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Ask and Act: A Practical Approach to Helping Patients with Tobacco Cessation Tom Houston, Ask and Act: A Practical Approach to Helping Patients with Tobacco Cessation Tom Houston, MD Director, Ohio. Health Nicotine Dependence Program at Mc. Connell Heart Health Center Saria Carter Saccocio, MD Clinical Assistant Professor of Nova Southeastern University

Smoking in the U. S. • Kills more than 440, 000 Americans each year Smoking in the U. S. • Kills more than 440, 000 Americans each year • 20. 9% of adult Americans smoke (23. 9 m, 18. 1 f) • 3, 000 children and adolescents become regular tobacco users every day • 5. 5 million years of potential life lost annually, cuts 14 years from average lifespan Ask and Act

Smoking in the U. S. • Adds $167 billion in health costs each year Smoking in the U. S. • Adds $167 billion in health costs each year 1997 -2001 average from CDC – $75 billion in direct healthcare costs – $92 billion in indirect costs (lost productivity, wages, etc) Ask and Act

500 The cigarette death epidemic in perspective 400 No. (000 s) 300 200 100 500 The cigarette death epidemic in perspective 400 No. (000 s) 300 200 100 0 Annual smoking deaths Environ. All mental World tobacco War II smoke deaths Annual Vietnam auto War accidents AIDS 19831990 Annual murders Annual heroin, morphine & cocaine deaths Ask and Act

Tobacco is not an equal opportunity killer • Smoking affects young, the poor, depressed, Tobacco is not an equal opportunity killer • Smoking affects young, the poor, depressed, uninsured, less educated, bluecollar, and minorities most in the US; • Addiction affects those with the least information about health risks, with the fewest resources to resist advertising, and the least access to cessation services; • Those below poverty line are >40% more likely to smoke than those above poverty line. Ask and Act

Unequal patterns of exposure use • 38% of persons with 9 -11 yrs education Unequal patterns of exposure use • 38% of persons with 9 -11 yrs education • 40% of cooks/truckers • Only 1/3 of service workers covered by smoke-free policies • Social norm for low SES different from high SES • Mental health dx confers high risk for smoking • 13% of persons with college degree or higher • 3% of lawyers/MDs • > ½ of white collar workers covered by smoke-free policies Ask and Act

Health effects of tobacco • Heart disease (86, 800) – Earlier onset with young Health effects of tobacco • Heart disease (86, 800) – Earlier onset with young age at initiation • Chronic lung diseases (90, 582) – Symptoms present in youth • Cancer—most from lung cancer (123, 836) – Duration & intensity matter • Prenatal exposure – Infant weight and intelligence – Lung function – Nearly 1000 deaths Ask and Act

Health effects of tobacco • Half of all smokers who don’t stop by middle Health effects of tobacco • Half of all smokers who don’t stop by middle age will die from a tobacco-related disease Ask and Act

Secondhand Cigarette Smoke Each year, secondhand cigarette smoke is responsible for up to: • Secondhand Cigarette Smoke Each year, secondhand cigarette smoke is responsible for up to: • • • 37, 000 deaths from heart disease in adults 3, 000 deaths from lung cancer in adults 13, 000 deaths from other cancers in adults Complications of pregnancy, SIDS 300, 000 cases of lung infections such as pneumonia and bronchitis in infants and young children • 400, 000 -1 million asthma attacks in kids 8% of all medical costs among young children No safe level of exposure Ventilation doesn’t work Ask and Act

Adult per capita cigarette consumption and smoking and health events 1900 -1998 Adult per capita cigarette consumption and smoking and health events 1900 -1998

Comparison of per-capita consumption and lung cancer death rates Ask and Act Comparison of per-capita consumption and lung cancer death rates Ask and Act

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Time August 4, 2003 Ask and Act Time August 4, 2003 Ask and Act

The Best Choice for Smokers Worried About Their Health is to Quit. The Next The Best Choice for Smokers Worried About Their Health is to Quit. The Next Best Choice is to Switch to Eclipse is for smokers who have decided not to quit, but who are interested in a cigarette that responds to concerns about certain smoking-related illnesses, including cancer. For many smokers, it may well be a better way to smoke. Ask and Act

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A rogue industry • Discouraged science to make cigarettes safer, manufacturing a defective product A rogue industry • Discouraged science to make cigarettes safer, manufacturing a defective product for four decades; • Denying links between smoking and health after Surgeon General’s Report in 1964; • Violating basic principles of business ethics; • Shifting advertising resources to take advantage of loopholes in MSA; • Economic research to show the benefit to society of dying early; • Attempting to buy scientists and distort risk. Ask and Act

Ebony August 2003 Ask and Act Ebony August 2003 Ask and Act

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Cancers caused by smoking • • • Lung Larynx Esophagus Stomach Pancreas Kidney/Bladder Cervix Cancers caused by smoking • • • Lung Larynx Esophagus Stomach Pancreas Kidney/Bladder Cervix Oral/pharyngeal Adult leukemia Ask and Act

