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Tobacco Use Cessation: A Brief Primary Care Intervention

Tobacco Use Cessation: A Brief Primary Care Intervention. Presented by Katherine M. Dollar, PhD VISN 2 Center for Integrated Healthcare. Acknowledgments.

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Tobacco Use Cessation: A Brief Primary Care Intervention

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  1. Tobacco Use Cessation: A Brief Primary Care Intervention Presented by Katherine M. Dollar, PhD VISN 2 Center for Integrated Healthcare

  2. Acknowledgments • Materials for this intervention are based on the 5As framework described and presented in Hunter et al., (2009). As noted elsewhere, materials were also adapted from Robinson & Reiter (2007) and Shipley (2009). Sessions 3 and 4 were adapted from the participant work book developed by the VA Cooperative Studies Program #519 prepared by Miles McFall, Ph.D. and Andrew Saxon, M.D. All sessions are consistent with Clinical Practice Guidelines, 2008 update and the VA/DOD 2004 Clinical Practice Guidelines, and 2010 update (draft). For questions please contact Dr. Katherine Dollar at katherine.dollar@va.gov or Dr. Margaret Dundon at margaret.dundon@va.gov • CIH sharepoint site with materials: https://vaww.visn2.portal.va.gov/sites/natl/cih/default.aspx • VA Tobacco Cessation sharepoint site: https://vaww.portal.va.gov/sites/tobacco/default.aspx

  3. Objectives At the conclusion of the program, participants will be able to: Discuss the benefits, risks, and appropriate use of pharmacological and behavioral interventions for tobacco cessation. Describe stepped-care models of service delivery in general and for tobacco cessation. Verbally demonstrate the essential elements of conducting a brief (mid-level) intervention for tobacco cessation within primary care.

  4. Clinical Practice Guideline (2008) • Encourage all patients attempting to quit to use effective stop-smoking medications • Except where contraindicated or where there is insufficient evidence of effectiveness: pregnant women, smokeless users, light smokers, adolescents • For a free guideline, call 800-311-3435, or download: www.ahrq.gov/path/tobacco.htm#clinic • Fiore, et al., 2008, Treating Tobacco Use and Dependence. USDHHS.

  5. Interventions • Pharmacological agents: Prescription and OTC • Behavior change interventions • Combination (Most effective. As treatment intensity increases, so does success)

  6. Non-Prescription Medicines MedicineMonths $/Month Success to Use (generic) Multiplier Nicotine 2–6 $80 (50) 2x Patch 2 mg Nicotine 3–6 $120 (95) 2x gum or lozenge 4 mg Nicotine 3–6 $120 (95) 3x gum or lozenge

  7. Prescription Medicines MedicineMonths $/Month Success to Use (generic) Multiplier Nicotine 3–6 $115 2x Nasal Spray Nicotine 3–6 $150 2x Inhaler Zyban/Wellbutrin 2–6 $220 (30) 2x (Bupropion ER) Chantix 3–6 $160 3x (Varenicline)

  8. NRT Dosing • Goal is to provide client’s usual amount of nicotine • Smoking-machine values are too low. Humans get about twice as much nicotine, averaging 2 mg nicotine per cigarette rather than 1 mg • Adjust NRT dose based on client’s reaction. If cravings and withdrawal symptoms, use more NRT. If dizzy or nauseous, use less NRT

  9. Using Gum or Lozenges:Patient Ed for Med Use Example • Gum. Chew slowly until a peppery taste emerges, then “park” between cheek and gum. After about a minute, repeat. Chew and park for 30 minutes. • Lozenge. Allow to dissolve over 20–30 minutes. Minimize swallowing. Do not chew or swallow the lozenge. Occasionally move lozenge from one side of the mouth to the other. • Both. Do not eat or drink (except water) for 15 minutes before or during use.

