Implementing an Effective

1

• Implementing an Effective
• Smoking Cessation Strategy
• in Medical Practice
• Janis M. Dauer, MS, CAC
• September 14, 2004
• Virginia Hospital Center
• Arlington, VA

2
Implementing an Effective Smoking Cessation
Strategy in Medical PracticeRATIONALE FOR
INTERVENING

• Save lives, reduce harm
• Amenable to treatment
• Effective treatments exist
• Clinical opportunities are numerous

3
Implementing an Effective Smoking Cessation
Strategy in Medical PracticeRATIONALE FOR
INTERVENING
Efficacy of Treatment Delivery Format Odds
Ratio Estimated Format (95 CI)
Abstinence Rate No format 1.0 10.8 Self-help
1.2 12.3 Proactive phone 1.2 13.1 counselin
g Group counseling 1.3 13.9 Individual
counseling 1.7 16.8
4
Implementing an Effective Smoking Cessation
Strategy in Medical PracticeRATIONALE FOR
INTERVENING

• Even brief interventions are effective

Efficacy of Various Intensity Levels
of Person-to-Person Contact Odds Ratio
Estimated Level of Contact (95 CI)
Abstinence Rate No contact 1.0 10.9 Minimal
(? 3 min) 1.3 13.4 Low intensity (3-10
min) 1.6 16.0 Higher intensity (? 10
min) 2.3 22.1
5
Counseling slide from Smoking Cessation with
emphasis on inpatients, by Richard J. Rosen, MD,
August 17, 2004, Charlotte, NC
Odds Ratio
6
Implementing an Effective Smoking Cessation
Strategy in Medical PracticeRATIONALE FOR
INTERVENING

• Non-physicians also have impact

Efficacy of Interventions by Various Types of
Clinicians Odds Ratio Estimated Level
of Contact (95 CI) Abstinence Rate No
clinician 1.0 10.2 Self-help 1.1 10.9 Non-
physician clinician 1.7 15.8 Physician
clinician 2.2 19.9
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Implementing an Effective Smoking Cessation
Strategy in Medical PracticeRATIONALE FOR
INTERVENING

• Treatment is cost-effective (counseling and
  medications)
• Demonstrates sincere
• commitment to patients
• well-being

8
Implementing an Effective Smoking Cessation
Strategy in Medical Practice CLINICAL PRACTICE
GUIDELINE

• Smoking Cessation clinical practice guideline
  published by AHCPR (now AHRQ), April 1996
• Based on 3,000 studies published between
  1975-1994
• Updated Treating Tobacco Use and Dependence
  guideline published jointly by AHRQ, USPHS and
  NCI, June 2000
• Based on additional 3,000 studies published
  between 1995-1999

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice GUIDELINE KEY
FINDINGS

• Chronic condition, often requires repeated
  interventions
• Effective treatments exist, therefore
• Every patient should be offered treatment
  (willing) or brief motivational intervention
  (unwilling)
• Essential institutionalizing consistent
  identification, documentation and treatment of
  every tobacco user

10
Implementing an Effective Smoking Cessation
Strategy in Medical Practice GUIDELINE KEY
FINDINGS

• Brief treatment is effective and should be
  offered to all users (minimum care)
• Strong dose-response relation between intensity
  of counseling and effectiveness
• Three types counseling especially effective
• Providing practical counseling
• Providing intra-treatment support
• Helping secure extra-treatment support

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice GUIDELINE KEY
FINDINGS

• Numerous effective pharmacotherapies exist (and
  should be used unless contraindicated)
• First-line pharmacotherapies include
• Bupropion SR Nicotine gum
• Nicotine patch Nicotine inhaler
• Nicotine lozenge Nicotine nasal spray
• Second-line pharmacotherapies include
• Clonidine Nortriptyline
• OTC nicotine patches are effective, use should be
  encouraged

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice GUIDELINE KEY
FINDINGS

• Treatments are both clinically effective and
  cost-effective, therefore
• Insurers and purchasers should ensure that
• Effective treatments (counseling and
  pharmacotherapy) are included as reimbursed
  benefits in all insurance plans
• Clinicians are reimbursed for providing treatment

