Transcript Rx for Change - University of California, San Francisco

Rx for CHANGE
Assisting Patients with Tobacco Cessation
TRAINING OVERVIEW

Epidemiology of Tobacco Use

Addiction to Nicotine and Medications for Quitting

Changing Behavior
EPIDEMIOLOGY
of TOBACCO USE
“CIGARETTE
SMOKING…
is the chief, single,
avoidable cause of death
in our society and the most
important public health
issue of our time.”
C. Everett Koop, M.D., former U.S. Surgeon General
ADULT PER-CAPITA CONSUMPTION
of TOBACCO, 1880–2005
14
Pounds of tobacco per capita
12
10
Snuff
8
6
Chewing
tobacco
Pipe/roll
your own
All forms
of
tobacco
are
harmful.
4
Cigarettes
2
Cigars
0
1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
Year
Adapted from NCI Smoking and Tobacco Control Monograph 8, 1997, p. 13. Data from U.S. Department of Agriculture.
Reprinted with permission. Thun et al. 2002. Oncogene 21:7307–7325.
TRENDS in ADULT SMOKING, by
SEX—U.S., 1955–2006
Trends in cigarette current smoking among persons aged 18 or older
60
50
20.8% of adults
are current
smokers
Male
Percent
40
30
20
23.9%
Female
18.0%
10
0
1955
1959
1963
1967
1971
1975
1979
1983
1987
1991
1995
1999
2003
Year
70% want to quit
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population
Survey; 1965–2005 NHIS. Estimates since 1992 include some-day smoking.
STATE-SPECIFIC PREVALENCE of
SMOKING among ADULTS, 2006
Prevalence of
current smoking
(2006)
< 18.0%
18.0 – 19.9%
20.0 – 21.9%
22.0 – 23.9%
≥ 24.0%
Centers for Disease Control and Prevention. (2007). MMWR 56:993–996.
PREVALENCE of ADULT SMOKING,
by RACE/ETHNICITY—U.S., 2006
32.4% American Indian/Alaska Native*
23.0% Black*
21.9% White*
15.2% Hispanic
10.4% Asian*
0%
10%
20%
30%
40%
50%
* non-Hispanic.
Centers for Disease Control and Prevention. (2007). MMWR 56:1157–1161.
PREVALENCE of ADULT SMOKING,
by EDUCATION—U.S., 2006
26.7% No high school diploma
46.0% GED diploma
23.8% High school graduate
22.7% Some college
9.6% Undergraduate degree
6.6% Graduate degree
0%
10%
20%
30%
40%
50%
Centers for Disease Control and Prevention. (2007). MMWR 56:1157–1161.
TRENDS in TEEN SMOKING, by
ETHNICITY—U.S., 1977–2007
Trends in cigarette smoking among 12th graders: 30-day prevalence of use
50
40
Percent
White
30
Hispanic
20
Black
10
0
1977
1982
1987
1992
1997
2002
2007
Year
Institute for Social Research, University of Michigan, Monitoring the Future Project
www.monitoringthefuture.org
PUBLIC HEALTH versus
“BIG TOBACCO”
The biggest opponent to tobacco
control efforts is the tobacco
industry itself.
Nationally, the tobacco industry is outspending
our state tobacco control funding.
For every $1 spent by the states, the tobacco industry
spends $18 to market its products.
TOBACCO INDUSTRY
ADVERTISING
Billions of dollars spent

$13.11 billion spent in the U.S. in 2005
 $35.9 million a day
 95% increase over 1998 figures
15
New marketing
restrictions
10
5
0
1970
1997
1998
1999
2000
2001
2002
2003
2004
2005
Year
Federal Trade Commission. (2007). Cigarette Report for 2004 and 2005.
The TOBACCO INDUSTRY


For decades, the tobacco industry publicly denied the addictive
nature of nicotine and the negative health effects of tobacco.
April 14, 1994: Seven top executives of major tobacco
companies state, under oath, that they believe nicotine is not
addictive: http://www.jeffreywigand.com/7ceos.php (video)



