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Clean Air for Healthy Children and Families

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Title: Clean Air for Healthy Children and Families


1
Clean Air for HealthyChildren and Families
Health Care Professional Training in Smoking
Cessation Counseling Techniques
Pennsylvania Chapter American Academy of
Pediatrics
Edward G. Rendell, Governor Calvin B. Johnson,
M.D., M.P.H., Secretary of Health
In partnership with Pennsylvania Area Health
Education Center (AHEC)
2
Program Goal
Every clinician, who interacts with pregnant
women, mothers, caregivers of young children,
teens and others, will deliver effective smoking
cessation advice and counseling.
3
Todays Learning Objectives
  • At the end of this training you should
  • Understand the 5 As/2 As and R brief smoking
    cessation
  • counseling intervention
  • Feel more confident in your ability to provide
    brief
  • smoking cessation counseling
  • Be motivated to discuss smoking cessation with
    your patients
  • and smoke-free environment with your patients
  • Develop a plan to implement the 5 As/2 As and
    R brief
  • smoking cessation counseling intervention

4
What Is Your Office Doing Now?
  • In what ways do you feel your office is
    effective or ineffective?
  • What works well?
  • What do you feel your patients need?
  • What skills do you feel you are lacking to
    counsel patients?
  • What do you hope to gain from the training today?

5
Program Components
  • Identify smokers and recent quitters
  • Counsel (5 As/2 As and R)
  • Patient education materials self-help
    magazines, optional
  • materials, etc.
  • Practice tools documentation
  • forms, stickers, etc.

6
USPHS Guideline
Integrating an evidence-based Intervention into
practice
  • Practical Counseling
  • Problem solving
  • Skills training
  • Relapse prevention
  • Stress management
  • Support by Providers
  • Social Support
  • Pharmacotherapy
  • Nicotine replacement
  • Bupropion
  • Varenicline

7
CounselingIntervention
5 As (3-5 min.) 2 As / R
(1-3 min.)
sk about tobacco use dvise to quit ssess
willingness ssist in quit attempt rrange for
follow-up
sk dvise efer
  • Community Resources
  • 1-800-QuitNOW
  • Rx Pharmacotherapy

Can extend to 10-15 min. for all patients Smoke
Free Families recommends 10-15 min. for pregnant
women
8
Recommendations of Center for Disease Control
  • Increase utilization of the 5 As
  • Every visit, every time
  • Reminder systems
  • Clinician education
  • Promote system change

9
The scope of the problem
10
Comparative Causes of Annual Deaths in the U.S.
USDHHS, CDC (TIPS) Comparative Causes of Annual
Deaths in the United States
11
Weve known for decades that smoking is bad for
your health...the toxins from cigarette smoke go
everywhere the blood flows. There is no safe
cigarette...the only way to avoid the health
hazards of smoking is to quit completely or to
never start smoking.
The Debateis Over
The scientific evidence is now indisputable
secondhand smoke is not a mere annoyance. It is
a serious health hazard that can lead to disease
and premature death in children and nonsmoking
adults.
U.S. Surgeon General Richard H. CarmonaNews
Release, 2004, SGR, The Health Consequences of
SmokingNews Release 06/27/06, SGR, The Health
Consequences of Involuntary Exposure to Tobacco
Smoke
12
The Life Cycle of the Effects of Smoking on Health
Asthma Otitis Media Fire-related Injuries
Influences to Start Smoking
SIDs Bronchiolitis Meningitis
Childhood
Infancy
Adolescence
Nicotine Addiction
In utero
Adulthood
Low Birth Weight Stillbirth Neurologic Problems
Cancer Cardiovascular Disease COPD
Aligne CA, Stodal JJ. Tobacco and children An
economic evaluation of the medical effects
of parental smoking. Arch Pediatr Adolesc Med.
1997151652
13
Prenatal/Neonatal Outcomes
  • 20-30 low birth weight infants
  • Fetal growth retardation
  • Spontaneous abortion
  • Fetal death
  • Pre-term deliveries
  • Ectopic pregnancies
  • Placenta previa and placental
  • abruption
  • Lower APGAR

14
SHS and Children Short TermHealth Effects
  • Respiratory tract infections such as pneumonia
    bronchitis
  • Decreased pulmonary function
  • Triggers asthma attacks
  • Ear Infection (Otitis Media)
  • Tooth decay
  • House fires

