and enforced: Requires private insurance plans to cover tobacco cessation treatments, including medications that help people quit smoking Provides Medicare beneficiaries with an annual wellness visit that includes referrals for tobacco cessation services Expands smoking cessation coverage for pregnant women who receive Medicaid

6. Marketplace Plans: Tobacco Use Screening and Tobacco Cessation Interventions* * Benefits for all adults; expanded counseling for pregnant women. https://www.healthcare.gov/what-are-my-preventive-care-benefits/

7. States Determine: Medicaid Policies for Tobacco Use Screening, Prevention, and Treatment CDC MMWR March 28, 2014 • Medicaid enrollees have a higher smoking prevalence than the general population (30.1% of adult Medicaid enrollees aged <65 years smoke, compared with 18.1% of U.S. adults of all ages), and smoking-related disease is a major contributor to increasing Medicaid costs. • Evidence indicates that states could reduce smoking-related morbidity and health-care costs among Medicaid enrollees by providing coverage for allEB-cessation treatments; removing all barriers to accessing these treatments; promoting coverage; and monitoring its use

8. State Medicaid Policies: ALA 2014 Analysis CDC MMWR March 28, 2014 • The American Lung Association evaluated coverage of all EB-cessation treatments (except telephone counseling) by state Medicaid programs (9 treatments), as well as data on barriers to accessing these treatments (e.g., charging copayments or limiting the number of covered quit attempts) from December 31, 2008, to January 31, 2014. • All 50 states and the District of Columbia covered some cessation treatments for at least some Medicaid enrollees, but only 7 states cover all nine treatments for all enrollees.

9. State Medicaid Policies: Improving Outcomes, Reducing Costs • Common barriers cited in 2014 include duration limits (40 states for at least some populations or plans); annual limits (37 states); prior authorization requirements (36 states); and copayments (35 states). • Comparing 2008 with 2014, 33 states added treatments to coverage, but 22 states removed treatments from coverage; and while 26 states removed barriers to accessing treatments, 29 states added new barriers. • States could benefit their communities by better aligning their Medicaid guidelines with comprehensive, evidence-based prevention & cessation interventions. CDC MMWR March 28, 2014

10. Status of State Medicaid Expansion Decisions, March 2014 Medicaid Expansion & Tobacco Cessation ME VT WA NH* MT ND MN OR MA NY WI* SD ID MI* RI CT WY PA* NJ IA* NE OH DE IN* IL NV MD CO UT WV VA CA DC KS MO KY NC TN AZ SC OK AR* NM GA AL MS AK LA TX FL HI Implementing Expansion in 2014 (27 States including DC) Not Moving Forward at this Time (19 States) Open Debate (5 States)

11. States, Synar, and Youth: Upstream Opportunities • Nearly all tobacco use begins during youth and young adulthood. • Among adults who have ever smoked daily, 88 % report that they first smoked by the age of 18, with 99% reporting that they first smoked by the age of 26. • Furthermore, more than one-third (36.7%) of adults who have ever smoked, report trying their first cigarette by the age of 14 (USDHHS, 2012). • These data suggest that if youth are prevented from smoking while they are young, they will be unlikely to begin smoking as adults. http://beta.samhsa.gov/sites/default/files/2012-annual-synar-report.pdf

12. SAMHSA & Synar SAMHSA’s Synar Program Works to Reduce Youth Access to Tobacco As a condition of receipt of their full Substance Abuse Prevention and Treatment Block Grant awards, the Synar amendment requires the 50 states, DC, and 8 U.S. territories to enact and enforce state laws prohibiting tobacco sales to youth

13. Synar FFY 2012 Report: State Progress and Progress Still to Come • FFY 2012 is the seventh year in Synar history where every state was found in compliance with the Synar requirements. • The number of states reporting RVRs below 10% (34 states) remained consistent between FFYs 2011 and 2012. • However, the number of states reporting RVRs below five% decreased from 12 in FFY 2011 to nine in FFY 2012. • National weighted average rate of tobacco sales to minors as reported by states and the District of Columbia was 9.1%. • While this rate is the second lowest retailer violation rate (RVR) in the history of the Synar program, it represents an increase from FFY 2011 (8.5%) http://beta.samhsa.gov/sites/default/files/2012-annual-synar-report.pdf

14. Snapshot of SAMHSA’s Tobacco Initiatives: Past, Present, & Future 100 Pioneers (SCLC collaboration) Leadership Academies for Wellness and Smoking Cessation (SCLC collaboration) State Policy Academy on Tobacco Control in Behavioral Health (SCLC collaboration) SABG Tobacco Cessation in Opioid Treatment Programs Other Discretionary Programs & Special Initiatives

15. SAMHSA’s Multi-Pronged Approach to Tobacco Prevention, Screening, and Treatment includes… SAMHSA/HRSA Center for Integrated Health Solutions: Developing resources to expand the use of tobacco cessation activities among SAMHSA’s Primary and Behavioral Health Care Integration grantees. Screening, Brief Intervention and Referral to Treatment (SBIRT): SAMHSA has integrated screening and intervention for tobacco use among their SBIRT grantees. TIP 42: Substance Abuse Treatment for Persons with Co-occurring Disorders: Addresses nicotine dependence.

16. SAMHSA’s Safe Schools/Healthy Students • Grantees required to develop local strategic plans that address five required elements across the three sectors including tobacco, alcohol, and other drug prevention activities: • Implement an enhanced, coordinated, and comprehensive plan of activities, programs, and services to promote healthy childhood development, prevent violence, and prevent alcohol and drug abuse. • Grantees have developed organizational, informational, and programmatic systems that bring together many diverse sectors of the community, creating the capacity for comprehensive system reform so all agencies concerned with the welfare of children and families could collaborate on an ongoing basis

17. IAA Between SAMHSA & FDA • SAMHSA and FDA’s Center for Tobacco Products interagency agreement focusing on tobacco prevention and cessation messaging. • Activity targeted specifically at current illicit drug users and those suffering from a mental illness. • Targeted populations include youth, LBGT populations, racial and ethnic minorities, and persons with co-occurring disorders.

18. SAMHSA’s Primary Care and Addiction Services Integration (PCASI) • Proposed new initiative related to the integration of substance abuse treatment services and primary care (pending FY2015 funding). • Goals: improve the physical health status of adults with SUDs who have or are at risk for co-occurring primary care conditions and chronic diseases. • Continuum of preventive and health promotion services will be offered to and/or coordinated for clients • Special emphasis on Wellness programs including tobacco cessation

19. SAMHSA’s RFAs Encourage Tobacco-Free Policies • Language now included in SAMHSA RFAs: • SAMHSA strongly encourages all grantees to provide a tobacco-free workplace and to promote abstinence from all tobacco products (except in regard to accepted tribal traditions and practices).

20. States Put it All Together through Policy, Leadership, & Hard Work: Thank You!!!

21. SAMHSA: Helping People Help Themselves Westley.Clark@samhsa.hhs.gov