  10. Varenicline and VA • Considered second-line smoking cessation medication in VA, to be used only for those patients who failed an appropriate trial of nicotine replacement therapy, Zyban, or combination therapy within the past year • Prior to starting varenicline, patients should be screened for feelings of hopelessness, which may increase the risk of suicide once the medication is started. Patients should also be screened for current suicidal ideation or intent as well as a history of past suicide attempts • Patients with suicidal or assaultive thoughts, ideation or behaviors within the past 12months are not candidates for varenicline until judged to be stable by a mental health professional. Providers should strongly consider closer monitoring of mental health symptoms for patients with prior suicidality • At each renewal (or at other times, per provider discretion), thoughts of harm to self or others should be evaluated

  11. VareniclineDosing • Start one week before the quit date -Day 1 to 30.5 mg white tablet 1x a day -Day 4 to 70.5 mg white tablet 2x a day • On Quit Date STOP SMOKING and take 1.0 mg blue tablet 2x a day for 11 weeks • If not smoking at the end of twelve weeks, may continue for an additional 12 weeks • May stop abruptly. No need to taper. • Take Varenicline after eating and with a full glass of water (to lessen the chance of nausea; VHA Clinical Practice Guidance for Tobacco Use Cessation Treatment, 2010)

  12. Behavioral Interventions • Higher quit rates compared to no counseling • Higher quit rates than medication alone • Unclear if difference between individual and group interventions (Lancaster & Stead, 2005; Ranney, Melvin, Lux, McClain, & Lohr, 2006) • It is clear that some patients prefer group and others 1:1, so we need to offer both, with 1:1 same day access

  13. Success Rates • Having at least 4 individual brief (10-15 minute) appointments substantially improves abstinence rates (2-3 sessions: 16%; 4-8 sessions: 21%) CPG 2008 Update

  14. A Stepped Care Approach • Matches the intensity of services to patients level of need • Population-based • All individuals receive basic intervention • Interventions are intensified for individuals with difficulty sustaining progress • Allows for increased flexibility and meeting specific patient needs • Success with multiple health behaviors (weight management, diabetes care, hypertension)

  15. Level One Support • Support for quitting starts with the primary care provider (PCP). Pt. simply talks with PCP about quitting. CRs will prompt periodically, but anytime is ok. Meds and brief advice can be given • If not successful, a higher level of care is indicated (i.e., level two or level three support)

  16. Level Two Support: IPC BHP • Level two support also starts with PCP. PCP links patient with IPC Behavioral Health Provider (BHP) for same-day, brief intervention and planning • Brief (15-20 min.) individual visits x 4 • If needed, the IPC staff will help pt. access medications to increase chances of success • Follow-up will happen in 2-3 brief additional visits, some of which can be on the telephone

  17. Level Three Support: Specialty Programs • The most intensive level of support • Often group format (e.g. QuitSmart™, ALA, ACS…) • Consider referring if previous unsuccessful quit attempts in integrated primary care • Most important: patient preference. The steps or not linear, or required to be sequential!

  18. Ask the Experts • Please consult with experts and other team members, as needed, for support and continued treatment recommendations • Specialty TUC program staff may be excellent resources • New Health Behavior Coordinators also likely to be good resources • Coordinate efforts: educate the Level 1 and 3 staff about Level 2 offerings

  19. Level 2 Intervention • PC staff (preferably PCP) refer patient to BHP in Primary Care for brief intervention • See: “Tobacco Use Cessation: A Brief Primary Care Intervention-Step by Step Guide” (full and summary versions available) • See also: companion patient handouts and brochures

  20. Tobacco Use Cessation: A Brief Primary Care InterventionStep by Step Guide • Overview of Full Intervention: (Ideally, meet with patient for 15 to 30 minutes at least 4 times in person or by phone) • Appointment 1: Preparing for the Quit Attempt • Appointment 2: On or before the Quit Date • Appointment 3: Approximately 1 week after the Quit Date (Maintenance) • Appointment 4: Approximately 1 Month after the Quit Date (Strategies for Relapse Prevention)

  21. Appointment 1 • Appointment 1 Overview: Preparing for the Quit Attempt • 1.1. Introduction and Verify Patient Interested in Assistance with Quitting • If No: Use Discontinuation script • If Yes: Assessment of Tobacco Use • If Ambivalent: Use MI language to discuss reasons for quitting, benefits of cessation, and treatment options • Ask if they would like to set a goal to quit smoking • If Yes: Assessment of Tobacco Use • If No: Discontinuation script • 1.2. Assessment of Tobacco Use • Provide with tobacco cessation brochure and "Tobacco Cessation: How to Change” handout (If time is limited, schedule 30 minute follow-up appointment. If time permits, begin assessment of tobacco use.) • 1.3.Develop Plan for Quitting. Use “Tobacco Cessation: How to Change” handout to provide written plan

  22. 1.1. Introduction and Verify Patient Interest in Assistance with Quitting "I’m the behavioral health provider for the clinic and I’m (a social worker/a health psychologist/a psychology intern….) It sounds like (medical provider’s name) is concerned about your tobacco use. One of my roles in the clinic is to work with (medical provider's name) to help people stop using tobacco. S/he asked me to help you with quitting tobacco. Is that something you would like? … Do you have 15 or 20 minutes today so we can get started?

