Advancing Quit Services podcast

Brandon Benzin:
You're listening to Advancing Quit Services, a podcast about tobacco cessation from Optum, where we discuss barriers to quitting tobacco, and strategies for overcoming them with experts at the forefront of tobacco research. I'm your host, Brandon Benzin. I'm a business strategy manager at Optum. Today's topic is tobacco priority populations. We'll cover who these populations are, why they exist and the barriers they face, followed by a discussion about what can be done to overcome those barriers. My guests today are Etta Short, public health leader and senior product manager for clinical development at Optum. And Dr. Kelly Carpenter, principal scientist at the Optum Center for Wellbeing Research. Thank you both for joining me today.

Etta Short: 
Thank you for having us.

Dr. Kelly Carpenter:
Yes, thank you.
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Brandon Benzin:
Let's start with the basics. What is a priority population in the context of tobacco use? And why do priority populations exist in the first place? Etta, I'd like to start with you.

Etta Short: 
Thanks for giving us the opportunity to talk on this topic today. For me, tobacco is a social justice issue and thinking about this gives me motivation every day for my work. Priority populations are those smoking at higher rates than the general US population. The tobacco use rate in the US has been steadily declining. Consider this, that the tobacco use rate was more than 40%, when it was peaking in the 1960s. And today, just under 14% of US adults are smoking. But that's actually not the full story. Because there are populations in the US that are smoking at higher rates, some 35% or more. And, you know, when you think about these populations, most of these are underserved. They are disadvantaged populations. So, when you're looking at where to put tobacco control money and money in tobacco cessation, it makes sense to put it there where you can help these vulnerable populations to work at lowering their quit rate and increasing the quality of their lives. And overall, what we'll be doing is lowering the overall tobacco use rate in the US. This lowers medical cost. This also lowers cost and increases productivity for businesses.

Dr. Kelly Carpenter:
Yeah, and even in addition to those groups that smoke at higher rates, there are also groups that while they may not smoke at higher rates, they really carry a disproportionate burden with regard to ability to quit, and they suffer higher rates of tobacco related illnesses and death.

Brandon Benzin:
Can you give me a few examples of populations that have been disproportionately affected by tobacco?

Dr. Kelly Carpenter:
Yeah, so tobacco related disparities affect a lot of different groups based on a variety of factors such as race and ethnicity, socio economic factors, minority groups like sexual and gender minorities. For example, African Americans smoke at rates not too different from other groups, but we see a disproportionate percentage of tobacco related illness and death. Tobacco use is a major contributor to the three leading causes of death among African Americans: heart disease, cancer and stroke. Another example is people with behavioral health conditions. They smoke at far higher rates than those without these conditions. In fact, about half of all cigarettes smoked in the US are smoked by people with behavioral health conditions. And among people with what we call serious mental illness, like schizophrenia, they lose 20 to 30 years of their lives related to tobacco-related illness. Also, people with low income tend to smoke at higher rates than others.

Etta Short: 
Listening to Kelly, you can see that there's just not one way to characterize these vulnerable populations. She mentioned a few different groups. On one hand are the racial and ethnic groups. I can add to the list, Native American and Alaska Natives which have really high smoking rates, maybe some of the highest in the US, the LGBTQ community, as Kelly mentioned, but you also can look at groups like pregnant women, they have a lower smoking rate, but they're included because the risk to the mother is so high and also the risk to the pregnancy. And then after the child is born, it's the secondhand smoke issues that also are important to consider. You can also look at geographical disparities as well. We see much higher tobacco use rates in the rural communities or in the Midwest and the southeast.

Brandon Benzin:
What kind of are barriers do priority populations face that other individuals don't have to overcome?

Etta Short: 
So, one of the barriers that span most of the groups is systematic discrimination. And then one of the other barriers that you see across all groups is increased stress.

Dr. Kelly Carpenter:
Yeah, other things are factors like inadequate access to health care, lower health literacy, and being a member of a community where tobacco use is common. And the norms around tobacco use are different than in other groups.

