1. Ask your patients about tobacco use. Act to help them quit.
Tobacco Cessation
Ask your patients about tobacco use.
Act to help them quit.

2. The Problem Tobacco use is a chronic disease.
24% of American men and 19% of American women smoke.
Smoking-related diseases claim 440,000 American lives each year.
Smoking costs the United States approximately $97.2 billion each year in health-care costs and lost productivity.

3. The Problem
Only 70% of family physicians ask their patients if they use tobacco.
Only 40% take action.

4. Why don’t doctors act? Too busy Lack of expertise
No financial incentive
Think smokers can’t or won’t quit
Don’t want to appear judgmental
Respect for patient’s privacy
Negative message might scare patients away

5. Opportunity for physicians
70% of smokers see a physician each year.
70% of smokers want to quit.
Physician’s advice to quit is an important motivator.
Patients are more satisfied with their health care if their provider offers smoking cessation interventions - even if they’re not yet ready to quit.

6. Physicians crucial to successful cessation
Even brief tobacco dependence treatment is effective and should be offered to every patient who uses tobacco.
Tobacco-cessation counseling is effective in improving tobacco quit rates among adults and has been recommended for adolescents.
PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

7. Ask and Act Ask every patient about tobacco use Act to help them quit
On- or off-site counseling
Quitlines
Patient education materials
Self-help guides or Websites
Cessation classes
Pharmacotherapy

8. Change the system to identify and document tobacco use status

9. Make system changes Incorporate into vital signs
Use chart stickers or computer prompts to document status: current, quit or never smoker
Develop templates for EHRs

10. Make system changes
Let patients know you can help -- posters, lapel pins, brochures
Ask office staff for ideas how to “Ask and Act”
Develop incentives for staff interventions with patients-teams, time off or special recognition

11. Make system changes
Offer tobacco cessation group visits and place sign-up sheets in the waiting room
Maintain tobacco cessation patient registry
Plan for follow-up calls by office staff after tobacco quit date

12. Counseling and brief interventions

13. Stages of change Precontemplation Contemplation Preparation Action
Don’t want to quit
Contemplation
Want to quit sometime
Preparation
Will quit in next 30 days
Am quitting now
Action
Relapse
Maintenance
Termination
Adapted from Knight, 1997

14. Encouraging patients who aren’t yet ready to quit
Relevance
Risks
Rewards
Roadblocks
Repetition
Relevance: Talk about why quitting is personally relevant.
Risks: Discuss side-effects and dangers of tobacco use.
Rewards: Discuss the benefits of stopping.
Roadblocks: Identify barriers to quitting.
Repetition: Talk about tobacco cessation at every visit.

15. Develop a treatment plan
Help create a quit plan
Provide practical counseling
Provide social support
Recommend pharmacotherapy
Provide supplementary materials
Help create a quit plan: Set a quit date, have patient tell friends and family about plan, remove all tobacco products.
Provide practical counseling: Anticipate challenges and ways to overcome them.
Provide social support: Offer supportive clinical environment and help patient identify social support system.

16. Counseling
Even brief tobacco dependence treatment is effective and should be offered to every patient who uses tobacco.
Tobacco-cessation counseling is effective in improving tobacco quit rates among adults and has been recommended for adolescents.
PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update 16

17. Counseling
Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity.
Especially effective
Practical counseling (problem solving/ skills training)
Social support
PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

18. Counseling
Counseling adds significantly to the effectiveness of tobacco cessation medications
Counseling increases abstinence among adolescent smokers

19. Types of counseling Practical counseling Teach problem-solving skills
Identify danger situations for smoker
Suggest coping skills to use with danger situations and how to avoid temptation
Provide basic information about smoking dangers, withdrawal symptoms and addiction
Danger situations include alcohol, stress, being around other smokers.

20. Types of counseling Intra-treatment support
Talk about treatment options
Communicate care and concern
Encourage patient to talk about quitting process
Encourage patient in quit attempt; talk about treatment options and communicate belief in patient’s ability to quit.
Communicate care and concern; ask about patient’s fears and experiences.
Encourage patient to talk about quitting process; ask about motivation and concerns about quitting.

