1. To create a comprehensive Benchmark plan that will assure maximum tobacco cessation coverage to all populations in Rhode Island:

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1 POSTION STATEMENT Submitted to the Rhode Island Health Benefits Exchange Submitted By the Public Policy Workgroup of the Statewide Tobacco Cessation Committee on Tobacco Cessation Treatment Benchmarks under the Affordable Care Act March 11, 2013 Following are some thoughts on how Rhode Island could effectively translate Public Health Policy into Comprehensive and Equitable Tobacco Cessation Insurance Coverage. The focus of the tobacco cessation workgroup has been on provision of services to populations that are most marginalized and are disproportionately affected by tobacco use. These disparate populations demonstrate the highest prevalence of tobacco use and could benefit most from a well-defined, comprehensive tobacco cessation benefit within the Essential Health Benefit Benchmark. These goals are informed by clinical practice and evidence-based best practice guidelines identified by the United Stated Public Health Service, Clinical Guidelines for Tobacco Use and Dependence (Fiore, 2018). We feel it is essential that the Health Benefit Exchange Advisory Board of Rhode Island include provider knowledge and experience when defining the Rhode Island Benchmark plan and Exchanges. Our goals are as follows: 1. To create a comprehensive Benchmark plan that will assure maximum tobacco cessation coverage to all populations in Rhode Island: a. Persons on Medicaid and the uninsured average a smoking rate of 32.4% compared to the private insurance population rate of 15.7%; b. Marginalized populations (e.g. mental health, substance abuse and HIV) will create the greatest impact on the exchanges; c. Marginalized populations also represent the more hardened smokers and demonstrate the greatest need for a comprehensive tobacco cessation benefit; d. Requiring smokers to pay higher premiums is a regressive fee requirement that will directly impact the lower income and more vulnerable populations (mental health, substance abuse, elderly). 2. To address the disproportionate prevalence of tobacco use in disparate populations when identifying the state Benchmark and Essential Health Benefit: a. Within behavioral treatment facilities, approximately 80% to 90% of clients smoke (ATTUD Position Paper); b. There is a 25-year mortality gap between people with behavioral health conditions and the general population (ATTUD Position Paper); c. Nicotine dependence is the most prevalent substance abuse disorder among individuals with mental illness (American Psychiatric Associate 1994); d. Tobacco use is associated with worsened substance abuse treatment outcomes (Prochaska 2010); e. 80% of clients in substance abuse treatment express interest in tobacco treatment (Prochaska, 2004);

2 f. Tobacco use is the leading cause of death in patients with psychiatric illness and addictive disorders (Prochaska, 2010); g. Mental health population (41%) smokes at 2X the rate of normal population (23%) (Prochaska, 2009); h. Individuals with co-occurring mental illness or addictive disorders are now estimated to comprise 44% to 46% of United States cigarette use (Prochaska 2010); i. Persons with mental illness might smoke more frequently and heavily than the general population and they might lack access to cessation services (CDC Vital Signs, February, 12013); j. In the State of New York, the rate of smoking among those reporting poor mental health (32.5%) was 2X the rate of those reporting good mental health (15.7%). k. Persons with any mental illness (AMI) often lack financial resources, face unstable and stressful living situations, and have difficulty coping with withdrawal symptoms. THEY MIGHT ALSO LACK HEALTH INSURANCE, INFORMATION ON THE HEALTH EFFECTS OF SMOKING, AND ACCESS TO CESSATION TREATMENT (Schroeder, 2010). 3. To provide proven best-practice interventions to directly impact disease prevalence among people who use tobacco and within disparate populations: a. 60% of deaths among smokers are attributable to their tobacco use (JHA et al 2013); b. Cigarette smoking remains the most important health hazard (Schroeder, 2013); c. Because smoking has become a stigmatized behavior concentrated among persons of lower socio-economic status, it risks becoming invisible to those who set health policies (Schroeder, 2013); d. Certified Tobacco Treatment Specialists are strategically placed within medical and behavioral healthcare systems and meet professional standards to be compensated as Fee-For-Service providers. i. Recent observations found that tobacco treatment specialists (TTS) were associated with higher quit rates than non-specialist (McDermott et al, Nicotine and Tobacco Research) e. $2.5 trillion is spent annually in the United States on health care due to chronic disease (heart disease, cancer, diabetes), the most prevalent smoking related diseases (Tom Harkin, U.S. Senate, 2013); f. Health hazards due to smoking may undermine benefits of HIV treatment on morbidity and mortality (Lifson, AR and Lando, HA, 2012): i. Over 40% of persons with HIV are current smokers; ii. Health risks of smoking include increases in some HIV-associated infections, cardiovascular disease, some cancers, bacterial pneumonia and other lung disease, and overall mortality. iii. Smoking is a modifiable risk factor that may further reduce morbidity and mortality in persons living with HIV. iv. The health care setting offers a unique opportunity to screen patients for smoking and to counsel them about smoking cessation. g. We are killing people by not acting. Nicola Roxon, former Australian Health Minister.