Etta Short: 
You know, one more thing I could add is that these populations are also specifically targeted by tobacco companies. In the past, free cigarettes were given away at housing projects, even to the kids. People were issued coupons for cheaper cigarettes. What is really common today is advertising, you know, the ads that people see, both in print and at the point of sale where people are buying tobacco products. I have a story to tell where I was in a store recently, where in an area where there's a high tobacco use, and it was actually a low-income community. I was in a grocery store. And I was at the register at the back of the counter was just blanketed with tobacco products and tobacco ads. And I compare that to my own grocery store, where the cigarettes are locked away in a cabinet and kind of almost even out of sight. So, it really brought to light how the environment really does normalize cigarette use in some places, and in some neighborhoods.

Brandon Benzin:
Okay, so we've discussed who priority populations are and why they exist, the problems that they might experience and the root causes of these problems. But it's not all bad news, right? There must be some strategies quitlines can use to address these barriers.

Etta Short: 
Yeah, there are a lot of things that we can do to meet the needs of these populations. And one of the big things we can do is training the quit coaches, you know, giving them training on specific tobacco-related and culture-related issues that impact their use of tobacco, and quitting tobacco. We can also train coaches or hire folks who have the facilitation skills to meet participants where they're at, so they can really listen and reflect the true meaning and feelings and work to build trust. We can make sure we bring in cultural sensitivity training, and awareness so coaches are aware of their biases, and work to be judgment free and assumption free. And then a really big thing we can do is build in health equity checks with our interventions, both the interventions that coaches do, and their interactions, but also look at any materials or digital materials looking at content and visual and make sure that we are looking at all populations and speaking to all populations. And to do this you have to learn about the populations that you are working with so you can understand the barriers, understand the strengths, they're bringing to change and understand the strategies that are going to work the most and make the biggest difference.

Dr. Kelly Carpenter:
I would say that tobacco Quitlines were designed as a way to reduce barriers. I mean, if you look at how they're structured, they're phone based so they're convenient, you don't need childcare to take a Quitline call, they're free, they offer free nicotine replacement in the majority of cases. Of course, there's still room to improve our reach and effectiveness. But I do think that Quitlines are just in and of themselves a way to reduce barriers.

Brandon Benzin:
So now to focus on Optum. Does Optum serve priority populations and address the systemic barriers they face?

Dr. Kelly Carpenter:
For tobacco quitlines, really their reason for being is to reduce these barriers. And we also have some specialized tailored programs. For example, our Behavioral Health Program, which we piloted in 2017, is now offered in 12 states, and this program offers increased nicotine replacement, additional coaching calls with specially trained coaches. The extra calls allow participants time to build skills and access support. There's a big emphasis on stress in this program, which is the most common reason cited for relapse to smoking. And we also facilitate communication between the participant and their healthcare provider by sending a letter to the provider, letting them know that their patient is trying to quit smoking and offering tips for supporting them.

Etta Short: 
Another example is our work with Native American. And one of the crucial elements of working with these folks is to be sure that you have Native American partners that you're working with, so you can build trust and build the bridges. When we created our first program with a Native Americans, we realized that we needed to spend time just having conversations and learning about what the issues are, and what was most meaningful. And as someone who is working on the program, it actually struck me in an emotional way. And as we started developing how we were going to deliver, in addition to the components of the program, we realized that training of coaches, our partners had to be part of it, they had to present the majority of the training, because they had to share their stories from their mouth to talk about how, you know, systematic racism affect them,  how the laws kind of separating families and trying to, you know, destroy the culture, or the impact that it had. Also, the issue of sacred tobacco. And there, that's such an important piece of the of the reason why commercial tobacco, you know, and sacred tobacco has to be separated, and having the coaches understand what that meant, really made a big difference. And what we also discovered is every time we brought in a new state to the program, we had to bring in partners, so the coaches can learn about the differences between the tribes, not only regionally, you know, between the states, but even within states, their tribal differences. One of the things that kind of hit me in terms of bringing ownership to the American Indian population, I was listening to a webinar that one of our partners was delivering, and she described it as our quitline. And that just got the biggest smile to my face, because I felt like we really bridged that gap and built that trust where the partners felt the ownership of the program.