Tobacco industry documents indicate otherwise
Documents available at http://legacy.library.ucsf.edu
The cigarette is a heavily engineered product.
 Designed and marketed to maximize bioavailability
of nicotine and addictive potential
 Profits over people
COMPOUNDS in TOBACCO
SMOKE
An estimated 4,800 compounds in tobacco smoke,
including 11 proven human carcinogens
Gases





Carbon monoxide
Hydrogen cyanide
Ammonia
Benzene
Formaldehyde
Particles





Nicotine
Nitrosamines
Lead
Cadmium
Polonium-210
Nicotine is the addictive component of tobacco products,
but it does NOT cause the ill health effects of tobacco use.
ANNUAL U.S. DEATHS ATTRIBUTABLE
to SMOKING, 1997–2001
Percentage of all smokingattributable deaths*
Cardiovascular diseases
Lung cancer
Respiratory diseases
137,979
123,836
101,454
32%
28%
23%
Second-hand smoke*
Cancers other than lung
Other
38,112
34,693
1,828
9%
8%
<1%
TOTAL: 437,902 deaths annually
* In 2005, it was estimated that nearly 50,000 persons died due to second-hand smoke exposure.
Centers for Disease Control and Prevention. (2005). MMWR 54:625–628.
2004 REPORT of the
SURGEON GENERAL:
HEALTH CONSEQUENCES OF SMOKING
FOUR MAJOR CONCLUSIONS:




Smoking harms nearly every organ of the body, causing many
diseases and reducing the health of smokers in general.
Quitting smoking has immediate as well as long-term benefits,
reducing risks for diseases caused by smoking and improving
health in general.
Smoking cigarettes with lower machine-measured yields of tar
and nicotine provides no clear benefit to health.
The list of diseases caused by smoking has been expanded.
U.S. Department of Health and Human Services. (2004). The Health
Consequences of Smoking: A Report of the Surgeon General.
HEALTH CONSEQUENCES
of SMOKING

Cancers











Acute myeloid leukemia
Bladder and kidney
Cervical
Esophageal
Gastric
Laryngeal
Lung
Oral cavity and pharyngeal
Pancreatic






Acute (e.g., pneumonia)
Chronic (e.g., COPD)



Abdominal aortic aneurysm
Coronary heart disease
Cerebrovascular disease
Peripheral arterial disease
Reproductive effects

Pulmonary diseases

Cardiovascular diseases
Reduced fertility in women
Poor pregnancy outcomes
(e.g., low birth weight, preterm
delivery)
Infant mortality
Other effects: cataract,
osteoporosis, periodontitis, poor
surgical outcomes
U.S. Department of Health and Human Services. (2004). The Health
Consequences of Smoking: A Report of the Surgeon General.
FORMS of SMOKED
TOBACCO PRODUCTS
Cigarettes:


Most common form in the U.S.; typically sold in packs of 20
cigarettes
Average machine yield (per cigarette)


Nicotine 0.88 mg (range <0.05 to 2.0 mg)
Tar 12 mg (range <0.5 to 27 mg)
Cigars:
 Increased popularity over past decade
 Tobacco content of cigars varies greatly

One cigar can deliver enough nicotine to establish and maintain dependence
Clove cigarettes:
 Mixture of tobacco and cloves
 Prevalent use among young smokers
 2 times the tar and nicotine content of standard U.S. cigarettes
Marlboro and Marlboro Light are registered trademarks of Philip Morris, Inc.
FORMS of SMOKED
TOBACCO PRODUCTS (cont’d)
Bidis

Imported from India

Resemble marijuana joints

Available in candy flavors


Exterior and interior of a bidi and a
standard U.S. cigarette
Deliver higher levels of tar,
carbon monoxide, and nicotine
than cigarettes
“Cigarettes with training wheels”
Images courtesy of the Centers for Disease Control and Prevention / Dr. Clifford H. Watson
FORMS of SMOKED
TOBACCO PRODUCTS (cont’d)
Hookah (waterpipe smoking)

