Disparities in knowledge and use of tobacco treatment among smokers in California following healthcare reform

Abstract

The Affordable Care Act (ACA) promised to narrow smoking disparities by expanding access to healthcare and mandating comprehensive coverage for tobacco treatment starting in 2014. We examined whether two years after ACA implementation disparities in receiving clinician advice to quit and smokers' knowledge and use of treatment resources remained. We conducted telephone interviews in 2016 with a stratified random sample of self-reported smokers newly enrolled in the Kaiser Permanente Northern California's (KPNC) integrated healthcare delivery system in 2014 ( N = 491; 50% female; 53% non-white; 6% Spanish language). We used Poisson regression with robust standard errors to test whether sociodemographics, insurance type, comorbidities, smoking status in 2016 (former, light/nondaily [<5 cigarettes per day], daily), and preferred language (English or Spanish) were associated with receiving clinician advice to quit and knowledge and use of tobacco treatment. We included an interaction between smoking status and language to test whether the relation between smoking status and key outcomes varied with preferred language. Overall, 80% of respondents received clinician advice to quit, 84% knew that KPNC offers cessation counseling, 54% knew that cessation pharmacotherapy is free, 54% used pharmacotherapy, and 6% used counseling. In multivariate models, Spanish-speaking light/nondaily smokers had significantly lower rates of all outcomes, while there was no association with other demographic and clinical characteristics. Following ACA implementation, most smokers newly enrolled in KPNC received clinician advice to quit and over half used pharmacotherapy, yet counseling utilization was low. Spanish-language outreach efforts and treatment services are recommended, particularly for adults who are light/nondaily smokers.

Understanding Racial Disparities in COVID-19–Related Complications: Protocol for a Mixed Methods Study

“…Despite this, pervasive racial, ethnic, and socioeconomic disparities exist within the KPGA population. For example, Kaiser Permanente has previously reported racial and socioeconomic disparities with respect to health and well-being [ 38 ], gastric cancer [ 39 ], smoking cessation [ 40 ], and diabetes care [ 41 ], and preliminary evidence suggests that Black members are twice as likely to experience housing instability, indicating that a social gradient exists within this integrated health system. Understanding the underlying mechanisms contributing to racial disparities in COVID-19 in a population with comparatively uniform access to care is the focus of this work, for which the KPGA data infrastructure is well-suited.…”

Effects of Medicaid coverage on receipt of tobacco dependence treatment among Medicaid beneficiaries with substance use disorder

“…Based on prior literature, one explanation could be the greater awareness and availability of medication treatment versus counseling services for nicotine dependence among the general population of tobacco users 17,18 . For example, one study reported that the majority of smokers were not aware of free counseling services and strategies such patient outreach (e.g., through secure messages) and provider referrals to counseling services could accelerate the use of counseling services among smokers 18 . Another could be that individuals with SUD are more likely to use counseling services for SUD treatment and could prefer medication over counseling for tobacco dependence treatment 32 .…”

“…17,18 For example, one study reported that the majority of smokers were not aware of free counseling services and strategies such patient outreach (e.g., through secure messages) and provider referrals to counseling services could accelerate the use of counseling services among smokers. 18 Another could be that individuals with SUD are more likely to use counseling services for SUD treatment and could prefer medication over counseling for tobacco dependence treatment. 32 These results could also reflect broader barriers experienced by Medicaid beneficiaries, including cost, transportation, or absence of local providers, particularly those with SUD, in accessing specialty outpatient mental health care for smoking cessation.…”

“…Medicaid recipients in states with comprehensive TDT coverage have higher quit rates 16,17 ; and enrollment expansions have increased rates of patient assistance and smoking cessation medication use. [17][18][19][20][21] TDT use has demonstrated effectiveness in reducing tobacco dependence among individuals with SUD, 22 but we are not aware of any studies assessing the effects of expanded TDT coverage on TDT use among individuals with SUD. Furthermore, studies evaluating the effects of TDT coverage expansion among the general population of Medicaid recipients have had limitations, including focusing on just a single state, 18 or focusing on patients already receiving tobaccorelated treatment at community health centers.…”

“…For example, from 2009 to 2013, 15 states changed coverage for individual/group counseling; five states changed coverage for gum, patch, or lozenge; 14 states changed coverage for inhaler or spray, and six states changed coverage for bupropion or varenicline (see Appendix S1 for details). Medicaid recipients in states with comprehensive TDT coverage have higher quit rates 16,17 ; and enrollment expansions have increased rates of patient assistance and smoking cessation medication use 17–21 …”