Treating Tobacco Use and Dependence

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Treating Tobacco Use and Dependence

• Aaron Swanson, MPH
• Iowa Department of Public Health
• Division of Tobacco Use Prevention and Control

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Tobacco Use in Iowa

• Approximately 4,500 tobacco-related deaths
  annually (Campaign for Tobacco Free Kids, 2007)
• 20 of high school students are current smokers
  (2004 Iowa Youth Tobacco Survey)
• 18 of adults are current smokers. (2006 IA Adult
  Tobacco Survey)
• Annual health care costs directly caused by
  smoking - 1 billion (Campaign for Tobacco Free
  Kids, 2006)
• Portion covered by Medicaid - 301 million
  (Campaign for Tobacco Free Kids, 2005)

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Smoking and Health

• Established cause of
• COPD
• Cancers
• esophageal, laryngeal, lung, tracheal, oral,
  pancreatic, etc.
• Cardiovascular Disease
• hypertension, MI, stroke

• Risk factor for
• Diabetes
• Peptic ulcer disease
• Asthma
• Impotence
• Infertility
• Osteoporosis
• Low birth weight babies

The Health Consequences of Smoking A Report of
the Surgeon General 2004
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Spit Tobacco and Health

• Not a safe substitute to smoking cigarettes.
• Smokeless tobacco contains 28 known carcinogens.
• Oral health problems strongly associated with
  smokeless tobacco use are leukoplakia and
  recession of the gums.
• The amount of nicotine absorbed from smokeless
  tobacco is 3 to 4 times the amount delivered by a
  cigarette.

Centers for Disease Control and Prevention
National Cancer Institute
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Secondhand Smoke (SHS)

• SHS exposure causes disease and premature death
  in children and adults who do not smoke.
• Children exposed to secondhand smoke are at an
  increased risk for SIDS, acute respiratory
  infections, ear problems, and more severe asthma.
  
• There is no risk-free level of exposure to
  secondhand smoke.

2006 Surgeon Generals Report on Secondhand Smoke
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Nicotine Addiction

• Immediate reinforcement of drug taking behavior
• Physical cravings, withdrawal symptoms
• Psychological situational use
• Euphoria without intoxication
• Behavior reinforced multiple times daily
• Relapse is common - not an indication of personal
  failure by the patient or the clinician

Mayo Clinic Nicotine Dependence Center
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2000 USPHS Guidelines

• Available Online
• http//www.surgeongeneral.gov/tobacco
• Individual copies available
• AHRQ 1-800-358-9295
• CDC 1-800-CDC-1311
• NCI 1-800-4-CANCER

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USPHS Clinical Practice Guidelines Major
Conclusions/Recommendations

• Tobacco dependence is a chronic condition
• A tobacco-user identification system should be
  implemented in every clinic
• Cessation counseling delivered by health care
  providers is effective
• Treatments are cost-effective
• Pharmacotherpay is effective, and all patients
  should be encouraged to use except in special
  circumstances
• http//www.ahrq.gov/path/tobacco.htm

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Effective clinical interventions exist

• ASK about tobacco use
• ADVISE to quit
• REFER patient to cessation resources
• American Dental Hygienists Association
  http//www.askadviserefer.org

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Step 1 Ask

Systemically ask every patient/client about
tobacco use at every visit.

Determine if patient/client is current, former,
or never tobacco user.

Document number of cigarettes smokes per day.

Document number of years smoked.

Document number of previous quit attempts

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Step 2 Advise 1 min

• In a clear, strong, and personalized manner, urge
  every tobacco user to quit.
• Employ the teachable moment link visit findings
  with advice.
• As your clinician, I need you to know that
  quitting smoking is the most important thing you
  can do to protect your health now and in the
  future.

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Meeting the patient where they are at....