Also known as






Shisha
Narghile
Goza
Hubble bubble
Tobacco flavored with fruit pulp,
honey, and molasses
Increasingly popular among young
smokers in coffee houses, bars, and
lounges
Image courtesy of Mr. Sami Romman / www.hookah-shisha.com
FORMS of SMOKELESS
TOBACCO PRODUCTS



Estimated 8.1 million users in
the U.S. in 2007
Loose leaf
Plug
Males (6.3%) more likely than
females (0.4%) to be current
users
Twist
Prevalence highest among



Young adults aged 18-25 years
American Indians and Alaskan
Natives
Residents of the southern U.S. and
rural areas
Snuff
The Copenhagen and Skoal logos are registered trademarks of U.S. Smokeless Tobacco Company, and
Red Man is a registered trademark of Swedish Match.
HEALTH CONSEQUENCES of
SMOKELESS TOBACCO USE
Periodontal effects



Gingival recession
Bone attachment loss
Dental caries
Oral leukoplakia
Cancer


Oral cancer
Pharyngeal cancer
Oral Leukoplakia
Image courtesy of Dr. Sol Silverman University of California San Francisco
ANNUAL SMOKING-ATTRIBUTABLE
ECONOMIC COSTS—U.S., 1995–1999
Prescription
drugs,
$6.4 billion
Medical
expenditures
(1998)
Ambulatory care,
$27.2 billion
Hospital care,
$17.1 billion
Other care,
$5.4 billion
Nursing home,
$19.4 billion
Societal costs:
$7.18 per pack
Annual lost
productivity
costs
(1995–1999)
Men,
$55.4 billion
0
10
20
30
Women,
$26.5 billion
40
50
60
70
80
Billions of dollars
Centers for Disease Control and Prevention. (2002). MMWR 51:300–303.
2006 REPORT of the
SURGEON GENERAL:
INVOLUNTARY EXPOSURE to TOBACCO SMOKE


Second-hand smoke causes premature death and disease
in nonsmokers (children and adults)
Children:



There is no
safe level of
second-hand
smoke.
Increased risk for sudden infant death syndrome
(SIDS), acute respiratory infections, ear problems, and
more severe asthma
Respiratory symptoms and slowed lung growth if parents smoke
Adults:

Immediate adverse effects on cardiovascular system

Increased risk for coronary heart disease and lung cancer

Millions of Americans are exposed to smoke in their homes/workplaces

Indoor spaces: eliminating smoking fully protects nonsmokers

Separating smoking areas, cleaning the air, and ventilation are ineffective
USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke:
Report of the Surgeon General.
FINANCIAL IMPACT of SMOKING
Buying cigarettes every day for 50 years @ $4.32 per pack
Money banked monthly, earning 4% interest
$755,177
$755,177
$503,451
$503,451
Packs
per
day
$251,725
$251,725
0
200
400
600
Dollars lost, in thousands
800
SMOKING CESSATION:
REDUCED RISK of DEATH
Prospective study of 34,439 male British doctors
Mortality was monitored for 50 years (1951–2001)