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice SYSTEMS
RECOMMENDATIONS

• Implement a tobacco user identification system
  (e.g., smoking status as 5th vital sign)

Smoker Identification Systems (95
C.I.) Screening System Estimated Estimated In
Place to Identify Intervention Abstinence Smoking
Status Rate Rate NO 38.5 3.1 YES 65.6
6.4
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Implementing an Effective Smoking Cessation
Strategy in Medical Practice SYSTEMS
RECOMMENDATIONS

• Promote provider interventions (provide
  education, resources, and feedback)
• Dedicate staff to provide treatment (and assess
  delivery in performance evaluations)
• Promote policies that support and provide tobacco
  dependence services

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice SYSTEMS
RECOMMENDATIONS

• Insurers and Managed Care Organizations should
• Include tobacco dependence treatments (both
  counseling pharmacotherapy) as paid or covered
  services
• Reimburse clinicians/specialists for delivery of
  effective tobacco dependence treatments (and
  include in defined duties of clinicians)

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice TREATMENT
STRATEGIES

• ASK
• Identify tobacco use status of every patient,
  each visit if necessary (in order to determine
  appropriate intervention)
• Current user (go on to next two As)
• Recent quitter (provide Relapse Prevention)
• Non-user (support non-use decision)

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice TREATMENT
STRATEGIES

• ADVISE and ASSESS
• Advise to quit in a manner that is
• Clear
• Strong
• Personal
• Assess willingness to quit
• Willing go on to last the two As
• Unwilling go to the five Rs

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice TREATMENT
STRATEGIES

• ASSIST
• Aid willing patient in developing a quit plan
• Provide practical counseling (problem-solving/sk
  ills training) ? ?
• Provide intra-treatment support/encouragement
• Help identify/obtain extra-treatment support ?
• Discuss/recommend approved pharmacotherapy
• Provide supplementary materials ? ?

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice TREATMENT
STRATEGIES

• ARRANGE
• Schedule (or arrange) follow-up if patient
  identified a quit date
• In person or via telephone (or at least a
  personal postcard) ?
• Soon after quit date (within one week) ?
• Second follow-up within the first month ?

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice TREATMENT
STRATEGIES

• THE FIVE Rs
• Providing motivational interventions to patients
  unwilling to quit
• RELEVANCE help make connection to disease
  status/risk, family/social/health concerns, etc.
  ?
• RISKS ask patient to identify potential
  negative consequences of continued use ?
• REWARDS ask patient to identify potential
  benefits of quitting ?

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice TREATMENT
STRATEGIES

• THE FIVE Rs, continued
• Providing motivational interventions to patients
  unwilling to quit
• ROADBLOCKS ask patient to identify barriers to
  quitting and help develop plans to address them ?
  ?
• REPETITION repeat motivational intervention
  each visit

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice RELAPSE PREVENTION

• Recent Quitters (first 12 months)
• Assist former smokers in preventing relapse
• Minimal Practice Relapse Prevention
• Use open-ended questions
• Encourage active discussion (benefits, successes,
  problems, risks, etc.) ? ?
• Prescriptive Relapse Prevention
• Help identify coping mechanisms to address
  threats (negative mood, withdrawal, weight) ?

23
Implementing an Effective Smoking Cessation
Strategy in Medical Practice NEVER/FORMER
SMOKERS

• Youth support mature decision not to
  smoke/use tobacco or be manipulated by others
• Ex-smokers congratulate on success in quitting
  (no matter how long ago)
• Secondhand smoke encourage advocacy for
  smoke-free environments

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice DEVELOPING A PLAN

• Goal reduce smoking/tobacco use
• Objective Implement guideline recommendations
  (5As/5Rs)
• Use the Needs Assessment table to identify
  strategies, process and staff, education and
  materials needed
• Use the 5 STEPS to develop a plan

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice NEEDS ASSESSMENT
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Implementing an Effective Smoking Cessation
Strategy in Medical Practice THE 5 STEPS

• Step 1 Develop a Plan
• Meet with staff
• Use Needs Assessment table as a tool
• Explain goal/objective (gain support)
• Involve staff in planning (get practical input)
• Assign a coordinator (to monitor procedures,
  order materials, identify glitches) and/or
  designate a Smoking Cessation Specialist

