Susan M. Zbikowski, PHD, Senior Vice President, Research, Training, & Evaluation 

I am pleased to announce that Alere Wellbeing had an important paper published this month in the Journal of Environmental and Public Health. Our article, “The 2009 US Federal Cigarette Tax Increase and Quitline Utilization in 16 States,” written by Terry Bush, Susan Zbikowski, Lisa Mahoney, Mona Deprey, Paul D. Mowery, and Brooke Magnusson, describes call volumes to 16 state quitlines, characteristics of callers, and cessation outcomes before and after the 2009 federal tax increase.

You may remember back to 2009 when smokers were once again hit with a large increase in the cost of their cigarettes. On February 4, 2009, the federal government enacted a 62-cent increase in the federal cigarette tax, along with increases in other tobacco taxes, to fund expansion of the State Children’s Health Insurance Program. The federal cigarette tax increased to $1.01 per pack on April 1, 2009. Right before the increase in cigarette tax was made public, tobacco companies sneaked in their own price increase on tobacco products. This dramatic increase in the costs of smoking was likely to be a tipping point for smokers to try to quit. With support from the Centers for Disease Control and Prevention (CDC), researchers at Alere Wellbeing decided to find out if these increased costs would result in more people calling state quitlines for help.

Results of this study were just released in the Journal of Environmental and Public Health. The study showed that the federal excise tax on cigarettes was associated with a 23.5% increase in calls to quitlines and attracted somewhat different types of smokers compared with the year before the tax. In particular, it seems that the tax had a greater impact on those who had less education and who were living with other smokers based on the increase in calls from this demographic. Although we also expected that more young smokers would call, this was not the case in this study.

Another important finding from the study was that quit rates among those who called after the tax increase did not differ from quit rates among those who called before the tax increase. The lack of a significant increase in quit rates is not surprising since the participating quitlines did not provide additional or different services to callers. Nonetheless, increasing the number of callers at the same quit rate means an increase in total number of successful quitters. In these 16 states, of the 19,911 additional tobacco users who called during the time of the tax an additional 5,714 would quit smoking (19,911 more callers after tax ∗ 28.7% quit rate).

If the money raised from increased taxation on cigarettes was put into cessation treatment, then it is likely the taxes would have an even greater effect on helping smokers to quit. Numerous studies have shown that quitlines increase ones chances for quitting, especially when multiple counseling calls plus nicotine replacement medications are made available. Unfortunately, states have been cutting back on the services they provide on order to contain costs. This study from Alere Wellbeing provides important data relevant to public health policy on tobacco control. Providing evidence-based cessation services combined with tax and price increases, smoke-free laws, anti-tobacco advertising, and bans on promoting tobacco use can increase quit rates and decrease the prevalence of tobacco use.

Reed Dunn, Senior Recruitment Marketing Manager

Every year on May 31, the World Health Organization celebrates World No Tobacco Day (WNTD). Established in 1987, WNTD is an annual recognition of global efforts against tobacco use. The theme of World No Tobacco Day 2012 is “tobacco industry interference.” WHO is urging countries to put the fight against the tobacco industry at the heart of its efforts to control the global tobacco epidemic.

In response, Alere Wellbeing plans to come together as one company on Thursday, May 31 to conduct at least 3,000 live tobacco interventions - helping at least 3,000 of the tobacco industry’s customers get one step closer to overcoming their deadly addiction for good. We will also be setting a new record for the number of tobacco users receiving support from the Quit For Life® Program in a single day.

We encourage tobacco users who are ready to quit to join the movement and call 1-866-QUIT-4-LIFE (1-866-784-8454) on Thursday, May 31, 2012.

For more information, please read the following press release.

Reed's drive to live a better life started when he joined the Alere Wellbeing team. As senior recruitment marketing manager, he works to educate eligible populations of the benefits available to them to achieve a healthier lifestyle. Read more blog posts by Reed Dunn.

Visit www.alerewellbeing.com to learn about Alere Wellbeing’s Quit For Life® Program, the only commercial tobacco cessation program in the U.S. with proof of effectiveness published in multiple peer-reviewed scientific journals over the course of 25 years.

