Purpose
This study delineates a number of Medicaid youth with tobacco use disorder (TUD), prescribing habits for treatment, and associated externalizing disorders.
Methods
Youth Medicaid claims from 2007-2017 processed in a large Midwestern city were analyzed for a diagnosis of TUD, related pharmacotherapy, and externalizing mental health and substance use disorders.
Results
Claims connected 6541 patients with 42 890 visits. Mean age was 16.4 with 40% female. 1232 of the 6541 charts contained a TUD diagnosis equating to 1848 visits. A comorbid diagnosis of ADHD, cannabis use, and conduct disorder were more common in males (3.9% vs 1.3% in females; 3.4% vs .8%; and 2.8% vs .8%; P < .05). 808 scripts were provided to 152 of the 1232 youths, with 4.7% of those scripts a nicotine replacement product.
Conclusions
Pharmacotherapy is underutilized in this Medicaid claims data set. Certain externalizing factors were associated with males with TUD more than females

Aalsma, Matthew C.

Adams, Zachary

Hulvershorn, Leslie

McBrayer, Kimberly

Ouyang, Fangqian

PubMed

IUPUIScholarWorks

Rates of Tobacco Use Disorder, Pharmacologic Treatment, and Associated Mental Health Disorders in a Medicaid Claim Review Among Youth in Indiana, USA

