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Utilization of smoking-cessation pharmacotherapy among chronic obstructive pulmonary disease (COPD) and lung cancer patients a
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Varun Vaidya , Meghan Hufstader-Gabriel , Nilesh Gangan , Surbhi Shah & Robert Bechtol a
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University of Toledo Toledo, OHUSA
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Office of the National Coordinator for Health IT Washington, DCUSA Published online: 26 May 2015.
Click for updates To cite this article: Varun Vaidya, Meghan Hufstader-Gabriel, Nilesh Gangan, Surbhi Shah & Robert Bechtol (2014) Utilization of smoking-cessation pharmacotherapy among chronic obstructive pulmonary disease (COPD) and lung cancer patients, Current Medical Research and Opinion, 30:6, 1043-1050 To link to this article: http://dx.doi.org/10.1185/03007995.2014.884493
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Current Medical Research & Opinion 0300-7995 doi:10.1185/03007995.2014.884493
Vol. 30, No. 6, 2014, 1043–1050
Article ST-0384.R1/884493 All rights reserved: reproduction in whole or part not permitted
Current Medical Research and Opinion 2014.30:1043-1050.
Original article Utilization of smoking-cessation pharmacotherapy among chronic obstructive pulmonary disease (COPD) and lung cancer patients
Varun Vaidya
Abstract
University of Toledo, Toledo, OH, USA
Meghan Hufstader-Gabriel Office of the National Coordinator for Health IT, Washington, DC, USA
Nilesh Gangan Surbhi Shah Robert Bechtol University of Toledo, Toledo, OH, USA Address for correspondence: Varun Vaidya PhD, Assistant Professor, Pharmacy Health Care Administration, Department of Pharmacy Practice, University of Toledo College of Pharmacy, Health Science Campus 3000 Arlington Ave., Toledo, OH 43614, USA. Tel: +1 419 383 1516; [email protected] Keywords: Chronic obstructive pulmonary disease – Disparities – Lung cancer – MEPS – Pharmacotherapy – Smoking cessation Accepted: 11 December 2013; published online: 5 February 2014 Citation: Curr Med Res Opin 2014; 30:1043–50
Objective: Smoking is one of the major risk factors causing morbidity and mortality in chronic obstructive pulmonary disease (COPD) and lung cancer patients. Use of smoking cessation pharmacotherapy is an effective way to help quit smoking. The purpose of the study was to determine the prevalence of smoking and the proportion of patients using smoking cessation agents, and to identify the socio-demographic factors that affect the use of these agents among COPD and lung cancer patients. Research design and methods: A retrospective study was done to identify smokers having COPD (ICD-9: 490–492) or lung cancer (ICD-9: 162), and those who use smoking cessation agents from 2006–2010, using Medical Expenditure Panel Survey (MEPS) data. A multiple logistic regression model was built to identify significant socio-demographic predictors associated with the use of smoking cessation agents. Results: Around 16.8% of COPD patients and 15.1% of lung cancer patients reported smoking after diagnosis. Out of the total smokers, 8.8% patients with COPD and 12.6% patients with lung cancer reported use of smoking cessation agents during the 5 year period. Logistic regression showed that odds for smoking cessation use in COPD patients were lower for Hispanics (OR ¼ 0.107, 95% CI 0.023–0.502) and higher for patients having insurance coverage (OR ¼ 3.453, 95% CI 1.240–9.617). Conclusion: Results showed that a large number of patients continued to smoke even after the diagnosis of COPD and lung cancer; whereas only a few among them used smoking cessation agents. Ethnicity disparities and insurance status were associated with the use of smoking cessation agents. Differential use among population sub-groups suggests a requirement for need based smoking cessation programs and appropriate prescription drug coverage. Further research needs to be done to evaluate reasons for disparities in smoking cessation agents’ use. The study had limitations common to research designs based on observational and self-reported datasets.
Introduction Respiratory diseases are a significant public health burden1. Chronic obstructive pulmonary disease (COPD) and lung cancer are the two major respiratory diseases causing significant morbidity and mortality in the United States. COPD is the third leading cause of all deaths while lung cancer is the primary cause of ! 2014 Informa UK Ltd www.cmrojournal.com
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cancer death in the country2. Smoking is the primary risk factor for both these diseases3. Additionally, smoking leads to worsening of these conditions and accounts for greater resource utilization. Approximately 90% of lung cancer cases4 and 75% of COPD cases5 are caused by cigarette smoking, in addition 85 to 90% of COPD deaths are caused by smoking3. Similarly, lung cancer patients who continue to smoke after diagnosis double their risk of dying from this disease6. It has also been shown that patients with COPD can develop lung cancer which often results in severe consequences. Patients’ quality of life, financial burden, and survival are impacted by these two chronic conditions7. The most effective strategy to prevent declining lung function among COPD patients is smoking cessation7. Quitting smoking reduces the mortality in lung cancer patients by 50%8. In patients with COPD, smoking cessation has been very beneficial resulting in a decrease in the risk of disease progression and risk of lung cancer9,10. The World Health Organization (WHO) and other clinical guidelines such as Global initiative for Chronic Obstructive Lung Disease (GOLD), the American College of Chest Physicians (ACCP) and the American Society of Clinical Oncology (ASCO), strongly advocate motivating COPD and lung cancer patients to stop smoking11,12. The current strategies for smoking cessation range from counseling to pharmacotherapy. The counseling strategies may include simple advising, written materials, or behavioral support by individuals and groups along with education on the adverse effects of smoking on health. Risk factor reduction and pulmonary rehabilitation may also be recommended. Even though such techniques are useful in helping quit smoking, it has been shown that pharmacological treatments are most effective and double the odds of cessation in healthy smokers13. Literature shows that the use of a pharmacologic agent could have a positive psychological effect on cessation attempts by smokers14. In fact, intermittent smoking cessation can reduce the risk of exacerbations and excess decline in lung function. Similar results can be expected in COPD and lung cancer patients. The availability of smoking cessation agents would motivate patients who have difficulty in quitting smoking. However, it was found that 14–38% of lung cancer patients and 30% of COPD patients continue to smoke even after diagnosis15,16. Fewer than 20% of smokers make an attempt to quit smoking despite the benefits of smoking cessation drugs14. Little is known about the use of smoking cessation agents among COPD and lung cancer patients. In the present study we attempt to address the literature gap by generating information on the prevalence of smoking and the use of smoking cessation agents in COPD and lung cancer patients. It will help clinicians and researchers better understand whether the use of smoking cessation agents among these patient populations is associated with certain factors. The overall objective of this study was to identify the prevalence of 1044
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smoking and use of smoking cessation agents in COPD and lung cancer patients, and predict the factors associated with the use of these agents among these patients.
