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Guidelines for Treating Tobacco Use and Dependence. Linda A. Thomas, MS UMHS Tobacco Consultation Service. Today’s Objectives . Become familiar with the National and Ohio related health and financial costs of tobacco Discuss nicotine addiction and best practices treatment

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guidelines for treating tobacco use and dependence

Guidelines for TreatingTobacco Use and Dependence

Linda A. Thomas, MS

UMHS Tobacco Consultation Service

today s objectives
Today’s Objectives
  • Become familiar with the National and Ohio related health and financial costs of tobacco
  • Discuss nicotine addiction and best practices treatment
  • Describe the clinical practice guidelines
  • Examine the 5As approach to implementation
toll of tobacco in the u s
Toll of Tobacco in the U.S.
  • Over 440,000 people die each year from their own cigarette smoking
  • 38,000 to 67,500 die each year from other’s smoking
  • 6,000,000+ Youth under 18 alive today who will ultimately die from smoking (@ current smoking rates)
  • Smoking kills more people than alcohol, AIDS, MVAs, illegal drugs, murders, and suicides COMBINED


toll of tobacco in the u s cont
Toll of Tobacco in the U.S. (cont.)
  • Total annual public and private healthcare cost due to smoking equals $89.0 billion
  • Annual healthcare cost from secondhand smoke exposure equals $4.98 billion
  • Productivity losses caused by smoking equal $93.6 billion
  • Taxpayers yearly tax burden from smoking-caused gov’t spending equals $64.6 billion ($596 per household)
  • Smoking-caused costs/losses per pack sold in US equals $9.42 per pack


ohio monetary costs
Ohio Monetary Costs
  • Annual healthcare costs directly caused by smoking equals $4.02 billion
  • Smoking-caused productivity losses equals $4.44 billion
  • Tax payers burden from smoking-caused gov’t expense equals $602 per household

Tobacco Free Kids, 2006


Smoking causes:

  • 30% of all cancer deaths
  • 22% of all heart disease
  • 90% of all chronic obstructive
  • lung disease deaths
inpatient morbidity
Inpatient Morbidity
  • Twice the rate of wound infections
  • Retards wound healing, both surgical and traumatic, including bed sores
  • Longer stays and 20% higher cost in recovery room
  • Most common form pulmonary morbidity during surgery and anesthesia
  • Greater incidence of gastrointestinal disease, prenatal/perinatal complications, orthopedic
  • Spinal fusions 30% less effective with patients who don’t stop smoking
inpatient morbidity cont
Inpatient Morbidity (cont.)
  • Direct medical cost of a complicated birth for a smoker is 66% higher than that of a nonsmoker
  • Using 1987 dollars, $7 billion represents 11% of the total medical expenditures for all complicated births related to smoking
  • Smokers with smoking-related diseases use services for nonsmoking-related diseases at a higher rate
  • Smokers tend to need more medications and have more procedures performed

One Quarter of All Deaths in the U.S. are Smoking Related

  • There is a 70% higher risk of Coronary Heart Disease in smokers compared to non-smokers and a 2-4 fold increased risk of sudden death
  • A smoker’s risk of Stroke is 4X higher than a non-smoker
  • Smokers with Type II Diabetes progress to ESRD twice as rapidly as non-smoking diabetics
other health problems due to smoking
Other Health Problems Due to Smoking
  • Pregnancy complications
  • Earlier onset of menopause
  • Duodenal and gastric ulcers
  • Impotence
  • Skin wrinkling
  • Osteoporosis
determinants of tobacco use
Determinants of Tobacco Use
  • Lower educational achievement (9-11 yrs)
  • Lower SES – below poverty level
  • Other Chemical Dependency use
  • Psychiatric Co-morbidity
  • Genetic predisposition (neuroreceptor gene abnormality)
  • Certain behavioral traits e.g. rebelliousness, impulsiveness, identity assertion, reward dependence, harm avoidance, novelty seeking

Ferry, L. (1998). Nicotine dependence: American’s “Drug of Choice”

adolescent initiation risk factors
Adolescent Initiation Risk Factors
  • Older same sex sibling who smokes
  • Parental smoking
  • Peer influences that are positive toward smoking
  • Poor school achievement
  • Depression
    • Poor integration into social peer groups (isolation, withdrawn)
  • Attention Deficit Disorder
reasons for wide acceptance of nicotine use in society
Reasons for Wide Acceptance of Nicotine use in Society
  • Unlike cocaine, heroin, and alcohol, nicotine has little positive effect on mood or mental performance
  • Nicotine is not intoxicating
  • Continued use is primarily to relieve repeated symptoms of withdrawal, not to enhance mood
  • Still viewed by public and many medical professionals as a habit or lifestyle choice

