Helping Your Patients Quit Using Tobacco

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Helping Your Patients Quit Using Tobacco

• Rebeckah Berry, MPH, CHES
• Tobacco Prevention and Control Program
• Salt Lake Valley Health Department
• rberry_at_slco.org
• http//www.tobaccofreeutah.org/healthcare1.html
• [phone]

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Objectives

• Present healthcare providers with a proven
  effective 3-minute intervention to help their
  tobacco using patients quit using tobacco.
• Discuss procedures for implementing this system.
• Supply healthcare providers with the support
  information necessary to deliver CONSISTENT
  tobacco cessation information to all tobacco
  using patients.

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Tobacco A Few of the Health Effects

• Long-term
• Heart disease
• Stroke
• Chronic lung disease
• Cancer (of lungs, mouth, esophagus, bladder,
  kidney, stomach, pancreas, throat, cheek, lip,
  voice box, tongue, womb)
• Emphysema
• Asthma
• Ulcer
• Infertility
• Reduction in the rate of lung growth and maximum
  level of lung function
• Adolescent smokers

• Short-term
• Increased coughs, shortness of breath, and
  respiratory illness
• Decreased lung capacity
• High blood pressure cholesterol
• Nervousness
• Gum disease
• Cavities
• Bad breath
• Yellow teeth
• Wrinkles
• Black, hairy tongue
• Reduced taste smell

Responsible for more than 400,000 premature
deaths each year.
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Health Effects for Tobacco Users Family

• Stillbirth
• Miscarriage
• Premature Birth
• Low Birth Weight
• Cleft Palates and Lips
• Sudden Infant Death Syndrome
• Infertility
• Tooth Decay

• Cancer
• Bronchitis
• Pneumonia
• Asthma
• Asthma attacks
• Upper Respiratory Tract Disease
• Ear Infections
• Coughs

Secondhand smoke is a powerful motivator!
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The Role of Health Care Providers

• The majority of smokers see a health care
  provider each year.
• Tobacco is the root of many health problems.
• Often times the effects of tobacco use are
  related to the condition you are treating!

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The Role of Health Care Providers

• In 2005, 59 of Utah adult smokers reported that
  a healthcare provider advised them to quit
  smoking during the past year. Even though health
  professional advice is proven to increase quit
  rates, the rate of Utah smokers receiving such
  advice has declined significantly since 2000.
  (BRFSS, 2000-2005 data).
• Brief tobacco dependence treatment is effective.
  
• Every patient who uses tobacco should be offered
  at least brief treatment.

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Tobacco Use Trends in Utah

• Average age of initiation - 12.5 years
• 60 by age 14
• 90 by age 19 (www.samhsa.gov/oas/nhsda.htm,
  2001)
• 79 of smokers report wanting to quit (BRFSS
  2005).
• More than half of Utahs current smokers report
  that they tried to quit within the past year
  (BRFSS 1990-2005).
• Most smokers try several times before they quit
  for good.

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Healthcare Providers
Hold the keys to
Contemplation
Knowing where to get help
Awareness
Pharmacotherapy
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Success Rates of Tobacco Dependence Treatments

• No help 7-8
• Health care provider advice (10-12, 15 for pregnant women
• Counseling (91-300 minutes) 10-20
• NRT 15-30
• NRT Counseling (91-300 minutes) 25-35
• Bupropion SR (Zyban) 25-35

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Varenicline (CHANTIX)

• New FDA approved smoking cessation medication
• Non-nicotine tablet
• Provides some nicotine effects to ease withdrawal
  symptoms
• Blocks the effect of nicotine from cigarettes
• In clinical trials, vareniclines short-term and
  long-term efficacy exceeded that of both placebo
  and bupropion SR (Jorenby, D.E., Hays, J.T.,
  Rigotti, N.A., etal. 2006)

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How Do I Help Tobacco Users Quit?

