Transcript Ask and Act - Welcome to the Everglades Area Health Education

Tobacco Cessation
Ask your patients about tobacco use.
Act to help them quit.
The Problem
• Tobacco use is a chronic disease.
• 24% of American men and 19% of
American women smoke.
• Smoking-related diseases claim
440,000 American lives each year.
• Smoking costs the United States
approximately $97.2 billion each
year in health-care costs and lost
productivity.
The Problem
• Only 70% of family physicians ask
their patients if they use tobacco.
• Only 40% take action.
Why don’t doctors act?
•
•
•
•
•
•
•
Too busy
Lack of expertise
No financial incentive
Think smokers can’t or won’t quit
Don’t want to appear judgmental
Respect for patient’s privacy
Negative message might scare
patients away
Opportunity for physicians
• 70% of smokers see a physician
each year.
• 70% of smokers want to quit.
• Physician’s advice to quit is an
important motivator.
• Patients are more satisfied with their
health care if their provider offers
smoking cessation interventions even if they’re not yet ready to quit.
Physicians crucial to
successful cessation
• Even brief tobacco dependence
treatment is effective and should
be offered to every patient who
uses tobacco.
• Tobacco-cessation counseling is
effective in improving tobacco quit
rates among adults and has been
recommended for adolescents.
PHS Clinical Practice Guideline: Treating
Tobacco Use and Dependence: 2008 Update
Ask and Act
• Ask every patient about tobacco
use
• Act to help them quit
– On- or off-site counseling
– Quitlines
– Patient education materials
– Self-help guides or Websites
– Cessation classes
– Pharmacotherapy
Change the system to identify and
document tobacco use status
Make system changes
• Incorporate into vital signs
• Use chart stickers or computer
prompts to document status:
current, quit or never smoker
• Develop templates for EHRs
Make system changes
• Let patients know you can help -posters, lapel pins, brochures
• Ask office staff for ideas how to
“Ask and Act”
• Develop incentives for staff
interventions with patients-teams,
time off or special recognition
Make system changes
• Offer tobacco cessation group
visits and place sign-up sheets in
the waiting room
• Maintain tobacco cessation patient
registry
• Plan for follow-up calls by office
staff after tobacco quit date
Counseling and brief interventions
Stages of change
Precontemplation
Contemplation
Preparation
Action
Relapse
Maintenance
Don’t want to quit
Want to quit sometime
Will quit in next 30 days
Am quitting now
Termination
Adapted from Knight, 1997
Encouraging patients who
aren’t yet ready to quit
•
•
•
•
•
Relevance
Risks
Rewards
Roadblocks
Repetition
Develop a treatment plan
•
•
•
•
•
Help create a quit plan
Provide practical counseling
Provide social support
Recommend pharmacotherapy
Provide supplementary materials
Counseling
• Even brief tobacco dependence
treatment is effective and should
be offered to every patient who
uses tobacco.
• Tobacco-cessation counseling is
effective in improving tobacco quit
rates among adults and has been
recommended for adolescents.
PHS Clinical Practice Guideline: Treating
Tobacco Use and Dependence: 2008 Update
Counseling
• Individual, group, and telephone
counseling are effective, and their
effectiveness increases with
treatment intensity.
• Especially effective
– Practical counseling (problem
solving/
skills training)
PHS Clinical Practice Guideline: Treating
– Social supportTobacco
Use and Dependence: 2008 Update
Counseling
• Counseling adds significantly to
the effectiveness of tobacco
cessation medications
• Counseling increases abstinence
among adolescent smokers
Types of counseling
• Practical counseling
– Teach problem-solving skills
– Identify danger situations for smoker
– Suggest coping skills to use with
danger situations and how to avoid
temptation
– Provide basic information about
smoking dangers, withdrawal
symptoms and addiction
Types of counseling
• Intra-treatment support
– Talk about treatment options
– Communicate care and concern
– Encourage patient to talk about
quitting process
Types of counseling
• Extra-treatment support
– Help patient learn how to ask for
social support
– Help patient identify additional
support options
– Arrange for outside support
Counseling patients with
mental illness
• Counseling is critical to success more and longer sessions often
necessary
• Patients may need more time to
prepare for quit
• Quit dates should be flexible
• Include problem-solving skills
training
Quitlines
• It only takes 30 seconds to refer a
patient to a toll-free tobaccocessation quitline.