Dr. Kelly Carpenter:
Yeah, and not only can we use tailored coaching programs like the two that we just described, but we've also been trying digital modalities to help address the needs of our priority population. In our Project Free Study, which was a four-year study funded by the American Cancer Society and conducted with the North Carolina Quitline, we looked at a video-based intervention that had been specifically developed to help African Americans quit smoking. The video had sections on the history of African Americans and the tobacco industry, menthol flavoring, which has been heavily marketed to African Americans and which makes it harder to quit, among other topics. And in the study, we had more than 1000 African American smokers randomized to either get our regular Quitline program alone, or the regular program plus access to this tailored video or a standard control video. And we found that those who were randomized to the video that had been tailored for African Americans, they were more likely to quit smoking. So, these digital methods of tailoring can be more flexibly offered. They don't require training or supervision of coaches or more time on the phone. So they can be expensive to develop, but once they're developed, that can be disseminated more easily and with less cost, and they can be sent to the correct person at the correct time. And now we're working at being able to offer this video intervention to all of our African American Quitline participants.

Brandon Benzin:
Thank you, Etta and Dr. Carpenter, you both clearly have a wealth of knowledge and tons of experience in driving outcomes for priority populations. As we close out with our final question, if you had to boil it down to one recommendation for helping priority populations successfully quit, what would that recommendation be?

Dr. Kelly Carpenter:
So, while considering developing interventions for vulnerable populations, it's really important to keep in mind the common challenges that they have, including systematic racism, and tobacco companies that target these populations, as well as the social determinants of health. And what I mean by that are things in your community that can set you up for success or failure, like lack of access to medical care, lack of access to transportation, childcare, and all those kinds of things.

Etta Short: 
Yeah, and you know, at the same time, it's essential to also consider that that one size does not fit all. We want to tease out those specific barriers and characteristics so the population that needs to be addressed for promotion of the services or engagement in the services and also what the strategies that will facilitate cessation for the participants. And then that involves bringing in people outside that know about the population, you know, not relying on our internal expertise regarding to external experts as well. And we also have to keep in mind that each participant has specific challenges and strengths. And while we can keep population generalizations in mind, we need to serve the individual. So, we like to say that we treat populations, one person at a time.

Brandon Benzin:
Thank you, Etta and Dr. Carpenter for joining me today.

Etta Short: 
Brandon, thanks.

Dr. Kelly Carpenter:
Thank you so much for having us.

Brandon Benzin:
And thank you everyone for listening to the priority populations podcast from Optum. For more on serving priority populations, including a recording of our recent priority populations webinar, please visit optum.com/quitservices. Stay safe and healthy out there.

Brandon Benson: 
Hello, and welcome back. You're listening to Advancing Quit Services. A podcast about tobacco cessation from Optum, where we discuss barriers to quitting tobacco, and strategies for overcoming them with experts at the forefront of tobacco research. I'm your host, Brandon Benson. I'm a business strategy manager at Optum. Today's topic is whole person view. We'll discuss what a whole person approach means. Why this approach matters in the context of tobacco cessation and how quitlines can implement a whole person strategy. My guests today are Etta Short, public health leader and senior product manager for clinical development at Optum. And Marsha Baker, Optum health coach and health equity initiative lead. Welcome Etta and Marsha, thank you both for joining me today.

Etta Short: 
Thanks, Brandon. It's good to be here.

Marsha Baker: 
Absolutely, thank you, Brandon and it's a great pleasure to be here with you both.