Tobacco Use InsightsVolume 15: 1–4© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1179173X221119133Rates of Tobacco Use Disorder, PharmacologicTreatment, and Associated Mental Health Disorders in aMedicaid Claim Review Among Youth in Indiana, USAKimberly McBrayer, DO, FAAP1, Fangqian Ouyang, MS2,Zachary Adams, PhD3, Leslie Hulvershorn, MD3 andMatthew C. Aalsma, PhD11Section of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine,Indianapolis, IN, USA. 2Department of Biostatistics, Indiana University Richard M. Fairbanks School ofPublic Health, Indianapolis, IN, USA. 3Department of Psychiatry, Indiana University School of Medicine,Indianapolis, IN, USA.ABSTRACTPURPOSE: This study delineates a number of Medicaid youth with tobacco use disorder (TUD), prescribing habits for treatment, and associatedexternalizing disorders.METHODS: Youth Medicaid claims from 2007-2017 processed in a large Midwestern city were analyzed for a diagnosis of TUD, related phar-macotherapy, and externalizing mental health and substance use disorders.RESULTS: Claims connected 6541 patients with 42 890 visits. Mean age was 16.4 with 40% female. 1232 of the 6541 charts contained a TUDdiagnosis equating to 1848 visits. A comorbid diagnosis of ADHD, cannabis use, and conduct disorder were more common in males (3.9% vs 1.3%in females; 3.4% vs .8%; and 2.8% vs .8%; P < .05). 808 scripts were provided to 152 of the 1232 youths, with 4.7% of those scripts a nicotinereplacement product.CONCLUSIONS: Pharmacotherapy is underutilized in this Medicaid claims data set. Certain externalizing factors were associated with males withTUD more than females.KEYWORDS: tobacco use disorder, tobacco use cessation, medicaid, adolescent behaviorRECEIVED: July 12, 2022. ACCEPTED: July 25, 2022.TYPE: Short ReportDECLARATION OF CONFLICTING INTERESTS: The author(s) declared no potential conflictsof interest with respect to the research, authorship, and/or publication of this article.FUNDING: The author(s) disclosed receipt of the following financial support for the research,authorship, and/or publication of this article: This study was funded by a grant from the Agency forHealthcare Research and Quality grant number AHRQ R01HS024296.IMPLICATIONSANDCONTRIBUTION: Tobacco product use is a problem in the adolescent agegroup. Pharmacologic therapy is indicated for some adolescents with heavy use. This studydelineates prescribing habits towards Medicaid recipients with tobacco use disorder in a large,Midwestern city and describes associated externalizing disorders.CORRESPONDING AUTHOR: Kimberly McBrayer, Section of Adolescent Medicine,Department of Pediatrics, Indiana University School of Medicine, 410 W 10th St Suite 1001Indianapolis, IN 46202, USA. Email: kimcbray@iu.eduMeSH terms: Tobacco Use Disorder, Tobacco Use Cessa-tion, Medicaid, Adolescent Behavior Close to a quarter ofhigh school students use 1 or more tobacco products.1Among adolescents with Tobacco Use Disorder (TUD),rates of tobacco cessation are low even with treatment,ranging from <5%-7.3% at 12 month follow-up.2,3 Evensmall amounts of tobacco use early in life are predictive ofcontinued use.3-5 Studies show that quitting prior to age 30reduces the chances of long-term morbidity.6 Moreover,evidence indicates nearly half of youth who use e-cigarettesare seriously interested in quitting.7 Development of TUD inadolescents can make quitting later in life more difficult,leading to comorbid conditions. TUD is associated withmany mental health conditions, including depression, anx-iety, and ADHD and can worsen mental health outcomes.1Adequate treatment, including medications for TUD such asnicotine replacement products (NRT) and bupropion, savesboth healthy people-years and money.8 For the purposes of thisstudy, we focused on Medicaid members as they have higherrates of TUD than their privately insured counterparts.8Medicaid is a state-funded insurance plan for children ofparents within a predetermined tax bracket. The purpose of thisbrief report is to assess clinician prescribing habits of medi-cations for TUD and delineate TUD-associated comorbidmental health diagnoses among Medicaid enrolled youth, sincethis is a highly vulnerable group.Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work withoutfurther permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).MethodsPopulation and SettingMedicaid claims for youth aged 10-18 from 2007-2017 pro-cessed in a large, Midwestern city were analyzed.Data CollectionRelevant mental health and substance use disorders werecategorized (ie tobacco/nicotine use, mood, ADHD,cannabis use, conduct, and psychosis disorders) andextracted from the claims using ICD9/10 codes. Demo-graphic data were also included (age, race, gender, andclaim year).AnalysisClaims coded for tobacco or nicotine use disorder wereanalyzed to identify cases where medications for TUD wereused, as indicated by national drug code (NDC) numbersassigned to NRT and bupropion. Bupropion was counted astreatment for TUD if an ICD10 code for tobacco use was alsoused in the same encounter and if the XR form was pre-scribed, as this is the form that is FDA approved for use inadults with TUD. Frequencies were computed for age, race,gender, and claim year, and bivariate analyses (Chi-squareand t-tests) were performed in regard to TUD, mental healthconditions, and gender. Analysis was performed via SASversion 9.4 to determine these associations. P values wereconsidered significant at less than 0.05. The study was ap-proved by the Indiana University Review Board (IRB number1605042518).ResultsMedicaid claims for 6541 patients representing 42 890 visitswere gathered. Of the total sample, 59% were white and 40%were African