Presentation on theme: "Ask your patients about tobacco use. Act to help them quit."— Presentation transcript:
1Ask your patients about tobacco use. Act to help them quit. Tobacco CessationAsk your patients about tobacco use.Act to help them quit.
2The 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.
3The ProblemOnly 70% of family physicians ask their patients if they use tobacco.Only 40% take action.
4Why don’t doctors act? Too busy Lack of expertise No financial incentiveThink smokers can’t or won’t quitDon’t want to appear judgmentalRespect for patient’s privacyNegative message might scare patients away
5Opportunity 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.
6Physicians 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
7Ask and Act Ask every patient about tobacco use Act to help them quit On- or off-site counselingQuitlinesPatient education materialsSelf-help guides or WebsitesCessation classesPharmacotherapy
8Change the system to identify and document tobacco use status
9Make system changes Incorporate into vital signs Use chart stickers or computer prompts to document status: current, quit or never smokerDevelop templates for EHRs
10Make system changesLet patients know you can help -- posters, lapel pins, brochuresAsk office staff for ideas how to “Ask and Act”Develop incentives for staff interventions with patients-teams, time off or special recognition
11Make system changesOffer tobacco cessation group visits and place sign-up sheets in the waiting roomMaintain tobacco cessation patient registryPlan for follow-up calls by office staff after tobacco quit date
13Stages of change Precontemplation Contemplation Preparation Action Don’t want to quitContemplationWant to quit sometimePreparationWill quit in next 30 daysAm quitting nowActionRelapseMaintenanceTerminationAdapted from Knight, 1997
14Encouraging patients who aren’t yet ready to quit RelevanceRisksRewardsRoadblocksRepetitionRelevance: 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.
15Develop a treatment plan Help create a quit planProvide practical counselingProvide social supportRecommend pharmacotherapyProvide supplementary materialsHelp 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.
16CounselingEven 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 Update16
17CounselingIndividual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity.Especially effectivePractical counseling (problem solving/ skills training)Social supportPHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update
18CounselingCounseling adds significantly to the effectiveness of tobacco cessation medicationsCounseling increases abstinence among adolescent smokers
19Types of counseling Practical counseling Teach problem-solving skills Identify danger situations for smokerSuggest coping skills to use with danger situations and how to avoid temptationProvide basic information about smoking dangers, withdrawal symptoms and addictionDanger situations include alcohol, stress, being around other smokers.
20Types of counseling Intra-treatment support Talk about treatment optionsCommunicate care and concernEncourage patient to talk about quitting processEncourage 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.
21Types of counseling Extra-treatment support Help patient learn how to ask for social supportHelp patient identify additional support optionsArrange for outside supportHelp 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.
22Counseling patients with mental illness Counseling is critical to success - more and longer sessions often necessaryPatients may need more time to prepare for quitQuit dates should be flexibleInclude problem-solving skills training
23QuitlinesIt 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.
24Advantages of quitlines AccessibilityAppeal to those who are uncomfortable in a group settingSmokers more likely to use a quitline than face-to-face programNo cost to patientEasy intervention for healthcare professionalsAccessibility: don’t have to wait for classes to form or worry about transportation. Good for people in remote areas.
25Quitlines1-800-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.
29Factors to consider when prescribing Clinician familiarity with medicationsContraindicationsPatient preferencePrevious patient experiencePatient characteristics (history of depression, weight gain concerns, etc.)
30First-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.