Years of life gained
15
On average, cigarette
smokers die approximately
10 years younger than do
nonsmokers.
10
5
0
30
40
50
60
Among those who continue
smoking, at least half
will die due to a
tobacco-related disease.
Age at cessation (years)
Doll et al. (2004). BMJ 328(7455):1519–1527.
QUITTING: HEALTH BENEFITS
Time Since Quit Date
Circulation improves,
walking becomes easier
Lung function increases
up to 30%
Excess risk of CHD
decreases to half that of a
continuing smoker
Lung cancer death rate
drops to half that of a
continuing smoker
Risk of cancer of mouth,
throat, esophagus,
bladder, kidney, pancreas
decrease
Lung cilia regain normal
function
2 weeks
to
3 months
1 to 9
months
Ability to clear lungs of mucus
increases
Coughing, fatigue, shortness of
breath decrease
1
year
5
years
Risk of stroke is reduced to that
of people who have never
smoked
after
15 years
Risk of CHD is similar to that of
people who have never smoked
10
years
TOBACCO DEPENDENCE:
A 2-PART PROBLEM
Tobacco Dependence
Physiological
Behavioral
The addiction to nicotine
The habit of using tobacco
Treatment
Medications for cessation
Treatment
Behavior change program
Treatment should address the physiological
and the behavioral aspects of dependence.
PROBLEM #1:
ADDICTION TO NICOTINE
WHAT IS ADDICTION?
”Compulsive drug use, without
medical purpose, in the face of
negative consequences”
Alan I. Leshner, Ph.D.
Former Director, National Institute on Drug Abuse
National Institutes of Health
NICOTINE DISTRIBUTION
Plasma nicotine (ng/ml)
80
Arterial
70
60
50
40
30
Venous
20
10
0
0
1
2
3
4
5
6
7
8
9
10
Minutes after light-up of cigarette
Nicotine reaches the brain within 11 seconds.
Henningfield et al. (1993). Drug Alcohol Depend 33:23–29.
DOPAMINE REWARD PATHWAY
Prefrontal
cortex
Dopamine release
Stimulation of
nicotine receptors
Nucleus
accumbens
Ventral
tegmental
area
Nicotine enters
brain
BIOLOGY of NICOTINE ADDICTION:
ROLE of DOPAMINE
Nicotine
stimulates
dopamine release
Nicotine addiction
is not just a bad habit.
Pleasurable feelings
Discontinuation leads to
withdrawal symptoms.
Repeat administration
Tolerance develops
Benowitz. (2008). Clin Pharmacol Ther 83:531–541.
NICOTINE PHARMACODYNAMICS:
WITHDRAWAL EFFECTS

Irritability/frustration/anger

Anxiety

Difficulty concentrating

Restlessness/impatience

Depressed mood/depression

Insomnia

Impaired performance

Increased appetite/weight gain

Cravings
Most symptoms manifest
within the first 1–2 days,
peak within the first
week, and subside within
2–4 weeks.
HANDOUT
Hughes. (2007). Nicotine Tob Res 9:315–327.
NICOTINE ADDICTION

Tobacco users maintain a minimum serum
nicotine concentration in order to




Prevent withdrawal symptoms
Maintain pleasure/arousal
Modulate mood
Users self-titrate nicotine intake by



Smoking/dipping more frequently
Smoking more intensely
Obstructing vents on low-nicotine brand cigarettes
Benowitz. (2008). Clin Pharmacol Ther 83:531–541.
FDA-APPROVED MEDICATIONS
for CESSATION
Nicotine polacrilex gum


Nicorette (OTC)
Generic nicotine gum (OTC)
Nicotine lozenge


Commit (OTC)
Generic nicotine lozenge (OTC)
Nicotine transdermal patch



Nicotine nasal spray

Nicotrol NS (Rx)
Nicotine inhaler

Nicotrol (Rx)
Bupropion SR (Zyban)
Varenicline (Chantix)
Nicoderm CQ (OTC)
Nicotrol (OTC)
Generic nicotine patches (OTC, Rx)
These are the only medications that are
FDA-approved for smoking cessation.
PHARMACOTHERAPY
“Clinicians should encourage all
patients attempting to quit to use
effective medications for tobacco
dependence treatment, except where
contraindicated or for specific
populations* for which there is
insufficient evidence of effectiveness.”
* Includes pregnant women, smokeless tobacco users, light smokers, and adolescents.
Medications significantly improve success rates.
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
PHARMACOTHERAPY:
USE in PREGNANCY

The Clinical Practice Guideline makes no recommendation
regarding use of medications in pregnant smokers

