Transcript PDA Software for Patients

Innovative
Approaches to
Smoking Cessation
Treatment
Scott M. Strayer, MD, MPH
Associate Professor
University of Virginia, Dept. of Family
Medicine
Center for Information Mastery
UVA Cardiology Grand Rounds, Feb 2008
Copyright© 2008 Scott Strayer
Objectives
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Review evidence-based smoking cessation
guidelines and preview of 2008 guidelines to be
published on May 1
Describe the latest evidence for treatments during
smoking cessation, including the use of tricyclic
anti-depressants in adults and patches in
adolescents.
Be able to describe the key components of
“Motivational Interviewing” and the “Stages of
Change” and how they are used in smoking
cessation counseling.
Identify web-based and computer resources that
assist physicians with smoking cessation
counseling.
Identify web-based and computer resources that
assist patients with smoking cessation.
How well do we address
smoking cessation?
• Not very well!!
– Only 35% of Physicians assist with
smoking cessation attempts (Thorndike
AN, Rigotti NA, Stafford RS, Singer DE.
National patterns in the treatment of
smokers by physicians. JAMA 1998;
279:604-608).
Am J Public Health. 2007 Oct;97(10):1878-83. Epub 2007 Aug 29. The treatment of
smoking by US physicians during ambulatory visits: 1994 2003. Thorndike AN, Regan S,
Rigotti NA.
Smoking Cessation is
Effective!
• Quitting at age 50, adds 6 years of life
expectancy, quitting at 30 adds up to 10
years1
• Colorectal cancer screening adds 7.3 to
21.9 days of life depending on strategy2
• Mammography adds 9.8 days for
women 60-69 and 11.7 days for women
50-593
1 Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years'
observations on male british doctors. BMJ. 2004;328:1519.
2 Frazier AL, Colditz GA, Fuchs CS, Kuntz KM. Cost-effectiveness of screening for colorectal
cancer in the general population. JAMA. 2000;284:1954-1961.
3 Kattlove H, Liberati A, Keeler E, Brook RH. Benefits and costs of screening and treatment
for early breast cancer. development of a basic benefit package. JAMA. 1995;273:142-148.
Examples in Cardiology
Pignone M, Eamshaw S, Tice J, Pletcher M, Aspirin, Statins, or Both Drugs for the Primary Prevention
Of Coronary Heart Disease Events in Men: A Cost-Utility Analysis. Ann Intern Med. 2006; 144:326-336
Explaining Declining CHD in
England
Unal B, Chitchley J, Capewell S, Explaining the Decline in Coronary Heart Disease Mortality in England
And Wales Between 1981 and 2000 Circulation. 2004;109:1101-1107.
What We Know…
New Guidelines
will be released in
May 2008
• Tobacco dependence is a chronic
condition that often requires
repeated intervention.
• Because effective tobacco
dependence treatments are available,
every patient who uses tobacco
should be offered at least one of
these treatments.
• It is essential that clinicians and
health care delivery systems
(including administrators, insurers,
and purchasers) institutionalize the
consistent identification,
documentation, and treatment of
every tobacco user seen in a health
care setting.
• Brief tobacco dependence treatment
is effective, and every patient who
uses tobacco should be offered at
least brief treatment.
• There is a strong dose-response
relation between the intensity of
tobacco dependence counseling and
its effectiveness.
• Three types of counseling and behavioral
therapies were found to be especially
effective and should be used with all
patients attempting tobacco cessation:
• Provision of practical counseling (problem
solving/skills training).
• Provision of social support as part of
treatment (intra-treatment social support).
• Help in securing social support outside of
treatment (extra-treatment social support).
• Numerous effective pharmacotherapies for smoking
cessation now exist. Except in the presence of
contraindications, these should be used with all
patients attempting to quit smoking.
• Five first-line pharmacotherapies were identified that
reliably increase long-term smoking abstinence rates:
• Bupropion SR.
• Nicotine gum.
• Nicotine inhaler.
• Nicotine nasal spray. Nicotine patch.
• Two second-line pharmacotherapies were identified as
efficacious and may be considered by clinicians if firstline pharmacotherapies are not effective:
• Clonidine.
• Nortriptyline.
• Over-the-counter nicotine patches are effective relative
to placebo, and their use should be encouraged.
New Medications Since
Guidelines Published
• There are now 7 first-line medications
– Nicotine Lozenges
– Varenicline
• Others are under development
– Nicotine Vaccines---currently in Phase 2
and 3 trials
New Drug Information for
2008 Guidelines
Combination Therapies in
2008 Guidelines
Caution with Varenicline
• Post-marketing suicides (39), erratic
behavior, mood changes (420) and
sedation during medication use
– Not all had quit smoking
– Not all had previous psychiatric dz
• Ongoing safety review at FDA
• Close f/u, warn patients about possible
side effects, caution with psychiatric
patients
Current FDA Warning
• Tobacco dependence treatments are
both clinically effective and costeffective relative to other medical
and disease prevention
interventions.
