12 Tobacco Use and Your Patient Donald Shell, M.D., MAInterim DirectorCenter for Health Promotion EducationAnd Tobacco Use PreventionDepartment of Health and Mental Hygiene
13 Tobacco Use and Your Patient Multiple Surgeon General’s reports (2004, 2006, 2010) have established long list of health consequences and diseases caused by tobacco use and exposure to tobacco smokeThis presentation will:Review the biological and behavioral mechanisms that may underlie the pathogenicity of tobacco smokeReview the health consequences caused by exposure to tobacco smokeNot review evidence on the mechanism of how smokeless tobacco causes disease (future webinar)
14 Quitting Will Save Your Patients’ Lives Tobacco UseRemains the leading preventable cause of death and disease in the United States.Recent studies show that brief advice from a clinician about smoking cessation yielded a 66% increase in successful quit rates.Tell your patient that quitting smoking is the most important step they can take to improve their health. They will listen to you.
15 Tobacco Use - Single Largest Preventable Cause of Death and Disease in the US Health consequences of tobacco useHeart diseaseMultiple types of cancerPulmonary diseaseAdverse reproductive effectChronic health conditions443,000 Americans die each yearSmoking costs US $193 billion in medical expenses & lost productivity
16 Health Consequences Causally Linked to Smoking Chronic DiseasesStrokeBlindness, cataractsPeriodontitisAortic aneurysmCoronary heart diseasePneumoniaAtherosclerotic peripheral vascular diseaseChronic obstructive pulmonary disease, asthma, and other respiratory effectsHip fracturesReproductive effects in women (including reduced fertility)
17 Health Consequences Causally Linked to Smoking CancersOropharynxLarynxEsophagusTrachea, bronchus, and lungAcute myeloid leukemiaStomach, Pancreas, Kidney and ureterCervix, Bladder
18 Health Consequences Causally Linked to Exposure to Secondhand Smoke ChildrenMiddle ear diseaseRespiratory symptoms, impaired lung functionLower respiratory illnessSudden infant death syndromeAdultsNasal irritationLung cancerCoronary heart diseaseReproductive effects in women: low birth weight
19 Tobacco Mechanisms of Disease Production There is no risk free level of exposure to tobacco smokeInhalation of tobacco smokes complex chemical mixture of combustion compounds causes adverse health outcomes through:DNA damageInflammationOxidative stressRisk and severity directly related to duration and level of exposure
20 Tobacco Mechanisms of Disease Production Insufficient evidence that product modification strategies to lower toxicant emissions in tobacco:Reduce risk for major adverse health outcomesSustained use and long term exposure to tobacco smoke:Mediated by diverse actions of nicotine at multiple nicotinic receptors in the brainPowerfully addictive
21 Tobacco and Cancer Mechanisms of Disease Production Carcinogen exposure and resultant DNA damage in smokers direct result of numerous cytogenetic changes present in lung cancerMutations in TP53 and KRAS in lung cancerPromoter methylation of key tumor suppressor genes such as P16 in smoking-caused cancersNicotine and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone activate signal transductionReceptor mediated eventsAllow survival of damaged epithelial cells that would normally die
22 Tobacco and Cancer Mechanisms of Disease Production Metabolic activation of cigarette smoke carcinogens by cytochrome P-450 enzymes has a direct effect on the formation of DNA adductsConsistent evidence for an inherited susceptibility of lung cancerSome less common genotypes are unrelated to familial clustering of smoking behaviorsSmoking cessation is the only proven strategy to reduce the pathogenic process leading to cancer
23 Tobacco and Cardiovascular Mechanisms of Disease Production Nonlinear dose response between tobacco smoke exposure and cardiovascular riskSharp increase at low levels of exposureInfrequent smoking or 2nd hand smoke exposureCigarette smoking:Leads to coronary and peripheral artery endothelial dysfunction resulting fromOxidizing chemicals and nicotine in tobacco smoke
24 Implicated in acute cardiovascular events and thrombosis Low levels of exposure (including 2nd hand smoke) lead to a rapid and sharp increase in endothelial dysfunction and inflammationImplicated in acute cardiovascular events and thrombosis
