Cancer and Heart Disease, A Case for Working Collaboratively to Reduce Tobacco Use

1. Cancer and Heart Disease, A Case for Working Collaboratively to Reduce Tobacco Use Sandra Villalaz, RN, MPH, CHES Community Manager for Health Initiatives Central Texas Region, American Cancer Society

2. The American Cancer Society is the nationwide community-based voluntary health organization dedicated to eliminating cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and service. American Cancer Society Mission

3. Objectives • Describe one health care system level initiative to reduce tobacco use among patients. • Identify three stakeholders critical to creating system level change and why. • List two best practices and at least three community level resources available to assist in client smoking cessation attempts.

5. Concern • Healthy People 2010 goal to reduce tobacco use to 12 % not met. • Actually we only met this goal for population 65 and older. • American Cancer Society Goal for 2015 is the same.

6. The Problem • Smoking “damages nearly every cell in your body.” • It can cause: • Cancers • COPD • Heart Disease • CV Disease • GI ulcers/periodontal disease • Reproductive effects • Eye disorders Richard Carmona, Surgeon General of the US, Surgeon General Report, May 2004

7. Case Study and Stakeholders

8. The Challenge • Seized the opportunity • Meeting with Austin Heart, PA Chief Operating Officer • Presented the challenge • Asked what protocol was used for tobacco users • Prepared for the meeting

9. Tobacco Use and Heart Disease Statistics • As many as 30 percent of all deaths in the United States each year from heart attack are attributable to cigarette smoking (2) • Smoking-caused heart disease results in more deaths per year than smoking-caused lung cancer (4) • Tobacco use increases blood pressure and risk of stroke (1) • Women who smoke and use oral contraceptives greatly increase their risk of heart attack and stroke (4) • Smokers’ risk of a heart attack is two to four times greater than that of non-smokers (3) 1. American Heart Association, Inc., Cigarette Smoking and Cardiovascular Disease, July 18, 2005 • American Heart Association, Inc., Circulation, 1997; 96:3243-3247, “Cigarette Smoking, Cardiovascular Disease, and Stroke A Statement for Healthcare Professionals From the American Heart Association, 1997 • American Heart Association, Inc., Risk Factors and Coronary Heart Disease, July 18, 2005 • U. S. Department of Health and Human Services, State Cardiovascular Disease Highlights, 1997, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1997

10. Austin Heart, PA • 47 physicians provide care at 13 Central Texas office locations – 8 counties • comprehensive range of services include prevention, general cardiology, vascular care, electrophysiology, and interventional cardiovascular services.

11. Article from Austin Heart Newsletter Feb 2009 Smoking Remains the No 1 Cause of Preventable Death in the United States • Did you know that cigarette smokers are two to four times • more likely to develop coronary heart disease than nonsmokers. • Smokers are also more than 10 times as likely as • nonsmokers to develop peripheral artery disease. After one • year off of cigarettes the excess risk of coronary heart • disease caused by smoking is reduced by half. 15 years • after quitting, the risk is similar to that for people who have never smoked.

12. The Meeting • Responded with information and orientation to service after learning about the practice • Met with Medical Director • Offered educational materials and briefing on American Cancer Society Quitline . • Offered Professional Education

13. Healthcare Professional Ed • Provided Provider and Nursing education as well as patient materials for 13 locations. • Involved appropriate level of professionals

14. Tobacco half the problem • Only 70% of primary care physicians ask their patients if they use tobacco. • Only 40% take action.

15. Providing Appropriate Tobacco Cessation Assistance is Important • 70% of smokers want to quit. • 93% of smokers who try to quit resume regular smoking within one year. • Five to seven attempts are usually required to succeed.

16. CDC Recommendations • Tobacco dependence is a chronic condition that requires repeated interventions • Every patient should be offered a treatment • Patients willing to try to quit-should be offered effective treatments • Patients unwilling to try to quit-should be offered a brief intervention designed to increase their motivation

17. Effective Tobacco Dependence Interventions • Fiore MC, Bailey, Cohen SJ, et. al. Treating Tobacco Use and Dependence. Rockville, MD: US Department of Health and Human Services. Public Health Service. October 2008. • MMWR/Recommendations and Reports: November 10,2000/Vol. 49/No.RR-12. A report on findings. • American Journal of Preventive Medicine.AM J Prev Med 2001:20 (2S); 16-66. A report on findings and evidence.

