Presented by Elizabeth Kraft, MD, MHS with support from:

1. Is Proud to Present our Monthly Webinar Series:Hot Topics in Tobacco Cessation & Secondhand Smoke Exposure ReductionTuesday, February 5, 2008 12- 1 pm MTGoToMeeting: https://www1.gotomeeting.com/register/136586400Call-in #: 888-305-2039 passcode: 74375#If you have any technical difficulties, please call 720-297-1681. Presented by Elizabeth Kraft, MD, MHS with support from:

2. 3 Things to Remember: Smoking Cessation/Secondhand Smoke Guideline: 1. ASK ADVISE REFER CCGC is your resource for tobacco information: 2. www.coloradoguidelines.org/tobacco Integrate tobacco cessation into your practice: 3. Call CCGC to schedule a TRIA Call Emma at 303/962-8992 or email egoforth@coloradoguidelines.org www.coloradoguidelines.org/tobacco

3. Objectives • CCGC/Tobacco Program: • Tobacco Cessation and Secondhand Smoke Exposure Guideline: ASK ADVISE and REFER • CCGC tobacco resources • Practice redesign: TRIA • Hot Topics: • Pharmacotherapy update • PREP and SNUS • Nicotine Vaccine • Recruiting for a prenatal tobacco committee • Upcoming Webinars www.coloradoguidelines.org/tobacco

4. Colorado Clinical Guidelines Collaborative (CCGC) A coalition of health plans, physicians, hospitals, employers and other entities working together to implement systems and use evidence-based guidelines to improve healthcarein Colorado. • Clinical Guidelines: • Diabetes • Depression • Screening for Colorectal Cancer • Asthma • Pediatric and Adult Immunizations • Upper Respiratory Infections • Gestational Diabetes • Obesity • CV/Stroke • Tobacco Cessation and Secondhand • Smoke Exposure • Lead Agency for provider education and resource for tobacco cessation • Home fora national pilot called IPIP to Improve Performance In primary care Practices www.coloradoguidelines.org 720/297-1681 www.coloradoguidelines.org/tobacco

5. Tobacco Use in CO 17.3% of Coloradans use Tobacco www.coloradoguidelines.org/tobacco

6. The 5As Intervention Model Works www.coloradoguidelines.org/tobacco

7. 2A/1R: ASK ADVISE REFER www.coloradoguidelines.org/tobacco

8. 7 days/week • Free coaching • Free NRT patches x 1 month • English, Spanish • Special protocols for teens, pregnancy, smokeless 1.800.QUIT.NOW 1.800.784.8669 www.coquitline.org March 4 12 – 1 MT Webinar on QuitLine: What Colorado Physicians Need to Know About QuitLine www.coloradoguidelines.org/tobacco

9. Have Tools Readily Available Order free supplies at: www.steppitems.com www.coloradoguidelines.org/tobacco

10. www.coloradoguidelines.org/tobaccoA Resource for You • Webinar recordings • Calendar of events • Training request forms • Current research • Funding opportunities • Professional development www.coloradoguidelines.org/tobacco

11. Question: How Can I Do a Better Job of Tobacco Cessation in My Practice? “Insanity: Doing the same thing over and over again and expecting different results.” -Albert Einstein www.coloradoguidelines.org/tobacco

12. Answer: Practice redesign with tobacco cessation guideline integration as the process Apply these systems changes to other chronic conditions Diabetes Obesity Tobacco Cessation www.coloradoguidelines.org/tobacco

13. Integrate Tobacco Cessation into YOUR Office: Tobacco Rapid Improvement Activity (TRIA) • Process: • Use the tobacco cessation/SHS guideline: 2A/1R • Lunch session with entire office staff: “TRIA” exercise • Why tobacco cessation is important for your practice • Brainstorm implementation goals for each team staff member • Make changes after each patient Tobacco Rapid Improvement Activity: Integrating Tobacco Cessation into Your Clinical PracticeYou Can Be the Difference! www.coloradoguidelines.org/tobacco

14. View a video simulation of a Tobacco Rapid Improvement Activity (TRIA) http://www.coloradoguidelines.org/tobacco/tria.asp www.coloradoguidelines.org/tobacco

15. Hot Topic: Pharmacotherapy What really works, how do we prescribe, and what should we be looking for? What is the buzz about Chantix? It is recommended by the national PHS guideline to offer pharmacotherapy support, if there are no contraindications, as integral to tobacco cessation efforts. May 20 12 – 1 MT Webinar: Pharmacotherapy for Tobacco Cessation: Treatment Update & Clinical Pearls www.coloradoguidelines.org/tobacco

