Transcript YoderUSPHSTobacco(2)

2010 PHS Clinical Practice
Guidelines:
Smoking Cessation
CDR Sherri Yoder PharmD, BCPS,
CER Program Principal Consultant
Indian Health Service
USPHS COA Symposium: Pre-conference Workshop
National Guidelines Update
June 19, 2011
Overview
2010 Surgeon General’s Report: How
Tobacco Smoke Causes Disease
 Treating Tobacco Use and Dependence:
2008 Update
Decision Aids for
Clinicians/Recommendations
Objectives
• To identify key conclusions in the 2010
Surgeon General Report on Smoking and
Health
• To identify key pharmacologic and nonpharmacologic recommendations associated
with smoking cessation therapy according to
the 2008 Clinical Guidelines Update
• To identify clinician decision aids
2010 Surgeon General Report
• With each SG Report on smoking,
beginning in 1964,
– List of adverse health effects has gotten
longer
– Evidence has gotten stronger
• The latest report, #30 in a series, was
published in 2010
Report Highlights
• There is no risk-free level of exposure to
tobacco smoke.
– There is no safe level of exposure.
• Tobacco smoke inhalation causes cancer,
cardiovascular, and pulmonary disease.
– Damage from smoke is immediate.
• Risk and severity are directly related to
duration and level of exposure
– Smoking longer means more damage.
Report Highlights
• Sustained use and long-term exposure are
due to addictive effects.
– Cigarettes are designed for addiction.
• Low levels of exposure, including
secondhand smoke, can lead to
cardiovascular events and thrombosis.
– Any exposure to tobacco smoke, even an
occasional cigarette or exposure to
secondhand smoke, is harmful.
Report Highlights
• There is a lack of evidence that product
modification strategies (lowering
emissions, lowering nicotine) decrease
risk.
– There is no safe cigarette.
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The only proven strategy for reducing the risk of
tobacco-related disease and death is to never
smoke, and if you do smoke to quit.
Tobacco Cessation/Prevention
• One of U.S. Public Health successes of
the last 50 years due in part to a
collaborative effort
– Policymakers
– Public health advocates
– Clinicians
http://depts.washington.edu/tobacco/docs/Warner08.pdf
2008 Clinical Practice Guideline
• 257 pages
• 222 Powerpoint slides
• Available at:
– http://www.ahrq.gov/path/tobacco.htm
– http://www.cdc.gov/tobacco/quit_smoking/cessation/
– http://www.surgeongeneral.gov/tobacco/treating_tobacco_u
se08.pdf
Guideline History
Initial - 1996
Revised – 2000 Updated - 2008
Literature from
1975-1995
Literature from
1995-1999
Literature from
1999-2007
Approximately
3,000 articles
Approximately
3,000 articles
Approximately
2,700 articles
Guideline Update
• Principle analytic technique used
with this Guideline update was
meta-analysis of RCTs
I never meta-analysis I liked
A complete and detailed review of the
meta-analytic methods used in the
Guideline can be found in the Smoking
Cessation Guideline Technical Report No.
18, available from the Agency for
Healthcare Research and Quality (AHRQ)
as AHCPR Publication No. 97-N004.
#1 Key Recommendation
• Tobacco dependence is a chronic
disease that often requires
repeated intervention and multiple
attempts to quit. However,
effective treatments exist that can
significantly increase rates of
long-term abstinence
#2 Key Recommendation
• It is essential that clinicians and
healthcare delivery systems
consistently identify and
document tobacco use status and
treat every tobacco user seen in a
healthcare setting.
Clinician Training
• Programs from:
– 4 hour Basic Tobacco Intervention Skills
Certification
– 5 day Intensive Tobacco Treatment
Specialist Certification
#3 Key Recommendation
• Tobacco dependence treatments are
effective across a broad range of
populations. Clinicians should
encourage every patient willing to
make a quit attempt to use the
counseling treatments and
medications recommended in this
Guideline.
#4 Key Recommendation
• Brief tobacco dependence treatment
is effective. Clinicians should offer
every patient who uses tobacco at
least the brief treatments shown to be
effective in this Guideline.
#5 Key Recommendation
• Individual, group and telephone
counseling are effective and their
effectiveness increases with treatment
intensity.
