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Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division.

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Presentation on theme: "Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division."— Presentation transcript:

1 Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division of Public Health, DHHS

2 Tobacco Use The number one preventable cause of death in the United States and North Carolina

3 Estimated Preventable Causes of Death in North Carolina (2007)
The preventable causes of death within North Carolina are identical to the preventable causes of death within the United States. The largest contributor of premature death for North Carolinians remains tobacco-related ranging from an estimated 11,000 to 15,000 per year. Source: North Carolina State Center for Health Statistics (NC SCHS), Health Profile of North Carolinians: 2007 Update – May 2007 North Carolina Department of Health and Human Services. Smoking harms nearly every organ of the body; causing many diseases and reducing the health of smokers in general.1 The adverse health effects from cigarette smoking account for an estimated 438,000 deaths, or nearly 1 of every 5 deaths, each year in the United States. Source: NC SCHS Health Profile of North Carolinians: 2009 Update North Carolina Department of Health and Human Services

4 Tobacco Use Today United States North Carolina
Deaths ,000/yr ,720/yr. Medical (US state average) Costs $1.89 billion $2.46 billion Total costs $150 billion $6.77 billion Source: Centers for Disease Control and Prevention. SAMMEC, Tobacco use results in close to 438,000 deaths in the US annually, and in an estimated 13,720 deaths in North Carolina per year. In North Carolina we spend $2.46 billion per year on illnesses that are a result of tobacco use – and that is just for direct medical costs, that is, the costs of taking care of those with tobacco-related illnesses. This is higher than the average spent by all the states of $1.89 billion. If you add in indirect costs, that is, productivity costs or time away from work, then the total is $6.77 billion. None of this accounts for the untold human suffering. Tobacco use clearly takes a significant health and economic toll on our communities.

5 Current Use Among NC Adults (aged >18 yrs), NC BRFSS, 2008
* Current smoking- everyday or some days Source: NC BRFSS

6 According to a Morbidity and Mortality Weekly Report, or MMWR, article released Nov. 13, 2009 the proportion of U.S. adults who were cigarette smokers declined from 24.1 percent in 1998 to 19.8 percent in However, the U.S. figure increased to 20.6 percent in [The 2008 NC rate, however, had another decline to 20.9% (NCBRFSS) making it almost even now to the U.S. smoking prevalence, instead of slightly higher as in past years.

7 Percentage of Adults Who Smoke Cigarettes by Race/Ethnicity - NC BRFSS, 2008
Note: Current users report using either every day or on some days Source: NC State Center for Health Statistics NC BRFSS

8 Percentage NC Adults Reporting Current Smoking, by Education—NC BRFSS, 2008
This slide shows there is a difference in smoking prevalence by educational level. In general, the higher the educational level, the less reported smoking. Note: Current users report using either every day or on some days Source: NC State Center for Health Statistics NC BRFSS

9 Percentage of Pregnant Women Reporting Smoking Status in NC –
North Carolina Birth Records, Source: NC Vital Records File from Odum Institute at UNC; Vital Statistics, 2007

10 This shows the typical pattern of smoking among pregnant women
This shows the typical pattern of smoking among pregnant women. When women find out they are pregnant, many of them will quit, but unfortunately after delivery a significant proportion of them will resume smoking. Giving up smoking during pregnancy is associated with an urge to protect the baby rather than any intention to quit in the long term. Relapse rates are high after the birth, say the authors. But it indicates the capacity to adapt to different circumstances and the ability to plan and to delay gratification, characteristics which seem to be missing in those who carry on smoking, they say. BMJ-British Medical Journal released 3/12/08.

11 Results based on North Carolina Youth Tobacco Survey administered biannually since 1999

12 Percentage of Middle and High School Students Reporting Current Tobacco Use*, by Type – NC Youth Tobacco Survey: 2007 Note: *Smoking 1 or more cigarettes during the previous 30 days. Bidis (also known as beedis or beedies) are small brown cigarettes, often flavored, consisting of tobacco hand-rolled primarily produced in India and in some Southeast Asian countries. Source: North Carolina Youth Tobacco Survey, 2007

13 The Toll of Tobacco Use In North Carolina:
Total health care costs from smoking: $2.46 billion Portion covered by state Medicaid program: $769 million Campaign for Tobacco-Free Kids, “The Toll of Tobacco in North Carolina” Fact Sheet accessed May 19, 2008 at Campaign for Tobacco-Free Kids, “The Toll of Tobacco in North Carolina” Fact Sheet accessed May 19, 2008 at

14 Sticker Shock… $75,000,000,000 In the United States more than
of annual healthcare costs are attributable directly to smoking. These costs do not reflect the total cost to society because it does not include burn care from smoking-related fires, perinatal care for low birth-weight infants of mothers who smoke and medical care costs associated with disease caused by secondhand smoke. In addition to healthcare costs, the costs of lost productivity due to smoking effects are estimated at $82 billion per year, bringing a conservative estimate of economic burden of smoking to more than $150 billion per year.” National Institute on Drug Abuse Research Report Series, What is the Extent and Impact of Tobacco Use?, July 2006 National Institute on Drug Abuse Research Report Series, What is the Extent and Impact of Tobacco Use?, July 2006

15 This is a list of some of the chemicals in cigarette smoke
This is a list of some of the chemicals in cigarette smoke. You may recognize some household products that you probably would not want to ingest: floor cleaner (ammonia), fingernail polish remover (acetone), lighter fuel (butane, for some examples.

16 Surgeon General’s Report on Secondhand Smoke
July 2006 A Surgeon General’s report on SHS was released last year, which contains the results of a systematic evidence review of the medical literature of the adverse health effects of SHS. This evidence-based review confirms that SHS is not just an annoyance but a serious health hazard.

17 2006 SGR: Major Conclusions
The debate is over. Secondhand smoke is a serious health hazard and causes early death and disease in North Carolinians who do not smoke. The scientific evidence indicates there is no risk-free level of exposure to secondhand smoke Ventilation does not protect people from being exposed to SHS , only elimination of all smoking protects SHS (supported by ASHRAE) American Society of Heating, Refrigerating, and Air Conditioning Engineers There are 6 major conclusions to the Surgeon General’s report on SHS. More of the conclusions follow in subsequent slides. A position statement from the Board of Directors for the American Society of Heating Refrigerating, and Air Conditioning Engineers American Society of Heating Refrigerating, and Air Conditioning Engineers (ASHRAE), the international standard-setting body for indoor air quality, supports the 6th major conclusion: Ventilation does not protect people from being exposed to SHS . ASHRAE unanimously adopted this important new position statement on secondhand tobacco smoke at its Summer 2005 conference in June.

18 2006 SGR’s Major Conclusions
SHS exposure of adults causes Immediate adverse affects on the cardiovascular system Coronary heart disease 30,000 deaths/yr Lung cancer estimated 3000 deaths/yr We know that SHS causes lung cancer and heart disease in non-smokers. An estimated 3000 deaths from lung cancer per year in non-smokers and an estimated 30,000 deaths per year among non-smokers from heart disease. These effects occur in non-smokers who are exposed to SHS on a regular basis, such as living with a smoker or working in the hospitality or entertainment industry where workers have 8-12 hour shifts in smoky environments. In children the list of SHS adverse effects is long – and this list is not complete, but SHS is well-known to cause an increased incidence of lung infections, asthma, and a decrease in lung growth that can result in lower lung function as an adult. CDC. Annual smoking-attributable mortality, years of potential life lost, and economic costs – United States, Morbidity and Mortality Weekly Report (14):

19 CDC recently reviewed the literature and issued this commentary:
All patients at risk of coronary heart disease or with known coronary artery disease should be advised to avoid all indoor environments that permit smoking. Source: British Medical Journal, 2004

20 Helena, Montana Study Smoking ban for 6 months
Reduced incidence of admissions for myocardial infarction of 40% during ban MI admissions increased when ban rescinded Sargent, RP, et al. BMJ, 328: , 2004. Replicated in studies: France (15%) Scotland (17%) Ireland (14%) Indiana (59%) New York State (3,813 fewer MI admissions) A recent study in Helena, Montana suggested that SHS exposure can actually cause heart attacks as well. Helena is an isolated community with 1 hospital that takes admissions from the surrounding area. In 2004, a ban on smoking in public places was passed in Helena for 6 months. The ban was rescinded after that time for political reasons. During the period of the ban, hospital admissions for heart attacks dropped by 40%, then when the ban was lifted, admission rates for heart attacks returned to the previous level. This was an observational study, but it got the attention of many people, including some at the CDC who reviewed all of the literature on SHS to see if this effect was even feasible. [Short version: In one Montana city, the rate of acute myocardial infarction (heart attack) declined over six months while a smoke-free law was in place, only to increase again once the law was revoked after pressure from the tobacco industry ] Replicated in studies, the following states and countries showed these decreases in MI admissions: France (15%), Indiana (59%), Scotland (17%), Ireland (14%), New York State (3,813 fewer MI admissions), etc., etc.

