TIM MCAFEE: I'm Tim McAfee.
I'm sure that Abigail has already introduced me.
And I just want to emphasize how excited I
am to have this opportunity to talk with you
remotely for a few minutes about a topic that's
near and dear to my heart, addressing disparities
in tobacco dependence treatment, an area
that I've been working on literally for probably
10 or 15 years in many different capacities,
from being a primary care physician to being a tobacco
treatment direct provider of care to overseeing services
in the quit line arena in Seattle,
both within Group Health Cooperative
but also within a private company that provided services
to states and employers and health systems.
And then for the last five years working for CDC in Atlanta.
And now out here in the Pacific Northwest,
and where part of my role has been
to try to improve the interface between tobacco treatment,
to increase its dissemination and uptick
and quality with other tobacco control activities.
So without further ado, what I hope to cover is first,
I'm going to talk a little bit just
to make sure we're on the same page around what we
mean by the word treatment.
And then I'm going to talk about tobacco users themselves
as a total population, being a population that suffers
from health care disparities.
And then we'll look at some of the specifics of priority
populations of tobacco users and how
they may suffer from health and health care
related disparities.
And then I'm actually going to spend some time, fortunately,
talking about some of the solutions
that we already know can work in this arena and others
that have promise.
And now I'm now on slide number three.
And I'll try to give examples of when I'm switching.
So when we say treatment what are we talking about?
Well, if we take the larger universe of all people,
within that, there's a subgroup of about 15% to 20%,
depending on how you define it, or larger, if you're poor,
et cetera, who are using tobacco products.
And within that subgroup, there's
a subgroup who are actively trying to make a quit attempt.
And at any time, that's going to be something like 10% to 20%.
Over a year, about 50% of people try to make a quick attempt.
Within that subset, there's a smaller subset
of people who actually use evidence-based treatment
to try to get help.
And within that subgroup, there's
the smallest group, which is those
that use sort of the full meal deal, that
take full advantage of all that we know potentially can work.
We'll talk more about this.
But it's important from a public health perspective
to keep in mind that if we only define treatment as hey,
can we make better that tiny little group of smokers
that are going to the Mayo Clinic for treatment
and getting hospitalized to be treated for their tobacco
dependence or whatever?
That we are going to be ending up
talking about a tiny, tiny, tiny fraction of smokers
that is essentially meaningless from actually impacting
the prevalence of tobacco use.
So we have to realize that all these different circles are
kind of permeable.
And people, whether they move between them or not,
depends on things that we do in society.
So for my next slide, I'm going to essentially take
the next phase of this, which is you take those circles
and look at them.
It's important to realize that the things that we might
be able to do to increase these, which I'm going to talk about
next, interact with each other.
And some of them only work in one circle, like having--
creating-- going from using nicotine replacement therapy
patches to using one of the higher
efficacy things like Varenicline,
will only work in the circle on the right.
And it won't necessarily affect how many people
are likely to make a quit attempt
or whether they're going to try to use anything at all.
But there are some things that may work on all three.
So what do we know that works for treatment in general?
We know that we can increase the likelihood that people
will make quit attempts through comprehensive clinic system
interventions.
This is called the 5-A model.
I don't know if you've been exposed to this,
but this basically means that we set up
clinic systems that encourage or require
health care providers to determine what people's tobacco
status is at almost every visit, that they give
brief advice, that they help provide a little assistance,
and that they try to connect them up with resources
to support them and make sure that they get follow up.
And that will affect all three of these potentially,
has the possibility.
Mass media campaigns definitely are
well-proven to increase quit attempts in the population.
I'll be talking more about that as a case example later.
We also know that state and local comprehensive tobacco
control programs, everything from [INAUDIBLE] to tax
increases to community mobilization,
will work to make more people in that geographic area
try to quit smoking.
For the second, for increasing use of evidence-based support,
first, what are we talking about here?