Brandon Benson:  
Thank you so much. So, let's start with the basics. What is a whole person view, broadly speaking?

Etta Short: 
So, we're talking about a whole person view as it relates to health behavior change today. For many people, the term healthcare is typically focused on medical treatment, or going to the doctor, medication, surgeries. The CDC addresses the concept of well-being where health is more than the absence of disease. And people can achieve well-being when they reach their health goals, satisfy their needs, and cope with barriers in their environment. So, from a public health perspective, well-being can be viewed as a feeling of being healthy and full of energy. So, there are several behaviors that the CDC defines as keys to better quality of life and the possibility of a longer life. And that includes not smoking, eating well, engaging in physical activity, managing stress, getting enough sleep, limiting alcohol. So, when designing prevention programs, it just makes sense to consider this aspect of well-being.

Marsha Baker:   
Absolutely Etta, I think you did a great job of actually providing that description. Because you're right, I think there's a big difference and maybe almost a misleading concept when we think about health care, versus, creating a healthy lifestyle. Healthcare can definitely be focused on treatment. So, when we think about the whole person wellness view, we really want to focus on every aspect of individual health and wellness that includes the many elements such as physical, mental, emotional, spiritual, and even our environmental and our social health. So as a health coach, I focus on supporting individuals and developing healthy lifestyle habits that lead to sustainable weight loss. But I recognize that many people are unaware of how each element of wellness is connected. For example, members will sign up for the program with a general focus on dieting and exercise. However, we also have stress management, healthy sleep habits and hygiene, along with even having a positive mindset. These are essential for long term wellness. I think members can be surprised that how much we actually focus on the emotional and psychological aspects of wellness. For instance, learning to refrain from negative thoughts and maintain a positive mindset is a healthy behavior that directly connects to sustaining weight loss. But this can take practice just as an individual learns to practice healthier eating habits.

Etta Short:   
You know, Marsha, that's a great point you made about addressing negative thoughts. That's true for helping people maintain other lifestyle behaviors, like quitting smoking, or increasing physical activity and so on.

Marsha Baker:  
Absolutely, definitely, it all connects, right, you're more likely to sustain tobacco cessation, when we’re managing stress, we're more likely to not have those triggers for smoking or other not so healthy behaviors, so definitely all connects.

Brandon Benson:   
Etta, I know you and I have talked about the three major anchors of a whole person view before, but can you share more about these three anchors with the audience?

Etta Short:  
Sure. When talking about whole person health, I think there are three ways of how helping people adopt a healthy lifestyle can make a difference in well-being, and then make a difference in their quality of life and in some cases the length of their lives. The first is better overall health. Lifestyle behaviors may help people to live a better quality of life, live to the best of their potential, feel better, have more energy and be more resilient. Just be able to face their stress and hardships head on. The second is chronic disease prevention because 6 in 10 of US adults have at least one chronic condition and 4 in 10 have two or more, and we're talking about conditions like heart disease, diabetes, lung diseases. It's important to look at how can whole health make a difference. While, different populations have a higher prevalence of chronic disease. However, at the same time, healthcare expenditures have risen, and chronic disease treatment has contributed to this increase in costs. So, lifestyle behaviors, the ones that CDC has on their list can help prevent chronic disease or treat chronic diseases at an early stage. And the third is healthy lifestyle behaviors can help people manage diseases or keep them from progressing. While there are medical treatments that help people manage chronic diseases, lifestyle behaviors are also effective interventions, and they can cost a whole lot less than medical treatments both to the individual and to society.

Brandon Benson:  
Let’s focus in on tobacco cessation. Why is a whole person view important in this context? Why not just focus on helping someone stop using tobacco products?