Methods Study design This retrospective study used the Medical Expenditure Panel Survey (MEPS) as the data source. MEPS database is commonly used to study the healthcare utilization pattern17. MEPS provides national estimates on access, use, and expenditures for healthcare which includes inpatient stays, outpatient visits, ER visits, physician services, prescription drugs and related medical services. It also provides information on the sources of payments to providers and the sources of coverage and health status of the population surveyed. The survey is administered every year by the Agency for Healthcare Research and Quality. It has a rotating panel design and each panel is composed of a non-institutionalized US population who are interviewed five times over 30 months. Except for the first year, two panels are interviewed each year and individual sampling weights are assigned to the participants in two panels to obtain a nationally representative statistic. The study was approved by The University of Toledo Biomedical Institutional Review Board.
Data collection and extraction Data was extracted from 2006 to 2010 full-year consolidated, medical conditions and prescribed medicines data files within the household component of MEPS. The household components provide information on the demographic characteristics, health conditions, health status, medical services use, charges and source of payments, access to care, satisfaction with care, health insurance coverage, income, and employment. The years from 2006 to 2010 were selected because they were the most recent at the time of the study. From 2006 to 2010 medical conditions data files all the COPD and lung cancer patients were identified separately by using their respective International Classification of Diseases, ninth revision (ICD-9) codes. The MEPS ascertains COPD and lung cancer diagnosis by recording those individuals with ICD-9 codes 490–492 and 162 respectively. We defined COPD as including chronic bronchitis and emphysema as described by the National Heart, Lung and Blood Institute (NHLBI). Asthma was excluded because its etiology and treatment differed from that of COPD. Information on patients’ smoking status was obtained from full-year consolidated data files. Patients who responded ‘yes’ to the question ‘do you currently smoke?’ were considered active smokers and were observed for their smoking www.cmrojournal.com ! 2014 Informa UK Ltd
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cessation agents utilization from the prescribed medicines files. The smoking cessation agents included all prescription as well as OTC drugs (Chantix, Zyban, Wellbutrin, Budeprion, nicotine transdermal patches and nicotine gums) classified by Multum therapeutic sub-classification used by MEPS to categorize prescription and nonprescription drugs. Patients who responded that they were taking smoking cessation agents were considered users while the others were labeled as non-users.
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Study variables The main variable of analysis was the use of smoking cessation agents by COPD and lung cancer patients who smoke. In order to identify the prevalent factors that led to the non-utilization of these drugs, a theoretical framework called Andersen’s model for healthcare utilization was used. Andersen’s model has been used in previous studies to evaluate various types of healthcare utilization18–20. According to Andersen’s model of health services utilization, there are predisposing factors, enabling factors, and need based factors that determine patients’ utilization of a particular health service. Predisposing factors are the socio-cultural characteristics of the individuals which decide their proclivity to utilize healthcare services. Therefore, it is theorized that a patient is more or less likely to use health services based on age, gender, race/ethnicity, education and patient knowledge of health service benefits, and satisfaction with health services. Enabling factors are the resources found within the family and community which enable them to utilize the health services. Need based factors are those related to the perception of need for health services due to functional and health problems. Based on Andersen’s model, it can be assumed that gender, age, race, ethnicity, and region are the predisposing factors. Income and insurance status were considered the enabling factors that may influence the behavior of using smoking cessation agents by the COPD and lung cancer patients who smoked.
Data analyses Descriptive statistics were used to obtain the number of COPD and lung cancer patients, their smoking status, and patients’ utilization of smoking cessation agents. A logistic regression model was constructed to determine the odds of using smoking cessation agents among these patients according to their characteristics. The complex survey design of MEPS was incorporated by using sample weights for stratum, cluster, and individual persons to obtain unbiased national estimates. Nonresponse bias was also adjusted using the sampling weights. SAS version 9.3 (SAS Institute Inc., Cary, NC, USA) was used to conduct ! 2014 Informa UK Ltd www.cmrojournal.com
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the data analysis and to accommodate for the complex sample design and weights.
Results The results showed an estimated 73 million non-institutionalized population suffering from COPD and 3 million patients from lung cancer during 5 years of study. This was based upon the unweighted data of 6713 individuals living with COPD and 256 with lung cancer during the years 2006–2010. The data showed that an estimated 15.5 million COPD patients and 470,000 lung cancer patients out of the total were current smokers (Table 1). Of those COPD and lung cancer patients who smoked, only 8.83% and 12.65% patients respectively were taking any form of smoking cessation agents (Table 2). Table 3 represents the socio-demographic characteristics of smoking cessation agents’ users and non-users. Lung cancer patients who smoked were mostly male Caucasians from the southern region of the US. They mostly had public insurance, an income less than $20,000, and belonged to the adult and elderly populations. It was found that compared to the elderly population, adults tend to continue smoking among COPD patients. Most of the COPD patients who smoked were Caucasian females with public or private insurance and an income less than $20,000. Lung cancer patients who used smoking cessation agents were mostly elderly (92.9%), non-Hispanic (100%), and from the southern region (53%) of the US. With regard to COPD, more females (63.3%) took smoking cessation agents compared to male patients. These patients were Table 1. Smoking status among lung cancer and COPD patients. Condition Lung cancer COPD
Smoking Status
N
Weighted N
Weighted %
Smokers Non-smokers Smokers Non-smokers
48 208 1423 12,924
468,728 2,308,178 15,585,428 57,351,757
16.87 83.13 15.18 84.82
Table 2. Use of smoking cessation agents among lung cancer and COPD patients who smoke. Condition
Lung cancer
COPD
Smoking cessation use Smoking cessation agent users Smoking cessation agent non-users Smoking cessation agent users Smoking cessation agent non-users
N
Weighted N
Weighted %
6
59,336
12.65
42
409,392
87.35
123
1,377,311
8.83
1300
14,208,116
91.16
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Less than 20,000 20,000–50,000 More than $50,000
South Midwest West Northeast
Insured Uninsured
Income
Region
Insurance
1133/40 167/2
484/18 287/7 177/6 149/2
805/31 409/11 86/0
136/9 791/23 373/10
787/31
Less than high school High school More than high school
Years of education
1204/40 96/2
No
Non-Hispanics Hispanics
Ethnicity
83/0 1011/20 198/22
513/11
Young adults Adults Elderly
Age category
781/16 519/26
1045/34 200/8 55/0
Frequency (COPD/lung cancer)
Yes
Female Male
Gender
Prescription drug insurance coverage
White African-American Other
Groups
Race
Characteristics
7,383,304/265,799
6,824,812/143,593
12,492,233/390,939 1,715,884/18,453
4,972,761/163,936 3,353,877/88,152 1,786,995/83,377 2,097,839/10,624
7,692,244/28,0561 5,262,333/128,831 1,253,540/0
1,185,347/72,087 8,380,578/239,098 4,642,192/98,207
13,577,205/398,450 630,911/10,942
1,031,060/0 10,995,001/194,167 2,102,091/215,225
8,207,893/156,416 6,000,223/252,975
12,548,814/369,037 1,133,267/40,354 526,036/0
Weighted frequency (COPD/lung cancer)
Smoking cessation non-users
51.96/64.93
48.03/35.07
87.923/95.48 12.076/4.50
40.722/47.36 27.464/25.47 14.486/24.09 17.179/3.06
54.139/68.53 37.037/31.46 8.822/0
8.342/17.60 58.984/58.40 32.672/23.98
95.559/97.32 4.440/2.67
7.297/0 77.823/47.42 14.878/52.57
57.769/38.20 42.230/61.79
88.32/90.14 7.97/9.85 3.70/0
Percentage weighted (COPD/lung cancer)
Table 3. Socio-demographic characteristics of COPD and lung cancer patients according to smoking cessation agents’ use.