31Varenecline $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 dreamsMonitor for psychiatric symptoms
32Bupropion SR $3.62 - $6.04 per day Start 150mg once daily for 3 days, then twice per day for seven to twelve weeks. Plan quit date around day seven of treatment.Common side effects include insomnia and dry mouth
33Nicotine gum$ $6.57 per day for 2mg $ $6.51 per day for 4mgWeeks 1-6: one every 1-2 hours Weeks 7-9: one every 2-4 hours Weeks 10-12: one every 4-8 hoursCommon side effects are jaw pain and mouth soreness
34Nicotine inhaler $5.29 per day 6-16 cartridges per day, initially one every 1-2 hoursCommon side effects are mouth and throat irritation
35Nicotine nasal spray $3.57 per day 1-2 doses (sprays) per hour Common side effects are nose and eye irritationMost addictive form of nicotine replacement therapy
36Nicotine 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 weeksCommon side effects are skin irritation or sleep issues if worn at night
37Nicotine 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 hoursSmoke first cigarette within thirty minutes of awakening, use 4mg. Others use 2mgCommon side effects or mouth soreness and dyspepsia
38Pharmacotherapy for lighter smokers Medications have not been shown to be beneficial to light smokersIf NRT is used, consider reducing the doseNo adjustments are necessary when using bupropion SR or varenicline
39Second-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
40For patients concerned with weight gain Bupropion SR and nicotine replacement therapies (especially gum and 4 mg lozenge) may delay, but not prevent, weight gainThe average weight gain from tobacco cessation is less than 10 pounds, more common in women
41For patients with past history of depression Bupropion SRNortriptylineNicotine replacement medications
42Patients with mental illness Most will need medicationPatients with bipolar disorder or eating disorders should not receive bupropionPatch is effective for those with schizophreniaVarenecline safety not yet established42
43Patients with mental illness Quitting can increase the effect of some psychiatric medications Dose adjustments may be neededCheck for relapse to mental illness with changes in smoking status
44For patients with a history of cardiovascular disease Nicotine replacement therapy -caution for drug class if MI within two weeks, severe arrhythmias or cardiovascular disease
45Pregnant 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 useBuproprion SR and varenicline are both pregnancy category CPrescription NRT is category D
46Can pharmacotherapies be used long term? Yes.Helpful with smokers with persistent withdrawal systemsLong-term use of NRT does not present a known health riskFDA approved the use of bupropion SR for up to 6 monthsVarenicline recommended for 12 weeks. May repeat for 12 more
47Can pharmacotherapies be combined? Yes.Evidence that combining nicotine patch with gum or nasal spray increase long-term abstinenceCombining nicotine patch with buproprion is more effective than patch alone
48Treatment follow-up Congratulate success! Schedule counseling intervention within first 3 monthsEncourage the patient to talk about the processSuccess the patient has achievedDifficulties encountered
49Benefit from a relapse A relapse provides useful information Information about the cause of the eventA formerly unknown stressful situationHow to correct it occurrence in the futureAn action plan for that eventRelapse is a normal part of the recovery process
50Relapse 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
52MedicarePays for tobacco cessation counseling for patients who smoke and have a tobacco-related disease or whose therapy is affected by tobacco usePrescription drug benefit covers smoking cessation treatments prescribed by a physicianOTC treatments are not covered
53Medicare 8 visits allowed in 12 month period (4 sessions per attempt) Intermediate cessation counseling = 3 to 10 minutes per sessionIntensive cessation counseling = more than 10 minutes per session.Counseling < 3 min covered under E&M code
54Medicare 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.
55MedicareAny qualified provider, such as physicians, clinical social workers, psychologists, hospitals, may bill for tobacco cessation counseling
56Private InsurersMost insurers provide coverage for at least one type of pharmacotherapy for tobacco cessation and at least one type of behavioral intervention
57Private Insurers Use billing codes in the categories of: Preventive Medicine TreatmentsTobacco Dependence Treatment as Part of the Initial or Periodic Comprehensive Preventive Medicine ExaminationTobacco Dependence Treatment as Specific Counseling and/or Risk Factor Reduction.
58Medicaid38 state Medicaid programs cover at least some stop-smoking treatments14 cover some form of tobacco- cessation counseling for all Medicaid participants; 12 more pay for counseling of pregnant women58
59Ask your patients if they use tobacco. Act to help them quit. www Ask your patients if they use tobacco. Act to help them quit.