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Is Proud to Present our Monthly Webinar Series: Hot Topics in Tobacco Cessation & Secondhand Smoke Exposure Reduction Tuesday, February 5, 2008 12-

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Presentation on theme: "Is Proud to Present our Monthly Webinar Series: Hot Topics in Tobacco Cessation & Secondhand Smoke Exposure Reduction Tuesday, February 5, 2008 12-"— Presentation transcript:

1 Is Proud to Present our Monthly Webinar Series: Hot Topics in Tobacco Cessation & Secondhand Smoke Exposure Reduction Tuesday, February 5, pm MT GoToMeeting: https://www1.gotomeeting.com/register/ Call-in #: passcode: 74375# If you have any technical difficulties, please call Presented by Elizabeth Kraft, MD, MHS with support from:

2 2. www.coloradoguidelines.org/tobacco
3 Things to Remember: Smoking Cessation/Secondhand Smoke Guideline: 1. ASK ADVISE REFER CCGC is your resource for tobacco information: 2. Integrate tobacco cessation into your practice: 3. Call CCGC to schedule a TRIA Call Emma at 303/ or

3 Objectives CCGC/Tobacco Program:
Tobacco Cessation and Secondhand Smoke Exposure Guideline: ASK ADVISE and REFER CCGC tobacco resources Practice redesign: TRIA Hot Topics: Pharmacotherapy update PREP and SNUS Nicotine Vaccine Recruiting for a prenatal tobacco committee Upcoming Webinars Over 50 Organizations are currently members. Organization began 10 years ago with the mission to have one evidenced based guideline for CO practitioners Since, we have recognized and begun to address the most difficult part of a guideline (after we moved past the “cookbook “ medicine push-back form providers)- that is implementation within a practice on a regular consistent basis and then, measurement of both process of integration and the clinical outcomes of implementation

4 Colorado Clinical Guidelines Collaborative (CCGC)
A coalition of health plans, physicians, hospitals, employers and other entities working together to implement systems and use evidence-based guidelines to improve healthcare in Colorado. Clinical Guidelines: Diabetes Depression Screening for Colorectal Cancer Asthma Pediatric and Adult Immunizations Upper Respiratory Infections Gestational Diabetes Obesity CV/Stroke Tobacco Cessation and Secondhand Smoke Exposure Lead Agency for provider education and resource for tobacco cessation Home for a national pilot called IPIP to Improve Performance In primary care Practices Over 50 Organizations are currently members. Organization began 10 years ago with the mission to have one evidenced based guideline for CO practitioners Since, we have recognized and begun to address the most difficult part of a guideline (after we moved past the “cookbook “ medicine push-back form providers)- that is implementation within a practice on a regular consistent basis and then, measurement of both process of integration and the clinical outcomes of implementation 720/

5 17.3% of Coloradans use Tobacco
Tobacco Use in CO Smoking among women declined from 19% to 15% Latino adults vs. Anglo adults (22.8% vs. 15.7%) Adults in poverty (32%) or near poverty (22.6%) vs. others (15.3%) Adults without health insurance (31% vs. 14%) Young adults (18 – 24) 24.5% vs. adults (25 – 64) 17.7% 8.5% of CO women smoke during pregnancy 17.3% of Coloradans use Tobacco

6 The 5As Intervention Model Works
Tobacco dependence and use (current or former) is a chronic relapsing condition that requires repeated interventions and a systematic approach. Integrate interventions for tobacco cessation and secondhand smoke exposure into every interaction with the patient using the 5As approach Utilize a combination of behavioral change coaching (including the Colorado QuitLine) and pharmacotherapy treatments for the highest rates of abstinence success. Exposure to secondhand smoke is a significant health risk to the general public, especially children, and the establishment of smoke-free environments should be encouraged. Evidence shows that patients are more likely to quit when their clinician tells them to- even a two to three minute clinician intervention has been shown to be effective. This is the 3rd iteration of the tobacco guideline We have made changes to reflect the current and forward thinking approaches to tobacco cessation and SHS exposure The committee was comprised of PCPs, SCPs, clinicians, tobacco control experts, public health officials, quality experts Changed the name to: Tobacco Cessation and Secondhand Smoke Exposure Guideline Included secondhand smoke exposure reduction points in each of the 5As Presented the 5A intervention model as a circle to support the chronic relapsing nature of nicotine addiction Included the 2A/1R with Colorado QuitLine in a prominent location Incorporated patient self-management by including “AGREEMENT” within the action steps for providers Updated the pharmacological recommendations and changed format Third hand smoke = toxic N residue on clothing