25 Tobacco and Cardiovascular Mechanisms of Disease Production Cigarette smoking produces:Chronic inflammationContributes to atherogenic disease processesElevates levels of biomarkers of inflammationPredictors of cardiovascular eventsAtherogenic lipid profilePrimarily due to an increase in triglycerides and a decrease in high-density lipoprotein cholesterolInsulin resistance and chronic inflammationAccelerates macrovascular and microvascular complications including nephropathy
26 Tobacco and Cardiovascular Mechanisms of Disease Production Smoking Reduction:Smoking fewer cigarettes per day does not reduce the risk of cardiovascular diseaseSmoking cessation:Reduces the risk of cardiovascular morbidity and mortality for smokers with or without coronary heart diseaseFacilitated by the use of nicotine or other medications in patients with known cardiovascular diseaseProduces far less cardiovascular risk that the risk of continued smoking
27 Tobacco and Pulmonary Mechanisms of Disease Production COPDOxidative stress from tobacco smoke exposure has a role in the pathogenic processInherited genetic variations in genes such as SER-PINA3 is involved in pathogenesisProtease-antiprotease imbalance has a role in the pathogenesis of emphysemaSmoking cessation is the only proven strategy for reducing the pathogenic process leading to COPD
28 Tobacco Reproductive and Developmental Mechanisms of Disease Production Consistent Evidence:Smoking in men linked to chromosome changes or DNA damage in sperm (germ cells)Affecting male fertility, pregnancy viability, offspring anomaliesAssociation of periconceptional smoking to cleft lip with or without cleft palateGenetic polymorphisms (i.e. transforming growth factor-alpha) modify risk of oral cleftingSmoking in women:Increased FSH and decreased estrogen and progesterone levels (nicotine endocrine effects)Diminished oviductal functioning (impaired fertility)
29 Tobacco Reproductive and Developmental Mechanisms of Disease Production Consistent Evidence That Maternal Smoking:Transiently increases maternal heart rate, BP (diastolic) by norepinephrine and epinephrine releaseInterferes with physiological transformation of spiral arteries and thickening of the villous membrane in the forming placentaFetal loss, preterm delivery, low birth weight
30 Tobacco Reproductive and Developmental Mechanisms of Disease Production Consistent Evidence That Maternal Smoking:Histopathologic changes in the fetusPrimarily in the brain and lungAdverse impact on a variety of reproductive endpoints from polycystic aromatic hydrocarbonsImmunosuppressive (dysregulated inflammatory response)Lead to miscarriage and preterm delivery
31 Tobacco Reproductive and Developmental Mechanisms of Disease Production Consistent Evidence Links:Carbon monoxide to birth weight and neurological (cognitive and neurobehavioral endpoint) deficitsPrenatal smoke exposure and genetic variation in metabolizing enzymes such as GSTT1 with increased risk of adverse pregnancy outcomeslowered birth weight and reduced gestation
32 Summary Tobacco Mechanisms of Disease Smoking cessation:The only proven strategy to reduce the pathogenic process leading to cancerreduces the risk of cardiovascular morbidity and mortality for smokers with or without coronary heart diseasethe only proven strategy for reducing the pathogenic process leading to COPDUse of nicotine or other medications in patients with known cardiovascular disease produces far less cardiovascular risk than continued smoking
33 Tobacco Use and Your Patient Donald Shell, M.D., MAInterim DirectorCenter for Health Promotion, EducationAnd Tobacco Use PreventionDepartment of Health and Mental Hygiene300 W. Preston Street, Suite 410Baltimore, MD 21201(410)
34 Brief Intervention and the 5 A’s: Helping Patients Quit TobaccoDr. Carlo DiClemente Director, MDQuit Resource CenterSponsored byMaryland Department of Health and Mental HygieneandUniversity of Maryland Baltimore County
36 Brief Intervention and the 5 A’s: Helping Patients Quit TobaccoDr. Carlo DiClemente Director, MDQuit Resource CenterSponsored byMaryland Department of Health and Mental HygieneandUniversity of Maryland Baltimore County
37 What is ?Resource center for tobacco use cessation and prevention for the State of Maryland.Funded by the Maryland Department of Health and Mental Hygiene (DHMH).Located on the campus of the University of Maryland, Baltimore County (UMBC).Dedicated to assisting providers and programs in reducing tobacco use among citizens across the state utilizing best practices strategies.
