Be a Lifesaver! Help your Clients Quit.

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Be a Lifesaver!Help your Clients Quit.
Your Name Title Agency
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Smoking kills more Americans than all of the
following combined

• AIDS
• Alcohol
• Motor vehicle injuries
• Fires
• Heroin
• Cocaine
• Homicide
• Suicide

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Tobacco Use in Michigan

• Heart Disease, Cancer, Stroke, and COPD are the
  four leading causes of death in Michigan and all
  associated with smoking
• Tobacco use is the leading preventable cause of
  death
• Second hand smoke is the third leading
  preventable cause of death

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TobaccoA Risk Factor for Chronic Disease

• Tobacco use is a known or probable cause of more
  than 25 specific diseases and is an important
  cause of chronic disease.1
• In 2007, 39 of the working-age population
  reported at least one chronic health condition.2
• Integration of tobacco dependence treatment into
  chronic disease programs is recognized as a CDC
  Best Practice.

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Smoking reduces life expectancy an average of
about 14 years by way of lung cancer, heart
disease other illnesses, according to the CDC.
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People with serious mental illness die 25 years
younger than the general population, largely due
to conditions caused or worsened by smoking.

• National Association of State Mental Health
  Program Directors. Morbidity and Mortality in
  People with Serious Mental Illness. Thirteenth in
  a Series of Technical Reports. Alexandria, VA
  2006.

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What is Tobacco Costing us?
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High Personal and Societal Cost

• Number one preventable cause of death in the US
• 1 in 5 deaths are attributed to tobacco (Healthy
  People 2010, 2005)
• 480,000 deaths attributed to smoking, annually
  (U.S. Surgeon General 2014)
• Enormous cost - 280 billion (U.S. Surgeon
  General 2014)
• Direct medical cost
• Indirect cost lost productivity and earnings
• Medicaid cost
• Medicare cost

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Royal Caribbean's Radiance of the Seas
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Michigans Personal Costs

• Each year 14,500 14,800 Michigan Residents die
  prematurely due to their own smoking.

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Secondhand Smoke causes

• 50,000 U.S. deaths a year (DHHS 2006)
• (3,000 from lung cancer, 46,000 from heart
  disease and 430 from sudden infant death)
• US Surgeon Generals Report on Secondhand
  Smoke 2006
• In Michigan, between 1,500 and 2,400 residents
  die annually from secondhand smoke
• Hundreds of studies show adverse health effects
  in adults and children

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Tobacco Addiction A Chronic Disease?
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Tobacco Dependence A Chronic Disease

• Similar to diabetes, heart failure, hypertension,
  hyperlipidemia
• Expectation for remission and relapse
• Provide ongoing treatment
• advice/counseling
• support
• appropriate pharmacotherapy

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Tobacco DependenceA Chronic Disease

• There is a spectrum of disease severity
• Effective treatments are available
• High dose and multi-drug regimens may be
  necessary to achieve the target goals
• May require referral to specialists
• Individualized therapy is important

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Nicotine is a Drug of Addiction

• After inhaling, nicotine reaches the brain in
• 7-10 seconds
• Euphoria without being Stoned
• Immediate REINFORCEMENT of drug-taking behavior
• Nicotine activates reward pathways in the brain
• Moment to moment titration of dose to achieve the
  desired effects

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How Can You Help Your Clients Fight Back?
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Clinicians Can Make a Difference!

• Treatment delivered by a variety of clinician
  types increases abstinence rates.
• Treatments delivered by multiple types of health
  care providers (nurse, medical assistant,
  psychologist, social worker or dentist) are more
  effective than interventions delivered by a
  single type of clinician.

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You Can Do It!

• As few as 3 minutes of counseling or other
  primary care interventions can increase the
  success rate of smoking cessation!6

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Most of the following slides are taken directly
from two documents

• Treating Tobacco Use and Dependence
• Quick Reference Guide for Clinicians
• 2008 Update
• and
• A how-to packet for implementing the US Public
  Health Service Clinical Practice Guidelines

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The 5 A Intervention

• ASK about Tobacco Use (Tobacco as a vital sign)
• ADVISE to stop
• ASSESS willingness to make an attempt
• ASSIST in the stop attempt
• ARRANGE for a follow-up visit

• Not since the polio vaccine has this nation
  had a better opportunity to make a significant
  impact in public health.
• -- David Satcher, MD,MPH US Surgeon General
• 1998-2002

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The "5 A's" Model for Treating Tobacco Use and
Dependence - 2008
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Ask