77/5
46/1
119/6 4/0
37/3 30/0 19/1 20/1
86/4 26/1 11/0
12/1 56/0 55/5
121/6 2/0
4/0 97/1 22/5
77/3 46/3
107/3 11/2 5/1
Frequency (COPD/lung cancer)
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808,183/47,638
569,129/11,698
1,330,354/59,337 46,958/0
360,720/29,315 347,857/0 232,571/11,698 286,477/14,120
927,296/38,278 285,162/9360 164,853/0
130,744/4203 624,143/0 622,242/55,133
1,371,584/59,336 5727/0
59,197/0 1,033,836/4203 284,279/55,133
872,718/25,561 504,593/33,776
1,267,312/29,315 68,189/18,323 41,811/11,698
Weighted frequency (COPD/lung cancer)
Smoking cessation users
58.67/80.28
41.32/19.72
96.590/100 3.409/0
29.383/53.17 28.335/0 18.944/21.21 23.335/25.61
67.326/64.21 20.704/15.77 11.969/0
9.493/7.08 45.322/0 45.184/92.91
99.584/100 0.4158/0
4.298/0 75.061/7.08 20.640/92.92
63.363/43.07 36.636/56.92
92.01/49.40 4.95/30.88 3.03/19.71
Percentage weighted (COPD/lung cancer)
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Table 4. Logistic regression results for COPD patients.
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Variable
Age Adults (25–65 yrs) Elderly (465 yrs) Gender Males Race African-American Others Ethnicity Hispanic Region Midwest Northeast South Insurance status Insured Prescription drug insurance No coverage Income 520,000 20,000–50,000 Years of education 5High school 4High school
Reference category
Smoking cessation agents use Odds ratio
95% confidence interval
Young adults (18–25 yrs)
1.288 1.632
0.377–4.406 0.441–6.035
Females
0.816
0.521–1.278
Caucasians (Whites)
0.532 0.596
0.246–1.152 0.190–1.87
Non-Hispanic
0.107
0.023–0.502
West
0.82 1.074 0.615
0.432–1.557 0.474–2.431 0.319–1.185
Uninsured
3.453
1.24–9.617
With coverage More than 50,000
1.303
0.767–2.214
1.149 0.545
0.534–2.472 0.295–1.007
1.343 1.932
0.490–3.676 0.993–3.759
High school
Variables in bold are statistically significant.
more likely to be adults (75%), Caucasian (92%), Hispanic (99.5%), and had an income less than $20,000 (67.3%). Logistic regression was carried out in order to predict the factors that define the use of smoking cessation agents among these patients. It was not possible to perform logistic regression for the patients with lung cancer because of the small sample size of these patients who utilized smoking cessation agents. Table 4 shows the results of logistic regression for COPD patients. Males had lower odds of using smoking cessation agents than females (OR ¼ 0.816, 95% CI 0.521–1.278). Adults and the elderly had greater odds of taking smoking cessation agents compared to young adults (OR ¼ 1.288, 95% CI 0.377–4.406 and OR ¼ 1.632, 95% CI 0.441–6.035 respectively). African-Americans were less likely to utilize smoking cessation agents than whites (OR ¼ 0.532, 95% CI 0.246–1.152). Hispanics were less likely to utilize smoking cessation agents compared to non-Hispanics (OR ¼ 0.107 95% CI 0.023–0.502) which was found to be significant. Patients with educational level more than and less than high school degree had greater odds of taking smoking cessation agents compared to those with a high school degree (OR ¼ 1.932, 95% CI 0.993–3.759 and OR ¼ 1.343, 95% CI 0.490–3.676 respectively). The use of smoking cessation agents among the insured population was significantly higher compared to those who were uninsured (OR ¼ 3.453, 95% CI 1.24–9.617). ! 2014 Informa UK Ltd www.cmrojournal.com
Discussion Continued smoking by patients with chronic conditions, such as lung cancer and COPD, can lead to worsening of disease condition, and reduced productivity and quality of life21,22. Lung cancer and COPD patients who smoke even after diagnosis are at increased risk of morbidity and mortality23. However, this related morbidity and mortality can be reduced to a certain extent by the use of appropriate smoking cessation strategies. The effectiveness of pharmacological agents in smoking cessation has been established24,25. Pharmacological treatment is more time-efficient and easy to follow compared to counseling which requires frequent clinic visits. In this study we found that a substantial proportion of lung cancer (16.87%) and COPD patients (15.18%) reported smoking even after diagnosis. This was comparable to other studies which reported that 14–39% of lung cancer patients and up to 43% of COPD patients smoke after diagnosis26–29. Despite the usefulness of smoking cessation agents in helping smokers quit, it was found that the proportion of COPD and lung cancer patients reporting use of any smoking cessation agents was remarkably low. Interestingly, previous research has also found similar results30. Regression analysis revealed some predictive characteristics for use of smoking cessation agents among COPD patients. The Hispanic population in particular showed significantly lower use of smoking cessation agents. This finding corroborates the overall underutilization of Smoking-cessation pharmacotherapy in COPD and lung cancer Vaidya et al.