21 Cardiovascular Risks of Second Hand Smoke
MI risk from tobacco smoke exposure is biologically feasible Small exposures (30 minutes) can induce changes in vessels in people at risk Short term reductions in exposure reduces heart attacks Pechacek,T., Babb, S. Commentary: How Acute and Reversible Are The Cardiovascular Risks of Second Hand Smoke? BMJ, 328: , April 24, 2004. These are the results of the CDC literature review done as a result of the Helena, Montana 40% reduction in MI’s while there was a 6 month ban of public smoking that got rescinded. They found that, based on what we know about the effects of SHS on platelets and blood vessels, that the effects seen in Helena were feasible. They also concluded that even small exposures (30 minutes) to SHS can cause changes in vessels that can lead to a heart attack in people with heart disease or at risk for heart disease. They also concluded that a decrease in exposure to SHS could reduce rates of heart attacks.

22 Second Hand Smoke – Health Risk in Workplaces
This prospective study evaluated 4729 men over 20 years of follow-up to determine the risk of the development of heart disease from secondhand smoke exposure. They found that those individuals with heavy exposure to SHS had the same risk of developing heart disease as did those who were active smokers (~ 1/2 pack per day), when adjusted for other cardiovascular risk factors. Whincup, P et. al., Passive smoking and risk of coronary heart disease and stroke: prospective study with cotinine measurement BMJ, Jun 2004; /bmj 22

23 2006 SGR’s Major Conclusions
Infants and children are at increased risk for SIDS (Sudden Infant Death Syndrome) acute respiratory infections ear problems more severe asthma decreased lung growth increased cases of bronchitis, pneumonia, and ear infections SGR conclusion #5 - Despite substantial progress in tobacco control, many millions of Americans, both children and adults are still exposed in their homes and in their workplaces. SGR conclusion #6 - Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposure of nonsmokers to secondhand smoke. Only eliminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke.

24 Secondhand Smoke Costs - NC
More sticker shock… Secondhand Smoke Costs - NC $289,000,000 This is a conservative estimate – does not consider: lost productivity impact on quality of life long-term care and disability services North Carolina’s Secondhand Smoke Healthcare Cost Burden, Pfannenschmidt and Wansink, Clinical Informatics Department, Blue Cross and Blue Shield of North Carolina

25 Effects on Youth Effects of secondhand smoke/active smoking
Increases asthma significantly (15%) increase $1.34 million/yr excess medical costs Sturm, J. et al: Effects of Tobacco Smoke Exposure on Asthma Prevalence and Medical Care Use in NC Middle School Children. American Journal of Public Health, 94(2): Feb. 2004 Effects of secondhand smoke Cognitive declines (decreases reading, math and block design) Lower scores on reading and visuo-spatial testing Yolton, K. et al: Exposure to Environmental Tobacco Smoke and Cognitive Abilities among U.S. Children and Adolescents. Environmental Health Perspectives, 113(1): January 2005 SHS also has serious health consequences for youth. This is a study from here in NC that showed that kids who were exposed to SHS had a significantly higher rate of asthma that resulted in an excess of 15% of asthma cases (these are totally preventable asthma cases) as well as $1.34 billion in excess medical costs. So a health burden but also a significantly economic burden as well. Another study demonstrated that kids who were exposed to SHS had lower scores on reading and visuo-spatial testing. Significant findings that show SHS may result in cognitive declines in youth.

26 This young guy must have read the study….
Yolton, K. et al (2005). Exposure to Environmental Tobacco Smoke and Cognitive Abilities among US Children and Adolescents. Environmental Health Perspectives, Vol 113 (1),

27 2004 Surgeon General’s Report The Health Consequences of Smoking

28 2004 Surgeon General’s Report - The Health Consequences of Smoking
“Doom and Gloom” Smoking harms nearly every organ of the body Cessation has immediate and long-term benefits Smoking low tar cigarettes provides no health benefits List of smoking-caused diseases includes COPD, pneumonia, cataracts, periodontitis, AAA, and cancers of lung, pancreas, stomach, cervix, kidney In 2004 the Surgeon General came out with another report on tobacco, this time outlining the adverse health effects. It’s a big report, but these are the overall conclusions. The report is available online at the Surgeon Gen. website Acute myelogenous leukemia (AML), which can also be caused by smoking, is a fast-growing cancer of the blood and bone marrow.

29 2004 SGR – Smoking and Youth  physical fitness  lung function
Children and adolescents who smoke have:  physical fitness  lung function  lung growth  respiratory illness  chronic cough and wheeze The report also listed adverse effects on pregnant women and children. This is not a comprehensive list of effects.

30 2004 SGR – Smoking and Pregnancy
Smoking during pregnancy Low birth weight Stillbirth Sudden Infant Death Syndrome Risk doubles - smoking after birth Risk 3-4 times greater - smoking before and after Nicotine  blood flow to fetus found in breast milk The report also listed adverse effects on pregnant women and children. This is not a comprehensive list of effects.

31 Tobacco dependence as a chronic disease
“Tobacco dependence shows many features of a chronic disease… A failure to appreciate the chronic nature of tobacco dependence may undercut clinicians’ motivation to treat tobacco use consistently.” Dr. Michael Fiore, Chair of Interagency Committee on Smoking and Health, 2000

32 Tobacco dependence as a chronic disease
Permanent abstinence is the goal Congratulate smaller successes Quitting consists of multiple relapses and remission Few quit for good on first attempt Each attempt is a learning experience No single ideal intervention Relapse is risk for weeks, months, years Requiring ongoing interventions Clinicians can feel ineffective, lose motivation Seeing tobacco dependence and nicotine addiction as a chronic condition helps clinicians better understand the relapsing nature of the ailment and the requirement for ongoing, rather than just acute care. Also, despite potential for relapse, there are numerous effective treatments available. Clinicians should remain aware that relapse is likely, and that this reflects the chronic nature of addiction, not their personal failure, nor a failure of their patients.

33 (Do you use tobacco? Do you want to quit?)
"In my view, a doctor isn't providing an appropriate standard of care …. if he or she doesn't ask two key questions —'Do you smoke?' and 'Do you want to quit?'— (Do you use tobacco? Do you want to quit?) and then work with that individual to make it happen.“ —Michael C. Fiore, MD, M.P.H., Director Center for Tobacco Research and Intervention University of Wisconsin Medical School

34 It takes on average, 6 to 7 attempts to quit for good…

35 Addiction Why do people use tobacco? Why do people engage in behaviors that they know are unhealthy? The next series of slides defines addiction and the factors that cause circular behavior.

36 Nicotine Stimulates Release of Many Different Neurotransmitters
DOPAMINE Pleasure, Appetite Suppression NOREPINEPHRINE Arousal, Appetite Suppression ACETYLCHOLINE Arousal, Cognitive Enhancement GLUTAMATE Learning, Memory Enhancement SEROTONIN Mood Modulation, Appetite Suppression BETA-ENDORPHIN Reduction of Anxiety and Tension GABA Reduction of Anxiety and Tension NICOTINE Nicotine could be called the perfect drug because it’s use can stimulate a wide range of effects including pleasure, mood modulation, reduction of anxiety, memory enhancement and appetite suppression.