Insufficient evidence of effectiveness

Category C: varenicline, bupropion SR

Category D: prescription formulations of NRT
“Because of the serious risks of smoking to the
pregnant smoker and the fetus, whenever
possible pregnant smokers should be offered
person-to-person psychosocial interventions
that exceed minimal advice to quit.” (p. 165)
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
PHARMACOTHERAPY:
OTHER SPECIAL POPULATIONS
Pharmacotherapy is not recommended for:

Smokeless tobacco users

No FDA indication for smokeless tobacco cessation

Individuals smoking fewer than 10 cigarettes per day

Adolescents


Nonprescription sales (patch, gum, lozenge) are restricted to
adults ≥18 years of age
NRT use in minors requires a prescription
Recommended treatment is behavioral counseling.
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
NRT: RATIONALE for USE



Reduces physical withdrawal from nicotine
Eliminates the immediate, reinforcing effects
of nicotine that is rapidly absorbed via tobacco
smoke
Allows patient to focus on behavioral and
psychological aspects of tobacco cessation
NRT products approximately doubles quit rates.
PLASMA NICOTINE CONCENTRATIONS
for NICOTINE-CONTAINING PRODUCTS
Nicotine levels for various nicotine-containing products
25
Cigarette
Cigarette
Moist snuff
Plasma nicotine (mcg/l)
20
Moist snuff
Nasal spray
15
Inhaler
10
Lozenge (2mg)
Gum (2mg)
5
Patch
0
1/0/1900
0
1/10/1900
10
1/20/1900
20
1/30/1900
30
Time (minutes)
2/9/1900
40
2/19/1900
50
2/29/1900
60
NICOTINE GUM
Nicorette (GlaxoSmithKline); generics

Resin complex





Nicotine
Polacrilin
Sugar-free chewing gum base
Contains buffering agents to enhance
buccal absorption of nicotine
Available: 2 mg, 4 mg; original, cinnamon,
fruit, mint (various), and orange flavors
NICOTINE LOZENGE
Commit (GlaxoSmithKline); generics

Nicotine polacrilex formulation




Delivers ~25% more nicotine
than equivalent gum dose
Sugar-free mint (various),
cappuccino or cherry flavor
Contains buffering agents to
enhance buccal absorption of
nicotine
Available: 2 mg, 4 mg
TRANSDERMAL NICOTINE PATCH
NicoDerm CQ (GlaxoSmithKline); generic



Nicotine is well absorbed across the skin
Delivery to systemic circulation avoids hepatic firstpass metabolism
Plasma nicotine levels are lower and fluctuate less
than with smoking
NICOTINE NASAL SPRAY
Nicotrol NS (Pfizer)




Aqueous solution of nicotine
in a 10-ml spray bottle
Each metered dose
actuation delivers
 50 mcL spray
 0.5 mg nicotine
~100 doses/bottle
Rapid absorption across
nasal mucosa
NICOTINE INHALER
Nicotrol Inhaler (Pfizer)

Nicotine inhalation system
consists of:



Mouthpiece
Cartridge with porous plug
containing 10 mg nicotine and
1 mg menthol
Delivers 4 mg nicotine vapor,
absorbed across buccal
mucosa
BUPROPION SR
Zyban (GlaxoSmithKline); generic



Nonnicotine
cessation aid
Sustained-release
antidepressant
Oral formulation
VARENICLINE
Chantix (Pfizer)



Nonnicotine
cessation aid
Partial nicotinic
receptor agonist
Oral formulation
HERBAL DRUGS
for SMOKING CESSATION