Relative risk of lung cancer by number of cigarettes smoked per day Ask and Relative risk of lung cancer by number of cigarettes smoked per day Ask and Act

Tobacco and cancer: mechanism of carcinogenesis Compounds in tobacco function as • Carcinogens – Tobacco and cancer: mechanism of carcinogenesis Compounds in tobacco function as • Carcinogens – • Tumor promoters – • Stimulate the development of established tumors Co-carcinogens – • Initiate tumor growth Enhance the mutagenic potential of carcinogens; possess little or no direct carcinogenic activity Irritants – Induce inflammation and compromise tissue integrity Ask and Act

Tobacco and cancer: mechanism of carcinogenesis Nicotine addiction Tobacco use PAHs, TSNAs, other carcinogens Tobacco and cancer: mechanism of carcinogenesis Nicotine addiction Tobacco use PAHs, TSNAs, other carcinogens Metabolic detoxification Excretion Metabolic activation DNA adducts Repair Normal DNA Persistence/miscoding Apoptosis Mutations, other changes Cancer Adapted with permission. Hecht. (1999). J Natl Cancer Inst 91: 1194– 1210. Ask and Act

Lung cancer mortality rates for smokers of 40+ CPD, never smokers and smokers who Lung cancer mortality rates for smokers of 40+ CPD, never smokers and smokers who quit at age 50 Ask and Act

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Smoking and cardiovascular disease • Coronary heart disease – Angina pectoris, ischemic heart disease, Smoking and cardiovascular disease • Coronary heart disease – Angina pectoris, ischemic heart disease, myocardial infarction • Cerebrovascular disease – Stroke, transient ischemic attacks • Abdominal aortic aneurysm • Peripheral arterial disease Ask and Act

Smoking and cardiovascular disease: postulated mechanisms • Smoking-induced atherogenesis and thrombosis – – Endothelial Smoking and cardiovascular disease: postulated mechanisms • Smoking-induced atherogenesis and thrombosis – – Endothelial injury/dysfunction Thrombosis Inflammation Lipids/lipid metabolism Ask and Act

Interactions between blood components and arterial wall • Endothelial dysfunction • Leukocyte and platelet Interactions between blood components and arterial wall • Endothelial dysfunction • Leukocyte and platelet activation and adherence to endothelium • Migration of leukocytes to endothelium • Increased LDL cholesterol Ask and Act

Changes within arterial wall • LDL oxidation • LDL accumulation in monocytes, turning them Changes within arterial wall • LDL oxidation • LDL accumulation in monocytes, turning them into foam cells • LDL and collagen accumulate in intercellular space • Smooth muscle cell proliferation/hyperplasia Ask and Act

Advanced changes in atherogenesis • Plaque inflammation • Endothelial denudation • Platelet activation, micro Advanced changes in atherogenesis • Plaque inflammation • Endothelial denudation • Platelet activation, micro and macro-thrombosis • Fibrinolysis of thrombi • Plaque and thrombus rupture-emboli Ask and Act

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Gangrene from PVD Ask and Act Gangrene from PVD Ask and Act

Smoking and respiratory disease • Acute respiratory diseases – Upper respiratory tract • Rhinitis, Smoking and respiratory disease • Acute respiratory diseases – Upper respiratory tract • Rhinitis, laryngitis, pharyngitis, sinusitis – Lower respiratory tract • Bronchitis, pneumonia Ask and Act

Smoking and respiratory disease • Chronic respiratory diseases § Reduced lung function in infants Smoking and respiratory disease • Chronic respiratory diseases § Reduced lung function in infants § Respiratory symptoms in children & adults § Cough, phlegm, wheezing, dyspnea § Poor asthma control § Chronic obstructive pulmonary disease Ask and Act

COPD • Cigarette smoking is associated with a ten-fold increased risk of dying from COPD • Cigarette smoking is associated with a ten-fold increased risk of dying from chronic obstructive lung disease. About 90% of all deaths from chronic obstructive lung diseases are attributable to cigarette smoking Ask and Act

Smoking and COPD: mechanisms Tobacco smoke induces inflammation and damage to pulmonary tissue through Smoking and COPD: mechanisms Tobacco smoke induces inflammation and damage to pulmonary tissue through – Release of inflammatory cells and mediators – Imbalance between proteases and antiproteases – Oxidative stress Ask and Act

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Anatomy of a cigarette Ask and Act Anatomy of a cigarette Ask and Act

Low yield cigarettes didn’t lead to reduced tar intake or a decrease in risk Low yield cigarettes didn’t lead to reduced tar intake or a decrease in risk of disease Smoker’s Compensation Industry Manipulation • Inhaling more deeply and/or more frequently • Holding smoke in lungs longer • Blocking air holes on filter with fingers • Smoking more cigarettes • Smoking further down to the butt • Devised advertising and marketing strategies used to reassure smokers • Promoted lower-yield cigarettes as safer alternatives • Created products that tested low on the machines but did not actually deliver less tar or nicotine to smokers Ask and Act

