Oregon Health Plan Members Still Puffing Away

But, at the same time, Oregon is known nationally for helping people quit the habit

April 12, 2012 -- Oregon has one of the strongest programs in the country to help people stop puffing on cigarettes, yet its preponderance of low-income smokers remains high. A survey conducted last year found that 31 percent of people on the Oregon Health Plan are smokers, roughly 201,000 Oregonians, compared to a 15 percent rate among the general public.

The Oregon Health Plan has a robust tobacco benefit,” said Dr. Charles Bentz, medical director of Legacy Health System’s tobacco cessation program. “The problem is getting people to access and use it. That’s a health system issue.”

Most of these programs have been designed based on an upper-middle class population, he said.

What Oregon needs to do is offer culturally competence smoking cessation benefits that are user friendly and culturally specific, along with peer groups, for people who want to quit,” said Brett Hamilton, executive director of the Tobacco Free Coalition of Oregon. “Not a one size fits all benefit.”

Smoking rates are higher among lower income adults in Oregon. Approximately 36 percent of those with incomes less than $15,000 a year smoke, compared to 7.6 percent of people who earn over $50,000 a year. At the same time, research has shown that smoking prevalence generally decreases with increasing education. In Oregon, 40.4 percent of those who didn’t graduate from high school smoke, compared to 4.9 percent of people with a college education.

When you control for income and education, the difference is eliminated,” Bentz said.

They (the low-income population) are marketed to more (by the tobacco industry) and they have less health literacy.”

Not only are people with lower incomes likely to smoke, they also face physical and mental health problems that compound the problem, said Wendy Bjornson, director of the Smoking Cessation Center at Oregon Health & Science University. “If you’re not well, it is difficult to achieve higher levels of education, which leads to higher levels of income.”

It’s hard to call a quit line when you don’t have a phone,” Bentz said. “Besides, frequently people self-medicate. We have found that those with lower socioeconomic status have fewer coping skills and more stress.”

People who smoke are often attempting to use nicotine to deal with depression and anxiety,” Bjornson said. “Nicotine is a central nervous system drug that influences brain functioning. Many people with mental illness find their way to nicotine and find that it helps them function more normally. Nicotine also affects the experience of pain so that people with chronic pain or other chronic conditions also find that nicotine helps them. At the same time, we’re finding that smoking and nicotine can actually make some of these conditions worse. So people become sort of trapped in a difficult situation in which nicotine is so much a part of their biochemistry that taking it away causes a big disruption in how they function. It is really difficult for people.”

Both Bentz and Bjornson challenge the idea that it’s somewhat cruel to take smoking away from people with mental illness because they have so few “pleasures.” Encouraging this line of thinking only leads to more suffering and even death.

Tobacco addiction is a killer,” Bentz said. “It is the biggest cause of cancer and heart disease.”

Reducing tobacco use among lower-income adults affects more than health outcomes. Medicaid costs related to smoking are estimated at $287 million per year, which is equivalent to 10 percent of Oregon’s Medicaid budget.

So what’s being done? “The Oregon Health Authority has worked to improve and advance access to tobacco cessation services for Oregon Health Plan clients,” said Alissa Robbins, spokesperson for the Oregon Health Authority. “Tobacco cessation is a top priority.”

Tobacco cessation programs offered to people on the Oregon Health Plan vary depending on their plan coverage, and many plans don’t routinely promote these benefits, which has resulted in low utilization, Robbins said.

Studies show that tobacco users are two times more likely to quit successfully if they receive help, specifically counseling and medication.

We’re all talking about healthcare transformation, well this (tobacco cessation) is what we need to do,” Bentz said.

As Oregon transforms its healthcare system, tobacco cessation remains a top priority, Robbins said. “Tobacco use is one of the core metrics that coordinated care organizations will be reporting on.”

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In my opinion, tobacco cessation remains the major publich health problem of our time (only because we have been so successful about other public health problems). The idea of recruiting low income former smokers and having them lead peer groups and using other culturally competent interventions is ideal. I hope that we can transform the current efforts to meet the needs of this group of people. The benefits last for decades as do the costs of doing what we are doing now and expecting different results. Maureen Nash, MD