Lobeline




Derived from leaves of Indian
tobacco plant (Lobelia inflata)
Partial nicotinic agonist
No scientifically rigorous trials
with long-term follow-up
No evidence to support use
for smoking cessation
Illustration courtesy of Missouri Botanical Garden ©1995-2005. http://www.illustratedgarden.org/
LONG-TERM (6 month) QUIT RATES for
AVAILABLE CESSATION MEDICATIONS
30
Active drug
Placebo
Percent quit
25
20
23.9
20.2
19.0
18.0
17.1
16.1
15.8
15
11.8
11.3
10
9.9
8.1
Nicotine
patch
Nicotine
lozenge
9.1
10.3
11.2
5
0
Nicotine gum
Nicotine
nasal spray
Nicotine
inhaler
Bupropion
Varenicline
Data adapted from Cahill et al. (2008). Cochrane Database Syst Rev; Stead et al. (2008).
Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev
COMBINATION PHARMACOTHERAPY
Regimens with enough evidence to be ‘recommended’ first-line

Combination NRT
Long-acting formulation (patch)

Produces relatively constant levels of nicotine
PLUS
Short-acting formulation (gum, inhaler, nasal spray)


Allows for acute dose titration as needed for nicotine
withdrawal symptoms
Bupropion SR + Nicotine Patch
YOUR ROLE in PROMOTING
CORRECT MEDICATION USE


Most patients under dose the products.
You can have an important impact on patients’
success in quitting if you:


Instruct patients to read all directions.
Advise patients to use the products according
to the recommended dosing schedule.

Use on a steady, consistent basis throughout the day

Do not use “as needed.”
COMPARATIVE DAILY COSTS
of PHARMACOTHERAPY
Average $/pack of cigarettes, $4.32
$8
$7
$6
$/day
$5
$4
$3
$2
$1
$0
Gum
Lozenge
Patch
Inhaler
Nasal spray
Bupropion
SR
Varenicline
Trade
$6.58
$5.26
$3.89
$5.29
$3.72
$7.40
$4.75
Generic
$3.28
$3.66
$1.90
-
-
$3.62
-
Medications are
effective, but they are
just one component of
comprehensive
treatment for tobacco
cessation.
Behavior change is
equally important.
CLOSE TO HOME © 2000 John McPherson.
Reprinted with permission of UNIVERSAL PRESS SYNDICATE.
All rights reserved.
PROBLEM #2:
CHANGING BEHAVIOR
TOBACCO CESSATION
REQUIRES BEHAVIOR CHANGE




Fewer than 5% of people who quit without assistance
are successful in quitting for more than a year.
Few patients adequately PREPARE and PLAN for their
quit attempt.
Many patients do not understand the need to change
behavior
Patients think they can just “make themselves quit”
Behavioral counseling is a key component of treatment
for tobacco use and dependence.
CHANGING BEHAVIOR (cont’d)

Often, patients automatically smoke in the
following situations:






When drinking coffee
While driving in the car
When bored
While stressed
While at a bar with friends




After meals
During breaks at work
While on the telephone
While with specific friends or family
members who use tobacco
Behavioral counseling helps patients learn to
cope with these difficult situations without
having a cigarette.
CLINICIANS CAN MAKE a
DIFFERENCE
Estimated abstinence at
5+ months
With help from a clinician, the odds of quitting approximately doubles.
30
n = 29 studies
Compared to patients who receive no assistance from a
clinician, patients who receive assistance are 1.7–2.2
times as likely to quit successfully for 5 or more months.
20
10
1.7
1.0
1.1
No clinician
Self-help
material
2.2
0
Nonphysician
clinician
Physician
clinician
Type of Clinician
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
Estimated abstinence rate
at 5+ months
The NUMBER of CLINICIANS
CAN MAKE a DIFFERENCE, too
30
n = 37 studies
Compared to smokers who receive assistance
from no clinicians, smokers who receive
assistance from two or more clinicians are 2.4–
2.5 times as likely to quit successfully for 5 or
more months.
2.5
20
1.8
10
2.4
(1.9,3.4)
(2.1,3.4)
Two
Three or more
(1.5,2.2)
1.0
0
None
One
Number of Clinician Types
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
BRIEF COUNSELING:
ASK, ADVISE, REFER
ASK
about tobacco USE
ADVISE
tobacco users to QUIT
REFER
to other resources
Patient receives assistance,
with follow-up counseling
arranged, from other
resources such as the
tobacco quitline
ASSIST
ARRANGE
STEP 1: ASK

ASK about tobacco use
Ask

“Do you, or does anyone in your household, ever smoke
or use any type of tobacco?”


