Smoking Cessation Strategies: Options for the Family Physician

1. Smoking Cessation Strategies: Options for the Family Physician Norman Wetterau MD Normwetterau@aol.com

2. Questions • 1. Can we can paid? • 2. Should we simply refer out to quitlines and internet sites? Is there a role for us as physicians? • 3.What about the patient who does not want to quit? • 4. What do we have to offer for those who want to quit? What really works? • 5. How can we reduce relapses?

3. Adult Smoking Cessation Strategies:A Rural Healthcare CME Initiative A CME program presented by The University of Illinois College of Medicine, Michigan Academy of Family Physicians and The Nurse Practitioner Healthcare Foundation U N I V E R S I T Y O FI L L I N O I SC O L L E G E O FM E D I C I N EA TR O C K F O R D

4. New York State Academy of Family Physicians Patient/Physician Partnership for Tobacco Cessation Lisa Thorn, M.D. Norman Wetterau, M.D. For full set of these slides e mail Normwetterau@aol.com

5. Learning Objectives • Learn a simple motivational intervention for behavioral change • Outline effective behavioral modification strategies for patients with nicotine addiction/dependence on smoking • Describe the pharmacologic interventions useful for smoking cessation • Discuss the issues in reimbursement for smoking cessation

6. Coding and Billing • ICD-9 Code: 305.1 (Tobacco Dependence) • Medicare covers minimal counseling (<3 min) at each visit + 2 practitioner-initiated counseling sessions/ year • CPT Codes: 99406 (3-10 min counseling); 99407 (> 10 min) • Payment 12.46 and 20.17 dollars For more information, see: http://www.endsmoking.org/resources/reimbursementguide/pdf/ reimbursementguide-3rd-edition.pdf (General Coding) www.cms.hhs.gov/MLNGenInfo (Medicare)

7. Billing • 214: First you need to address at least one problem in the past + family or social history. Tobacco or alcohol can be that issue. • 214: 25 minutes with half the time spent in counseling. • 214: 3 chronic problems, e.g. COPD, nicotine dependence and alcohol abuse or marijuana abuse

8. Practice Recommendation Providers should screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. Strength of Recommendation: “A” Level Evidence. The USPSTF found good evidence that brief smoking cessation interventions, including screening, brief behavioral counseling (< 3 min), and pharmacotherapy delivered in primary care settings, are effective in increasing the proportion of smokers who successfully quit smoking and remain abstinent after 1 year. The USPSTF found good evidence that smoking cessation lowers the risk for heart disease, stroke, and lung disease and concluded that there is good indirect evidence that even small increases in the quit rates from tobacco cessation counseling would produce important health benefits, and that the benefits of counseling interventions substantially outweigh any potential harms. EBM Source: Agency for Healthcare Research and Quality. US Preventive Services Task Force (USPSTF). Counseling to Prevent Tobacco Use, 2003. http://www.ahrq.gov/clinic/uspstf/uspstbac.htm

9. Family Doctors can Help

10. Variety • Some patients quit on their own • Quit lines have up to 30% success for those patients who use them • Those with underlying mental health problems have a great deal of difficulty quitting. Those with chronic psychiatric problems die 20 years earlier than expected, mainly due to SA including tobacco. Need intensive treatment.

11. Smoking and Depression:A Common Combination • Persons with psychiatric conditions are twice as likely to smoke as general population1 • 1 in 3 smokers is depressed and smokes to self-medicate2,3 • Tailored psychotherapy or combined psycho- and pharmacotherapy more likely to result in abstinence4,5 • Bupropion indicated for treatment of depression and smoking cessation Sources:1el-Guebaly N, et.al. Psychiatr Serv. 2002;53:1166-1170; 2Rakel RE, Blum A. In: Rakel R, ed. Textbook of Family Practice. 6th ed. Philadelphia: WB Saunders; 2002:1523-1538; 3Anda RF, et.al. JAMA. 1990;264:1541-1545; 4Brown RA, et al. J Consult Clin Psychol. 2001;69:471-480; 5Hitsman B, et al. J Consult Clin Psychol. 1999;67:547-554.