15
SHS and Children Long TermHealth Effects
  • Sudden Infant Death Syndrome (SIDS)
  • Asthma
  • SHS accounts for 8-13 of asthma cases in
    children lt15 years
  • SHS exposure increases frequency of episodes and
    severity of
  • symptoms
  • 200,000-1 million asthmatic children are
    affected by SHS
  • Possible problems with cognitive functioning and
    behavioral development
  • More likely to become smokers

16
Risks for Women Who Smoke
  • Reproductive health problems
  • Infertility
  • Conception delay
  • Pregnancy complications
  • Menstrual irregularity
  • Earlier menopause
  • Compromised immune system
  • Respond differently to nicotine
  • Cancer
  • Less likely to breast feed
  • Osteoporosis
  • Thrombosis with use of
  • oral contraceptives

17
Adult Health Risks AssociatedWith Tobacco Use
  • Cancer
  • Major cause of lung, oral and nasal cavity,
    laryngeal, esophageal,
  • bladder and cervical
  • Increased risk for pancreas, uterine, penile,
    kidney, liver, anal and
  • stomach
  • Visual difficulties
  • Decline in hearing
  • Facial wrinkles
  • Tooth loss, plaque staining
  • Dementia Alzheimers
  • House fires
  • Lung changes, COPD, Asthma
  • Cardiovascular heart disease
  • Male female reproductive problems
  • Digestive disorders
  • Rheumatoid arthritis
  • Impaired healing

18
SHS and AdultHealth Risks
  • Nonsmokers who are exposed to secondhand smoke at
    home or at the workplace are at an increased risk
    of developing
  • Lung cancer 20-30
  • Coronary heart disease (25-30)
  • Acute respiratory problems
  • Other significant health risks as per the SGR
  • http//www.surgeongeneral.gov/library/secondha
    ndsmoke

There is no risk-free level of exposure to SHS.
Breathing even a little SHS can be harmful to
your health. Separating smokers from nonsmokers,
cleaning the air, and ventilating buildings
cannot eliminate SHS smoke exposure that controls
the health risks.
USDHHS, The Health Consequences of Involuntary
Exposure to Tobacco Smoke A Report of the SGR
(2006).
19
What can be done?
20
SmokersWant to Quit
  • 70 report wanting to quit
  • 3 out of 4 smokers want to quit
  • Most have made at least one quit attempt
  • Smokers cite physician/clinician advice as
  • important

21
Nicotine Addiction

22
Addiction
3 Components
  1. Physical A physical craving for tobacco and
    withdrawal symptoms may be present in the absence
    of the drug
  2. Habit The use is ritualistic and done without
    thought
  3. Psychological The belief that the user cannot
    function without the habit

Recovery is possible when all 3 components are
treated
23
The Process of BehaviorChange
Pre-Contemplator
Preparation
Contemplator
Relapse
Action
Ex-Smoker
Maintenance
Prochaska and DiClemente, 1983
24
The Process of Behavior Changeand Pregnancy
  • Pregnant women often are more open to change and
    can
  • move through the stages of change differently
    than when
  • they are not pregnant (The fetus can be a
    wonderful
  • motivator)
  • May have more support to quit while pregnant
  • May not be socially acceptable to smoke in
    public if
  • pregnant

25
Motivational Interviewing/Consulting
  • Principles
  • Express empathy to show you understand the
    persons point of
  • view
  • Develop discrepancy between smoking and future
    goals
  • Avoid arguing and confrontation be collaborative
    and friendly
  • Roll with the resistance and avoid argument
  • Support patients self-efficacy and belief in
    the possibility of
  • making a change

26
CounselingIntervention
5 As (3-5 min.) 2 As / R
(1-3 min.)
sk about tobacco use dvise to quit ssess
willingness ssist in quit attempt rrange for
follow-up
sk dvise efer
  • Community Resources
  • 1-800-QuitNOW
  • Rx Pharmacotherapy

Can extend to 10-15 min. for all patients Smoke
Free Families recommends 10-15 min. for pregnant
women
27
sk About Tobacco Use
  • Ask or verify responses in a non-judgmental way
  • Identify smoking status
  • Counsel all smokers and recent quitters
  • Household environment
  • Determine possible barriers to quitting
  • Possible affects of SHS
  • If they smoke assess
  • Nicotine dependence
  • Patterns of use
  • Past quit attempts