7 2A/1R: ASK ADVISE REFER

8 1.800.QUIT.NOW 1.800.784.8669 www.coquitline.org
7 days/week Free coaching Free NRT patches x 1 month English, Spanish Special protocols for teens, pregnancy, smokeless 1.800.QUIT.NOW February 2007 QuitLine: 90% enroll when call to QuitLine- esp with NRT 28% were tobacco free for 6 months 36% with NRT were tobacco free for 6 months Fax forms: 30% enroll Best results are when patient is in the contemplative phase- 7 d/week English and Spanish Teens, pregnant and spit protocols March 4 12 – 1 MT Webinar on QuitLine: What Colorado Physicians Need to Know About QuitLine

9 Have Tools Readily Available
Nicotine most addicting substance known to man Smoking sends nicotine to brain within 10 seconds Nicotine…binds to nAChRs (Nicotinic ACh receptors) in the mesolimbic-DA system, particularly in the ventral tegmental and nucleus accumbens areas…releases DA…get a feeling of pleasure Addiction due to rapid onset and pleasurable positive feedback Order free supplies at:

10 www.coloradoguidelines.org/tobacco A Resource for You
Webinar recordings Calendar of events Training request forms Current research Funding opportunities Professional development

11 Question: How Can I Do a Better Job of Tobacco Cessation in My Practice?
“Insanity: Doing the same thing over and over again and expecting different results.” -Albert Einstein So, we know how important smoking cessation and reduction of SHS exposure is. We know nicotine addiction is very powerful. We know that applying the 5As (or 2A/1R) works, we know pharmacotherapy increases quit success, we know having tools such as patient information and referring to the QL work. We know that doing this through a systematic sustainable process works. So, with all this that we know how do we make it happen in your practice for your patients?

12 Answer: Practice redesign with tobacco cessation guideline integration as the process
Apply these systems changes to other chronic conditions Diabetes Obesity Tobacco Cessation Vision: Optimum care for every patient, every time! It is not a matter of knowledge or desire, but lack of systems and infrastructure. CCGC can help you redesign your office processes to integrate the tobacco guideline in a fun and effective manner- without having to add soemthing to your plate to do. We can show you with tobacco and then, you can begin to address other chronic illnesses in the same fashio.

13 Tobacco Rapid Improvement Activity (TRIA)
Integrate Tobacco Cessation into YOUR Office: Tobacco Rapid Improvement Activity (TRIA) Process: Use the tobacco cessation/SHS guideline: 2A/1R Lunch session with entire office staff: “TRIA” exercise Why tobacco cessation is important for your practice Brainstorm implementation goals for each team staff member Make changes after each patient Tobacco Rapid Improvement Activity: Integrating Tobacco Cessation into Your Clinical Practice You Can Be the Difference! TRIA = introduction to practice redesign by use of a rapid cycle improvement activity/exercise focused on the integration of the tobacco cessation guidelines and the 2A/1R 92% of participants reported receiving helpful tools & ideas to make changes in their practice 93% of practices have made at least one change to daily processes

14 Tobacco Rapid Improvement Activity (TRIA)
View a video simulation of a Tobacco Rapid Improvement Activity (TRIA)

15 Hot Topic: Pharmacotherapy
What really works, how do we prescribe, and what should we be looking for? What is the buzz about Chantix? It is recommended by the national PHS guideline to offer pharmacotherapy support, if there are no contraindications, as integral to tobacco cessation efforts. May – 1 MT Webinar: Pharmacotherapy for Tobacco Cessation: Treatment Update & Clinical Pearls

16 Pharmacotherapy Doubles cessation rates Can use >1 NRT
Additive therapies Long term usage Tailor to your patient Nicotine most addicting substance known to man Smoking sends nicotine to brain within 10 seconds Nicotine…binds to nAChRs (Nicotinic ACh receptors) in the mesolimbic-DA system, particularly in the ventral tegmental and nucleus accumbens areas…releases DA…get a feeling of pleasure Addiction due to rapid onset and pleasurable positive feedback

17 % Quit Rates at 6 Months Additive therapies increase quit rates
Graph explanation: These are 6 month quit rates (except for quitline and patch + spray = 3 month quit rates) Only 3% able to quit on own Clinician advice to quit: increases quit rates by 10% 3-10 minute counseling: 16% Pharmacologic treatment: % Telephone counseling: 23% long-term quit rates in CO; With patch 43% Additive therapies increase quit rates Key Points: A clinician, just by telling a patient to quit, can increase quit rates by 10% over baseline. For every 10 patients you tell to quit, only one will do it, and that is a success! As clinicians, we are used to better success rates than 1 out of 10, and that’s one of the major reasons docs give up on tobacco cessation counseling. If you take only one thing away from this presentation, its DON”T GIVE UP! You are the best chance your patient has to quit. Managing withdrawal WE ARE GOING TO TOUCH ON EACH AND THE RESOURCES YOU HAVE AT HAND Am Fam Phys July 2006 page 263; JAMA July 2006