3 4. To provide a meaningful and consistent definition of comprehensive tobacco treatment that is evidence-based (Fiore, 2008): a. More fact-to-face contact (intensive evidence based treatment) can yield longer term outcome with demonstrated quit rates of 26.47%at 3 months and 21.73% at 12 months, with 51.02% of patients completing treatment (Sheffer, et al, 2009); b. In-person treatment (group and individual) outperformed quit lines and internet using American Cancer Associate Fresh Start and American Lung Association Freedom from Smoking protocols, with longer retention of hardened smokers (Hughes, 2013); c. Covered benefits should be sufficient in amount, duration and scope to reasonably achieve their purpose (Medicaid regulations for pregnant women 42CFR (b); d. Individual in-person or phone counseling of at least 4 sessions was 1.3 times higher than that with medications alone with some evidence of greater quit rates with greater intensity of treatment (Hughes, 2013); e. There is evidence that hardening is occurring among smokers seeking treatment and it is important that clinicians be able to demonstrate that counseling is especially helpful to justify treatment to health agencies (Hughes, 2013). f. Compliance with evidence-based treatment is associated with improved treatment outcome, utilizing a 60-minute intake and six (6) weekly 90-minute group sessions. The overall quit rate of 31% at 6 months is higher than the mean overall abstinence rates for higher intensity counseling (22.1%) or treatment involving more than 8 person-to-person treatment sessions (24.7%) reported in the USPHS guideline (Foulds, J. et al, 2006). 5. To align the Essential Health Benefit with the Mental Health Parity and Addiction Equity Act of 2008: a. Charging higher premiums for smokers is in direct violation of the Mental Health Parity and Addiction Equity Act of 2008 by creating barriers to treatment based on stigma and the desire of health insurance companies to save short term dollars (Richter, Kimber, 2009); i. Nicotine dependence and withdrawal are well defined diagnoses in the DSM-IV; ii. Tobacco use is a form of drug dependence and mental illness; iii. Tobacco use is the top preventable cause of death in the United States; iv. 59% of people with mental health and substance abuse problems also smoke and will be required to pay higher premiums. This equates to 2/3 of all people who are supposed to be beneficiaries of the MHPAEA will pay higher insurance premiums. 6. To demonstrate the cost-effectiveness of comprehensive tobacco coverage: a. A study completed among Massachusetts Medicaid subscribers in 2010 found that use of a comprehensive tobacco cessation pharmacotherapy benefit was associated with a 46% DECREASE IN HOSPITALIZATIONS FOR HEART ATTACKS

4 AND A 49% DECREASE IN HOSPITALIZATIONS FOR CARDIOVASCULAR DISEASE AMONG BENEFIT USERS; b. The study s authors estimated that for every $1 in program costs, the Mass Health program received an estimated medical savings of $3.12, a return on investment of $2.12 for every dollar spent (Land, Thomas et al, 2010); c. For low-income smokers, removing the barriers to the use of smoking cessation pharmacotherapy has the potential to decrease short-term utilization of hospital services. References: ATTUD Policy Statement, Integrating Tobacco Treatment within Behavioral Health, Disparate Populations Committee. Foulds, J. et al. Factors Associated with Quitting Smoking at a Tobacco Dependence Treatment Clinic. Am. J. Health Behav. 2006; 30(4): Fiore, MJ. US Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, Hall, SM and Prochaska, JJ. Treatment of Smokers with Co-occurring Disorders: Emphasis on Integration in Mental Health and Addiction Treatment Settings. Annual Review Clinical Psychology, 2009; 5:P Harkin, Thomas. U. S. Senate (Iowa), Healthier Lifestyles and Prevention America Act (2013). Hughes, J. Efficacy of Adding Counseling to Medications for Smoking Cessation: When is Counseling Justified.ATTUD Blog, Jha P, Ramasundarahettige C, Landsman V, et al. 21st Century hazards of smoking and benefits of cessation in the United States. New England Journal of Medicine 2013; 368: Land, Thomas, et al., Medicaid coverage for tobacco dependence treatments in Massachusetts and Associated decreases in smoking prevalence, PloS One 5(3) (March 5, 2010) Land, T. et al. A longitudinal study of Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in hospitalizations for cardiovascular disease. A Longitudinal Study of Medicaid Coverage for Tobacco.PLoS Medicine, December 2010, Vol. 7 (2). Lifson, Alan R and Lando, HA. Smoking and HIV: Prevalence, Health Risks, and Cessation Strategies. Curr HIV/AIDS Rep (2012) 9: McDermott, MS et al. Factors Associated with Differences in Quit Rates Between Specialist and Community Stop-Smoking Practioners in the English Stop-Smoking Services. Nicotine and Tobacco Research, (2012) The Mental Health Parity and Addiction Equity Act of 2008.

5 Prochaska, JJ. Failure to Treatment Tobacco Use in Mental Health and Addiction Treatment Settings: A form of harm reduction? Drug and Alcohol Dependence 110(2010) Schroeder, SA and Morris CD.Confronting a Neglected Epidemic: Tobacco Cessation for Persons with Mental Illness and Substance Abuse Problems. Annual Review Public Health, 2010; 31: Schroeder, SA. New Evidence that Cigarette Smoking Remains the Most Important Health Hazard. New England Journal of Medicine 368; 4 (2013).

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