Be a Lifesaver! Help your Clients Quit.

1. Be a Lifesaver!Help your Clients Quit. Your Name Title Agency

2. Smoking kills more Americans than all of the following combined: • AIDS • Alcohol • Motor vehicle injuries • Fires • Heroin • Cocaine • Homicide • Suicide

3. Tobacco Use in Michigan • Heart Disease, Cancer, Stroke, and COPD are the four leading causes of death in Michigan and all associated with smoking • Tobacco use is the leading preventable cause of death • Second hand smoke is the third leading preventable cause of death

4. Tobacco:A Risk Factor for Chronic Disease • Tobacco use is a known or probable cause of more than 25 specific diseases and is an important cause of chronic disease.1 • In 2007, 39% of the working-age population reported at least one chronic health condition.2 • Integration of tobacco dependence treatment into chronic disease programs is recognized as a CDC Best Practice.

5. Smoking reduces life expectancy an average of about 14 years by way of lung cancer, heart disease other illnesses, according to the CDC.

6. People with serious mental illness die 25 years younger than the general population, largely due to conditions caused or worsened by smoking. National Association of State Mental Health Program Directors. Morbidity and Mortality in People with Serious Mental Illness. Thirteenth in a Series of Technical Reports. Alexandria, VA: 2006.

7. What is Tobacco Costing us?

8. High Personal and Societal Cost • Number one preventable cause of death in the US • 1 in 5 deaths are attributed to tobacco (Healthy People 2010, 2005) • 480,000 deaths attributed to smoking, annually (U.S. Surgeon General 2014) • Enormous cost - $280 billion (U.S. Surgeon General 2014) • Direct medical cost • Indirect cost – lost productivity and earnings • Medicaid cost • Medicare cost

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10. Michigan’s Personal Costs Each year 14,500 – 14,800 Michigan Residents die prematurely due to their own smoking.

11. Secondhand Smoke causes 50,000 U.S. deaths a year (DHHS 2006) (3,000 from lung cancer, 46,000 from heart disease and 430 from sudden infant death) —US Surgeon General’s Report on Secondhand Smoke 2006 In Michigan, between 1,500 and 2,400 residents die annually from secondhand smoke Hundreds of studies show adverse health effects in adults and children

12. Tobacco Addiction: A Chronic Disease?

13. Tobacco Dependence: A Chronic Disease Similar to diabetes, heart failure, hypertension, hyperlipidemia • Expectation for remission and relapse • Provide ongoing treatment: • advice/counseling • support • appropriate pharmacotherapy

14. Tobacco Dependence:A Chronic Disease There is a spectrum of disease severity Effective treatments are available High dose and multi-drug regimens may be necessary to achieve the target goals May require referral to specialists Individualized therapy is important

15. Nicotine is a Drug of Addiction After inhaling, nicotine reaches the brain in 7-10 seconds “Euphoria” without being “Stoned” Immediate REINFORCEMENT of drug-taking behavior Nicotine activates reward pathways in the brain Moment to moment titration of dose to achieve the desired effects

16. How Can You Help Your Clients Fight Back?

17. Clinicians Can Make a Difference! • Treatment delivered by a variety of clinician types increases abstinence rates. • Treatments delivered by multiple types of health care providers (nurse, medical assistant, psychologist, social worker or dentist) are more effective than interventions delivered by a single type of clinician.

18. You Can Do It! • As few as 3 minutes of counseling or other primary care interventions can increase the success rate of smoking cessation!6

19. Most of the following slides are taken directly from two documents Treating Tobacco Use and Dependence Quick Reference Guide for Clinicians 2008 Update and A how-to packet for implementing the US Public Health Service Clinical Practice Guidelines

20. The 5 “A” Intervention ASK about Tobacco Use (Tobacco as a vital sign) ADVISE to stop ASSESS willingness to make an attempt ASSIST in the stop attempt ARRANGE for a follow-up visit “Not since the polio vaccine has this nation had a better opportunity to make a significant impact in public health.” -- David Satcher, MD,MPH US Surgeon General 1998-2002