18 Recent Headlines “Is Stopping Smoking a Suicide Risk?”
“Chantix Suicidal Ideation Reports Doubled in 2 Months” “Girlfriend Believes Chantix contributed to Texas Musician’s Death” 1

19 Chantix: Update Chantix pharmacology: Chantix labeling update:
Selective nicotinic 4 β2 receptor partial agonist. Results in 30% less DA release than nicotine (lower craving) + antagonistic action that blocks reward properties (decrease satisfaction) Chantix labeling update: In January 2008, the CHANTIX product insert was updated to include a warning that patients who are attempting to quit smoking with CHANTIX should be observed for serious neuropsychiatric symptoms, including changes in behavior, agitation, depressed mood, suicidal ideation and suicidal behavior. What should I be doing with this new information? Observe all patients, including Chantix patients, for potential neuropsychiatric symptoms while trying to quit. Monitor frequently. Discuss risks of smoking, benefits of quitting, withdrawal symptoms, strategies to deal with withdrawal, support options (such as the QuitLine), & other pharmacotherapy options. Chantix + bupropion- no contraindications NRT- male > female Chantix- male = female response No studies in smokeless • See patient 1 to 3 days after he or she initiates smoking cessation • Monitor weekly for the 1st four weeks for signs of psychotic relapse, onset of depressive illness or increased depressive symptoms, and for the need to change medication levels • After 1st month, continue monitoring monthly for 6 months • Communication between the primary care provider and mental health provider should occur during cessation initiation and during the cessation period if any psychiatric complications occur. [1] Strasser, K., Moeller-Saxone, K., Hocking, B., Stanton, J., & Kee, P (2002). Smoking cessation in schizophrenia. General practice guidelines. Australian Family Physician, 31, [2] Provincial Health Services.(2006). Tobacco reduction in the context of mental illness and addictions: A review of the evidence. Centre for Addiction Research of British Columbia. Clinical Monitoring Recommendations1,2 Tobacco & Medication Metabolism • Smoking induces CYP1A2 isoenzyme • Approximately doubles clearance of: Antipsychotics: fluphenazine, haloperidol, olanzapine, clozapine, chlorpromazine Antidepressants: amitriptyline, nortriptyline, imipramine, clomipramine, doxepin, fluvoxamine • Cessation may produce rapid, significant increase in blood levels • Monitor for side effects, weight gain

20 SNUS/SLT/PREP- the Next Generation of Tobacco Products
Hot Topic: SNUS/SLT/PREP- the Next Generation of Tobacco Products What is PREP, SLT and SNUS? PREP = potentially reduced exposure products (SNUS, snuff, lozenges) SNUS = “snuff” in Sweden; fine moist pasteurized smokeless spitless tobacco; teabag-like pouches; SLT = smokeless tobacco SNUS = Snuff (Swedish term = SNUS). Smokeless spitless tobacco a Swedish type of smokeless tobacco that's not your grandfather's dip or chew ( Dip is fermented < less starch and more sugars + carcinogens> vs. pasteurized (kills bacteria, less salt)) . Snus comes in teabag-like pouches that a user sticks between the upper lip and gum, leaves there for up to 30 minutes and discards without spitting. Chewing tobacco: loose-leaf, plug, twist Snuff: moist dry or packets Familiar branding, new attractive packaging, “pleasure for wherever”; instead of a smoke, tuck a Taboka”, no smoke, no spit, no hassle”; Cig-like PREP: Accord, Advance, Exlipse, Fact, Quest Oral PREPs- Ariva, SNUS, Exalt, Koal Dry Oral PREPs for smokeless uses: Bacc-off, snus, stonewall N delivery systems: Njoy, NicStic, Aeros Hx: filters (KENT made with asbestos), low tar, Now: Smoke: advanced filters (ECLIPSE still with fiberglass), chips in Accord to allow 8 deep puffs, heat no burn oral- SNUS, cigaletts (ARIVA)