• Even a minimal intervention, lasting 3 minutes or
  less, can significantly increase overall tobacco
  abstinence rates.
•  The 5 As
• ASK the patient if he or she uses tobacco
• ADVISE him or her to quit
• ASSESS willingness to make a quit attempt
• ASSIST him or her in making a quit attempt
• ARRANGE for follow-up contacts to prevent
  relapse

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• 1. ASK
• Ask EVERY patient about tobacco use status.
• Current
• Former
• Never
• This occurs most consistently when there are
  systems in place, such as question on intake
  form, chart stickers, or electronic prompts on
  electronic medical records. Chart stickers are
  available online.

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Asking Pregnant Women

• Which of the following statements best describes
  your tobacco use?
• I smoke regularly nowabout the same as before I
  found out I was pregnant.
• I smoke regularly now, but Ive cut down since I
  found out I was pregnant.
• I smoke every once in a while.
• I have quit smoking since I found out I was
  pregnant.
• I wasnt smoking around the time I found out I
  was pregnant, and I dont currently smoke
  cigarettes.

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2. ADVISE Health care providers should urge
all tobacco users to quit. Even brief advice to
quit by a clinician results in greater quit
rates. Smokers cite a clinician's advice to quit
as an important motivator for attempting to stop
smoking.

• Advice should be
• Clear
• Strong
• Personalized
• Specific to the individual 's own situation
• (e.g. medical condition, family status, costs of
  tobacco).

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3 ASSESS "Are you willing to try to quit at
this time?"
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What if they are not willing?

• People may not desire to quit because of
• fear they will be unable to quit
• dread of withdrawal symptoms
• pleasure of smoking or chewing
• Offer a motivational intervention, the 5 R's
• Relevance
• Risks
• Rewards
• Roadblocks
• Repetition

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The 5 Rs

• Relevance Why is quitting important to their own
  personal situation?
• Risks Outline the risks of continued tobacco
  use.
• Rewards Outline the benefits of quitting.
• Roadblocks What are the barriers preventing this
  person from quitting? What are some solutions to
  these barriers?
• Repetition Repeat this discussion frequently,
  until the person is ready to quit.

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Stages of Change Model(Prochaska and Di Clemente)
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What if they are not willing? Continue to
encourage cessation attempts with every contact
with the patient. EMPHASIZE rewards and
benefits of cessation. Give the patient the Quit
Line's toll free telephone number
1-888-567-TRUTH, a Quit Card or the TRUTH Network
Think About It Pamphlet.
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4. Assist

• Set a quit date. Within 2 weeks is best.
• Tell family and friends. Social support helps!
• Review past quit attempt experiences. What
  worked? What didnt?
• Anticipate challenges. Symptoms such as
  irritability, cravings, insomnia coughing may
  occur for 2-3 weeks after quitting.
• Remove tobacco products. In addition,ask family
  members not to smoke around you or leave tobacco
  products where you can get them.
• Avoid alcohol. About half of smokers who try to
  quit and relapse do so when drinking.

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Utah Tobacco Quit Line

• Quit Kits, including information on how to quit
  and items such as gum and worry stones that can
  be used instead of tobacco.

• Professional counseling sessions by telephone
  (up to five sessions lasting 40 minutes each).
• Referrals to cessation classes
• NRT patch and gum upon qualification.

Spanish Quit Line 1.877.629.1585
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• http//utahquitnet.com

• Quitting guide
• Community support day and night
• Expert counseling through forums

• Tools to plan a quit date and learn about your
  level and type of dependency
• Medication guide
• Online NRT purchase

Lifetime membership!
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Local Services

• First Step Prenatal Cessation
• Adult Cessation Information/Classes
• Ending Nicotine Dependence Youth Cessation.