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healthcare services by minority populations reported in many studies31–33. Reasons such a language barriers are supported in the literature behind the underutilization among Hispanic population. Considering the initiation of smoking is also found to be high among Hispanics youths and the rates of quitting is low34,35, special attention to this population is warranted. Use of smoking cessation agents was found to be low among AfricanAmericans; however, when adjusted for covariates the association was not statistically significant. Nonetheless, considering the fact that African-Americans have lower odds of quitting smoking34, the low utilization among the African-American population remains a concern. Other than race and ethnicity, insurance status was also found to be significantly associated with the use of smoking cessation agents. Patients having any kind of health insurance coverage (public or private) had higher odds of reporting smoking cessation agents’ use than patients who were uninsured. This finding adds to the several studies looking at medication and service utilization that have shown significant underuse of medicines and services among the uninsured as compared to the insured. Underuse is an issue that needs to be addressed, as it has been shown that the uninsured show poorer health outcomes compared with their insured counterparts36. An interesting finding observed in the study was the statistically insignificant association between prescription drug coverage and use of smoking cessation agents. Some of the possible reasons behind it could be the exclusion of smoking cessation pharmacotherapy or a formulary structure discouraging use of it by imposing higher copays. It will be interesting to see how the current scenario will change after the full implementation of the Affordable Care Act (ACA) which categorizes smoking cessation pharmacotherapy as preventive therapy and requires mandatory coverage in all prescription drug plans37. Based on the findings from this study it appears to be an important inclusion in the ACA. Future research should explore the reasons for reluctance among lung cancer and COPD patients to use smoking cessation agents. Policies are adapting in response to mitigate this trend. Smoking cessation strategies of physicians especially recommending medications has been shown to be cost-effective38. Therefore, low use of smoking cessation agents among COPD and lung cancer patients who smoke warrants special attention from the physicians in terms of counseling. The Centers for Medicare and Medicaid Services (CMS) in collaboration with the Office of the National Coordinator for Health Information Technology (ONC) have included the core requirement of recording smoking status for patients 13 years and older to the Electronic Health Records (EHR) Incentive Programs for the Meaningful Use of Electronic Health Records39. This is a national health outcome priority to help improve quality, safety and efficiency, and reduce health disparities. 1048
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This requirement requires that eligible providers record more than 50% of all unique patients 13 years or older that are seen by the healthcare professional or are admitted to the hospital. Additionally, beginning in 2014, all participants in the CMS EHR Incentive Program will be required to report several core clinical quality measures (CQMs). Included among these are the recommended core measure questions about tobacco use and the resulting screening and smoking cessation interventions for patients currently using tobacco products. This highlights the national importance of smoking cessation. Also, the Physician Quality Reporting System (PQRS) provides incentives to physicians for satisfactory reporting of quality measures. One of the quality measures requires the physician to advise smokers to quit smoking by discussing cessation medications and strategies. With the changing healthcare system, the service provided by healthcare providers is being evaluated in order to provide them incentives for provision of good quality service. Therefore, physicians should discuss the importance of smoking cessation with lung cancer and COPD patients and at the same time collaborate with other healthcare professionals such as pharmacists so that appropriate counseling on cessation medications is provided to these patients. This would help improve the quality of service and would benefit the patient and the physician. One of the strengths of our study is that the reported estimates are nationally representative of the US civilian, non-institutionalized population, i.e. our results are generalizable.
Limitations A limitation of the study is that the information was obtained from a secondary database; there could be a possibility thereby of bias due to missing information. Also, smoking status and use of smoking-cessation agents were self-reported by the patients, hence social desirability bias and recall bias could be a potential threat to validity. Studies have shown that patient recall declines over time and recall depends on perceived social acceptability of behavior or condition. Therefore, the proportion of smokers and users of smoking cessation agents among lung cancer and COPD patients reported might be an underestimated figure. Moreover, causal inference could not be drawn from the results due to the retrospective and cross-sectional nature of the database. However, this study opens the scope for further investigation on the probable reasons for occurrence of disparities found in the study. It was difficult to collect information on the time of diagnosis in relation to smoking status and smoking cessation use. This information could have given some insights into prevalence of smoking and use of smoking cessation agents in terms of time to diagnosis and disease www.cmrojournal.com ! 2014 Informa UK Ltd
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length. It was also difficult to distinguish if buproprion brands were prescribed for smoking cessation or depression. As smoking cessation was the priority among the patient population, it can be assumed the drugs were prescribed for smoking cessation.
Current Medical Research and Opinion 2014.30:1043-1050.
Conclusion Despite the usefulness of smoking cessation agents in helping smokers quit their habit, the proportion of COPD and lung cancer patients that reported using smoking cessation agents was very low, which was highlighted by this study. The use of smoking cessation agents among COPD patients was significantly less in the Hispanic population compared to the non-Hispanic population. Other than this finding, the insured population had higher use of smoking cessation agents than the uninsured population. Finding out reasons for such disparities in the future may help bring about policy changes as well as reduce morbidity and mortality among the study population.
Transparency Declaration of funding The authors received no funding in preparation of this manuscript. Declaration of financial/other relationships V.V., M.H.-G., N.G., S.S., and R.B. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article. CMRO peer reviewers may have received honoraria for their review work. The peer reviewers on this manuscript have disclosed that they have no relevant financial relationships. Acknowledgments We thank Neha Gangal from the division of Health Outcomes and Socio-economic Sciences, College of Pharmacy, University of Toledo for her assistance regarding preparing and reviewing this manuscript. Previous presentation: Poster presentation at ISPOR 18th Annual International Meeting, New Orleans, Louisiana, 18–22 May 2013.
References 1. Mannino DM, Homa DM, Akinbami LJ, et al. Chronic obstructive pulmonary disease surveillance – United States, 1971–2000. Respir Care 2002;47:1184-99 2. Heron M. Deaths: leading causes for 2008. National vital statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System. 2012;60:1-94 3. The 2004 United States Surgeon General’s Report: The health consequences of smoking. NSW Public Health Bulletin 2004;15:107