21. Types of counseling Extra-treatment support
Help patient learn how to ask for social support
Help patient identify additional support options
Arrange for outside support
Help patient learn how to ask for social support from family, friends and co-workers.
Help patient identify additional support options, such as community groups, quitlines and Internet resources.
Arrange for outside support; invite others to cessation sessions, assign ex-smoker “buddies,” or send notes of encouragement to patient.

22. Counseling patients with mental illness
Counseling is critical to success - more and longer sessions often necessary
Patients may need more time to prepare for quit
Quit dates should be flexible
Include problem-solving skills training

23. Quitlines
It only takes 30 seconds to refer a patient to a toll-free tobacco-cessation quitline.
Quitlines are staffed by trained cessation experts who tailor a plan and advice for each caller.
Calling a quitline can increase a smoker’s chance of successfully quitting.

24. Advantages of quitlines
Accessibility
Appeal to those who are uncomfortable in a group setting
Smokers more likely to use a quitline than face-to-face program
No cost to patient
Easy intervention for healthcare professionals
Accessibility: don’t have to wait for classes to form or worry about transportation. Good for people in remote areas.

25. Quitlines
1-800-QUIT-NOW callers are routed to state-run quitlines or the National Cancer Institute quitline.
Quitline referral cards are free for AAFP members. Go to askandact.org.

26. Pharmacotherapy

27. Pharmacotherapy Who should receive it?
Nearly all smokers trying to quit, except those with medical contraindications, adolescents and those who smoke fewer than 10 cigarettes per day.

28. First-line pharmacotherapies
Buproprion SR
Nicotine gum
Nicotine inhaler
Nicotine nasal spray
Nicotine patch
Nicotine lozenge
Varenicline

29. Factors to consider when prescribing
Clinician familiarity with medications
Contraindications
Patient preference
Previous patient experience
Patient characteristics (history of depression, weight gain concerns, etc.)

30. First-line pharmacotherapies
Varenicline: agonizes and blocks α4β2 nicotinic acetylcholine receptors.
Buproprion SR mechanism for smoking cessation unknown; inhibits neuronal uptake of norepinephrine, serotonin and dopamine.
NRT: binds to CNS and peripheral nicotinic-cholinergic receptors.

31. Varenecline $4.00 - $4.22 per day
Start .5mg daily for 1-3 days, then increase to twice daily for 1-4 days. Increase to 1 mg twice daily on quit date.
Most common side effects are nausea and vivid dreams
Monitor for psychiatric symptoms

32. Bupropion SR $3.62 - $6.04 per day
Start 150mg once daily for 3 days, then twice per day for seven to twelve weeks. Plan quit date around day seven of treatment.
Common side effects include insomnia and dry mouth

33. Nicotine gum
$ $6.57 per day for 2mg $ $6.51 per day for 4mg
Weeks 1-6: one every 1-2 hours Weeks 7-9: one every 2-4 hours Weeks 10-12: one every 4-8 hours
Common side effects are jaw pain and mouth soreness

34. Nicotine inhaler $5.29 per day
6-16 cartridges per day, initially one every 1-2 hours
Common side effects are mouth and throat irritation

35. Nicotine nasal spray $3.57 per day 1-2 doses (sprays) per hour
Common side effects are nose and eye irritation
Most addictive form of nicotine replacement therapy

36. Nicotine patch $1.90 - $3.89 per day
>25 cigarettes per day: 21mg every twenty-four hours for four weeks, then 14mg for two weeks, then 7 mg for two weeks
Common side effects are skin irritation or sleep issues if worn at night

37. Nicotine lozenge $3.66 - $5.25 per day
Weeks 1-6: one every 1-2 hours Weeks 7-9: one every 2-4 hours Weeks 10-12: one every 4-8 hours
Smoke first cigarette within thirty minutes of awakening, use 4mg. Others use 2mg
Common side effects or mouth soreness and dyspepsia

