Transcript Beating Joe Camel

Beating Joe Camel:
The American
Society of
Anesthesiologists
Smoking Cessation
Initiative
Beating Joe Camel…
• Why bother?
• Barriers
• The ASA Smoking Cessation Initiative
• How to help in three minutes or less…
(and get paid for doing it….)
Why Bother?
Quitting Smoking
Improves Surgical
Outcomes
Surgery May
Promote Quitting
Smoking
Tobacco Cessation Improves
Surgical Outcomes
• Cardiovascular Complications
• Respiratory Complications
• Wound-related Complications
Short-term Cardiovascular Benefits
of Smoking Cessation
• Nicotine


half life of ~1-2 h
decreases in heart rate and systolic blood pressure
within 12 hours
• Carbon monoxide


half life of ~4 hours
carboxyhemoglobin level near normal at 12 hours
• Preoperative abstinence decreases the
frequency of intraoperative ischemia*
*Woehlck et al, Anesth Analg 89: 856, 1999
Smoking Cessation Reduces
Postoperative Complications
60
Control
Intervention
50
%
40
30
20
10
• 120 Orthopedic patient
randomized to tobacco
intervention or control, 68 weeks prior to surgery
• ~80% of intervention
patients were able to quit
or reduce smoking
0
Any
Wound
Complication
Cardiac
Moller, Lancet 359:114, 2002
Why bother?
Quitting Smoking
Improves Surgical
Outcomes
Surgery May
Promote Quitting
Smoking
Surgery Promotes Tobacco Cessation
• Opportunity to intervene

contact with healthcare system

forced abstinence
• Major medical interventions improve quit rates


Occurs even in the absence of tobacco interventions
May also improve the effectiveness of tobacco
interventions
Smoking Cessation After Surgery
100
% quitting at one
year
80
60
40
20
0
Self-help
Outpatient Major Non- Coronary
Cessation
cardiac
Bypass
Programs
Surgery
Surgery
Lung
Cancer
Surgery
Barriers to Perioperative Smoking
Cessation
• Quitting just before surgery increases
pulmonary complications
• Nicotine replacement therapy is
dangerous
• Surgical patients are already too stressed
• Patients don’t want to hear about their
smoking – they have enough to worry
about
Recent Smoking Cessation Does Not
Increase Pulmonary Complications
25%
Overall
Pneumonia
20%
15%
10%
5%
0%
Continued
Smokers
Recent
Quitters
Past
Quitters
Non
Smokers
(n=13)
(n=39)
(n=184)
(n=64)
• 300 patients for lung
cancer resection
• “Recent” quitters:
>1 week, < 2 months
• “Past” quitters:
> 2 months
Barrera et al, Chest 127:1977, 2005
Nicotine Replacement Therapy and
Wound Healing
30%
Non-abstinent
25%
Abstinent, active patch
20%
Abstinent, placebo
15%
10%
• 48 smokers randomized
to continuous smoking or
abstinence, with or
without nicotine
replacement
• Standardized wounds
over a 12 week period
5%
0%
Infection
Dehiscience
Sorensen et al, Ann Surg 238:1, 2003
Perioperative Stress in Smokers
Perceived Stress
4
Smokers
Nonsmokers
3
2
1
0
Preop Postop POD1
POD2
POD7
• 141 smokers, 150 nonsmokers for elective surgery
• Perceived stress measured
from before surgery up to one
week postoperatively
• Smoking status does not
affect changes in perceived
stress
• Also no evidence for
significant cigarette cravings
Warner et al, Anesthesiology 199:1125, 2004
What do smokers expect?
• Essentially all smokers are aware of general
health hazards

Most are not aware of how it might affect their surgery
– and want to know!
• They want information and options
• Almost all will not be offended if you discuss
their smoking…
• But they do not want a sermon
Warner et al, unpublished observations
The Real Barriers
to Intervention
“I don’t know how”
“I don’t have time”
“It’s not my job”
What are we doing now?
100%
Anesthesiologists
Surgeons
80%
60%
40%
20%
0%
Ask
Advise
• Survey responses from 329
anesthesiologists and 299
general surgeons
• Proportions that “always”
performed intervention
• Actual patient perceptions
may differ (e.g., ~30% of
patients recall being advised)
Assist
Warner et al, Anesth Analg 99:1766,2004
ASA Smoking Cessation Initiative Rationale
• Smoking cessation improves perioperative outcomes
• Sustained abstinence produced by this teachable
moment produces an average 6-8 years of life gained
• Demonstrate to the public that anesthesiologists are
perioperative physicians who care about patient
health
• Recent CMS changes make it possible to bill for brief
tobacco interventions
ASA Smoking Cessation Initiative –
Vision and Goals
• Vision