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Pharmacotherapy

• Medications reduce cravings and other withdrawal
  symptoms.
• All patients attempting to quit should be
  encouraged to use effective pharmacotherapies for
  smoking cessation except in the presence of
  special circumstances. -PHS

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Special Issues for Pharmacotherapy

• Adolescents
• Not known to be harmful to adolescents
• Not proven beneficial
• Not approved by the FDA for adolescents
• Adolescents often smoke for psychosocial and
  behavioral reasons rather than nicotine
  dependency.
• Pregnancy Use only when
• Unable to quit with behavioral interventions
  alone
• The increased likelihood of smoking cessation
  outweighs the risks of pharmacotherapy and
  potential continued smoking.

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4. Assist

• Give the patient the TRUTH Network Welcome Guide

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5. ARRANGE Follow-up with the Utah Tobacco Quit
Line Fax Referral System
Would you like the Utah Tobacco Quit Line to
help you quit?
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ARRANGE Follow-up continued

• If the answer is NO
• Offer a Utah Tobacco Quit Line card so that the
  client can contact the Quit Line or QuitNet when
  ready.

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ARRANGE Follow-up continued If the answer is
YES Schedule follow-up using Utah Tobacco
Quit Line Proactive Fax Referral System. (3
Simple Steps)
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ARRANGE Follow-up continued

• Step 1
• Write the office contact name on item 1 of the
  fax referral form and ask the client to fill out
  items 2-13.
• The client must sign the form or, if the client
  is a minor, the clients guardian must sign the
  form.

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ARRANGE Follow-up continued Step 2 When
the client finishes filling out the form, verify
that all items are filled in, that the
handwriting is readable and that the mandatory
signature is present.
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• ARRANGE Follow-up continued
• Step 3
• Fax the form to the Utah Tobacco Quit Line's toll
  free fax number
• 1-800-483-3076

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• ARRANGE Follow-up continued
• The Utah Tobacco Quit Line Faxes You to inform
  you of services your patient received.
• Add the fax to the patient's health record. The
  next time you see the patient, ask them about how
  their quit attempt went.

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What About A Relapse?

• A relapse should be viewed as a learning
  experience. Each time the patient relapses he or
  she learns more about what will help and what
  will be harmful for the next quit attempt.
• Relapse is consistent with the chronic nature of
  tobacco dependence it is not a sign of personal
  failure of the tobacco user or the clinician.
• Continue to provide encouragement!
• It takes an average of 4 to 9 quit attempts to
  successfully quit using tobacco!

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Learning from Unsuccessful Quit Attempts

• What were the most likely triggers that caused
  you to slip?
• Persons
• Places
• Things
• Situations
• For each trigger list two new ways to deal
  with the trigger so you wont slip.
• Repeat process if new ways dont work.

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Billing Your Time

• ICD-9 Code is 305.1
• ADA Code D1320

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Review

• Ask
• Advise
• Assess
• Assist
• Brief Advice on How to Quit
• Referral to Cessation Programs
• NRT, Bupropion SR or CHANTIX
• Arrange follow-up Use the Utah Tobacco Quit Line
  Fax Referral System

For more information, contact Tobacco
Free Resource Line 1-877-220-3466
or http//www.tobaccofreeutah.org/healthcare1.html
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Utah Tobacco Free Resource Line
Tobacco Free Resource Line1-877-220-3466 TheTRUTH
_at_utah.gov http//www.tobaccofreeutah.org/healthcar
e1.html

• Brochures and Self-Help Manuals targeted to many
  specific populations.
• Health Care Provider materials such as the
  laminated 5 As reminder cards and tear pads.
• Referral Materials such as Quit Line cards and
  fax referral forms.

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Tobacco Cessation Websites for Health Care
Providers

• 1. Tobacco Cessation Guideline Publications 
• http//www.surgeongeneral.gov/tobacco/default.htm
  
• Dr. Fiore's course in the 5 A's
  http//www.cme.wisc.edu/online/Smoking/accmeCTRI.h
  tml
• Utah Department of Health, Tobacco Prevention
  Control Program
• http//www.tobaccofreeutah.org/healthcare1.html

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Questions?