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Smoking and reproductive health • Reduced fertility in women • Pregnancy and pregnancy outcomes Smoking and reproductive health • Reduced fertility in women • Pregnancy and pregnancy outcomes § Placenta previa § Placental abruption § Preterm premature rupture of membranes § Preterm delivery § Low infant birth weight • Infant mortality § Sudden infant death syndrome (SIDS) Ask and Act

Unique qualities of nicotine addiction through smoking • Cigarette is a highly engineered drug-delivery Unique qualities of nicotine addiction through smoking • Cigarette is a highly engineered drug-delivery system • Inhaling produces a rapid distribution of nicotine to the brain • Drug levels peak within 10 seconds in the brain • Acute effects dissipate within minutes, causing the smoker to continue frequent dosing throughout the day • Average smoker takes 200 -300 boluses to the brain per day Nature 1989; 393: 76 Ask and Act

Tobacco industry executives in Congress, 1994 Ask and Act Tobacco industry executives in Congress, 1994 Ask and Act

"Moreover, nicotine is addictive. We are, then, in the business of selling nicotine, an addictive drug effective in the release of stress mechanisms. " Addison Yeaman, vice president and general counsel, Brown & Williamson (1963). Ask and Act

Reinforcing properties of nicotine • Stimulating effect – Increased alertness & cognitive performance • Reinforcing properties of nicotine • Stimulating effect – Increased alertness & cognitive performance • Reward effect – Increased relaxation Low doses: stimulating effects predominate High doses: reward effects predominate Ask and Act

Nicotine withdrawal symptoms • Constant craving of cigarettes • Insomnia • Irritability • Anxiety Nicotine withdrawal symptoms • Constant craving of cigarettes • Insomnia • Irritability • Anxiety • Frustration • Anger • Depression • Difficulty concentrating • Restlessness • Decreased heart rate • Increased appetite Withdrawal peaks within 24 -48 hours and diminishes over 1 month. Ask and Act

Neuropharmacology • Norepinephrine Stimulation, arousal • Acetylcholine Memory, cognition • Glutamate Memory, cognition NICOTINE Neuropharmacology • Norepinephrine Stimulation, arousal • Acetylcholine Memory, cognition • Glutamate Memory, cognition NICOTINE • GABA Relaxation, Anxiolytic • DOPAMINE Pleasure, Arousal • Vasopressin H 2 O, blood pressure • ACTH Adrenal steroids • Prolactin Lactation, (other? ) Ask and Act

DOPAMINE REWARD PATHWAY Prefrontal cortex Dopamine release Nucleus accumbens Stimulation of nicotine receptors Ventral DOPAMINE REWARD PATHWAY Prefrontal cortex Dopamine release Nucleus accumbens Stimulation of nicotine receptors Ventral tegmental area Nicotine enters brain Ask and Act

Helping patients quit Helping patients quit

Assessing the degree of addiction • How much does the patient smoke? • When Assessing the degree of addiction • How much does the patient smoke? • When do they smoke their first cigarette? • Longest period of time between cigarettes before craving. • . Ask and Act

Smoking initiation and cessation NEVER SMOKER ADOLESCENCE THINKING ABOUT SMOKING EXPERIMENTATION NONSMOKER ADULTHOOD REGULAR Smoking initiation and cessation NEVER SMOKER ADOLESCENCE THINKING ABOUT SMOKING EXPERIMENTATION NONSMOKER ADULTHOOD REGULAR USE QUIT DEPENDENT SMOKER SHORT-TERM SUCCESS Cessation Cycle CONTEMPLATION of CESSATION ACTION LONG-TERM SUCCESS

Stages of change Precontemplation Contemplation Preparation Action Relapse Maintenance Don’t want to quit Want Stages of change Precontemplation Contemplation Preparation Action Relapse Maintenance Don’t want to quit Want to quit sometime Will quit in next 30 days Am quitting now Termination Adapted from Knight, 1997 Ask and Act

Physicians are crucial to successful cessation • Tobacco-cessation counseling by clinicians is effective in Physicians are crucial to successful cessation • Tobacco-cessation counseling by clinicians is effective in improving tobacco quit rates among adults and has been recommended for adolescents. • 3% quit/year if you do nothing • 6% quit for 6 months with 3 minute counseling or practice system USPHSR, 2000 Ask and Act

Tobacco dependence treatment is more cost-effective than… • Mammography • Colon cancer screening • Tobacco dependence treatment is more cost-effective than… • Mammography • Colon cancer screening • Pap tests • Pharmacologic treatment of mild to moderate hypertension • Pharmacologic treatment of hypercholesterolemia Source: Fiore et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. USDHHS, 2000. Ask and Act

Elements of a counseling intervention • Quit date: – Set a stop date, preferably Elements of a counseling intervention • Quit date: – Set a stop date, preferably within 2 weeks – Starting on the quit date, total abstinence is essential • Past quit experience: – Identify what helped and what hurt in previous quit attempts Ask and Act