37 Characteristics of Nicotine lead to Reinforcement of Use & Addiction
High concentrations of nicotine within 7-10 seconds Half-life = min. Able to respond quickly to additional doses “Euphoria” without “Intoxication” Behavior reinforced multiple times daily Cigarette smoking is one of the most common forms of addictive behavior in the United States and researchers tell us that it is the ‘reinforcing properties’ nicotine is at the root of this compulsive behavior. How does nicotine lead to this addictive behavior? Nicotine is one of many compounds found in tobacco that enter your lungs when tobacco leaves are smoked. From your lungs, nicotine is transported via blood circulation into your brain where nicotine delivers its pleasurable affect. While many of the details remain to be discovered, much is known about how nicotine works. First, we know that nicotine (like other drugs of abuse such as heroin, cocaine, and amphetamine) interacts directly with cells in our brain to change the way they function. Not every brain cell is affected, but those cells which do respond to nicotine have proteins on their surface (called nicotinic receptors) which bind nicotine. Second, research done during the last two decades has revealed that there is, in fact, a large family of receptor proteins in our brains which bind nicotine. Furthermore, we now know that the binding of nicotine stimulates this family of receptor proteins and that such receptor activation represents the first step in a complex process which eventually leads to addiction

38 Nicotine Addiction: “A Brain Disease”
“Up-Regulation” Increased numbers of Nicotinic receptors Nicotine causes an up-regulation (increase in number) of receptors in the brain (alpha4) that have some of the highest sensitivity to nicotine. This happens in a cell-specific fashion in the dopamine-producing portions of the brain, but not in the dopamine neurons themselves. Instead, the increase in receptor number occurs only in neurons that inhibit dopamine neurons--a group called the GABAergic neurons. This surprising result led researchers to conduct experiments on mice with delicate electrical probes. In chronic nicotine-treated mice (and presumably in chronic smokers), the dopamine neurons are chronically inhibited from firing in the absence of nicotine. And nicotine itself still excites the dopamine neurons, leading to pleasure, but much less than expected.

39 Withdrawal Syndrome or "Abstinence Syndrome"
Pathophysiologic disturbances which result when a drug to which an organism is physically dependent is stopped. When receptors are no longer stimulated because of absence of nicotine (as in a quit attempt), and are now blocked from naturally occurring release of dopamine, you have resultant withdrawal symptoms. Additionally, tobacco users need more nicotine to get the same effect and achieve their comfort zone.

40 Smoking Cessation “…is the easiest thing I ever did; I ought to know because I have done it a thousand times”. - Mark Twain Mark Twain said it best….. Many people who have tried to quit several times feel that they will never be able to quit. We try to switch this around by telling them that the more times they quit, if they apply what they learned about what worked and what didn’t work from a previous quit attempt, to the next attempt, then they are more likely to quit each time they try. The message is - keep trying.

41 Withdrawal Symptoms Symptoms may begin within a few hours of last use, but typically within the first few days, and begin to subside within a few weeks. Cravings, which may relate to certain “triggers” , can occur for months to years. Craving will pass without a cigarette The “relaxing” effect that nicotine provides may not be due to physical relaxation; rather, it may be the elimination of early withdrawal symptoms. A distinction needs to be made between “withdrawal symptoms” and “cravings” which may not be the same thing. True nicotine withdrawal will not last for months, but cravings certainly can. Nicotine withdrawal usually subsides in a couple of weeks.

42 Withdrawal Symptoms Psychological/Behavioral: giving up a habit
Physical: absence of nicotine Nicotine craving is a major obstacle to success Depression Irritability; anger Trouble concentrating; restlessness Sleep disturbances; tiredness Headache Increased appetite Repeat exposure to nicotine creates tolerance Higher doses required to create same stimulation When [tobacco users] try to cut back or quit, the absence of nicotine leads to withdrawal symptoms. Withdrawal is both physical and psychological. Physically, the body is reacting to the absence of nicotine. Psychologically, the tobacco user is faced with giving up a habit, which is a major change in behavior. Both must be dealt with if quitting is to be successful. Withdrawal symptoms (see ppt slide) are uncomfortable and lead the user to again start using tobacco to boost blood levels to nicotine back to a level where there are no symptoms. NRT can help with the physical symptoms of withdrawal. Counseling methods, like the Quitline, help with the psychological withdrawal symptoms. (from Ernest Carbone, Consumerhealthdigest.com) <Chronic exposure to nicotine results in addiction. Greater than 90 percent of those smokers who try to quit without seeking treatment fail, with most relapsing within a week. Repeated exposure to nicotine results in the development of tolerance, the condition in which higher doses of a drug are required to produce the same initial stimulation. Nicotine is metabolized fairly rapidly, disappearing from the body in a few hours. Therefore some tolerance is lost overnight, and smokers often report that the first cigarettes of the day are the strongest and/or the "best." As the day progresses, acute tolerance develops, and later cigarettes have less effect.> <Cessation of nicotine use is followed by a withdrawal syndrome that may last a month or more; it includes symptoms that can quickly drive people back to tobacco use. Nicotine withdrawal symptoms include irritability, craving, cognitive and attentional deficits, sleep disturbances, and increased appetite…. Symptoms peak within the first few days and may subside within a few weeks. For some people symptoms may persist for months or longer.> <An important but poorly understood component of the nicotine withdrawal syndrome is craving, an urge for nicotine that has been described as a major obstacle to successful abstinence. High levels of craving for tobacco may persist for 6 months or longer. While the withdrawal syndrome is related to the pharmacological effects of nicotine, many behavioral factors also can affect the severity of withdrawal symptoms. For some people, the feel, smell, and sight of a cigarette and the ritual of obtaining, handling, lighting, and smoking the cigarette are all associated with the pleasurable effects of smoking and can make withdrawal or craving worse. While nicotine gum and patches may alleviate the pharmacological aspects of withdrawal, cravings often persist. (http://teens.drugabuse.gov/drnida/drnida_nic1.asp#long_periods)

43 Teens Underestimate the Addiction…
Most high school smokers believe they will not be smoking in 5 years, however 73% remain daily smokers 5-6 years later (CDC longitudinal studies) Over half (57%) of teen smokers report trying to quit in the previous 12 months (CDC, 1994)

44 Addiction and Youth Adolescents may be more sensitive to nicotine, especially in combination with other chemicals found in tobacco. Depending on age of initiation, this may increase the likelihood of tobacco addiction. Combined with social influences, this puts young people at greater risk for becoming addicted. Source: (National Institute on Drug Abuse: Tobacco Addiction Series) Tobacco use in teens is not only the result of psychosocial influences, such as peer pressure; recent research suggests that there may be biological reasons for this period of increased vulnerability. Indeed, even intermittent smoking can result in the development of tobacco addiction in some teens. Animal models of teen smoking provide additional evidence of an increased vulnerability. Adolescent rats are more susceptible to the reinforcing effects of nicotine than adult rats, and take more nicotine when it is available than do adult animals. Adolescents may also be more sensitive to the reinforcing effects of nicotine in combination with other chemicals found in cigarettes, thus increasing susceptibility to tobacco addiction. Acetaldehyde increases nicotine’s addictive properties in adolescent, but not adult, animals. That is, adolescent animals performing a task to receive nicotine showed greater response rates to nicotine when combined with acetaldehyde. NIDA continues to actively support research aimed at increasing our understanding of why and how adolescents become addicted, and to develop prevention, intervention, and treatment strategies to meet the specific needs of teens.

45 Cessation: What Works Works best when combined Behavioral support
Treats the psychological and habit aspects Pharmacotherapy Treats nicotine addiction Works best when combined Behavioral support and pharmacotherapy have been proven to increase quit rates in adults and it works best when you have both.

46 How do we help people quit
How do we help people quit? We are fortunate in the field of tobacco control to have evidence-based recommendations that have been shown to be effective for adults – to guide us and should be considered for use with children and adolescents. In 2008 the Public Health Service updated this guide, which is the result of a comprehensive literature search looking at what is effective to help tobacco users quit.

