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)
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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?

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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

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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
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Recommendations of Center for Disease Control

• Increase utilization of the 5 As
• Every visit, every time
• Reminder systems
• Clinician education
• Promote system change

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The scope of the problem
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Comparative Causes of Annual Deaths in the U.S.
USDHHS, CDC (TIPS) Comparative Causes of Annual
Deaths in the United States
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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
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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
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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

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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

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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

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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

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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

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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).
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What can be done?
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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

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Nicotine Addiction

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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
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The Process of BehaviorChange
Pre-Contemplator
Preparation
Contemplator
Relapse
Action
Ex-Smoker
Maintenance
Prochaska and DiClemente, 1983
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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

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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

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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
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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

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Health Surveys
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Chart Stickers
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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

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ssess Willingness to Make a Quit
Attempt

• Assess patients level of interest in quitting
  and intention
• to take action to quit
• Ask key questions

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Assess KeyQuestions
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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

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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)

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A combination of pharmacotherapy and intervention
doubles
a patients chance of successfully quitting
smoking
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Pharmacotherapy for Cessation

• Nicotine gum
• Nicotine patch
• Nicotine nasal spray
• Nicotine inhaler
• Bupropion SR (Zyban)
• Lozenge
• Varenicline (Chantix)

Unless contraindicated
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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
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Handouts forPatients
Note Most materials available in Spanish
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Personalized Plan forPatients
Note Most materials available in Spanish
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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

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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

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PA DOH Free Quitline transitioning
from1-877-724 -1090 to 1-800-QUIT-NOW
1-800-784-8669
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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

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

Clean Air Website www.cleanairforhealthychildren.
org
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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

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Documentation Forms
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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
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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
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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
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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
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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
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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
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Implementation and Follow-Up Forms
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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?

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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

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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

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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.
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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

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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

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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
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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

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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

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GoodLuck!
Please feel free to contact Dottie
Schell [phone] or [phone] (PA
only) cafhc_at_paaap.org
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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