Elements of a counseling intervention • Anticipate triggers or challenges in upcoming attempt: – Elements of a counseling intervention • Anticipate triggers or challenges in upcoming attempt: – Discuss challenges/triggers and how patient will successfully overcome them • Alcohol: – Since alcohol can cause relapse, the patient should consider limiting/ abstaining from alcohol while quitting Ask and Act

Elements of a counseling intervention • Other smokers in the household: – Quitting is Elements of a counseling intervention • Other smokers in the household: – Quitting is more difficult when there is another smoker in the household – Patients should encourage housemates to quit with them or not smoke in their presence Ask and Act

Alternative therapies • Acupuncture • Hypnosis • Massage RCTs don’t show any clinical effectiveness Alternative therapies • Acupuncture • Hypnosis • Massage RCTs don’t show any clinical effectiveness using these modalities Ask and Act

Pharmacotherapy – Who should receive it? • Nearly all smokers trying to quit, except Pharmacotherapy – Who should receive it? • Nearly all smokers trying to quit, except those with medical contraindications, adolescents and those who smoke fewer than 10 cigarettes per day. Ask and Act

Recommended first-line pharmacotherapies • Varenicline • Bupropion SR • Nicotine gum • Nicotine inhaler Recommended first-line pharmacotherapies • Varenicline • Bupropion SR • Nicotine gum • Nicotine inhaler • Nicotine nasal spray • Nicotine patch • Nicotine lozenge Ask and Act

First-line pharmacotherapies • Varenicline-agonizes and blocks α 4β 2 nicotinic acetylcholine receptors. • Bupropion First-line pharmacotherapies • Varenicline-agonizes and blocks α 4β 2 nicotinic acetylcholine receptors. • Bupropion SR-mechanism for smoking cessation unknown; inhibits neuronal uptake of norepinephrine, serotonin and dopamine. • NRT-binds to various CNS and peripheral nicotinic-cholinergic receptors. Ask and Act

Increase in nicotine concentration ( ng/ml ) 14 12 Smoking produces much higher nicotine Increase in nicotine concentration ( ng/ml ) 14 12 Smoking produces much higher nicotine levels and much more rapidly than NRT 10 Cigarette 8 Gum 4 mg 6 Gum 2 mg 4 Patch 42 mg Inhaler 2 0 Patch 21 mg Minutes 5 10 15 20 25 30 Source: Balfour DJ & Fagerström KO. Pharmacol Ther 1996 72: 51 -81. Ask and Act

First-line pharmacotherapies Varenicline–average cost per day is $4. 00. Start. 5 mg daily for First-line pharmacotherapies Varenicline–average cost per day is $4. 00. Start. 5 mg daily for three days, then increase to twice daily for four days. On the eighth day, stop smoking and increase to 1 mg twice daily. Most common side effects are nausea and vivid dreams. Ask and Act

First-line pharmacotherapies Bupropion SR-average cost per day is $4. 33. Start 150 mg once First-line pharmacotherapies Bupropion SR-average cost per day is $4. 33. Start 150 mg once daily for three days, then twice per day for seven to twelve weeks. Plan quit date around day seven of treatment. Common side effects include insomnia and headaches. Ask and Act

First-line pharmacotherapies Nicotine gum-average cost per day is $9. 33 for 2 mg and First-line pharmacotherapies Nicotine gum-average cost per day is $9. 33 for 2 mg and $10. 33 for 4 mg dose. Patients who smoke less than 15 cigarettes per day chew one 2 mg piece every one to two hours and those who smoke more than 15 a day chew 4 mg piece every one to two hours. Common side effects are jaw pain and mouth soreness. Ask and Act

First-line pharmacotherapies Nicotine inhaler-average cost per day is $9. 50. Start with six to First-line pharmacotherapies Nicotine inhaler-average cost per day is $9. 50. Start with six to sixteen 10 mg cartridges per day for three months, then taper over six to twelve weeks. Common side effects are mouth and throat irritation. Ask and Act

First-line pharmacotherapies Nicotine nasal spray-average cost per day is $16. 00. Start one or First-line pharmacotherapies Nicotine nasal spray-average cost per day is $16. 00. Start one or two. 5 mg doses in each nostril every hour for three to six months, then taper over four to six weeks. Common side effects are nose and eye irritation. This is the most addictive form of nicotine replacement therapy. Ask and Act

First-line pharmacotherapies Nicotine patch-average cost per day is $4. 00 for 21 mg patch, First-line pharmacotherapies Nicotine patch-average cost per day is $4. 00 for 21 mg patch, $3. 40 for 14 mg patch and 7 mg patch. For patients who smoke more than 10 cigarettes a day start at 21 mg every twenty-four hours for six to eight weeks, then step down to 14 mg for two to four weeks, then 7 mg for two to four weeks. Common side effects are skin irritation or sleep issues if worn at night. Ask and Act

Nicotine Patch Therapy • Nicotine Replacement Therapies are Inefficient Delivery Systems compared to Tobacco Nicotine Patch Therapy • Nicotine Replacement Therapies are Inefficient Delivery Systems compared to Tobacco • ~50% median replacement with standard dose • Higher doses of NRT may be more efficacious Ask and Act