Janice Milliman, Quit Coach, Service Delivery

Tobacco use among adults who live below the poverty line was about 28 percent in 2010, compared to 19 percent for those at or above.  State Medicaid programs who serve those in poverty need to beef up their tobacco-cessation benefits and reduce the barriers enrollees face when trying to access those benefits.

Tobacco cessation benefits may include support calls and medication, such as nicotine replacement (patches or gum) or prescription medications. Tobacco users cost Medicaid programs much more than non-tobacco users, so according to the Tobacco-Free Kids January 2012 factsheet, Comprehensive Statewide Tobacco Prevention Programs Effectively Save Money, Medicaid programs have more to gain by funding and promoting tobacco cessation.  A recently published study on the  return on investment (ROI) of a state medicaid tobacco cessation program found that Massachusetts saved more than $3 for every $1 spent, and that the reductions in cardiovascular hospitalizations alone saved about $14.7 million for the state Medicaid program.

Medicaid programs have a specific process that each enrollee must adhere to in order to receive the benefits to which they are entitled. Such processes are in place likely to control cost, ensure proper treatment, and possibly to prevent fraud. Unfortunately, some state Medicaid programs have too many hoops to jump through. With so many possible breakdowns in the system, enrollees face delays in quitting, discouragement, and some simply give up. Additionally, many Medicaid enrollees are less-well educated and may have physical or mental limitations that make it more difficult to jump through hoops.

The million-dollar question is, then, if tobacco prevention and cessation programs reduce smoking, save lives, and save money by reducing tobacco-related health care costs, why don’t more state Medicaid programs allocate funding and create a reasonable process for accessing benefits?

Most tobacco users say quitting is one of the hardest things they've ever done. Janice, a Quit Coach®, feels that helping people succeed and overcome feelings of shame are some of the highlights working at Alere Wellbeing. Read more of Janice Milliman's blog posts.

Learn more about the Quit For Life® Program

Read more stories from current and former Quit Coaches

Ken Wassum, Associate Director, Clinical Development & Support

For the past two or three decades, some brilliant people in the US and abroad have made a priority of reducing disease and death – and those committed to reducing the toll of tobacco continue to work tirelessly and with tremendous optimism. Having just returned from the 15th World Conference on Tobacco or Health in Singapore, I am encouraged by the progress made in some areas of tobacco control, yet very discouraged by the lack of progress in others.

Over the course of the next several weeks I will be posting a series of blog posts that address many of these issues and more in greater detail.

To get started, let’s look at some of the accomplishments we’ve made over the past couple decades:

• 174 countries have signed and ratified the World Health Organization’s Framework Convention on Tobacco Control that addresses the tobacco epidemic from both policy and treatment perspectives.
• More countries than ever provide access to toll-free tobacco Quitlines, including North America where all 50 states, 3 US territories, and 12 Canadian provinces have such services. Quitlines exist throughout Europe and in many parts of Asia and Oceania.
• Many countries with National Health Services, such as the UK, have expanded community-based clinical treatment for tobacco use.
• Graphic warnings on cigarette packs have been adopted by many countries around the world. In some countries “plain packaging” is on the horizon.
• Many countries have raised taxes on tobacco products, especially cigarettes, resulting in lower tobacco use prevalence.
• The US FDA has been given unprecedented authority to regulate tobacco products.
• Tobacco use prevalence in the US has declined from about 27% in 1991 to about 19% in 2010.

Yet, should you think these accomplishments mean we are “winning” the battle, here are some sobering, even chilling, facts:

• In 2011, tobacco use killed almost 6 million people worldwide.
• Global tobacco-related deaths have nearly tripled in the past decade.  The number of annual deaths in the US from tobacco use (443,000) has remained unchanged for the past couple decades.
• Each day, nearly 4,000 kids in the US try their first cigarette and an additional 1,000 kids under 18 years of age become new regular, daily smokers. That’s nearly 400,000 new underage daily smokers in this country each year.
• If trends continue, 1 billion people around the world will die from tobacco use and exposure during the 21st century. To put that mind-boggling number in perspective, that’s 1 person every 6 seconds.
• Tobacco tax revenues in the US have reached unprecedented levels at the state level and the national level, yet tobacco control remains shamefully under-funded and under-resourced. Margaret Chan, Director General of the World Health Organization, sums it up succinctly when she states, “Measures to tackle the epidemic remain seriously under-funded.”
• Cessation services to help tobacco users quit remains the “orphan” of tobacco control and fails to be resourced to its full potential. It has become an issue of social justice.
• The tobacco industry in their multi-national capacity have increased their efforts to both confound and delay tobacco control in the US and have increased efforts to sell their deadly products abroad, targeting women and children in developing countries. They continue to challenge the FDA in implementation of evidence-based initiatives by the Center for Tobacco Products.
• According to the March 2012 Surgeon General’s Report, one in five high school students in the US smokes, and over half of these youths also use a smokeless tobacco product. Nearly 90% of youths start smoking before the age of 18.

