Implementing an Effective

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• Implementing an Effective
• Smoking Cessation Strategy
• in Medical Practice
• Janis M. Dauer, MS, CAC
• Alliance for the Prevention and Treatment of
  Nicotine Addiction
• 757-858-9934
• jdauer_at_aptna.org

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Implementing an Effective Smoking Cessation
Strategy in Medical PracticeRATIONALE FOR
INTERVENING

• Save lives, reduce harm
• Amenable to treatment
• Effective treatments exist
• Clinical opportunities are numerous
• Even brief interventions are effective
• Non-physicians (nurses, health educators) are
  effective
• Treatment is cost-effective (counseling and
  medications)
• Demonstrates sincere commitment to patients
  well-being

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice CLINICAL PRACTICE
GUIDELINE

• Most recent update May 2008 (based on
  meta-analysis of over 8,700 studies published
  between 1975-2007)
• NEW EMPHASIS
• Chronic condition, often requires repeated
  interventions
• Counseling is especially important for certain
  groups (e.g., comorbid medical conditions like
  diabetes)
• Treatment is effective with diverse populations
  (minorities, low SES, comorbid conditions)

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice GUIDELINE - NEW
EMPHASIS

• Healthcare policies and systems changes can
  significantly reduce barriers to treatment
• Coverage as health-insurance benefit
• Training clinicians along with having a
  charting/documentation system in place
• Investing in treatment (counseling and
  medications) it pays for itself
• New strategies exist to assist patients not yet
  ready to quit (by increasing motivation)

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice GUIDELINE - NEW
RECOMMENDATIONS

• Quitlines are effective and have broad reach
• Callers are four times more likely to succeed
  than those trying to quit without treatment
• Combination counseling medication is
  significantly more effective than either alone
• Effective, FDA-approved medications exist (7)
• NRT (nicotine gum, patch, lozenge, nasal spray
  or inhaler), bupropion (Zyban), varenicline
  (Chantix)
• Combination medications are effective
• Nicotine patch another NRT (often the gum)
• Nicotine patch bupropion SR

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice GUIDELINE -
TREATMENT STRATEGIES

• THE FIVE As
• ASK
• Identify tobacco use status of every patient
• (current, former, never)
• ADVISE
• Advise patient to quit
• (clear, strong, personal manner)
• ASSESS
• Assess willingness to quit
• (Yes continue with the As No do the
  Rs)

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice GUIDELINE -
TREATMENT STRATEGIES

• ASSIST
• Assist willing patient in developing a quit plan
• (skills training, support, pharmacotherapy,
  materials)
• ARRANGE
• Arrange follow-up if patient identified a quit
  date
• (In person, by phone/mail - soon after quit date)
• For the unwilling patient

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice GUIDELINE -
TREATMENT STRATEGIES

• THE FIVE Rs
• Interventions to increase patient motivation
• RELEVANCE connect to disease/risk, concerns
• RISKS identify negative impact of continued use
• REWARDS identify potential benefits of quitting
• ROADBLOCKS identify barriers ways to cope
• REPETITION repeat each visit while still
  unwilling
• Recent Quitters (first 12 months)
• Interventions to assist former smokers in staying
  quit
• Minimal Practice/Prescriptive Relapse Prevention

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Implementing an Effective Smoking Cessation
Strategy in Medical PracticeINTEGRATION INTO
PRACTICE

• Goal reduce smoking/tobacco use
• Objective Implement guideline recommendations
• (5As/5Rs)
• Tool Needs Assessment table
• Use to identify strategies, process staff,
  education materials needed
• Tailor to suit practice/clinic

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice NEEDS ASSESSMENT
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Implementing an Effective Smoking Cessation
Strategy in Medical Practice RESOURCES

• Provider Training/Education
• Online (free/low-cost)
• Downloadable manuals (free)
• Print materials (free/low-cost)
• Patient Education/Self-Help Materials
• Quitline provides (to callers)
• Links to online sources (free/low-cost)
• Quitline Information/Materials
• Print/audio/video
• Fax referral registration

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice RESOURCES,continued

• APTNA
• Training/consultation
• Resources and materials
• Fax referral project
• CA Diabetes Program (cAARd)
• Toolkit developed
• Adaptable to Virginia
• ATTUD
• Inexpensive (75/year)
• Network of tobacco treatment specialists

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Implementing an Effective Smoking Cessation
Strategy in Medical PracticePROVIDER BARRIERS

• Reasons Given for Not Helping Patients Quit

• Too busy
• Lack of expertise
• No financial incentive
• Most smokers cant/wont quit
• Negative message might scare away patients
• I smoke myself

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Implementing an Effective Smoking Cessation
Strategy in Medical PracticePROVIDER BARRIERS

• Helping is Easier Than You Think
• Too busy clinicians can effectively help in 1
  minute or less (refer to a specialist)
• Lack of expertise not much needed to refer to a
  specialist (e.g., the Quitline)
• No financial incentive its worth 1 minute, make
  it part of basic treatment

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Implementing an Effective Smoking Cessation
Strategy in Medical PracticePROVIDER BARRIERS

• Helping is Easier Than You Think, continued
• Most smokers cant/wont quit persevere -
  multiple sessions or attempts may be needed
• Negative message might scare away patients
  research studies show patient satisfaction is
  greater when clinicians address tobacco
  use/secondhand smoke

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Implementing an Effective Smoking Cessation
Strategy in Medical PracticePROVIDER BARRIERS

• Helping is Easier Than You Think, continued
• I smoke myself healthcare professionals also
  need help and support in quitting smoking (and
  policies that are motivational)
• Tobacco-Free Nurses initiative makes online
  cessation via QuitNet available to nurses for
  free www.tobaccofreenurses.org

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice1-800-QUIT NOW

• Can be the main counseling service
• Quit Coaches are skilled specialists
• Tailored interventions are available
• Minimal clinician time/resources needed
  (Ask-Advise-Refer-Medication assistance)
• Print materials provided
• Services for Spanish-speaking and hearing
  impaired

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice1-800-QUIT NOW,
continued

• Can be an adjunct service
• Part of patients support system
• Synergism with other services
• Unlimited calls, forever
• Providers can also consult with Quit Coaches for
  advice/information

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice1-800-QUIT NOW,
continued

• Can be a resource information/materials
• Quit Coaches can answer questions
• Self-help booklets available (low-literacy,
  Spanish version) call to get a sample
• Any call made can increase motivation, facilitate
  request for help
• Family/loved ones can also call

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice 1-800-QUIT NOW,
continued

• Can be Accessed by Fax Referral
• Initial call made by Quit Coach
• Reduces clinician frustration
• Facilitates quit attempt
• All fax referred patients eligible to enroll in
  the Multiple Session protocol

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice 1-800-QUIT NOW,
continued

• Fax Referral, continued
• Providers can get call outcome feedback on each
  patient referred
• Providers can call to request patient follow-up
  information
• Doesnt cost anything
• Requires registration

Questions?