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Service Delivery Innovation Profile

Culturally Tailored Cessation Program for Lesbian, Gay, Bisexual, and Transgender Smokers Enhances Access and Patient Satisfaction


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Snapshot

Summary

Blue Cross Blue Shield of Minnesota’s Stop-Smoking Program provides welcoming and culturally relevant tobacco cessation support to members of the lesbian, gay, bisexual, and transgender community. The statewide program includes a quit guide that is specifically targeted toward lesbian, gay, bisexual, and transgender smokers, culturally tailored promotional campaigns, a cultural competency training for the program's tobacco cessation coaches, and a sexual orientation/gender identity question that was added to Minnesota’s two largest tobacco quitlines as part of the program’s registration process. The program has enhanced access to culturally tailored smoking cessation services; increased knowledge and understanding among tobacco cessation coaches of issues related to smoking within the lesbian, gay, bisexual, and transgender community; and generated high levels of satisfaction among participants.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of callers to the program’s dedicated LGBT triage telephone line, anecdotal feedback from pilot participants, training evaluations and pre- and post-test survey responses from tobacco cessation coaches.
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Developing Organizations

Blue Cross Blue Shield of Minnesota
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Use By Other Organizations

Blue Cross Blue Shield of Minnesota is using the program’s counselor training as a template for internal training sessions with nurse guides and health guides. In addition, the Gay and Lesbian Medical Association has modified a version of the training for its members as part of a continuing medical education program.

Date First Implemented

2008
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Patient Population

Vulnerable Populations > Lesbian/gay/bisexual/transgenderend pp

Problem Addressed

Tobacco use, a leading cause of preventable deaths in the United States, is especially prevalent in the lesbian, gay, bisexual, and transgender (LGBT) community. Traditional tobacco cessation programs often do not address the unique cultural issues that lead to high smoking rates in this population.
  • Higher smoking rates: Members of the LGBT community are 40 to 70 percent more likely to smoke than are non-LGBT people.1 In Minnesota, 41 percent of LGBT adults smoke,2 well above the 17.6 percent rate among all Minnesotans.3
  • Leading to serious health consequences: According to the American Cancer Society, tobacco kills at least 30,000 LGBT people every year.4 Heavy rates of smoking among gay men have been associated with increased risky behaviors and lower overall health ratings,5 while transgender people who take hormones and smoke are at higher risk for cardiovascular and circulation problems.6
  • Failure of smoking cessation programs to address LGBT issues: Several social factors, including higher levels of stress and discrimination, frequent patronage of bars and clubs, and higher rates of drug and alcohol use may contribute to higher smoking rates in the LGBT community.1 Because most traditional tobacco cessation programs are not culturally tailored to address these issues, LGBT people are less likely to use such programs, and less likely to benefit when they do. In addition, LGBT individuals may be reluctant to contact traditional smoking cessation programs for fear of encountering discrimination or misunderstanding. Studies have also demonstrated that many physicians are uncomfortable treating LGBT patients, and that patients report a perceived lack of knowledge of providers to their particular health concerns. 7

What They Did

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Description of the Innovative Activity

Blue Cross Blue Shield of Minnesota’s Stop-Smoking Program provides welcoming and culturally relevant tobacco cessation support to members of the LGBT community. To serve them, the statewide program includes a quit guide that is specifically targeted toward LGBT smokers, culturally tailored promotional campaigns, a cultural competency training for the program's tobacco cessation coaches, and a sexual orientation/gender identity question that was added to Minnesota’s two largest tobacco quitlines as part of the program’s registration process. Key program elements include:
  • Cultural competency training: Blue Cross Blue Shield of Minnesota partnered with the National LGBT Tobacco Control Network to provide cultural competency training on LGBT issues to all tobacco cessation coaches (called Quit Coaches) operating within the Call It Quits Collaborative, a network of seven Minnesota health plans and ClearWay Minnesota that encompasses a total of eight telephone quitlines across the state. Training, which takes approximately 2 hours, can occur in person or via videoconference or audioconference, depending on the location of the tobacco cessation coaches. Each training session contains two modules. The first provides an overview of LGBT communities, appropriate terminology, and detailed information on factors influencing LGBT smoking. The second focuses on specific strategies to be used with LGBT smokers, including tips for creating a welcoming and safe environment, conveying openness to a caller’s disclosure of LGBT status, and facilitating LGBT individuals throughout the process.
  • Culturally tailored promotional campaigns: The program launched an LGBT-targeted promotional media campaign featuring a variety of outreach materials, including billboards, postcards, mint boxes, bus stop signs, and magazine advertisements. All promotional materials use culturally tailored messages and images designed to convey the supportive nature of the program. Materials direct smokers to call a dedicated “triage” telephone number, where an automated system will direct them to the appropriate quitline for their health plan (or to the state’s QUITPLAN program for those without insurance). Materials also direct callers to a one-page introductory Web site (see References and Related Articles for more information) that serves as an intermediate step to let LGBT individuals know what to expect when calling the quitline and to help them feel confident that the quitline will provide safe, culturally competent support.
  • Sexual orientation/gender identity registration question: The program developed a quitline registration question that allows callers to self-identify their sexual orientation and/or gender identity during the intake process. The question helps to assure LGBT callers that the quitline can provide safe, welcoming support that addresses the unique needs of the LGBT community.
  • LGBT quit guide: The program developed a supplemental, culturally tailored LGBT guide to quitting, offered to all LGBT callers as an enhancement to the standard smoking cessation materials provided to callers. The supplemental guide provides LGBT-specific information on triggers, targeting, and motivation for quitting, along with photographs and personal stories from local LGBT community members who have successfully used the quitline and a list of local community resources.