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Relapse

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Step 3 Refer 1 min

• Assess willingness to quit
• If willing to quit
• Develop Personalized Quit Plan
• Refer to Quitline Iowa
• If unwilling to quit
• Provide a motivational intervention
• Arrange follow-up

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• Helping patients build an individualized
  treatment plan

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The Spirit of Motivational Interviewing (MI)

• COLLABORATION
• Not confrontation
• EVOCATION
• Not education/advice
• AUTONOMY
• Not authority

Miller, W.R. Rollnick, S. (2002) Motivational
Interviewing, Preparing People for Change.
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Principles of Motivational Interviewing

• Express Empathy
• Develop Discrepancy
• Roll with Resistance
• Support Self-efficacy

Miller, W.R. Rollnick, S. (2002) Motivational
Interviewing, Preparing People for Change
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When Exchanging InformationElicit-Provide-Elici
t

• Step One Ask the client what he/she already
  knows about the topic youd like to present.
• Step Two Ask the clients permission to provide
  information, give an opinion/advice or express
  concerns.
• Step Three Ask for the client's thoughts about
• the information you have provided.

Miller, W.R. Rollnick, S. (2002) Motivational
Interviewing, Preparing People for Change
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Examine the Pros and Cons
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Negotiating a Change Plan

• Setting goals
• What do you think is the first step in your
  process right now?
• Considering change options
• Here are a variety of possibilities that people
  have used successfully. Which do you think might
  work best for you?
• Arriving at a plan
• So what is it specifically that you plan to do?
  When?
• Eliciting commitment
• Is this what you want to do?

Miller, W.R. Rollnick, S. (2002) Motivational
Interviewing, Preparing People for Change
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Identify Triggers and Coping Strategies

• What are the times, places, and situations when
  the patient is most likely to smoke?
• Maintain smoking record or journal.
• What plans does the patient have to cope with
  cravings that are likely during those times,
  places, and situations?
• Avoidance of triggers.

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For those ready to quitSTAR

• Set a quit date
• Tell family and friends
• Anticipate challenges
• Remove all reminders/temptations

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For the patient unwilling to quit

• Relevance
• Risks
• Rewards
• Roadblocks
• Repetition

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Reinforcement strategies

• Provide positive reinforcement for quitting or
  engaging in a healthy coping response.
• Congratulate patient for successes.
• Identify patients plans for reinforcement.
• Identify a reward after a certain period of
  remaining smoke free.
• Enhance natural rewards of being a non-smoker.
• Image of being a non-smoker (e.g., How does it
  feel to be a non-smoker?).

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Referral options for health care providers
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What is Quitline Iowa?

• Toll-free tobacco cessation helpline 1-800-QUIT
  NOW (784-8669)
• Effective, research-based cessation resource
• Available free of charge to all Iowans
• Free two-week supply of either the nicotine patch
  or gum
• Hours of service
• Monday Thursday 700 a.m. 1200 a.m.
• Friday 700 a.m. 900 p.m.
• Saturday Sunday 800 a.m. 700 p.m.
• Services in English Spanish interpreter
  service available for most other languages
• TDD line 1-888-229-2182
• Offers follow-up counseling calls tailored to
  clients needs

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Fax Referral Program

• Efficient method for referring patients who smoke
  to effective cessation services
• Alleviates some of the problems posed by limited
  time and resources
• Takes the burden of initiating services off of
  the patient
• New fax number beginning 1/1/08 800-261-6259
• Form can be downloaded at http//www.idph.state.ia
  .us/tobacco/common/pdf/quitline_fax_referral.pdf

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Medicaid Program for Smoking Cessation

• Initial prescription
• 14 nicotine patches AND/OR
• 110 pieces of nicotine gum
• Subsequent prescriptions
• Four-week supply of nicotine patches (at one
  unit/day) AND/OR
• 330 pieces of nicotine gum
• Maximum allowed duration of therapy 12 weeks
  within a 12 month period

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Medicaid conditions of coverage

• Diagnosis of nicotine dependence from a health
  care provider
• Referral to Quitline Iowa for counseling
• PA forms can be downloaded at http//www.iowamedic
  aidpdl.com
• Confirmation of enrollment in a Quitline Iowa
  program
• Must be 18 years of age or older to receive
  benefit

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Thank You!!

• Aaron Swanson, MPH
• Iowa Department of Public Health
• Division of Tobacco Use Prevention and Control
• 515-281-5491
• aswanson_at_idph.state.ia.us