This is predominantly conceived of as medications,
seven FDA-approved medications, and counseling,
which can be provided in multiple locations
and multiple modalities.
Lots of evidence that these work.
The big issue is how do we actually
get people to be aware that these exist
and remove barriers to them actually
being interested in using them and then actually using them?
And finally, how do we increase the effectiveness
of the support and treatment for people who are saying,
yeah, I'd like to do something?
And there's a couple of fairly straightforward ways
to do this.
And these include the combining modalities,
so people don't just use medications.
They also use counseling, and vice versa.
It also can mean that they use multiple medications.
Now, the other one is to essentially increase
the dose and duration and instruction
that people get on how to use these different modalities,
whether that's counseling or whether that's medication.
All of these things definitely have
been shown to increase the effectiveness of support
and treatment for people that are interested in getting it.
I want to now toss out something that--
I don't know if this has come up in any of your previous talks
that you've had.
But I just want to throw out the idea, based
on my long experience working with smokers and systems,
et cetera, that people with tobacco dependence
experience health care disparity compared
to non-tobacco dependent people.
So before we go into subpopulations
of tobacco users, I think it's very important
to realize that tobacco users as a category,
as a subpopulation of all of us, experience health care related
especially disparities.
And I'm just going to talk about a few of those.
The first is that tobacco treatment research
historically, over the last 20, 30 years, although there's
been a lot of it and we've made a lot of progress,
it has not been prioritized in an urgent sense
consistently, the way many other forms of treatment development
have been in kind of traditional medical care.
We have seven medications that work.
But the reality is five of them are just
variations on nicotine.
And one of them is an anti-depressant
that's been repurposed.
And the other one is actually a variant on an old Eastern
European herbal medication.
So there has not been the kind of aggressive attention
to pharmaceutical development that there
has been in, say, chemotherapies,
antibiotic development, et cetera.
And the same is true with counseling modalities as well.
But we do have things that work.
And of those, it's been incredibly frustrating
over the last 20 plus years, the efforts
that it has taken to get these exquisitely proven modalities
that work to be covered.
And if covered, to then be integrated into health care
and health care systems.
Now, the other thing that is worthy of note
is that users of this exquisitely addictive product
are taxed heavily on the product.
It varying widely from state to state,
and certainly a state like Washington,
there's a pretty strong tax as well as
master settlement revenue that's coming to the state.
Almost a billion dollars comes into the coffers
for the state of Washington from the sale of tobacco products.
But the revenue that the state generates,
or the federal government, and in some cases municipality
generates is not applied to treatment or prevention
of tobacco.
So we're taking the money out of the pockets of the smokers,
hoping that the fact that they have to pay a little more
will help them be a little more motivated to quit,
but we are not in general using that money
to provide treatment.
Now, under the Affordable Care Act,
tobacco users also now are one of the only groups in which
insurers are allowed, if the state allows insurers,
they have it.
But they have the authority and OK from the federal government,
that if they want to, they can charge significantly higher
premiums, as much as 50% higher, to somebody based solely
on tobacco status.
They can't do that if you're diabetic.
They can't do that if you're an alcoholic.
They can't do that if you really have almost any other kind
of medical condition.
Now, there's reasons for that.
But it creates a health care disparity.
And then finally, as I'm going to go into an a little bit
more detail, the environment that smokers are facing right
now has been designed historically
in collusion between the tobacco industry, government,
and other parts of society over the last 100 years
to really support addiction and make it harder to quit.
So bottom line is, if you're a smoker, the money that you're
spending to purchase the product that you're addicted
to is going to be used to help pay for other people's health
care, as well as potholes and roads, et cetera, whatever
the state decides it wants to, through taxes
through the tobacco master settlement.
However, despite this, you may be denied coverage, awareness,
and access to well proven treatments that
could quadruple your chances of success
if you use them full bore.
And in addition, you may have to pay significantly more
for your health care solely because you're
a smoker, while your next door neighbor with diabetes,
alcoholism, or obesity does not.
