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© 2001 American Public Health Association
RESEARCH |
Elizabeth M. Barbeau, Glorian Sorensen, and Karen Emmons are with the Department of Adult Oncology, Dana–Farber Cancer Institute, and the Department of Health and Social Behavior, Harvard School of Public Health, Boston, Mass. Yi Li is with the Department of Biostatistical Sciences, Dana–Farber Cancer Institute, and the Department of Biostatistics, Harvard School of Public Health, Boston, Mass. Kathleen M. Conlan is with the Laborers' Health and Safety Fund of North America, Washington, DC. Richard Youngstrom is with the Department of Adult Oncology, Dana–Farber Cancer Institute, Boston, Mass.
Correspondence: Requests for reprints should be sent to Elizabeth M. Barbeau, ScD, MPH, Population Sciences, Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115 (e-mail: elizabeth_barbeau{at}dfci.harvard.edu).
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ABSTRACT |
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Objectives. This study determined the level of insurance coverage for smoking cessation treatment and factors associated with coverage among health and welfare funds affiliated with a large labor union.
Methods. A self-administered written survey was mailed to fund and union officials. Analyses were conducted by 
2 tests.
Results. Twenty-nine percent of funds provided coverage for some type of smoking cessation treatment, with the odds of coverage significantly increased among funds whose administrators reported having received members' requests for smoking cessation treatment in the past year (odds ratio = 4.9, P = .05).
Conclusions. Coverage for smoking cessation services is low, comparable to coverage offered by other health insurers. Interventions with union members and fund officials are needed to provide union members with access to affordable and effective smoking cessation treatments.
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INTRODUCTION |
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Class-based disparities in tobacco use are increasing. The gap in smoking prevalence by occupational category has been steadily widening, with blue-collar workers (defined by census occupational categories 401–785 as craftsmen/kindred workers, operatives, and laborers)1,2 being more likely to smoke, to smoke more heavily, and to be less successful in quitting smoking than either white-collar or service workers.1–4 In 1997, 36% of blue-collar workers were smokers, compared with 21% of white-collar workers, with occupational class remaining a significant predictor of smoking after age, sex, and race/ethnicity were controlled for.1 Decades of tobacco control efforts have met with limited success among these workers, suggesting that new strategies and community partners are needed.
Labor unions are a natural ally in such efforts, in that they are likely to represent workers in these at-risk occupations and because many unions offer health insurance to their members.5 Through their health insurance programs, unions can offer fully paid coverage of smoking cessation services, a benefit that has been shown to be effective in other insured populations.6 Health insurance is provided by some unions to their members through health and welfare (Taft–Hartley) funds. These funds are financed by contracting employers' contributions to regional funds on behalf of their unionized employees under terms negotiated in the collective bargaining process, which is based on the National Labor Relations Act. The funds either purchase health insurance or self-insure. They are governed equally by representatives from labor and management and operated at regional or district levels. It is estimated that health and welfare funds provide health insurance coverage to approximately 9 million smokers in the United States.7 These funds are therefore a unique vehicle for increasing labor union members' access to affordable smoking cessation services, which may, in turn, redress class-based disparities in smoking prevalence.
In this article, we report the findings of a survey of health and welfare funds affiliated with the Laborers' International Union of North America (LIUNA), which represents approximately 800 000 construction, health care, service, public sector, and environmental laborers in the United States. We determined the level of coverage for smoking cessation services by health and welfare funds; we also tested for associations between coverage and (1) survey respondents' perceptions of members' smoking as a problem, (2) their level of concern about it and its potential impact on the health and welfare fund, and (3) the number of member requests for coverage of smoking cessation services.
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METHODS |
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Study Design
A self-administered survey was mailed to study participants from the Laborers' Health and Safety Fund of North America (LHSFNA), a separate labor–management fund affiliated with LIUNA and established to address the health and safety concerns of the union and its signatory employers. An LHSFNA staff member contacted nonrespondents by telephone.