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4. Koshiol J, Rotunno M, Consonni D, et al. Chronic obstructive pulmonary disease and altered risk of lung cancer in a population-based case–control study. PLoS One 2009;4:e7380 5. Brown DW, Croft JB, Greenlund KJ, et al. Trends in hospitalization with chronic obstructive pulmonary disease – United States, 1990–2005. COPD 2010;7:59-62 6. Parsons A, Daley A, Begh R, et al. Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis. BMJ 2010;340:b5569 7. Yohannes AM. Lung cancer in patients with chronic obstructive pulmonary disease is a double blow. Expert Rev Respir Med 2012;6:3-6 8. Anthonisen NR, Skeans MA, Wise RA, et al. The effects of a smoking cessation intervention on 14.5-year mortality: a randomized clinical trial. Ann Intern Med 2005;142:233-9 9. Wu J, Sin DD. Improved patient outcome with smoking cessation: when is it too late? Int J Chron Obstruct Pulmon Dis 2011;6:259-67 10. Cataldo JK, Dubey S, Prochaska JJ. Smoking cessation: an integral part of lung cancer treatment. Oncology 2010;78:289-301 11. Vestbo J, Hurd SS, Agusti AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Criti Care Med 2013;187:347-65 12. Celli BR, MacNee W. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004;23:932-46 13. Hughes J, Stead L, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2004;4:CD000031 14. Cummings KM, Hyland A. Impact of nicotine replacement therapy on smoking behavior. Annu Rev Publ Health 2005;26:583-99 15. Cox LS, Africano NL, Tercyak KP, et al. Nicotine dependence treatment for patients with cancer. Cancer 2003;98:632-44 16. Jimenez-Ruiz CA, Riesco Miranda JA, Altet Gomez N, et al. Treatment of smoking in smokers with chronic obstructive pulmonary disease. Archivos de Bronconeumologia 2013;49:354-63 17. Vaidya V, Partha G, Howe J. Utilization of preventive care services and their effect on cardiovascular outcomes in the United States. Risk Manag Healthc Pol 2011;4:1-7 18. Conner NE. Predictive factors of hospice use among Blacks: applying Andersen’s Behavioral Model. Am J Hospice Palliative Care 2012;29:368-74 19. Moczygemba LR, Barner JC, Lawson KA, et al. Impact of telephone medication therapy management on medication and health-related problems, medication adherence, and Medicare Part D drug costs: a 6-month follow up. Am J Geriatr Pharmacother 2011;9:328-38 20. Unni E, Farris KB. Determinants of different types of medication non-adherence in cholesterol lowering and asthma maintenance medications: a theoretical approach. Patient Educ Counsel 2011;83:382-90 21. Almagro P, Castro A. Helping COPD patients change health behavior in order to improve their quality of life. Int J COPD 2013;8:335-45 22. Jyrkkio S, Bostrom P, Minn H. [Smoking and cancer – what are the benefits of cessation?]. Duodecim; laaketieteellinen aikakauskirja 2012;128: 1081-7 23. Thun MJ, Carter BD, Feskanich D, et al. 50-year trends in smoking-related mortality in the United States. N Engl J Med 2013;368:351-64 24. Laniado-Laborin R. Smoking cessation intervention: an evidence-based approach. Postgrad Med 2010;122:74-82 25. Patel DR, Feucht C, Reid L, et al. Pharmacologic agents for smoking cessation: a clinical review. Clinical Pharmacol Advances Applications 2010;2:17-29 26. Hopenhayn C, Christian WJ, Christian A, et al. Factors associated with smoking abstinence after diagnosis of early stage lung cancer. Lung Canc 2013;80:55-61 27. Cooley ME, Sarna L, Kotlerman J, et al. Smoking cessation is challenging even for patients recovering from lung cancer surgery with curative intent. Lung Canc 2009;66:218-25
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34. Kandel DB, Kiros G-E, Schaffran C, et al. Racial/ethnic differences in cigarette smoking initiation and progression to daily smoking: a multilevel analysis. Am J Publ Health 2004;94:128-35 35. Covey LS, Botello-Harbaum M, Glassman AH, et al. Smokers’ response to combination bupropion, nicotine patch, and counseling treatment by race/ ethnicity. Ethn Dis 2008;18:59-64 36. Health, United States, 2009: With Special Feature on Medical Technology. Hyattsville MD, 2010. Available at: http://www.cdc.gov/nchs/data/hus/ hus09.pdf 37. Fiore MC, Goplerud E, Schroeder SA. The Joint Commission’s New TobaccoCessation Measures – Will Hospitals Do the Right Thing? N Engl J Med 2012;366:1172-4 38. Buck DJ, Richmond RL, Mendelsohn CP. Cost-effectiveness analysis of a family physician delivered smoking cessation program. Prev Med 2000;31:641-8 39. Centers for Medicare and Medicaid Services. Available at: http:/// www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms [Last accessed 5 September 2013]
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28. Park ER, Japuntich SJ, Rigotti NA, et al. A snapshot of smokers after lung and colorectal cancer diagnosis. Cancer 2012;118: 3153-64 29. Thabane M, Group CW. Smoking cessation for patients with chronic obstructive pulmonary disease (COPD): an evidence-based analysis. Ontario Health Tech Assess 2012;12:1-50 30. Tilea L, Postolache P, Lica F, et al. Ethics and smoking cessation: should the medical treatment be a freewill choice or a mandatory issue for hospitalized COPD patients? Chest 2012;142:1089A 31. Waidmann TA, Rajan S. Race and ethnic disparities in health care access and utilization: an examination of state variation. Med Care Res Rev 2000;57(Suppl 1):55-84 32. Vaidya V, Holiday-Goodman M, Pinto S. Demographic disparities in patientreported use of inhaled corticosteroids among patients with persistent asthma. J Asthma Allergy 2010;3:101-6 33. Vaidya V, Peeters MJ, Partha G, et al. Evaluating the association between type of prescription drug plan and asthma patients’ use of controller medications. J Pharmaceut Health Serv Res 2012;3:65-9
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Utilization of smoking-cessation pharmacotherapy among chronic obstructive pulmonary disease (COPD) and lung cancer patients a
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Varun Vaidya , Meghan Hufstader-Gabriel , Nilesh Gangan , Surbhi Shah & Robert Bechtol a
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Click for updates To cite this article: Varun Vaidya, Meghan Hufstader-Gabriel, Nilesh Gangan, Surbhi Shah & Robert Bechtol (2014) Utilization of smoking-cessation pharmacotherapy among chronic obstructive pulmonary disease (COPD) and lung cancer patients, Current Medical Research and Opinion, 30:6, 1043-1050 To link to this article: http://dx.doi.org/10.1185/03007995.2014.884493
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Article ST-0384.R1/884493 All rights reserved: reproduction in whole or part not permitted
Current Medical Research and Opinion 2014.30:1043-1050.
Original article Utilization of smoking-cessation pharmacotherapy among chronic obstructive pulmonary disease (COPD) and lung cancer patients
Varun Vaidya
Abstract
University of Toledo, Toledo, OH, USA
Meghan Hufstader-Gabriel Office of the National Coordinator for Health IT, Washington, DC, USA
Nilesh Gangan Surbhi Shah Robert Bechtol University of Toledo, Toledo, OH, USA Address for correspondence: Varun Vaidya PhD, Assistant Professor, Pharmacy Health Care Administration, Department of Pharmacy Practice, University of Toledo College of Pharmacy, Health Science Campus 3000 Arlington Ave., Toledo, OH 43614, USA. Tel: +1 419 383 1516; [email protected] Keywords: Chronic obstructive pulmonary disease – Disparities – Lung cancer – MEPS – Pharmacotherapy – Smoking cessation Accepted: 11 December 2013; published online: 5 February 2014 Citation: Curr Med Res Opin 2014; 30:1043–50
Objective: Smoking is one of the major risk factors causing morbidity and mortality in chronic obstructive pulmonary disease (COPD) and lung cancer patients. Use of smoking cessation pharmacotherapy is an effective way to help quit smoking. The purpose of the study was to determine the prevalence of smoking and the proportion of patients using smoking cessation agents, and to identify the socio-demographic factors that affect the use of these agents among COPD and lung cancer patients. Research design and methods: A retrospective study was done to identify smokers having COPD (ICD-9: 490–492) or lung cancer (ICD-9: 162), and those who use smoking cessation agents from 2006–2010, using Medical Expenditure Panel Survey (MEPS) data. A multiple logistic regression model was built to identify significant socio-demographic predictors associated with the use of smoking cessation agents. Results: Around 16.8% of COPD patients and 15.1% of lung cancer patients reported smoking after diagnosis. Out of the total smokers, 8.8% patients with COPD and 12.6% patients with lung cancer reported use of smoking cessation agents during the 5 year period. Logistic regression showed that odds for smoking cessation use in COPD patients were lower for Hispanics (OR ¼ 0.107, 95% CI 0.023–0.502) and higher for patients having insurance coverage (OR ¼ 3.453, 95% CI 1.240–9.617). Conclusion: Results showed that a large number of patients continued to smoke even after the diagnosis of COPD and lung cancer; whereas only a few among them used smoking cessation agents. Ethnicity disparities and insurance status were associated with the use of smoking cessation agents. Differential use among population sub-groups suggests a requirement for need based smoking cessation programs and appropriate prescription drug coverage. Further research needs to be done to evaluate reasons for disparities in smoking cessation agents’ use. The study had limitations common to research designs based on observational and self-reported datasets.