28
Health Surveys
29
Chart Stickers
30
dvise to Quit
  • Advice to quit should be clear, strong and
    personalized while
  • using a non-judgmental manner
  • Discuss the effects of smoking on the patient,
    fetus and
  • children
  • Discuss the health benefits
  • of quitting
  • Acknowledge the difficulty
  • in quitting

31
ssess Willingness to Make a Quit
Attempt
  • Assess patients level of interest in quitting
    and intention
  • to take action to quit
  • Ask key questions

32
Assess KeyQuestions
33
ssist in Quit Attempt
  • Pre-Contemplation and Contemplation Stages
  • (Unwilling to make a quit attempt)
  • The 5 Rs
  • Relevance to patients individual situation
  • Risks of smoking
  • Rewards of quitting smoking
  • Roadblocks or barriers to quitting
  • Repeat intervention at every visit
  • In successful interventions clinicians should be
    empathetic, promote patient choices, avoid
    arguments, listen, reflect and instill
    self-confidence

34
ssist in Quit Attempt
  • Preparation Stage
  • (Willing to quit)
  • Help the patient with a quit plan
  • Provide practical counseling
  • Provide social support
  • Social support with treatment (Intra-treatment)
  • Social support outside treatment
    (Extra-treatment)
  • Recommend pharmacotherapy
  • Provide supplemental materials (Quitline, groups)

35
A combination of pharmacotherapy and intervention
doubles
a patients chance of successfully quitting
smoking
36
Pharmacotherapy for Cessation
  • Nicotine gum
  • Nicotine patch
  • Nicotine nasal spray
  • Nicotine inhaler
  • Bupropion SR (Zyban)
  • Lozenge
  • Varenicline (Chantix)

Unless contraindicated
37
Pharmacotherapy and Pregnancy
If the increased likelihood of smoking
cessation, with its potential benefits, outweighs
the unknown risk of nicotine replacement and
potential concomitant smoking, nicotine
replacement products or other pharmaceuticals may
be considered.
ACOG. (2005). Committee Opinion Smoking
Cessation During Pregnancy, Number
316. Concomitant accompanying
38
Handouts forPatients
Note Most materials available in Spanish
39
Personalized Plan forPatients
Note Most materials available in Spanish
40
PA DOH Free Quitline1-800-QUIT-NOW
  • In partnership with the American Cancer Society
  • Intake 24 hours a day/7 days a week
  • Proactive referral (Fast Fax) versus
  • Reactive referral (patient calls)
  • Develop a personalized plan for quitting

41
PA DOH Free Quitline1-800-QUIT-NOW
  • Up to 5 follow-up scheduled counseling sessions
    (8 if
  • pregnant)
  • Special counseling for pregnant smokers
    available for teens
  • Offered printed materials, referrals,
    information on medications
  • (NRTs)
  • English and Spanish other languages as
    necessary
  • Confidential HIPPA compliant

42
PA DOH Free Quitline transitioning
from1-877-724 -1090 to 1-800-QUIT-NOW
1-800-784-8669
43
CommunityResources
  • Pre-Approved Tobacco Cessation Registry
    Pennsylvania
  • Department of Health http//www.dsf.health.sta
    te.pa.us (click
  • on tobacco or Quit NOW (1-800-Quit-NOW) and
    follow
  • prompts
  • Local tobacco coalitions, county websites, and
    county
  • organizations or groups committed to smoking
    cessation
  • Quitline also refers to community resources

44
OptionalMaterials
See Appendix B of the Clean Air program manual
for additional patient handouts and practice
tools

Clean Air Website www.cleanairforhealthychildren.
org
45
rrange forFollow-Up
  • Pre-Contemplation or Contemplation stage
    requires
  • continual support and encouragement
  • Preparation stage
  • Follow-up within 1 week of Quit Date
  • Ask at next visit about progress
  • Action or Maintenance stage
  • Praise success at quitting
  • Problem solve challenges to maintaining
    abstinence

46
Documentation Forms
47
Case Study 1 Sylvia
  • 19-year old
  • Smokes 16 cigarettes a day for past
  • 3 years
  • Fights frequently with husband
  • Pregnant with first baby
  • One prior quit attempt for a few days
  • Interested in effects on baby
  • children

