Tobacco Use in Diabetes and Heart Disease

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Tobacco Use in Diabetes and Heart Disease
The Elephant in the Room
Tim McAfee, M.D., M.P.H. Chief Medical
Officer 206-876-2551 tim.mcafee_at_freeclear.com Adj
unct Assistant Professor School of Public
Health University of Washington
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Why? General

• One in five
• 45
• 8,000

() Washington State Department of Health
Tobacco Prevention Control Program. Progress
Report, March 2005.
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Why Diabetes?

• Epidemiology
• Smoking rate in diabetics population
• Advice rate improving
• Prevention
• Relative Risk 1.4 to 3.3X if smoke20 cigs
• Impact of smoking on diabetics
• Like opening Pandoras Box

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Coronary disease risk 1.7-2.7X
ESRD 5-year mortality 4X
All-cause mortality 1.4-2.1X
Pandoras Box
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Why Heart Disease?

• Awareness
• 60 of smokers think they are not at increased
  risk of MI
• Impact of smoking
• 6X increase in MI risk in women, 3X in men
• 1/3 of popn attributable risk in world
• 48K CV deaths from second-hand smoke
• Impact of quitting post MI, CABG, angio
• Meta-analysis of 20 studies (18K)
• RR of mortality 0.64

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Courtesy of Dr. Jeff Probstfield
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Cost of Medical Care

• An average American with coronary heart disease
• Drugs 2,000
• EKG 50
• Physician visit 100
• Hospitalization 5,000
• Cardiac Cath Stent 5,000
• Bypass Surgery 20,000
• Defibrillator 40,000

Courtesy of Kiyon Chung, MD
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Crossing the Quality Chasm
2001 Institute of Medicine report There remains
a dearth of clinical programs with the
infrastructure required to provide the full
complement of services needed by people with
heart disease, diabetes, asthma, and other
chronic conditions.
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An 18-month old with a limp
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How To Treat Tobacco Dependence

• Nicotine is addictive and regular use results in
  drug dependence
• Tobacco dependence is like achronic disease
• An evidence-based clinical practice guideline has
  been developed

http//www.surgeongeneral.gov/tobacco/clinpack.htm
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Systematizing Tobacco Cessation
Patient presents to health care provider
If YES
If NO
Did the patient previously use tobacco?
Is the patient currently willing to quit?
If NO
If NO
If YES
If YES
Encourage continued abstinence
Prevent Relapse
Provide treatment Refer to Free Clear
Promote motivation
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The 5 As

• ASK about tobacco use
• ADVISE to quit
• ASSESS willingness to make a quit attempt
• ASSIST in quit attempt
• ARRANGE follow-up

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Free Clear Participation Group Health Enrollees
One-year quit rate 25-30 (30-day abstinence
Intent-to-Treat)
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Smoking Prevalence
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Assist Removing Barriers

• Developing a Quit Plan
• Set a quit date
• Tell others, and elicit their support
• Anticipate challenges
• Remove tobacco products and accessories
• Other strategies
• Review past quit attempts
• Avoid triggers
• Change routines

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Assist Removing Barriers

• If NOT ready to make a quit attempt
• Work with the patient to identify
• RELEVANCY
• RISKS of continued smoking
• REWARDS of quitting
• ROADBLOCKS to quitting
• REPEAT

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Assistance

• Practical counseling
• Provide basic information
• Recognize dangerous situations
• Develop coping skills
• Intra-treatment support
• Encourage patient in quit attempt
• Communicate caring and concern
• Extra-treatment support
• Help patient to identify and seek support from
  others
• Help arrange outside support (refer to WAQL)

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Pharmacotherapy

• Augments increases interest in behavioral
  therapies
• Increases cessation rates

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Pharmacotherapies

• First-line agents
• Bupropion SR
• Nicotine patch
• Nicotine gum
• Nicotine lozenge
• Nicotine inhaler
• Nicotine nasal spray
• Second-line
• other agents (clonidine, nortriptyline)
• dual therapy
• Stronger and longer therapy

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Combination Pharmacotherapy

• Combination NRT
• Patch gum or patch nasal spray are more
  effective than a single NRT
• Encourage use if unable to quit with single agent
• Caution regarding nicotine toxicity
• Not FDA approved
• Bupropion NRT
• Less evidence for effectiveness
• Additive side-effect profile