16. Pharmacotherapy • Doubles cessation rates • Can use >1 NRT • Additive therapies • Long term usage • Tailor to your patient www.coloradoguidelines.org/tobacco

17. % Quit Rates at 6 Months www.coloradoguidelines.org/tobacco Am Fam Phys July 2006 page 263; JAMA July 2006

18. Recent Headlines • “Is Stopping Smoking a Suicide Risk?” • “Chantix Suicidal Ideation Reports Doubled in 2 Months” • “Girlfriend Believes Chantix contributed to Texas Musician’s Death” www.coloradoguidelines.org/tobacco

19. Chantix: Update • Chantix pharmacology: Selective nicotinic 4 β2 receptor partial agonist. Results in 30% less DA release than nicotine (lower craving) + antagonistic action that blocks reward properties (decrease satisfaction) • Chantix labeling update: In January 2008, the CHANTIX product insert was updated to include a warning that patients who are attempting to quit smoking with CHANTIX should be observed for serious neuropsychiatric symptoms, including changes in behavior, agitation, depressed mood, suicidal ideation and suicidal behavior. • What should I be doing with this new information? Observe all patients, including Chantix patients, for potential neuropsychiatric symptoms while trying to quit. Monitor frequently. Discuss risks of smoking, benefits of quitting, withdrawal symptoms, strategies to deal with withdrawal, support options (such as the QuitLine), & other pharmacotherapy options. www.coloradoguidelines.org/tobacco

20. Hot Topic: SNUS/SLT/PREP- the Next Generation of TobaccoProducts • What is PREP, SLT and SNUS? • PREP = potentially reduced exposure products (SNUS, snuff, lozenges) • SNUS = “snuff” in Sweden; fine moist pasteurized smokeless spitless tobacco; teabag-like pouches; • SLT = smokeless tobacco www.coloradoguidelines.org/tobacco

21. Harm Reduction vs. Exposure Reduction • Harm reduction – reduction in amount of tobacco related morbidity and mortality even with continued exposure to tobacco-related toxicants • Exposure reduction- intervention designed to lessen intake of tobacco delivered toxicants • National Guideline does not support harm reduction • FDA does not regulate toxicant levels (as in Sweden) in SLT • Data not clear and conflicting • Nicotine still addictive • SLT toxicants still harmful: Pancreatic cancer, metabolic effects (metabolic syndrome, fetal toxicity, unclear cardiac) & oral pathology www.coloradoguidelines.org/tobacco

22. Hot Topic: Nicotine Vaccine • Nicotine is not immunogenic • Vaccine makes antibodies against nicotine • Antibody is a large protein that binds to nicotine, making it unable to reach brain • Linked to a viral base particle that will give mild viral syndrome (70%) • Currently, 3 vaccines being tested: • NABI - 2 vaccinations with 2 boosters 25% stop smoking • TA-Nic- good efficacy (25% at 1 year); phase 3 • CYTOS – lots of side effects, phase 2, 9% improvement vs. placebo www.coloradoguidelines.org/tobacco

23. Prenatal Tobacco Advisory Committee • Prenatal tobacco use one of top reasons for low birth weight • CCGC tobacco team is putting together an advisory committee • If you have an interest or know of a provider who might be interested, please contact Emma at CCGC: 303/962-8992 or egoforth@coloradoguidelines.org www.coloradoguidelines.org/tobacco

24. National Tobacco Guideline • First update since 2000 • Will update 11 specific areas with evidence-based information • CCGC asked to be a peer reviewer • Anticipate release this Spring www.coloradoguidelines.org/tobacco

25. CCGC Tobacco Webinars:Mark Your Calendar All webinars from 12-1 pm • Mar. 4, 2008: What Colorado Physicians Need to Know about the QuitLine, presented by Dr. David Tinkelman • Mar. 18, 2008: Clinical Practice Grant Opportunities • Apr. 1, 2008: Tobacco Cessation for Persons with Mental Illnesses: Primary Care Strategies, presented by Drs. Jeanette Waxmonsky & Alexis Giese • Apr. 15, 2008: Stages of Change & Motivational Interviewing with Clinical Populations, presented by Dr. Heather LaChance • May 20, 2008: Pharmacotherapy for Tobacco Cessation: Treatment Update and Clinical Pearls, presented by Laura Hansen, RPA • For more information on each webinar visit www.coloradoguidelines.org/tobacco and click on “Professional Development.” www.coloradoguidelines.org/tobacco

26. Visit:www.coloradoguidelines.org/tobaccoQuestions?tobaccoinfo@coloradoguidelines.org For a TRIA, contact:Emma at 303/962-8992 or egoforth@coloradoguidelines.org 28

27. Thank you for your time www.coloradoguidelines.org/tobacco