June 2009 Tobacco Prevention & Control Branch Division of Public Health, DHHS

1. Brief Tobacco Cessation Counseling For physicians and other providers and healthcare professionals to use in clinical practice June 2009 Tobacco Prevention & Control Branch Division of Public Health, DHHS

2. Tobacco Use The number one preventable cause of death in the United States and North Carolina

3. Efficacy of Physician Advice to Quit Abstinence Rate % • No advice 7.9 • Physician Advice 10.2 • Patients expect healthcare providers to ask about tobacco use and advise them to quit Source: Treating Tobacco Use andDependence, USDHHS, Public Health Service, 2000

4. Cessation: What Works • Behavioral support • Treats the psychological and habit aspects • Pharmacotherapy • Treats nicotine addiction Works best when combined

5. http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdfhttp://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf

6. The 5A’s of Tobacco Cessation • Treating Tobacco Use and Dependence Clinical Practice Guidelines: 2008 Update - U.S. Department of Health and Human Services, Public Health Service • A brief evidence-based tobacco cessation intervention

7. The 5A’s of Tobacco Cessation • Ask about tobacco use • Advise patient to quit • Refer (1-800-QUIT-NOW or local prgm) • Assess readiness to quit • Assist in quit attempt • Arrange follow-up

8. Ask • Ask about tobacco use at every visit • Systematically identify all tobacco users • Make identification/documentation a vital sign • Create a universal identification system (stickers, computer reminders, etc.)

9. Create a Reminder System Include tobacco use in other medical / dental advice • Use an identification system • Stamp, Sticker, EMR Tobacco Use and Exposure Tobacco Use: (circle one): Current Former Never Secondhand Smoke Exposure: YES NO Tobacco use is the single most preventable cause of death in the US.

10. Advise • Clear, Strong, Personalized “Quitting smoking ... • ...is the single best thing you can do for your health” • ...will reduce your risk of …” • Employ the teachable moment: • Link visit findings with advice.

11. Assess • Willingness to make quit attempt in next 30 days • “I want to quit” NOT “I need to quit”

12. Examples • Very specific reasons to quit smoking: • “I want to quit smoking so I can go shopping without stopping 10 times.” • “I want to quit smoking so I will not have a stroke like my dad.” • “I want to quit smoking so my dogs will not get emphysema.” (real quote) • I want to quit so I won’t smell like an ashtray

13. Stages of Change • Pre-contemplation • Contemplation • Preparation • Action • Maintenance

14. 5R’s for Patients Not Ready To Make a Quit Attempt • Relevance • Risks • Rewards • Roadblocks • Repetition

15. Assist • Develop a quit plan • STAR: - Set a quit date (within 2 weeks) - Tell family, friends, coworkers - Anticipate challenges to quitting - Remove tobacco products from environment

16. Arrange • Schedule follow-up • in person • via telephone • NC Tobacco Use Quitline • 4 visits/calls is evidence based • Congratulate progress/success • Identify problems/anticipate challenges • Evaluate pharmacotherapy use/problems

17. Help for the busy practice….

18. Health Care Provider’s Quick Intervention • ASK about tobacco use • ADVISEto quit • REFERto NC Tobacco Use Quitline, Become An Ex, other resource • PRESCRIBE as appropriate

19. REFER • Quitline information to all • Consider fax referral • Patients ready to quit within 30 days • Consider cessation medications • Provide Quitline number to all patients, even those not ready to quit • Other resources such as BecomeAnEx • Follow-up at next/every visit

20. North Carolina Tobacco Use Quitline • 1-800-QUIT-NOW (1-800-784-8669) • 8a.m. – 3 a.m., 7 days a week; Toll-free; Confidential • All North Carolinians - youth and adult • Proactive – Quit coaches can call tobacco users back upon request, or make 1st call • Fax referral • Multiple language Quit Coaches Administered by: Tobacco Prevention and Control Branch Funded by: NC Division of Public Health, NC Health and Wellness Trust Fund

21. Quitline can Assess, Assist, Arrange • Quit coach helps set Quit Date, and • Develop quit plan • Make follow-up calls • Discuss pharmacotherapy • Mail targeted resources • Patients can call the Quitline anytime

