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

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

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

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

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

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

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

Change the system to identify and document tobacco use status

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

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

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

Counseling and brief interventions

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

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

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

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

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

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

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

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

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

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

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

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

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

Pharmacotherapy

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

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

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

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

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

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

Nicotine gum $3.28 - $6.57 per day for 2mg $4.31 - $6.51 per day for 4mg Weeks 1-6: one every 1-2 hours Weeks 7-9: one every 2-4 hours Weeks 10-12: one every 4-8 hours Common side effects are jaw pain and mouth soreness

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Getting Paid

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

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

Medicare CPT codes 99406: 3-10 minutes 99407: More than 10 minutes Report 305.1 Tobacco use disorder and related condition or interference with the effectiveness of medications.

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

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

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

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

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