We are clearly at a crossroads. Smoke-free laws have taken effect across the US, and the public has the mistaken perception that the battle against tobacco use has been won. Yet those dying of tobacco-related diseases continue to die behind closed doors, away from public view. Dying from smoking is rarely quick and never painless. Many governments around the world, including the US, continue to underfund proven strategies to reduce disease and death caused by tobacco products and under-prioritize the enormity of the tobacco epidemic, especially among our children and our most vulnerable populations.

There is a lot to discuss here, so please stay tuned.

Ken Wassum has been treating tobacco users for over 19 years. He is past President of The Association for the Treatment of Tobacco Use and Dependence and previously served on its Board of Directors. Join him as he blogs about the effects of the tobacco epidemic, the efforts of cessation advocates, and the work left for us to rid the world of nicotine addiction. Read Ken Wassum's blog posts.

Visit www.alerewellbeing.com to learn about Alere Wellbeing’s Quit For Life® Program, the only commercial tobacco cessation program in the U.S. with proof of effectiveness published in multiple peer-reviewed scientific journals over the course of 25 years.

Ken Wassum, Associate Director, Clinical Development & Support

The CDC, and specifically its Office of Smoking and Health, should be heartily congratulated on the graphic ad promotional campaign scheduled to launch today, March 19. We’ve greatly anticipated these ads, especially in light of a recent (misguided) court ruling that the government could not require the tobacco industry to put graphic warnings on cigarette packs to replace the tired old ineffective warnings that have been on cigarette packs since the 1970’s.

After seeing the ads some in the press have wondered if the ads are too graphic and too shocking. I would suggest that they are not too graphic and the reason is that the public has become immune to the current warnings on cigarette packaging. Here are the facts after over 40 years of text-based warnings on cigarette packs:

• Over 1,200 people die every day (443,000 per year) in the US as a direct result of smoking.
• One of every two smokers will die prematurely.
• The average smoker will die 14 years early.
• Cigarettes are the only product sold in the US that when used as recommended (needless to say advertised, promoted and discounted) by the manufacturer results in disease and death.

There is hope that the new ads will help shed light on the harrowing reality of tobacco-related diseases. Cancer of the throat is an abstract concept for those who do not have it. The "Tip From a Former Smoker" ad featuring Terrie makes it real – certainly not as real as it is for her, but certainly a lot more real than a text on a cigarette pack that says, “Smoking can cause cancer of the throat.”

In response to these ads, the Atria Group, the parent company of Philip Morris USA and U.S. Smokeless Tobacco, states, “We support a three-part approach to reducing the harm caused by cigarette smoking: preventing underage tobacco use, promoting quitting and a focus on the development of and appropriate communications about potentially lower risk tobacco products,” the company said in a statement. “We believe we can play an important role in this effort and will continue to work with the FDA and others in public health to help reduce the overall harm of tobacco products.”

Yet the tobacco industry does everything it can to sell their deadly products to youth in the US and especially in foreign countries (like Indonesia) and promote their deadly products to adults in the US and overseas (like Camel Orbs).

So hats off to the CDC for taking action. Hopefully the courts will come to their senses and reverse the decision by Judge Richard Leon banning implementation of graphic warnings on cigarette packs. Let’s hope these new ads cause smokers to pick up the phone and call their state tobacco quitline for help.

Ken Wassum has been treating tobacco users for over 17 years. He is past President of The Association for the Treatment of Tobacco Use and Dependence and previously served on its Board of Directors. Join him as he blogs about the effects of the tobacco epidemic, the efforts of cessation advocates, and the work left for us to rid the world of nicotine addiction. Read Ken Wassum's blog posts.