  23. Tobacco Use Intervention Decision Tree They (PCP) asked me to help you with quitting tobacco. Is that something you would like to do? Yes: Tobacco Use Assessment Ambivalent: MI Language, Reasons for Quitting, Benefits, Tx Options No: Discontinuation Script Would you like to set a goal to quit smoking? Yes: Tobacco Use Assessment No: Discontinuation Script

  24. If “No”: Discontinuation Script • "It doesn’t sound like you are interested in quitting right now, but if you ever change your mind and want to consider quitting, (your medical provider) and I will be happy to help you quit. We can help you right here in the clinic or we can refer you to a more intensive treatment program. We both consider quitting tobacco to be the most important change you can make for your health. I can give you this brochure with information about our programs and the benefits of quitting tobacco. You can contact me or any of these numbers on the brochure if you want help with quitting.” • Offer brochure with your contact information if desired and conclude session.

  25. If AMBIVALENT: Using MI language, discuss reasons for quitting, benefits of cessation, and treatment options • "Would you be interested in talking about reasons for quitting and hearing more about treatment options? (If yes, continue) Let’s start by reviewing your reasons for quitting tobacco.“ • Using MI language, elicit reasons why the patient would like to stop tobacco and why they might want to continue use (pros and cons).   • "What are some of the good things about quitting tobacco? Why would you like to stop using it? “ • "I know that there are also reasons why people continue to “smoke”/”chew”…. What are some of the things that might stop you from quitting?"

  26. Discuss patient's responses and provide additional information about health benefits of quitting • Although there are some things that people enjoy about using tobacco, the health benefits that you get from quitting are dramatic. Would you like hear more specific information about health benefits? (if yes- provide brochure.) If you would like, you can take this with you today. It provides information about the benefits of quitting tobacco, the types of programs we have, and other numbers you can call for assistance. For example, some of the benefits include fresher smelling breath and clothes, and improved ability to do everyday tasks (climbing stairs, walking…)

  27. MI Language • Provide overview of treatment options (brochure if available) • Assess readiness to change: • Give patient readiness ruler, explain scale and ask them to rate their current level of readiness to change

  28. Readiness Ruler Assessing Importance and Confidence Importance How important is it to you to quit tobacco ? On a scale of 0 to 10, with 0 being not important & 10 being very important… 0 1 2 3 4 5 6 7 8 9 10 Not at allSomewhat Very Confidence How confident are you that you could stop smoking/using…, if you decided to? On a scale of 0 to 10, with 0 being not confident at all & 10 being very confident? 0 1 2 3 4 5 6 7 8 9 10 Not at all Somewhat Very

  29. MI (Cont) • "On a scale of 1 to 10, with 1 meaning not that important and 10 meaning very important, how important do you think it is for you to quit smoking?” • "On a scale of 1 to 10, with 1 meaning not at all confident and 10 meaning completely confident, how confident do you feel about quitting? • "Why are you at a __instead of a (lower number here) __?" and/or "What would need to happen to make your ____increase to (slightly higher number)___? • Given everything that we have talked about today, including the benefits of quitting, the types of treatment we can offer, and your readiness to change, would like to set a goal to quit smoking?

  30. 1.2. Tobacco Use Assessment • Gather pattern of use (what, when, exactly how much, and why) • What kind of tobacco do you use? • How much tobacco do you use? • How often do you use tobacco? • Everyday or on the weekends? • Understand what factors predispose use • Gather history of cessation attempts (stop smoking medications, what worked) • Determine potential alternatives for stress management. (In subsequent sessions, it may be beneficial to teach relaxation strategies- such as diaphragmatic breathing)

  31. 1.3. Develop Plan for Quitting; use “Tobacco Cessation: How to Change” handout • Review information on patient handout “Tobacco Cessation: How to Change” about the factors that contribute to using tobacco • Help patient establish exact quit date and time • Help patient develop plan for success by preparing environment (also on pt. HO) • Help the patient choose a method or combination of methods to quit (document on handout) • Recommend use of tobacco cessation medications and provide information • Facilitate medication process with the PCP, pharmacy, etc ., as needed

