SmokeFree Initiative and Brief Officebased Interventions CME Available: See us after talk

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Smoke-Free Initiative and Brief Office-based
InterventionsCME Available See us after talk

• Scott McIntosh, Ph.D.
• Director, Greater Rochester Area
• Tobacco Cessation Center
• University of Rochester
• Department of Community and Preventive Medicine

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True Story
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True Story
The picture caused an uproar. A week later she
was interviewed again to respond She said she
has tried every way to quit without success. As
for smoking while pregnant, she said her doctor
told her "it would be good if I cut back, but if
I totally quit, it would not only cause stress on
me but it would cause stress on the baby."
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True Story
A spokesman for her Health System said any
pregnant person who comes to its facilities "is
going to be advised to quit smoking." It is
possible, he said, that a person having
difficulty quitting would be advised at least to
cut down. Williamson said she cut down from two
packs one-half pack per day. FULL
STORY http//www.roanoke.com/columnists/kennedy/1
1293.html
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True Story
She's an easy target, but a spokesperson for the
American Cancer Society had the most thoughtful
response "We have to see her as an audience we
need to reach out to."
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OUTLINE

• Clinician Training Brief Office Interventions
• URMC Procedures
• Nicotine Replacement Therapy (NRT), meds
• Resources / Referral
• Smoke Free Initiative

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Ways to Become Smoke-Free

• Clinics / Classes / Groups (good, if attended)
• Health Care Provider Interventions
• Geof Williams, MD, PhD (GRATCC, Free)
• Brief Office Interventions (1-3min, OR MORE)
• Best with office system support, policy changes
• Telephone Quitlines
• Reactive (they call) and Proactive (we call)
• (Public Health Impact reach X effectiveness)
• WATI (Web Assisted Tobacco Intervention)
• Self-Help Interventions
• Manuals, pamphlets, materials
• Clinically Proven Medications
• Nicotine Patch, Gum and Lozenges (OTC)
• Nicotine Spray and Inhaler (Prescription)
• Zyban (a.k.a., Wellbutrin )
• 2nd Line Medications
• NEW MEDS in 2006
• Chantix Ramonabant

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Health Care Provider Interventions

• For individual clinician interventions,
  physicians have the greatest influence on
  abstinence in their patients.
• The length of counseling time and the variety of
  clinicians who counsel the patient have a direct
  impact on the number of patients who quit.
• Combinations of two and three clinician types
  have greater influence on abstinence rates.
• MORE IS BETTER

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I. Stages of Change
SIMPLE BEHAVIOR CHANGE MODELS

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Relapse / Recycle

II. Readiness To ChangeAre you willing to set a
quit date in the next 30 days?
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The 5-A Model Using the AHRQ Smoking Cessation
Guideline for Health Care Provider Intervention

• At all patient/client contacts
• Ask whether patient smokes
• Advise to stop
• Assess whether they want to take action
• Assist in developing plan
• Arrange follow-up
• http//www.surgeongeneral.gov/tobacco/

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ASK
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ADVISE
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ASSESS
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ASSIST
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ARRANGE
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Strong Memorial Hospital Inpatient Guidelines
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What happens to Patients who smoke?

• There is an NRT and smoking cessation pathway in
  the new CIS
• Screening for smoking status/NRT begins at
  admission
• Smoking status and cessation resources will soon
  be added to the 1089 which is automatically faxed
  to the PCP upon discharge

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5-A Checklist Template

• ASK about patient's tobacco use
• Cigarettes /Cigars / Pipe Tobacco / Spit
  tobacco /2nd hand smoke exposure /Former
  tobacco user /Never a tobacco user
• ADVISE
• ASSESS ASSIST
• ARRANGE for follow-up
• Included is information on the NYSQuitline,
  Intensive Treatment Program, Fax-to-Quit, and the
  NYSQuitline website.

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Strong Memorial Hospital NRT Adult Inpatient
Guideline Recommended treatment
This is only part of a larger order set
available to prescribers at URMC
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US Public Health Service Clinical Practice
Guideline

• Recommendation Minimal interventions lasting
  less than 3 minutes increase overall tobacco
  abstinence rates. Every tobacco user should be
  offered at least a minimal intervention whether
  or not he or she is referred to an intensive
  intervention. (Strength of Evidence A)

Source Fiore, M. C. et. al. Treating Tobacco
Use and Dependence An Introduction to the US
Public Health Service Clinical Practice
Guideline. Respiratory Care. 45 (10). 1200-62.
2000.
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PRACTICAL RECOMMENDATIONS

