Implementing an Effective Smoking Cessation Strategy in Medical Practice Janis M. Dauer, MS, CAC September 14, 2004 Virg

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% counseling 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 Cessationwith 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%

7. Implementing an Effective Smoking Cessation Strategy in Medical PracticeRATIONALE FOR INTERVENING • Treatment is cost-effective (counseling and medications) • Demonstrates sincere commitment to patient’s well-being

8. Implementing an Effective Smoking Cessation Strategy in Medical PracticeCLINICAL 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

9. Implementing an Effective Smoking Cessation Strategy in Medical PracticeGUIDELINE – 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 PracticeGUIDELINE – 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

11. Implementing an Effective Smoking Cessation Strategy in Medical PracticeGUIDELINE – 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

12. Implementing an Effective Smoking Cessation Strategy in Medical PracticeGUIDELINE – 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

13. Implementing an Effective Smoking Cessation Strategy in Medical PracticeSYSTEMS RECOMMENDATIONS • Implement a tobacco user identification system (e.g., smoking status as 5th vital sign) Smoker Identification Systems (95% C.I.) Screening SystemEstimated Estimated In Place to Identify Intervention Abstinence Smoking Status Rate Rate NO 38.5% 3.1% YES 65.6% 6.4%

14. Implementing an Effective Smoking Cessation Strategy in Medical PracticeSYSTEMS 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

15. Implementing an Effective Smoking Cessation Strategy in Medical PracticeSYSTEMS 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)

16. Implementing an Effective Smoking Cessation Strategy in Medical PracticeTREATMENT 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 “A”s) • Recent quitter (provide Relapse Prevention) • Non-user (support non-use decision)

17. Implementing an Effective Smoking Cessation Strategy in Medical PracticeTREATMENT 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 “A”s • Unwilling – go to the five “R”s

18. Implementing an Effective Smoking Cessation Strategy in Medical PracticeTREATMENT STRATEGIES ASSIST Aid willing patient in developing a quit plan: • Provide “practical counseling” (problem-solving/skills training)   • Provide intra-treatment support/encouragement • Help identify/obtain extra-treatment support  • Discuss/recommend approved pharmacotherapy • Provide supplementary materials  

19. Implementing an Effective Smoking Cessation Strategy in Medical PracticeTREATMENT 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 

20. Implementing an Effective Smoking Cessation Strategy in Medical PracticeTREATMENT STRATEGIES THE FIVE “R”s 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 

21. Implementing an Effective Smoking Cessation Strategy in Medical PracticeTREATMENT STRATEGIES THE FIVE “R”s, 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

22. Implementing an Effective Smoking Cessation Strategy in Medical PracticeRELAPSE 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 PracticeNEVER/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

24. Implementing an Effective Smoking Cessation Strategy in Medical PracticeDEVELOPING 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

25. Implementing an Effective Smoking Cessation Strategy in Medical PracticeNEEDS ASSESSMENT

26. Implementing an Effective Smoking Cessation Strategy in Medical PracticeTHE “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”

27. Implementing an Effective Smoking Cessation Strategy in Medical PracticeTHE “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

28. Implementing an Effective Smoking Cessation Strategy in Medical PracticeTHE “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)

29. Implementing an Effective Smoking Cessation Strategy in Medical PracticeTHE “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)

30. Implementing an Effective Smoking Cessation Strategy in Medical PracticeTHE “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)

31. Implementing an Effective Smoking Cessation Strategy in Medical PracticeTHE “5 STEPS” Step 4: Implement Plan • Begin procedures on start date • Monitor and identify glitches as they occur (Coordinator’s task?) • Get feedback from staff (how to improve the plan, what resources they need)

32. Implementing an Effective Smoking Cessation Strategy in Medical PracticeTHE “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)

33. Implementing an Effective Smoking Cessation Strategy in Medical PracticeRESOURCES 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 PracticeRESOURCES 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

35. Implementing an Effective Smoking Cessation Strategy in Medical PracticeRESOURCES FOR PATIENTS ONLINE RESOURCES • Freedom From Smokingwww.lungusa.org/ffs (free ALA online cessation program) • Federal Online Programwww.smokefree.gov (free USDHHS online program includes Instant Messaging) • Smoke-Free Virginia Websitewww.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.)

36. Implementing an Effective Smoking Cessation Strategy in Medical PracticeOTHER 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/guide_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

37. Implementing an Effective Smoking Cessation Strategy in Medical PracticeOTHER 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

38. 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_use.pdf http://speakerskit.chestnet.org/wgtlc/pres-cessation.php

39. “Lozenge” slide from Smoking Cessationwith 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.

40. 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 can’t/won’t 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 – it’s worth a minute, make it part of basic treatment (also, see practitioner reimbursement guide available at: www.endsmoking.org/) • Most smokers can’t/won’t 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

44. Implementing an Effective Smoking Cessation Strategy in Medical PracticeTAKE ACTION • IT’S A PROCESS: take a small step now in planning or doing • USE WHAT’S 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