Treating Tobacco Dependence in Health Departments

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Treating Tobacco Dependence in Health Departments
Kimber Richter, PhD, MPH Edward Ellerbeck, MD,
MPH University of Kansas Medical
Center Departments of Preventive Medicine and
Public Health KU-MPH For more info, or
worksheets included in this talk, contact me at
krichter_at_kumc.edu
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Objectives

• Understand the public health rationale for
  promoting cessation
• Describe how to treat tobacco what works in
  health departments?
• Varying levels of intensity
• Using resources available in Kansas
• Pregnant smokers
• Intake/assessment forms for clinic use

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Projected Mortality Patterns
Prevention Effect
Cumulative Deaths(Millions)
Current Course
Prevention andTreatment Effect
Year
Source Henningfield JE, Slade J. Food and Drug
Law Journal. 199853.
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The Best Drug Delivery System Cigarettes

• Heroin and other injected drugs vein, heart,
  lungs, heart, brain
• Nicotine, delivered by cigarettes lungs, heart,
  brain (3 sec)
• Ph-altered (freebased) to be absorbed deep in
  lungs
• Alveolar epithelium has the surface area of a
  tennis court
• Delivers a large amount of nicotine to the brain
  with every puff
• People take 12-15 puffs/cigarette do the math
• 12 X 20 cigs/day X 365 day/yr 87,000 puffs per
  year for pack-a-day smoker
• More common than any other voluntary, many
  involuntary behaviors (how many times do you
  blink?)
• How come Johnny didnt stop the first time he
  tried?
• Better to ask, how can anyone stop?
• Adapted from presentations by Ray Niaura, John
  Slade.

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Smokeless, Cigar, Pipe Tobacco

• In 2005, 13.7 mil (5.7) cigars 7.2 million (3)
  smokeless 1.8 million (0.8) pipe
• Cigar use is all over the place
• Daily smokeless use is addictive same levels of
  nicotine as cigarettes hard to quit
• Health risks smokeless CVD, oral health, cancer
• High risk men 18-44 no high school degree
  Southerners rural
• Chew to relax, get calm, when bored, during
  sports, television, after meals
• Reasons for quitting health, be a better role
  model, think its dirty, awkward to use around
  girlfriends/coworkers, cost
• Can use many same strategies for cessation as
  cigarette smokers
• Important to Ask about cigarettes and other
  tobacco use to identify users

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Pregnant Smokers

• For moms quitting smoking before/during
  pregnancy reduces risk for
• conception delay
• infertility
• premature rupture of membranes
• For babies, moms quitting can achieve
• 20 reduction in lowbirth-weight babies
• 17 decrease in preterm births
• Average increase in birth weight of 28 g

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Pregnant Smokers, Contd

• A woman is more likely to quit smoking during
  pregnancy than at any other time in her life
• 1/5 pregnant smokers quit before first doctor
  visit during pregnancy
• Brief counseling (5 -15 mins total) is all that
  is needed to help many pregnant smokers quit
• Many (up to 32) remain smoke free after delivery
• However, 70 of women who quit smoking after
  learning they are pregnant (spontaneous quitters)
  relapse within 6 months of delivery
• It is important to help smokers quit during
  pregnancy and prevent relapse after delivery
• Intervention works best for moderate (cigarettes/day) smokers
• Smoking Cessation in Pregnancy A Review of
  Postpartum Relapse Prevention Strategies J Am
  Board Fam Pract 17(4)264-275, 2004.

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Health Departments Can Help

• How many people get any form of health care from
  Health Departments in Kansas?
• Who gets their health care from Health
  Departments?
• _______________________________________
• _______________________________________
• _______________________________________
• _______________________________________
• What types of health care do they get?
• What are Health Departments currently doing to
  treat tobacco dependence?

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Clinical Practice Guidelines

• Intervene with all smokers, regardless of
  readiness to quit
• Our goal is to reduce the decades-long gap
  between initiation and cessation
• Smokers uninterested in quitting soon should
  receive a brief motivational intervention
• Smokers interested in quitting soon should
  receive
• Pharmacotherapy, unless contraindicated
• 4 or more sessions of supportive, practical
  counseling
• Often delivered in format of 5As
• Brief physician/other clinician intervention is
  helpful to all smokers
• Important to tailor intervention to the needs of
  special groups
• Pregnant smokers
• Developing a clinic system is important!