American. Overall mean age was 16.4 years with40% female. We found 1232 (18.8%) had a diagnosis of TUD,which corresponded to 1848 visits. Among those with TUD,mean age was 17.2 years with 78% white, 21% AfricanAmerican and 60% female. A total of 808 scripts for TUDmedications were provided to 152 (12%) of the 1232 youths; 5%of scripts were for a nicotine replacement product, and 95%werefor bupropion (see Table 1 for further details). There was nosignificant difference between scripts provided to male and femalepatients. Of those prescribedmedication, themean number of totalscripts over the course of their treatment was 3. A comorbiddiagnosis of ADHDwasmore common in males (3.9% vs 1.3% infemales, P < 0.05). Cannabis use and conduct disorder also hadhigher rate in males compared to females (3.4% vs 0.8% and 2.8%vs 0.8%, P < 0.05). There was no significant difference in mooddisorders or psychosis between males and females with TUD (seeTable 2). The rate of tobacco or nicotine use disorder diagnosisrose yearly to a peak in 2012 and then fell dramatically towards2016. Data for 2017 was only reported for half of the year and wasnot included in the yearly rate diagnosis calculation.DiscussionThe use of pharmacotherapy in adolescents with TUD has beena subject of interest for years, but results have been mixed re-garding efficacy.4,9,10 A review of early studies assessing bu-propion and NRT showed some short-term promise with littlelong-term cessation, with side effects noted to be similar to adultTable 1. Patient demographics and treatment.OVERALL POPULATION(N = 6541)TOBACCO USEDISORDER (N = 1232,18.8%a)TOBACCO USEDISORDER(N = 1232)PROVIDEDSCRIPT (N = 152,12.3%b)Age at first appointment (mean, std) 16.4 (1.6) 17.2 (1.6) 16.2 (1.8)Gender (n, %)Female 2596 (39.7%) 743/2596 (28.6%) 743 (60.3%b) 85/743 (11.4%)Male 3945 (60.3%) 489/3945 (12.4%) 489 (39.7%b) 67/489 (13.7%)Race (n, %)Asian 30 (.5%) 5/30 (17.0%) 5 (.4%b) 1 (20.0%)African American 2589 (39.6%) 254/2589 (9.8%) 254 (20.6%b) 26 (10.2%)Other 74 (1.1%) 11/74 (14.9%) 11 (.9%b) 2 (18.2%)White 3847 (58.8%) 962/3874 (25.0%) 962 (78.1%b) 123 (12.8%)Ethnicity (n, %)Hispanic 349 (5.3%) 19/349 (5.4%) 19 (1.5%b) 1 (5.2%)Non-hispanic 6191 (94.7%) 1213/6191 (19.6%) 1213 (98.5%b) 151 (12.4%)a% of total number of patients.b% of patients diagnosed with nicotine use disorder.2 Tobacco Use Insightsn npatients.11,12 In adult studies, the use of NRT has been shownto reduce Medicaid spending (as much as 3 dollars saved forevery 1 dollar spent).13,8 The FDA has not approved NRT inyouth, though the American Academy of Pediatrics recom-mends consideration in adolescents with daily nicotine use andmoderate to severe TUD.1,3Our study found low rates of pharmacotherapy prescriptionamong adolescents across all genders and races (12%), though thisis higher than in previous studies.8,9,14 Among 1 adult populationwith TUD enrolled in Medicaid, 10% were prescribed medica-tion,8 and another regional adolescent Medicaid survey found that1.3% of adolescents and young adults received medication.14Bupropion was prescribed more often than NRT in our sam-ple, though the average total number of scripts for each patienttreated with pharmacotherapy was 3, leading to questions aboutcompliance for either therapy. The low rate of NRT prescribing isconcerning. As highlighted in the introduction, the populationinsured by Medicaid is particularly vulnerable to the effects oftobacco use disorder,8 so it is important that clinicians are sensitiveto the issue with close monitoring.Bupropion can be useful in adolescents with comorbidmental health disorders if there are no contraindications.1 It isknown that TUD is associated with various psychiatric disor-ders.15 Boys more than girls in our sample had higher diagnosesof ADHD, cannabis use, and conduct disorder. Previous studiesindicate that externalizing problems increase risk of nicotineproduct use.16,17 Cannabis use has a known prevalence higher inboys than girls, though this gap has been narrowing in otherstudies.18 These findings highlight the importance of routinemental health screenings and referral to mental health serviceswhen these youth are identified, and that bupropion may beparticularly helpful for adolescents with comorbid disorders.There are several limitations to this study. It is unknown ifcounselling was given regarding over-the-counter nicotine re-placement products, as this would be difficult to trace in this dataset. However, encouragement of over-the-counter NRT is un-likely, as Indiana Medicaid will pay for nicotine replacementproducts when prescribed. During the period of this study, the rateof combustible nicotine products fell as the use of vapor productsincreased in this age group, and this may have affected the pre-scribing habits of physicians seen in this data set.19 Unfortunatelyno data are available regarding the use of vaping vs other tobaccoproducts in this data set.We did find that there were more slightlymore males than females within the dataset. This finding wasunexpected; however, we do not believe this affected the overallanalysis or outcome of the study. A final limitation to the study isthat we were unable to determine severity of TUD in the claims,thus some of the adolescents may have not met criteria formoderate or severe use to warrant treatment with medication.According to SAMHSA, over 14% of adolescent tobacco users useat least a pack daily, so it is credible that a higher percentage thanthat number would meet criteria from our sample.20In conclusion, nicotine replacement products were un-derutilized in this sample of Medicaid enrolled youth in a large-Midwestern county. Use of bupropion XR was marginallybetter, although most patients left