38 The Big Picture – 2007 There are 90.7 million ever smokers in the U.S. Over 52% of these are now former smokersPrevalence has dropped from 42% in 1965 to 19.8% in 200743.4 million people are still smoking the U.S. (19.8% of adults)77.8 % of smokers smoke every day38.4% stopped smoking for one day in the past year because they were trying to quitAn ever smoker is one that has had 100 or more cigarettes in their lifetime.20% smoke some days3838
39 The Smoker’s Journey Social pressure Policy Products & Services Price SupportSmokingInNetworkPromotionLongTermSuccessTobaccoAdvertisingSatisfiedDependentor CasualSmokerChoosingA MethodNRT, TX, Cold Turkey,QuitlineDissatisfied but ambivalentDecided toMake a QuitAttemptQuitAttemptShortTermSuccessPersonalConcernsSpecialEventsRelapseAndRecyclingPsychiatricConditionsAnd OtherLife ProblemsQuittingHistoryBeliefs& Myths
40 Stages of Change for Smoking Cessation: 2008 MATS Precontemplation: Current smokers who are not planning on quitting smoking in the next 6 monthsContemplation: Current smokers who are planning on quitting smoking in the next 6 months but have not made a quit attempt in the past yearPreparation: Current smokers who are definitely planning to quit within next 30 days and have made a quit attempt in the past yearAction: Individuals who are not currently smoking and have stopped smoking within the past 6 monthsMaintenance: Individuals who are not currently smoking and have stopped smoking for longer than 6 months but less than 5 yearsDiClemente, 200340
41 Changes with 2008Note: includes ever-smokers (100+ cigarettes in lifetime) who are current smokers or former smokers (including those who have quit for 5+ years)
44 Physician Brief Intervention is a Best Practice “All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates.”“Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates.”“Every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to intensive intervention.”Recommendations with Strength of Evidence = AFiore et al. (2008). Treating Tobacco Use and Dependence: Clinical Practice Guideline 2008 Update.
45 Doctors Helping Smokers: Myths and Realities Thought of as…But actually…Patientan individual lacking in knowledge about the harmful effects of smoking who would quit if he or she were aware of these factsknows about the harmsprobably would like to quithas a 40-percent probability of trying to quit in a given yearis unlikely to remain abstinent after any single attemptProvideran autonomous individual who would try to convince the smoker to quit if he or she were aware of the harmful effects of smokingaware of the harmful effectshas misconceptions about how to help smokers quitlacks the resources to identify the smokers who want to quit and provide them with helpexperiences intense competition for timeSettingdesigned to help the physician meet the demands of the patient for acute careoffers little support to the physician who would like to help patients stop smokingDoctors Helping Smokers was designed to be an interdisciplinary clinic-based program that sought to help at each level:Patient: (1) identified all smokers but focused on providing help to the smokers who wanted to quit smoking, were trying to quit smoking, or who had recently quit smoking.Provider: (2) conceived of the physician as an individual who is highly dependent on office staff for support and, therefore, involved the entire office staff in the effort to identify smokers, advise them to quit, and provide them with the help they might want or need in the smoking cessation effort.Setting: (3) provided a clinic environment that cued the staff to act and reinforced them when they did act.Through the program, they found that in a group of nonvolunteer clinics, that at least some clinics can be recruited to adopt the program described above and that this adoption, even at incomplete levels, results in significant increases in the rates at which smokers are identified, advised to quit, and reinforced in their quit attempts. This type of process does not need to be done as an entire program, however…Kottke et al., 1994 (NCI)45
46 Brief Intervention for Tobacco: Goals Focus on supporting quit attempts based on the extent to which a patient is:ReadyWillingAbleProvide the patient with feedback and assistance that meets his/her current needs.AbilitiesWillingnessReadinessx
47 Treating Tobacco Using the 5 A’s Current UserNo Current UseReady to QuitYesNo
48 The “5 A’s” For Brief Intervention ASK about tobacco use(<1 minute)Identify and document tobacco use for EVERY patient at EVERY visit.ADVISE to quit smoking(< 30 seconds)In a clear, strong, personalized manner, urge EVERY user to quit.ASSESS willingness to make a quit attempt (<1-2 minutes)Is the tobacco user willing to make a quit attempt at this time?ASSIST in quit attempt(<1-3 minutes)Give all patients a brochure. For the patient willing to make a quit attempt, provide pharmacotherapy and counseling if possible.ARRANGE follow-upSchedule follow-up contact, preferably within first week after the quit date.48
49 1. ASK: about tobacco use every time Implement a standard system to ensure that for every patient at every visit, tobacco use is queried and documented.Some settings expand the vital signs to include tobacco use, viewing it as equally important as taking a patient’s blood pressure or asking about current symptoms.Ask patients:Have you smoked a cigarette, even a puff, in the past 30 days?On average, how many cigarettes do you smoke per day?How long have you been smoking at that rate?A person’s smoking status and readiness to make a quit attempt can change across visits.