• ISSUES
• Time constraints
• MORE IS BETTER (Dose Response, Variety of
  Clinicians, etc.)
• Baseline for all pts 1-3 Minutes, Physician
  Advice is EFFECTIVE
• With excellent local resources (centers,
  quitlines), many are proposing A, A, R (Ask,
  Advise, Refer).
• Reimbursement
• Example Medicare reimburses for 10 Minutes
  Counseling
• Strategies for discussion for 10 minutes OR MORE
• Advice to quit
• Setting a Quit date (Powerful BEHAVIOR-oriented
  intervention)
• Assisting with REFERRALS
• GRATCC Face-to-Face Free Intensive Counseling
  (Dr. Williams)
• NY State Telephone Quitline (FAX TO QUIT)
• Websites (nysmokefree.com, qweb.org)
• Discussion of NRT, Zyban, Chantix, etc. (e.g.,
  STAY ON MEDS PER INSTRUCTIONS IN PACKAGING)

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NRT Strategy Maintain addiction while
breaking the habit
Blood Nicotine Levels Red Cigarette Green
Average Daily Level Blue Nicotine Replacement
Therapy (NRT)
(Withdrawal Symptoms)
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Medication Zyban

• Shown to be effective (31 Abstinence vs. 17
  Placebo)
• Works on both craving and withdrawal
• Can be COMBINED with NRT
• Begin ONE WEEK before Quit Date
• 150mg for 3 days, then 300mg for 7-12 weeks.
• Wellbutrin is the same drug (Bupropion).

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Medication Chantix/Varenicline

• Pfizer's new drug, Chantix (Varenicline), mimicks
  nicotine to block its effects without activating
  the reward circuit.
• According to company data in June, 2005, 48
  percent of smokers who took Varenicline for 7
  weeks quit, compared with 17 percent on placebo.
  The trial of 500 smokers also found a 33-percent
  quit rate among those who took Zyban.

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Second Line PharmacotherapiesClonidine
Nortriptyline

• Clonidine is for hypertension.
• Nortriptyline is depression, chronic severe pain,
  and other indications.
• Neither is approved by FDA for tobacco
  dependence. Evidence shows they can be effective,
  so they could be prescribed Off Label with
  clinical judgment and follow-up.
• Considered for people unable to use first-line
  medications or when those medications are not
  effective.
• Should Monitor side effects.

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Medication Rimonabant

• The drug Rimonabant (Acomplia), developed by
  Sanofi Aventis, is close to market. Early in 2005
  the company reported a 36-percent quit rate among
  787 U.S. smokers in a phase III clinical trial.
  About 20 percent of the smokers quit when given
  placebo.

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Medication Rimonabant

• Sanofi is also seeking FDA approval to market
  Rimonabant as a weight-loss drug. Trial data show
  that the drug does help smokers keep off extra
  pounds, a second incentive for those who want to
  quit but fear weight gain.
• Rimonabant is the first drug to target and block
  cannabinoid receptors in the brain. These
  receptors reinforce pleasurable behaviors, such
  as smoking and eating, and stimulate the dopamine
  reward circuit. Deeply connected to memory,
  emotion, and motivation, the circuit is disrupted
  in people with addictions.

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Resources

• GRATCC (Greater Rochester Area Tobacco Cessation
  Center)
• Refer Patients to 530-2050
• Intensive outpatient visits (4-5) with clinician
• New York State Smokers Quitline
• 1-866-NY QUITS (866-697-8487)
• The Quitlines FAX to QUIT Program
• Free 2-week supply of Gum, Patch, or Lozenge
• Additional NRT with Proactive calls for Medicaid
• WATI (Web Assisted Tobacco Intervention)
• www.nysmokefree.com
• www.qweb.org (intervention for teens)
• www.myclearhorizons.com (mid-life and older)

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www.nysmokefree.com
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www.qweb.org -- for Adolescent, Young Adult
Smokers
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www.myclearhorizons.com -- for Midlife and
Older Smokers
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Implementing A Smoke-Free Environment
September 2006
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Smoking Kills

• About 438,000 deaths each year are smoking
  related.
• More than all alcohol, cocaine, crack, heroin,
  homicide, suicide, car crash, fire, and AIDS
  deaths together.

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• Smoking costs the U.S. nearly 150 billion each
  year in healthcare and other expenses.
• Second-hand smoke is the third leading cause of
  preventable death behind active smoking and
  alcohol abuse.

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Intervention Matters

• Former U.S. Surgeon General David Satcher calls
  smoking intervention one of the preventive
  services that offers the biggest bang for the
  buck.

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Hospitals

• Studies show hospitalization leads to substantial
  long-term quitting for virtually all categories
  of smokers.
• Half will quit smoking for the duration of their
  stay. These patients are also twice as likely to
  remain abstinent one year later.