Introduction Respiratory diseases are a significant public health burden1. Chronic obstructive pulmonary disease (COPD) and lung cancer are the two major respiratory diseases causing significant morbidity and mortality in the United States. COPD is the third leading cause of all deaths while lung cancer is the primary cause of ! 2014 Informa UK Ltd www.cmrojournal.com
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cancer death in the country2. Smoking is the primary risk factor for both these diseases3. Additionally, smoking leads to worsening of these conditions and accounts for greater resource utilization. Approximately 90% of lung cancer cases4 and 75% of COPD cases5 are caused by cigarette smoking, in addition 85 to 90% of COPD deaths are caused by smoking3. Similarly, lung cancer patients who continue to smoke after diagnosis double their risk of dying from this disease6. It has also been shown that patients with COPD can develop lung cancer which often results in severe consequences. Patients’ quality of life, financial burden, and survival are impacted by these two chronic conditions7. The most effective strategy to prevent declining lung function among COPD patients is smoking cessation7. Quitting smoking reduces the mortality in lung cancer patients by 50%8. In patients with COPD, smoking cessation has been very beneficial resulting in a decrease in the risk of disease progression and risk of lung cancer9,10. The World Health Organization (WHO) and other clinical guidelines such as Global initiative for Chronic Obstructive Lung Disease (GOLD), the American College of Chest Physicians (ACCP) and the American Society of Clinical Oncology (ASCO), strongly advocate motivating COPD and lung cancer patients to stop smoking11,12. The current strategies for smoking cessation range from counseling to pharmacotherapy. The counseling strategies may include simple advising, written materials, or behavioral support by individuals and groups along with education on the adverse effects of smoking on health. Risk factor reduction and pulmonary rehabilitation may also be recommended. Even though such techniques are useful in helping quit smoking, it has been shown that pharmacological treatments are most effective and double the odds of cessation in healthy smokers13. Literature shows that the use of a pharmacologic agent could have a positive psychological effect on cessation attempts by smokers14. In fact, intermittent smoking cessation can reduce the risk of exacerbations and excess decline in lung function. Similar results can be expected in COPD and lung cancer patients. The availability of smoking cessation agents would motivate patients who have difficulty in quitting smoking. However, it was found that 14–38% of lung cancer patients and 30% of COPD patients continue to smoke even after diagnosis15,16. Fewer than 20% of smokers make an attempt to quit smoking despite the benefits of smoking cessation drugs14. Little is known about the use of smoking cessation agents among COPD and lung cancer patients. In the present study we attempt to address the literature gap by generating information on the prevalence of smoking and the use of smoking cessation agents in COPD and lung cancer patients. It will help clinicians and researchers better understand whether the use of smoking cessation agents among these patient populations is associated with certain factors. The overall objective of this study was to identify the prevalence of 1044
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smoking and use of smoking cessation agents in COPD and lung cancer patients, and predict the factors associated with the use of these agents among these patients.
Methods Study design This retrospective study used the Medical Expenditure Panel Survey (MEPS) as the data source. MEPS database is commonly used to study the healthcare utilization pattern17. MEPS provides national estimates on access, use, and expenditures for healthcare which includes inpatient stays, outpatient visits, ER visits, physician services, prescription drugs and related medical services. It also provides information on the sources of payments to providers and the sources of coverage and health status of the population surveyed. The survey is administered every year by the Agency for Healthcare Research and Quality. It has a rotating panel design and each panel is composed of a non-institutionalized US population who are interviewed five times over 30 months. Except for the first year, two panels are interviewed each year and individual sampling weights are assigned to the participants in two panels to obtain a nationally representative statistic. The study was approved by The University of Toledo Biomedical Institutional Review Board.
Data collection and extraction Data was extracted from 2006 to 2010 full-year consolidated, medical conditions and prescribed medicines data files within the household component of MEPS. The household components provide information on the demographic characteristics, health conditions, health status, medical services use, charges and source of payments, access to care, satisfaction with care, health insurance coverage, income, and employment. The years from 2006 to 2010 were selected because they were the most recent at the time of the study. From 2006 to 2010 medical conditions data files all the COPD and lung cancer patients were identified separately by using their respective International Classification of Diseases, ninth revision (ICD-9) codes. The MEPS ascertains COPD and lung cancer diagnosis by recording those individuals with ICD-9 codes 490–492 and 162 respectively. We defined COPD as including chronic bronchitis and emphysema as described by the National Heart, Lung and Blood Institute (NHLBI). Asthma was excluded because its etiology and treatment differed from that of COPD. Information on patients’ smoking status was obtained from full-year consolidated data files. Patients who responded ‘yes’ to the question ‘do you currently smoke?’ were considered active smokers and were observed for their smoking www.cmrojournal.com ! 2014 Informa UK Ltd
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cessation agents utilization from the prescribed medicines files. The smoking cessation agents included all prescription as well as OTC drugs (Chantix, Zyban, Wellbutrin, Budeprion, nicotine transdermal patches and nicotine gums) classified by Multum therapeutic sub-classification used by MEPS to categorize prescription and nonprescription drugs. Patients who responded that they were taking smoking cessation agents were considered users while the others were labeled as non-users.
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Study variables The main variable of analysis was the use of smoking cessation agents by COPD and lung cancer patients who smoke. In order to identify the prevalent factors that led to the non-utilization of these drugs, a theoretical framework called Andersen’s model for healthcare utilization was used. Andersen’s model has been used in previous studies to evaluate various types of healthcare utilization18–20. According to Andersen’s model of health services utilization, there are predisposing factors, enabling factors, and need based factors that determine patients’ utilization of a particular health service. Predisposing factors are the socio-cultural characteristics of the individuals which decide their proclivity to utilize healthcare services. Therefore, it is theorized that a patient is more or less likely to use health services based on age, gender, race/ethnicity, education and patient knowledge of health service benefits, and satisfaction with health services. Enabling factors are the resources found within the family and community which enable them to utilize the health services. Need based factors are those related to the perception of need for health services due to functional and health problems. Based on Andersen’s model, it can be assumed that gender, age, race, ethnicity, and region are the predisposing factors. Income and insurance status were considered the enabling factors that may influence the behavior of using smoking cessation agents by the COPD and lung cancer patients who smoked.
Data analyses Descriptive statistics were used to obtain the number of COPD and lung cancer patients, their smoking status, and patients’ utilization of smoking cessation agents. A logistic regression model was constructed to determine the odds of using smoking cessation agents among these patients according to their characteristics. The complex survey design of MEPS was incorporated by using sample weights for stratum, cluster, and individual persons to obtain unbiased national estimates. Nonresponse bias was also adjusted using the sampling weights. SAS version 9.3 (SAS Institute Inc., Cary, NC, USA) was used to conduct ! 2014 Informa UK Ltd www.cmrojournal.com
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the data analysis and to accommodate for the complex sample design and weights.