12. SMOKING AND ALCOHOL

13. Part of the spectrum of addiction • One third of male smokers have an underlying alcohol problem. Unless you screen for this and deal with it, quitting either tobacco or the alcohol will be difficult. Use motivational approaches. • Many young smokers also smoke marijuana. Ask about this and use motivational approaches.

14. Male Smokers with current or past alcohol problem

15. NYSAFP PROGRAM • 32 physicians participated • Physicians trained and given materials (video, booklets, charting and patient materials) • Physician did intake and made an individual quit plan for each patient • Physicians saw patients 4 to 6 times, plus phone calls • Patients and Physicians evaluated program

16. NYSAFP Project at a Glance • Only the 214 patients in Phase II have data re: length of quit success • 146 of the 214 (68%) quit • 68 (47%) quit for 1-2 mos • 37 (25%) quit for 3 mos • 41 (28%) quit for 4 mos 19.1% of entire group

17. What we learned 1. Physicians are able to do intensive smoking interventions and have good results 2. Physicians can use materials and provide practical advice 3. Some physicians did not use NRT 4. Patients felt that the relationship with their physicians was the most important factor in their success 5. 20% quit for 4 months or more, and after the study, many others quit.

18. NYSAFP project • At end of studies patient who had not been successful indicated reasons why? • They were also asked what else might have worked. • They were asked to evaluate every intervention and indicate: had to have, lot of help, some help, little help, no help

19. Patient survey

20. WHAT HELPED PATIENTS • Rated “some help”, “lot of help” or “had to have this” • Partnership with you doctor: 81% • 94% of those who quit 4 months and 67% of those who never quit • Office visits to doctor: 74% of all enrollees • Phone calls: 59% of those who were called • Booklets to read: 55% of those who read them • Nicotine Patch: 57% of those who used them, • Bupropion: 74% of those who used this (82% of those who quit and 62% of those relapsed before 2 months)

21. Something hopeful • Eight months after the study half of the physicians said that patients who had previously failed tried again and succeeded. • One said several did. • Smoking was now viewed as a chronic disease and the patient-physician team could build on past successes and failures • SO WHAT YOU DO ARE LAY BUILDING BLOCKS. SMOKING CESSATION IS OFTEN NOT A ONE SHOT DEAL.

22. Aspects of Nicotine Addiction Physical/ Biochemical Social Nicotine Dependence Psychological Behavioral Sources:1Giovino GA, et.al. Epidemiol Rev. 1995;17:48-65; 2US Public Health Service. JAMA. 2000;283:3244-3254; 3Hughes JR. J Gen Intern Med. 2003;18:1053-1057.

23. Assessing the Degree of Nicotine Addiction Ask about it: • How much do you smoke (how often, # of cigarettes/day)? • When do you smoke the day’s first cigarette? • Note: some patients may only smoke a few cigarettes a day and still be addicted, especially adolescents (craving and loss of control without much withdrawal).

24. What do you do next 1. Tell them to quit 2. Ask if they want to quit 3. Ask if they have ever tried to quit before 4 Refer them to a quit line or website Marketing methods: 5-8 5. Tell them how bad cigarettes are for them (or give them a booklet). 6. Connect health effects to their health 7. Talk about reasons to quit: cost, health, breath, etc. 8. Convince them: one liners, demythologize 9. Use some type of motivational assessment

25. Benefits of Quitting • Substantially reduces risk of all-cause mortality among patients with coronary heart disease1 • Significantly decreases mortality among those who have had a myocardial infarct2 • Substantially decreases cancer risk3 • Decreases risk of stroke4 • Improves airflow obstruction regardless of baseline lung function5 Sources:1Critchley JA, Capewell S. JAMA. 2003;290:86-97; 2Wilson K, et.al. Arch Intern Med. 2000;160:939-944; 3U.S. Department of Health and Human Services. Health Benefits of Smoking Cessation. A Report of the US Surgeon General. Rockville, MD: U.S. Department of Health and Human Services; 1990; 4Wannamethee SG, et.al. JAMA. 1995;274:155-160; 5Scanlon PD, et al. Am J Resp Crit Care Med. 2000;161:381-390.