• Quitlines are staffed by trained
cessation experts who tailor a plan
and advice for each caller.
• Calling a quitline can increase a
smoker’s chance of successfully
quitting.
Advantages of quitlines
• Accessibility
• Appeal to those who are
uncomfortable in a group setting
• Smokers more likely to use a
quitline than face-to-face program
• No cost to patient
• Easy intervention for healthcare
professionals
Quitlines
• 1-800-QUIT-NOW
callers are routed
to state-run quitlines
or the National
Cancer Institute quitline.
• Quitline referral cards are free for
AAFP members. Go to
askandact.org.
Pharmacotherapy
Pharmacotherapy
• Who should receive it?
– Nearly all smokers trying to quit,
except those with medical
contraindications, adolescents and
those who smoke fewer than
10 cigarettes per day.
First-line pharmacotherapies
•
•
•
•
•
•
•
Buproprion SR
Nicotine gum
Nicotine inhaler
Nicotine nasal spray
Nicotine patch
Nicotine lozenge
Varenicline
Factors to consider when
prescribing
•
•
•
•
•
Clinician familiarity with medications
Contraindications
Patient preference
Previous patient experience
Patient characteristics (history of
depression, weight gain concerns,
etc.)
First-line pharmacotherapies
• Varenicline: agonizes and blocks
α4β2 nicotinic acetylcholine
receptors.
• Buproprion SR mechanism for
smoking cessation unknown; inhibits
neuronal uptake of norepinephrine,
serotonin and dopamine.
• NRT: binds to CNS and peripheral
nicotinic-cholinergic receptors.
Varenecline
• $4.00 - $4.22 per day
• Start .5mg daily for 1-3 days, then
increase to twice daily for 1-4
days. Increase to 1 mg twice daily
on quit date.
• Most common side effects are
nausea and vivid dreams
• Monitor for psychiatric symptoms
Bupropion SR
• $3.62 - $6.04 per day
• Start 150mg once daily for 3 days,
then twice per day for seven to
twelve weeks. Plan quit date
around day seven of treatment.
• Common side effects include
insomnia and dry mouth
Nicotine gum
• $3.28 - $6.57 per day for 2mg
$4.31 - $6.51 per day for 4mg
• Weeks 1-6: one every 1-2 hours
Weeks 7-9: one every 2-4 hours
Weeks 10-12: one every 4-8 hours
• Common side effects are jaw pain
and mouth soreness
Nicotine inhaler
• $5.29 per day
• 6-16 cartridges per day, initially
one every 1-2 hours
• Common side effects are mouth
and throat irritation
Nicotine nasal spray
• $3.57 per day
• 1-2 doses (sprays) per hour
• Common side effects are nose and
eye irritation
• Most addictive form of nicotine
replacement therapy
Nicotine patch
• $1.90 - $3.89 per day
• >25 cigarettes per day: 21mg
every twenty-four hours for four
weeks, then 14mg for two weeks,
then 7 mg for two weeks
• Common side effects are skin
irritation or sleep issues if worn at
night
Nicotine lozenge
• $3.66 - $5.25 per day
• Weeks 1-6: one every 1-2 hours
Weeks 7-9: one every 2-4 hours
Weeks 10-12: one every 4-8 hours
• Smoke first cigarette within thirty
minutes of awakening, use 4mg.
