Transcript Smoking Status? Current Past Never Advised to Quit? Yes No

I do not have any relevant financial relationships to disclose.
A PRACTICAL GUIDE TO
HELPING PATIENTS STOP
SMOKING
E. H. Maynard, Jr. MD
Benson Area Medical Center
Benson, NC
Goals of Presentation
1.
2.
3.
4.
Review the scope of the problem of tobacco
use
Review evidence-based interventions that work
Present a toolkit to help other practices get
started with a smoking cessation program
Discussion of our practice’s experiences and
challenges with initiating a smoking cessation
program
The Problem of Smoking



21% of Americans smoke
45 million American adults smoke
1,200 children & adolescents become new smokers
each day
Cost to Individuals




Smoking is a chronic disease often requiring repeated
interventions and multiple attempts to quit
Smoking greatly increases risk of developing cancer,
heart disease, stroke, pregnancy complications, lung
disease, etc.
50% of smokers will die of smoking-caused disease
$5.11/pack
Cost to Society



$96 billion/year in smoking-related direct health
costs
$97 billion/year in smoking-related indirect costs due
to loss of productivity
The combined cost to society, individuals, and families
is estimated at nearly $40/pack
It is Difficult for Smokers to
Stop on Their Own



70% of smokers report wanting to quit
44% of smokers report trying to quit each year
Only 4-7% are successful on their own
We in the Healthcare Field
Have Opportunities to Help


70% of smokers are
seen by a physician
each year
Smokers report
physicians’ advice as
an important motivator
to quit
A Golden Opportunity for
Success




Most smokers are interested in quitting
Healthcare providers are in frequent contact with
smokers
Clinicians have high credibility with smokers
There are proven strategies that greatly increase
the likelihood of successful smoking cessation
But…




Only 70% of insured smokers receive smoking
cessation advice from their physician
Only 25% of Medicaid smokers reported receiving
practical help with smoking cessation
Only 33% of adolescents receive counseling
regarding tobacco use from their physicians
Only 39% of smokers reported that they were given
specific help from their physicians regarding smoking
cessation
Physicians say…






They are too busy
They have no financial incentive
They feel smokers cannot or will not quit
They don’t want to make patients angry
They don’t want to be judgmental
They will scare patients away if they discuss smoking
cessation
Actually…



Even brief tobacco dependence treatment can be
effective
Tobacco cessation counseling is effective at
improving quit rates
Smokers are more satisfied with their healthcare if
providers offer smoking cessation interventions even
when the patients are not ready to stop smoking
Actually…


Many smoking cessation interventions are
reimbursable
It is doubtful that there is any other intervention
which could have a greater benefit to a smoker’s
health than helping him/her quit smoking
A significant system failure
“…it is difficult to identify any other condition that
presents such a mix of lethality, prevalence, and
neglect, despite effective and readily available
interventions.”
- Treating Tobacco Use and Dependence: 2008 Update
US Department of Health and Human Services
Public Health Service
May 2008
Tobacco field
Johnston County, NC
Tool #1
Treating Tobacco Use and Dependence: 2008 Update
Clinical Practice Guidelines



Based on 8,700 research articles
Identifies effective, experimentally-validated
tobacco treatments and practices
Provided detailed rationale for recommended
practices
Treating Tobacco Use and Dependence: 2008 Update
Clinical Practice Guidelines

Sponsored by:
Agency for Health Care Research and Quality
 Centers for Disease Control and Prevention
 National Cancer Institute
 National Heart, Lung, and Blood Institute
 National Institute on Drug Abuse
 American Legacy Foundation
 Robert Wood Johnson Foundation
 University of Wisconsin School of Medicine and Public
Health Center for Tobacco Research and Intervention

Recommendations summed up
by the 5 As:





ASK about smoking status
ADVISE smokers to quit
ASSESS willingness to quit
ASSIST smoking cessation efforts
ARRANGE for ongoing follow-up
ASK:
“Implement an office system to document tobacco use
status for every patient at every clinic visit.”
Possibilities
Incorporate into vital signs
 Use chart stickers or computer prompts
 Develop templates for electronic health records