And finally, you continue to be exposed
to almost unfettered marketing and access
to a deadly, highly addictive product.
So this is really an unusual situation and one
where I think it's very important,
as we drill down on subpopulations of smokers,
to not forget that smokers as a group
are suffering from health care disparities.
Now, just a little bit more on the environment larger.
This is not just looking at treatment.
But it affects treatment, because it
affects the ability of a health care provider
and a patient being treated to be able to be successful.
So what's the situation been historically?
And this has been changing.
But this is what we face certainly up until 10,
15 years ago.
Tobacco is remarkably easily accessible.
You can literally buy it at something that's
called a convenience store.
It's convenient to get it.
It's also accessible because the price has
been historically quite low.
And in many states it still is quite low.
Smoking in public up until 15 years ago
in most of the United States was legal,
making it much harder for people to quit, because they
are exposed to nicotine as well as being
likely to have the reinforcers.
There's unfettered advertising.
Go back 50 years, and there is advertising on television.
Go to 2015, and now there is again
advertising on television for some tobacco products.
There was poor to no access to cessation help.
The first medications were not even approved until the 1990s.
And then finally, the cigarette itself as a product
is exquisitely designed still, despite having
been under FDA authorities, still exquisitely designed
to addict, which makes it harder for smokers,
when they're trying to quit, to be able to quit.
Now, I just want to emphasize a couple of points
that I've made around here with a few specific facts.
The first is, one of the things that we call for around this
is the fully funding of comprehensive, statewide
tobacco control programs.
And by the way, we're now on slide nine,
in case there's been any trouble following this.
So this is a graph that shows what's
happening in terms of money that's coming in.
The states get $25 billion, as you
can see in the left, of tobacco tax revenue.
The federal government gets $15 billion.
So the government is getting $40 billion, $40 billion dollars,
from the sale of tobacco products, which
is a little bit more than the global profits from tobacco
sales.
Now, the tobacco industry is still
spending almost $9 billion on marketing promotion.
CDC recommends that a little over $3 billion
should be spent by government on tobacco control
activities writ large.
The reality is state tobacco programs
are only spending about half a billion dollars.
And funding is perpetually at risk.
Even the money that's being spent by the Centers
for Disease Control on tobacco, for instance,
is under threat literally this week,
being threatened with having its budget cut in half.
I'll mention this a little bit more when we talk about some
of the solutions that are under way.
So we as a society are now collecting $40 billion
from smokers, but spending less than 2% of that on anything.
And that does not--
that's including everything.
So treatment is only a small fraction of that.
Now, so what has been done over the past few decades
to try to do something about this conundrum, this disparity,
this social justice issue?
Up until relatively recent times,
mostly what had been done is what I would call jury rigged
solutions.
It was people trying to figure out
ways to get smokers help realizing that they don't have
what they should have, which is that this was just
embedded and worked into health care financing and health care
delivery.
So for instance, we had initially we
had NGO groups, maybe philanthropic hospital
organizations, the Cancer Society,
the Lung Association creating little groups that worked well.
They were in the inner circle that I showed you earlier,
something that was effective.
But a tiny, tiny, tiny fraction of smokers used them.
They either had to be paid for by the individual,
or the NGO, the non-governmental organization,
had to support the costs.
We then developed in the 1990s state sponsored
quit lines that really mostly existed outside of health care
and were paid for by the state government,
not by health care system financing.
And then, within the health care systems themselves,
it was basically left to health care providers and clinic
managers, et cetera to sort of decide
what they were going to do or get research dollars to support
any efforts that they made to help smokers,
because it was not reimbursed.
If you talked with a smoker to try to help him quit,
it was just off your hide.
You couldn't bill for it up until remarkably recently.
The other thing that then happened
after this was the development of these more systematic
approaches to try to integrate treatment into care.
We had the 5-A health system approach that I talked with.
We said we started having quality improvement
and assurance indicators of providers who
were providing services.
