Implementing an Effective Smoking Cessation Strategy in Medical Practice Janis M. Dauer, MS, CAC

1. Implementing an Effective Smoking Cessation Strategy in Medical Practice Janis M. Dauer, MS, CAC Alliance for the Prevention and Treatment of Nicotine Addiction 757-858-9934 jdauer@aptna.org

2. Implementing an Effective Smoking Cessation Strategy in Medical PracticeRATIONALE FOR INTERVENING • Save lives, reduce harm • Amenable to treatment • Effective treatments exist • Clinical opportunities are numerous • Even brief interventions are effective • Non-physicians (nurses, health educators) are effective • Treatment is cost-effective (counseling and medications) • Demonstrates sincere commitment to patient’s well-being

3. Implementing an Effective Smoking Cessation Strategy in Medical PracticeCLINICAL PRACTICE GUIDELINE Most recent update: May 2008 (based on meta-analysis of over 8,700 studies published between 1975-2007) NEW EMPHASIS: • Chronic condition, often requires repeated interventions • Counseling is especially important for certain groups (e.g., comorbid medical conditions like diabetes) • Treatment is effective with diverse populations (minorities, low SES, comorbid conditions)

4. Implementing an Effective Smoking Cessation Strategy in Medical PracticeGUIDELINE - NEW EMPHASIS • Healthcare policies and systems changes can significantly reduce barriers to treatment • Coverage as health-insurance benefit • Training clinicians along with having a charting/documentation system in place • Investing in treatment (counseling and medications) – it pays for itself • New strategies exist to assist patients not yet ready to quit (by increasing motivation)

5. Implementing an Effective Smoking Cessation Strategy in Medical PracticeGUIDELINE - NEW RECOMMENDATIONS • Quitlines are effective and have broad reach • Callers are four times more likely to succeed than those trying to quit without treatment • Combination counseling & medication is significantly more effective than either alone • Effective, FDA-approved medications exist (7) • NRT (nicotine: gum, patch, lozenge, nasal spray or inhaler), bupropion (Zyban), varenicline (Chantix) • Combination medications are effective • Nicotine patch + another NRT (often the gum) • Nicotine patch + bupropion SR

6. Implementing an Effective Smoking Cessation Strategy in Medical PracticeGUIDELINE -TREATMENT STRATEGIES THE FIVE “A”s ASK Identify tobacco use status of every patient (current, former, never) ADVISE Advise patient to quit (clear, strong, personal manner) ASSESS Assess willingness to quit (“Yes” = continue with the A’s & “No” = do the R’s)

7. Implementing an Effective Smoking Cessation Strategy in Medical PracticeGUIDELINE -TREATMENT STRATEGIES ASSIST Assist willing patient in developing a quit plan (skills training, support, pharmacotherapy, materials) ARRANGE Arrange follow-up if patient identified a quit date (In person, by phone/mail - soon after quit date) For the “unwilling patient…

8. Implementing an Effective Smoking Cessation Strategy in Medical PracticeGUIDELINE -TREATMENT STRATEGIES THE FIVE “R”s Interventions to increase patient motivation: • RELEVANCE: connect to disease/risk, concerns • RISKS: identify negative impact of continued use • REWARDS: identify potential benefits of quitting • ROADBLOCKS: identify barriers & ways to cope • REPETITION: repeat each visit while still unwilling Recent Quitters (first 12 months) Interventions to assist former smokers in staying quit: Minimal Practice/Prescriptive Relapse Prevention

9. Implementing an Effective Smoking Cessation Strategy in Medical PracticeINTEGRATION INTO PRACTICE Goal: reduce smoking/tobacco use Objective: Implement guideline recommendations (5As/5Rs) Tool: “Needs Assessment” table • Use to identify strategies, process & staff, education & materials needed • Tailor to suit practice/clinic

10. Implementing an Effective Smoking Cessation Strategy in Medical PracticeNEEDS ASSESSMENT

11. Implementing an Effective Smoking Cessation Strategy in Medical PracticeRESOURCES • Provider Training/Education • Online (free/low-cost) • Downloadable manuals (free) • Print materials (free/low-cost) • Patient Education/Self-Help Materials • Quitline provides (to callers) • Links to online sources (free/low-cost) • Quitline Information/Materials • Print/audio/video • Fax referral registration

12. Implementing an Effective Smoking Cessation Strategy in Medical PracticeRESOURCES,continued • APTNA • Training/consultation • Resources and materials • Fax referral project • CA Diabetes Program (cAARd) • Toolkit developed • Adaptable to Virginia • ATTUD • Inexpensive ($75/year) • Network of tobacco treatment specialists

13. Implementing an Effective Smoking Cessation Strategy in Medical PracticePROVIDER BARRIERS Reasons Given for Not Helping Patients Quit • Too busy • Lack of expertise • No financial incentive • Most smokers can’t/won’t quit • Negative message might scare away patients • I smoke myself

14. Implementing an Effective Smoking Cessation Strategy in Medical PracticePROVIDER BARRIERS Helping is Easier Than You Think • Too busy: clinicians can effectively help in 1 minute or less (refer to a specialist) • Lack of expertise: not much needed to refer to a specialist (e.g., the Quitline) • No financial incentive: it’s worth 1 minute, make it part of basic treatment

15. Implementing an Effective Smoking Cessation Strategy in Medical PracticePROVIDER BARRIERS Helping is Easier Than You Think, continued • Most smokers can’t/won’t quit: persevere - multiple sessions or attempts may be needed • Negative message might scare away patients: research studies show patient satisfaction is greater when clinicians address tobacco use/secondhand smoke

16. Implementing an Effective Smoking Cessation Strategy in Medical PracticePROVIDER BARRIERS Helping is Easier Than You Think, continued • I smoke myself: healthcare professionals also need help and support in quitting smoking (and policies that are motivational) • Tobacco-Free Nurses initiative makes online cessation via QuitNet available to nurses for free: www.tobaccofreenurses.org

17. Implementing an Effective Smoking Cessation Strategy in Medical Practice1-800-QUIT NOW • Can be the main counseling service • Quit Coaches are skilled specialists • Tailored interventions are available • Minimal clinician time/resources needed (Ask-Advise-Refer-Medication assistance) • Print materials provided • Services for Spanish-speaking and hearing impaired

18. Implementing an Effective Smoking Cessation Strategy in Medical Practice1-800-QUIT NOW, continued • Can be an adjunct service • Part of patient’s support system • Synergism with other services • Unlimited calls, forever • Providers can also consult with Quit Coaches for advice/information

19. Implementing an Effective Smoking Cessation Strategy in Medical Practice1-800-QUIT NOW, continued • Can be a resource: information/materials • Quit Coaches can answer questions • Self-help booklets available (low-literacy, Spanish version) – call to get a sample • Any call made can increase motivation, facilitate request for help • Family/loved ones can also call

20. Implementing an Effective Smoking Cessation Strategy in Medical Practice1-800-QUIT NOW, continued • Can be Accessed by Fax Referral • Initial call made by Quit Coach • Reduces clinician frustration • Facilitates quit attempt • All fax referred patients eligible to enroll in the Multiple Session protocol

21. Implementing an Effective Smoking Cessation Strategy in Medical Practice1-800-QUIT NOW, continued Fax Referral, continued • Providers can get call outcome feedback on each patient referred • Providers can call to request patient follow-up information • Doesn’t cost anything • Requires registration Questions?