Higher dose nicotine patch • There is a dose-response effect • Long-term abstinence improved; Higher dose nicotine patch • There is a dose-response effect • Long-term abstinence improved; OR=1. 21 (95% CI 1. 03 -1. 42)* • Treatment-related adverse events are uncommon • Withdrawal symptoms less with higher dose NRT *Cochrane Database of Systematic Reviews 2005 Ask and Act

First-line pharmacotherapies Nicotine lozenge-average cost per day is $8. 88. Start one lozenge every First-line pharmacotherapies Nicotine lozenge-average cost per day is $8. 88. Start one lozenge every one to two hours for the first six weeks, then one lozenge every two to four hours for three weeks, then one lozenge every four to eight hours. For patients who smoke their first cigarette within thirty minutes of awakening, use 4 mg dose and other use 2 mg dose. Common side effects or mouth soreness and dyspepsia. Ask and Act

Factors clinicians should consider when choosing first-line pharmacotherapies – Clinician familiarity with medications – Factors clinicians should consider when choosing first-line pharmacotherapies – Clinician familiarity with medications – Contraindications for selected patients – Patient preference – Previous patient experience – Patient insurance coverage and cost of treatment – Patient characteristics (history of depression, weight gain concerns, etc. ) Ask and Act

Recommended second-line pharmacotherapies (off label use) – Clonidine-mechanism for smoking cessation unknown; stimulates α Recommended second-line pharmacotherapies (off label use) – Clonidine-mechanism for smoking cessation unknown; stimulates α 2 adrenergic receptors (centrally-acting antihypertensive) – Nortriptyline-mechanism for smoking cessation unknown; inhibits norepinephrine and serotonin uptake Ask and Act

What should be considered for patients concerned with weight gain? – Bupropion SR and What should be considered for patients concerned with weight gain? – Bupropion SR and nicotine replacement therapies (especially gum) may delay, but not prevent, weight gain. – The average weight gain from tobacco cessation is 5 pounds, more common in women. Ask and Act

Should pharmacotherapy be avoided in patients with a history of cardiovascular disease? • Nicotine Should pharmacotherapy be avoided in patients with a history of cardiovascular disease? • Nicotine replacement therapy-caution for drug class if MI within two weeks, severe arrhythmias or cardiovascular disease. • Bupropion SR-caution if recent MI or hypertension. • Varenicline-no contraindications or cautions in patients with a history of cardiovascular disease. Ask and Act

What about pregnant smokers? – Counseling is best choice. – Risks of premature birth What about pregnant smokers? – Counseling is best choice. – Risks of premature birth or stillbirth caused by smoking may be higher than the potential risk of birth defects caused by pharmacotherapy. – Bupropion SR and varenicline are both pregnancy category C. – Nicotine replacement therapy is pregnancy category D, except for gum and lozenges, which are pregnancy category C. Ask and Act

Can pharmacotherapies be used long-term? – Yes. – Helpful with smokers with persistent withdrawal Can pharmacotherapies be used long-term? – Yes. – Helpful with smokers with persistent withdrawal systems. – Long-term use of NRT does not present a known health risk. – FDA approved the use of bupropion SR for long-term maintenance. – Varenicline is recommended for 12 week course; may repeat for another 12 weeks. Ask and Act

Can pharmacotherapies be combined? – Yes. – Evidence that combining nicotine patch with gum, Can pharmacotherapies be combined? – Yes. – Evidence that combining nicotine patch with gum, inhaler or nasal spray increases long-term abstinence rates. – Combining nicotine patch with bupropion is more effective than patch alone but not bupropion alone. Ask and Act

Patient variables associated with lower success rates – High nicotine dependence. – High stress Patient variables associated with lower success rates – High nicotine dependence. – High stress level. – Severe withdrawal during previous quit attempts. – Smokes heavily, and/or has first cigarette of the day within 30 minutes after awakening in the morning. Ask and Act

Patient variables associated with lower success rates – History of depression, schizophrenia, alcoholism, or Patient variables associated with lower success rates – History of depression, schizophrenia, alcoholism, or other chemical dependency. – Stressful life circumstances or major life changes (divorce, job change, marriage, etc. ). Ask and Act

Patient variables associated with higher success rates – High motivation. – Ready to change. Patient variables associated with higher success rates – High motivation. – Ready to change. – Moderate to high self efficacy. – Supportive social network. Ask and Act

Patient variables associated with higher success rates – Tobacco user reports motivation to quit Patient variables associated with higher success rates – Tobacco user reports motivation to quit and is ready to quit within a 1 -month period. – Confidence in his or her ability to quit. – A smoke-free workplace, home and social environment. Ask and Act

Managing withdrawal symptoms – Most intense usually during the first three to seven days. Managing withdrawal symptoms – Most intense usually during the first three to seven days. – May continue for several weeks or even longer at a declining level of intensity. – Can experience periodic cravings months after stopping. Triggers or cues that were associated with smoking can provoke the cravings. Ask and Act