• Systematically identify all tobacco users at
  every visit

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Advise

• Strongly urge all tobacco users to quit
• In a clear, strong, and personalized manner, urge
  every tobacco user to quit.
• Clear Important, cutting down not enough
• Strong Most important thing you can do to
  protect your health
• Personalized link to current symptoms and
  health concerns, social and or economic situations

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Assess

• Determine willingness to make a quit attempt at
  the time
• If the patient is willing to participate in
  intensive treatment deliver such treatment or
  make a referral
• Modify for special populations
• Dont want to quit? provide motivational
  intervention

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Assist

• Aid the patient in quitting
• Pharmacologicalif not contraindicated
• Set a quit date
• Counseling
• Skills training-Anticipate Challenges
• Problem solving
• Social Support
• Intra-treatment social support
• Extra-treatment social support

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Combinations Medication and Counseling
Effectiveness of and estimated abstinence rates
for the combination of counseling and medication
versus medication alone (n 18 studies)
Treatment Number of arms Estimated odds ratio (95 C.I.) Estimated abstinence rate (95 C.I.)
Medication alone 8 1.0 21.6
Medication and counseling 39 1.3 (1.1, 1.6) 27.0 (22.7, 31.4)
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Medication

• Seven first-line medications shown to be
  effective and recommended for use by the
  Guideline Panel
• Bupropion SR
• Nicotine Gum
• Nicotine Inhaler
• Nicotine Lozenge
• Nicotine Nasal Spray
• Nicotine Patch
• Varenicline

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Guidelines for pharmacotherapy

• Second line Pharmacotherapies
• Clonidine
• Oral
• Transdermal
• Nortriptyline
• Lighter smokers - lower NRT
• 10-15 cigarettes/day
• no adjustment for bupropion SR or varenicline

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Possible Side Effects for all Nicotine
Replacement products

• Dizziness
• Nausea
• Headaches
• Should not be used after recent MI (2 weeks)

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NRT Indicators

• Anyone who smokes gt 10 cigarettes per day
• Anyone who reports withdrawal symptoms during a
  past quit attempt
• Each quit attempt is different so okay to try
  same medication again motivation may have
  shifted
• All NRTs are better than placebo

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Rationale for Nicotine Replacement

• Prevention/relief of nicotine withdrawal symptoms
• Allows patients time to develop strategies to
  avoid relapse
• Avoids the exposure to carcinogens in cigarette
  smoke
• Allows for controlled tapering of the nicotine
• Improves success of quitting

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E-Cigarettes

• E-cigarettes (or electronic cigarettes) are
  battery powered devices that claim to provide
  inhaled doses of nicotine by way of a vaporized
  solution.

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E-Cigarettes

• Are NOT FDA approved for treating tobacco
  dependence.
• Do not have dosage recommendations and have
  varying levels of nicotine.
• Contain detectable levels of carcinogens and
  toxic chemicals.
• There is no scientific evidence that e-cigarettes
  help smokers quit.

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Arrange schedule follow up

• Timing
• Quit week
• First month
• Follow-up conversation

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Motivational InterviewingFor the Patient
Unwilling to Quit

• Express empathy
• How important do you think it is for you to
  quit? What might happen if you quit?
• Develop discrepancy
• It sounds like you are very devoted to your
  family/ friends/job. How do you think your
  smoking is affecting your children/relationships/w
  ork?
• Roll with resistance
• Sounds like you are feeling pressured about your
  smoking. Would you like to hear about
  strategies that can help you address your
  concerns when you quit?
• Support self-efficacy
• So you were fairly successful the last time you
  quit.

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Diagnosis and Billing Codes

• ICD-9 305.1 Tobacco Use Disorder will become
• ICD-10 F17.2 Nicotine Dependence with multiple
  use subsections (October 1, 2015)
• CPT 99406
• Intermediate
• Smoking and tobacco-use cessation counseling
  visit more than 3 minutes, up to 10 minutes.
• CPT 99407
• Intensive
• Smoking and tobacco-use cessation counseling
  visit more than 10 minutes.