– Two components of counseling are especially
effective and clinicians should use these when
counseling patients making a quit attempt:
• Practical counseling (problem-solving/skills
training)
• Social support delivered as part of treatment
#6 Key Recommendation
• There are numerous effective medications
for tobacco dependence and clinicians
should encourage their use by all patients
attempting to quit smoking, except when
medically contraindicated or with specific
populations for which there is insufficient
evidence of effectiveness (i.e., pregnant
women, smokeless tobacco users, light
smokers and adolescents).
#6 Key Recommendation
Seven first-line medications
reliably increase long-term
smoking abstinence rates:
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–
–
–
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Bupropion SR
Varenicline
Nicotine gum
Nicotine inhaler
Nicotine lozenge
Nicotine nasal spray
Nicotine patch
Clinicians should
also consider the
use of certain
combinations of
medications
identified as
effective in this
Guideline.
Specific Populations
• each have their own sections of this
Guideline update:
– usually excluded from the RCTs used to
evaluate the effectiveness of
interventions presented in this Guideline
– may have other special issues, for
example, safety.
#7 Key Recommendation
• Counseling and medication are effective
when used by themselves for treating
tobacco dependence. However, the
combination of counseling and medication
is more effective than either alone. Thus,
clinicians should encourage all individuals
making a quit attempt to use both
counseling and medication.
#8 Key Recommendation
• Telephone quitline counseling is
effective with diverse populations and
has broad reach. Therefore, clinicians
and healthcare delivery systems
should both ensure patient access to
quitlines and promote quitline use.
#9 Key Recommendation
• If a tobacco user is currently unwilling
to make a quit attempt, clinicians
should use the motivational
treatments shown in this Guideline to
be effective in increasing future quit
attempts.
#10 Key Recommendation
• Tobacco dependence treatments are both
clinically effective and highly cost-effective
relative to interventions for other clinical
disorders.
– Providing coverage for these treatments
increases quit rates.
– Insurers and purchasers should ensure that
all insurance plans include the counseling and
medication identified as effective in this
Guideline as covered benefits.
Corrections & Additions to the PHS
Guideline
• Addition #1 (posted 7/09) issued new warnings
for both varenicline and bupriopion
• Correction #1 (posted 7/09): inaccurate number
of study arms, but results were similar.
• Correction #2 (posted 11-09): Clinician
guideline: smoking slips versus lapses.
Corrections and Additions to the Public Health Service (PHS) Clinical Practice Guideline: Treating
Tobacco Use and Dependence—2008 Update. Agency for Healthcare Research and Quality,
Rockville, MD. http://www.ahrq.gov/clinic/tobacco/correctadd.htm
Decision Aids
• Quick Reference Guide for Clinicians 2008
Update
– Presents summary points from the Guideline
– Offers many recommendations for
practitioners to adopt depending on available
resources, clinical environment, and patient
circumstances.
http://www.ahrq.gov/clinic/tobacco/tobaqrg.pdf
Quick Reference Guide
– 5 A’s (ask, advise, assess, assist, arrange)
– Organized around 3 main groups of users
• Those willing to quit
• Those who are unwilling to quit now
• Those who recently quit
– Enhancing motivation
• 5 R’s (relevance, risks, rewards, roadblocks,
repetition)
New Recommendations
• Formats of Psychosocial Treatments
• Combining Counseling and Medication
• For Tobacco Users Not Willing to Quit
Now
• Nicotine Lozenge
• Varenicline
• Specific Populations
• Light Smokers
Clinician Training
• Programs from:
– 4 hour Basic Tobacco Intervention Skills
Certification
– 5 day Intensive Tobacco Treatment
Specialist Certification
– Important where billing is concerned
•
•
•
•
Rural health centers (RHC)
Federally qualified health centers (FQHC)
Indian Health Service (IHS)
Critical access hospitals (CAH)
Recommendations
•
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Websites (AHRQ, CDC, ACS)
Know your state’s indoor air laws
Know your quitline resources
Keep up to date with FDA’s Center for
Tobacco Products
• Be informed regarding novel tobacco
products: e-cigs, dissolvable nicotine, true
pulmonary nicotine inhalers, hookah use
Real Reasons
• Fear of failure
• Know the disadvantages but don’t
understand them
• Fear of standing out: social pressure
• Comfortable with unhealthy lifestyle
• Not knowing how to quit
http://ezinearticles.com/?Real-Reasons-Why-People-Keep-On-Smoking&id=1161727
Questions?