And we saw improvements and changes
in health care treatment for the easy things
like checking in on status or giving brief advice.
But there are still major gaps around making sure
that people get medications, people
get counseling if they want it, and that they get systematic
follow up.
We still have significant way to go on that.
The other thing that we have seen,
which has been very exciting, in the last three or four years
has been mandates, essentially, within the Affordable Care
Act that have--
and that CMS, Medicare and Medicaid
are requiring for health care systems and providers
to provide smoking cessation.
But this is still very early, and there's
a long way to go before it's clear
that this is going to happen.
So again, smokers as a class are experiencing health disparity
around this condition that takes 10, 11, 12 years just
on average off their life expectancy.
They can't get the kind of treatment
for their smoking dependence that they
could get for other health care conditions.
And lastly, we've been working, and I'll talk more about this,
to integrate media campaigns that
are happening at the national level with a call
to try to help link people up with evidence-based care.
Now, so in summary, where are we trying to get to?
And where we're trying to get to is to make it so,
for the individual, their tobacco addiction
can roll downhill, instead of the earlier slide
that I showed where they had to push it uphill.
So tobacco is more expensive, so they have to think twice
before buying it.
It's less accessible.
There are thorough smoke-free policies, ubiquitous,
which you may not realize being in Washington state,
there's still a large number of communities
where you can still smoke in a restaurant, et cetera.
You may even be able to smoke at work.
Where there are well-financed counter marketing campaigns
and promotion restrictions with teeth.
And of course, which is what we're going to focus on,
continue to focus on, is easy, reliable access
to help quitting, to treatment for those who want it.
And then lastly, that cigarettes are made less or non addictive,
which is essentially something that only the Food and Drug
Administration can do.
Now again, the Surgeon General in 2014
called specifically that we needed
to fulfill the opportunity that the Affordable Care
Act provides of access to barrier free proven tobacco use
treatment.
And this includes both the seven approved cessation medications,
of which five are variants on nicotine replacement
therapy, bupropion, which is also an antidepressant,
and Veranicline, which is a variant on cytosine, which
was a Eastern European herbal medication that
helps people quit.
And then we have the association counseling delivered
both in multiple modalities, whether that's
in one on one face to face sessions,
whether that's delivered over the telephone,
or whether that's delivered in group,
and increasingly, even potential other modalities
like web and text support delivered
by potential multiple different kind of practitioners.
Now, next I'm going to talk about where
that happens that we know there's evidence
that if you do this, it works.
And again, there's a lot that we know about the system
stuff around this.
It's more a question of application.
We need to expand cessation, primary and speciality
care, with health system support, health care provider
training, in-person counseling, medication availability,
quit lines, web and text, and affordable coverage act,
as I've talked about.
OK, so that's for smokers writ large.
But there are some really, really significant disparities
and social justice issues around treatment
specifically in priority tobacco control populations
or subpopulations.
And many of these patients that you've been learning about,
the treatment applies to them as well.
There are a few others which again, I
don't know if you've talked about,
but that also are becoming more significant around treatment.
And I'll just start off with some
of the ones you might be less likely to think about.
One is geography that, particularly as
in the south and the lower Midwest, the states that
did not opt in for Medicaid expansion and are, in general,
have a far larger uninsured population.
All those people are sort of out of luck
if they want to get help quitting smoking.
And many of those are states that
also have less in the way of state
supported resources, like quit line support.
And another variant on this is rural access,
which can be true all across the country.
And then there's a large bucket, which
I will talk about more, around mental health, substance abuse
and chronic diseases.
And for all three of these categories,
there have been enormous, enormous biases
built in to the systems that have made it much, much harder
for people that have schizophrenia, that
have manic depression, that are suffering
from serious depression or anxiety.
It's even harder for them to get treatment
or to be in an environment while they're
getting health care treatment that
is supportive for quitting.
There is strong historical-- it's probably
the mental health and substance abuses is the worse.