Managing withdrawal TIPS FOR PATIENTS – Exercise. – Reduce or avoid caffeine or other Managing withdrawal TIPS FOR PATIENTS – Exercise. – Reduce or avoid caffeine or other stimulants. – Drink plenty of water. – Use cough drops to relieve throat irritation. Ask and Act

Managing withdrawal TIPS FOR PATIENTS – Relax before going to bed. – Don't eat, Managing withdrawal TIPS FOR PATIENTS – Relax before going to bed. – Don't eat, watch television or discuss problems in bed. – Make your bedroom quiet, and keep a bedtime routine. – Change your morning routine to avoid that first tobacco dose of the day. Ask and Act

Managing withdrawal TIPS FOR PATIENTS If you’re having trouble concentrating: – Adjust your schedule Managing withdrawal TIPS FOR PATIENTS If you’re having trouble concentrating: – Adjust your schedule to a lighter workload. – Lower expectations on the amount of work you can do. – Understand the amount of energy and time it takes to stop smoking. Ask and Act

Managing withdrawal TIPS FOR PATIENTS If your appetite has increased: – Eat healthy snacks. Managing withdrawal TIPS FOR PATIENTS If your appetite has increased: – Eat healthy snacks. – Don’t delay regular meals. – Drink more water. – Exercise regularly. Ask and Act

Managing withdrawal TIPS FOR PATIENTS If you crave a cigarette: – Wait out the Managing withdrawal TIPS FOR PATIENTS If you crave a cigarette: – Wait out the craving, which is usually less than five minutes. – Try deep breathing. – Use distractions. Ask and Act

Motivate your patients to quit or think about quitting • • Ask every patient Motivate your patients to quit or think about quitting • • Ask every patient at every visit. Advise all tobacco users to quit. Assess if they are willing to quit. Assist by offering counseling and/or pharmacotherapy. • Arrange follow-up care. Ask and Act

How do you encourage a patient who is not ready to quit? • • How do you encourage a patient who is not ready to quit? • • • Relevance Risks Rewards Roadblocks Repetition Ask and Act

Overcome objections let’s try it Overcome objections let’s try it

Let’s Motivate! Scenario # 1 17 year-old baseball player who has been chewing tobacco Let’s Motivate! Scenario # 1 17 year-old baseball player who has been chewing tobacco since he was 10 years old wants to quit because his girlfriend doesn’t like his habit. Ask and Act

Let’s Motivate! Scenario # 2 28 year-old female who smokes 1 pack per day Let’s Motivate! Scenario # 2 28 year-old female who smokes 1 pack per day who is being seen today for her first prenatal visit. Ask and Act

Let’s Motivate! Scenario # 3 45 year-old male smokes 2 packs per day since Let’s Motivate! Scenario # 3 45 year-old male smokes 2 packs per day since he was 13 years old wants to quit because of his “midlife crisis”. Ask and Act

Let’s Motivate! Scenario # 4 53 year-old female with a 40 pack year history Let’s Motivate! Scenario # 4 53 year-old female with a 40 pack year history presents to the office for follow-up of her diabetes and hypertension but also complains of a nagging cough. Ask and Act

Let’s Motivate! Scenario # 5 37 year-old male with a history of depression and Let’s Motivate! Scenario # 5 37 year-old male with a history of depression and smokes 2 packs per day is requesting a refill on medications. During his past medical history review, it is evident that his father died at 47 years old of a heart attack. Ask and Act

The key to successful treatment of smoking is relapse prevention Ask and Act The key to successful treatment of smoking is relapse prevention Ask and Act

Relapse prevention • Goal of relapse prevention is to teach patients who are trying Relapse prevention • Goal of relapse prevention is to teach patients who are trying to stop tobacco how to anticipate and cope with the problems of relapse. • Relapse prevention includes both behavioral and cognitive components • A self management program designed to enhance the maintenance stage of the change process Ask and Act

Relapse prevention planning • • • Increase patient confidence in change Elicit barriers and Relapse prevention planning • • • Increase patient confidence in change Elicit barriers and ideas to cope Identify and discuss nicotine withdrawal Discuss medication options Elicit triggers and high risk situations Elicit coping skills – Behavioral – Cognitive • Elicit options for support Ask and Act

Relapse prevention • Critical timeframe—first 3 months • Encourage continued abstinence • Discuss benefits, Relapse prevention • Critical timeframe—first 3 months • Encourage continued abstinence • Discuss benefits, milestones, problems • Support unsuccessful attempts Ask and Act

Maintenance Stage • Patient must work hard to maintain the commitment to change over Maintenance Stage • Patient must work hard to maintain the commitment to change over time • Patient will be faced with a variety of temptations, stressors and the pull of a powerful “old habit pattern” Ask and Act

Preventing Relapse – Congratulate success – Encourage continued abstinence – Discuss with your patient: Preventing Relapse – Congratulate success – Encourage continued abstinence – Discuss with your patient: • benefits of quitting • barriers • If your patient has used tobacco, remind him or her that the relapse should be viewed as a learning experience • Relapse is consistent with the chronic nature of tobacco dependence; not a sign of failure Ask and Act