Others use 2mg
• Common side effects or mouth
soreness and dyspepsia
Pharmacotherapy for lighter
smokers
• Medications have not been shown
to be beneficial to light smokers
• If NRT is used, consider reducing
the dose
• No adjustments are necessary
when using bupropion SR or
varenicline
Second-line
pharmacotherapies (off label)
• Clonidine: mechanism for smoking
cessation unknown; stimulates α2adrenergic receptors (centrallyacting antihypertensive)
• Nortripyline: mechanism for
smoking cessation unknown;
inhibits norepinephrine and
serotonin uptake
For patients concerned with
weight gain
• Bupropion SR and nicotine
replacement therapies (especially
gum and 4 mg lozenge) may
delay, but not prevent, weight gain
• The average weight gain from
tobacco cessation is less than 10
pounds, more common in women
For patients with past history
of depression
• Bupropion SR
• Nortriptyline
• Nicotine replacement medications
Patients with mental illness
• Most will need medication
• Patients with bipolar disorder or
eating disorders should not receive
bupropion
• Patch is effective for those with
schizophrenia
• Varenecline safety not yet
established
Patients with mental illness
• Quitting can increase the effect of
some psychiatric medications
Dose adjustments may be needed
• Check for relapse to mental illness
with changes in smoking status
For patients with a history of
cardiovascular disease
• Nicotine replacement therapy caution for drug class if MI within
two weeks, severe arrhythmias or
cardiovascular disease
Pregnant smokers
• Counseling is best choice
• Risks of premature birth or stillbirth
caused by smoking may be higher
than the potential risk of birth
defects caused by NRT use
• Buproprion SR and varenicline are
both pregnancy category C
• Prescription NRT is category D
Can pharmacotherapies be
used long term?
• Yes.
• Helpful with smokers with
persistent withdrawal systems
• Long-term use of NRT does not
present a known health risk
• FDA approved the use of
bupropion SR for up to 6 months
• Varenicline recommended for 12
weeks. May repeat for 12 more
Can pharmacotherapies be
combined?
• Yes.
• Evidence that combining nicotine
patch with gum or nasal spray
increase long-term abstinence
• Combining nicotine patch with
buproprion is more effective than
patch alone
Treatment follow-up
• Congratulate success!
• Schedule counseling intervention
within first 3 months
• Encourage the patient to talk about
the process
– Success the patient has achieved
– Difficulties encountered
Benefit from a relapse
• A relapse provides useful
information
– Information about the cause of the event
• A formerly unknown stressful situation
– How to correct it occurrence in the future
• An action plan for that event
• Relapse is a normal part of the
recovery process
Relapse prevention
• Tobacco Dependence is a Chronic
Disease
• MDs and patients often have unrealistic
expectations for treatment of chronic
disease, too often using a short
treatment course
Getting Paid
Medicare
• Pays for tobacco cessation
counseling for patients who smoke
and have a tobacco-related
disease or whose therapy is
affected by tobacco use
• Prescription drug benefit covers
smoking cessation treatments
prescribed by a physician
– OTC treatments are not covered
Medicare
• 8 visits allowed in 12 month period
(4 sessions per attempt)
• Intermediate cessation counseling
= 3 to 10 minutes per session
• Intensive cessation counseling =
more than 10 minutes per session.
• Counseling < 3 min covered under
E&M code
Medicare CPT codes
• 99406: 3-10 minutes
• 99407: More than 10 minutes
• Report 305.1 Tobacco use
disorder and related condition or
interference with the effectiveness
of medications.
Medicare
• Any qualified provider, such as
physicians, clinical social workers,
psychologists, hospitals, may bill
for tobacco cessation counseling
Private Insurers
• Most insurers provide coverage
for at least one type of
pharmacotherapy for tobacco
cessation and at least one type of
behavioral intervention
Private Insurers
• Use billing codes in the categories
of:
– Preventive Medicine Treatments
– Tobacco Dependence Treatment as
Part of the Initial or Periodic
Comprehensive Preventive Medicine
Examination
– Tobacco Dependence Treatment as
Specific Counseling and/or Risk
Factor Reduction.
Medicaid
• 38 state Medicaid programs cover
at least some stop-smoking
treatments
• 14 cover some form of tobaccocessation counseling for all
Medicaid participants; 12 more pay
for counseling of pregnant women
Ask your patients if
they use tobacco.
Act to help them quit.
www.askandact.org