47 Efficacy of Physician Advice to Quit
Abstinence Rate % No advice Physician Advice Patients expect healthcare providers to ask about tobacco use and advise them to quit Source: Treating Tobacco Use and Dependence, USDHHS, Public Health Service, 2000 One of the findings from the literature review was the effectiveness of brief physician advice in helping adult tobacco users quit. If someone tries to quit smoking without any help at all, they have about an 8% chance of quitting – out of 100 people who try to quit this way, about 8 will quit long term (months). If a physician gives brief advice to someone who wants to quit – and this can take only 1-2 minutes, ex. “It’s important that you quit using tobacco and here’s why” “It will reduce your risk of ….” etc., then that increases their chances of quitting significantly to 10.2%. This may not seem like much but it represents 500,000 to 1,000,000 tobacco users who quit with brief advice – that is very cost-effective. This doesn’t mean that the same brief advice from other health care professionals won’t have the same effect – it just so happens that the studies that were done were with physicians – we do have data that show that the same cessation message from a variety of health care providers does increase quit rates. Advice from a physician to quit using tobacco will lead the patient along a cyclical path to quitting. Smokers generally move through stages of not thinking about quitting, then thinking about it, making a quit attempt followed by relapse, and another period of no interest (Prochaska and DiClemente, 1983). However, repeated advice to quit, together with messages from other sources, will help reinforce the process so that eventually the smoker will make a successful attempt. It is important to remember that these techniques should also be used with children and teens, but the approach should be modified to be developmentally appropriate. Teens, in particular, may respond more to the aesthetic (bad smell, “kissing a smoker is like kissing an ashtray”, early wrinkling, yellow fingernails) of being a smoker even more than hearing that smoking/smokeless tobacco will cause health effects decades into the future.

48 5 A’s For Patients Willing to Quit
Ask about tobacco use Advise patient to quit Refer (1-800-QUIT-NOW or local prgm) Assess readiness to quit Assist in quit attempt Arrange follow-up The 5 As of cessation is the cessation method that has been shown to be effective in helping people quit. A variation on this is the “Ask, Advise and Refer” method. If you don’t have time to do the entire process, at least ask about tobacco use and advise to quit, then refer to an evidence-based service like the quitline, which can take tobacco users through the rest of the quitting process.

49 Ask Ask about tobacco use at every visit
Systematically identify all tobacco users Make identification/documentation a vital sign Create a universal identification system (stickers, computer reminders, etc.) The important thing about asking is to ask everyone and to make this a systems change involving the entire practice. Making asking about tobacco use a vital sign and including this information in the EMR or on a stamp or sticker for the chart is a way to identify patients that can The important thing about asking is to ask everyone and to make this a systems change involving the entire practice. Making asking about tobacco use a vital sign and including this information in the EMR or on a stamp or sticker for the chart is a way to identify patients that can then receive advice and referral to cessation resources.

50 Create a Reminder System
Include tobacco use in other medical / dental advice Use an identification system Stamp, Sticker, EMR Tobacco Use and Exposure Tobacco Use: (circle one): Current Former Never Secondhand Smoke Exposure: YES NO Tobacco use is the single most preventable cause of death in the US. Reminder systems are key to helping busy providers incorporate the 5A’s into their busy patient schedules. It gets others in the office involved with process of asking all patients about tobacco use, at every visit.

51 Advise Clear, Strong, Personalized “Quitting smoking ...
...is the single best thing you can do for your health” ...will reduce your risk of …” Employ the teachable moment: Link visit findings with advice. Advice doesn’t have to take a long time – clear, strong and personalized minutes can be effective.

52 Assess Willingness to make quit attempt in next 30 days
“I want to quit” NOT “I need to quit” Important to distinguish between wanting to quit and needing to quit. Most people today know that they need to quit, and are aware of the health effects of tobacco use. For a serious quit attempt, a tobacco user needs to really want to make a quit attempt.

53 Examples Very specific reasons to quit smoking:
“I want to quit smoking so I can go shopping without stopping 10 times.” “I want to quit smoking so I will not have a stroke like my dad.” “I want to quit smoking so my dogs will not get emphysema.” (real quote) I want to quit so I won’t smell like an ashtray Helping tobacco users identify reasons they want to quit can be helpful. These are actual quotes from the UNC tobacco cessation clinic. It can be useful to help tobacco users come up with reasons such as these to help motivate them and remind them why they want to quit. There are supposedly some data on animals getting emphysema from SHS. There are also data on animals (pets) getting cancer from SHS because they not only inhale it, but ingest it because it gets on their dander and they lick it.

54 Stages of Change Pre-contemplation Contemplation Preparation Action
Maintenance Pre-contemplation stage – Most tobacco users here, they know they need to quit but don’t want to. Do brief intervention to motivate. Provide information about harmful effects. Address fears: Financial resources, previous relapse, demoralized from previous attempts. 5R’s Contemplation stage - now ambivalent, weighing the pros and cons. When patient is ambivalent, there is opportunity. Pt is assessing barriers and benefits to quitting. May be anticipating or feeling a sense of loss, despite the perceived gain. Listen to patient, validate feelings. Motivational interviewing techniques are effective - incorporates empathy and reflective listening with key questions. “I’ve know you’ve handled some tough stuff, I know you’ll be able to conquer this” “Tell me about previous attempts to quit, what worked, what didn’t work, what was the hardest thing about it?” If barriers or gaps in knowledge surface you have an opportunity for further discussion. Preparation stage - Experiment with small changes commendable. Set a quit date. Tell family, friends, co-workers. Anticipate challenges, remove cigarettes (dispose of them) and ashtrays from home, car, clothing, etc. Action stage – Praise any action taken! Over time, attempts to maintain the new behavior occur. Tob user is trying to make a change. What method are they using to quit? Note treatment options/resources in community/websites, FFS, Quitline, etc. Ask patient: Why do you want to quit? What concerns or worries you about quitting? What success have you had? What difficulties do you anticipate, have you run up against? Express concern and willingness to help: Half of all smokers quit! You can do it! How do you feel about quitting? Be open to expressions of fear, difficulties, ambivalence. Encourage patient to talk about quitting process. Pile on the praise Maintenance – the “long haul” – need to f/up to prevent relapse. Change is rarely a discrete, single event. Schedule follow-up visits/telephone calls. Congratulate continued success. Strong encouragement to stay quit. Active discussion: Open-ended questions for problem-solving: benefits of quitting: health, money saved, time saved, staying quit longer, decreased withdrawal symptoms. Discuss problems or threats to staying quit: best friend smokes, custody battle, loneliness. Address status at every visit Relapse – are common but can be demoralizing; need to assess causes; are inevitable; part of the process of making life-long change. Multiple quit attempts are common before permanent quit. These are learning experiences. Focus on successes. What can a relapse teach? Avoid smoke-filled rooms, Take a walk after dinner, Find ways to manage stress , Ask friends not to smoke around you, Make your car & home smoke-free. Other Points: Tobacco users may feel “immune” to health problems. They may have tried so many times to quit that they have given up. Advise to quit and congratulate even small successes like quitting for 24 hours.

55 5R’s for Patients Not Ready To Make a Quit Attempt
Relevance Risks Rewards Roadblocks Repetition Patients not ready to make a quit attempt may respond to a motivational intervention. The clinician can motivate patients to consider a quit attempt with the 5R’s: Relevance – Encourage the patient to indicate why quitting is personally relevant Risks – Ask the patient to identify potential negative consequences of tobacco use Rewards – Ask the patient to identify potential benefits of stopping tobacco use Roadblocks – Ask the patient to identify barriers or impediments to quitting Repetition – The motivational intervention should be repeated every time an unmotivated patient has an interaction with a clinician. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful, and that you learn from each attempt. Don’t spend time on the 5 R’s with a motivated, ready to quit, patient. This patient is ready to make a quit plan.