  32. Appointment 2 Appointment 2 Overview:(On or before the quit date) • 2.1. Review Benefits of Quitting • 2.2. Review Quit Plan • 2.3. Discuss Concerns/Fears (Confidence and Motivation / Develop Plan to Address Concern) • 2.4. Discuss Plan for Handling Urges • 2.5. Introduce Relaxation Strategies - Such as DiaphragmaticBreathing

  33. 2.1.Review Benefits of Quitting • Suggest and highlight benefits that seem most relevant to the patient. Examples of benefits: • Improved health and reduced risk of disease and early death • Food will taste better • Improved sense of smell • Easier breathing and less “smoker’s coughing” • Save money to purchase things and vacations you really want • Elicit others from patient (“what do you see as some of the benefits of quitting?”)

  34. 2.2 Review Quit Plan • If patient did not bring a copy of plan from previous session, provide another copy to discuss • Using “Tobacco Cessation: How to Change” handout. Teach the patient 4 As of quitting (i.e., Avoid, Alter, use Alternatives, stay Active) • Revise as needed

  35. 2.3. Discuss Concerns /Fears (Confidence and Motivation/Develop Plan to Address Concerns) • "Are there any other specific concerns that you have? It is good that we know some of your concerns before hand- that way we can come up with ways to address them." (Help to develop plan to address these concerns and review additional strategies. For example, help the patient consider how they will live differently. Ask questions.) • Will you stop carrying lighters in your pocket? • Will you be able to drink alcohol without using tobacco? • How will you still take breaks at work without using tobacco? • “It is often helpful to get the support of others when you are trying to quit. How would you feel about asking your significant other/spouse and coworkers to help you quit? Could you let your friends and coworkers know you are quitting?”

  36. 2.4. Discuss Plan for Handling Urges "The Goal is not to have a single puff or chew. Once a person quits tobacco, they often struggle with urges. Thus, it is important to have a plan for when you feel the urge to use tobacco. It can help to know that the urge will pass in just a few minutes whether you use tobacco or not. Remember that you can always look back at the plan that we have developed. The most common reason for returning to tobacco is stress. I am wondering what besides using tobacco you might do if you feel stressed and have urges to use/smoke/chew?"

  37. 2.5. Introduce Additional Strategies such as Diaphragmatic Breathing • Consider other relaxation training (e.g., progressive muscle relaxation) • Consider cognitive strategies • Recommend NRT (gum/lozenge) or other meds –for withdrawal and cravings, if not included in initial plan

  38. Appointment 3 • Appointment 3 Overview: Maintenance (approximately 1 week after quit date) • 3.1 Assessment of Current Tobacco Use Status • 3.2 Discuss Maintenance Strategies • 3.3 Address Stress Management

  39. 3.1. Assessment of Current Tobacco Use Status • Determine if patient has quit • Ask the patient to describe his/her smoking cessation experiences on Quit Date and subsequent days. Complete abstinence? • If no: Discuss what happened, if they actually made the quit attempt, how long it lasted, and what factors lead to starting again. Assess motivation and confidence for making another attempt- Encourage and return to planning phase (see materials in session 1 and 2)- ask the patient to consider different strategies, including NRT or other medications.

  40. 3.2. Discuss Maintenance Strategies • Explain to the patient that despite great plans, slips and relapse often occur • Reinforce previous success • Acknowledge that it is difficult and often takes multiple attempts • Do not become hopeless after a failed attempt • Frame as an opportunity for learning and problem-solving

  41. 3.3. Address Stress Management for Success • Consider teaching additional brief relaxation methods (e.g. deep breathing) that were not discussed in sessions 2, cognitive techniques, and encouraging physical activity.