Follow-up planning • Congratulate or reassure • Assess nicotine withdrawal • Assess medication proper Follow-up planning • Congratulate or reassure • Assess nicotine withdrawal • Assess medication proper use and adequate withdrawal management • Discuss triggers/urges, and “new discoveries” • Discuss high risk situations • Assess utilization of coping skills, make adjustments • Discuss support system • Increase patient confidence, encourage Ask and Act

Benefit from a lapse • A lapse provides useful information • Information about the Benefit from a lapse • A lapse provides useful information • Information about the cause of the event – A formerly unknown stressful situation • How to correct it occurrence in the future – An action plan for that event • Lapse is a normal part of the recovery process Ask and Act

Relapse prevention: maintenance therapy • Tobacco Dependence is a Chronic Disease • Both MDs Relapse prevention: maintenance therapy • Tobacco Dependence is a Chronic Disease • Both MDs and patients often have unrealistic expectations for treatment of chronic disease, too often using a short treatment course • Forces driving relapse (biological, psychological, emotional) continue to influence well beyond the period of active treatment • Long-term therapy to maintain remission (prevent relapse) should be encouraged Ask and Act

ASK every patient AND ACT every time! Ask and Act ASK every patient AND ACT every time! Ask and Act

The Problem • Only 70% of family physicians currently ask their patients if they The Problem • Only 70% of family physicians currently ask their patients if they use tobacco. • Only 40% take action. Ask and Act

Few doctors counsel patients Asked by Doctors if Patient Smokes, Percent of All Patient Few doctors counsel patients Asked by Doctors if Patient Smokes, Percent of All Patient Visits Doctor Provides Smoking Counseling, Percent of Smoker Visits Doctor Prescribes Nicotine Replacement Therapy, Percent of Smoker Visits 30% 60% Source: Substance Abuse: The Nation’s Number One Health Problem from Thorndike An et al. “National Patterns in the Treatment of Smokers by Physicians. ” JAMA, 1998; 279(8): 604 -8.

Why don’t doctors ask? • • Too busy. Lack of expertise. No financial incentive. Why don’t doctors ask? • • Too busy. Lack of expertise. No financial incentive. Feeling that most smokers can’t or won’t quit. Ask and Act

Why don’t doctors ask? • Don’t want to appear judgmental. • Respect for patient’s Why don’t doctors ask? • Don’t want to appear judgmental. • Respect for patient’s privacy. • Negative message might scare patients away. • Health professional smokes. Ask and Act

Opportunity for physicians • 70% of smokers see a physician each year. • 70% Opportunity for physicians • 70% of smokers see a physician each year. • 70% of smokers want to quit. • Physician’s advice to quit is an important motivator. • Patients are more satisfied with their health care if their provider offers smoking cessation interventions - even if they’re not yet ready to quit. Ask and Act

Identification and Assessment: The 2 As • Ask • Act – On- or off-site Identification and Assessment: The 2 As • Ask • Act – On- or off-site counseling – Quitlines – Patient education materials – Self-help guides or Websites – Cessation classes – NRT or other pharmacotherapy Ask and Act

Make system changes to identify all tobacco users and document interventions: • Incorporate into Make system changes to identify all tobacco users and document interventions: • Incorporate into vital signs. • Use chart stickers or computer prompts to document status-current, quit or never smoker. • Develop templates on paper or by EHR for tobacco cessation. Ask and Act

Make system changes to identify all tobacco users and document interventions: • Let patients Make system changes to identify all tobacco users and document interventions: • Let patients know you can help -posters, lapel pins, brochures. • Ask office staff for ideas how to “Ask and Act”. • Develop incentives for staff interventions with patients-teams, time off or special recognition. Ask and Act

Make system changes to identify all tobacco users and document interventions: • Offer tobacco Make system changes to identify all tobacco users and document interventions: • Offer tobacco cessation group visits and place sign-up sheets in the waiting room. • Maintain tobacco cessation patient registry. • Plan for follow-up calls by office staff after tobacco quit date. Ask and Act

Quitlines • 1 -800 -QUIT-NOW callers are routed to a state-run quitline or the Quitlines • 1 -800 -QUIT-NOW callers are routed to a state-run quitline or the National Cancer Institute quitline. • Quitline referral cards are free for AAFP members. Go to askandact. org. • Easy intervention to incorporate into office redesign. Ask and Act

Quitlines play a central role through: – Direct counseling – Central resource for materials, Quitlines play a central role through: – Direct counseling – Central resource for materials, information and referrals – triage callers. – Easily accessible, convenient, economies of scale – Multi-language, culturally tailored services – Trained staff; quality assurance Ask and Act

Getting Paid Ask and Act Getting Paid Ask and Act

Getting Paid • Effective March 22, 2005, Medicare covers tobacco cessation counseling for patients Getting Paid • Effective March 22, 2005, Medicare covers tobacco cessation counseling for patients who smoke and have a tobacco-related disease or whose therapy is affected by tobacco use. Ask and Act