28. Assess Motivation • Ask them to list: reasons they want to continue to smoke versus reasons they want to quit • Or use the 1 to 10 scale: One is I will never quit smoking. Ten is I will quit this week • Scale 1-10 on desire to quit, then 1-10 on their belief that then can quit

29. Interventions Pharmacologic Behavioral • Self-help materials • Brief Advice • Counseling • Exercise • Nicotine-replacement therapy • Bupropion • Varenicline

30. Multi-Component Interventions Increase Long-Term Quit Rates Source:Hughes JR. CA Cancer J Clin 2000;50:147.

31. FDA-Approved Pharmacotherapy Prescription Medications Nicotine-replacement Therapy (NRT) • Patch (OTC) • Gum (OTC) • Lozenge (OTC) • Inhaler (Prescription) • Nasal Spray (Prescription) • Bupropion • Varenicline

32. NRT, why so little??? • Cost • Physician beliefs • Patient fears and beliefs • Previous failures • Physician survey: 7/10 recommended it 2/10 did not (cost and Burpropion works better) 3/10 said their patients did not want it

33. Nicotine-Replacement Therapy (NRT) • Reduces nicotine withdrawal symptoms (e.g., anxiety, cravings, hunger)1 • All forms are effective2 • Effectiveness appears independent of intensity of additional support programs2 • Compatible with all other cessation interventions • Limited evidence that combination NRT more effective than single formulations2 Sources:1Hughes JR, et.al. Arch Gen Psychiatry. 1991;48:52-59; 2Silagy C, et.al. Cochrane Database Syst Rev. 2004;3:CD000146.

34. Nicotine-Replacement Therapy • Headache • Insomnia • Jaw Pain • Site Irritation • Recent MI • Arrhythmias • TMJ Contraindications: Possible Side Effects: MI; myocardial infarct; TMJ; temporomandibular joint disease.

35. Practice Recommendation Providers should recommend nicotine replacement therapy in any formulation as part of a strategy to promote smoking cessation. Strength of Recommendation: Meta-analysis of 103 randomized trials (duration > 6 months) that compared nicotine replacement therapy (NRT) to placebo/no treatment or compared different doses of NRT. All forms of NRT were found to increase abstinence rates by 1.5-2.0-fold, regardless of setting. EBM Source: Cochrane Database of Systemic Reviews. Silagy C, et.al. “Nicotine replacement therapy for smoking cessation.” Cochrane Database Syst Rev 2007(3):CD000146. http://www.cochrane.org/reviews/en/ab000146.html

36. Bupropion • Nor epinephrine and dopamine reuptake inhibitor • Doubles odds of cessation relative to placebo1 • Efficacy undiminished by previous NRT use2 • Combining with NRT does not confer significant additive benefit1 Sources:1Hughes JR, et.al. Cochrane Database Syst Rev. 2007(1):CD000031; 2Durcan MJ, et al. Am J Health Behav. 2002;26:213-220.

37. Bupropion • Headache • Dry mouth • Tremor • Rash • Eating disorders • Seizure disorders • Bipolar disorder • Recent MAOI use Contraindications: Possible Side Effects: MAOI; monoamine oxidase inhibitor.