without any script. Cliniciansshould be aware of the risk factors associated with nicotineproduct use and appropriate treatment for these youth toprevent continued tobacco-related harms into adulthood.AcknowledgmentsWe would like to thank Stanley Taylor for compiling the dataset and supporting data analysis. This study was presented as aposter at the Society for Adolescent Health and Medicineinternational conference in 2020.Author ContributionsAll authors approved the final manuscript as submitted andagree to be accountable for all aspects of the work. KimberlyMcBrayer drafted the paper and guided analysis. FangqianOuyang contributed her expertise in statistical analysis andreviewed the methods and results sections of the manuscript.Zachary Adams edited the paper and aided in clinical impli-cations in the discussion. Leslie Hulvershorn edited the paperand aided in interpretation of results. Matthew C. Aalsmaconceived the study, received funding to complete the study,and aided in drafting and edited the paper.Table 2. Summary of comorbid diagnoses by gender.aDIAGNOSIS TOBACCO USEDISORDER(N = 1232)FEMALE(N = 743)MALE(N = 489)P-VALUEBMood disorder 124 (10.1%) 69 (5.6%) 55 (4.5%) .26ADHD 64 (5.2%) 16 (1.3%) 48 (3.9%) <.0001Cannabis use 52 (4.2%) 10 (.8%) 42 (3.4%) <.0001Conduct disorder 44 (3.6%) 10 (.8%) 34 (2.8%) <.0001Psychosis disorder 31 (2.5%) 12 (1.0%) 19 (1.5%) .01aPercentages expressed are percentage of total TUD.bMale compared to Female, significant if P < .05.3McBrayer et aln nREFERENCES1. Cavallo DA, Krishnan-Sarin S. Nicotine use disorders in adolescents. Pediatr ClinNorth Am. Dec 2019;66(6):1053-1062. doi:10.1016/j.pcl.2019.08.002.2. Patten CA, Ames SC, Ebbert JO, Wolter TD, Hurt RD, Gauvin TR. Tobacco useoutcomes of adolescents treated clinically for nicotine dependence. Arch PediatrAdolesc Med. Jul 2001;155(7):831-837. doi:10.1001/archpedi.155.7.831.3. Siqueira LM, Ryan SA, Gonzalez PK, Patrick SW, Quigley J, Walker LR. Nicotineand Tobacco as substances of abuse in children and adolescents. Pediatrics. Jan 2017;139(1):e20163436. doi:10.1542/peds.2016-3436.4. Botello-Harbaum M, Schroeder JR, Collins CC, Moolchan ET. Nicotine re-placement therapy use among adolescent smokers seeking cessation treatment. EthnDis. Spring. 2010;20(2):180-184.5. Walker JF, Loprinzi PD. Longitudinal examination of predictors of smokingcessation in a national sample of U.S. adolescent and young adult smokers. NicotineTob Res. Jun 2014;16(6):820-827. doi:10.1093/ntr/ntu005.6. Villanti AC, McKay HS, Abrams DB, Holtgrave DR, Bowie JV. Smoking-cessation interventions for U.S. young adults: A systematic review. Am J PrevMed. Dec 2010;39(6):564-574. doi:10.1016/j.amepre.2010.08.009.7. Smith TT, Nahhas GJ, Carpenter MJ, et al. Intention to quit vaping among UnitedStates adolescents. JAMA Pediatr. Jan 1 2021;175(1):97-99. doi:10.1001/jamapediatrics.2020.2348.8. Ku L, Bruen BK, Steinmetz E, Bysshe T. Medicaid Tobacco cessation: Big gapsremain in efforts to get smokers to quit. Health Aff (Millwood). Jan 2016;35(1):62-70. doi:10.1377/hlthaff.2015.0756.9. Klesges LM, Johnson KC, Somes G, Zbikowski S, Robinson L. Use of nicotinereplacement therapy in adolescent smokers and nonsmokers. Arch Pediatr AdolescMed. Jun 2003;157(6):517-522. doi:10.1001/archpedi.157.6.517.10. Scherphof CS, van den Eijnden RJ, Lugtig P, Engels RC, Vollebergh WA. Ad-olescents’ use of nicotine replacement therapy for smoking cessation: predictors ofcompliance trajectories. Psychopharmacology (Berl). Apr 2014;231(8):1743-1752.doi:10.1007/s00213-014-3511-8.11. Bailey SR, Crew EE, Riske EC, Ammerman S, Robinson TN, Killen JD. Efficacyand tolerability of pharmacotherapies to aid smoking cessation in adolescents.Paediatr Drugs. Apr 1 2012;14(2):91-108. doi:10.2165/11594370-000000000-00000.12. Stanton A, Grimshaw G. Tobacco cessation interventions for young people. Co-chrane Database Syst Rev. Aug 23 2013;8:Cd003289. doi:10.1002/14651858.CD003289.pub5.13. Richard P,West K,KuL.The return on investment of amedicaid tobacco cessation programin Massachusetts. PLoS One. 2012;7(1):e29665. doi:10.1371/journal.pone.0029665.14. Chadi N, Rodean J, Earlywine JJ, et al. Treatment for nicotine use disorder amongmedicaid-enrolled adolescents and young adults. JAMA Pediatr. Nov 1 2019;173(11):1103-1105. doi:10.1001/jamapediatrics.2019.3200.15. Hakko H, Lintunen J, Lappalainen J, Mäkikyrö T, Räsänen P, Timonen M.Nicotine use and dependence and their association to psychiatric disorders in a largesample of adolescent psychiatric inpatients. Addict Behav. Oct 2006;31(10):1873-1880. doi:10.1016/j.addbeh.2006.01.001.16. RiehmKE, Young AS, Feder KA, et al. Mental health problems and initiation of E-cigarette and combustible cigarette use. Pediatrics. Jul 2019;144(1), e20182935. doi:10.1542/peds.2018-2935.17. Audrain-McGovern J, Rodriguez D, Testa S, Alexander E, Pianin S. Adolescent E-cigarette onset and escalation: Associations with internalizing and externalizing symp-toms. J Adolesc Health. Apr 2021;68(4):801-807. doi:10.1016/j.jadohealth.2020.09.033.18. Hemsing N, Greaves L. Gender norms, roles and relations and cannabis-usepatterns: A scoping review. Int J Environ Res Public Health. 2020;17(3):947.Published 2020 Feb 4. doi:10.3390/ijerph17030947.19. Johnston LD, Miech RA, O’Malley PM, Bachman JG, Schulenberg JE, PatrickME. Monitoring the Future National Survey Results on Drug Use 1975201 9:Overview, Key Findings on aAolescent Drug Use. 2020.20. Administration SAaMHS. Key Substance Use and Mental Health Indicators in the UnitedStates: Results From the 2018 National Survey on Drug Use and Health. HHS Publication.No. PEP19-5068, NSDUH Series H-54. 2019. https://www.samhsa.gov/data/4 Tobacco Use Insightsn n