Getting Paid • Effective January 2006, Medicare's prescription drug benefit covers smoking cessation treatments Getting Paid • Effective January 2006, Medicare's prescription drug benefit covers smoking cessation treatments prescribed by a physician. – Over-the-counter treatments are not covered. Ask and Act

Billing for tobacco cessation counseling - HCPCS codes • G 0375: Smoking and tobacco Billing for tobacco cessation counseling - HCPCS codes • G 0375: Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes; national average payment $12. 89 • G 0376: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes; national average payment $25. 39 Ask and Act

Billing for tobacco cessation counseling - HCPCS codes • 8 visits allowed in 12 Billing for tobacco cessation counseling - HCPCS codes • 8 visits allowed in 12 month period (4 sessions per attempt or 2 quit attempts per year). • Counseling < 3 min covered under E&M code. • Can have an appropriate E/M service on same day, use modifier -25. • Face-to-face counseling time can be “incident to”. Ask and Act

Billing for tobacco cessation counseling - HCPCS codes • Any qualified provider, such as Billing for tobacco cessation counseling - HCPCS codes • Any qualified provider, such as physicians, clinical social workers, psychologists, hospitals, may bill for tobacco cessation. • May be billed as inpatient as long as tobacco cessation not primary diagnosis for admission. Ask and Act

Billing for tobacco cessation counseling – ICD-9 codes • 305. 1: Tobacco Use Disorder Billing for tobacco cessation counseling – ICD-9 codes • 305. 1: Tobacco Use Disorder • V 15. 82: History of Tobacco Use • Provide other clinically relevant diagnosis code, such as cough 786. 2. • Document time spent counseling for tobacco cessation. Ask and Act

Private Insurers • Most insurers provide coverage for at least one type of pharmacotherapy Private Insurers • Most insurers provide coverage for at least one type of pharmacotherapy for tobacco cessation and at least one type of behavioral intervention. • Coverage tripled from 1997 to 2002. Ask and Act

Medicaid • Thirty-seven states now cover one or more treatments for tobacco dependence. • Medicaid • Thirty-seven states now cover one or more treatments for tobacco dependence. • Go to medicaid website to locate your state benefits: http: //statehealthfacts. org Ask and Act

Policy Interventions Ask and Act Policy Interventions Ask and Act

Policy Interventions • Increase the cost • Clean indoor air • Increase access and Policy Interventions • Increase the cost • Clean indoor air • Increase access and reimbursement for cessation • Comprehensive tobacco control programs Ask and Act

Recommendations from the Community Guide Task Force Interventions to Reduce Tobacco Use and ETS Recommendations from the Community Guide Task Force Interventions to Reduce Tobacco Use and ETS Exposure in Communities and Health Care Systems Ask and Act

Community Preventive Services Findings • • Increase the price of tobacco products Enact clean Community Preventive Services Findings • • Increase the price of tobacco products Enact clean indoor air policy Counter-advertising/media campaigns Reduce out-of-pocket costs for cessation Telephone support for cessation Educate providers about tobacco control Increase access and reimbursement for cessation Ask and Act

Ask and Act Ask and Act

California’s media campaign • Analysis of early impact (1990 -1992) showed drop in sales California’s media campaign • Analysis of early impact (1990 -1992) showed drop in sales attributed to media campaign of 232 million packs of cigarettes • 1996 evaluation showed campaign increased number of adult quit attempts, more negative attitudes toward tobacco industry • California adult smoking prevalence dropped by 33% since the tobacco control program and media campaign began in 1988—now at 15. 4% Ask and Act

Massachusetts tobacco control program • Strong media component as part of comprehensive approach • Massachusetts tobacco control program • Strong media component as part of comprehensive approach • Program elements apart from tax effects were estimated to have produced 55% of the drop in smoking prevalence • Adult prevalence dropped 22% between 1993 and 2002, double the rate of the rest of the US—now 19. 2% • Smoking among key population groups such as youth and pregnant women dropped significantly faster than other states without comprehensive programs Ask and Act

Tobacco addiction is a chronic disease and deserves ongoing clinical treatment. Effective smoking cessation Tobacco addiction is a chronic disease and deserves ongoing clinical treatment. Effective smoking cessation can reduce illness and improve patient quality of life. Every time, ask your patients if they use tobacco. Act to help them quit. Ask and Act

Resources • www. askandact. org • • www. tobacco. org www. cdc. gov/tobacco http: Resources • www. askandact. org • • www. tobacco. org www. cdc. gov/tobacco http: //www. smokefree. gov www. tobaccofreekids. org • http: //smokingcessationleadership. ucsf. edu/ Ask and Act

Ask and Act Ask and Act

Canadian cigarette warning Ask and Act Canadian cigarette warning Ask and Act

Canadian cigarette warning Ask and Act Canadian cigarette warning Ask and Act

Ask and Act Ask and Act