Source Fiore et al. Treating Tobacco Use and
Dependence Clinical Practice Guideline.
USDHHS, 2008.
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The 5-As of Tobacco Treatment

• Ask if client smokes
• Advise all smokers to quit
• Assess readiness to quit
• If ready, proceed to other As
• If not ready, do brief motivational intervention
• Assist smoker to quit
• referral/direct assistance
• Medications
• Counseling
• Arrange follow-up check up on progress
  afterwards
• HAVE AN OFFICE SYSTEM
• TO MAKE SURE EACH OF THESE OCCUR

Source Fiore et al. Treating Tobacco Use and
Dependence Clinical Practice Guideline.
USDHHS, 2008.
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Also, A A R - Ask, Advise, Refer

• Ask
• Advise
• Refer to physician, quitline, and other resources
• HAVE AN OFFICE SYSTEM TO MAKE SURE EACH OF THESE
  OCCUR

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1 ASK ABOUT TOBACCO AT EVERY OPPORTUNITY How
many of you do this already in your clinics?
What type of system do you have for it?
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Example Office System (TOBACCO USE)
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Pregnant Smokers Asking about Smoking
Which of the following statements best describes
your cigarette smoking?
I have never smoked or have smoked fewer than
100 cigarettes in my lifetime
I stopped smoking before I found out I was
pregnant and am not smoking now
I stopped smoking after I found out I was
pregnant and am not smoking now
I smoke some now but have cut down since I found
out I am pregnant
I smoke about the same amount now as I did
before I found out I was pregnant
Congratulate patient
Advise
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2 ADVISE ALL SMOKERS/TOBACCO USERS TO
STOP How many of you do this already in your
clinics? What type of system do you have for it?
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Routinely Advise All Smokers to Quit

• Even a minimal intervention is effective it
  adds up!
• Provide clear, direct advice to quit
• I really care about you the single best thing
  you can do for your health is to quit smoking
• Have an office system to ensure it occurs

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Practice Advising Smokers to Quit

• Provide clear, direct advice to quit
• I really care about you the single best thing
  you can do for your health is to quit smoking
• I know you know this, but as your health care
  provider I need to say it again the best thing
  you can do for you and your baby is to quit
  smoking.
• Ive known you for XX years, and I know your
  family. I want to keep taking care of you! The
  best way for you to protect your health is to
  quit smoking.
• Ok, Im just going to lay it out there you
  really need to quit smoking. How can I help?
• Your turn ______________________________________
  _____
• How can you make sure this happens routinely in
  your clinic?

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• 3 ASSESS
• Whether or not ready to quit
• Level of Interest in quitting
• Nicotine dependence
• How many of you do this already in your clinics?
  
• What type of system do you have for it?

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Practice Assessing Readiness

• Ask client if she/he is ready to quit
• How many do you think will be ready to quit?
  ______
• Are you ready to quit smoking?
• Are you ready to try again?
• Your turn ______________________________________
  _____
• How can you make sure this happens routinely in
  your clinic?
• What do you do with people who arent ready?
• Do brief motivational intervention
• Leave door open to talk about smoking in future

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For Unmotivated Smokers Strategy 1
--Assessing/Discussing Interest in Quitting

• Interest Ruler
• You said a 5 - thats a lot higher than a 1, so
  youve been thinking about this - what makes you
  that interested in quitting?
• You said a 5 - what keeps you from being a 10?/
  OR What would need to happen for you to get from
  from X to (higher number)?
• Summarize talk (dont have to follow this script
  just provides an idea).
• You are really motivated to quit because
  _________, __________, _________. ________has
  been a bit of a barrier for you. You are
  confident that you can quit because _______, but
  you are worried about ______. Did I leave
  anything out?