56 Assist Develop a quit plan STAR: - Set a quit date (within 2 weeks)
- Tell family, friends, coworkers - Anticipate challenges to quitting - Remove tobacco products from environment The Assist part of the 5As can take the longest amount of time, but remember that the Quitline or a local program can also do this. This acronym helps remind you of the important parts of this. During the Assist step, work with your patient to prepare to quit, anticipate problem areas, and develop strategies for dealing with them. Some quitters find it helpful to formalize their plans for a quit date by signing a contract with their clinician. Others want additional information about withdrawal symptoms and how to manage them. It’s helpful to discuss ways to minimize the risk of smoking, such as removing all tobacco products from their home or creating smoke-free zones in their homes, and how to manage situations in which the specific cues for smoking will offer serious temptations to smoke. It helps to address your patient’s most pressing concerns and then refer her to the Quitline and other materials that you are giving her.

57 Arrange Schedule follow-up in person via telephone
NC Tobacco Use Quitline 4 visits/calls is evidence based Congratulate progress/success Identify problems/anticipate challenges Evaluate pharmacotherapy use/problems Arrange follow-up. Tobacco users making a quit attempt who had follow-up after their quit date had higher quit rates than those who did not have follow-up. This does not have to take a long time – 10 minutes or so to answer questions, find out how things are going.

58 Help for the busy practice….

59 Health Care Provider’s Quick Intervention
ASK about tobacco use ADVISE to quit REFER to NC Tobacco Use Quitline, Become An Ex, other resource PRESCRIBE as appropriate Let the NC Tobacco Use Quitline help with the time consuming work. They are experts at quit coaching and will help Assess, Assist, and Arrange)

60 REFER Quitline information to all Consider fax referral
Patients ready to quit within 30 days Consider cessation medications Provide Quitline number to patients not ready to quit Other resources such as BecomeAnEx Follow-up at next/every visit Most people today know that they need to quit, and are aware of the health effects of tobacco use. For a serious quit attempt, a tobacco user needs to really want to make a quit attempt. Fax referral to the quitline should be made only for those who are serious about setting a quit date. All patients who use tobacco, even those not ready to discuss quitting with a quit coach or to set a quit date, should leave the office with a brochure or card with the Quitline number for when they are ready to take this step. Even those fax referred should have the Quitline number. They might change their mind about talking to a quit coach or they may decide to call on their own, immediately or weeks or months later. Some patients have even been known to ask for fax referral but then call the quitline as soon as they get home. The beauty of the Quitline is that it is available when the person is ready to quit. They don’t have to try to find a program or wait until the day of the program or class – no time to change their mind!

61 North Carolina Tobacco Use Quitline
1-800-QUIT-NOW ( ) 8a.m. – 3 a.m., 7 days a week; Toll-free; Confidential All North Carolinians - youth and adult Proactive – Quit coaches can call tobacco users back upon request, or make 1st call Fax referral Multiple language Quit Coaches Administered by: Tobacco Prevention and Control Branch Funded by: NC Division of Public Health, NC Health and Wellness Trust Fund The NC Tobacco Use Quitline was launched in November 2005, funded by NC HWTF, the Division of Public Health using CDC funds. It is free for youth and adults in NC, and is staffed by trained quit coaches who can help tobacco users with the entire quitting process. Quit coaches can even call them back to check on progress if caller would like. Also has a website: Available in English, Spanish and translation service for many other languages, and has a fax referral program.

62 Quitline can Assess, Assist, Arrange
Quit coach helps set Quit Date, and Develop quit plan Make follow-up calls Discuss pharmacotherapy Mail targeted resources Patients can call the Quitline anytime The Assist part of the 5As can take the longest amount of time, but remember that the quitline or a local program can also do this.

63 What happens on first call with the Quitline
Intake specialist determines readiness to quit First call - plan for minutes to enroll Transfer to Quit Coach for those ready Quitline can call patients back 4 visits is an evidence based intervention If not ready to set quit date, Encouraged to call back when ready, and offered enrollment for: Cessation materials (mailed) Web Coach access Quitters don’t have to give any information to get cessation services. However, to get call-backs quitter has to enroll and give phone number. Have to give address to get cessation materials mailed. Calling in 4 times without enrolling is Okay but is not as consistent as the call-back program. Enrolled participants set a quit date and arrange up to 3 follow-up calls from the quit coach, the first of which is on or near the quit date, the second call is usually about 1 week later and another call is within a few weeks to a month, for a total of 4 calls. The quitter who has completed all the calls can always call the quitline back if they relapse or are afraid they may relapse.

64 Caller would like to speak to a Quit Coach
One Call Program: Conversation with the Quit Coach for support Support materials for quitting Referral to local resources Medication information Help to develop a plan, including setting a quit date Access to Web Coach Four Call Program: One Call program, plus Quit Coach will call back -- A quit date is set -- Dates and times are made for three more calls from a Quit Coach Three attempts, then letter is sent Quitters may call if they relapse. There’s no real limit to using the Quitline, although the 1 call or 4 call Call-Back program are most commonly employed. Quit Coach will try to call three times, 3 days in a row, to reach for an agreed upon call date, then they will send a follow-up letter. If caller agrees to one call program, multiple call program, or to have cessation materials mailed, they are eligible to sign up for Web Coach and will be given a temporary password. This will be discussed in the next few slides.

65 Caller does not want to talk to a Quit Coach
Caller will be offered: Messages to promote quitting Support materials for quitting Referral to local resources Encouragement to call again

66 Other Quitline Features
Web Coach Progress tracking Coaching s Discussion Forums Click to Call Available on Web Coach Web Coach makes it possible for the person to work on a quit plan, with or without the quit coach. During operational hours, however, you can also Click to Call while on the web site and the Quitline will call you. The quit coach can you, see your quit plan on Web Coach and assist you in real time.

67 Fax Referral to Quitline Helps With…
Referral to effective cessation services Provider’s limited time and resources The burden of patient initiating services NOTE: Provider referral to a cessation program is associated with higher rates of participation than simply telling patients they should stop using tobacco Research indicates that physician referral of patients to smoking cessation programs is associated with a significantly higher participation rate than simply telling patients they should stop smoking

68 Quitline Outcomes Report
Tool to follow patient progress with your advice to quit / utilize Quitline services Most useful in clinic setting with dedicated fax machine/staff to retrieve reports Outcomes Report information: Accepted services Declined services Unreachable The outcomes report helps providers follow patients in their quit attempt – it will provide information about whether the patient enrolled into the quitline and their quit status upon the first call with a quit coach.

69 Clinics may provide their patients with the option of being fax referred to the Quitline. The provider completes the top section and the patient completes the patient information section and must sign and date the form. Providers who appropriately complete the form, including HIPAA information and a correct return fax may receive an Outcomes Report on the patient. Regardless of the HIPAA status, the quitline will attempt to contact the patient to offer enrollment in the Quitline program.

70 NC Tobacco Use Quitline Fax Referral Flow Chart
Take patient’s vital signs & ask about tobacco use. Advise to quit. Is the patient ready to quit? NO Give patient cessation resources: 1-800-QUIT-NOW ( ), or other resource. YES INTERVENE: Offer cessation medications if indicated, Quitline #, fax referral option Does patient want a quit coach to call them? This flow chart is an example of how fax referral to the Quitline can be implemented in practice. Give patient cessation resources: 1-800-QUIT-NOW ( ), or other resource. NO YES Complete fax referral consent form & fax to Quitline. The Quitline will make at least 5 attempts to call the patient.

71 How Fax Referral Works Patient has been identified as a tobacco user
Patient educated on services of Quitline Patient wants to quit tobacco use within 30 days Patient would like a quit coach to call at time/date they select HCP completes Provider Information, including Hospital-Clinic Name, Contact Name and Number. Patient completes Patient Information and signs form, providing consent for HCP to release information Patient must provide contact information and sign and initial the fax referral form. Quitline can provide Fax Referral Outcomes Report: Accepted Services, Refused Services, Not Reached If you do not want the Outcomes Report contact the Tobacco Prevention and Control Branch at Quitline will begin contact attempts to enroll patient in program based on time and date provided by patient It is not required that you get the fax-back Outcomes Report on patients. Just do not check the HIPAA or provide a fax back number. The patient will still be contacted by the Quitline as long as the Patient Section is completed, including best times to be called, and the patient signs the form.