21. The "5 A's" Model for Treating Tobacco Use and Dependence - 2008 PHS

22. Ask • Systematically identify all tobacco users at every visit

23. Advise • Strongly urge all tobacco users to quit • In a clear, strong, and personalized manner, urge every tobacco user to quit. • Clear – Important, cutting down not enough • Strong – Most important thing you can do to protect your health • Personalized – link to current symptoms and health concerns, social and or economic situations

24. Assess • Determine willingness to make a quit attempt at the time • If the patient is willing to participate in intensive treatment deliver such treatment or make a referral • Modify for special populations • Don’t want to quit? – provide motivational intervention

25. Assist • Aid the patient in quitting • Pharmacological–if not contraindicated • Set a quit date • Counseling • Skills training-Anticipate Challenges • Problem solving • Social Support • Intra-treatment social support • Extra-treatment social support

26. Combinations: Medication and Counseling Effectiveness of and estimated abstinence rates for the combination of counseling and medication versus medication alone (n = 18 studies) PHS

27. Medication Seven first-line medications shown to be effective and recommended for use by the Guideline Panel: • Bupropion SR • Nicotine Gum • Nicotine Inhaler • Nicotine Lozenge • Nicotine Nasal Spray • Nicotine Patch • Varenicline PHS

28. Guidelines for pharmacotherapy • Second line Pharmacotherapies • Clonidine • Oral • Transdermal • Nortriptyline • Lighter smokers - lower NRT • 10-15 cigarettes/day • no adjustment for bupropion SR or varenicline

29. Possible Side Effects for all Nicotine Replacement products Dizziness Nausea Headaches Should not be used after recent MI (2 weeks)

30. NRT Indicators Anyone who smokes > 10 cigarettes per day Anyone who reports withdrawal symptoms during a past quit attempt Each quit attempt is different so okay to try same medication again – motivation may have shifted All NRTs are better than placebo

31. Rationale for Nicotine Replacement Prevention/relief of nicotine withdrawal symptoms Allows patients time to develop strategies to avoid relapse Avoids the exposure to carcinogens in cigarette smoke Allows for controlled tapering of the nicotine Improves success of quitting

32. E-Cigarettes E-cigarettes (or electronic cigarettes) are battery powered devices that claim to provide inhaled doses of nicotine by way of a vaporized solution.

33. E-Cigarettes • Are NOT FDA approved for treating tobacco dependence. • Do not have dosage recommendations and have varying levels of nicotine. • Contain detectable levels of carcinogens and toxic chemicals. • There is no scientific evidence that e-cigarettes help smokers quit.

34. Arrange – schedule follow up • Timing • Quit week • First month • Follow-up conversation

35. Motivational InterviewingFor the Patient Unwilling to Quit • Express empathy • “How important do you think it is for you to quit?” “What might happen if you quit?” • Develop discrepancy • “It sounds like you are very devoted to your family/ friends/job. How do you think your smoking is affecting your children/relationships/work?” • Roll with resistance • “Sounds like you are feeling pressured about your smoking.” “Would you like to hear about strategies that can help you address your concerns when you quit?” • Support self-efficacy • “So you were fairly successful the last time you quit.”

36. Diagnosis and Billing Codes • ICD-9 305.1 Tobacco Use Disorder will become: • ICD-10 F17.2 Nicotine Dependence with multiple use subsections (October 1, 2015) • CPT 99406 • Intermediate • Smoking and tobacco-use cessation counseling visit more than 3 minutes, up to 10 minutes. • CPT 99407 • Intensive • Smoking and tobacco-use cessation counseling visit more than 10 minutes.