Visit www.alerewellbeing.com to learn about Alere Wellbeing’s Quit For Life® Program, the only commercial tobacco cessation program in the U.S. with proof of effectiveness published in multiple peer-reviewed scientific journals over the course of 25 years.

Yuki Yang, Vice President of Client Services

Last week I wrote about the growing trend of employers to administer cotinine tests (otherwise known as nicotine tests) to verify employees’ tobacco use status in light of hefty healthcare discounts offered to nonsmokers through premium differentials programs. Today I’m going to share with you some best practices on how to set up a nicotine-testing policy at the worksite.

Before I go any further, it’s important to mention that at Alere Wellbeing, we don’t believe that nicotine tests are necessary to prove a person’s abstinence from tobacco. Studies have shown that nicotine tests often validate that the honor system usually does work. However, given the dollar value of premium differentials, we do see a place for randomized nicotine testing.

Random testing can act as a deterrent to dishonesty.

Employers may opt to randomly administer the test to employees who claim to be tobacco free when premium differentials are offered. Used in this way, the test acts as a deterrent to employees who may otherwise be dishonest about their tobacco use in order to obtain the incentive.

Testing new employees can ensure compliance with a no-hire policy for tobacco users.

Employers may also test new employees who join organizations with a no-hire policy for tobacco users. It’s important to note that many states have anti-discrimination laws around this issue (sometimes known as "smokers' laws" or "lifestyle laws"), so we recommend the consultation of appropriate resources prior to implementation of a nicotine test.

There are a few ways companies can ensure that employees are on board with the implementation of nicotine testing as a part of their premium differential plan:

• Randomly test employees. The random nature of the test will encourage those who may be tempted to lie about their tobacco use to be more truthful or take advantage of the opportunity to quit.
• Clearly communicate why the tests are being administered. Make sure employees understand that the purpose of the test is to help support the premium differentials program, which is intended to encourage the entire workforce to make healthy decisions. Keep communications positive and encouraging. Also clearly communicate the available options if an employee tests positive.
• Do not respond to a positive test with punishment. Instead, use the results as a “teaching moment,” taking into account the possibility of a false negative and using the opportunity to test again, or, in the case of a true positive, provide support in encouraging the use of the Quit For Life® Program for assistance in quitting.

Note: Self-reported quit rates are highly correlated with the results of biochemical verification tests such a cotinine tests. Alere Wellbeing does not recommend using cotinine testing to verify quit rates.

If you missed the popular March 13 webinar  Best Practices for Premium Differentials in Tobacco Cessation, sign up for the next presentation on March 20 at 11am PDT. Yuki and a panel of human resources professionals experienced in premium differentials from Sherwin-Williams, Family Dollar, and WellPoint will share lessons learned and best practices. Visit Clear Insights to register.

Read Yuki’s blog post, Nicotine Testing for Employee Tobacco Use

Yuki Yang, Vice President of Client Services

An increasing number of organizations now offer premium differentials for tobacco cessation at their worksites. By the end of 2011, 40% of Alere Wellbeing’s clients had set up programs requiring tobacco users to pay a higher premium on healthcare than non-tobacco users.

Self-reporting works, but random testing can be a safeguard against dishonesty.

There are many ways to determine whether a person is abstinent from tobacco – many employers simply ask employees sign an affidavit or make a non-smoking pledge. Our experience shows us that self-reporting does work. Yet premium differentials can be quite large – as high as 20% of the total health insurance premium and increasing in 2014 under regulations associated with the Healthcare Reform Act – and some people worry that tobacco users will be tempted to dishonesty at the promise of financial reward.

Because the perceived threat of a randomized test can oftentimes be a deterrent to dishonesty, some employers have turned to nicotine testing - sometimes referred to as cotinine testing - to ensure that their premium differentials program is truly rewarding those who are making the healthiest decisions.

What is cotinine?

Cotinine is an alkaloid found in tobacco and is produced when the body metabolizes nicotine after ingestion. This means that cotinine can be used as a biomarker for exposure to tobacco. Cotinine is typically detectable for several days after the use of tobacco.

What kinds of cotinine tests are available?