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice THE 5 STEPS

• Step 1 Develop a Plan (continued)
• Develop methods for integration into current
  procedures
• Screening documentation of smoking status
• Assessing willingness to quit documentation of
  motivation
• Advising quitting documentation of advice given
• Assisting (counsel/refer) OR- Motivating (5Rs),
  documentation
• Arranging/doing follow-up (and documentation)
• Identify a start date and a review date

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice THE 5 STEPS

• Step 2 Gather Resources
• Obtain pro-cessation lobby/waiting room materials
• Posters, signs, pamphlets, etc.
• Videos (include cessation topic in televised
  services)
• Obtain individualized patient materials
• Pamphlets specific to patient traits/disease
  status
• Quit plan aids (e.g., list of local programs,
  Quitlines)
• Sample medications or fact sheets on meds (NRT)

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice THE 5 STEPS

• Step 2 Gather Resources, continued
• Obtain staff education materials, as needed
• Information on online CME/CE courses
• CTRI provider training manual (with video)
• Develop a referral resource list
• Local programs and/or support groups
• Internet resources, Quitlines, other phone
  resources
• Community specialists (HMO/hospital/health dept)

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice THE 5 STEPS

• Step 3 Train Staff
• Provide print materials and/or staff education
  videos
• Provide Internet training opportunities
• Provide onsite staff training (using CTRI manual
  or recruiting a Specialist)

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice THE 5 STEPS

• Step 4 Implement Plan
• Begin procedures on start date
• Monitor and identify glitches as they occur
  (Coordinators task?)
• Get feedback from staff (how to improve the plan,
  what resources they need)

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice THE 5 STEPS

• Step 5 Review and Revise
• Conduct chart audits
• Inventory materials used
• Revise procedures (using chart audit results,
  staff feedback and materials inventory)
• Give staff positive feedback (including
  incentives)

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice RESOURCES FOR
PATIENTS

• ?QUITLINES trained phone counselors provide
  practical counseling, support, materials, relapse
  prevention and follow-up
• American Legacy Foundation 1-800-399-5589
  (Washington DC Quitline but serves Virginia
  residents)
• Great Start Quitline 1-866-66-START
• (For pregnant women, English or Spanish
  speaking)
• ALA Call Center 1-800-548-8252
• (Registered Nurses/Respiratory Therapists)
• NCI Smoking Cessation Quitline 1-877-44U-QUIT

34
Implementing an Effective Smoking Cessation
Strategy in Medical Practice RESOURCES FOR
PATIENTS

• ? PRINT MATERIALS can be used as self-help for
  solving problems or developing skills/coping
  mechanisms, as part of a quit plan, to provide
  patient education, to help family members, extra
  information for special populations/issues, etc.
• USPHS publications (English/Spanish, free)
• Download www.surgeongeneral.gov/tobacco
• Order AHRQ www.ahrq.gov/clinic/tobacco/order.pdf
• Sentara Quit Kit (booklet and audiotape/CD)
  free, call Smoke-Free Virginia Helpline
  1-877-856-5177

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice RESOURCES FOR
PATIENTS

• ? ONLINE RESOURCES
• Freedom From Smoking www.lungusa.org/ffs
• (free ALA online cessation program)
• Federal Online Program www.smokefree.gov
• (free USDHHS online program includes Instant
  Messaging)
• Smoke-Free Virginia Website www.smokefreevirginia.
  org
• (with Resource Directory of local programs and
  links to online cessation programs, websites with
  information and materials, smoke-free restaurant
  listings, additional toll-free phone numbers,
  advocacy organizations, etc.)