38. Pharmacotherapy for lighter smokers
Medications have not been shown to be beneficial to light smokers
If NRT is used, consider reducing the dose
No adjustments are necessary when using bupropion SR or varenicline

39. Second-line pharmacotherapies (off label)
Clonidine: mechanism for smoking cessation unknown; stimulates α2-adrenergic receptors (centrally-acting antihypertensive)
Nortripyline: mechanism for smoking cessation unknown; inhibits norepinephrine and serotonin uptake

40. For patients concerned with weight gain
Bupropion SR and nicotine replacement therapies (especially gum and 4 mg lozenge) may delay, but not prevent, weight gain
The average weight gain from tobacco cessation is less than 10 pounds, more common in women

41. For patients with past history of depression
Bupropion SR
Nortriptyline
Nicotine replacement medications

42. Patients with mental illness
Most will need medication
Patients with bipolar disorder or eating disorders should not receive bupropion
Patch is effective for those with schizophrenia
Varenecline safety not yet established 42

43. Patients with mental illness
Quitting can increase the effect of some psychiatric medications Dose adjustments may be needed
Check for relapse to mental illness with changes in smoking status

44. For patients with a history of cardiovascular disease
Nicotine replacement therapy -caution for drug class if MI within two weeks, severe arrhythmias or cardiovascular disease

45. Pregnant smokers Counseling is best choice
Risks of premature birth or stillbirth caused by smoking may be higher than the potential risk of birth defects caused by NRT use
Buproprion SR and varenicline are both pregnancy category C
Prescription NRT is category D

46. Can pharmacotherapies be used long term?
Yes.
Helpful with smokers with persistent withdrawal systems
Long-term use of NRT does not present a known health risk
FDA approved the use of bupropion SR for up to 6 months
Varenicline recommended for 12 weeks. May repeat for 12 more

47. Can pharmacotherapies be combined?
Yes.
Evidence that combining nicotine patch with gum or nasal spray increase long-term abstinence
Combining nicotine patch with buproprion is more effective than patch alone

48. Treatment follow-up Congratulate success!
Schedule counseling intervention within first 3 months
Encourage the patient to talk about the process
Success the patient has achieved
Difficulties encountered

49. Benefit from a relapse A relapse provides useful information
Information about the cause of the event
A formerly unknown stressful situation
How to correct it occurrence in the future
An action plan for that event
Relapse is a normal part of the recovery process

50. Relapse prevention Tobacco Dependence is a Chronic Disease
MDs and patients often have unrealistic expectations for treatment of chronic disease, too often using a short treatment course

51. Getting Paid

52. Medicare
Pays for tobacco cessation counseling for patients who smoke and have a tobacco-related disease or whose therapy is affected by tobacco use
Prescription drug benefit covers smoking cessation treatments prescribed by a physician
OTC treatments are not covered

53. Medicare 8 visits allowed in 12 month period (4 sessions per attempt)
Intermediate cessation counseling = 3 to 10 minutes per session
Intensive cessation counseling = more than 10 minutes per session.
Counseling < 3 min covered under E&M code

54. Medicare CPT codes 99406: 3-10 minutes 99407: More than 10 minutes
Report Tobacco use disorder and related condition or interference with the effectiveness of medications.

55. Medicare
Any qualified provider, such as physicians, clinical social workers, psychologists, hospitals, may bill for tobacco cessation counseling

56. Private Insurers
Most insurers provide coverage for at least one type of pharmacotherapy for tobacco cessation and at least one type of behavioral intervention

57. Private Insurers Use billing codes in the categories of:
Preventive Medicine Treatments
Tobacco Dependence Treatment as Part of the Initial or Periodic Comprehensive Preventive Medicine Examination
Tobacco Dependence Treatment as Specific Counseling and/or Risk Factor Reduction.

58. Medicaid
38 state Medicaid programs cover at least some stop-smoking treatments
14 cover some form of tobacco- cessation counseling for all Medicaid participants; 12 more pay for counseling of pregnant women 58

59. Ask your patients if they use tobacco. Act to help them quit. www
Ask your patients if they use tobacco. Act to help them quit.