But this is true even within diabetes, HIV treatment, et
cetera.
Now, the other one that is incredibly important
is low SES.
And I'm going to talk about that more,
and I'll also talk a little more specifically
about racial and ethnic.
So I'm going to go on to that.
So socioeconomic status influences a person's ability
to access and receive health care,
including their ability to access help quitting.
So we know that quantitatively, low SES smokers
are less likely to receive cessation assistance
from a health care provider, and that the cost
and lack of coverage is a barrier to cessation treatment.
It's harder for people with low SES to access resources,
especially if they require things like payment,
but also time away from family, arranging
transportation, et cetera.
There's also a little bit more of a generic distrust
in the medical establishment.
And particularly smokers may be less likely even to be seen.
And I do want to mention--
I'm going to get to solutions.
And I will mention that many of these
are-- we have determined-- for instance,
I'll just say from my own experience
around quit lines that being less likely to receive
assistance, if you remove the cost barrier and the access
barriers by making it incredibly easy for somebody
to get access, then you do get people who are low income.
They do use the services, and they do benefit from them.
So this is not something that, again, has to stay this way.
It's just the way it historically has been.
Now, excuse me, the other thing just on SES--
and by the way, I'm on slide 15.
Now, the environment is more tobacco user friendly.
We know that convenience stores that
sell tobacco are at a higher density in low SES communities,
which just makes it harder for people to quit and stay quit.
There's also evidence even around things
like secondhand smoke that low SES communities may have more
exposure to secondhand smoke.
OK, going on to slide 16.
Just to talk a little bit about race, ethnicity, specifically.
Just a couple of things that we do know.
I'm kind of using African-Americans as an example
here.
We know, interestingly, going back to the very first slide,
I showed you about quit attempts and success, et cetera,
Africa-Americans have a higher baseline
quit attempt rate than the general population of smokers,
which is good.
But they have a lower quit success rate.
And interestingly, those two kind of almost, you know,
they cancel each other out so that their overall rate
of quitting over a year is similar to whites,
for instance.
But we know that they also have a lower utilization--
and I've had some articles that some of you
may have read that talked about their lower
utilization of some health care associated
treatments, particularly medication use and longer term
medication use.
However, the other thing that we know
is that they do use treatment.
They have similar success rates to other smokers.
And just to give one specific example that
has been very well researched, almost counterintuitively, what
we found-- the California Smokers Help Line help
us found this.
And this actually was found in Washington and Alaska
and Oregon as well, that African-Americans actually use
quit lines at a higher rate, even without there being a--
the campaign itself not being targeted to African-Americans
or the promotion of the quit line
not being targeted to African Americans.
So there's a lot of potential there.
I'll talk about a specific example in a little.
Now, I wanted to give another example of a chronic disease
where smoking historically has been--
there's a health disparity within a health disparity.
And this is within really the HIV community,
for which the LGBT community disproportionately suffers,
particularly gay men.
And this slide, just to convince you of how dramatic this is,
this is slide 17, a graph.
If you look at this, if you're in--
the bottom line on the right, which shows HIV and smoker,
is a mortality, all cause mortality
curve as people age done from following
13,000 people in Denmark.
And essentially what they found is, if you are HIV
and you are a smoker, you are going to die a whole lot--
at a much higher rate than if you--
you're going to lose over a decade of additional life
beyond just having HIV or beyond just having smoker.
That HIV alone and smoker alone have actually similar effects
on mortality.
This is true now because we have treatments for HIV that
have turned it into a chronic disease instead of a death
sentence.
But it now means, and this is what
HIV experts around the country and the world
are beginning to grasp and try to figure out
what to do about, it means that the single strongest most
powerful intervention can be done in people that are
in good HIV care settings are getting antiretroviral therapy
et cetera, the single strongest most powerful thing
that they can do if they smoke is to quit.
And as this slide illustrates, they
smoke at 2 and 1/2 times the rate of the general population
despite this fact.