Sample
The survey was conducted among LIUNA health and welfare fund administrators and district council business managers; individuals in these positions are key players in determining fund health insurance coverage policies. Fund administrators are nonunion employees hired to oversee operations and to provide guidance to fund trustees on coverage policies and other matters. Business managers are union officials who represent members' concerns about their health insurance policies and who are most likely to receive any requests from members for coverage of specific services. Trustees make decisions about coverage policies. We surveyed business managers and fund administrators because of their knowledge of members' needs and trustees' concerns and their involvement in assisting trustees in determining coverage policies. We chose not to survey fund trustees, because their level of involvement in funds varies widely and thus, in some cases, their responses would not be meaningful. The study sample consisted of all LIUNA district-level business managers (n = 58) and administrators for all health and welfare funds for whom current mailing addresses were available (n = 92). The response rate was 84% (n = 49) for business managers and 73% (n = 67) for fund administrators. No information is available for comparing respondents with nonrespondents.
Measures
Survey questions determined whether funds provided coverage of nicotine replacement therapy, smoking cessation classes, or both, as well as coverage for alcohol and illicit drug addiction. Using a 5-point Likert scale, we measured respondents' perceptions of members' smoking as a problem, their level of concern about it, and its potential impact on the health and welfare fund. Using a question with categorical responses, we asked about the number of member requests for coverage of smoking cessation services. The survey also assessed respondents' awareness of and interest in receiving guidelines for smoking cessation issued in 1996 by the Agency for Health Care Policy and Research (AHCPR).8 The surveys for administrators and business managers differed slightly on the basis of their distinct responsibilities; administrators were asked more detailed questions about coverage policies and about their perceptions of trustees' concern about members' smoking and its cost impact.
Analyses
Data were analyzed to determine response frequencies and to detect associations between coverage for smoking cessation services and factors related to coverage; 2 tests were used to produce unadjusted odds ratios. Responses to survey items were dichotomized for ease of interpretation, with the top 2 categories of Likert responses ("very much" and "to a great extent") considered a yes response. Ordinal responses to the question about number of requests for smoking services received in the past year were also dichotomized (0 vs 1 or more), because a test for linear trend in the association between number of requests and coverage was not significant.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Coverage of Smoking Cessation Services
Only 28% (n = 19) of administrators reported that their funds covered any type of smoking cessation service. Of these, 84% (n = 16) covered use of the nicotine patch, 47% (n = 9) covered nicotine gum, 11% (n = 2) covered smoking cessation classes, 47% (n = 9) covered more than one of these services, and 5% (n = 1) covered them all. Fewer than half (46%; n = 31) of fund administrators received any requests from members for smoking cessation services; 25% (n = 17) received between 1 and 5 requests and 28% (n = 19) received 6 or more. Of plans offering coverage, 68% did so as a prescription benefit, with 8% planning to drop coverage of the nicotine patch and gum because they had become available over-the-counter. In contrast to the low rates of coverage for smoking cessation services, 81% (n = 54) of funds provided coverage for treatment of alcohol or illicit drug dependency.
Factors Related to Coverage of Smoking Cessation Services
About half (53%; n = 31) of fund administrators and nearly two thirds (63%; n = 31) of business managers considered members' smoking to be a problem (difference not statistically significant); 65% (n = 32) of business managers reported concern about members' use of tobacco, whereas 27% (n = 17) of fund administrators reported that they believed that trustees are concerned about members' tobacco use (P < .001); and 67% (n = 33) of business managers and 39% (n = 24) of fund administrators thought that members' smoking had a financial impact on the funds (difference not statistically significant). About half of fund administrators (54%) and business managers (54%) reported that the issue of smoking cessation benefits had been brought to their attention by at least 1 member in the past year. Very few respondents (3%) were aware of the AHCPR smoking cessation guidelines, but most (86%) were interested in receiving them.