Context of the Innovation

Blue Cross Blue Shield of Minnesota, a nonprofit organization, serves 2.7 million members, making it the largest health plan in Minnesota. Since 2000, the plan has run a telephone-based tobacco cessation program, called Stop-Smoking Support. To make tobacco cessation services more accessible and effective for all, program staff became interested in tailoring telephone quitline services for priority populations. When local data showing the high prevalence of smoking among LGBT individuals in Minnesota became available, staff began discussing how to put together a targeted initiative to address this disparity.

Did It Work?

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Results

Although the impact on health outcomes has not yet been formally evaluated, the program has enhanced access to culturally tailored smoking cessation services, increased knowledge and understanding among tobacco cessation coaches of issues related to smoking within the LGBT community, and generated high levels of satisfaction among participants and LGBT community members.
  • Enhanced access to culturally appropriate services: Since 2008, over 100 people have accessed the dedicated LGBT “triage” line, which is advertised only on LGBT-targeted promotional materials. (Program leaders believe this figure represents the minimum number of LGBT individuals affected by the program, as it does not include those who bypass the triage line and contact their respective quitlines directly.) Because 41.5 percent of all Blue Cross Blue Shield members enrolled in the tobacco cessation program during 2008 successfully quit, increased enrollment of LGBT individuals has very likely reduced levels of smoking in the LGBT community.
  • Increased knowledge among tobacco cessation coaches: Tobacco cessation coaches rate the program’s LGBT training highly, with an average satisfaction score of 9.5 out of 10 for the LGBT Orientation module, and 9.4 out of 10 for the LGBT Quitline Strategies module. Pre- and post-test results indicated that 91 percent of tobacco cessation coaches reported increased confidence that they knew specific strategies to help create a welcoming environment for LGBT callers.
  • Highly satisfied participants: Participants of the pilot research consistently reported gratitude for the culturally sensitive support offered by the program, especially when asked whether they identify themselves as LGBT during the registration process, as this step makes them feel safe in accessing the quitline and increases their trust in the program. Additionally, the Web site or weblet (see Description of the Innovative Activity) was viewed by participants as a key step in facilitating trust and access for LGBT individuals.
A more robust qualitative and quantitative evaluation is being planned. Contact the investigators for details.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of callers to the program’s dedicated LGBT triage telephone line, anecdotal feedback from pilot participants, training evaluations and pre- and post-test survey responses from tobacco cessation coaches.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Obtaining internal buy-in: Program leaders conducted one-on-one informational sessions with more than 20 key staff within Blue Cross Blue Shield of Minnesota, including senior leaders, representatives from sales and marketing, account managers, and others. During these sessions, program leaders presented data demonstrating the need for a targeted smoking cessation initiative for the LGBT community.
  • Involving statewide collaborative: Program leaders presented the concept to the Call it Quits Collaborative, which includes tobacco cessation quitlines for seven of Minnesota’s health plans as well as a statewide QUITPLAN telephone line for the uninsured and underinsured. All participating quitlines agreed to have their counselors trained in how to provide culturally sensitive services to LGBT callers.
  • Developing and piloting new registration question: Blue Cross Blue Shield of Minnesota partnered with the National LGBT Tobacco Control Network to identify and tailor a question that would allow LGBT quitline callers to self-identify by sexual orientation and/or gender identity during the registration process. Program leaders commissioned the network to complete two rounds of cognitive testing on the question to ensure its appropriateness and effectiveness.
  • Developing quit guide: Working with the national network, program leaders conducted a review of tobacco cessation materials available for LGBT people. Finding that most of these materials contained specific guidelines, program leaders decided to create their own supplemental LGBT pamphlet that would not overlap with the strategies already offered by the state’s tobacco cessation quitplan materials.
  • Using focus groups to design promotional campaign: The program held several focus groups with LGBT community members to gather input on promotional messages, images, and formats that would best convey the quitline as a safe and welcoming place to call. The group identified the importance of having the Web site or weblet (see Description of the Innovative Activity section) for facilitating LGBT trust and access.
  • Working with local advisory boards: Program leaders engaged two advisory boards throughout the planning process. First, a community advisory board consisting of LGBT health leaders assisted in reviewing the guide and promotional materials. Second, the Tobacco-Free Lavender Communities, a Minnesota LGBT tobacco coalition funded by Blue Cross Blue Shield of Minnesota, provided ongoing feedback on program development and distributed promotional materials throughout the community.
  • Conducting interviews for program improvement: At the end of 2010, the program conducted interviews with LGBT quitline users to determine the impact of program components and identify opportunities for improvement. As a result of these interviews, program leaders plan to initiate ongoing education for quitline staff regarding the program's promotional campaign efforts, and they plan to use more imagery and prompts to encourage quitline staff to reference the LGBT quit guide when appropriate.