1. Ask about smoking status using a health
history or survey. 2. How will you Advise with a
clear, strong, personalized message to quit
smoking? 3. Assess the patients stage of
readiness to quit. 4. To Assist her in making a
quit plan what might you include? 5. What
barriers or concerns about quitting would you
address and would you do this? 6. Arrange for
follow-up via appointment, telephone, or
referral. 7. Document the intervention in the
patient chart.
Remember to discuss pharmacotherapy if
appropriate Refer to the Quitline
(1-800-QUITNOW) and/or community resources
48
Case Study2 Linda
  • 27-year old
  • Lives with her boyfriend who smokes
  • Smokes a pack a day for past 13 years
  • Has little interest in quitting
  • 3 Children 6, 4, and 2
  • Several prior quit attempts one in
  • last pregnancy for 1 month
  • Reluctant to set a quit date

1. Ask about smoking status using a health
history or survey. 2. How will you Advise with a
clear, strong, personalized message to quit
smoking? 3. Assess the patients stage of
readiness to quit. 4. To Assist her in making a
quit plan what might you include? 5. What
barriers or concerns about quitting would you
address and would you do this? 6. Arrange for
follow-up via appointment, telephone, or
referral. 7. Document the intervention in the
patient chart.
Remember to discuss pharmacotherapy if
appropriate Refer to the Quitline
(1-800-QUITNOW) and/or community resources
49
Case Study6 Lisa
  • 17-year old
  • 6 months pregnant, admitted to hospital
  • for pre-term labor
  • Smokes a pack a half a day and has
  • smoked for 6 years
  • Boyfriend smokes
  • Hospitalized 4 days medicated to
  • stop contractions
  • Contraction free being discharged
  • Enjoys smoking has no interest
  • in quitting

1. Ask about smoking status using a health
history or survey. 2. How will you Advise with a
clear, strong, personalized message to quit
smoking? 3. Assess the patients stage of
readiness to quit. 4. To Assist her in making a
quit plan what might you include? 5. What
barriers or concerns about quitting would you
address and would you do this? 6. Arrange for
follow-up via appointment, telephone, or
referral. 7. Document the intervention in the
patient chart.
Remember to discuss pharmacotherapy if
appropriate Refer to the Quitline
(1-800-QUITNOW) and/or community resources
50
Case Study8 John
  • 32-year old father
  • Smokes a pack a day for past 14 years
  • John is sick with bronchitis
  • Has a son who has asthma
  • Concerned about stress with work home
  • life and avoiding weight gain
  • Had several prior quit attempts
  • Occasionally uses smokeless
  • tobacco instead of cigarettes
  • Wife encourages him to quit
  • Not sure about trying again

1. Ask about smoking status using a health
history or survey. 2. How will you Advise with a
clear, strong, personalized message to quit
smoking? 3. Assess the patients stage of
readiness to quit. 4. To Assist him in making a
quit plan what might you include? 5. What
barriers or concerns about quitting would you
address and would you do this? 6. Arrange for
follow-up via appointment, telephone, or
referral. 7. Document the intervention in the
patient chart.
Remember to discuss pharmacotherapy if
appropriate Refer to the Quitline
(1-800-QUITNOW) and/or community resources
51
Case Study8 Grace
  • 55-year old women
  • Has emphysema
  • Smokes a pack a day for the past 30 years
  • Has tried to quit several times in the past
  • Daughter and grandson lives with her

1. Ask about smoking status using a health
history or survey. 2. How will you Advise with a
clear, strong, personalized message to quit
smoking? 3. Assess the patients stage of
readiness to quit. 4. To Assist him in making a
quit plan what might you include? 5. What
barriers or concerns about quitting would you
address and would you do this? 6. Arrange for
follow-up via appointment, telephone, or
referral. 7. Document the intervention in the
patient chart.
Remember to discuss pharmacotherapy if
appropriate Refer to the Quitline
(1-800-QUITNOW) and/or community resources
52
Implementing into a Healthcare Setting
What will it take to implement this
intervention into your office?
Create A
Quit Smoking Team
Step 1. Develop administrative
commitment
Step 2. Involve staff early
Step 3. Assign one
coordinator
Step 4. Provide training
Step 5. Adapt procedures
to your setting
Step 6. Monitor and provide feedback
53
Implementation and Follow-Up Forms
54
HEDIS
  • Health Employer Data Information Set
  • Survey of randomly sampled patients who were
    seen in the past year.
  • Used as a qualitative measure of practices to
    determine the level of care consistently
  • given to patients.
  • Survey Questions
  • Have you smoked at least 100 cigarettes in your
    lifetime?
  • Do you now smoke cigarettes every day, some days
    or not at all?
  • How long has it been since you quit smoking?
  • In the past 12 months, on how many visits were
    you advised to quit smoking?
  • On how many visits was medication recommended or
    discussed?
  • On how many visits did your doctor or healthcare
    provider recommend or discuss
  • methods or strategies to assist you with
    quitting?