18. Austin Heart, PA • Physicians will address smoking and quitting. • Physician’s advice to quit is an important motivator. • Nurses and office staff will answer questions, help with resources and encourage patients. • Patients can make an appointment with physician for smoking cessation support and resources. • Insurance provides payment to physicians for smoking cessation interventions. • All personnel are responsible for encouraging and promoting a healthy lifestyle.

19. Changes reported • 2007 we had 4 physicians counsel 73 patients. • 2008 we had 4 physicians counsel 96 patients. • 2009 we had 36 physicians counsel 603 patients

20. Good News and Not such Good News • Document in the EMR patients smoking status • Documented what counseling and support services were provided. • Documented the appropriate diagnosis codes for tobacco abuse. • BUT have not tracked if patients have actually stopped.

21. Best Practices and Resources

22. The Stages of Change • Pre-contemplation: At this stage, the tobacco user is not thinking seriously about quitting right now. • Contemplation: The tobacco user is actively thinking about quitting but is not quite ready to make a serious attempt yet. • Preparation: Tobacco users in the preparation stage seriously intend to quit in the next month and often have tried to quit in the past 12 months. They usually have a plan. • Action: This is the first 6 months when the user is actively quitting. • Maintenance: This is the period of 6 months to 5 years after quitting when the ex-user is aware of the danger of relapse and take steps to avoid it.

23. 5 A’s • Ask –systematically identify all tobacco users at every visit • Advise-strongly urge tobacco users to quit with each visit • Assess-determine willingness to make a quit attempt (within 30 days) • Assist-aid patient in quitting • Arrange-schedule a follow up contact

25. 5 R’s for those unwilling to quit • Relevance-encourage pt to identify personal reason to quit • Risks-ask pt to list negative consequences of smoking • Rewards-list potential benefits of quitting • Roadblocks-identify barriers • Repetition-repeat with each visit

27. Provider Reminder Systems When: • Patients who use tobacco are identified; • Providers receive information to help them help their patients understand the risks and dangers Results in: • Delivery of advice to quit by providers • Number of patients who do quit

28. Nurses • You are an invaluable resource. • Patients are more likely to quit successfully with the nurses’ support. (Good, Frazier, Wetta-Hall, Ablah, & Molgaard, 2004) • If you don’t mention it to your patients, they won’t see it as important. • Nurses are a trusted professional. • We are failing our patients if we don’t offer smoking cessation help. (Roberts, 2002)

29. Common Barriers • Patients perceived or actual lack of interest or motivation • Lack of time and skill • Lack of knowledge and resources • Thought that it is an invasion of patient privacy • Negative message may scare patients away. (Good, et al, 2004)

30. Behavioral Interventions & 5 month Quit Rates • Self-help: 12.3% • Proactive telephone counseling: 13.1% • Group counseling: 13.9% • Individual counseling: 16.8% • The American Cancer Society’s Quitline has a 1 year quit rate of 36%. • The addition of pharmacologic agents have significantly improved success rates. Hopkins, David, et al. Reviews of Evidence Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke, 2001. Am J Prev Med 2001;20(2):16-66.

31. ACS Quit For Life • It only takes 30 seconds to refer a patient to a toll-free tobacco-cessation quitline. • Quitlines are staffed by trained cessation experts who tailor a plan and advice for each caller. • Calling a quitline can increase a smoker’s chance of successfully quitting.

32. Ethical Considerations • Screening • Ask at each visit • Efficacious Treatment • Recommending Smoking Cessation • Counseling • Group, Individual or Phone

33. ACS Community Resources Client • ACS Quit For Life - a quitline In Texas: • 1-877-YES-QUIT (877-937-7848) • Pamphlets to provide information • Spanish/ English • Wallet card-Spanish/English • American Cancer Society • www.cancer.org • 1-800-ACS-2345 • American Cancer Society Fresh Start

34. Community Resources Professional • Quick Guide to Helping Tobacco Users-Toolkit (5A’s and 5R’s cards for exam rooms) – pdf available from the Texas Dept of State Health Service • Ask and Act –American Academy of Family Practitioners • ACS Quit For Life –Promotional Materials- a quitline in Texas • American Cancer Society • www.cancer.org • 1-800-ACS-2345 • American Cancer Society Fresh Start -facilitator online training - www.cancer.org

35. Conclusion • There is no clinical intervention available today that can reduce illness, prevent death, and increase quality of life more than effective tobacco treatment interventions. • Be part of the solution. • Be sure providers address tobacco addiction with every visit.

36. Sandra.villalaz@cancer.org512-919-1854