Results The results showed an estimated 73 million non-institutionalized population suffering from COPD and 3 million patients from lung cancer during 5 years of study. This was based upon the unweighted data of 6713 individuals living with COPD and 256 with lung cancer during the years 2006–2010. The data showed that an estimated 15.5 million COPD patients and 470,000 lung cancer patients out of the total were current smokers (Table 1). Of those COPD and lung cancer patients who smoked, only 8.83% and 12.65% patients respectively were taking any form of smoking cessation agents (Table 2). Table 3 represents the socio-demographic characteristics of smoking cessation agents’ users and non-users. Lung cancer patients who smoked were mostly male Caucasians from the southern region of the US. They mostly had public insurance, an income less than $20,000, and belonged to the adult and elderly populations. It was found that compared to the elderly population, adults tend to continue smoking among COPD patients. Most of the COPD patients who smoked were Caucasian females with public or private insurance and an income less than $20,000. Lung cancer patients who used smoking cessation agents were mostly elderly (92.9%), non-Hispanic (100%), and from the southern region (53%) of the US. With regard to COPD, more females (63.3%) took smoking cessation agents compared to male patients. These patients were Table 1. Smoking status among lung cancer and COPD patients. Condition Lung cancer COPD
Smoking Status
N
Weighted N
Weighted %
Smokers Non-smokers Smokers Non-smokers
48 208 1423 12,924
468,728 2,308,178 15,585,428 57,351,757
16.87 83.13 15.18 84.82
Table 2. Use of smoking cessation agents among lung cancer and COPD patients who smoke. Condition
Lung cancer
COPD
Smoking cessation use Smoking cessation agent users Smoking cessation agent non-users Smoking cessation agent users Smoking cessation agent non-users
N
Weighted N
Weighted %
6
59,336
12.65
42
409,392
87.35
123
1,377,311
8.83
1300
14,208,116
91.16
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Less than 20,000 20,000–50,000 More than $50,000
South Midwest West Northeast
Insured Uninsured
Income
Region
Insurance
1133/40 167/2
484/18 287/7 177/6 149/2
805/31 409/11 86/0
136/9 791/23 373/10
787/31
Less than high school High school More than high school
Years of education
1204/40 96/2
No
Non-Hispanics Hispanics
Ethnicity
83/0 1011/20 198/22
513/11
Young adults Adults Elderly
Age category
781/16 519/26
1045/34 200/8 55/0
Frequency (COPD/lung cancer)
Yes
Female Male
Gender
Prescription drug insurance coverage
White African-American Other
Groups
Race
Characteristics
7,383,304/265,799
6,824,812/143,593
12,492,233/390,939 1,715,884/18,453
4,972,761/163,936 3,353,877/88,152 1,786,995/83,377 2,097,839/10,624
7,692,244/28,0561 5,262,333/128,831 1,253,540/0
1,185,347/72,087 8,380,578/239,098 4,642,192/98,207
13,577,205/398,450 630,911/10,942
1,031,060/0 10,995,001/194,167 2,102,091/215,225
8,207,893/156,416 6,000,223/252,975
12,548,814/369,037 1,133,267/40,354 526,036/0
Weighted frequency (COPD/lung cancer)
Smoking cessation non-users
51.96/64.93
48.03/35.07
87.923/95.48 12.076/4.50
40.722/47.36 27.464/25.47 14.486/24.09 17.179/3.06
54.139/68.53 37.037/31.46 8.822/0
8.342/17.60 58.984/58.40 32.672/23.98
95.559/97.32 4.440/2.67
7.297/0 77.823/47.42 14.878/52.57
57.769/38.20 42.230/61.79
88.32/90.14 7.97/9.85 3.70/0
Percentage weighted (COPD/lung cancer)
Table 3. Socio-demographic characteristics of COPD and lung cancer patients according to smoking cessation agents’ use.
77/5
46/1
119/6 4/0
37/3 30/0 19/1 20/1
86/4 26/1 11/0
12/1 56/0 55/5
121/6 2/0
4/0 97/1 22/5
77/3 46/3
107/3 11/2 5/1
Frequency (COPD/lung cancer)
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808,183/47,638
569,129/11,698
1,330,354/59,337 46,958/0
360,720/29,315 347,857/0 232,571/11,698 286,477/14,120
927,296/38,278 285,162/9360 164,853/0
130,744/4203 624,143/0 622,242/55,133
1,371,584/59,336 5727/0
59,197/0 1,033,836/4203 284,279/55,133
872,718/25,561 504,593/33,776
1,267,312/29,315 68,189/18,323 41,811/11,698
Weighted frequency (COPD/lung cancer)
Smoking cessation users
58.67/80.28
41.32/19.72
96.590/100 3.409/0
29.383/53.17 28.335/0 18.944/21.21 23.335/25.61
67.326/64.21 20.704/15.77 11.969/0
9.493/7.08 45.322/0 45.184/92.91
99.584/100 0.4158/0
4.298/0 75.061/7.08 20.640/92.92
63.363/43.07 36.636/56.92
92.01/49.40 4.95/30.88 3.03/19.71
Percentage weighted (COPD/lung cancer)
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Table 4. Logistic regression results for COPD patients.
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Variable
Age Adults (25–65 yrs) Elderly (465 yrs) Gender Males Race African-American Others Ethnicity Hispanic Region Midwest Northeast South Insurance status Insured Prescription drug insurance No coverage Income 520,000 20,000–50,000 Years of education 5High school 4High school
Reference category
Smoking cessation agents use Odds ratio
95% confidence interval
Young adults (18–25 yrs)
1.288 1.632
0.377–4.406 0.441–6.035
Females
0.816
0.521–1.278
Caucasians (Whites)
0.532 0.596
0.246–1.152 0.190–1.87
Non-Hispanic
0.107
0.023–0.502
West
0.82 1.074 0.615
0.432–1.557 0.474–2.431 0.319–1.185
Uninsured
3.453
1.24–9.617
With coverage More than 50,000
1.303
0.767–2.214
1.149 0.545
0.534–2.472 0.295–1.007
1.343 1.932
0.490–3.676 0.993–3.759
High school
Variables in bold are statistically significant.
