Transcript Document

Evidence-Based Smoking
Cessation Counseling for
HIV-Infected Patients
Julia H. Arnsten, MD, MPH
Chief, Division of General Internal Medicine
Associate Professor of Medicine, Epidemiology, and Psychiatry
Montefiore Medical Center
Albert Einstein College of Medicine
Background
• More than 50% of HIV-infected patients smoke
• Smoking poses unique health risks to HIVinfected patients
– pulmonary infections
– oropharyngeal lesions
– AIDS-defining and non-AIDS-defining malignancies.
• Smoking is a known RF for atherosclerosis and is
associated with coronary events in patients on PIs
• “Graying” of HIV-infected population necessitates
screening for and prevention of chronic disease
– Coronary heart disease
– Diabetes
– Obesity
Prevalence of smoking among HIVinfected patients in New York
Burkhaler et al, Tobacco use and readiness to quit smoking in low-income HIVinfected persons, Nicotine Tob Res, 2005; 7(4):511-22.
• 428 HIV+ Medicaid recipients, NYC
–
–
–
–
Age: 22-75
59% males
53% African Americans, 30% Latinos
HS education or less : 87%
• 67% current smokers (mean=16 cig./day)
• 19% former smokers, 16% never smokers
• Current smokers
– Greater use of illicit substances (ever and current)
– Lower perceived health risk of continued smoking
Living Longer
Distribution of HIV/AIDS Discharges by
Age-group, 1994-2002
% of total HIV/AIDS discharges
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1994
1995
1996
1997
0-19
1998
20-29
1999
30-49
2000
50+
Source: SPARCS (Statewide Planning and Research Cooperative System)
2001
2002
Distribution of Medicaid recipients with
HIV/AIDS by age group, 1993-2001
100%
90%
80%
70%
%
60%
50%
40%
30%
20%
10%
0%
1993
1994
1995
1996
1997
1998
1999
0-19
20-29
30-49
50+
Source: NYS Medicaid Claims Database
2000
2001
Changing Morbidity and Mortality
Cancer
Lung disease
Cardiovascular disease
Cancer rates before and after
HAART
Trends in AIDS-Defining and Non–AIDSDefining Malignancies: 1989–2002
Bedimo, R et al. Trends in AIDS-defining and non-AIDS-defining malignancies
among HIV-infected patients: 1989-2002. Clin Inf Dis 2004;39:1380-1384
40
35
30
25
20
15
10
Years
5
0
89-96
97-02
ADM
non-ADM
Cancers of the larynx and oropharynx
Per 100,000 HIV/AIDS discharges
150
HAART
125
100
75
50
25
0
Per 100,000 recipients with HIV/AIDS
1994
1995
1996
1997
1998
1999
2000
2001
2002
160
140
HAART
120
100
80
60
40
20
0
1993
1994
1995
1996
Oropharynx
1997
1998
1999
Larynx
2000
2001
Cancers of the lung/trachea
800
Per 100,000 HIV/AIDS discharges
700
600
500
400
300
200
100
0
1994
1995
1996
1997
1998
1999
Lung, Trachea
Source: SPARCS
2000
2001
2002
Lung disease
per 100,000 HIV/AIDS discharges
Chronic Bronchitis and Emphysema
1400
1200
1000
800
600
400
200
0
1994
1995
1996
1997
Chronic Bronchitis
Source: SPARCS database, NYSDOH
1998
1999
2000
Emphysema
2001
2002
Cardiovascular disease
Myocardial infarction
Rate per 1000 patient-yrs
3.5
3
2.5
2
1.5
1
0.5
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
Holmberg et al. Trends in rates of Myocardial infarction among patients with HIV
N Engl J Med 2004; 350:730-731
2002
per 100,000 HIV/AIDS discharges
Acute Myocardial Infarction
800
700
600
500
400
300
200
100
0
1994
1995
1996
Source: SPARCS database, NYSDOH
1997
1998
1999
2000
2001
2002
Risk Factors Are Additive
The total severity of multiple low-level risk factors often exceeds that of
a single severely elevated risk factor.
27%
30
25
19%
20
15
10
13%
8%
5
0
BP 165/95 mm Hg
BP 165/95 mm Hg
Age 56 years
BP 165/95 mm Hg
Age 56 years
LDL-C 155 mg/dL
Grundy SM et al. J Am Coll Cardiol 1999;34:1348-1359.
BP 165/95 mm Hg
Age 56 years
LDL-C 155 mg/dL
Smoker
Are physicians intervening in
tobacco use?
Ellerbeck, Ahluwalia, et al. Direct observation of smoking cessation activities in
primary care practice. J Fam Pract. 2001; 50:688-693
In 38 primary care practices:
Tobacco was discussed in 21% of encounters.