Etta Short: 
Tobacco use is related to several chronic diseases, including heart disease, hypertension, COPD, cancer, diabetes, and tobacco use prevention will contribute to reducing the prevalence of these diseases to help people manage these conditions. But how does this play out? There are several key behaviors that we know will help people quit. But the hard part is getting people to maintain their quit. So, what we could do is incorporate other lifestyle behaviors as one approach to help people stay quit. As an example, stress and weight gain are the most common reasons for relapse. So, by including stress management, and strategies for good nutrition, we can provide people with the knowledge and skills they need to stay on track. Physical activity is a great distraction for curbing urges. I can also connect the dots to better sleep, because not getting enough sleep is related to weight gain and stress. And to top the list off, alcohol is a common trigger for smoking, which opens the door for participants to consider how and when they drink. And as Marsha mentioned, people are complex and these chronic conditions are all interrelated. A whole person perspective takes into account that people often need to make many changes in their life.

Marsha Baker:  
That is so true Etta. People can quit smoking, but how many times do you actually quit, how do you maintain it? And that's similar to the healthy weight management. I have serial dieters, I start my diet, many times but how, how do I do sustaining my healthy weight. So, we know that life can bring about you know, chain reactions that can cause individuals to get off track with healthy lifestyle habits, which may lead to a slight weight gain or reverting back to tobacco products. These are the times that I always try to support members in retracing our steps to find the kink in the chain because of how all of the elements of wellness connect. So, in most cases, it was, something that was indirectly related, that may have caused that unhealthy food choice or decrease in exercise or, reverting back to smoking or using tobacco products. When someone experiences a relapse with quitting smoking, the trigger for a relapse likely leads back to other aspects of wellness, such as our stress, or mental health there or even environmental components. So, it's definitely always important to look at the complete picture.

Etta Short: 
Your coach point of view is so right on, because I'm sure, you've talked to a lot of people and, and watch them go through this struggle, and use your depth of knowledge to help navigate them back. Looking at stress management, looking at physical activity, being able to look at those emotional factors that also impact people, it's important to kind of consider all of that in one package.

Brandon Benson:  
Thank you both for your perspectives. Marsha, I'd like to start with you on this next question. How do social determinants of health relate to a whole person view?

Marsha Baker:   
This is such an important topic, I'm so glad that this is actually a part of today's conversation, as social determinants of health can have what can almost seem like an invisible effect on the health of individuals or our whole communities. For anyone not familiar with the term social determinants of health refers to the conditions in which an individual was born, we live, we work, worship, learn, play – our entire community. So as a health coach, it is very important for me to remain aware of the impact of these environmental factors when I'm partnering with clients, because it can be difficult to achieve some of our health goals when it comes to weight loss, or even tobacco cessation. Due to some of the barriers that may be beyond an individual's control. For example, an individual's environment may have limited access to fresh healthy foods or the actual neighborhood may not be safe for regular exercise, which poses a barrier. And again, of course, not to mention dealing with stress from that that may come from living in an environment that does not have the healthy foods or access to a safe neighborhood. So, this connects us to kind of the main components we think of a wellness as a whole, or you know, our hierarchy of needs. If we haven't met our basic needs, such as shelter, food, safety, we're less likely to be able to move on to those higher-level needs, such as tobacco cessation or weight loss. So, it's really important to think about all of those different elements and try to work together with clients to break down those barriers or provide additional access so that we don't have these outside social determinants of health impacting when an individual is making all efforts to create that healthier lifestyle. I would love to hear from Etta as far as you know how that actually relates to when you work with clients in regards to tobacco cessation?

Etta Short:   
Well, you know, social determinants of health is particularly relevant for tobacco, because most smokers are from underserved and vulnerable populations. And Marsha, you describe the importance of considering the full range of needs for people with complex life situations, quit services programs like the one that Optum, offers a way for people who face barriers with transportation, childcare, or live in one of those areas where a full range of health care services are not available. It gives those folks the opportunity to work on quitting tobacco. Quitlines have a 24/7 access with a variety of evidence-based approaches for getting coaching, including telephonic and online, and chat and text messages. So, access to nicotine replacement therapy, like patches and gum, is another barrier for those who are vulnerable populations. So quit services can deliver these products at no cost to the participant directly to their home. Quit services can also provide enhanced services to people in vulnerable populations, like those with behavioral health conditions, we can provide additional coaching, we can provide more resources, we can provide more NRT, and these are all ways of reducing the barriers to quitting smoking.

