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• The Brief Tobacco Intervention

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Overview

• We will discuss
• An effective approach you can use to counsel your
  patients about tobacco cessation.
• How to use this approach.
• Tobacco cessation resources that are available
  for your patients.

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Tobacco Use

• Tobacco Use is still the single greatest cause of
  preventable disease and premature death in the
  United States.

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Why Dont They Just Quit?

• Chain of Addiction
• Biologically Addictive
• Psychologically Addictive
• Culturally Addictive

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You Can Make a Difference

• Research shows that YOU can have a significant
  influence on your patients decision to quit by
  recommending that they stop using tobacco.

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The Opportunity

• Most tobacco users want to quit.
• Half make a serious attempt each year.
• 80 see a healthcare provider each year.

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Provider Impact

• The National Cancer Institute projects that if
  providers assisted even 10 of their
  tobacco-using patients in quitting, the number of
  tobacco users in the U.S. would drop by 2 million
  people annually.
• Fiore et al., 1990

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Best Practices

• The Public Health Service Guidelines Treating
  Tobacco Dependence A Systems Approach.

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Why Do the PHSG Matter?

• Bring information learned through research into
  mainstream practice.
• Good summary of concrete best practices.
• Widely used and recommended.

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Ten Strategies of the Public Health Service
Guidelines

• Tobacco dependence is a chronic disease that
  requires repeated intervention and multiple
  attempts to quit.

• Brief tobacco dependence treatment is effective.

• Individual, group and telephone counseling are
  effective and their effectiveness increases with
  treatment intensity.

• Clinicians and Health Care Delivery Systems
  should consistently identify and document tobacco
  use status.

• Tobacco dependence treatments are effective
  across a broad rang of populations.

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Ten Strategies of the Public Health Service
Guidelines

• Numerous effective medications are available for
  tobacco dependence.

• If tobacco user currently is unwilling to make a
  quit attempt, clinicians should use motivational
  treatments.

7. Counseling and medications are effective.
However, the combination of both is more
effective than either alone.
10. Tobacco dependence treatments are both
clinically effective and highly cost-effective
relative to interventions.

• Telephone counseling is effective with diverse
  populations and has broad reach.

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Ten Strategies of the Public Health Service
Guidelines

• Tobacco dependence is a chronic disease that
  requires repeated intervention and multiple
  attempts to quit.

• Brief tobacco dependence treatment is effective.

• Individual, group and telephone counseling are
  effective and their effectiveness increases with
  treatment intensity.

• Clinicians and Health Care Delivery Systems
  should consistently identify and document tobacco
  use status.

• Tobacco dependence treatments are effective
  across a broad rang of populations.

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Evidence for Brief Intervention

• Substantial evidence shows that Brief Tobacco
  Interventions are effective.
• The Surgeon general states that if every health
  professional used the brief tobacco intervention
  every time they saw a tobacco user, we would
  reduce tobacco use by 20.

• Selected Evidence
• Schroeder What to do with a patient who smokes
  (JAMA 2005)
• Public Health Service Guidelines US Department
  of Health and Human Services (June 2000)
• U.S. Preventive Services Task Force, Counseling
  to Prevent Tobacco Use (November 2003)

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Traditional Tools
The 5A Intervention

• ASK about tobacco use.

?
ADVISE the patient to quit.
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ASSESS readiness to quit.
?
ASSIST the patient in quitting.
?
ARRANGE for follow-up.
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New Tools
The 2A and R Intervention

• ASK about tobacco use.

?
ADVISE the patient to quit.
?
REFER to resources internal or external entity
that completes the rest of the 5As.
ASSESS ASSIST ARRANGE
?
Schroeder (2005), JAMA.
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Brief Intervention - 2As and R

• Ask about tobacco use
• Have you used tobacco in the past 30
  days?

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Brief Intervention - 2As and R

• Advise the patient to quit
• Quitting tobacco is one of the best things you
  can do for your health. I strongly encourage you
  to quit. Have you thought about quitting?

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Brief Intervention - 2As and R

• Refer to Resources
• If Ready to Quit
• Provide direct referral to a resource that will
  complete the Assess, Assist and Arrange steps.
• This is a resource I recommend. They will
  provide you with support, create a quit plan and
  help you overcome urges.

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Not Ready to Quit?

• Not everyone who uses tobacco is
• ready to quit.
• If Not Ready to Quit
• Provide self-help materials and let patients know
  you are available for future support
• When you are ready to quit, I am here to support
  you and have resources that can assist you.

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Referral Resources
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Referral Resources

• The WA State Tobacco Quit Line
  1-800-QUIT-NOW or 1-877-2NO-FUME
• INSERT LOCAL RESOURCES THAT YOU HAVE RESEARCHED
  HERE
• INSERT LOCAL RESOURCES THAT YOU HAVE RESEARCHED
  HERE

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Why Use a Quit Line?

• Easy for people to access
• Promoted statewide
• Supports busy clinical practices
• Individually tailored programs
• Combined free medication counseling
• Confidential and private
• Easy to incorporate new research
• Strong evidence based, effectiveness

Orleans, Schoenbach et al. (1991), J Consult Clin
Psychol. Zhu, Tedeschi et al. (1996) J Coun
Dev. Swan et al. (2003) Arch Intern Med.
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WA State Tobacco Quit Line

• Free telephone counseling support for all
  Washington residents.
• Free medication (if appropriate)
• Free stage and language appropriate quitting
  materials.
• Provider Fax Referral Program for direct referral
  to the Quit Line.

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Who is Covered?

• All adult residents in Washington State are
  eligible for free telephone-based counseling with
  medication.
• In some cases, the overall benefit may be more
  for specific populations if covered by their
  employer or health plan.
• Detailed coverage always available on TCRC
  website.

For the latest coverage updates, see
http//www.tobaccoprc.org/TCRC/QuitLine.cfm
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How to Refer to the Quit Line

• Card
• Fax

? Patient calls Quit Line
? Quit Line calls Patient
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To Order Materials
Instructions for ordering available on
www.tobaccoprc.org/TCRC/ ? order materials
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ADD SLIDE WITH LOCAL RESOURCES

• INSERT SLIDE WITH YOUR LOCAL RESOURCES HERE

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Other Resources
When used alone, these resources do not complete
the rest of the 3As. However, they can be
effectively used with a state or local resource
as part of the Ask, Advise, Refer process.

• Pharmacotherapy
• With counseling can double quit rates.
• Materials
• Can provide self-help to patients.

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2A and R Review
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Delivering an Intervention

• Asking and advising is more effective than
  telling.
• Non-confrontational interventions keep the
  patient from being resistant to advice.
• Tailoring advice to the visit or health issues
  can help the patient be more receptive.
• Let the patient know that you have heard and
  understood her concerns.
• Meet the patient where he is in his willingness
  to discuss cessation.

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An Organizational Approach
Agencies generally have the greatest success with
Brief Tobacco Interventions when they

• Institutionalize tobacco as a vital sign (like
  blood pressure or weight).
• Implement a process for the intervention where
  each member of the organization has a role (e.g.,
  the MA asks about tobacco use, the doctor advises
  the patient to quit and recommends a resource,
  the nurse provides resource information).
• Have materials readily accessible to refer
  patients to the resources they determine to be
  the most appropriate for their community and
  patient population.

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Practice
Mary is a 24 year old woman who is coming to see
you today because her asthma is getting worse.
She has a history of smoking cigarettes.

• How would you
• Ask about her tobacco use?
• Advise her to quit in a relevant manner?
• Refer her to an internal or external resource or
  to the WA State Tobacco Quit Line?

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Next Steps

• How can you make a difference?

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QA