72 More Cessation Resources

73 Become an EX www.becomeanEX.org
Web-based cessation program for adults Fun, edgy, interactive Personalized quit plan to: “Relearn life without cigarettes” Relearn habit Relearn addiction Relearn support Free and in English and Spanish The BecomeAnEX.org/ConvierteTeEnUnEX.com Web site brings the “re-learn” idea to life, offering action-oriented content and videos to help smokers re-learn all aspects of their smoking addiction. The site helps users develop a personalized quit plan that includes medication and support, plus it gives them an opportunity to practice breaking the “glue” between cigarettes and their associated triggers, before they actually stop smoking. Visitors to the Web site can: Create customized quit plans; Connect to a virtual support group; Learn more about pharmacotherapy resources, Link to quit-smoking resources in Alliance states. The National Alliance of Tobacco Cessation: a new public health campaign created by an alliance of national organizations and states. The program helps change the way smokers think about the difficult process of quitting, and guide them to valuable free resources to build a successful quit attempt. Encourages smokers to approach quitting smoking as "re-learning life without cigarettes." EX provides smokers with information that can help them prepare for a quit attempt by 1) "Re-learning" their thinking on the behavioral aspects of smoking and how different smoking triggers can be overcome with practice and preparation (how to have that first cup of coffee without a cigarette, driving without a cigarette, dealing with stress without a cigarette); 2) "Re-learning" their knowledge of addiction and how medications can increase their chances for quitting success; and 3) "Re-learning" their ideas of how support from friends and family members can play a critical role in quitting.

74 Two booklets created by American Legacy Foundation in cooperation with Mayo Clinic – Ex Easy Read Booklet and Fotonovella The Re-learn Life Without Cigarettes booklets are available for download to those enrolled in the Ex web-based program. From the book: We are EX — a group of people who’ve learned how to quit smoking. Our free plan is based on personal experiences, as well as the latest scientific research. Whether this is your first try or your 10th, this plan can help you quit smoking. What you’ll discover about our plan is that it’s not just about quitting. It’s about re learning your life without cigarettes. And we can help you do just that.

75 Women and Children Resources

76 Resources for Youth PROJECT ASPIRE – A smoking prevention interactive experience for youth: Project ASPIRE: Whether you are a smoker looking to quit, a non-smoker seeking information about smoking and its effects or anywhere in between, this self-paced learning experience offers interactive activities, videos, support strategies and fun animations to help you reach your goal. You'll learn how to make the best choices for you — and how to stay on the path of good health. Project ASPIRE is based on the school curriculum called ASPIRE (A Smoking Prevention Interactive Experience) - jointly developed by M. D. Anderson Cancer Center and The University of Texas Health Science Center at Houston and was funded by a grant from the National Cancer Institute. Funding for this Web site was provided by the George & Barbara Bush Endowment for Innovative Cancer Research which was awarded to Dr. Alexander V. Prokhorov. My Last Dip: A unique Web-based intervention that is designed to help chewing tobacco users aged 14 to 25 quit. The program was developed by researchers with over 30 years' experience in smokeless tobacco research and funded by a government grant from the National Cancer Institute. The MyLastDip research project provides scientifically tested content that has proven effective in helping people quit their use of chewing tobacco or snuff. It is free to use — in fact, participants are paid to answer questions using an online survey several times over a 6-month period. MyLastDip can be used anytime you can access the Internet. The group of scientists at the Oregon Research Institute that designed this project is headed by Herbert H. Severson, Ph.D. My Last Dip – An on line program for age who use spit or smokeless tobacco:

77 Healthy Start Foundation
Two brochures can be ordered If You Smoke And Are Pregnant Oh Baby! We Want To Keep You Safe From Secondhand Smoke These beautiful educational booklets are for women who are pregnant or planning to become pregnant, or have a baby at home – to help them understand the importance of quitting smoking, for their own health and the health of their baby while pregnant and after the baby is born. These are available at Organizations can fax orders in to get quantities of 100.

78 You quit. Two quit. www.youquittwoquit.com
Informational website for Pregnant women New mothers Family and friends Health professionals UNC Center for Maternal and Infant Health Funded by North Carolina Health and Wellness rust Fund Comprehensive system to screen and treat pregnant and postpartum women for tobacco use with unique focus on new mothers and recidivism prevention. UNC Center for Maternal and Infant Health were grant funded by the HWTF for a 4 county pilot, web site and educational booklet. The booklet is available for download from the website. There is also a very nice 5A’s tutorial on the web site and much more information. A sample web page is available for viewing on the next PPT.

79

80 Tobacco Cessation Training for HCP’s Working with Women
For more information on the Women’s Health and Tobacco Use Program, contact: Judy Ruffin A Guide for Counseling Women Who Smoke is a comprehensive 5 A’s tutorial that includes helping patients who are in different stages of change. It is available through the Women’s Branch of the Division of Public Health at the web link: It is also available at each of the local health departments in NC. The Guide is available on the Division of Public Health / Women’s Health Branch webpage:

81

82 Pharmacotherapy – First Line
Nicotine Replacement Therapy - Patch - Gum - Lozenge - Inhaler - Nasal Spray Zyban (bupropion) Chantix (varenicline) We’ll talk briefly about the pharmacotherapy of cessation. There are five FDA approved nicotine replacement agents and 2 FDA approved pills, Zyban and Chantix.

83 Over the Counter Medications
Nicotine Patch Dose: 21mg, 14mg or 7mg per 24 hours 1 pack/day, start with higher dose, taper duration 8 weeks step down after 4 wks in 2 wk increments Nicotrol is used for 16 hours, off at night Adverse effects: local skin reaction, insomnia, vivid dreams Contraindications: Recent MI, unstable angina, arrhythmia Cost: 7mg box - $37 14mg box - $47 21mg box - $48 The patch comes in 2 forms, one that is put on every 24 hours, and one (Nicotrol) that is put on every 16 hours (you take it off at night). Some people prefer the 16 hour patch if they are having problems with insomnia. Keep in mind that this patient may have a harder time first thing in the morning, and may need to use an additional short acting NRT product such as the gum or the lozenge upon first awakening. It takes the patch about 4 hours to get nicotine levels back up. Can be dosed according to the number of cigarettes smoked – approximately 1mg of nicotine per cigarette. So someone who smokes 1 pack per day (20 cigarettes) would start with the 21mg patch and taper after 4 week in two week increments.

84 Nicotine Patch Dose Based on Smoking Rate CPD = Cigarettes per day
10 cpd mg/d cpd mg/d cpd mg/d >40 cpd mg/d This dosing for those who smoke greater than 1 pack per day is based on a 2009 Mayo Clinic Webinar: Pharmacologic Therapy for Tobacco Use and Dependence, J. Taylor Hays, MD, Mayo Clinic Nicotine Dependence Center, Rochester, MN. Studies show that high dose NRT patches are effective. See the Public Health Service Clinical Practice Guidelines, Treating Tobacco Use and Dependence, Table 6.26 Meta-analysis (2008). Webinar – Pharmacologic Therapy for Tobacco Use and Dependence, J. Taylor Hays, MD, Mayo clinic Nicotine Dependence Center, Rochester, MN © 2008 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED 2008 Update to CPGs do not recommend NRT for light smokers due to Insufficient evidence

85 Over the Counter Medications
Nicotine Gum Dose: up to 24 pieces per day x 12 weeks (longer if needed) 2mg for <25 cigarettes per day 4mg for >25 cigarettes per day Chew, chew, park Avoid acidic beverages Consider using on a fixed schedule Long term patch and gum use are effective Adverse Effects: Mouth soreness, hiccups, jaw ache, dyspepsia Contraindications: As for patch Cost: 2mg box ( pieces) ~ $45 (generic) 4mg box ( pieces) ~ $63 (generic) The gum comes in 2 doses – 2mg and 4mg. Important to remember that the gum should not be chewed like regular gum. It should be chewed until a peppery or tingly sensation occurs – that’s the nicotine being released – then it should be parked in the cheek, until another craving comes, then chew again, then park. Gum should be slowly and intermittently “chewed and parked” for abut 30 min. or until the taste dissipates/no longer causes the peppery sensation – nicotine is gone – discard the gum. Also, should not eat or drink anything acidic15 minutes (coffee, tea, juices, soft drinks) before, during or after chewing – that will decrease nicotine absorption. Water is acceptable. 2008 Clinical Practice Guideline’s (Treating Tobacco Use and Dependence): Patients often do not use enough NRT to obtain optimal clinical effects. Instruction to chew gum on a fixed schedule) at least one piece every 1-2 hours) for at least 1-3 months may be more beneficial than using “as needed”. The idea is to stop cravings before they occur. 2008 CPG Update: Evidence indicates that the long-term use of gum may be more effective than a shorter course of gum therapy. The Lung Health Study, of almost 4000 smokers with evidence of early COPD, reported that approximately one-third of long-term quitters still were using nicotine gum at 12 months, and some for as long as 5 years, with no serious side effects. Most insurance companies do not cover over the counter NRT.

