I do not have any relevant financial relationships to disclose.

A PRACTICAL GUIDE TO HELPING PATIENTS STOP SMOKING

E. H. Maynard, Jr. MD

Benson Area Medical Center

Benson, NC

Goals of Presentation

1. Review the scope of the problem of tobacco use

2. Review evidence-based interventions that work

3. Present a toolkit to help other practices get started with a smoking cessation program

4. Discussion of our practice’s experiences and challenges with initiating a smoking cessation program

The Problem of Smoking

21% of Americans smoke 45 million American adults smoke 1,200 children & adolescents become new

smokers each day

Cost to Individuals

Smoking is a chronic disease often requiring repeated interventions and multiple attempts to quit

Smoking greatly increases risk of developing cancer, heart disease, stroke, pregnancy complications, lung disease, etc.

50% of smokers will die of smoking-caused disease

$5.11/pack

Cost to Society

$96 billion/year in smoking-related direct health costs

$97 billion/year in smoking-related indirect costs due to loss of productivity

The combined cost to society, individuals, and families is estimated at nearly $40/pack

It is Difficult for Smokers to Stop on Their Own

70% of smokers report wanting to quit 44% of smokers report trying to quit each

year Only 4-7% are successful on their own

We in the Healthcare Field Have Opportunities to Help

70% of smokers are seen by a physician each year

Smokers report physicians’ advice as an important motivator to quit

A Golden Opportunity for Success

Most smokers are interested in quitting Healthcare providers are in frequent

contact with smokers Clinicians have high credibility with

smokers There are proven strategies that greatly

increase the likelihood of successful smoking cessation

But…

Only 70% of insured smokers receive smoking cessation advice from their physician

Only 25% of Medicaid smokers reported receiving practical help with smoking cessation

Only 33% of adolescents receive counseling regarding tobacco use from their physicians

Only 39% of smokers reported that they were given specific help from their physicians regarding smoking cessation

Physicians say…

They are too busy They have no financial incentive They feel smokers cannot or will not quit They don’t want to make patients angry They don’t want to be judgmental They will scare patients away if they

discuss smoking cessation

Actually…

Even brief tobacco dependence treatment can be effective

Tobacco cessation counseling is effective at improving quit rates

Smokers are more satisfied with their healthcare if providers offer smoking cessation interventions even when the patients are not ready to stop smoking

Actually…

Many smoking cessation interventions are reimbursable

It is doubtful that there is any other intervention which could have a greater benefit to a smoker’s health than helping him/her quit smoking

A significant system failure

“…it is difficult to identify any other condition that presents such a mix of lethality,

prevalence, and neglect, despite effective and readily available interventions.”

- Treating Tobacco Use and Dependence: 2008 Update

US Department of Health and Human Services

Public Health Service

May 2008

Tobacco fieldJohnston County, NC

Tool #1

Treating Tobacco Use and Dependence: 2008 Update

Clinical Practice Guidelines

Based on 8,700 research articles Identifies effective, experimentally-

validated tobacco treatments and practices

Provided detailed rationale for recommended practices

Treating Tobacco Use and Dependence: 2008 UpdateClinical Practice Guidelines

Sponsored by: Agency for Health Care Research and Quality Centers for Disease Control and Prevention National Cancer Institute National Heart, Lung, and Blood Institute National Institute on Drug Abuse American Legacy Foundation Robert Wood Johnson Foundation University of Wisconsin School of Medicine and

Public Health Center for Tobacco Research and Intervention

Recommendations summed up by the 5 As:

ASK about smoking status ADVISE smokers to quit ASSESS willingness to quit ASSIST smoking cessation efforts ARRANGE for ongoing follow-up

ASK:

“Implement an office system to document tobacco use status for every patient at every clinic visit.”

Possibilities Incorporate into vital signs Use chart stickers or computer prompts Develop templates for electronic health records

ADVISE:

“In a clear, strong, and personalized manner, urge every smoker to quit smoking at every visit.”

ASSESS:

“Assess every tobacco user’s willingness to make an attempt to quit at the time of each visit.”

Tool #2

PROGRESS NOTES

Date:_/_/_ Patient Name: _______ DOB:_/_/_ Chart: _____

Ht:__ Wt:__ BMI:__ Temp:__ RR:__ Pulse:__ BP:_/_ Nurse/MA:__

Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No

Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No

Help the patient develop a quit plan Provide practical counseling and problem solving

advice Provide medication to help Provide supplemental materials Provide a supportive clinical environment

ASSIST

Tool #3

Rx for Success to Stop Smoking

Provide Practical Counseling

Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No

Abstinence from tobacco is essential Build on past quit experiences Anticipate triggers, challenges Avoid alcohol Encourage others in home to quit Referral for formal counseling if needed

Tool #4

Success with Smoking Cessation- Practical Counseling for the Busy

Clinician

Medication

Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No

Except when medically contraindicated, all smokers attempting

to quit should be encouraged to use medication.

First Line Drugs: Bupropion SR Nicotine replacement (gum, inhaler, lozenge, spray, patch) Varenicline

Second Line Drugs: Clonidine Imipramine

Tool #5

Comparison of Smoking Cessation Drugs

Provide a Supportive Clinical Environment

Smoking Status? Current Past Never

Advised to Quit? Yes No

Willing to Quit? Yes No

Physician/Provider Commitment

Provide information that is culturally, racially, educationally, and age-appropriate

Serve as advocates for patients who want to quit smoking

Consider group visits

Tool #7

AAFP Guide to Group Visits for Smoking Cessation

ARRANGE

Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No

Appropriate follow-up should be arranged for smokers trying to quit

Some form of patient follow-up during the first week after quit date

Address tobacco use at subsequent clinical visits If tobacco use has recurred, consider more

intensive treatments

For Those Reluctant to Quit…

Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No

“For patients not ready to make a quit attempt, clinicians should use a brief intervention designed to promote the motivation to quit.”

Motivational Interviewing

Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No

Uncovers ambivalence about tobacco use Uses this ambivalence to address interest in

quitting Expresses empathy Develops discrepancies Rolls with resistance Supports self-efficacy

Tool #8

Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No

Brief Guide to Motivational Interviewing

The 5 Rs

Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No

Relevance Risks Rewards Roadblocks Repetition

Tool #9

Guide to the 5 Rs

Getting Paid

Medicare covers counseling and medications Some state Medicaid programs cover some forms

of counseling and medication Smoking cessation counseling can increase E/M

coding levels during problem-related visits Private insurances vary but most cover some

form of counseling and some medication

Tool #10

AAFP Guide to Appropriate Coding for Smoking Cessation

In Summary

Tobacco use should be assessed at every visit Smoking cessation should be advised at every visit Willingness to quit should be assessed for smokers Those willing to quit should be supported with

counseling, medication, supportive clinical environment, additional information

Those unwilling to quit should receive interventions to help motivate commitment to quit in the future

Tobacco use must be treated as a chronic illness with frequent surveillance and follow-up

Tobacco FieldJohnston County, NC

Benson Area Medical Center

Staff smoking area at BAMC

Getting Started at Benson Area Medical Center

Recognize cultural differences Gather a toolkit of information to assist

clinicians in providing appropriate and helpful information

Create a supportive environment for smoking cessation

Choose an initial small target group to pilot project

Train advocates within the practice to assist smokers who want to quit

Results from pilot project at BAMC

Before After

% Smokers asked about smoking 57% 100%

% Smokers counseled to quit 50% 93%

% Smokers with documented quit attempt

7% 29%

July 1, 2008- July 1, 2009

Tobacco FieldJohnston County, NC