On a scale of 0 to 10, with 10 being very
interested, how interested are you in quitting
smoking? 0 1 2 3
4 5 6 7 8
9 10 Not at all Somewhat
Very
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For Unmotivated Smokers Strategy 2 Discuss
Pros/Cons of Smoking/Quitting
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4 ASSIST THE PATIENT IN STOPPING

• Pharmacotherapy
• Counseling
• Social Support

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Build an Ongoing Action Plan
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Pharmacotherapy

• First-line therapy
• Nicotine replacement --- PatchKS MEDICAID
• Bupropion --- KS MEDICAID
• Varenicline --- KS MEDICAID
• How many of you prescribe to Medicaid Pts?
• Second-line therapy
• Nortriptyline
• Clonidine

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Monthly Cost of Pharmacotherapy
3.89/pack
28.99/carton x 4
47.99 x 2
Bupropion 60 68.99
106.99
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Providing Information About Pharmacotherapy
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Pregnant Smokers, Pharmacotherapy

• Medications double quit rates among non-pregnant
  smokers.
• First-line medications for smokers include
  bupropion SR, varenicline (chantrix), nicotine
  gum, nicotine inhaler, nicotine nasal spray, and
  nicotine patch.
• Second-line medications for smokers include
  clonidine.
• The safety and efficacy of these treatments for
  pregnant smokers remain unknown.
• Pharmacotherapy should be considered when a
  pregnant woman is otherwise unable to quit, and
  when the likelihood of quitting, with its
  potential benefits, outweighs the risks of the
  pharmacotherapy and potential continued smoking.
  (ACOG)

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Pregnant Smokers, Pharmacotherapy

• The one existing trial did not find an effect of
  the patch on pregnant smokers
• However, babies born to women in the NRT group
  had significantly higher birth weights than those
  in the placebo group
• This suggests that the intrauterine growth
  restriction caused by smoking is probably not
  attributable to nicotine
• Nicotine is known to be harmful to the fetus
  though it is believed to be much less harmful
  than cigarette smoke
• Many pregnant smokers want NRT and it may be a
  way of engaging with them so that they can
  receive behavioural support which has been shown
  to be effective

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Common Elements of Supportive Counseling

• Provide basic information about smoking and
  quitting
• Encourage patient in the quit attempt
• Communicate caring and concern
• Encourage patient to talk about quitting process
• Targeted to readiness
• Smokers not ready to quit soon should be provided
  with motivational counseling
• Smokers ready to quit should be provided with
  how-to assistance

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Individual Treatment Initial Session

• FIRST SESSION (Just a suggestion! Modify as
  needed)
• Ask permission to discuss tobacco use
• Collect brief tobacco use history
• Explore importance of quitting, confidence in
  being able to quit
• Summarize, list in behavioral action plan
• Low importance build motivation
• High importance, low confidence build
  confidence
• High importance, high confidence quit plan,
  quit date
• Learn from past quit attempts
• Discuss quit smoking medications/counseling
• Summarize, set time/goals for next time you meet

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Individual Treatment Follow up

• FOLLOWING SESSIONS (Just a suggestion! Modify as
  needed)
• Ask how they are doing, reflect on any
• Assess current tobacco use
• Still smoking at regular rates explore
  discrepancy bet. behav/goals
• Still smoking, but made progress celebrate! Ask
  what helped
• Quit celebrate! Ask what helped, cover relapse
  prevention
• Assess withdrawal
• Troubleshoot pharmacotherapy if withdrawal a
  problem
• Elicit-provide-elicit (use worksheet)
• Address other issues as needed (driving, weight
  gain, etc)
• Summarize, set time/goals for next session

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5 ARRANGE FOLLOW-UP Monitor progress at
future visits What would a system look like for
this?
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OR 1 ASK 2 ADVISE 3 a REFER REFER out for
Assess/Assist/Arrange What would a system look
like for this?
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• 3 a REFER
• Fax refer to KanStop
• Refer to websites, other phone counseling
• Refer to physician for medications

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The KanStop Quitline
Clients can call in or you can fax-refer them to
the Quitline OR The national number at
1-800-QUITNOW
Call them yourself to get a provider information
packet or to arrange for fax referrals
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Other Resources, Patients

• Online resources for patients
• Become An Ex www.becomeanex.org
• Quit Smoking Now www.Smokfree.gov
• QuitNet www.quitnet.com
• Freedom from Smoking Online www.ffsonline.org
• Most medications come with phone-based assistance
  