Discussion was:
– more common in those practices (58%) with standard forms for
recording smoking status
– more common during new patient visits
– less common with older patients
– less common with physicians in practice more than 10 years
Barriers to treating tobacco
dependence
“Not enough time.”
“Patients don’t want to hear about it.”
“I can’t help patients stop.”
“Not enough time”
“Minimal interventions lasting less than 3
minutes increase overall tobacco abstinence
rates.”
The PHS Guideline
(Strength of Evidence = A)
“Patients don’t want to hear
about it”
• In several studies, smoking cessation interventions
during physician visits associated with increased
patient satisfaction with care among smokers
• 1,898 patients who reported that they had been
asked about tobacco use or advised to quit during
the latest visit had 10% greater satisfaction rating
and 5% less dissatisfaction than those not
reporting such discussions Mayo Clin Proc. 2001;76:138-143
Positive Changes in Health Promoting
Behavior Following Diagnosis with HIV
Collins et al, Health Psychology 2001; 20(5):351-360
100
90
80
70
60
50
40
30
20
10
0
Exercise
Diet
Smoking
Alcohol-drug
use
Interest in Quitting Smoking
Mamary et al, Cigarette smoking and the desire to quit among individuals living
with HIV, AIDS Patients Care and STDs 2002; 16(1):39-42
100
90
80
70
60
50
40
30
20
10
0
Thinking about
quitting
Interested in a
group
Interested in NRT
“I can’t help patients stop”
Effective clinical interventions
exist
The Public Health Service Clinical
Practice Guideline Treating
Tobacco Use and Dependence was
published in June, 2000 and offers
effective treatments for tobacco
dependence.
Summary Algorithm for
Treating Tobacco Dependence
The 5 A’s
For Patients Willing To Quit
• ASK about tobacco use at every visit.
• ADVISE to quit with a clear, strong,
personalized message.
• ASSESS willingness to make a quit
attempt within the next 30 days.
• ASSIST in quit attempt with a brief (3-5
min) counseling intervention.
• ARRANGE for follow-up
(ANTICIPATE relapse).
ASK
EVERY patient at EVERY visit
VITAL SIGNS
Blood Pressure: _______________________________
Pulse: ________________ Weight: _______________
Temperature: ________________________________
Respiratory Rate: _____________________________
Tobacco Use:
Current
Former
Never (circle one)
ADVISE
• Once tobacco use status has been identified and
documented, advise all tobacco users to quit
• Even brief advice to quit results in greater quit
rates
• Advice should be:
- clear
- strong
- personalized
“As your health care
provider, I must tell you that
the most important thing you
can do to improve your
health is to stop smoking.”
ASSESS
After providing a clear, strong,
and personalized message to
quit, you must determine
whether the patient is willing to
quit at this time
“Are you willing
to try to quit at
this time? I can
help you.”
ASSIST
• Help develop a quit plan
• Provide practical counseling
– Identify events, internal states, or activities that increase the risk of
smoking or relapse (e.g. drinking, other smokers).
– Identify and practice coping or problem-solving skills.
– Provide basic information about smoking and successful quitting.
• Provide intra-treatment social support
– Encourage the patient in the quit attempt.
– Communicate caring and concern.
– Encourage the patient to talk about the quitting process
• Help patient obtain extra-treatment social support
• Recommend pharmacotherapy (ex. special circumstances)
• Provide supplementary materials
Developing a quit plan
• Set a quit date
• Review past quit attempts
• Anticipate challenges
• Remove tobacco products
• Avoid
– Alcohol use
– Exposure to tobacco
Counsel your patients to quit
“Minimal interventions lasting less than 3 minutes
increase overall tobacco abstinence rates”
The PHS Guideline
(Strength of Evidence = A)
“There is a strong dose-response relation between the
session length of person-to-person contact and
successful treatment outcomes. Intensive
interventions are more effective than less intensive
interventions and should be used whenever
possible”
The PHS Guideline
(Strength of Evidence = A)
Brief Intervention
• 5-15 minute counseling session
• Four components
– State your concern about your patient’s
behaviors (smoking, use of alcohol/drugs, diet)
– Make explicit recommendation for change in
behavior
– Discuss patient’s reaction
– Review treatment options; negotiate plan
ARRANGE and ANTICIPATE
• Schedule a follow-up contact within one week
after the quit date
– Telephone contact
– Quit lines
• The majority of relapse occurs in the first two
weeks after quitting
Relapse
• Preventing Relapse
– Congratulate success
– Encourage continued abstinence
– Discuss with your patient:
• benefits of quitting
• barriers
“How has stopping
tobacco use helped
you?.”