50 2. ADVISE: Urge ALL tobacco users to quit Provide Clear, Concise, Strong and Personalized Advice:As your physician, I recommend that you quit using tobacco. The clinic staff and I will help you.As your smoking has increased, your breathing has worsened. Right now, quitting smoking is the best thing you can do for your health.Expect ambivalence. Be willing to listen non-judgmentally to patient concerns. Ask:What do you make of this advice?
51 3. ASSESS: Current willingness to make a quit attempt Talk to each tobacco user about his/her readiness to make a quit attempt.A ‘Readiness Ruler’ is a helpful tool that allows you to emphasize the patient’s existing motivation to quit. Ask:On a scale of 1 to 10, with 10 being very ready, how ready are you to quit smoking?What makes you a  and not a lower number?For the Less ReadyThe 5 R’s:RelevanceRisksRewardsRoadblocksRepetitionFor patients with low readiness, additional strategies help to enhance motivation, including the use of open-ended questions, expressing empathy, discuss the 5 R’s and managing resistance through reflective listening. With practice, these skills improve.For patients with low readiness, discussion of the 5 R’s can help address concerns and enhance motivation.51
52 Readiness Ruler I don’t want to quit. Tobacco is not a problem for me. 13452768109Low ReadinessModerate ReadinessHigh ReadinessI don’t want to quit.Tobacco is not a problem for me.Trying to quit would be a waste of my time.I am thinking about quitting.I know that quitting would be good for my health.I am interested in hearing about ways to quit.I am ready to quit using tobacco.I would like help to quit using tobacco.Another way to think about readiness is on a scale of 1-10.Use this ruler to think about how ready you are to quit.Take a moment now to rate yourself on this scale of 1-10.Some of the thoughts that go along with these numbers are below the ruler….This ruler is available for download at: mdquit.org/fax-to-assist/module-252
53 4. ASSIST: Provide help for a successful quit attempt Offer an array of effective treatment options:Free telephone counseling through the Maryland QuitlineSmoking cessation groupsLocal health department resourcesPharmacotherapy and NRT (when medically advisable - consider pregnancy, other medications, allergies, etc.)Help the client set a personal quit date.
54 5. ARRANGE: Schedule follow-up contact Follow-up contact (in-person or by phone) is most helpful within the first few weeks of the quit date and again at the next appointment.Congratulate successes and address challenges.Treat continued tobacco use as a chronic illness. Repeat follow-up supports change.Consider referrals to more intensive treatment, especially for special populations like pregnant women and individuals with mental illness.