So there is something around a health care disparity
associated with smoking that cannot and must not be ignored,
because it is causing a markedly higher death rate in almost
half the people that have HIV.
But yet historically, this as a risk factor
has been almost ignored.
Now, OK, I'm going to talk about solutions now.
I'm going to close up with some solutions.
What can we do about this?
Why haven't we done more?
Well, here's an awesome example.
About a decade ago, we had Romneycare. in Massachusetts.
Didn't call it that now, but let's call it Romneycare,
where we essentially had the precursor to the Affordable
Care Act.
And as part of this, when this was rolled out
there was a general smoking cessation benefit
that covered multiple modalities of counseling and medications.
There was a very strong promotion
and systems in place in Massachusetts
that were unusual for making it easy for people
to access them for help quitting.
And when they did this, 37% of Medicaid recipients
over a very short period of time, just a few years,
used the benefit.
And this is tenfold more than what we see
under ordinary circumstances.
It was amazing.
And among the Medicaid users in Massachusetts,
the prevalence of smoking fell from 38% to 28%
in just a couple of years after this happening.
And in the next few years, they saw a 50% reduction
in cardiovascular hospitalizations.
So basically, what this showed was that insurance based
coverage in smoking cessation treatment,
especially with strong promotion and access,
increased quit attempts, the use of treatments,
and successful cessation.
So you would think, 10 years later,
that all 50 states would have set something up
like Massachusetts.
That has not happened.
That's a more complicated question.
But certainly Massachusetts showed
that it could be done at the state level.
Now, here's again another system.
The Veterans Administration has been doing a lot of work
over the last 20 plus years trying to figure out
what to do about veterans who have
a significantly higher rate of smoking
than the general population.
So they did a trial where, rather than just
try to fiddle with what to do with veterans
that came in for care, they actually had an outreach
where they--
and this is a randomized trial, where half the people got
usual care, the half the people who
got an offer of telephone or in person cessation
services via mail and proactive phone recruitment that
was very carefully executed.
They followed them up all the way to a year
and found 13.5% abstinence, which was statistically
significant compared to 10.9%.
When they started adjusting for things,
the effect size got actually larger.
And that may sound like not very much.
But if you're getting a couple percentage points
more of people quitting every year,
that is a very, very powerful population-based intervention.
This was measuring a population effect, not just those
who took part in treatment.
It was everybody in the population
was part of the denominator.
Now, I'm going to close.
There are multiple other things like that.
And I gave you some reading for some of those other things that
have been done kind of along those lines, ways in which we
can proactively outreach to smokers
in a defined population, rather than
just sitting back and hoping that they'll come in.
I'm going to close just talking a little bit
about the thing I've had the most experience
about over the last four or five years around this issue, which
is the Tips From Former Smokers' national mass media campaign.
So just I'm going to give you a little background about that.
And then I'm going to focus in on why am I telling you
about this since I think you heard from Cheryl Healton
previously about mass media campaigns.
What's the tie in?
Well, the tie in is it provides a golden opportunity
to also do stuff around treatment, access,
and awareness issues.
So this is a large national media campaign
that has been run by CDC over the last four years, first time
in 50 years that the federal government ran
a large national funded media campaign.
Its goals were to raise the awareness of negative health
effects caused by smoking, to encourage smokers to quit,
and to let people know that free help is available
b calling 1-800-QUITNOW.
And so a lot of work went into that last third bullet
to make sure that it could really happen.
It was no mean feat getting that to occur.
Now, in terms of the issue of subpopulation, social justice,
health equity, health care issues,
the Tips campaign targeted this pretty long list
of targeted populations.
And I would just add that, in addition to the large bullet
ones, upcoming there are three other groups that
were added to this.
One of them is essentially e-cigarette users
who are continuing to dual use, because we see them
as a very high risk, somewhat akin to what happened 30,
40 years ago with filtered cigarettes,
that if people think that dual use is
a solution to their problem, using both e-cigarettes
and cigarettes, the will probably be very sorry in five,
10, 20 years.