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Quitting is Good Medicine

• Patients who smoke before surgery have a higher
  rate of infection than nonsmokers.
• Smoking slows healing after surgery.
• A smokers broken bones take longer to heal than
  nonsmokers.

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Its Our Mission

• Allowing smoking on our campus is inconsistent
  with our mission of improving community health.
• Hundreds of community hospitals and academic
  health centers are going smoke-free.
• URMC committed to making the switch on November
  16, 2006.

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Implementing a Smoke-Free
Environment

• Concern Patients will go to other hospitals
  where they can smoke.
• Response Other hospitals will also be
  smoke- free as of November 16th.

Continued..
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Implementing a Smoke-Free Environment

• Concern Employees may not be able to comply
  while under stress at work/home.
• Response Nicotine Replacement Therapy (NRT)
  will be available at cost to employees so they
  are comfortable while at work. There are also
  many other resources available (see slides16 and
  17).

• Concern Employees may encounter resistance when
  asking others not to smoke.
• Response Other institutions have found that
  the person being asked not to smoke will comply.
  

Continued..
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Implementing a Smoke-Free Environment

• Concern - Employees will leave the organization.
• Response This has not been the experience of
  other facilities.

• Concern There is an increased risk that smokers
  will find a place to smoke inside the building.
• Response Each of us needs to be aware of and
  monitor our surroundings so that this does not
  occur.

Continued..
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Creating a Smoke-Free
Environment
FACT It has been the experience of other
healthcare facilities that the transition to a
smoke-free environment was not as difficult as
was originally thought.
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Assistance Is Available Now
Assistance is available if employees want to quit
smoking. For information

• Go to the Well-U website http//www.rochester.edu/
  working/hr/wellness/smoking.php
• Call 273-5240 to inquire about the free Well-U
  smoking cessation groups.
• Click on the Smoke FREE icon on the URMC
  intranet. http//stronghealth.com/smokefree/index.
  cfm

Continued..
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Assistance Is Available Now

• Resources are also available to employees and
  others

• Greater Rochester Area Tobacco Cessation Center
  (GRATCC) - 530-2050 for information on an
  intensive tobacco dependence treatment program
  and medication. http//cvhpinstitute.org/tcc
• NYS Quit Line 1-866-NYQUITS (1-866-697-8487) for
  free phone assistance and to find out about a
  free Nicotine Replacement Therapy (NRT) starter
  kit. http//nyquits.com/

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For our visitors comfort, single doses of
Nicotine Replacement Therapy (NRT) will be
available for purchase at cost from

• the Outpatient Pharmacy 830am to 700pm, Mon
  thru Fri 900am to 300pm on Sat and 900am to
  100pm on Sun.
• the Gift Shop 800am to 730pm, Mon thru Fri.
• Pics Place 700am to 400pm, Mon thru Fri.

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Suggested Script If You See Someone
Smoking
Excuse me, (in a friendly voice and using open
body language) did you know that we are a
smoke-free Medical Center? We would appreciate
it if you would not smoke within our perimeter.
We do have single-dose Nicotine Replacement
Therapy (NRT) available for purchase to help you
feel more comfortable while you are here. You can
get NRT at the Outpatient Pharmacy, Gift Shop, or
Pics Place.
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Suggested Script If You See Someone Smoking

• If they ask where they can smoke, tell them they
  need to move outside of the perimeter.
• Hand them a perimeter map, or direct them to
  where they can get a map, and walk away.
• Maps will be available at the Ambassadors
  Desk, Security and other department-specific
  locations (ask your supervisor).

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What If the Person Does Not Comply
with My Request?
Don't debate or discuss the reasons behind a
smoke-free Medical Center campus. Simply state,
When you are finished smoking, please take the
remainder with you so that others will not think
it is O.K. to smoke here. Thank you.
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What If the Smoker Says
Do you expect me to walk all the way over there
(in the rain / snow / cold)? You could say, If
you decide to smoke, it will need to be outside
our campus perimeter. You can also remind them
that single dose NRT is available to help them
feel more comfortable while they are here.
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Questions??
Will physicians be trained?
Yes, all faculty and staff will receive training.
Clinicians will also be trained in how to assist
their patients who want to quit smoking.
Where can I get more information?
Go to http//www.QWEB.org for information on
several smoking cessation programs.
Continued..
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Do We Need to Document Training?
Yes, training needs to be documented in HRMS,
using the same method as for HIPAA and the
Mandatories. Training should be completed no
later than November 3, 2006. Please contact
Annette Schillaci via e-mail or at x5-0326 if you
have questions or need assistance with recording
compliance.
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• THANK YOU!
• Questions?

Scott McIntosh, PhD University of
Rochester Department of Community and Preventive
Medicine 273-3876 scott_mcintosh_at_urmc.rochester
.edu