Cotinine tests can be based on blood, urine, saliva, or hair. Tests that are based on blood, urine, and hair are a bit more complex and must be conducted by a professional biometrics service provider, oftentimes offsite in a laboratory setting (though some blood and urine tests can be conducted onsite where appropriate). Saliva-based tests, however, are easy to administer and can be done by any designated member of the Human Resources staff or other internal delegate.

Advantages of a saliva-based cotinine test:

• Test can be administered 4-7 days after last tobacco use.
• Inexpensive and non-invasive. 
• Observed collections mean limited possibility for specimen tampering. 
• Rapid tests can provide results within 15 min.   
• Each test comes with detailed instructions for use.

Saliva-based tests are easy to administer and can be done by any designated member of staff. Each test comes with detailed instructions for use.

Note: Self-reported quit rates are highly correlated with the results of biochemical verification tests such a cotinine tests. Alere Wellbeing does not recommend using cotinine testing to verify quit rates.

Join Yuki for the next Clear Insights webinar, Best Practices for Premium Differentials in Tobacco Cessation, March 13 and March 20 at 11am PST. Yuki and a panel of human resources professionals experienced in premium differentials from Sherwin-Williams, Family Dollar, and WellPoint will share lessons learned and best practices. Visit Clear Insights to register.

Subscribe to our RSS feed to make sure you don’t miss Yuki’s upcoming blog post, Creating a Nicotine Testing Policy.

Yuki Yang, Vice President of Client Services

Tobacco use remains the number one cause of preventable death and disease in the United States and costs employers an estimated excess cost of $21 per smoker, per day, or $7,874 per year. What was once a debate is now an accepted fact: employers must take an active role in helping their tobacco users quit successfully.

Healthier workforces mean better productivity and fewer medical expenses, and according to the Centers for Disease Control and Prevention, an evidence-based tobacco cessation program is one of the only employer benefits with a proven ROI. If you already have a tobacco cessation program in place at your organization, you may wonder how to effectively drive participation. Will offering incentives discriminate against nonsmoking employees, reward smokers for unhealthy behaviors, or negate the ROI for the program?

Alere Wellbeing has found that employers successfully increase participation in wellness programs when they reward healthy behaviors throughout the course of the program rather than focusing on the end result. By implementing an approach that includes an evidence-based program, is supported by a positive environment, and is led by a team that anticipates the future, you will find that offering incentives can promote positive behavior change, positively impact your bottom line, and improve your employee relations.

What motivates people to change?

People are innately motivated by the possibility of rewards, and a person’s motivation increases with confidence in his or her ability to perform the task at hand. Most smokers say they want to quit, but many who have tried to quit in the past have not succeeded. This leads to a lack of confidence and a decrease in motivation to try again. In order to promote lasting behavior change, you must provide the kind of environment that encourages and rewards healthy choices rather than punishes those caught in an addictive cycle.

• Increase motivation with knowledge. Tobacco use is an addiction that hits a smoker on three fronts – he is addicted physically, behaviorally, and emotionally. Helping smokers understand the kind of battle they are up against – and offering the tools to help them face each part of this battle – will give smokers more confidence in their ability to quit successfully. Nonsmokers will benefit from reminders that tobacco use is an addiction and that smokers should be encouraged rather than vilified.
• Build confidence through practice. Practicing new behaviors in situations that used to involve tobacco builds confidence in a smoker’s ability to change.
• Reframe destructive thoughts by developing cognitive skills. Developing new ways of thinking about tobacco use by reframing incongruous thoughts prepares smokers to make rational choices rather than giving way to addictive behaviors.
• Emphasize tangible and intangible rewards. Smokers who quit will experience tangible rewards such as better health and financial gain (this will be especially true if you offer a premium differential, which I will address in upcoming blog posts). Through an effective program, they may also experience intangible benefits such as happiness, positive competition, and reduced stress. Remind your employees of the benefits they will receive—those they will acquire from you as well as those they will achieve for themselves.

Join Yuki for the next Clear Insights webinar, Best Practices for Premium Differentials in Tobacco Cessation, March 13 and March 20 at 11am PST. Yuki and a panel of human resources professionals experienced in premium differentials from Sherwin-Williams, Family Dollar, and WellPoint will share lessons learned and best practices. Visit Clear Insights to register.