55 Pharmacotherapy for Smoking Cessation All patients attempting to quit should be encouraged to use pharmacotherapy with special attention to smokers who may:Medical contraindicationsSmoking fewer than 10 cigarettes/dayPregnant/breastfeeding womenAdolescentsMany patients will be unsure about using medications/NRT. Keep the option for medication/NRT use open and have these tools available if and when a patient is willing to try them.55
56 Pharmacotherapy Options Nicotine replacementOTC: Nicorette, nicotine gum, Commit Lozenge, Habitrol, Nicoderm CQ, Nicotrol, Nicotine Transdermal SystemPrescription: Nicotrol Inhaler, Nicotrol NS Nasal SprayBupropion SR (Zyban): works through dopamine as an agonist (same formula as Wellbutrin)Varenicline (Chantix): partial agonist at the α4β2 nicotinic acetylcholine receptor; may relieve nicotine withdrawal and cigarette craving, and block nicotine’s reinforcing effects56
57 The Maryland Tobacco Quitline Service provided by Free & Clear Inc.Free reactive and proactive phone counseling servicesQuit CoachesTM - Trained specialistsProvides individually-tailored quit plansReferral to local county resources – cessation classes, in-person counseling and free medicationOperational seven days a week - 8:00am to 3:00 amFree NRT (the patch or gum) 4 week supplyFree & Clear is a nationally recognized leader in the field of tobacco cessation.Their program is consistently recognized by the CDC and Robert Wood Johnson Foundation as a model tobacco cessation program.They have over 225 clients, 28 of which are state health depts. Some corporate clients include Campbell’s and Whirlpool.Free reactive and proactive phone counseling services are available for all Marylanders.Provide individually-tailored quit plans.Quit Coaches are Master-level and trained in cessation treatmentProfessionals in Psychology, Counseling, Other healthcare fields - Many are ex-smokersProvide referrals to local resources for more information and for NRT (also referred to insurers for NRT)Quitline hours of operation: Seven days a week, 8am – 3amSpanish speaking Quit Coaches are available during hours of operation.57
58 Fax Referral Program “Fax to Assist”- launched Dec. 2006 by On-line training & certification for HIPAA-covered entitiesProviders can refer their patients or clients (who wish to quit, preferably within 30 days) to the Maryland Tobacco QuitlineTobacco users will sign the Fax Referral enrollment form during a face-to-face intervention with a provider(e.g., at a doctor's office, hospital, dentist's office, clinic or agency site)The provider will then fax the form to the QuitlineWithin 48 hours, a Quit Coach™ makes the initial call to the tobacco user to begin the coaching process
60 Fax to Assist Provider Kits When you complete the certification quiz, MDQuit will send you:Training CD-Rom with all 4 Modules5A’s Clipboard5A’s MousepadMDQuit ink pen
61 Quitline Satisfaction and Quit Rates Year 4 Evaluation
62 Cyclical Model for Intervention Most smokers will recycle through multiple quit attempts and multiple interventions.However, successful cessation occurs for large numbers of smokers over time.Keys to successful recyclingPersistent effortsRepeated contactsHelping the smoker take the next stepBolster self-efficacy and motivationMatch strategy to patient stage of change62
63 Brief Intervention for Tobacco: Private Payer Benefits HCPCS/CPT Codes:99406: Smoking and tobacco-use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes. Short descriptor: Smoke/Tobacco counseling 3-10: Preventive medicine services: Health & Behavior Assessment/Intervention (Non-physician only)Private payer benefits are subject to specific plan policies. Before providing service, benefit eligibility and payer coding requirements should be verified.AAFP, 2011
64 Brief Intervention for Tobacco: Cost-effectiveness Tobacco interventions from brief clinician advice to specialized treatment are highly cost-effective (Strength of Evidence = A)Evidence-based tobacco use interventions compare well with other prevention and chronic disease interventions.Counseling about smoking cessation was found to be more cost-effective than treatment of moderate hypertension or hypercholesterolemia and as effective as mammography.Cost per year of life saved estimated at $3,539.(TTUD, 2008; Cummings et al., 1989, NCI (1994) monograph, p. 110)
65 Strategies for Increasing Cessation Know the SmokerUnderstand the Cessation JourneyTreat the Smoker as a ConsumerCreate a continuum of careDevelop collaborations and create synergyTake advantage of opportunities
66 Contact Us MDQuit Resource Center UMBC Psychology 1000 Hilltop Circle, Baltimore, MD 21250(410)
67 ReferencesAmerican Academy of Family Physicians (2011). HCPCS, CPT, & ICD-9 Codes Related to Tobacco Cessation Counseling. Retrieved on September 13, 2011 fromCromwell J, Bartosch WJ, Fiore MC, et al. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. JAMA 1997;278:Cummings, S.R.; Rubin, S.M.; Oster, G. The cost-effectiveness of counseling smokers to quit. JAMA, 1989, 261,Fiore, M.C., Jaen, C.R., Baker, T.B., et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.Kottke, T. E., Solberg, L. I., Brekke, M. L., Conn, S. A., Maxwell, C., & Brekke, M. J. (1994). In National Cancer Institute, Tobacco and the clinician: interventions for medical and dental practice. Monograph No. 5. NIH Publication No , pp