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On the Horizon

• Varenicline (Chantix-FDA approved)
• May 2006
• Partial nicotine agonist
• Quit rates appear better than bupropion
• No serious side-effects identified
• Mild-moderate nausea common
• Rimonabant
• Nicotine vaccines

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Arrange Follow Up

• Most relapse occurs in the first two weeks after
  quitting
• Follow up improves outcomes

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Relapse

• Preventing relapse
• Congratulate success
• Encourage continued abstinence
• Remind patients that
• Relapse is consistent with the nature of tobacco
  dependence and is not a sign of failure
• Relapse is a learning opportunity

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Alternate Model
Schroeder S JAMA August 2005
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Quitline/Primary Care Comparison

• 838 VA smokers randomized to
• Usual primary care
• Telephone counseling

An LC, Zhu SH, Nelson DB, Arikian NJ, Nugent S,
Partin, MR, Joseph AM. Benefits of telephone care
over primary care for smoking cessation. Arch
Intern Med. 2006166536-542.
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Cochrane Review Efficacy of NRT and Telephone
Counseling
Source Cochrane Review 2004
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Washington Quitline877-270-STOPPaid by Tobacco
taxes MSABrought to you by Washington Dept of
Health

• All callers eligible for single counseling
  session
• Uninsured, Medicaid some others eligible for
• Proactive telephone calls
• Unlimited inbound calls
• Pharmacotherapy assistance
• Boeing, Microsft, WaMu, GHC, UMP, VM pregnant
  women

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Dan Karna

• A Quit Story

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Population Management
Proactive Outreach - HIP NY

• DM firms identified smokers to HIP NY via
  electronic file
• Transferred to FC uploaded into call queue
• Dedicated registration staff (including
  Spanish-speaking) make attempts
• Three attempts made per person

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What Happened?

• 1293 people were called (3214 attempts)
• 598 successfully reached (46)
• 317 enrolled in program (53)
• 25
• potential pool accepted treatment

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Swedish Outreach

• Scand J Prim Health Care. 2006
  Jun24(2)75-80. Smoking cessation
  iC\GetARef\Refs\Reprint.ref 336 n patients
  with diabetes mellitus Results from a controlled
  study of an intervention programme in primary
  healthcare in Sweden.Persson LG, Hjalmarson
  A.- Health Care Centre of Habo and Development
  Unit for Primary Health Care, Jonkoping.Objectiv
  e
• To evaluate an intervention programme on smoking
  cessation in patients with diabetes mellitus in
  primary healthcare. Design. Regional controlled
  intervention study.
• Setting
• Seventeen primary healthcare centres in Sweden.
  Intervention. In the intervention centres, nurses
  with education in diabetes were given one
  half-day of training in motivational interviewing
  and smoking cessation. An invitation to
  participate in a smoking cessation group was
  mailed to patients from the intervention centres
  followed by a telephone call from the patient's
  diabetes nurse. The nurses who intervened were
  specially educated in smoking cessation. The
  control group received a letter containing advice
  to stop smoking and information about a one-year
  follow-up. Patients. Daily smokers with diabetes
  mellitus, 30-75 years of age. In the intervention
  centres 241 patients fulfilled the criteria and
  in the control centres 171 patients. Main outcome
  measures. Self-reported smoking habits after one
  year.
• Results
• In total, 21 of the smokers accepted group
  treatment. After 12 months, 20 (42/211) in the
  intervention centres reported that they had
  stopped smoking and 7 (10/140) in the control
  centres 40 (19/47) of the smokers who had
  participated in group treatment reported that
  they had stopped smoking. Conclusion. A
  computerized record system for patients in
  primary healthcare was used to identify diabetic
  patients who were smokers. The selected group was
  invited to a stop smoking programme. At a
  one-year follow-up significantly more patients in
  the intervention centres had stopped smoking
  compared with patients in the control centres

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The Chronic Care Model
Community
Health System
Resources and Policies
Organization of Health Care
Self-Management Support
ClinicalInformationSystems
DeliverySystem Design
Decision Support
Productive Interactions
Informed, Empowered Patient and Family
Prepared, Proactive Practice Team
Improved Outcomes
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How to Order Materials

• Order WAQL materials online https//fortress.wa.
  gov.prt/printwa/wsprt/default.asp
• Register if a first time user shop by agency
  DOH Tobacco Prevention Program choose your
  topic
• Clinical Practice Guidelines online
• http//www.surgeongeneral.gov/tobacco/clinpack.htm
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