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice OTHER RESOURCES

• Alliance for the Prevention and Treatment of
  Nicotine Addiction www.aptna.org
• Resources for healthcare providers
• Links to online training for clinicians
• Links to provider education materials and
  resources
• Links to patient education materials
• Center for Tobacco Research and
  Interventionwww.ctri.wisc.edu/main_dept/guide/gui
  de_main.html
• Healthcare provider training materials, including
  clinician packets
• "Practical Strategies to Help Your Patient Quit"
  Training Manual (with video/CD)
• Provider training manual specifically for
  hospitalized patients

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Implementing an Effective Smoking Cessation
Strategy in Medical Practice OTHER RESOURCES

• Handheld Computer Smoking Intervention
  Toolwww.smokefree.gov/hp-hcsit.html
• Downloadable software from NCI, based on USPHS
  guideline
• Can be used with both Palm and MicrosoftTM
  Pocket PC handheld computers
• Guides clinicians through appropriate questions
  and makes intervention recommendations (including
  re medications)
• Includes motivational intervention strategies
• American Lung Association 1-800-LUNG USA
• Field Office staff will check the Smoke-Free
  Virginia website and provide information on local
  programs to callers who do not have Internet
  access

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Implementing an Effective Smoking Cessation
Strategy in Medical PracticeAPPROVED
PHARMACOTHERAPIES

• Nicotine Replacement Therapy (NRT)
• Nicotine Patch OTC Nicotine Gum - OTC
• Nicotine Inhaler Rx Nicotine Nasal Spray - Rx
• Nicotine Lozenge OTC
• Non-Nicotine Medications
• Bupropion SR Rx Clonidine Rx
• Nortriptyline Rx
• www.surgeongeneral.gov/tobacco/treating_tobacco_us
  e.pdf
• http//speakerskit.chestnet.org/wgtlc/pres-cessati
  on.php

39
Lozenge slide from Smoking Cessation with
emphasis on inpatients, by Richard J. Rosen, MD,
August 17, 2004, Charlotte, NC

• Lozenge
• Placebo controlled trial showed Odds Ratio of 2
  mg lozenge 2.1 for low dependence and for 4mg
  lozenge in high dependence patients Odds Ratio of
  3.69 at six weeks, and effect maintained for one
  year.
• Lozenge use permitted for up to 24 weeks, but
  most stopped by 12 weeks.
• Quit rate highest for those using greatest number
  of lozenges.
• Side effects nausea hiccups, heartburn
• Arch Int Med vol 162 (11) 1267-76, 2002, June 10.

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Implementing an Effective Smoking Cessation
Strategy in Medical PracticePROVIDER BARRIERS

• Reasons for Not Helping Patients Quit
• Too busy
• Lack of expertise
• No financial incentive
• Most smokers cant/wont quit
• Stigmatizing smokers
• Respect for privacy
• Negative message might scare away patients
• I smoke myself

41
Implementing an Effective Smoking Cessation
Strategy in Medical PracticePROVIDER BARRIERS

• Helping is Easier Than You Think
• Too busy clinicians can help in 1 minute or
  less
• Lack of expertise not much needed to refer to
  Quitline
• No financial incentive its worth a minute,
  make it part of basic treatment (also, see
  practitioner reimbursement guide available at
  www.endsmoking.org/)
• Most smokers cant/wont quit multiple sessions
  increase success (recent evidence shows repeated
  Quitline use triples success in quitting)

42
Implementing an Effective Smoking Cessation
Strategy in Medical PracticePROVIDER BARRIERS

• Helping is Easier Than You Think, continued
• Stigmatizing smokers it is an addiction
  (usually started in teens), empower smokers to
  quit by support and emphasis on effective plans
• Respect for privacy most want to quit and
  want/expect support from those they highly
  respect (healthcare providers)
• Negative message might scare away patients
  research has shown that patient satisfaction is
  greater when clinician addresses tobacco
  use/secondhand smoke

43
Implementing an Effective Smoking Cessation
Strategy in Medical PracticePROVIDER BARRIERS

• Helping is Easier Than You Think, continued
• I smoke myself healthcare professionals also
  need help and support in quitting smoking
• Smoke-Free Virginia website has links to numerous
  resources, including residential programs
  www.smokefreevirginia.org
• Tobacco-Free Nurses initiative makes online
  cessation via QuitNet available to nurses for
  free www.tobaccofreenurses.org

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Implementing an Effective Smoking Cessation
Strategy in Medical PracticeTAKE ACTION

• ITS A PROCESS take a small step now in planning
  or doing
• USE WHATS AVAILABLE
• Free materials from AHRQ
• Free phone counseling from Quitlines
• Free online resources
• ASK URGE
• Ask if they use tobacco and are willing to talk
  to someone
• Urge them to call one of the free Quitlines