Maximizing federal CPPW funding, reach and tobacco-related outcomes in Georgia [2012]

Maximizing Federal CPPW Funding, Reach and Tobacco-Related Outcomes in Georgia
Dwana "Dee" Calhoun, MS, CHES and Antionette Lavender, MPH | Health Promotion Disease Prevention Section, Georgia Tobacco Use Prevention Program (GTUPP) | Georgia Department of Public Health

Introduction

Background (continued)

Evidence featured in the Independent Task Force on Community Prevention Services' Guide to Community Preventive Services has demonstrated that comprehensive health communication media campaigns combined with other interventions can 1) stimulate public support for population-based tobacco control interventions 2) create a supportive environment for policy and programmatic community efforts and 3) promote tobacco cessation.
As noted by Rachael L. Murray, etal. and others significant improvements in health status among populations are likely to be achieved by 1) reducing the proportion of current tobacco users and 2) reducing the proportion of current tobacco users from vulnerable populations. In the United States, smoking rates among adults aged 18-65 who are uninsured (33.2 percent) and Medicaid enrollees (36.5 percent) are higher compared to the general population (22.7 percent).
The Georgia Tobacco Use Prevention Program (GTUPP) utilized Federal Communities Putting Prevention to Work (CPPW) funding along with Centers for Disease Control and Prevention (CDC) resources, and the Ten Essential Public Health Services Framework to address tobacco-related disparities impacting vulnerable population groups by gender, health status, health insurance coverage and region. In addition, elements from the CDC's Media Campaign Resource Center, Expanded Chronic Care Model and various evidence-based health behavioral theories were utilized to implement health communication and systems interventions.

Health Insurance Status: Uninsured Georgia adult tobacco users (35%) possess higher smoking rates compared to adult tobacco users with health insurance (15%).
Gender: Male adult tobacco users (primarily Non-Hispanic Whites) possess smoking rates and lung cancer incidence rates significantly higher than the state and national average.
Race/Ethnicity: Adult tobacco users of various racial/ethnic groups such as: Non-Hispanic Blacks possess high cardiovascular mortality rates.
Geography: Smoking rates are higher in primarily rural regions compared to non-rural regions. Moreover, 9 out of 18 public health districts are characterized by a significantly higher lung cancer incidence rate than the state average for male adults.
In an effort to minimize the onset or severity of tobacco-related diseases or complications especially among vulnerable adult population groups in Georgia, an "upstream" approach was adopted to engage younger adult tobacco users (aged 18- 54). This multi-prong approach was adopted to address both National Tobacco Control Program (NTCP) goals and GTUPP goals including a.) reduce disparities related to tobacco use prevalence and morbidity and b.) promote tobacco cessation among adults and youth.

Design, Setting, Population and Method

During a six month period beginning July 25, 2011 GTUPP implemented multiphase and multi-prong interventions to increase awareness about tobaccorelated disease severity and susceptibility targeting vulnerable population groups.

GTUPP evaluated the effects of the multi-phase and multi-prong approach which included a statewide "Quitting Takes Practice" media campaign, multisector engagement, combined with free Georgia Tobacco Quit Line (GTQL) telephone cessation counseling services. In addition, free nicotine replacement therapy (NRT) medication was also provided to uninsured adults aged 18 and older residing in several targeted disparate regions. Georgia adult tobacco users and members of their support system residing in both rural and non-rural public health districts characterized by high smoking rates, lung cancer incidence rates, and cardiovascular mortality rates were engaged.

Table 1. Georgia Quitline Adult Tobacco Users by Chronic Disease and Health Insurance Status (At Registration)

Chronic Disease Status at Registration
Asthma Health Insurance Status Commercial Medicare Medicaid *Uninsured Total Heart Disease Health Insurance Status Commercial Medicare Medicaid *Uninsured Total COPD (Chronic Obstructive Pulmonary Disease) Health Insurance Status Commercial Medicare *Medicaid *Uninsured Total Diabetes Health Insurance Status Commercial Medicare Medicaid *Uninsured Total No Chronic Disease Health Insurance Status *Commercial Medicare Medicaid *Uninsured Total

July 2009-Dec 2009

July 2011-Dec 2011

(Baseline Period: No Intervention) (Intervention Period: Multi-Prong Approach)

n

%

n

%

P value

46

18.9%

92

37

15.2%

66

80

32.8%

144

81

33.2%

207

244

509

18.1% 13.0% 28.3% 40.7%

ns ns ns 0.048

27

17.8%

33

33

21.7%

55

56

36.8%

71

36

23.7%

97

152

256

12.9% 21.5% 27.7% 37.9%

ns ns 0.055 0.003

42

17.4%

64

52

21.6%

92

96

39.9%

127

51

21.2%

189

241

472

15.0% 21.5% 29.7% 44.3%

ns ns 0.008 <.001

38

20.0%

61

41

21.6%

60

68

35.8%

85

43

22.6%

121

190

327

18.7% 18.4% 26.0% 37.0%

ns ns 0.019 .001

258

30.9%

48

5.6%

143

17.1%

386

46.2%

835

383 101 255 1,102 1,841

20.8% 5.5% 13.9% 59.9%

<.001 ns ns <.001

Note: Self-Reported Chronic disease category at GTQL registration includes: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Heart Disease, and Diabetes. All chronic health conditions were self-reported by quitline participants. There was some variation in the total N for each category due to nonresponses. * Statistically significant increase in quitline calls at p value< .05
ns = not statistically significant.