PURPOSE: This study delineates a number of Medicaid youth with tobacco use disorder (TUD), prescribing habits for treatment, and associated externalizing disorders. METHODS: Youth Medicaid claims from 2007-2017 processed in a large Midwestern city were analyzed for a diagnosis of TUD, related pharmacotherapy, and externalizing mental health and substance use disorders. RESULTS: Claims connected 6541 patients with 42 890 visits. Mean age was 16.4 with 40% female. 1232 of the 6541 charts contained a TUD diagnosis equating to 1848 visits. A comorbid diagnosis of ADHD, cannabis use, and conduct disorder were more common in males (3.9% vs 1.3% in females; 3.4% vs .8%; and 2.8% vs .8%; P < .05). 808 scripts were provided to 152 of the 1232 youths, with 4.7% of those scripts a nicotine replacement product. CONCLUSIONS: Pharmacotherapy is underutilized in this Medicaid claims data set. Certain externalizing factors were associated with males with TUD more than females

PubMed Central

Rates of Tobacco Use Disorder, Pharmacologic Treatment, and
Associated Mental Health Disorders in a Medicaid Claim Review Among Youth in
Indiana, USA

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Rates of Tobacco Use Disorder, Pharmacologic Treatment, and Associated Mental Health Disorders in a Medicaid Claim Review Among Youth in Indiana, USA

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