Title: Beating Joe Camel: The American Society of Anesthesiologists Smoking Cessation Initiative
1Beating Joe Camel The American Society of
Anesthesiologists Smoking Cessation Initiative
2Beating Joe Camel
- Why bother?
- Barriers
- The ASA Smoking Cessation Initiative
- How to help in three minutes or less (and get
paid for doing it.)
3Why Bother?
4Tobacco Cessation Improves Surgical Outcomes
- Cardiovascular Complications
- Respiratory Complications
- Wound-related Complications
5Short-term Cardiovascular Benefits of Smoking
Cessation
- Nicotine
- half life of 1-2 h
- decreases in heart rate and systolic blood
pressure within 12 hours - Carbon monoxide
- half life of 4 hours
- carboxyhemoglobin level near normal at 12 hours
- Preoperative abstinence decreases the frequency
of intraoperative ischemia
Woehlck et al, Anesth Analg 89 856, 1999
6Smoking Cessation Reduces Postoperative
Complications
- 120 Orthopedic patient randomized to tobacco
intervention or control, 6-8 weeks prior to
surgery - 80 of intervention patients were able to quit
or reduce smoking
Moller, Lancet 359114, 2002
7Why bother?
8Surgery Promotes Tobacco Cessation
- Opportunity to intervene
- contact with healthcare system
- forced abstinence
- Major medical interventions improve quit rates
- Occurs even in the absence of tobacco
interventions - May also improve the effectiveness of tobacco
interventions
9Smoking Cessation After Surgery
10Barriers to Perioperative Smoking Cessation
- Quitting just before surgery increases pulmonary
complications - Nicotine replacement therapy is dangerous
- Surgical patients are already too stressed
- Patients dont want to hear about their smoking
they have enough to worry about
11Recent Smoking Cessation Does Not Increase
Pulmonary Complications
- 300 patients for lung cancer resection
- Recent quitters gt1 week, lt 2
months - Past quitters gt 2 months
Barrera et al, Chest 1271977, 2005
(n13)
(n64)
(n39)
(n184)
12Nicotine Replacement Therapy and Wound Healing
- 48 smokers randomized to continuous smoking or
abstinence, with or without nicotine replacement - Standardized wounds over a 12 week period
Sorensen et al, Ann Surg 2381, 2003
13Perioperative Stress in Smokers
- 141 smokers, 150 non-smokers for elective surgery
- Perceived stress measured from before surgery up
to one week postoperatively - Smoking status does not affect changes in
perceived stress - Also no evidence for significant cigarette
cravings
Warner et al, Anesthesiology 1991125, 2004
14What do smokers expect?
- Essentially all smokers are aware of general
health hazards - Most are not aware of how it might affect their
surgery and want to know! - They want information and options
- Almost all will not be offended if you discuss
their smoking - But they do not want a sermon
Warner et al, unpublished observations
15The Real Barriers to Intervention
- I dont know how
- I dont have time
- Its not my job
16What are we doing now?
- Survey responses from 329 anesthesiologists and
299 general surgeons - Proportions that always performed intervention
- Actual patient perceptions may differ (e.g., 30
of patients recall being advised)
Warner et al, Anesth Analg 991766,2004
17ASA Smoking Cessation Initiative - Rationale
- Smoking cessation improves perioperative outcomes
- Sustained abstinence produced by this teachable
moment produces an average 6-8 years of life
gained - Demonstrate to the public that anesthesiologists
are perioperative physicians who care about
patient health - Recent CMS changes make it possible to bill for
brief tobacco interventions
18ASA Smoking Cessation Initiative Vision and
Goals
- Vision
- Every smoker cared for by an anesthesiologist
will receive assistance in quitting as an
integral part of care - Goal
- Increase the involvement of ASA members in
smoking cessation efforts, thus increasing
abstinence rates for their patients who smoke
19ASA Smoking Cessation Initiative Strategies
- Encourage all anesthesiologists to consistently
apply the Ask, Advise, and Refer technique - Develop anesthesiologists who can serve as
leaders for local efforts to provide tobacco
intervention services in perioperative practice - Educate the public regarding the importance of
perioperative smoking cessation - Create partnerships with other healthcare
professionals to promote a comprehensive
perioperative strategy for patients who smoke
20ASA Smoking Cessation Initiative Strategies
- Encourage all anesthesiologists to consistently
apply the Ask, Advise, and Refer technique - Develop anesthesiologists who can serve as
leaders for local efforts to provide tobacco
intervention services in perioperative practice - Educate the public regarding the importance of
perioperative smoking cessation - Create partnerships with other healthcare
professionals to promote a comprehensive
perioperative strategy for patients who smoke
21What should we do for smokers who need surgery?
- ASK - assess tobacco use at every visit
- ADVISE - strongly urge all tobacco users to quit
- REFER To a tobacco quitline or other resources
22What are Quitlines?
- Free via telephone to all Americans
- Staffed by trained specialists
- Up to 4-6 personalized sessions
- Some offer free nicotine replacement therapy
- Up to 30 success rates for patients who complete
sessions
Most providers, and most patients, know nothing
about quitlines.
23ASK every patient about tobacco use
- Ask even if you already know the answer
- Reinforces message that you as a physician think
that their tobacco use is significant
24ADVISE all smoker to quit
- Why quit for surgery? Talking points.
- Quit for as long as possible before and after
surgery - Day of surgery especially important fast from
both food and cigarettes - Benefits of quitting to wound healing, heart and
lungs - Great opportunity to quit for good
- Many people dont have cravings
- Need to be smoke free in the hospital anyway
25REFER smokers to quitlines or other resources
- What are quitlines? talking points
- Quitlines are free
- Talk with a specialist, not a recording
- Free stop smoking medications may be available
- Can call anytime, even after surgery
- Can help you stay off cigarettes even if you have
already quit - Can also use proactive fax referral
- 1-800-QUIT-NOW
26ASA Quitcard
27ASA Patient Brochure
28Other resources for your patients
- Tobacco treatment specialists
- Available in many practice settings
- Often hospital-based
- Websites
- www.smokefree.gov
- Insurers
- E.g., Blue Cross/Shield, BluePrint for Health
stop smoking program
29CMS Reimbursement for Tobacco Interventions
- Who is covered?
- Patients who use tobacco and have a disease or
adverse health effect found by the US Surgeon
General to be linked to tobacco use - HCPCS Codes
- G0375 Smoking and tobacco-use cessation
counseling visit intermediate, gt 3 minutes up to
10 minutes - G0376 Smoking and tobacco-use cessation visit
intensive, gt 10 minutes
30CMS Reimbursement for Tobacco Interventions
- Cessation counseling attempt occurs when a
qualified physician or other Medicare-recognized
practitioner determines that a beneficiary meets
the eligibility requirements above and initiates
treatment with a cessation counseling attempt - Two attempts (of up to 4 sessions) allowed every
12 months - No credentialing requirements as of yet
31ASA Smoking Cessation Initiative Task Force
Pilot program
- Identify approximately 10 practices nationally
- Identify a champion within each practice to
promote the Ask-Advise-Refer strategy - Implement strategy for 3 months, beginning Sept
2007 - Survey practices after this period to determine
feasibility and gather feedback
32Bottom Line
- You can make a difference in the lives of your
patients who smoke - You can help without being an expert in tobacco
control and get paid for doing it - The ASA is working to provide you with the tools
you need to do this effectively
33What about Joe Camel?