Implementing an Effective Smoking Cessation Strategy in Medical Practice Janis M. Dauer, MS, CAC Alliance for the Preve

1. Implementing an Effective Smoking Cessation Strategy in Medical Practice Janis M. Dauer, MS, CAC Alliance for the Prevention and Treatment of Nicotine Addiction 757-858-9934 jdauer@aptna.org

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 Even brief interventions are effective Non-physicians (nurses, health educators) are effective Treatment is cost-effective (counseling and medications) Demonstrates sincere commitment to patient’s well-being #1 cause of preventable death; much suffering Can be treated, people do stop We do know how to help/what works – can double or triple quit rates Smokers access healthcare system a lot 1-3 min. really can make a difference (research/practice confirm) Patients trust & listen to all healthcare providers For the $$$ it takes, return is more cost effective than many other things we do so it’s worth doing Shows you care#1 cause of preventable death; much suffering Can be treated, people do stop We do know how to help/what works – can double or triple quit rates Smokers access healthcare system a lot 1-3 min. really can make a difference (research/practice confirm) Patients trust & listen to all healthcare providers For the $$$ it takes, return is more cost effective than many other things we do so it’s worth doing Shows you care

3. Implementing an Effective Smoking Cessation Strategy in Medical Practice CLINICAL PRACTICE GUIDELINE Most recent update: May 2008 (based on meta-analysis of over 8,700 studies published between 1975-2007) NEW EMPHASIS: Chronic condition, often requires repeated interventions Counseling is especially important for certain groups (e.g., comorbid medical conditions like diabetes) Treatment is effective with diverse populations (minorities, low SES, comorbid conditions) We have: evidence-based Clinical Practice Guideline Contains strategies/recommendations to help clinicians & health systems deliver effective treatments New emphasis on: Chronic nature – requires repeated interventions Certain groups espec. in need of counseling (partic. if can’t use meds) Treatment works with all kinds of peopleWe have: evidence-based Clinical Practice Guideline Contains strategies/recommendations to help clinicians & health systems deliver effective treatments New emphasis on: Chronic nature – requires repeated interventions Certain groups espec. in need of counseling (partic. if can’t use meds) Treatment works with all kinds of people

4. Implementing an Effective Smoking Cessation Strategy in Medical Practice GUIDELINE - NEW EMPHASIS Healthcare policies and systems changes can significantly reduce barriers to treatment Coverage as health-insurance benefit Training clinicians along with having a charting/documentation system in place Investing in treatment (counseling and medications) – it pays for itself New strategies exist to assist patients not yet ready to quit (by increasing motivation) Guideline also emphasizes how healthcare policy and system changes can significantly reduce barriers to treatment – like: Health insurance coverage of counseling & meds Training clinicians along with system for documenting what they do (training alone not enough) Investing time and resources to make cess tx routine practice Guideline also points out effec. strategies for patients not ready to quit – Ways to increase motivation – know how to do that, don’t have to wait Can be used for other pt. behav. chg.s tooGuideline also emphasizes how healthcare policy and system changes can significantly reduce barriers to treatment – like: Health insurance coverage of counseling & meds Training clinicians along with system for documenting what they do (training alone not enough) Investing time and resources to make cess tx routine practice Guideline also points out effec. strategies for patients not ready to quit – Ways to increase motivation – know how to do that, don’t have to wait Can be used for other pt. behav. chg.s too

5. Implementing an Effective Smoking Cessation Strategy in Medical Practice GUIDELINE - NEW RECOMMENDATIONS Quitlines are effective and have broad reach Callers are four times more likely to succeed than those trying to quit without treatment Combination counseling & medication is significantly more effective than either alone Effective, FDA-approved medications exist (7) NRT (nicotine: gum, patch, lozenge, nasal spray or inhaler), bupropion (Zyban), varenicline (Chantix) Combination medications are effective Nicotine patch + another NRT (often the gum) Nicotine patch + bupropion SR Additional emphases in updated Guideline are on facts that: Quitlines work and have broad reach – callers 4 X more likely succeed than those trying quit on own Counseling & meds together - much more effective than either alone Now have 7 effective FDA-approved medications to help (all 5 NRTs plus 2 Rx meds, bupropion & Chantix) Combination meds are safe and effective – espec. a 2nd NRT with patch or combining patch with bupropion (Guideline is very user-friendly and specific - HANDOUT has more details about the guideline and order form to get one free) Additional emphases in updated Guideline are on facts that: Quitlines work and have broad reach – callers 4 X more likely succeed than those trying quit on own Counseling & meds together - much more effective than either alone Now have 7 effective FDA-approved medications to help (all 5 NRTs plus 2 Rx meds, bupropion & Chantix) Combination meds are safe and effective – espec. a 2nd NRT with patch or combining patch with bupropion (Guideline is very user-friendly and specific - HANDOUT has more details about the guideline and order form to get one free)