New Counseling Interventions
for 2008 Guidelines
• Use of proactive telephone counseling
(OR of quitting=1.6 [1.4,1.8], abstinence
rates 12.7%, meta-analysis of 9 studies
vs. minimal, no counseling or self-help)
• Emphasis on counseling + meds
• More on motivational treatments
• Calls for innovative and more effective
counseling strategies
Is It Possible?
• To deliver all the preventive services
recommended by the USPTF to an
average panel of patients, family
physicians would need to spend 7.5
hours of every working day on
prevention alone…
Yarnell KS, Pollac KI, Ostbye T, Krause KM, Michener JL. Primary care: is
there enough time for prevention? AM J Public Health 2003;93:635-41.
Leveraging 1 Minute for
Prevention
1 minute is the realistic average amount
of time that primary care providers can
devote to prevention during a typical
office visit
Stange, KC, Woolf, SH, Gjeltema K. One minute for prevention: The
power of leveraging to fulfill the promise of health behavior counseling.
Am J Prev Med, 2002; 22:320-323.
Opportunities for Intervention
• Most people visit their doctor about three
times per year.
• Even 2-3 minute interventions are effective,
especially when followed up with telephone,
e-mail, nurse calls, referrals, 1-800 numbers,
etc.
• Many primary care providers provide 2-3
minute health promotion/behavior
interventions at every outpatient visit.
Stange, KC, Woolf, SH, Gjeltema K. One minute for prevention: The power of
leveraging to fulfill the promise of health behavior counseling. Am J Prev Med,
2002; 22:320-323.
The other elements of brief
health promotion
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Goal setting
Specific Behavior Change Techniques
Self-help Materials
Regular Follow-up
In the 1 minute devoted to
preventive/behavioral issues,
the doctor can either “plant
the seed” for Interactive
Behavioral Change
Technology (IBCT) to
cultivate after the visit, or
“reap the fruit” of IBCT
interventions that have taken
place prior to the visit.
Glasgow R, Bull S, Piette J, Steiner J. Interactive behavior change technology:
A partial solution to the competing demands of primary care. Am J Prev Med
2004; 27:80-87.
Glasgow R, Bull S, Piette J, Steiner J.
Interactive behavior change technology: A
partial solution to the competing demands of
primary care. Am J Prev Med 2004; 27:80-87.
Effective Behavioral Change
Theories
• Stages of Change----assess patient’s
readiness to change and then deliver
stage-appropriate interventions (Prochaska
and DiClemente)
• Motivational Interviewing (MI)---a nonconfrontational, patient-centered
technique for helping patients change
their health behavior (Miller and Rollnick)
Stages of Change
• Pre-contemplation-pt is not ready to
initiate change.
• Contemplation-pt is considering
making change in next 6 months.
• Preparation-pt is ready to make
change in 30 days.
• Action-pt is making change.
• Maintenance-pt has made change.
Assess
• Are you thinking about quitting in the next 6
months? (No=Precontemplation)
– If YES
– Are you thinking about quitting in the next 30
days? (No=Contemplation, Yes=Preparation)
• How important do you think it is for you to
quit smoking?
• How confident are you that you could quit
smoking if you wanted to?
Overview of MI
• Directive, patient-centered counseling
• Focus on user’s feelings, beliefs, ideas
and values about using tobacco
• Attempt to uncover ambivalence about
tobacco use
• Then elicit supports and strengthen
“change talk” and “commitment talk”
Techniques for MI
• Precontemplation
– Pros and cons of smoking
– Personalizing risks
– Re-assess after intervention
• Contemplation
– How long have they been considering?
– What has worked in the past (if quit
before)?
– Pros and cons of quitting
– Personalize risks and rewards
Techniques for MI
• Preparation
– Clarify goal (quit entirely, cut down)
– Get input on patient’s plans on how to
do it
– Discuss a “change plan”---use of
medication, start date, what’s gone
wrong in the past and how to avoid
these things this time, social support
– Summarize and next steps
Techniques for MI
• Action
– IF patient has had a “slip” identify reasons
and strategies for avoiding (e.g. cues, selfefficacy, assess confidence)
– If no slips
• Support self-efficacy (e.g. elicit confidence talk,
personal strengths and supports,
brainstorming, how will things be different?)
• Refine or adjust action plan
• Discuss coping skills (identify smoking triggers
and ways of dealing with them)
MI with Patient
Motivational InterviewingDARES
• Develop Discrepancy-between patient’s
current behavior and their goals e.g. “It
sounds like you are very devoted to your
family, how do you think your smoking is
affecting your children?”