Every smoker cared for by an anesthesiologist will receive
assistance in quitting as an integral part of care
• Goal

Increase the involvement of ASA members in smoking
cessation efforts, thus increasing abstinence rates for their
patients who smoke
ASA Smoking Cessation Initiative –
Strategies
• Encourage all anesthesiologists to consistently apply the Ask,
Advise, and Refer technique
• Develop anesthesiologists who can serve as leaders for local
efforts to provide tobacco intervention services in perioperative
practice
• Educate the public regarding the importance of perioperative
smoking cessation
• Create partnerships with other healthcare professionals to
promote a comprehensive perioperative strategy for patients
who smoke
ASA Smoking Cessation Initiative –
Strategies
• Encourage all anesthesiologists to consistently apply the Ask,
Advise, and Refer technique
• Develop anesthesiologists who can serve as leaders for local
efforts to provide tobacco intervention services in perioperative
practice
• Educate the public regarding the importance of perioperative
smoking cessation
• Create partnerships with other healthcare professionals to
promote a comprehensive perioperative strategy for patients
who smoke
What should we do for smokers
who need surgery?
• ASK - assess tobacco use at every visit
• ADVISE - strongly urge all tobacco users to
quit
• REFER – To a tobacco quitline or other
resources
What are “Quitlines”?
•
•
•
•
•
Free via telephone to all Americans
Staffed by trained specialists
Up to 4-6 personalized sessions
Some offer free nicotine replacement therapy
Up to 30% success rates for patients who
complete sessions
Most providers, and most patients, know nothing about quitlines….
ASK every patient about tobacco use
• Ask even if you already know the answer

Reinforces message that you as a physician think
that their tobacco use is significant
ADVISE all smoker to quit
• Why quit for surgery? – Talking points….

Quit for as long as possible before and after surgery
• Day of surgery especially important – “fast” from both food
and cigarettes


Benefits of quitting to wound healing, heart and lungs
Great opportunity to quit for good
• Many people don’t have cravings
• Need to be smoke free in the hospital anyway
REFER smokers to quitlines or
other resources
• What are quitlines? – talking points





Quitlines are free
Talk with a specialist, not a recording
Free stop smoking medications may be available
Can call anytime, even after surgery
Can help you stay off cigarettes even if you have
already quit
• Can also use proactive fax referral
• 1-800-QUIT-NOW
ASA “Quitcard”
ASA Patient Brochure
Other resources for your patients
• Tobacco treatment specialists


Available in many practice settings
Often hospital-based
• Websites

www.smokefree.gov
• Insurers

E.g., Blue Cross/Shield, BluePrint for Health stop
smoking program
CMS Reimbursement for Tobacco
Interventions
• Who is covered?

Patients who use tobacco and have a disease or adverse
health effect found by the US Surgeon General to be linked
to tobacco use
• HCPCS Codes


G0375 Smoking and tobacco-use cessation counseling
visit; intermediate, > 3 minutes up to 10 minutes
G0376 Smoking and tobacco-use cessation visit; intensive,
> 10 minutes
CMS Reimbursement for Tobacco
Interventions
• Cessation counseling attempt occurs when a
qualified physician or other Medicare-recognized
practitioner determines that a beneficiary meets
the eligibility requirements above and initiates
treatment with a cessation counseling attempt
• Two attempts (of up to 4 sessions) allowed every
12 months
• No credentialing requirements as of yet
ASA Smoking Cessation Initiative
Task Force – Pilot program
• Identify approximately 10 practices nationally
• Identify a champion within each practice to
promote the Ask-Advise-Refer strategy
• Implement strategy for ~3 months, beginning
Sept 2007
• Survey practices after this period to determine
feasibility and gather feedback
Bottom Line…
• You can make a difference in the lives of your
patients who smoke
• You can help without being an expert in
tobacco control – and get paid for doing it
• The ASA is working to provide you with the
tools you need to do this effectively
What about Joe Camel?