6. Implementing an Effective Smoking Cessation Strategy in Medical Practice GUIDELINE - TREATMENT STRATEGIES THE FIVE “A”s ASK Identify tobacco use status of every patient (current, former, never) ADVISE Advise patient to quit (clear, strong, personal manner) ASSESS Assess willingness to quit (“Yes” = continue with the A’s & “No” = do the R’s) So here’s what the Guideline says works to help patients quit smoking/using tobacco (and remember – these strategies have been shown to be effective in research and in practice): They call it the 5 A’s and it starts with ASK: First – a practice/clinic or health system must have a procedure in place that ensures screening of patients for smoking or other tobacco use. Because that determines what’s needed next: If a patient currently smokes/uses tobacco, the clinician goes on to the next two A’s (Advise and Assess) Advise means: in clear, strong manner pt needs be advised to quit and clinician should make that personal to the pt.s illness/life Assess means: clinician then asks if pt willing to make quit attempt within next month: If “yes,” clinician goes on to last 2 A’s If “no” clinician should do a MI (called 5R’s)So here’s what the Guideline says works to help patients quit smoking/using tobacco (and remember – these strategies have been shown to be effective in research and in practice): They call it the 5 A’s and it starts with ASK: First – a practice/clinic or health system must have a procedure in place that ensures screening of patients for smoking or other tobacco use. Because that determines what’s needed next: If a patient currently smokes/uses tobacco, the clinician goes on to the next two A’s (Advise and Assess) Advise means: in clear, strong manner pt needs be advised to quit and clinician should make that personal to the pt.s illness/life Assess means: clinician then asks if pt willing to make quit attempt within next month: If “yes,” clinician goes on to last 2 A’s If “no” clinician should do a MI (called 5R’s)

7. ASSIST Assist willing patient in developing a quit plan (skills training, support, pharmacotherapy, materials) ARRANGE Arrange follow-up if patient identified a quit date (In person, by phone/mail - soon after quit date) For the “unwilling patient… Implementing an Effective Smoking Cessation Strategy in Medical Practice GUIDELINE - TREATMENT STRATEGIES For pt willing to make quit attempt, the next A is called ASSIST - means help pt develop effective plan. Guideline identifies actions & strategies to use – how to help pt: Problem solve and develop coping skills Enhance their sense of self-efficacy (very important factor in success) Find/access a support system Figure out appropriate meds (and Rx, if needed) The last A is ARRANGE - simply means arrange for some kind of follow-up soon after quit day (even if only phone call or personal note) NOTE: all of these A’s are evidence-based – we know these work. For pt not willing to make quit attempt…For pt willing to make quit attempt, the next A is called ASSIST - means help pt develop effective plan. Guideline identifies actions & strategies to use – how to help pt: Problem solve and develop coping skills Enhance their sense of self-efficacy (very important factor in success) Find/access a support system Figure out appropriate meds (and Rx, if needed) The last A is ARRANGE - simply means arrange for some kind of follow-up soon after quit day (even if only phone call or personal note) NOTE: all of these A’s are evidence-based – we know these work. For pt not willing to make quit attempt…

8. THE FIVE “R”s Interventions to increase patient motivation: RELEVANCE: connect to disease/risk, concerns RISKS: identify negative impact of continued use REWARDS: identify potential benefits of quitting ROADBLOCKS: identify barriers & ways to cope REPETITION: repeat each visit while still unwilling Recent Quitters (first 12 months) Interventions to assist former smokers in staying quit: Minimal Practice/Prescriptive Relapse Prevention Implementing an Effective Smoking Cessation Strategy in Medical Practice GUIDELINE - TREATMENT STRATEGIES For pt not willing make quit attempt… Guideline describes how to increase motivation (these actions are also evidence-based). Call them 5 R’s and they stand for: RELEVANCE, RISKS, REWARDS, ROADBLOCKS and REPETITION. (Guideline has details on how to do these R’s) For pt who has recently quit, Guideline has info on how to do effective relapse prevention counseling (2 types)For pt not willing make quit attempt… Guideline describes how to increase motivation (these actions are also evidence-based). Call them 5 R’s and they stand for: RELEVANCE, RISKS, REWARDS, ROADBLOCKS and REPETITION. (Guideline has details on how to do these R’s) For pt who has recently quit, Guideline has info on how to do effective relapse prevention counseling (2 types)

9. Implementing an Effective Smoking Cessation Strategy in Medical PracticeINTEGRATION INTO PRACTICE Goal: reduce smoking/tobacco use Objective: Implement guideline recommendations (5As/5Rs) Tool: “Needs Assessment” table Use to identify strategies, process & staff, education & materials needed Tailor to suit practice/clinic But no matter how well providers learn any of these strategies, they aren’t likely to get done if not integrated into routine practice. HANDOUT packet has a tools to use to achieve that: “Needs Assessment” table - can be completed in order to id: Which strategies need to/can be implemented How the practice/clinic/system can do that Who needs learn what & how can get that education What materials will be needed More successful if tailored to a specific clinical setting, staff & pt. pop.But no matter how well providers learn any of these strategies, they aren’t likely to get done if not integrated into routine practice. HANDOUT packet has a tools to use to achieve that: “Needs Assessment” table - can be completed in order to id: Which strategies need to/can be implemented How the practice/clinic/system can do that Who needs learn what & how can get that education What materials will be needed More successful if tailored to a specific clinical setting, staff & pt. pop.

10. Implementing an Effective Smoking Cessation Strategy in Medical Practice NEEDS ASSESSMENT