But we also are focusing more on mental illness.
And this has to do with some results I'll show you.
And there's also some specific work
being done with the military, as with the VA,
in terms of higher smoking rates in that subpopulation.
So one of the things is the ad campaign was developed.
There was a very strong commitment
to showing the diversity of US smokers.
However-- so there was a higher proportion
of African-Americans, Native Americans,
Hispanics than actually is their prevalence within the smoking
population, just to name a few.
We also-- we're sure to do some LGBT ads explicit.
These are just a few of these ads.
But the interesting thing in our findings,
and that have been true in other findings as well,
is that it did not seem that the race or ethnicity of the ad
participants affected the receptivity of the people that
saw the ads.
If you were white, you were still equally moved
by seeing an African-American, say Julia in the ad
that you see here.
By the way, we're on slide 22.
You're equally moved by seeing her as you would
by seeing somebody that had the same skin color that you had.
So we didn't try to literally make sure
that African-Americans saw African-American ads,
whites saw white ads, LGBT people saw
LGBT ads, et cetera, et cetera.
There was some effort along those lines.
But we didn't worry about it too much because of this evidence
that people can empathize with other human beings
regardless of the color of their skin.
I'm just giving you this to also say, however, that we tried
to look at people from the--
we most surely tried to use people
from the target populations that have a specific experience.
This also shows our recent effort
to try to mobilize both people with HIV
but also the practitioner community
to be more aware of the fact of the important role
that smoking plays in increasing people's life
expectancy if they have HIV.
We did a lot of work that was specific
to specific subpopulations that might have particular barriers.
And this slide actually illustrates the one
that, in many ways, I think the most important,
is language and cultural relevance.
So even though, if you look at the slide-- and again,
this is slide 24.
If you look at the one on the left,
you'll notice that the three ad participants [INAUDIBLE]
not Asian.
But it is in an Asian language, and the 1-800-QUITNOW number
at the bottom is not 1-800-QUITNOW.
It's a different number run by the California Smokers Help
Line, although the ads were done throughout
some major metropolitan areas in the US
with special Asian language help lines to help people.
And on the right side of the slide,
you see a shot from some of the shows that
were done on TV in conjunction with this that
have to do with the Spanish lines,
that people who speak Spanish could call a Spanish line.
So that is probably the most important way
in which clearly, the treatment needs to be tailored.
If you can't provide language appropriate treatment,
everything else is kind of irrelevant.
Now, I'm not going to go into detail around this.
This just basically shows there was a lot of work
also to make sure that these different subpopulations
actually were able to see the ads.
And if you look at the reach, you'll
see that it was between 70% and 90%
in all these target populations.
And the Spanish one is probably an underestimate,
because it does not include the Spanish speaking--
the ads were done specifically in Spanish speaking media.
We also developed a lot of active partnerships
with community organizations.
A lot of these are in treatment communities
related to specific medical conditions
like colostomies, retinal, macular degeneration,
the cancer treatment centers, on and on,
with the different conditions that were highlighted
in the Tips campaign.
And we tried to work to not just have this be about oh, the ads,
but also as an opportunity to talk with them about how they
could increase treatment access for the people
that they served.
This just shows that awareness was
high in the subpopulations for the various conditions
across ages, across gender, across race,
and that in some of them, again, they
tended to be higher in the ones that we were targeting.
Now, I also just want to mention that the receptivity of the ads
actually tended to be higher in African-Americans
and Hispanics, that they thought the ads were convincing,
attention grabbing, and powerful,
and had stronger reactions.
Now, honing in now on the question
of how we use this to improve treatment access.
Every ad at the end was tagged "You can quit.
For free help, call 1-800-QUITNOW."
Or a web site was given for some of the ads,
particularly later at night.