86 Over the Counter Medications
Nicotine Lozenge (Commit) Dose 2mg (1st cig. >30 min. after awake) 4mg (1st cig. <30 min. after awake) 9 (min) to 20 (max) lozenges/day x 12 weeks (longer if needed) Allow to dissolve in mouth Avoid acidic beverages Adverse Effects: Nausea, hiccups, heartburn 4mg dose - headache, cough Contraindications: as for patch Cost: 2mg box (72 lozenges) - $34 4 mg box (72 lozenges) - $39 (9 lozenges/day =1 box/wk = $136-$156/mo) Patients often do not use enough prn NRT to obtain optimal clinical effects. Generally, patients should use 1 lozenge every 1-2 hours during the first 6 weeks of treatment, using a minimum of 9 lozenges per day, then decrease to 1 lozenge every 2-4 hours during week 7-9, and then decrease to 1 lozenge every 4-8 hours during weeks Should be used for up to 12 weeks. No more than 20 lozenges per day. Insurance usually does not cover this.

87 Prescription Medications
Nicotine Inhaler Dose: 4mg nicotine 80 puffs=4mg nicotine Best effects with frequent puffing/at least 6 cartridges per day (can use 6-16 cartridges/day) Use for up to 6 months Reduce frequency over the last 6-12 weeks of tx Avoid acidic beverages Adverse Effects: mouth/throat irritation, coughing, rhinitis Contraindications: as for patch Cost: 1 box (168 10mg cartridges) - $196 In cold weather (<40 deg) inhaler should be kept in an inside pocket or other warm area. The nicotine inhaler is by prescription only. The nicotine from the “inhaler” is absorbed in the buccal (oral) mucosa like the gum and the lozenge. Best effects are achieved by frequent puffing (not inhaling) of the inhaler and using at least six cartridges a day. Patients often do not use enough prn NRT to obtain optimal clinical effects. Use is recommended for up to 6 months, with gradual reduction in frequency of use over the last 6-12 weeks of treatment. Most insurance companies do not cover this. It can be quite expensive.

88 Prescription Medications
Nicotine Nasal Spray Dose: 1 dose = 1 mg (0.5mg per nostril) 1-2 doses per hour initially Increase as needed for symptom relief 8 min/40 max doses per day for 3-6 months Do not sniff, swallow or inhale Head titled slightly back Adverse Effects: Nasal irritation, congestion; transient changes in smell, taste Contraindications: as for patch Cost: $49 per bottle (100 doses) Nicotine nasal spray produces higher peak nicotine levels than other NRTs and has the highest dependence potential. Approximately 15-20% of patients report using the active spray for longer periods than recommended (6-12 months); 5% used the spray at a higher dose than recommended. Insurance usually does not cover this.

89 NRT and Cardiovascular Disease
Not an independent risk factor for acute myocardial events Use with caution in patients who: are within 2 weeks of MI have serious arrhythmias have serious or worsening angina pectoris After the patch came out there were concerns about smoking with the patch on causing a heart attack – this has been disproven. NRT is not a risk factor for heart attacks. 3 groups of people should be considered on a case-by-case basis – they are listed here. Also, pregnant women should try to quit initially without any meds – benefit vs. harm must be considered when pregnant smoker can not quit without cessation medications.

90 Prescription Medications
Zyban, Wellbutrin (bupropion SR 150) Begin 1-2 weeks before quit date Dose: 150 mg in a.m. for 3 days 150 mg twice daily for 7 to 12 weeks May consider long-term tx for 6 months post quit Adverse Effects: Insomnia, dry mouth Contraindications: history of seizure d/o, eating d/o, recent MAO inhibitor use in past 14 days Cost: 1 box of 60 tablets $97/month (generic) $197-$210 (brand name) Some people on buproprion may stop smoking prior to the quit date, or will spontaneously reduce the amount they smoke. If insomnia is marked, taking the PM dose (earlier in the afternoon, at least 8 hours after the first dose) may provide some relief. Buproprion is by prescription only and should be started 1 to 2 weeks before the quit date. It should not be given to those who have a history of seizures as it can lower the seizure threshold. Many insurance companies are covering this. Wellbutrin is covered as an anti-depressant, Zyban for smoking cessation. Different insurers may cover one over another. Buproprion reduces cravings, can “smooth you out” as one former smoker put it. Monoamine oxidase (MAO) inhibitors are a class of drugs used for depression and Parkinson's Disease.

91 Prescription Medications
Chantix (varenicline) Stimulates nicotine receptors. Also blocks nicotine at receptor site Start Chantix 1 week before quit date Dose: 0.5 mg daily for 3 days 0.5mg twice daily for 4 days 1.0mg twice daily for 3 months May decrease dosage (1mg/day) if significant side effects Adverse Effects: nausea, insomnia, abnormal/vivid dreams New warning label Jan. 2008– observe for neuro- psychiatric symptoms (post marketing data) Cost: 1 box of 56 - $131 (~30 day supply) Research shows that at 1 year, 21% of those on Chantix are still abstinent compared to 8% with a placebo Although a causal relationship has not been established Pfizer has added an updated label to include a warning to watch patients for serious neuropsychiatric symptoms such as changes in behavior, agitation, depressed mood, and suicidal thoughts and behavior. In some postmarketing reports these symptoms could not be ruled out. Patients with serious psychiatric illnesses did not participate in the controlled clinical trial program. In clinical trials the rate of psychiatric symptoms occurred at the rate of placebo-treated patients. Varenicline mildly stimulates nicotine receptors in the brain, but also blocks them so that nicotine from tobacco cannot bind. This results in a lack of the effects of nicotine that smoking or using tobacco brings, while also minimizing withdrawal symptoms. To reduce nausea, take on a full stomach. To reduce nausea, take second pill at supper rather than bedtime. Some patients may lose their desire to smoke prior to their quit date or will spontaneously reduce the amount they smoke. Studies have indicated significantly increased quit rates among patients who used this compared to placebo. From Before using Chantix, tell your doctor if you have kidney disease. FDA pregnancy category C. This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether Chantix passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. Do not give this medicine to anyone younger than 18 years old.

92 More on Pharmacotherapy
Combined therapy improves abstinence rates Patch + gum, nasal spray, or inhaler Patch plus buproprion (FDA approved) Do not combine NRT with Chantix Buproprion and gum or lozenge may delay weight gain NRT for smokers not willing to quit – promising but warrants further research In adults pharmacotherapy can be combined. Can be expensive. Do not use NRT with Chantix – causes increased side effects such as nausea and headaches. Also, because of the blocking of nicotine at the receptor site, it is counter-intuitive. P. 123 CPG 2008 Update: Research has examined the use of NRT in patients not currently willing to make a quit attempt. In general these studies have found that NRT used in this way increased the likelihood that smokers will make a quit attempt and succeed in quitting. Table 6.29 shows … the use of NRT more than doubled the likelihood that a smoker would be abstinent at 12 months, despite the smoker’s unwillingness to make a quit attempt at the time of initial assessment. Cochrane analysis found that NRT significantly increased quit rates among smokers not initially motivated to quit. The authors concluded, however, that there was insufficient evidence to recommend this as a standard treatment approach with this population. The Panel believes that this topic warrants further research.