• If your patient has used tobacco, remind him or
her that the relapse should be viewed as a learning
experience
• Relapse is consistent with the chronic nature of
tobacco dependence; not a sign of failure
Cell Phone Intervention Pilot Study:
Houston, Texas
Lazev et al, Increasing access to smoking cessation treatment in a low-income,
HIV-positive population: The feasibility of cellular telephones. Nicotine &
Tobacco Research, 2004; 6(2):281-286.
• Pilot study of a proactive cell phone smoking cessation
intervention (n=20)
• Thomas St. Clinic – 4000 medically indigent patients
(mostly Black and Hispanic)
• Six scheduled cell-phone delivered counseling sessions
delivered over two weeks (1 d prior to quit date, on quit
date, and 2, 4, 7, and 14 d post) – average 5 min
• 24 hr/7 d/week quit line, patient info also provided
• Highly successful: 95% made a quit attempt and 75% were
abstinent at 1 and 2 weeks post quit date
Treating patients who are not
ready to make a quit attempt with
Motivational Interviewing
• RELEVANCE: Tailor advice and discussion to each
patient, avoid argument!
• RISKS: Outline specific risks of smoking.
• REWARDS: Outline the benefits of quitting.
• ROADBLOCKS: Identify barriers to quitting.
• REPETITION: Reinforce the motivational message at
every visit, avoid argument!
Motivational Interviewing
Motivational interviewing is a directive,
client-centered counseling style for eliciting
behavior change by helping clients to
explore and resolve ambivalence.
Stephen Rollnick, William R. Miller, 1995
Rollnick, S., & Miller, W. R. What is motivational interviewing? Behavioural and Cognitive Psychotherapy.
1995;23:325-334.
Readiness to Change Model
Precontemplation
Relapse
Contemplation
Maintenance
Preparation
Action
Stages of Change in Two Populations of
HIV-infected Smokers
100
90
80
70
60
50
40
30
20
10
0
New York
p
Pr
e
p
nt
em
Co
Pr
e
co
nt
Houston
NY: Burkhaler et al, Tobacco use and readiness to quit smoking in low-income HIVinfected persons, Nicotine Tob Res, 2005; 7(4):511-22.
Houston: Gritz et al, Smoking behavior in a low-income multiethnic HIV/AIDS
population, Nicotine Tob Res, 2004; 6(1):71-77.
Precontemplation
Goal is to raise doubt, increase perception/
consciousness of problem
express concern
state the problem non-judgmentally
agree to disagree
advise a trial of abstinence or cutting down
importance of follow-up (even if still smoking/using drug
& alcohol )
less intensity is better
Samet, JH, Rollnick S, Barnes H. Arch Intern Med. 1996;156:2287-93.
Contemplation
Goal is to tip the balance
elicit positive and negative aspects of smoking or drug &
alcohol use
elicit positive and negative aspects of not smoking or
using drugs & alcohols
summarize (patient could write these down)
demonstrate discrepancies between values and actions
advise a trial of abstinence or cutting down
Preparation
Goal is to help determine the best course of action
working on motivation is not helpful
supporting self-efficacy is (remind of strengths--i.e.
previous quits, periods of sobriety, coming to doctor)
help decide on achievable goals
caution re: difficult road ahead
relapse won’t disrupt relationship
Action
Goal is to help patient take steps to change
support and encouragement
acknowledge discomfort (losses, withdrawal)
reinforce importance of recovery
Maintenance
Goal is to help prevent relapse
anticipate difficult situations (triggers)
recognize the ongoing struggle
support the patient’s resolve
reiterate that relapse won’t disrupt your relationship
Relapse
Goal is to renew the process of contemplation
explore what can be learned from the relapse
express concern
emphasize the positive aspects of prior abstinence and of
current efforts to quit smoking or drug & alcohol use
support self-efficacy
Ingredients of Effective Brief
Interventions (FRAMES)
FEEDBACK of personal risk or impairment
i.e. CHD, lung disease, state consequences or risks
emphasis on personal RESPONSIBILITY for
change
“…it’s up to you to decide…”
clear ADVICE to change
identify the problem, explain why change is important,
advocate specific change
Ingredients of Effective Brief
Interventions (FRAMES)
a MENU of alternatives
a range of options
EMPATHIC counseling style
understanding and reflective
enhancement of SELF-EFFICACY
reinforce it, state your belief they can do it
Physician’s Treatment Goals
• Maintain awareness of smoking and other drug &
alcohol issues
• Ask, assess and advise
• Consider smoking and drug & alcohol problems as a
mainstream medical issues
• Counsel patients about behavior change at every
visit
Parliament ad in Details, Cosmopolitan,
Mademoiselle, Penthouse, 1995
Parliament ad in Out magazine, 1995
Adult smoking
rates
NYC
2003 21.5%
2004 18.9%
USA
2003 21.6%
2004 20.7%
For more HIV-related resources,
please visit www.hivguidelines.org