A retrospective review of GTQL data from national tobacco cessation vendor

Figure 1. Ten Essential Public Health Services Framework

Alere Wellbeing (formerly Free & Clear) was conducted to examine data

corresponding to the period in the absence of and during the adoption of the

This presentation contributes to the evidence-base by evaluating the effects of a multi-prong approach.

multi-prong approach on adult vulnerable population groups that meet at least

one of the following criteria: Adult tobacco users with no form of health insurance or considered

Statistical Methods

uninsured.

Adult tobacco users with self-reported chronic diseases including: asthma, The Pearson Chi-Square test was used to determine statistical significance

chronic obstructive pulmonary disease (COPD), heart disease and diabetes. (p value <.05) between the percent of tobacco user callers at baseline (July,

Adult tobacco users without one of the four chronic diseases noted

2009-December, 2009) and the percent of callers during the first six months

above but reside in regions characterized by smoking rates or lung cancer of the multi-prong intervention period (July, 2011-December, 2011). When

incidence rates higher than the state and national average.

comparing two proportions, the Chi-Square test is equivalent to using the two

sized Z test for comparing two independent proportions. All statistically analyses

were performed using SAS version 9.2.

Background

Smoking rates in Georgia over the past decade from 2000 to 2010 has been characterized by slow declines. In addition, approximately $1.8 billion each year in healthcare costs is attributed to tobacco use among adults aged 18 and older.
Moreover, cancer accounts for approximately 43% of all deaths due to smoking among Georgia adults aged 35 and older. Moreover, cardiovascular diseases and respiratory diseases account for 30% and 27% of all deaths due to smoking, respectively. Smoking rates and tobacco-related diseases disproportionately impact vulnerable adult population groups.

Evaluation Question Proposed
Did the targeted population group (i.e. asymptomatic tobacco users, adult tobacco users with chronic conditions, male adults, residing in rural regions, younger than 55 yrs of age, members of ethnic population groups) change behaviors (i.e. call the Georgia Tobacco Quit Line, enroll in GTOL multi-call program and/or select nicotine replacement therapy medication support) as intended?

Tobacco Cessation Counseling Enrollment and NRT Medication Support
As shown in Table 2, although a steady increase in single call tobacco cessation counseling enrollment occurred; there was a statistically significant increase in quitline participants enrolled in multi-call tobacco cessation counseling from 66.9% to 78.1% (p value: <.001 ). This represents a percent increase of 16.7% in multi-call tobacco cessation counseling enrollment.

Results
Overall, the number of Georgia tobacco user adults participating in Georgia Tobacco Quit Line services steadily increased by 100% from 1,682 adults in the baseline period (July, 2009-December, 2009) to 3,359 adults during the first six months of the Georgia "Quitting Takes Practice" campaign (July, 2011-December, 2011). Results not shown.
In addition, during the first six months of the multi-prong approach (including the Georgia "Quitting Takes Practice" campaign), GTUPP staff also observed statistically significant associations in GTQL service utilization among adult tobacco users by chronic disease status and health insurance status (shown in Table 1).
Overall, statistically significant increases in GTQL service utilization rates were observed among the number of adult tobacco users who are uninsured regardless of absence or presence of self-reported chronic diseases.
Conclusion
The results from the retrospective data review reveals that adult tobacco users from vulnerable population groups such as adult tobacco users who are uninsured, and those residing in rural and non-rural regions in a southern state can be influenced to engage in evidence-based tobacco cessation interventions.
References
An LC, Schillo BA, Kavanaugh AM, et al. Increased reach and effectiveness of a statewide tobacco Quitline after the addition of access to free nicotine replacement therapy. Tob Control 2006; 15:28693.
Fiore, etal. (2008). Treating Tobacco Use and Dependence. 2008 Update. Clinical Practice Guidelines. Rockville, MD. USDHHS, PHS, May 2008.
Jeff Niederdeppe, PhD, Michael C. Fiore, MD, MPH, Timothy B. Baker, PhD, and Stevens S. Smith, PhD Smoking-Cessation Media Campaigns and Their Effectiveness Among Socioeconomically Advantaged and Disadvantaged Populations. Am J Public Health. 2008; 98: 916924.
Acknowledgements
Mandatory statement: Supported by from CDC's Communities Putting Prevention to Work (CPPW) Program Cooperative Agreement No. 3U58DP002005-01S3. The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of the U.S. Department of Health and Human Services or the CDC.
The authors wish to thank the following persons: Kimberly Redding, MD, MPH (Principal Investigator/Director) Shonta Chambers, MSW (Director, Office of Prevention and Wellness) Kenneth Ray, MPH Georgia Tobacco Use Prevention Program 18 Georgia Public Health District Coordinators Statewide Georgia Department of Public Health-Office of Communications Tri-Health Organizations: American Lung Association, American Cancer Society, American Heart Association (Georgia Chapter) Georgia Regional Cancer Coalitions Georgia Hospital Association (GHA) & Other Health System Organizations Georgia Universities, Colleges and Technical Schools (Statewide) Georgia Businesses & Employers (Statewide) CPPW Workshop Team: Medical Professors and Evaluators
Abstract # 1883 Contact information: Dwana Calhoun, MS, CHES | dwcalhoun@dhr.state.ga.us For more information, please visit us at www.livehealthygeorgia.org