Brandon Benson:   
So, we've discussed what a whole person view is, and why it matters in the context of tobacco cessation. But what does it actually look like in practice? Can you both talk about how Optum implements a whole person approach and how someone trying to quit might experience such an approach? Etta, can we start with you?

Etta Short: 
Sure, Optum has designed quit services product with the whole person view in mind. As mentioned earlier, there are those lifestyle behaviors that serve as strategies to stay quit, you know, the eating well, physical activity, stress management, and those are all those ways of helping people manage urges or prevent relapse. So, the content for knowledge and skill building is woven into the program as coaches address triggers and strategies for change. And the digital platform is able to weave these lifestyle content areas throughout the participants’ journey with trackers, knowledge, building videos and articles and interactive action steps. In a recent survey, eight out of ten said that their health was better because of participating in Quit For Life. Over 90% said they attempted to change their lifestyle. And of those more than half reported successfully making changes. In fact, 90% said they were confident that they can maintain those changes. So Optum’s lifestyle programs are all designed with the same evidence base and whole person point of view. So, we have the expertise in the various lifestyle areas, participants who are eligible can move from one change goal and content focus to another. And while new skills are offered, and the content may go deeper, the interventions and strategies are consistent. We're also in the process of looking at innovative ways to create bridges between our programs so that participants can take advantage in the breadth of expertise is available.

Marsha Baker:   
I would just add on that, we do a really good job at having those different lifestyle programs available, as Etta has shared, which are easily accessible, which is a big part of it as well, making sure that members are aware of the available resources that address the different aspects of creating and maintaining a healthy lifestyle. I would also add that I think it's important to stay committed to removing the barriers to any healthcare when we go back to talking about the social determinants of health. So, having that increased awareness of developing health equity throughout all of our systems and programs is such a big, important element. I believe this means remaining aware and open to continuous improvement because it is always changing.

Etta Short: 
Marsha, I'm so glad you reminded us and brought up the issue of health equity, again, because I think we need to keep that in the forefront. As we look at whole person point of view, we need to consider how we can be inclusive and ensure that we're providing services that are meaningful to everybody.

Marsha Baker:   
Exactly. We don't want to have barriers in front of people when they're doing all they can to create this, you know, healthier sustainable lifestyle. We want to create an environment where that actually is accessible and available for everyone.

Brandon Benson:   
So, to wrap things up, what should state and commercial quit services buyers look for in a quitline, to make sure they offer a whole person approach?

Etta Short:  
So, when looking for a vendor. One of the things to look for is expertise in lifestyle behaviors. In addition to expertise in tobacco cessation, best practices, we want to look at that whole person point of view as well. When you do this, be sure that there's relevant and rich content related to the lifestyle programs. You'll also want to look for a vendor that can provide a common thread throughout the suite of lifestyle behavior change programs. So, when consumers are exposed to the whole point of view, they can get that same perspective, regardless of where they start out, and you want to look for services where coaches are able to leverage the whole person view, and the digital content can support people to make broad changes, and I can say that Optum is in the position to do just that.

Marsha Baker:  
I would just add on to what Etta’s mentioned in regards to the importance of having that continuity of care within the coaching platforms and also with the systems. Having members, be aware that again of the availability of all of the different lifestyle services and programs, and also having coaches be on that same wavelength I guess I can use, as far as the whole person approach and how those systems all connect.

Brandon Benson: 
Thank you, Etta and Marsha, for taking the time to share your insights on this topic and thank you everyone for listening to the Advancing Quit Services Podcast from Optum. For more on a whole person view, as well as other resources, please visit optum.com/quitservices. Stay safe and healthy out there.