more likely to be adults (75%), Caucasian (92%), Hispanic (99.5%), and had an income less than $20,000 (67.3%). Logistic regression was carried out in order to predict the factors that define the use of smoking cessation agents among these patients. It was not possible to perform logistic regression for the patients with lung cancer because of the small sample size of these patients who utilized smoking cessation agents. Table 4 shows the results of logistic regression for COPD patients. Males had lower odds of using smoking cessation agents than females (OR ¼ 0.816, 95% CI 0.521–1.278). Adults and the elderly had greater odds of taking smoking cessation agents compared to young adults (OR ¼ 1.288, 95% CI 0.377–4.406 and OR ¼ 1.632, 95% CI 0.441–6.035 respectively). African-Americans were less likely to utilize smoking cessation agents than whites (OR ¼ 0.532, 95% CI 0.246–1.152). Hispanics were less likely to utilize smoking cessation agents compared to non-Hispanics (OR ¼ 0.107 95% CI 0.023–0.502) which was found to be significant. Patients with educational level more than and less than high school degree had greater odds of taking smoking cessation agents compared to those with a high school degree (OR ¼ 1.932, 95% CI 0.993–3.759 and OR ¼ 1.343, 95% CI 0.490–3.676 respectively). The use of smoking cessation agents among the insured population was significantly higher compared to those who were uninsured (OR ¼ 3.453, 95% CI 1.24–9.617). ! 2014 Informa UK Ltd www.cmrojournal.com
Discussion Continued smoking by patients with chronic conditions, such as lung cancer and COPD, can lead to worsening of disease condition, and reduced productivity and quality of life21,22. Lung cancer and COPD patients who smoke even after diagnosis are at increased risk of morbidity and mortality23. However, this related morbidity and mortality can be reduced to a certain extent by the use of appropriate smoking cessation strategies. The effectiveness of pharmacological agents in smoking cessation has been established24,25. Pharmacological treatment is more time-efficient and easy to follow compared to counseling which requires frequent clinic visits. In this study we found that a substantial proportion of lung cancer (16.87%) and COPD patients (15.18%) reported smoking even after diagnosis. This was comparable to other studies which reported that 14–39% of lung cancer patients and up to 43% of COPD patients smoke after diagnosis26–29. Despite the usefulness of smoking cessation agents in helping smokers quit, it was found that the proportion of COPD and lung cancer patients reporting use of any smoking cessation agents was remarkably low. Interestingly, previous research has also found similar results30. Regression analysis revealed some predictive characteristics for use of smoking cessation agents among COPD patients. The Hispanic population in particular showed significantly lower use of smoking cessation agents. This finding corroborates the overall underutilization of Smoking-cessation pharmacotherapy in COPD and lung cancer Vaidya et al.
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healthcare services by minority populations reported in many studies31–33. Reasons such a language barriers are supported in the literature behind the underutilization among Hispanic population. Considering the initiation of smoking is also found to be high among Hispanics youths and the rates of quitting is low34,35, special attention to this population is warranted. Use of smoking cessation agents was found to be low among AfricanAmericans; however, when adjusted for covariates the association was not statistically significant. Nonetheless, considering the fact that African-Americans have lower odds of quitting smoking34, the low utilization among the African-American population remains a concern. Other than race and ethnicity, insurance status was also found to be significantly associated with the use of smoking cessation agents. Patients having any kind of health insurance coverage (public or private) had higher odds of reporting smoking cessation agents’ use than patients who were uninsured. This finding adds to the several studies looking at medication and service utilization that have shown significant underuse of medicines and services among the uninsured as compared to the insured. Underuse is an issue that needs to be addressed, as it has been shown that the uninsured show poorer health outcomes compared with their insured counterparts36. An interesting finding observed in the study was the statistically insignificant association between prescription drug coverage and use of smoking cessation agents. Some of the possible reasons behind it could be the exclusion of smoking cessation pharmacotherapy or a formulary structure discouraging use of it by imposing higher copays. It will be interesting to see how the current scenario will change after the full implementation of the Affordable Care Act (ACA) which categorizes smoking cessation pharmacotherapy as preventive therapy and requires mandatory coverage in all prescription drug plans37. Based on the findings from this study it appears to be an important inclusion in the ACA. Future research should explore the reasons for reluctance among lung cancer and COPD patients to use smoking cessation agents. Policies are adapting in response to mitigate this trend. Smoking cessation strategies of physicians especially recommending medications has been shown to be cost-effective38. Therefore, low use of smoking cessation agents among COPD and lung cancer patients who smoke warrants special attention from the physicians in terms of counseling. The Centers for Medicare and Medicaid Services (CMS) in collaboration with the Office of the National Coordinator for Health Information Technology (ONC) have included the core requirement of recording smoking status for patients 13 years and older to the Electronic Health Records (EHR) Incentive Programs for the Meaningful Use of Electronic Health Records39. This is a national health outcome priority to help improve quality, safety and efficiency, and reduce health disparities. 1048
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This requirement requires that eligible providers record more than 50% of all unique patients 13 years or older that are seen by the healthcare professional or are admitted to the hospital. Additionally, beginning in 2014, all participants in the CMS EHR Incentive Program will be required to report several core clinical quality measures (CQMs). Included among these are the recommended core measure questions about tobacco use and the resulting screening and smoking cessation interventions for patients currently using tobacco products. This highlights the national importance of smoking cessation. Also, the Physician Quality Reporting System (PQRS) provides incentives to physicians for satisfactory reporting of quality measures. One of the quality measures requires the physician to advise smokers to quit smoking by discussing cessation medications and strategies. With the changing healthcare system, the service provided by healthcare providers is being evaluated in order to provide them incentives for provision of good quality service. Therefore, physicians should discuss the importance of smoking cessation with lung cancer and COPD patients and at the same time collaborate with other healthcare professionals such as pharmacists so that appropriate counseling on cessation medications is provided to these patients. This would help improve the quality of service and would benefit the patient and the physician. One of the strengths of our study is that the reported estimates are nationally representative of the US civilian, non-institutionalized population, i.e. our results are generalizable.
Limitations A limitation of the study is that the information was obtained from a secondary database; there could be a possibility thereby of bias due to missing information. Also, smoking status and use of smoking-cessation agents were self-reported by the patients, hence social desirability bias and recall bias could be a potential threat to validity. Studies have shown that patient recall declines over time and recall depends on perceived social acceptability of behavior or condition. Therefore, the proportion of smokers and users of smoking cessation agents among lung cancer and COPD patients reported might be an underestimated figure. Moreover, causal inference could not be drawn from the results due to the retrospective and cross-sectional nature of the database. However, this study opens the scope for further investigation on the probable reasons for occurrence of disparities found in the study. It was difficult to collect information on the time of diagnosis in relation to smoking status and smoking cessation use. This information could have given some insights into prevalence of smoking and use of smoking cessation agents in terms of time to diagnosis and disease www.cmrojournal.com ! 2014 Informa UK Ltd
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length. It was also difficult to distinguish if buproprion brands were prescribed for smoking cessation or depression. As smoking cessation was the priority among the patient population, it can be assumed the drugs were prescribed for smoking cessation.
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Conclusion Despite the usefulness of smoking cessation agents in helping smokers quit their habit, the proportion of COPD and lung cancer patients that reported using smoking cessation agents was very low, which was highlighted by this study. The use of smoking cessation agents among COPD patients was significantly less in the Hispanic population compared to the non-Hispanic population. Other than this finding, the insured population had higher use of smoking cessation agents than the uninsured population. Finding out reasons for such disparities in the future may help bring about policy changes as well as reduce morbidity and mortality among the study population.
Transparency Declaration of funding The authors received no funding in preparation of this manuscript. Declaration of financial/other relationships V.V., M.H.-G., N.G., S.S., and R.B. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article. CMRO peer reviewers may have received honoraria for their review work. The peer reviewers on this manuscript have disclosed that they have no relevant financial relationships. Acknowledgments We thank Neha Gangal from the division of Health Outcomes and Socio-economic Sciences, College of Pharmacy, University of Toledo for her assistance regarding preparing and reviewing this manuscript. Previous presentation: Poster presentation at ISPOR 18th Annual International Meeting, New Orleans, Louisiana, 18–22 May 2013.
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