21 Harm Reduction vs. Exposure Reduction
Harm reduction – reduction in amount of tobacco related morbidity and mortality even with continued exposure to tobacco-related toxicants Exposure reduction- intervention designed to lessen intake of tobacco delivered toxicants National Guideline does not support harm reduction FDA does not regulate toxicant levels (as in Sweden) in SLT Data not clear and conflicting Nicotine still addictive SLT toxicants still harmful: Pancreatic cancer, metabolic effects (metabolic syndrome, fetal toxicity, unclear cardiac) & oral pathology Both harm and exposure reduction have had a critical roles in minimizing tobacco caused morb and mort in the 21st century- growing literature Exposure reduction- intervention designed to lessen intake of tobacco delivered toxicants: N or its metabolite cotinine (relevant to dependence) reduced CO (relevant to CV disease) Carcinogens/carcinogen metabolites (relevant to cancer) Data not clear: decrease lung CA in Sweden but no change in Norway TSNA (tobacco specific nitrosamines): *NNK is 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (toxicant) indexed as NNAL (carcinogen) 20 fold range of levels in moist snuff Heat and aging increases TSNA and therefore, see it refrigerated. Vs NRT_ FDA intentionally makes it slow release for QUIT and SLT is nt the bridge (N levels not reportable) ScienceDaily (May 11, 2007) — People who use Swedish moist snuff (snus) run twice the risk of developing cancer of the pancreas. This is the main result of a follow-up study conducted by Karolinska Institutet researchers amongst almost 300,000 male construction workers. The study is published online in the medical journal The Lancet. The debate on whether the net effect of snus is positive or negative has been raging for many years. Some scientists and health carers have advocated the use of snus, as it is likely to lead to that people will smoke less. However, Professor Nyrén argues that it is important to have all the facts on the table before any advice can be given about snus as a way to cut down on smoking. "We don't only need reliable and accurate measures of the risks of both smoking and taking snus, we also need know the effects of other, alternative methods to cut smoking. We also have to be certain that an increase in snus marketing will not cause addictions in young people who otherwise wouldn't have started to smoke," he says. Article: "Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung and pancreas in male construction workers; a retrospective cohort study" Authors: Juhua Luo, Weimin Ye, Kazem Zendehdel, Johanna Adami, Hans-Olov Adami, Paolo Boffetto, Olof Nyrén The Lancet, online, 10 May 2007

22 Hot Topic: Nicotine Vaccine
Nicotine is not immunogenic Vaccine makes antibodies against nicotine Antibody is a large protein that binds to nicotine, making it unable to reach brain Linked to a viral base particle that will give mild viral syndrome (70%) Currently, 3 vaccines being tested: NABI - 2 vaccinations with 2 boosters 25% stop smoking TA-Nic- good efficacy (25% at 1 year); phase 3 CYTOS – lots of side effects, phase 2, 9% improvement vs. placebo Antibody holds drug in blood stream NABI- N antibody not as efficient and that is why need boosters CYTOS – lots of side effects (injection site reactions, flu like symptoms), phase 2, 9% improvement vs. placebo XENOVA product = TA-Nic Females are less of an antibody generators than males

23 Prenatal Tobacco Advisory Committee
Prenatal tobacco use one of top reasons for low birth weight CCGC tobacco team is putting together an advisory committee If you have an interest or know of a provider who might be interested, please contact Emma at CCGC: 303/ or Antibody holds drug in blood stream NABI- N antibody not as efficient and that is why need boosters CYTOS – lots of side effects (injection site reactions, flu like symptoms), phase 2, 9% improvement vs. placebo XENOVA product = TA-Nic Females are less of an antibody generators than males

24 National Tobacco Guideline
First update since 2000 Will update 11 specific areas with evidence-based information CCGC asked to be a peer reviewer Anticipate release this Spring

25 CCGC Tobacco Webinars: Mark Your Calendar
All webinars from 12-1 pm Mar. 4, 2008: What Colorado Physicians Need to Know about the QuitLine, presented by Dr. David Tinkelman Mar. 18, 2008: Clinical Practice Grant Opportunities Apr. 1, 2008: Tobacco Cessation for Persons with Mental Illnesses: Primary Care Strategies, presented by Drs. Jeanette Waxmonsky & Alexis Giese Apr. 15, 2008: Stages of Change & Motivational Interviewing with Clinical Populations, presented by Dr. Heather LaChance May 20, 2008: Pharmacotherapy for Tobacco Cessation: Treatment Update and Clinical Pearls, presented by Laura Hansen, RPA For more information on each webinar visit and click on “Professional Development.”

26 Visit: www. coloradoguidelines. org/tobacco Questions
Visit: Questions? For a TRIA, contact: Emma at 303/ or 28

27 Thank you for your time


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