93 Pregnancy and Pharmacotherapy
Abstinence early produces greatest benefits Quitting at any point yields benefits Person to person intervention should be offered to pregnant and post partum women Should exceeds minimal advice to quit Inconclusive evidence that cessation medications increase abstinence rates From 2008 CPG’s: Nicotine most likely does have adverse effects on the fetus during pregnancy. Although the use of NRT exposes pregnant women to nicotine, smoking exposes them to nicotine plus numerous other chemicals that are injurious to the woman and fetus. These concerns must be considered in the context of inconclusive evidence that cessation medications boost abstinence rates in pregnant women. No pharmacotherapy has been evaluated in pregnant women. All NRT, buproprion, and varenicline are all pregnancy Category C drugs.

94 Treating Tobacco Use and Dependence: Children and Adolescents
Recommendations Clinicians screen children and adolescents for tobacco use Consider counseling and behavioral interventions that are effective with adults Offer smoking cessation advice and interventions to parents All of these recommendations are from studies on adults. However, the Guideline does make recommendations (see below) for young people. These are from an expert panel rather than from the literature. So far we just don’t have the research studies in young people like we do in adults to guide us. The panel recommends screening young people for tobacco use - in fact the American Academy of Pediatrics recommends discussing tobacco use with children as young as 5. There is reason to believe that the behavioral interventions that work with adults also will work with young people. Clinicians should screen pediatric and adolescent patients, and their parents, for tobacco use and provide a strong message regarding the importance of totally abstaining from tobacco use. Counseling and behavioral interventions shown to be effective with adults should be considered for use with children and adolescents. The content of these interventions should be modified to be developmentally appropriate. Clinicians in a pediatric setting should offer smoking cessation advice and interventions to parents to limit children’s exposure to second-hand smoke. Thee is a lack of evidence to support using pharmacotherapy with youth.

95 Insurance Coverage for Cessation Medications
Medicaid now covers ALL cessation pharmacotherapy Nicotine patch, gum, lozenge, nasal spray, inhaler Zyban Chantix No Prior Authorization needed Prescription required, even for OTC

96 Counseling Coverage in NC
Medicaid added two CPT codes Jan. 1, 2009 99406 – minutes 99407 – > 10 minutes May be billed the same day as an E/M or Health Check visit Use ICD-9 Code: (tobacco abuse) Unbundled – can use a second ICD-9 code Medicare, BCBSNC, and State Health Plan also reimburse these codes As of Jan 2008 there are two new CPT codes for tobacco cessation counseling. These replace the old G-codes used by Medicare. Not all insurers are reimbursing for these codes at the present time, but Medicare as well as BCBSNC and the SHP are (and Medicaid as of Jan. 2009). An appropriate tobacco-related diagnosis must be submitted along with either CPT code for intermediate counseling of more than 3 but less than 10 minutes, or for intensive counseling that last for more than 10 minutes. These codes are reported in addition to the E&M code for the visit. [ICD-9=Diagnosis code; E/M=Evaluation and Management code; CPT=Current Procedural Terminology code] Jan NC Medicaid Bulletin, CPT Code Update – Medicaid is adding Codes 99406, 99407: In addition to physicians, nurse practitioners, and health departments, these codes can be billed “incident to” the physician by the following professional specialties: licensed psychologists, licensed psychological associates, licensed clinical social workers, licensed professional counselors, licensed marriage and family counselors, certified nurse practitioners, certified clinical nurse specialists, licensed clinical addictions specialists or certified clinical supervisors. Practitioners must continue to follow the guidelines for services provided “incident to” the physician. Refer to the article tiled Modification in Supervision When Practicing “Incident To” a Physician in the October 2008 general Medicaid bulletin (http://www.ncdhhs.gov/dma/bulletin/1008bulletin.htm) for additional information.

97 Who can bill Medicaid? In addition to physicians, nurse practitioners, and health departments, these codes can be billed “incident to” the physician by the following professional specialties: Licensed psychologists and psychological associates Licensed clinical social workers Licensed professional counselors Licensed marriage and family counselors Certified nurse practitioners Certified clinical nurse specialists Licensed clinical addictions specialists or Certified clinical supervisors Practitioners must continue to follow the guidelines for services provided “incident to” the physician.

98 Medicaid Coverage for Treatment
For more information see Medicaid Bulletins: Jan 2009: Oct.2008: `More complete information about counseling coverage can be found in the Medicaid Bulletins, available at these links.

99 More Cessation Counseling Reimbursement Codes
Other codes: ; minutes (dedicated visit) 99354 can be added to regular visit (must document counseling) 99411 is used for group counseling (per participant) MD, PA or FNP on premises, must talk to group RN (etc.) may facilitate session The codes are for different lengths of time of cessation counseling but they can only be used for a visit that is solely dedicated to cessation counseling, so they are not used much.  Most of the time a provider will give cessation counseling when a pt is in clinic for another reason, and in that case the codes can not be used.  The code CAN be used to bill for counseling given at the time a pt comes in for another reason but the provider must document in the chart that cessation counseling was done.  The code is for group counseling.  The provider can use this code to bill for each patient in the group and another provider (RN, etc) can run the group session but the provider must come in for a least a few seconds and say hello, etc. A provider should use the (tobacco abuse) diagnosis code anytime it applies to a pt and especially when the provider has given counseling.  It can be used with other diagnosis codes. 

100 Helpful Web Sites and Links:
The fax form is available on three websites for download: (http://www.quitnownc.org/pdfs/FaxReferral.pdf) This fax form is a pdf but it can be printed out and then you can write the name of your school on the top and use for making copies.

101 Learning More / CE Options
Counseling for Change: An On-line Tobacco Cessation Course - Northwest AHEC Contact Nedra Edwards Hines ; $20 fee for course credits; free to view Medscape: Treating Tobacco Use and Dependence Free Approved for 1hour CE AMA PRA Category 1 Credit(s)™ Requires registration to Medscape TobaccoFreePatients.com Based on NCI educational program Available free for study and review $15 per credit hour / letter of completion Medscape’s Treating Tobacco Use and Dependence – written by Dr. Michael Fiore, chair of clinical practice guidelines of same name. Very good review of 5A’s, etc. TobaccoFreePatients is a comprehensive online training program in how to provide clinical tobacco interventions based on a National Cancer Institute educational program, Help Your Patients Be Tobacco Free (Mecklenburg, 1997). Courses were reviewed by tobacco experts and primary care physicians and feature evidence-based, clinically relevant information, key points, interactive questions, patient handouts, clinical forms, and helpful links. Practicing health professionals may obtain ACCME, ACPE, CAADAC, NASW, NBCC, NYS OASAS , and TCBAPcredit at $15 per credit hour. Other users may obtain a Letter of Completion for $15 per credit hour.

102 Take-Home Message for Health Care Providers
Brief cessation counseling is effective Longer cessation counseling is more effective Pharmacotherapy can double quit rates Pharmacotherapy should be offered to all - few exceptions Evidence-based resources are available As mentioned, health care providers Asking about tobacco use, providing brief advice to quit and referring to the NC Tobacco Use Quitline is an evidence-based intervention that can significantly increase a tobacco user’s chance of quitting for good. Pharmacotherapy can double quit rates and is safe and should be offered to everyone except those in categories mentioned (recent MI, ongoing serious arrhythmias, ongoing chest pain from angina, or pregnant women).

103 You only have two minutes
Ask every everyone about tobacco use Advise to quit with a clear, strong, personalized message Refer to NC Tobacco Use Quitline 1-800-QUIT-NOW ( ) Become An Ex Pharmacotherapy – for most Remember, if you only have two minutes, even a small amount of counseling can be effective in helping tobacco users quit. Longer counseling is even more effective. Ask everyone about their tobacco use, advise them to quit by asking them for reasons why quitting makes sense for them, and refer patients to resources than can help them quit, like the quitline. Prescribe medications to appropriate patients to help them with the addiction of tobacco.

104 Tobacco Prevention and Control Branch Division of Public Health North Carolina Department of Health and Human Services Main Ph: Fax: The Tobacco Prevention and Control Branch has resources available free for download on their website. Please contact us if you need assistance or have questions.


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