Erin Thompson Curlett, Senior Content & Social Media Marketing Manager

Today we are excited to announce our industry-leading tobacco cessation program, Quit For Life®, is now available in Spanish, removing language as a major barrier to quitting for Spanish speakers.

Quit For Life® in Spanish, available to employers and health plans, features phone-based coaching with a native Spanish-speaking Quit Coach®, integrated with Web Coach®, the most innovative and advanced online learning and social support community available for tobacco users. Clients receive dedicated account management, transparent reporting, and a customizable promotions package including a website (www.quitnow.net) and more than 100 materials and emails in Spanish.

Nearly 15 percent of our service delivery staff has been trained to support Spanish-speaking participants, including registration intake specialists, Quit Coaches, and supervisors. Quit For Life® has the highest standards for coaching in the industry, including ongoing mentoring, training, and evaluation.  As such, Spanish Quit Coaches must graduate from 12 weeks of immersive training on clinical protocols and tobacco cessation coaching, and 4 weeks of training on cultural and dialect differences, dosing regimens for medication, and symptomology. We recruit staff with a background or education in counseling, addiction studies, community health education, or social work. Our Spanish-speaking Quit Coaches are native speakers hailing from countries like Puerto Rico, Mexico, Colombia, and more.

Read the press release about Quit For Life® in Spanish

More information about Quit For Life® can be found at www.alerewellbeing.com or by emailing wellbeingsales@alere.com.

Ken Wassum, Associate Director, Clinical Development & Support

Nicotine replacement therapy (NRT) has been used for decades to help smokers quit. This week’s newspapers and online sources were awash with “breaking news” that nicotine replacement therapy does not work. This study* came out of the Harvard school of public health, and frankly its findings should not be worth the hype.

I will take this a step further by saying that NRT options work better than ever. Tobacco treatment professionals now better understand how to recommend combinations of these medications as well as match them with highly effective behavioral strategies that improve quitting success greatly.

Here is what the Harvard researchers did. Between 2001 and 2006 they interviewed a total of 787 individuals who had recently quit smoking. They conducted 3 waves of interviews over the course of 5 years. Results showed that those who used NRT (nicotine patches or nicotine gum) and/or professional assistance were more likely to relapse back to smoking as those who quit without NRT or professional help. I do no dispute their findings, but I do question their interpretation of the results.

We have known for years that their findings are largely true, but it does not mean that NRT is not effective. It certainly does not mean that professional help is not effective. What it means is that those who seek treatment (counseling and/or use of quit medications) are typically more nicotine dependent than those who do not seek treatment and as a result have less success in quitting. Those who are less dependent typically feel they can quit on their own.  As Saul Shiffman pointed out in his 2008 publication** surveys of the type done by the Harvard researchers are subject to recall bias. He states, “past quit attempts are easily forgotten, particularly as many are undertaken spontaneously, and many are short-lived. Treatment seeking itself likely makes quit attempts more memorable because smokers must undertake unusual actions, like seeking counseling or purchasing and using medications. Thus, treatment failures may be remembered and unaided failures forgotten, leading to biased estimates of effectiveness.”

Many experts in the field of tobacco dependence treatment feel the Harvard study had some limitations. The most obvious was the self-selection bias, where individuals are not randomized to a certain treatment, but rather select a treatment or quitting approach based on their assessment of their own needs. I am not saying that randomized controlled trials (RCTs) for cessation medications do not have some problems – they do. In my opinion they frequently exclude too many individuals who are representative of real world smokers. But randomization goes a long way to remove the element of bias in study results.

It is sad that many reputable news agencies ran the article without doing due diligence by researching the findings. The effect is that many people who very much need to quit smoking and would benefit hugely from professional treatment will not seek help because they now may believe that these medications do not work. In fact, they do. 

In my opinion, rather than saying that medication treatments are not effective or that they are not a good use of scarce public health expenditures, what we need is more research showing us how to better implement what we already know is effective. And one of these effective treatment elements is NRT.

*Alpert, H.  A prospective cohort study challenging the effectiveness of population-based medical intervention for smoking cessation.  Tobacco Control 2012.
**Shiffman, S. Use of Smoking-Cessation Treatments in the United States. Am J Prev Med 2008.