38. Practice Recommendation Providers should recommend bupropion to patients who wish to stop smoking, as it doubles the odds of quitting relative to alternative therapies. Strength of Recommendation: Meta-analysis of 40 randomized trials, each of duration 6 months or longer, that compared bupropion to placebo or an alternative pharmacotherapy. EBM Source: Cochrane Database of Systemic Reviews. Hughes JR, et.al. “Antidepressants for smoking cessation.” Cochrane Database Syst Rev 2007(1):CD000031. http://www.cochrane.org/reviews/en/ab000031.html

39. Varenicline • Nicotine partial receptor agonist that can ease craving and withdrawal symptoms • Approved for smoking cessation in 2006 • Increases smoking cessation ~3-fold compared to placebo1 Source:1Cahill K, et.al. Cochrane Database Syst Rev. 2007;1:CD006103.

40. Varenicline • Nausea • Headache • Insomnia • Severe renal • impairment Contraindications: Possible Side Effects:

41. Practice Recommendation Providers should recommend varenicline to patients who wish to stop smoking, as it triples the odds of quitting relative to non-pharmacotherapeutic options. Strength of Recommendation: Meta-analysis of 6 randomized trials (n=4924) that compared varenicline to placebo or an alternative pharmacotherapy. EBM Source: Cochrane Database of Systemic Reviews. Cahill K, et.al. “Nicotine receptor partial agonists for smoking cessation.” Cochrane Database Syst Rev 2007(1):CD006103. http://www.cochrane.org/reviews/en/ab006103.html

42. Relative Cost of Pharmacotherapy

43. 1-Year Abstinence Rates for Pharmacotherapy *Studies and reported rates vary widely. Rates cannot be compared across treatment types. Sources: 1Silagy C, et.al. Cochrane Database Syst Rev. 2004;3:CD000146; 2Shiffman S, et,al. Arch Intern Med. 2002;162:1267-1276; 3Gonzales D, et al. JAMA. 2006;296:47-55; 4Nides M, et al. Arch Intern Med. 2006;166:1561-1568; 5Jorenby DE, et al. JAMA. 2006;296:56-63.

44. Smoking Cessation and Pregnancy • Active counseling interventions promote quitting in pregnant women1 • Interventions implemented during pregnancy reduce low birth-weight and incidence of pre-term birth • Use of NRT controversial for pregnant and breastfeeding women due to potential fetotoxicity and neuroteratogenicity2,3 Sources:1Lumley J, Oliver SS, et.al. Cochrane Database Syst Rev. 2004(4):CD001055; 2Ginzel KH, et al. J Health Psychol. 2007;12:215-224; 3Ginzel KH. Ob Gyn News. 2007;42:8.

45. FDA Pregnancy Categories for Cessation Pharmacotherapy

46. The medication can put you on the 20 yard line, but the final 20 yards is the hardest.

47. Behavioral Interventions • Self-help materials • Brief Advice • Counseling • Exercise

48. Self-Help Materials • Appear to increase long-term abstinence ~1.5-fold relative to no intervention1 • May be tailored to individual or type • Should be available in office and provided to all smokers Source:1Lancaster T, Stead LF. Cochrane Database Syst Rev. 2005(3):CD001118.

49. Brief Advice (<3 Min) • May be offered by clinician or nurse • Should include firm quit recommendation and call attention to health outcomes and practical issues • Increases odds of quitting ~1.7-fold compared to no advice1 • Absolute benefit appears greater for motivated patients Source:1Lancaster T, Stead LF. Cochrane Database Syst Rev. 2004(4):CD000165.

50. Individual Counseling • Improves quit rates for adults1 • Recommended by US Public Health Service for adolescents • May be more effective than team-based counseling2 • When possible, should be >10 minutes, face-to-face, with trained specialist3 Sources:1U.S. Department of Health and Human Services. Reducing Tobacco Use. A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services; 2000; 2Gorin SS, Heck JE. Cancer Epidemiol Biomarkers Prev. 2004;13:2012-2022; 3Lancaster T, Stead LF. Cochrane Database Syst Rev. 2002(3):CD001292.