22. Fax Referral to Quitline Helps With… • Referral to effective cessation services • Provider’s limited time and resources • The burden of patient initiating services • NOTE: Provider referral to a cessation program is associated with higher rates of participation than simply telling patients they should stop using tobacco

24. NC Tobacco Use Quitline Fax Referral Flow Chart Take patient’s vital signs & ask about tobacco use. Advise to quit. Is the patient ready to quit? Give patient cessation resources: 1-800-QUIT-NOW (1-800-784-8669), www.becomeanex.org, or other resource. NO YES INTERVENE: Offer cessation medications if indicated, Quitline #, fax referral option Does patient want a quit coach to call them? Give patient cessation resources: 1-800-QUIT-NOW (1-800-784-8669), www.becomeanex.org, or other resource. NO YES Complete fax referral consent form & fax to Quitline. The Quitline will make at least 5 attempts to call the patient.

25. Quitline Outcomes Report • Tool to follow patient progress with your advice to quit / utilize Quitline services • Most useful in clinic setting with dedicated fax machine/staff to retrieve reports • Outcomes Report information includes: • Accepted services • Declined services • Unreachable

26. For more patient cessation resources, view Cessation Resources PPT at:www.tobaccopreventionandcontrol.ncdhhs.gov www.becomeanex.org

27. Counseling Coverage in NC Medicaid added two CPT codes Jan. 1, 2009 99406 – 3-10 minutes 99407 – > 10 minutes May be billed the same day as an E/M or Health Check visit Use ICD-9 Code: 305.1 (tobacco abuse) Unbundled – can use a second ICD-9 code Medicare, BCBSNC, and State Health Plan also reimburse these codes

28. Medicaid Coverage for Counseling For more information see Medicaid Bulletins: Jan 2009:http://www.dhhs.state.nc.us/dma/bulletin.htm Oct.2008:http://www.ncdhhs.gov/dma/bulletin/1008bulletin.htm

29. More Cessation Counseling Reimbursement Codes • 99401-04- 15-60 minutes (dedicated visit) • 99354can be added to regular visit (must document counseling) • 99411 is used for group counseling (per participant) • MD, PA or FNP on premises, must talk to group • RN (etc.) may facilitate session

30. Helpful Web Sites and Links: • www.tobaccopreventionandcontrol.ncdhhs.gov/cessation • www.tobaccopreventionandcontrol.ncdhhs.gov/FaxForm.pdf • www.QuitLineNC.com • www.QuitNowNC.org

31. Learning More / CE Options • Counseling for Change: An On-line Tobacco Cessation Course - Northwest AHEC • Contact Nedra Edwards Hines • 336-713-7727; nedwards@wfubmc.edu • $20 fee for course credits; free to view • Medscape: Treating Tobacco Use and Dependence http://www.medscape.com/viewarticle/570604 • Free • Approved for 1hour CE • AMA PRA Category 1 Credit(s)™ • Requires registration to Medscape • TobaccoFreePatients.com http://www1.tobaccofreepatients.com/TopicReq? • Based on NCI educational program • Available free for study and review • $15 per credit hour / letter of completion

32. A Guide for Counseling Women Who Smoke For more information on the Women’s Health and Tobacco Use Program, contact: Judy Ruffin Judy.ruffin@ncmail.net 919-707-5712 The Guide is available on the Division of Public Health / Women’s Health Branch webpage: http://whb.ncpublichealth.com/provPart/pubmanbro.htm#top

33. Take-Home Message for Health Care Providers • Brief cessation counseling is effective • Longer cessation counseling is more effective • Pharmacotherapy can double quit rates • Pharmacotherapy should be offered to all - few exceptions • Evidence-based resources are available

34. You only have two minutes • Ask every everyone about tobacco use • Advise to quit with a clear, strong, personalized message • Referto • NC Tobacco Use Quitline • 1-800-QUIT-NOW (1-800-784-8669) • Other resources as appropriate • Prescribe • For information on more cessation resources and medications visit:www.tobaccopreventionandcontrol.ncdhhs.gov

35. www.tobaccopreventionandcontrol.ncdhhs.gov Tobacco Prevention and Control BranchDivision of Public HealthNorth Carolina Department of Health and Human Services Main Ph: 919-707-5400Fax: 919-870-4844