And this slide, slide number 29, just
shows basically how, in all four years of the campaign,
the tag in the ad resulted in something like a doubling
of calls to quit lines.
And we worked hard to make sure that people
that called the quit lines would get brief counseling,
encourage them to get medication.
We're actually going to do more work in 2016
after doing a pilot last year that would actually
advertise the fact that people may be able to get--
improve their access to nicotine replacement therapy
by calling a quit line.
So we're trying to make sure that people feel like they can
get easy access to evidence-based treatment
and to improve the quality of the infrastructure,
to actually be able to deliver on our promise, which
is no mean feat.
This year we're also going to be trying to work more
to try to get the state sponsored quit lines to work
more closely with the health care systems that
should be footing the bill for some of this.
This just shows you, we saw the same thing
when we had a week where with the Spanish speaking line,
you can see week nine was particularly high.
You can see the variation from week
to week in times when ads were tagged or not tagged with--
the Spanish speaking ads were tagged with this de Ayuda
telephone number.
Now, I'm just going to close a little bit
with some of what we've found in our big studies of this.
This was a study that was published last year
in The Lancet that looked at pre and post, a cohort of people
that we looked at pre and post.
And basically, very, very briefly,
we found that about 1.3 million people, if you extrapolated
from the cohort, made a quit attempt who otherwise wouldn't
because of the campaign.
You already saw that we also saw this doubling of calls
to the quit line, that it was remarkably cost effective.
Now, the next year, we did a randomized trial
that was at the regional market level that
is about to be published in two weeks in Tobacco Control.
And this what was a dosing trial, where
we gave an increased dose to people
in some of these randomly selected markets.
And what we found was there was an increase
in quit attempts, ad awareness and disease knowledge.
And this effect was particularly strong, dramatically strong,
in African-Americans.
Their quit attempt rate went from 32% to 51%.
So an incredible finding.
We also found that it was higher in those
with a non-mental chronic disease,
so diabetes, heart disease, cancers, et cetera.
So we've made it.
We're at the end of my little talk,
and I hope you can have some great conversation
in the time remaining around this important topic.
Thank you for your attention.
I'm going to close with this recap of the top line points.
Treatment as a disparity issue is multifaceted.
It requires looking both at how you increase quit attempts
in the process of delivering treatment
and how you increase quit success,
how you have effectiveness, how you increase reach.
Smokers and tobacco users as a category of human beings
suffer currently from significant health disparities,
especially health care access disparities and social justice
concerns that many people are trying to address
but need to be addressed more aggressively.
It is unethical-- let's take the state of Washington--
for the state of Washington to get $1 billion in revenue
from the sale of tobacco products,
but not commit any of that revenue,
or hardly any of that revenue, or its own power as a regulator
of insurers to making certain that everybody's
having to pay that tax, because their addiction
gets assistance.
The good news is that despite low levels of research
over the last 20 or 30 years relative to what
could have been done, we have identified
a set of effective treatments.
And although the barriers to this treatment use
have decreased, they're still far more higher
than we should be tolerating.
And there are multiple priority populations
that I talked about, including many that have a high smoking
burden that have worse access to treatment
and worse patterns of use of treatment.
So we've got to something about that.
And the good news again is, we have solutions
both at the individual level.
Hey, we've got medications, we've got counseling.
But also at the macro level, we have systems changes,
we have societal things that we can do around insurance
coverage and promotion and mixing in
with health care and media campaigns,
et cetera, that work.
So this is a public health issue predominantly
of application, of dissemination,
of policy implementation.
And with that, I will leave you to your devices,
and I wish you the best of luck in the conclusion
of this incredibly important class that you've been taking
and with your careers.
Thank you very much.
Thank you very much for your attention.
Bye bye.
For more infomation >> UNC Hospital School helps sick children keep learning while getting treatment - Duration: 2:26. 
For more infomation >> Beyond the walls: Pueblo treatment center victim speaks out - Duration: 2:56. 
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