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Comparison of Four Cessation Programs: What Works Best ? For Whom?. Comparison of Four Cessation Programs: What Works Best? For Whom?. Acknowledgement of Collaborating Vendors Helpline: Free & Clear, Inc. Website: QuitNet.com, Inc.

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comparison of four cessation programs what works best for whom1

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

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

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

learner outcomes
Learner Outcomes:
  • Understand key program components of MPAAT’s 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.

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minnesota partnership for action against tobacco mpaat
Minnesota Partnership for Action Against Tobacco (MPAAT)
  • Established in 1998 as 501(c)3 as part of Minnesota’s 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

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how is minnesota different from other states
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

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mpaat resources
MPAAT Resources

www.mpaat.org

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slide7
Cessation services provided by MPAAT
  • QUITPLAN Helpline 1-888-354-PLAN
  • quitplan.com
  • QUITPLAN Centers
  • QUITPLAN at Work
  • QUITPLAN Community-tailored Programs

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helpline goals
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

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

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health plan partners 7
Health Plan Partners (7)
  • Blue Cross Blue Shield of Minnesota
  • HealthPartners
  • Mayo Health Plan
  • Medica
  • Metropolitan Health Plan
  • PreferredOne Community Health Plan
  • UCare

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slide11
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

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evolution of helpline services
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

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evolution of helpline services1
Evolution of Helpline Services

June 2004 - Present

Health plan systems changes initiated

Began collecting health plan identification numbers

Further adjusted scripting to triage clients

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helpline volumes 2001 2005
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

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

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www quitplan com
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

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quitplan sm at work
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

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face to face programs january 2004 present
Face-to-face Programs January 2004 – Present
  • QUITPLAN Centers
    • Over 950 clients
  • QUITPLAN at Work
    • Over 650 clients
    • Recent high demand post ordinance implementation

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quitplan community tailored programs
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

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slide20
Numbers Served by QUITPLAN Programs

Helpline (4 years)

Website (18 months)

Centers (18 months)

Worksite (18 months)

(Community tailored programs are being evaluated separately.)

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methodology
RxMethodology

worksite

website

helpline

treatment center

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scope of the evaluation
Scope of the Evaluation
  • Process
    • Track services provided and to whom; participant satisfaction
  • Outcome evaluation
    • Participant outcomes

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today s presentation
Today’s 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

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today s presentation1
Today’s 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?

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evaluation methods intake
Evaluation Methods: Intake
  • Intake Form at Registration
    • Demographic information, tobacco use and quit history, confidence quitting

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

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slide27
Consent Rates to Date

366/457

292/351

685/1139

296/301

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

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slide28
Response Rates to Date

36.8%

Phone

41.3%

Online

257/366

230/292

535/685

219/296

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using mats to compare to intervention samples of smokers
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

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who uses the quitplan programs
RxWho Uses the QUITPLAN Programs?

worksite

website

helpline

treatment center

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slide31
Gender

* Significantly different than MATS (p ≤ .05)

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slide32
Mean Age

* Significantly different than MATS (p ≤ .05)

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slide33
Education

* Significantly different than MATS (p ≤ .05)

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slide34
Employment Status

* Significantly different than MATS (p ≤ .05)

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slide35
Insurance Status

* Significantly different than MATS (p ≤ .05)

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are there demographic user profiles
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

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gen x gen y
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)

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ms executive
Ms. Executive
  • All female
  • 25 - 50 years old
  • High proportion of college grads (59%)
  • All employed
  • ½ married
  • 90% white

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

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slide40
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

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mr executive
Mr. Executive
  • All male
  • 31 - 60 years old
  • High proportion of college grads (59%)
  • All employed
  • 2/3 married
  • 90% white

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blue collar workers
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

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proportion of participants in each demographic cluster
Proportion of Participants in Each Demographic Cluster

Weighted so that each intervention is 25%

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who uses the helpline
Who Uses the Helpline?

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who uses the centers
Who Uses the Centers?

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who uses quitplan at work
Who Uses QUITPLAN at Work?

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who uses the website
Who Uses the Website?

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who uses each program

Who Uses Each Program?

Tobacco Use and Quit History

slide49
Time to First Cigarette

* Significantly different than MATS (p ≤ .05)

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slide50
Daily Smokers

* Significantly different than MATS (p ≤ .05)

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slide51
Smoking Intensity

* Significantly different than MATS (p ≤ .05)

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slide52
Quit Attempt in Last Year

* Significantly different than MATS (p ≤ .05)

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slide53
Ever Quit for a Year or More?

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are there tobacco use quit history user profiles
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

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lighter smokers
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

#1

Lighter Smokers

Poised to Quit

#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

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lighter smokers1
Light smokers (82%)

½ smoke daily

Only 1/3 highly addicted

All recent quit for 30+ days

None 1-yr quit

#1

Lighter Smokers

Poised to Quit

#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

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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

Moderates

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rookie quitters
Moderate to heavy smokers (50%/30%)

All smoke daily

85% highly addicted

No recent quit

No 1-year quit

Rookie Quitters

Second Chance

#4

#5

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

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rookie quitters1
Moderate to heavy smokers (50%/30%)

All smoke daily

85% highly addicted

No recent quit

No 1-year quit

Rookie Quitters

Second Chance

#4

#5

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

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heaviest
Moderate to heavy (50%/40%)

80% daily smokers

93% highly addicted

All recent quit, most for <30 days

Few 1-year quit

Heaviest

#6

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proportion of participants in each tobacco use quit history cluster
Proportion of Participants in Each Tobacco Use / Quit History Cluster

Lighter Smokers

Poised to Quit

Mod-erates

Rookie Quitters

Second Chance

Heaviest

Weighted so that each intervention is 25%

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who used the helpline
Who Used the Helpline?