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Wrapping It Up

• Clients should be routinely offered tobacco
  treatment, but not required to quit
• Consider providing information about quit options
  before asking whether theyre ready to quit or
  not
• Do brief motivational intervention with clients
  with low interest
• Use collaborative approach to quitting
• Encourage/troubleshoot quit smoking medications
• Use tobacco relapse as a learning/building step

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Wearing a mask to guard against SARS, a Toronto
SURGEON takes a puff break outside St. Michaels
Hospital
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Other Resources, Training

• Materials, Guides For Treating Smoking Available
  Online
• University of Wisconsin Center for Tobacco
  Research and Intervention. Information for
  Researchers, Healthcare Providers, Smokers,
  Insurers, Employers, Advocates. Patient and
  clinician handouts, posters, training manuals and
  videos, links to research and advocacy.
  http//www.ctri.wisc.edu/
• Agency for Healthcare Research and Quality.
  How-To Guides for Implementing the Public Health
  Service Guidelines.
• http//www.ahrq.gov/clinic/tobacco/
• Treatobacco.net provides evidence-based
  information about how to treat tobacco, including
  a QuitTip database of stop-smoking products.
  http//www.treatobacco.net/home/home.cfm/
• Center for Tobacco Cessation. American Dental
  HygienistsAssociation Smoking Cessation
  Initiative. Ask, Advise, Refer. Toolkit for
  brief intervention, tobacco news, patient
  resources. http//www.askadviserefer.org/
• CDC Tobacco Information and Prevention Source.
  Offers patient education materials for quitting
  smoking in English and Spanish.
• http//apps.nccd.cdc.gov/osh_pub_catalog/
• American Lung Association. ALA web site includes
  a Tobacco Control section with information on
  smoking and cessation, as well as Freedom From
  Smoking Online, a free quit-smoking program.
  http//www.lungusa.org/
• American Cancer Society. Includes a Tobacco
  Control section with information on health,
  cessation programs, and more http//www.cancer.o
  rg/
• Addressing Tobacco in Managed Care A Resource
  Guide for Health Plans. Includes case studies of
  various types of interventions how to develop
  and implement a tobacco control initiative.
  www.ahip.org/content/default.aspx?docid2270
• The Association for the Treatment of Tobacco Use
  Dependence (ATTUD) is an organization of
  tobacco treatment providers from many disciplines
  dedicated to the promotion of and increased
  access to evidence-based tobacco treatment for
  the tobacco user. ATTUD advocates for policy
  change, supports an excellent listserve for
  tobacco treatment providers, and develops
  competency guidelines to define the field of
  tobacco treatment specialists.
  http//www.attud.org/
• Online Training
• The Alliance for the Prevention and Treatment of
  Nicotine Addiction (APTNA) maintains a
  comprehensive listing of online trainings for
  treating tobacco dependence at http//www.aptna.or
  g/APTNA_Online_Courses_General.html. APTNA also
  provides information on specialist training,
  Medicare and Medicaid coverage of tobacco
  treatment, and links to other resources through
  its homepage at http//www.aptna.org
• On-site Training for Brief Intervention
• The University of Mississippi Medical Center ACT
  Center. The ACT Center offers Brief Treatment of
  the Tobacco Dependent Patient A Training
  Program for Health Care Providers. More
  information is available at http//actcenter.umc.
  edu/TreatingtheTobaccoUser.htm. The ACT Center
  also offers intensive tobacco treatment
  specialist training.
• On-site Training for Intensive Intervention
• The University of Massachusetts Medical Schools
  Center for Tobacco Prevention and Control offers
  a Tobacco Treatment Specialist (TTS) Training and
  Certification Program. This is an intensive
  program designed for persons who deliver moderate
  to intensive tobacco treatment services within a
  health care or community setting.
  http//www.umassmed.edu/behavmed/tobacco/train.cfm
  . UMASS also offers a Basic Skills for Working
  with Smokers online course, available through the
  same web page.
• The University of Medicine and Dentistry of New
  Jerseys Tobacco Control Program offers Tobacco
  Treatment Specialist trainings as well as
  consultation services. http//www.tobaccoprogram.
  org/. UMDNJ also developed a comprehensive
  manual for treating tobacco dependency in
  chemical dependency treatment programs. A new
  edition should be available soon at the same web
  page.