55
JCAHO - Joint Commission of Accreditation of
Hospitals
  • Diagnoses that are mandated to receive tobacco
    education counseling
  • At least 2 of 3 measures - congested heart
    failure myocardial
  • infarctions community acquired pneumonia
  • Patients that have quit tobacco use one year
    prior to their
  • admission
  • Interventions - advice to quit, assistance to
    quit, brochures,
  • video, referral or tobacco cessation aids
  • Must be documented

56
Billing for Smoking CessationCounseling
  • Always have your billing person/department check
    with health plan benefits contact person to see
    what is covered and what codes they recognize
  • Also ask what page in billing manual you can find
    this information
  • Even if not reimbursed it is important to code to
    promote future coverage

57
ICD-9 Diagnostic Codes Smoking Related
  • COPD
  • 491.2
  • Emphysema
  • 492.8
  • Asthma
  • 493.00
  • Diabetes
  • 250
  • Chest Pain
  • 786.50
  • Carcinoma in situ/broncus, lung
  • 231.2
  • Bronchitis
  • 490
  • Cough
  • 786.2
  • Toxic Effect/Tobacco
  • 989.84
  • Tobacco Dependence/Disorder
  • 305.1

Also can use ICD-9 Codes for medical procedures
related to smoking co-morbidity.
58
ICD-9 Diagnosis Codes for Counseling Parents on
Harms of SHS
  • Sample codes for the childs diagnosis
  • Routine infant/child health
  • check
  • V20.2
  • Acute bronchiolitis due to
  • respiratory synctial virus
  • 466.11
  • Extrinsic asthma, with acute
  • exacerbation
  • 493.02
  • Sample codes associated with the parents
    smoking
  • Other specified personal
  • history presenting hazards to
  • health (exposure to tobacco
  • smoke as a potential risk)
  • V15.89
  • Toxic effects of tobacco
  • 989.84

59
CPT Billing Codes
  • Preventive Medicine Examination
  • New Patients 99383-99387
  • Established Patients 99393-99397
  • Pediatric under 1 year 99381
  • Pediatric age 5-11 99393
  • Higher level 99213 only if face to face
    counseling gt50 of visit time
  • Tobacco Dependence Treatment
  • Individual Counseling 99401-99404
  • Group Counseling 99411-99412
  • Psychiatric Therapeutic Procedures
  • Outpatient 90804-90809
  • Inpatient 90816-90822
  • CPT code 99211 if nurse counsels and not
    physician

60
MedicalAssistance
  • PA DOH pre-approved list
  • Bulletins 99-02-02, 99-04-11, and clarification
    02-06
  • www.dpw.state.pa.us/omap
  • Billing Code S9075
  • Promise billing system if available
  • If Health Choices provider discuss carve out in
    contract?
  • Medications are covered if patient has
    prescription coverage but each plan may have
    rules

Become a Pre-Approved Tobacco Cessation Provider
by applying at PA Department of Health
Website http//www.dsf.health.state.pa.us/health/
cwp/view.asp?A174Q236582
61
Clean Air Program Evaluation (optional)
  • Pre Post Training Evaluation Forms
  • Implementation Plan (initial practice
    assessment)
  • 2, 6 12 Month Follow-Up of practice
  • Smoking Cessation Counseling Documentation Form
  • System change

62
Clean AirWebsite
  • Please visit us at our Website
  • www.cleanairforhealthychildren.org
  • Request a training
  • Order and download materials
  • Participate and view teleconferences
  • Access resources and other links
  • Contact us

63
GoodLuck!
Please feel free to contact Dottie
Schell (484)446-3002 or (800)375-5217 (PA
only) cafhc_at_paaap.org
64
Clean Air for Healthy Children Program PA
Chapter of the American Academy of
Pediatrics Rose Tree Corporate Center II 1400 N.
Providence Road, Suite 3007 Media, PA
19063-2043 www.paaap.org
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