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Resources to Help you Succeed!
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Michigan Patient Resources

• The Michigan Department of Community Health has
  online quit kits. To print on demand go to
  www.michigan.gov/tobacco
• American Cancer Society offers printed material
  and sponsors the Great American Smokeout on the
  third Thursday in November. Call 1-800-227-2345.
  www.cancer.org
• American Heart Association offers printed
  material. Call 1-800-242-8721.
  www.americanheart.org
• American Lung Association offers quit smoking
  classes, printed material, cessation website.
  Call 1-800-586-4872. Telephone referral and
  cessation advice is available by calling
  1-866-784-8937. www.lungusa.org
• National Cancer Institute offers a quit kit and
  telephone advice at 1-877-44U-QUIT.
  www.cancer.gov/cancertopics/smoking

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Michigan Patient Resources

• Nicotine Anonymous at 415-750-0328.
  www.nicotine-anonymous.org
• QuitNet Online Smoking Cessation
  www.quitnet.com
• Try to Stop A website offering an online quit
  smoking program called Quit Wizard.
  www.trytostop.org
• BecomeanEX A website offering an online quit
  smoking program. www.becomeanex.org
• U.S. Public Health Service offers a free booklet,
  You Can Quit Smoking Now! Call 1-800-QUITNOW.
  www.surgeongeneral.gov/tobacco

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Provider Cessation Resources

• http//www.aafp.org/tobacco.xml American Academy
  of Family Physicians Ask and Act
• MI Providers Tobacco Cessation Tool Kit
  www.michigancancer.org/WhatWeDo/tob-providerstoolk
  it.cfm
• University of Wisconsin Center for Tobacco
  Research Intervention offers videos and other
  tobacco training materials at www.ctri.wisc.edu
• Web-based training offered by the State of
  Michigan at www.michigan.gov/tobacco

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Telephone Quitlines
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Tobacco Quitlines

• Work in conjunction with clinician or health care
  worker intervention.
• Can provide the treatment intensity that often
  cannot be provided in an office setting due to
  time constraints.
• Increase access to treatment and reduce barriers
• Can provide assistance in multiple languages.

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The Michigan Tobacco Quitline

• 1-800-QUIT-NOW (784-8669)
• 1-877-777-6534 (TTS)
• Counseling appointments available between 7 am to
  1 am EST
• Provides
• Referrals to local programs
• One time counseling
• Intensive counseling proactive sessions
• Unlimited reactive calls for one year
• Free NRT to the uninsured
• Self-help materials
• Free text messaging and online program

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Michigan Tobacco Quit Line Services

• All Michigan Callers Receive
• Information Referral, Text Messaging
• Medicaid Veterans
• Counseling
• 4 sessions for general enrollees
• 9 sessions for prenatal
• Medicare, Uninsured, Prenatal, Cancer Patients
  County Health Plan
• Counseling (same as above)
• Up to 8 weeks of nicotine patch, gum or lozenge

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Enhanced Prenatal Protocol

• Began February 1, 2012
• There are specially trained counselors whose time
  is dedicated to working with prenatal callers
• Prenatal enrollees will receive 9 counseling
  calls-5 prior to delivery and 4 post-partum
• Prenatal enrollees receive incentives for
  participation

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Prenatal Quitline Poster
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Who Qualifies for Counseling?

• Medicaid, including MOMS
• Medicare
• Veterans
• Uninsured
• People with a Cancer Diagnosis
• Prenatal
• County Health Plans
• Youth 13-17 (no insurance information is
  collected)

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Michigan Quit Line Fax Referral Form for Health
Care Providershttps//michigan.quitlogix.org/prov
iders_partners/default.aspx
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With Special Thanks to

• Gregory S. Holzman, MD, MPH
• Formerly, Chief Medical Executive, MDCH
• Linda Thomas, MS
• Formerly,Tobacco Consultation Service,
  University of Michigan Health Systems
• Many of the slides in this presentation were
  borrowed from previous lectures.

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References

• Department of Health and Human Services (US).
  The Health Benefits of Smoking Cessation A
  Report of the Surgeon General. Rockville (MD)
  Department of Health and Human Services, National
  Center for Chronic Disease Prevention and Health
  Promotion, Office on Smoking and Health 1990.
• Ha T. Tu, Genna Cohen. Financial and Health
  Burdens of Chronic Conditions Grow. Tracking
  Report No. 24. Center for Studying Health System
  Change. Washingron, DC 2009.
• Maciosek MV, Coffield AB, Edwards NM, Flottemesch
  TJ, Goodman MJ, Solberg LI. Priorities among
  effective clinical preventive services results
  of a systematic review and analysis. American
  Journal of Preventive Medicine 200631(1)5261.
• Miller DP, Villa KF, Hogue SL, and
  Sivapathasundaram D. (2001). Birth and first-year
  costs for mothers and infants attributable to
  maternal smoking. Nicotine and Tobacco Research,
  3, 25-35.
• Benowitz, N. Nicotine Addiction. Tobacco Use and
  Cessation 26(3)611-631, 1999
• United States Preventive Services Task Force,
  2009

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