As shown in Table 1
, the odds ratios of providing coverage for smoking cessation services were significantly greater among funds whose administrators reported having received 1 or more member requests for smoking cessation services in the past year (odds ratio = 4.9, 95% confidence interval = 1.0, 23.3; P = .05). Positive associations (not significant) were observed between coverage of smoking cessation services and survey respondents' considering smoking to be a problem, being concerned about it, believing it had a financial impact on the fund, and having received members' requests for smoking cessation services, with the exception of a negative (not significant) association for business managers' considering member smoking to be a problem.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The AHCPR guidelines for smoking cessation, issued in 1996 and updated in 2000, advise that use of a pharmacologic treatment, in conjunction with counseling, should be a fully paid health insurance benefit.8,9 Among our study sample, only 1 health and welfare fund provided coverage consistent with the guidelines. Although most respondents reported being concerned about members' tobacco use, this concern has yet to be translated into coverage of services. It is noteworthy that only 27% of fund administrators reported that they believed that their trustees, who ultimately decide coverage policies, are concerned about members' smoking. These data suggest that there is significant room for improvement in funds' coverage of smoking cessation services. In this regard, health and welfare funds are similar to other types of health insurers, among which coverage for smoking cessation services is also uncommon.10 A recent survey of managed care organizations revealed that only 39% had partially implemented the AHCPR guidelines and only 9% had fully implemented them.11
Our results point to interventions with union members and fund officials that may help to bring about increased coverage of smoking cessation services. With regard to member-based interventions, the union could encourage members (a) to find out whether their health funds cover smoking cessation services, (b) to use these benefits in accordance with the AHCPR guidelines if they do, and (c) to request that their funds add coverage of smoking cessation services if they do not.
The union could inform fund officials about (a) the immediate and long-term health benefits for members who quit smoking, (b) the positive association between offering cessation services as a fully paid benefit and members' use and success in quitting,6 (c) the cost-effectiveness of coverage for smoking cessation services relative to other disease prevention interventions and medical treatments,12–19 and (d) the AHCPR guidelines for smoking cessation pertaining to care providers (which have been disseminated to fund officials since completion of the survey). In addition to preventing health problems, covering prevention services through a union health and welfare fund is often cost-effective because members typically remain in the union throughout their working lives and often into retirement, so that costs associated with prevention help to avoid costs of treating smoking-related diseases in later life. Furthermore, many of the laborers' funds offer reciprocity, so that health benefits move with workers if they are transferred to another geographic area. This is not the case with other insurance providers, which experience more subscriber turnover and so have little financial incentive to invest in prevention that may benefit another provider in the future.
Our study has some limitations. First, owing to a small sample size, we had limited power (7%–37%) to detect statistically significant associations between various factors and coverage for smoking cessation services. This limitation was largely unavoidable, given that we surveyed all LIUNA district council business managers and the vast majority of fund administrators and achieved acceptable response rates (84% for business managers and 73% for fund administrators). The sample size was made slightly smaller owing to the unavailability of mailing addresses for 38 fund administrators who communicate infrequently with LHSFNA staff. We have no information on whether the coverage policies of their funds differ from those reported in the survey. Second, we concurrently collected information on the number of requests for smoking cessation services and coverage of these services by funds. It may be that funds that already provided coverage were the ones that received requests, or that because of requests, these funds added coverage. Our study design does not allow us to discern the direction of this relationship. Third, we did not survey fund trustees directly because of the anticipated variation in their awareness of fund policies. However, this group's perceptions are very important, because any changes in coverage must be approved by both labor and management trustees. Future research is needed to investigate trustees' knowledge of and attitudes toward this and other important health issues for the union.
There are more than 2500 multiemployer health and welfare funds in the United States (Pension and Welfare Benefits Administration, US Dept of Labor, unpublished data, 2000), which together provide insurance coverage to 9 million smokers.7 Insurance coverage of smoking cessation increases the likelihood of successful quitting and is cost-effective for insurers. Increasing access to affordable and effective smoking cessation services to unionized workers will help in redressing class-based disparities in tobacco use and tobacco-related diseases.
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Acknowledgments |
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This research was funded by the Robert Wood Johnson Foundation (grant 029471).
The authors wish to acknowledge Ruth Lederman, Kathleen Yaus, and Richard Martins for assistance in preparing this manuscript.
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Footnotes |
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Peer Reviewed
E. M. Barbeau led the analysis and the writing of the paper. Y. Li conducted the statistical analyses. G. Sorensen participated in the study design and interpretation of analyses. K. M. Conlan and R. Youngstrom participated in survey development and administration. K. Emmons led the conception, design, and implementation of the study and contributed to the interpretation of analyses. All authors contributed to the writing and editing.
Accepted for publication April 26, 2001.
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