  42. Appointment 4 • 4.1 Assessment of Current Tobacco Use Status • Determine if patient has continued abstinence • 4.2 Initiate a Brief Discussion of Positive Experiences Associated with Quitting Tobacco and Successful Methods Used to Quit • Encourage the patient to vigorously continue using coping strategies and medications that worked since Quit Date • 4.3 Assess and Resolve Problems Encountered in Quitting Smoking and/or Anticipated Threats to Abstinence • 4.4 Discuss the Difference between a Slip and a Relapse • 4.5 Discuss Strategies for Managing and Preventing Relapse • Provide information about the most common high-risk situations for relapse • Query the patient about his/her highest risk smoking trigger that could lead to resumption of smoking after Quit Date

  43. Encounter Information • This mid-level intervention is intended to be used by behavioral health providers integrated in primary care clinics and should not be coded or documented as specialty care. • Diagnostic Code: Tobacco Use Disorder (305.1) • Procedure Code (CPT): Will depend on the length of appointment as follows: • 99407 = Smoking and tobacco use cessation counseling visit: intensive, Greater than 10 minutes • 99406 = Smoking and tobacco use cessation counseling visit: intermediate, Greater than 3 minutes up to 10 minutes • Although specific clinic names and note titles will vary by individual clinics, appointments for this intervention should be entered in the standard clinic used for patients receiving behavior health services in primary care. Similarly, note titles should reflect services provided in primary care rather then specialty tobacco cessation programs.

  44. References Centers for Disease Control and Prevention. Cigarette smoking among adults – United States, 2006. (2007). Morbidity and Mortality Weekly Report, 56, 1157-1161. Fiore, M. C., Bailey, W. C., Cohen, S. J., Dorfman, S. F., Goldstein, M. G., Gritz, E. R., . . . Wewers, M. E. (2008) Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD: U.S. Department of Health and Human Services. Hajek, P., Stead, L. F., West, R., Jarvis, M., & Lancaster, T. (2009) Relapse Prevention Interventions for Smoking Cessation. Cochrane Database of Systematic Reviews. Retrieved from Cochrane Library database. Hunter, C. L., Goodie, J. L., Oordt, M. S., & Dobmeyer, A. C. (2009). Integrated Behavioral Health in Primary Care: Step-By Step Guidance for Assessment and Intervention. Washington, DC: American Psychological Association. Institute of Medicine. (2009) Combating Tobacco Use in Military and Veteran Populations. Washington, DC: The National Academies Press. Lancaster, T., & Stead, L. F. (2005). Individual behavioral counselling for smoking cessation. Cochrane Database of Systematic Review. Retrieved from Cochrane Library database. Miller, D. R., Kalman, D., Ren, X. S., Lee, A. F., Niu, Z., & Kazis, L. E. (2001). Office of Quality and Performance, Veterans Health Administration. Health Behaviors of Veterans in the VHA: Tobacco Use. 1999 Large Health Survey of VHA Enrollees. Washington, DC: Veterans Health Administration. Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L. (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 291, 1238-1245. Nelson, D. E., Mowery, P., Tomar, S., Marcus, S., Giovino, G., & Zhao, L. (2006). Trends in smokeless tobacco use among adults and adolescents in the United States. American Journal of Public Health, 96, 897-905.

  45. References (Cont.) Piasecki, T. M. (2006). Relapse to smoking. Clinical Psychology Review, 26, 196-215. Ranney, L., Melvin, C., Lux, L., McClain, E., & Lohr, K. N. (2006). Systematic review: Smoking cessation intervention strategies for adults and adults in special populations. Annals of Internal Medicine, 145, 845-856. Shiffman, S., & Ferguson, S. G. (2008) Nicotine patch therapy prior to quitting smoking: a meta-analysis. Addiction, 103, 557-563. Shipley, R. H. (2009). QuitSmart® Leader Manual: Scientific Foundations and Implementation guidelines for the QuitSmart® Stop Smoking Method. Durham, NC: QuitSmart Stop Smoking Resources, Inc. Tonstad, S., Tønnesen, P., Hajek, P., Williams, K. E., Billing, C. B., & Reeves, K. R. (2006). Effect of maintenance therapy with varenicline on smoking cessation: A randomized controlled trial. Journal of the American Medical Association, 296, 64-71. U.S. Department of Health and Human Services. (2008). Treating Tobacco Use and Dependence. U.S. Department of Health and Human Services. VHA Clinical Practice Guidance for Tobacco Use Cessation Treatment, 2010. Westman, E. C., Behm, F. M., Simel, D. L., & Rose, J. E. (1997). Smoking behavior on the first day of a quit attempt predicts long-term abstinence. Archives of Internal Medicine, 157, 335-340. Williams, K. E., Reeves, K. R., Billing, C. B., Jr., Pennington, A. M., & Gong, J. A. (2007). A double-blind study evaluating the long-term stafety of varenicline for smoking cessation. Current

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