Tobacco Cessation Strategies and Resources: Epidemiology, Evidence and Availability May 29, 2013 The National Tobacco-Free College Campus Initiative: Building and Supporting Community Health on Campus Michael C. Fiore, MD, MPH, MBA Professor of Medicine Director, Center for Tobacco Research & Intervention University of Wisconsin School of Medicine and Public Health 1

Today’s Talk The Epidemiology of Tobacco Use and Cessation Tobacco Cessation Treatments – What the Science Tells Us Tobacco-Free Campuses – An Opportunity to Promote Cessation 2

Today’s Talk The Epidemiology of Tobacco Use and Cessation Tobacco Cessation Treatments – What the Science Tells Us Tobacco-Free Campuses – An Opportunity to Promote Cessation 3

Smoking Prevalence Among Adults 18 and Older, United States, Source: NHIS 2011 = 18.9% 4

― The Poor ― The least educated ― Those with co-morbid mental health or addictive disorders ― Certain/Specific racial and ethnic minorities: e.g.: Native Americans Four Populations in Particular Continue to Smoke at High Rates:

Smoking Rates by Education Source: National Health Interview Survey, United States—

Smoking Rates by Poverty Status Source: National Health Interview Survey, United States—

Chronic Illnesses Tobacco directly causes:  30% of all cancers, including 90% of all lung cancers  30% of all cardiovascular diseases  90% of all COPD

The Result More than 400,000 deaths each year 1 out of every 5 deaths in America are directly caused by smoking

Acute Diseases In addition to chronic illnesses, tobacco is also a cause of acute illnesses:  Upper and lower respiratory tract infections  Asthmatic exacerbations 11

Epidemiology of Cessation 47 million adults in the U.S. continue to smoke Of those 47 million, almost 40 million report they have tried to quit and have failed About 50% of smokers try to quit each year Most try to quit “cold turkey,” with less than 25% using evidence-based treatment Young and poor smokers are less likely to use evidence based treatments

Economic Costs  $100 billion in added healthcare costs  $100 billion in lost productivity The Average Smoker costs  $1,600/year more in healthcare costs than the average non-smoker The Average Smoker ―takes 2 extra sick days/year ―is 8% less productive ―spends 30 minutes per work shift on smoking rituals

Today’s Talk The Epidemiology of Tobacco Use and Cessation Tobacco Cessation Treatments – What the Science Tells Us Tobacco-Free Campuses – An Opportunity to Promote Cessation 14

Treating Tobacco Use and Dependence: The Clinician’s Role 70% of smokers report that they want to quit About 80% see a clinician each year Only about 25% of those seeing a clinician leave that visit with evidence- based counseling and/or medication

PHS Guideline evidence-based treatments  Counseling  Medications  Health System Changes Updated Guideline published Literature from1975 – 2007 Approximately 8,700 total articles The Guideline

Key Findings Effective Tobacco Dependence Treatments Consist of: Brief clinician coaching/counseling One of the 7 FDA Approved medications Systems-level changes that institutionalize cessation treatment

The 5 A’s for Patients Willing to Quit ASK all patients about their tobacco use ADVISE all smokers to quit ASSESS willingness to make a quit attempt ASSIST in quitting attempt (counseling & meds) ARRANGE for follow-up

Counseling: 5 Key Points for the Smoker Willing to Make a Quit Attempt 1.Set a quit date 2.Review past quit experience 3.Anticipate challenges to the upcoming quit attempt 4.Other smokers in the household 5.Alcohol

Medications Seven FDA-Approved Medications for Tobacco Dependence 1.Bupropion SR 2.Nicotine gum 3.Nicotine inhaler 4.Nicotine nasal spray 5.Nicotine patch 6.Nicotine lozenge 7.Varenicline Cessation medications have been shown to double or even triple quit rates

Motivational Interventions 1.For smokers not yet ready to quit 2.Interventions that increase quit attempts and success

Motivational Interviewing (MI) Elements Express Empathy  Express empathy Open-ended questions: “What might happen if you try to quit?” Reflect back meaning: “I hear that you are worried about weight gain.” Highlight Discrepancy  Show discrepancy between behavior & goals: “So, you worry about hurting your kids’ health, but can’t seem to stop smoking?” “You really want to quit, but don’t want to gain weight.”  Support change talk : “I can see you are already planning how you will quit”

MI Elements (cont.) Roll with Resistance  Back off: “OK, I hear that this is not the right time for you.” “Well, is there any treatment that might help?”  Capture ambivalence: “Part of you wants to quit, but part is afraid to try.”  Ask permission to help Support Self-Efficacy  Build on past success: “You were able to quit for several weeks last time. That shows you have the skills to quit.”  Be open to the patient’s preferences/desires

Systems Level Change

Systems Intervention Strategies 1.Implement a tobacco user identification system in every clinic 2.Provide education, resources, and feedback to promote provider intervention 3.Dedicate staff to provide tobacco dependence treatment, and assess the delivery of this treatment in staff performance evaluations 4.Include tobacco dependence treatment (both counseling and medication) identified as effective in the USPHS Guideline as paid or covered services for all subscribers or members of health insurance packages

Smoking Status as a Vital Sign

The National Tobacco Quitline QUIT NOW

Quitlines – A National Treatment QUIT NOW Effective Available in all 50 States Services and promotion differ markedly  $130 Million in services in 2009  500,000 smokers served in 2009

Today’s Talk The Epidemiology of Tobacco Use and Cessation Tobacco Cessation Treatments – What the Science Tells Us Tobacco-Free Campuses – An Opportunity to Promote Cessation 30

A Campus-Wide Cessation Program: Components Implement before smokefree campus Cessation as an option, not an obligation Message: Campus Smokefree Implementation – A Great Time to Quit Three targeted populations: students, faculty, staff Remove barriers to treatment access Implement ongoing systems of cessation, not just a one-time program 31

A Campus-Wide Cessation Program: Elements of Success Integrate services into student, faculty, and staff health services Identify a campus health services champion Publicize Remove cost/access barriers Designate a smoking cessation clinical coordinator Use QUIT NOW to supplement, not substitute for, campus programs Expand insurance coverage to include counseling and all FDA-approved medications 32

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