37. Resources to Help you Succeed!

38. Michigan Patient Resources • The Michigan Department of Community Health has online quit kits. To print on demand go to www.michigan.gov/tobacco • American Cancer Society offers printed material and sponsors the Great American Smokeout on the third Thursday in November. Call 1-800-227-2345. www.cancer.org • American Heart Association offers printed material. Call 1-800-242-8721. www.americanheart.org • American Lung Association offers quit smoking classes, printed material, cessation website. Call 1-800-586-4872. Telephone referral and cessation advice is available by calling 1-866-784-8937. www.lungusa.org • National Cancer Institute offers a quit kit and telephone advice at 1-877-44U-QUIT. www.cancer.gov/cancertopics/smoking

39. Michigan Patient Resources • Nicotine Anonymous at 415-750-0328. www.nicotine-anonymous.org • QuitNet Online Smoking Cessation www.quitnet.com • Try to Stop: A website offering an online quit smoking program called Quit Wizard. www.trytostop.org • BecomeanEX: A website offering an online quit smoking program. www.becomeanex.org • U.S. Public Health Service offers a free booklet, You Can Quit Smoking Now! Call 1-800-QUITNOW. www.surgeongeneral.gov/tobacco

40. Provider Cessation Resources • http://www.aafp.org/tobacco.xml American Academy of Family Physicians “Ask and Act” • MI Providers Tobacco Cessation Tool Kit: www.michigancancer.org/WhatWeDo/tob-providerstoolkit.cfm • University of Wisconsin Center for Tobacco Research & Intervention offers videos and other tobacco training materials at www.ctri.wisc.edu • Web-based training offered by the State of Michigan at www.michigan.gov/tobacco

41. Telephone Quitlines

42. Tobacco Quitlines Work in conjunction with clinician or health care worker intervention. Can provide the treatment intensity that often cannot be provided in an office setting due to time constraints. Increase access to treatment and reduce barriers Can provide assistance in multiple languages.

43. The Michigan Tobacco Quitline • 1-800-QUIT-NOW (784-8669) • 1-877-777-6534 (TTS) • Counseling appointments available between 7 am to 1 am EST • Provides: • Referrals to local programs • One time counseling • Intensive counseling proactive sessions • Unlimited reactive calls for one year • Free NRT to the uninsured • Self-help materials • Free text messaging and online program

44. Michigan Tobacco Quit Line Services • All Michigan Callers Receive • Information & Referral, Text Messaging • Medicaid & Veterans • Counseling • 4 sessions for general enrollees • 9 sessions for prenatal • Medicare, Uninsured, Prenatal, Cancer Patients & County Health Plan • Counseling (same as above) • Up to 8 weeks of nicotine patch, gum or lozenge

45. Enhanced Prenatal Protocol • Began February 1, 2012 • There are specially trained counselors whose time is dedicated to working with prenatal callers • Prenatal enrollees will receive 9 counseling calls-5 prior to delivery and 4 post-partum • Prenatal enrollees receive incentives for participation

46. Prenatal Quitline Poster

47. Who Qualifies for Counseling? • Medicaid, including MOMS • Medicare • Veterans • Uninsured • People with a Cancer Diagnosis • Prenatal • County Health Plans • Youth 13-17 (no insurance information is collected)

48. Michigan Quit LineFax Referral Form for Health Care Providershttps://michigan.quitlogix.org/providers_partners/default.aspx

49. With Special Thanks to: • Gregory S. Holzman, MD, MPH Formerly, Chief Medical Executive, MDCH • Linda Thomas, MS Formerly,Tobacco Consultation Service,University of Michigan Health Systems • Many of the slides in this presentation were borrowed from previous lectures.

50. References • Department of Health and Human Services (US). The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Rockville (MD): Department of Health and Human Services, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1990. • Ha T. Tu, Genna Cohen. Financial and Health Burdens of Chronic Conditions Grow. Tracking Report No. 24. Center for Studying Health System Change. Washingron, DC; 2009. • Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Solberg LI. Priorities among effective clinical preventive services: results of a systematic review and analysis. American Journal of Preventive Medicine 2006;31(1)52–61. • Miller DP, Villa KF, Hogue SL, and Sivapathasundaram D. (2001). Birth and first-year costs for mothers and infants attributable to maternal smoking. Nicotine and Tobacco Research, 3, 25-35. • Benowitz, N. Nicotine Addiction. Tobacco Use and Cessation; 26(3):611-631, 1999 • United States Preventive Services Task Force, 2009