1. Cherokee Health Systems Encouraging Tobacco Cessation Through the Five A’s: Ask, Advise, Assess, Assist, Arrange Mary Clare Champion, Ph.D. Cherokee Health Systems Kentucky Primary Care Association Annual Conference October 18, 2011 Lexington, KY

2. Cherokee Health Systems "Starting today, every doctor, nurse, health plan, purchaser, and medical school in America should make treating tobacco dependence a top priority." —David Satcher, MD, Ph.D. Former U.S. Surgeon General Director, National Center for Primary Care, Morehouse School of Medicine

3. Cherokee Health Systems According to the Centers for Disease Control: Approximately 20% of Americans smoke Disparities present –49.1% of adults with GED smoke –31.1% of adults who live below poverty level smoke Approximately 20% of Americans smoke Disparities present –49.1% of adults with GED smoke –31.1% of adults who live below poverty level smoke

4. Cherokee Health Systems According to the Centers for Disease Control’s Office on Smoking and Health: More deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined. Smoking cigarettes, pipes, or cigars increases the risk of dying from cancers of the lung, esophagus, larynx, and oral cavity. More deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined. Smoking cigarettes, pipes, or cigars increases the risk of dying from cancers of the lung, esophagus, larynx, and oral cavity.

5. Cherokee Health Systems From the CDC, cont. Cigarette smoking causes about 1 of every 5 deaths in the United States each year. Cigarette smoking is estimated to cause the following: 443,000 deaths annually (including deaths from secondhand smoke) 49,400 deaths per year from secondhand smoke exposure 269,655 deaths annually among men 173,940 deaths annually among women Cigarette use causes premature death: On average, adults who smoke cigarettes die 14 years earlier than nonsmokers. Based on current cigarette smoking patterns, an estimated 25 million Americans who are alive today will die prematurely from smoking-related illnesses, including 5 million people younger than 18 years of age.

6. Cherokee Health Systems How to help? The 5 A’s

7. Cherokee Health Systems Who can use the 5 A’s? Anyone! –Doctors –Nurse Practitioners –Psychologists –Social Workers –Nurses –Ancillary staff Anyone! –Doctors –Nurse Practitioners –Psychologists –Social Workers –Nurses –Ancillary staff

8. Cherokee Health Systems ASK Identify ALL tobacco users at EVERY visit Vital Signs Blood Pressure:__________________________________________ Pulse: _____________________ Weight: _____________________ Temperature: ____________________________________________ Respiratory Rate: ________________________________________ Tobacco Use: (circle one) Current Former Never Fiore MC, Bailey WC, Cohen SJ, et. al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. October 2000. Vital Signs Blood Pressure:__________________________________________ Pulse: _____________________ Weight: _____________________ Temperature: ____________________________________________ Respiratory Rate: ________________________________________ Tobacco Use: (circle one) Current Former Never Fiore MC, Bailey WC, Cohen SJ, et. al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. October 2000.

9. Cherokee Health Systems ASK Options for tracking include: –Adjusting vital sign documentation to include tobacco assessment –Tobacco status stickers for paper charts –Tag in electronic medical record, reminder texts for documentation Options for tracking include: –Adjusting vital sign documentation to include tobacco assessment –Tobacco status stickers for paper charts –Tag in electronic medical record, reminder texts for documentation

10. Cherokee Health Systems Why ask? Important to understand tobacco use as a chronic illness Anticipate periods of relapse Heightened awareness Important to understand tobacco use as a chronic illness Anticipate periods of relapse Heightened awareness

11. Cherokee Health Systems ADVISE Strongly encourage all tobacco users to quit –Clear –Strong –Personalized Strongly encourage all tobacco users to quit –Clear –Strong –Personalized

12. Cherokee Health Systems ASSESS Is the patient willing to make a quit plan within the next 30 days? If yes, –Provide assistance with quit plan –Deliver treatment needed for plan or refer to appropriate treatment –Provide additional information for special populations (adolescents, pregnant women) Is the patient willing to make a quit plan within the next 30 days? If yes, –Provide assistance with quit plan –Deliver treatment needed for plan or refer to appropriate treatment –Provide additional information for special populations (adolescents, pregnant women)

13. Cherokee Health Systems ASSESS What if the person says, “No!” Provide motivational interventions –Consider the 5 R’s Relevance Risks Rewards Roadblocks Repetition What if the person says, “No!” Provide motivational interventions –Consider the 5 R’s Relevance Risks Rewards Roadblocks Repetition

14. Cherokee Health Systems ASSESS Be prepared to repeat these interventions as necessary Remember that even if the patient continues to say, “NO!,” when asked about a quit plan, repeated interventions still contribute to heightened awareness Be prepared to repeat these interventions as necessary Remember that even if the patient continues to say, “NO!,” when asked about a quit plan, repeated interventions still contribute to heightened awareness

15. Cherokee Health Systems ASSIST Aid the patient in quitting

16. Cherokee Health Systems How to Assist? Help with quit plan: –Set a date –Tell family/friends –Anticipate challenges –Remove tobacco products Help with quit plan: –Set a date –Tell family/friends –Anticipate challenges –Remove tobacco products Provide practical help: –Goal of abstinence –Review past quit attempts –Discuss triggers –Risk of alcohol use –Peers who smoke

17. Cherokee Health Systems How to Assist? Intra-treatment social support: –Support of providers and staff –Consider smoking cessation group in the practice Intra-treatment social support: –Support of providers and staff –Consider smoking cessation group in the practice Extra-treatment social support: –Support outside of office Friends Family Online supports

18. Cherokee Health Systems How to Assist? Consider pharmacotherapy: –Consult medical providers with use of medicines, inhalers, patches, and/or nicotine replacement gum. Consider pharmacotherapy: –Consult medical providers with use of medicines, inhalers, patches, and/or nicotine replacement gum. Supplementary materials: –Collect materials from local/federal agencies –Have materials readily available at all workstations

19. Cherokee Health Systems ARRANGE Provide follow-up contact –First follow-up preferably within the week after the quit date –Second follow-up within the month Provide follow-up contact –First follow-up preferably within the week after the quit date –Second follow-up within the month

20. Cherokee Health Systems Resources for Clinicians http://www.surgeongeneral.gov/tobacco/tobaqr g.htm (Reference guide for clinicians) http://www.theipcrg.org/resources/IPCRG%20S MOKE%20CES%20TO%20PRINT%20V2%20FI NAL%20Oct%2007.pdf (Printable handout for clinician use) http://www.tnpca.org/displaycommon.cfm?an= 1&subarticlenbr=66 (TPCA’s resource website, multiple links/documents) http://www.surgeongeneral.gov/tobacco/tobaqr g.htm (Reference guide for clinicians) http://www.theipcrg.org/resources/IPCRG%20S MOKE%20CES%20TO%20PRINT%20V2%20FI NAL%20Oct%2007.pdf (Printable handout for clinician use) http://www.tnpca.org/displaycommon.cfm?an= 1&subarticlenbr=66 (TPCA’s resource website, multiple links/documents)

21. Cherokee Health Systems Other resources – for patients www.smokefree.gov www.ahrq.gov/path/tobacco.html 1-800-QUIT-NOW http://www.cdc.gov/tobacco/quit_smoking/how _to_quit/you_can_quit/ www.smokefree.gov www.ahrq.gov/path/tobacco.html 1-800-QUIT-NOW http://www.cdc.gov/tobacco/quit_smoking/how _to_quit/you_can_quit/

22. Cherokee Health Systems Questions? maryclarechampion@cherokeehealth.com