Lighter Smokers

Poised to Quit

Mod-erates

Rookie Quitters

Second Chance

Heaviest

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who used the centers
RxWho Used the Centers?

Lighter Smokers

Poised to Quit

Mod-erates

Rookie Quitters

Second Chance

Heaviest

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who used quitplan at work
Who UsedQUITPLAN at Work?

Lighter Smokers

Poised to Quit

Mod-erates

Rookie Quitters

Second Chance

Heaviest

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who used the website
Who Used theWebsite?

Lighter Smokers

Poised to Quit

Mod-erates

Rookie Quitters

Second Chance

Heaviest

Smokers

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programs serve different tobacco quit groups
Programs Serve Different Tobacco / Quit Groups

Lighter Smokers

Poised to Quit

Mod-erates

Rookie Quitters

Second Chance

Heaviest

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summary
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.

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summary1
RxSummary

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.

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summary2
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.

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results at six months

Results at Six Months

How effective is each cessation program?

desired outcomes at six months
Desired Outcomes at Six Months
  • Quit attempt of at least 24 hours
  • 7-day point prevalence
  • 30-day point prevalence

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slide72
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

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calculating quit rates
Calculating Quit Rates

Artificially high quit rate:

“Quitters” / Respondents = Quit rate

Intention to treat rate:

“Quitters” / (Respondents + Nonrespondents)

= ITT Rate

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the majority of participants successfully quit for at least 24 hours
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)

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used no tobacco in past 7 days
100%

80%

60%

26.7%

40%

22.1%

18.5%

15.6%

20%

0%

Helpline

Centers

Work

Website

Used No Tobacco in Past 7 Days

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

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used no tobacco in past 30 days
100%

80%

60%

40%

24.0%

19.4%

14.7%

11.8%

20%

0%

Helpline

Centers

Work

Website

Used No Tobacco in Past 30 Days

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

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which programs work best for whom is there a relationship between cessation and
Tobacco use/quit history
  • Demographics
  • Program utilization
  • Pharmacotherapy use

Which programs work best for whom?

Is there a relationship between cessation and:

slide79
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.

7-Day Abstinence Rates (ITT) at Six Months for Each Cluster

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slide80
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.

Includes 50% of all Helpline participants

7-Day Abstinence Rates (ITT) at Six Months for Each Cluster

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slide81
Rx

Centers show the highest quit rates in the light and moderate tobacco use clusters.

7-Day Abstinence Rates (ITT) at Six Months for Each Cluster

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slide82
Rx

Centers show the highest quit rates in the light and moderate tobacco use clusters.

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

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slide83
Work program shows strong results with three clusters, one light, one moderate and the heaviest group.

7-Day Abstinence Rates (ITT) at Six Months for Each Cluster

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slide84
Work program shows strong results with three clusters, one light, one moderate and the heaviest group.

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

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slide85
Website participants did not have statistically significant differences in the quit rates of tobacco use groups. Quit rates ranged from 10% to 22%.
slide86
Programs have success with different tobacco use groups.

Quit rates 30% or higher

Quit rates20% - 29.9%

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slide88
Demographic Clusters

Centers highest rates are seen in the demographic clusters with older age groups.

7-Day Abstinence Rates (ITT) at Six Months for Each Cluster

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slide89
Demographic Clusters

Centers highest rates are seen in the demographic clusters with older age groups.

10%

20%

70% of all Center participants

7-Day Abstinence Rates (ITT) at Six Months for Each Cluster

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slide90
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.

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slide91
Utilization

How do participants make use of available program services?

How is level of use related to cessation at each of the programs?

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slide92
Programs have mixed patterns of utilization

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participants using more program services have higher quit rates
Participants Using More Program Services Have Higher Quit Rates

* p < .05

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slide94
Pharmacotherapy Use

How is pharmacotherapy used by QUITPLAN participants?

How is use of medications related to cessation?

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used meds to help quit
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.

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type of medications used
Type of Medications Used

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pharmacotherapy users have higher quit rates
Pharmacotherapy Users have Higher Quit Rates

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slide98
Tobacco Use Clusters

NRT Alone Is Helpful for all except the heaviest users.

7-Day Abstinence Rates (respondents only)

at Six Months for Each Cluster

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slide99
Demographic Clusters

NRT Use is helpful to all demographic groups,

especially “Hard Luck” group.

! ! !

7-Day Abstinence Rates (respondents only)

at Six Months for Each Cluster

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slide100
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

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slide101
Logistic Regression Results

Demographic profiles: Not significant

Tobacco 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

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slide102
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.

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slide103
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.

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why conduct a synthesis evaluation
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

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why conduct a synthesis evaluation1
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

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limitations in using synthesis evaluation results
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

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what do we know about the initiative based on the synthesis evaluation
What do we know about the initiative based on the synthesis evaluation?
  • Who is using MPAAT’s 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

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what do we know about the initiative based on the synthesis evaluation1
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

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what do we know about each individual evaluation based on the synthesis evaluation
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

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what do we know about each individual evaluation based on the synthesis evaluation1
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

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future directions
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

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for additional information
For Additional Information

Dr. Ann Wendling

MPAAT

952-767-1411

[email protected]

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