“We like to ask our patients about tobacco use,
because it has the potential to interact with many
medications.”
“We like to ask our patients about tobacco use,
because it contributes to many medical conditions.”
STEP 2: ADVISE

ADVISE tobacco users to quit (clear, strong,
personalized)

“It’s important that you quit as soon as possible, and I can help
you.”

“Cutting down while you are ill is not enough.”

“Occasional or light smoking is still harmful.”

“I realize that quitting is difficult. It is the most important thing
you can do to protect your health now and in the future. I have
training to help my patients quit, and when you are ready, I will
work with you to design a specialized treatment plan.”
STEP 3: REFER

REFER tobacco users to other resources
Referral options:




A doctor, nurse, pharmacist, or other clinician, for
additional counseling
A local group program
The support program provided free with each smoking
cessation medication
The toll-free telephone quit line: 1-800-QUIT-NOW
BRIEF COUNSELING:
ASK, ADVISE, REFER (cont’d)

Brief interventions have been shown to be effective

In the absence of time or expertise:

Ask, advise, and refer to other resources, such as
local group programs or the toll-free quitline
1-800-QUIT-NOW
This brief
intervention can be
achieved in less
than 1 minute.
WHAT ARE
“TOBACCO QUITLINES”?





Tobacco cessation counseling, provided at no cost
via telephone to all Americans
Staffed by trained specialists
Up to 4–6 personalized sessions (varies by state)
Some state quitlines offer nicotine replacement
therapy at no cost (or reduced cost)
Up to 30% success rate for patients who complete
sessions
Most health-care providers, and most patients,
are not familiar with tobacco quitlines.
WHEN a PATIENT CALLS the
QUITLINE

Counselor or Intake Specialist Answers


Caller is routed to language-appropriate staff
Brief Questionnaire



Contact and demographic information
Smoking behavior (e.g., cigarettes per day)
Choice of services
WHEN a PATIENT CALLS the
QUITLINE (cont’d)

Services provided



Referral to local programs
Quitting literature mailed within 24 hrs
Individualized telephone counseling


Confidential
Professional, trained counselors
Quitlines have broad reach and are recommended as an
effective strategy in the 2008 Clinical Practice Guideline.
WHY SHOULD CLINICIANS
ADDRESS TOBACCO?


Tobacco users expect to be encouraged to quit
by health professionals.
Screening for tobacco use and providing
tobacco cessation counseling are positively
associated with patient satisfaction (Barzilai et
al., 2001).
Failure to address tobacco use tacitly implies that
quitting is not important.
Barzilai et al. (2001). Prev Med 33:595–599.
HELPING PATIENTS QUIT IS a
CLINICIAN’S RESPONSIBILITY
TOBACCO USERS DON’T PLAN TO FAIL.
MOST FAIL TO PLAN.
Clinicians have a professional obligation
to address tobacco use and can have
an important role in helping patients
plan for their quit attempts.
THE DECISION TO QUIT LIES
IN THE HANDS OF EACH PATIENT.
MAKE a COMMITMENT…
Address tobacco use
with all patients.
At a minimum,
make a commitment to incorporate brief tobacco
interventions as part of routine patient care.
Ask, Advise, and Refer.
DR. GRO HARLEM BRUNTLAND,
FORMER DIRECTOR-GENERAL of the WHO:
“If we do not act decisively, a hundred
years from now our grandchildren and
their children will look back and
seriously question how people claiming
to be committed to public health and
social justice allowed the tobacco
epidemic to unfold unchecked.”
USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS.
WHAT IF…
a patient asks you
about your use of
tobacco?