Beating Joe Camel: The American Society of Anesthesiologists Smoking Cessation Initiative

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• Beating Joe Camel The American Society of
  Anesthesiologists Smoking Cessation Initiative

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Beating Joe Camel

• Why bother?
• Barriers
• The ASA Smoking Cessation Initiative
• How to help in three minutes or less
• How to get paid for helping (under some
  circumstances)

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Why bother?
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Tobacco Cessation Improves Surgical Outcomes

• Cardiovascular complications
• Respiratory complications
• Wound related complications

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Short Term Cardiovascular Benefits of Smoking
Cessation

• Nicotine
• Half life of 1-2 h
• Decreases in heart rate and systolic blood
  pressure in 24 hrs
• Carbon Monoxide
• Half life of 4 hours
• Level near normal at 12 hrs
• Preoperative abstinence decreases the frequency
  of intraoperative ischemia

Woehlck et al, Anesth Analg 89 856, 1999
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Smoking Cessation Reduces Postoperative
Complications

• 120 Orthopedic patients randomized to tobacco
  intervention or control, 6-8 weeks prior to
  surgery
• 80 of intervention patients were able to quit
  or reduce smoking

Moller, Lancet 359114, 2002
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Why bother?
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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

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Smoking Cessation After Surgery
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Perioperative Smoking Cessation Barriers

• Quitting just before surgery increases pulmonary
  complications
• Nicotine replacement therapy is dangerous
• Surgical patients are already too stressed
• Patients dont want to hear about their smoking
  they have enough to worry about

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Recent Smoking Cessation Does Not Increase
Pulmonary Complications

• 300 patients for lung cancer resection
• Recent quitters 1 week, months
• Past quitters 2 months

Barrera et al, Chest 1271977, 2005
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Nicotine Replacement Therapy and Wound Healing

• 48 smokers randomized to continuous smoking or
  abstinence, with or without nicotine replacement
• Standardized surgical wounds over a 12 week
  period

Sorensen et al, Ann Surg 2381, 2003
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Perioperative Stress in Smokers

• 141 smokers, 150 non-smokers for elective surgery
• Perceived stress measured from before surgery up
  to one week postoperatively
• Smoking status does not affect changes in
  perceived stress
• No evidence for significant cigarette cravings

Warner et al, Anesthesiology 1991125, 2004
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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, Am J Prev Med 35S486, 2008
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The Real Barriers to Intervention

• I dont know how
• I dont have time
• Its not my job

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What are we doing now?

• 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)

Warner et al, Anesth Analg 991766,2004
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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
  tobacco interventions lasting three or more
  minutes

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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

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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

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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

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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 patients know nothing about
quitlines.
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ASK every patient about tobacco use

• Ask even if you already know the answer
• Reinforces the message that as a physician you
  think their tobacco use is significant

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ADVISE all smokers 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 dont have cravings
• Need to be smoke free in the hospital anyway

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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

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ASA Quitline Card
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ASA Patient and Provider Brochures
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Other Patient Resources

• Tobacco treatment specialists
• Available in many practice settings
• Often hospital-based
• Web sites
• www.smokefree.gov
• www.asahq.org/stopsmoking
• Insurers
• E.g., Blue Cross/Shield, BluePrint for Health
  stop smoking program

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Tobacco Intervention CMS Reimbursement

• 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
• Patients who take certain therapeutic agents
  whose metabolism or dosage is affected by tobacco
  use as based on FDA-approved information
• CPT Codes
• 99406 Smoking and tobacco-use cessation
  counseling visit intermediate, greater than 3
  minutes up to 10 minutes
• 99407 Smoking and tobacco-use cessation
  counseling visit intensive, greater than10
  minutes

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Tobacco Intervention CMS Reimbursement

• Cessation counseling attempt occurs when a
  qualified physician or other Medicare recognized
  practitioner determines that a beneficiary meets
  the eligibility requirements and initiates
  treatment
• Two attempts, up to 4 sessions, allowed every 12
  months
• No credentialing requirements

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ASA Smoking Cessation Initiative Task Force
Pilot Program

• Identified 14 practices nationally, both private
  practices and academic
• Implemented Ask-Advise-Refer strategy from Oct.
  Dec. 2007
• Practices surveyed after this period to determine
  feasibility and gather feedback

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Pilot Project Highlights (n94 responses)

• 50 expressed increased self-efficacy
• 75 agree that they would incorporate AAR in
  their practice
• High acceptance of materials
• 80 agree that the ASA should encourage

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Rates That Anesthesiologists Performed
Ask-Advise-Refer Elements
frequently or always
Baseline data from 2004 national survey of ASA
members, Warner et al, AA, 991766, 2004
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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
  needed to do this effectively

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What about Joe Camel?