ADVISE:
“In a clear, strong, and personalized manner, urge
every smoker to quit smoking at every visit.”
ASSESS:
“Assess every tobacco user’s willingness to make an
attempt to quit at the time of each visit.”
Tool #2
PROGRESS NOTES
Date:_/_/_ Patient Name: _______ DOB:_/_/_ Chart: _____
Ht:__ Wt:__ BMI:__ Temp:__ RR:__ Pulse:__ BP:_/_ Nurse/MA:__
Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No
ASSIST
Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No
Help the patient develop a quit plan
 Provide practical counseling and problem solving advice
 Provide medication to help
 Provide supplemental materials
 Provide a supportive clinical environment

Tool #3
Rx for Success to Stop Smoking
Provide Practical Counseling
Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No
Abstinence from tobacco is essential
 Build on past quit experiences
 Anticipate triggers, challenges
 Avoid alcohol
 Encourage others in home to quit
 Referral for formal counseling if needed

Tool #4
Success with Smoking CessationPractical Counseling for the Busy Clinician
Medication
Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No
Except when medically contraindicated, all smokers attempting
to quit should be encouraged to use medication.
First Line Drugs:



Bupropion SR
Nicotine replacement (gum, inhaler, lozenge, spray, patch)
Varenicline
Second Line Drugs:


Clonidine
Imipramine
Tool #5
Comparison of Smoking Cessation Drugs
Provide a Supportive Clinical
Environment
Smoking Status? Current Past Never
Advised to Quit? Yes No
Willing to Quit? Yes No
Physician/Provider
Commitment
 Provide information that is
culturally, racially,
educationally, and ageappropriate
 Serve as advocates for
patients who want to quit
smoking
 Consider group visits

Tool #7
AAFP Guide to Group Visits for Smoking Cessation
ARRANGE
Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No
Appropriate follow-up should be arranged for smokers
trying to quit
 Some form of patient follow-up during the first week after
quit date
 Address tobacco use at subsequent clinical visits
 If tobacco use has recurred, consider more intensive
treatments

For Those Reluctant to Quit…
Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No
“For patients not ready to make a quit attempt, clinicians should
use a brief intervention designed to promote the motivation to
quit.”
Motivational Interviewing
Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No
Uncovers ambivalence about tobacco use
 Uses this ambivalence to address interest in quitting
 Expresses empathy
 Develops discrepancies
 Rolls with resistance
 Supports self-efficacy

Tool #8
Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No
Brief Guide to Motivational Interviewing
The 5 Rs
Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No
 Relevance
 Risks
 Rewards
 Roadblocks
 Repetition
Tool #9
Guide to the 5 Rs
Getting Paid




Medicare covers counseling and medications
Some state Medicaid programs cover some forms of counseling
and medication
Smoking cessation counseling can increase E/M coding levels
during problem-related visits
Private insurances vary but most cover some form of counseling
and some medication
Tool #10
AAFP Guide to Appropriate Coding
for Smoking Cessation
In Summary






Tobacco use should be assessed at every visit
Smoking cessation should be advised at every visit
Willingness to quit should be assessed for smokers
Those willing to quit should be supported with counseling,
medication, supportive clinical environment, additional
information
Those unwilling to quit should receive interventions to help
motivate commitment to quit in the future
Tobacco use must be treated as a chronic illness with frequent
surveillance and follow-up
Tobacco Field
Johnston County, NC
Benson Area Medical Center
Staff smoking area at BAMC
Getting Started
at Benson Area Medical Center





Recognize cultural differences
Gather a toolkit of information to assist clinicians in
providing appropriate and helpful information
Create a supportive environment for smoking
cessation
Choose an initial small target group to pilot project
Train advocates within the practice to assist smokers
who want to quit
Results from pilot project at BAMC
July 1, 2008- July 1, 2009
Before
After
% Smokers asked about smoking
% Smokers counseled to quit
57%
50%
100%
93%
% Smokers with documented quit attempt
7%
29%
Tobacco Field
Johnston County, NC