• Avoid Argumentation
• “Roll with Resistance”
• Express Empathy-use open-ended questions
and reflective listening
• Support Self-Efficacy-help patient identify and
build on past experiences
The 5 R’s of Motivational
Interventions (NOT
Interviewing)
• Risks-have patient identify risks of smoking
• Rewards-have the patient identify rewards of
quitting
• Relevance-how is quitting relevant to the
patient and their dz status or risk, family or
social situation
• Roadblocks-barriers or impediments to
quitting
• Repetition-repeat at every visit
Training in Motivational
Interviewing
• Motivational Interviewing Network of
Trainers (MINT)
• Motivational Interviewing by Miller and
Rollnick
Integrating the Behavioral
Theories
Programs for Physicians
• Modular Lifestyle Intervention Tool (MLIT)
(http://www.prescriptionforhealth.org/too
lkit/index.html)
• Calculators (www.statcoder.com and
http://hin.nhlbi.nih.gov/atpiii/atp3palm.htm)
• C-Tools 2.0
(http://www.cancer.org/docroot/COM/content/
div_TX/COM_5_1x_The_CTools_20.asp?SiteArea=)
• Websites
Development of the MLIT
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Operationalize the Stages of Change
Identify stage based interventions
Scripted motivational interviewing
Risk calculators
Pharmacotherapy info
Local and national resources
Modular design
Evaluation of MLIT
• Pilot study (n=17)
• VAPSRN academic physicians
• Pretest Posttest survey (46 items)
– Behavior – 5 A’s, TTM, MI, Rx
– Comfort/Self-efficacy
– Knowledge – TTM, PHS, OEI
– Adapted from prior work
• Intervention = MLIT on handheld with
encouragement of use
• Four month period
Results: Counseling
behaviors
• More likely to advise patients to stop smoking
(p = 0.049)
• Increased overall use of the "5 A's" during
patient encounters for smoking cessation (p =
0.031)
• Increased general counseling behaviors
– frequency of counseling, provision of behavior
specific information, and use of pharmacotherapy and
referrals for both smoking cessation (p = 0.047)
Results: Comfort and Selfefficacy
• Improved self-efficacy in counseling
patients regarding smoking cessation (p =
0.006)
• Increased comfort in providing follow-up to
help patients sustain their efforts at
smoking cessation (p = 0.042)
Results: Knowledge
• There was no change in physician
knowledge either overall or within the
four domains
– stages of change classification
– appropriate stage-based interventions
– knowledge of PHS smoking cessation
guidelines
Technology Development
• Silverchair’s staff adapted our platforms to create an IT
Ecosystem:
Technology Development
C-Tools
• Download at cancer.org (search on ctools)
• Guidelines for smoking cessation
• Pharmacotherapy Information
• Websites
• Quitline numbers
InfoRetriever to help with
treatment decisions
• A 46 y/o male, smoker
– PMH significant for hypertension treated
with HCTZ. Most recent BP = 138/86.
– FH: Both parents have HTN over age 70,
no h/o CAD.
– Lipids: Chol = 197; HDL = 41; LDL = 141.
• Questions:
– What is his risk of an AMI or sudden
cardiac death in the next 10 years?
– How much will lowering the SBP below
130 reduce the risk?
– How much will stopping smoking affect
his risk?
Should his SBP be lowered
to <130?
What if he quit smoking
instead?
What if your patient asks
about?
• Smoking Cessation Quitlines
– 1-800 QUIT NOW, available to all
Virginians 18 and older, fax referrals
coming soon
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Accupuncture
Hypnotherapy
Tricyclics
Is the patch effective in adolescents?
Websites for Physicians
• Treating Tobacco Use and Dependence
(http://www.surgeongeneral.gov/tobacc
o/default.htm)
• NCI website (www.smokefree.gov)
• American Cancer Society
(www.cancer.org)
• American Lung Association
(www.lungusa.org)
Programs for
Patients
PinnacleHealth Hospitals Grand Rounds 2005
Copyright© 2005 Scott Strayer
RWJ MyHealthyLiving Website
• www.pubinfo.vcu.edu/myhealthyliving/
• Other RWJ resources
(http://www.prescriptionforhealth.org/too
lkit/index.html)
American Cancer Society
• www.cancer.org/quittobacco
• Online resources for patients and
providers
• Localized resources
• Tobacco Cessation Leadership Institute
(UCSF)
American Lung Association
• Patient Resources
• Freedom From Smoking Online
Summary
• Discussed evidence-based guidelines
for smoking cessation counseling and
treatment
• Discussed MI and Stages of Change for
counseling
• Resources for physicians and patients