Resources Used and Skills Needed

  • Staffing: At Blue Cross Blue Shield of Minnesota, two project managers guided the program’s planning and implementation, along with an internal team of four key staff from within the organization’s Center for Prevention. All staff worked on the program as a part of their regular job responsibilities. In addition, representatives from the Call it Quits Collaborative, along with several research and creative development consultants, contributed time to project development. At present, the manager of the overall Stop Smoking Program at Blue Cross oversees ongoing administration of the program targeted at LGBT individuals.
  • Costs: The initial development, implementation, and promotion of the program cost approximately $45,000 in 2008. The cognitive testing and pilot testing cost approximately $45,000. Data on ongoing costs are not available, as program responsibilities are spread out among various departments and contributing teams at Blue Cross Blue Shield of Minnesota.
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Funding Sources

Blue Cross Blue Shield of Minnesota
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Adoption Considerations

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Getting Started with This Innovation

  • Gather data on magnitude of problem: To demonstrate the need for the program, collect local and national data that illustrates the existence and extent of the disparity in smoking rates between LGBT individuals and other populations.
  • Obtain internal buy-in: Use existing data and community testimonials to engage key leaders and staff from within the organization. Garnering their support will help to establish the program, and the problem it addresses, as organization-wide priorities.
  • Seek and use partnerships: Consult with national experts and a wide range of community advisers and stakeholders to develop, implement, and spread program components.
  • Build on existing efforts: Rather than starting from scratch, search broadly for existing resources and then tailor them to meet the needs and priorities of the local community.

Sustaining This Innovation

  • Integrate new efforts with existing procedures: Ensure that any smoking cessation efforts targeted toward the LGBT community, particularly use of culturally sensitive language and counseling skills, are established as procedural norms within the organization.
  • Create long-term promotional plan: Establish a visible and ongoing community presence, including within local and statewide media, so as to reduce long-term reliance on more labor-intensive marketing campaigns.

Use By Other Organizations

Blue Cross Blue Shield of Minnesota is using the program’s counselor training as a template for internal training sessions with nurse guides and health guides. In addition, the Gay and Lesbian Medical Association has modified a version of the training for its members as part of a continuing medical education program.

More Information

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Contact the Innovator

Sarah Senseman, MPH
Community Initiatives Manager
Center for Prevention
Blue Cross and Blue Shield of Minnesota
Route #S113
1750 Yankee Doodle Rd.
Eagan, MN 55121-1600
Phone: 651-662-7102
E-mail: sarah_e_senseman@bluecrossmn.com

Christina Wetterling
Wellness Program Manager
Blue Cross and Blue Shield of Minnesota
Route #S113
1750 Yankee Doodle Rd.
Eagan, MN 55121-1600
Phone: 651-662-0766
E-mail: Christina_Wetterling@bluecrossmn.com

Innovator Disclosures

Ms. Senseman and Ms. Wetterling have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

The LGBT Quit Guide is available at: http://www.lgbttobacco.org/files/Final%20Quitguide2.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Footnotes

1 National Coalition for LGBT Health. LGBT People and Smoking: Fact Sheet. [Web site] Available at: http://www.lgbttobacco.org/files/smokinglgbt.pdf
2 Cardona A, Hastings P, Zemsky B. Creating an effective tobacco plan for Minnesota’s gay, lesbian, bisexual & transgender communities: a final report. Minneapolis, MN: Rainbow Health Initiative; December 2005.
3 Giovino GA, Chaloupka FJ, Hartman AM, et al. Cigarette smoking prevalence and policies in the 50 states: an era of change—The Robert Wood Johnson Foundation ImpacTeen Tobacco Chart Book. Buffalo, NY: University at Buffalo, State University of New York; 2009. Available at: http://impacteen.org/statetobaccodata/chartbook_final060409.pdf
4 American Cancer Society. Tobacco and the GLBT community. 2003. Available at: http://www.glbthealth.org/documents/GLBTTobacco.pdf
5 Stall RD, Greenwood GL, Acree M, et al. Cigarette smoking among gay and bisexual men. Am J Public Health. 1999;89(12):1875-8. [PubMed]
6 Xavier J, Hitchcock D, Hollinshead S, et al. An overview of U.S. trans health priorities: a report by the Eliminating Disparities Working Group. National Coalition for LGBT Health: August 2004. Available at: http://www.transequality.org/PDFs/HealthPriorities.pdf
7 Dean, L, Meyer IH, Robinson K, et al. Lesbian, gay, bisexual and transgender health: findings and concerns. J Gay Lesbian Med Assoc. 2000;4(3):102-51.
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Original publication: July 07, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 05, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 28, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.