Tobacco Addiction





Social Factors

what is nicotine
What is Nicotine?
  • The most common cause of drug addiction in the world
  • Naturally occurring in the tobacco plant
  • A colorless alkaloid that turns brown when burned
  • Toxic levels 40-60mg; each cigarette delivers 1- 2mg
  • Nicotine is absorbed through the mucosal membrane, skin, and lungs

National Institute on Drug Abuse Research Report, 1998

  • In pure state, clear, oily liquid
  • Toxic and addictive
  • Nicotine poisoning symptoms:
    • Nausea, salivation, abdominal pain, vomiting, sweating, dizziness, mental confusion, rapid heart beat
    • Convulsions, respiratory failure due to paralysis of respiratory muscles
nicotine metabolism
Nicotine Metabolism
  • Metabolized in liver to cotinine
  • Nicotine half-life is 2 hours, cotinine is 20 hours
  • Some individuals have more rapid metabolisms, leading to more cigarettes smoked per day and potentially earlier addiction as a teenager
  • For example: males > females Caucasian > African American

Swan, G.E, Handbook of Psychiatric Genetics, 1997: pp. 379-398

effects of neurotransmitters hormones released by nicotine
Effects of Neurotransmitters & Hormones Released by Nicotine

Dopamine  Pleasure, Appetite Suppressor

Norepinephrine  Arousal, Appetite Suppressor

Acetylcholine  Arousal, Cognitive Enhancement

NICOTINE Vasopressin  Memory Improvement

Serotonin  Mood Modulation, Appetite Suppressor

Beta-Endorphin  Reduction of Anxiety & Tension

Benowitz, N. (1999).

effects of nicotine
Effects of Nicotine


  • Stimulates memory and alertness
  • Mood altering agent that tends to alleviate boredom and reduce stress
  • Can reduce aggressive responses to stressful events
  • Appetite suppressant, specifically for simple carbohydrates (sweets)
  • Euphoric and mood enhancing effects
effects of nicotine cont
Effects of Nicotine (cont.)


  • Increases the blood level of glucose and insulin production
  • Tends to enhance platelet aggregation which can lead to thrombotic events
  • Chronic exposure to nicotine may cause acceleration of coronary artery disease, peptic ulcer disease, reproductive disturbances, esophageal reflux, hypertension, fetal illness and death, and delayed wound healing
effects of nicotine cont21
Effects of Nicotine (cont.)
  • Increased risk for cancer of various body organs
  • Nicotine is both a stimulant and depressant on the body
  • Introduction of nicotine to the body increases bowel tone and activity, saliva and bronchial secretions, heart rate, blood pressure, and may also increase sweating, nausea, and diarrhea
  • Decreased blood flow especially to extremities and skin
best treatment practices in nicotine addiction
Best Treatment Practices in Nicotine Addiction
  • Use of nicotine replacement therapy and/or bupropion
  • Cognitive-Behavioral intervention
  • High level of motivation to quit
  • Implementation of an exercise program
nicotine in tobacco products delivered to brain
Nicotine in Tobacco Products(delivered to brain)

1 cigarette = 1-2mg

1 can spit tobacco = approx. 60 - 80mg

1 average size dip = approx. 3 - 5mg

1.5 ounce stogie = 12 - 24mg the same as a one pack cigarettes

pharmacological aids and understanding withdrawal
Pharmacological Aidsand Understanding Withdrawal
  • Withdrawal begins a few hours after the last cigarette peaks on the third day
  • Symptoms of withdrawal:
    • Craving
    • Anxiety
    • Restlessness
    • Irritability
    • Depressed mood
    • Difficulty concentrating
    • Increased appetite
    • Stomach cramps
    • Coughing
    • Constipation
    • Mouth sores
nicotine replacement therapy nrt why use it
Nicotine Replacement Therapy (NRT) Why use it?
  • Using NRT gets rid of the carbon monoxide and numerous other toxic chemicals in the cigarette smoke
  • The smoker is gradually weaned from the physical addiction, making it easier to deal with the mental, emotional and behavioral aspects of the behavior
nrt indications
NRT: Indications
  • Any one who smokes > 10 cigarettes a day
  • Anyone who reports withdrawal symptoms during a previous quit attempt
  • Each quit attempt is different; if NRT didn’t help before, it’s OK to try it again; motivation may have shifted
  • All NRTs are better than placebo
  • All NRTs are category D for pregnancy except
  • nicotine gum is category C
efficacy of nrts
Efficacy of NRTs
  • Efficacy enhanced when in combination with a cognitive-behavioral support program
  • All forms NRTs double abstinence rates (15-25%) over placebo (3-10%) at 12 months
nrt contraindications
NRT: Contraindications
  • Use in Pregnancy is contraindicated. No studies have addressed the safety of NRT or bupropion in pregnancy
  • FDA Pregnancy category ratings: C - gum D - patch/spray/inhaler
  • Plastic tape allergies
  • Unstable CAD*
  • *Stable CAD is not a contraindication
typical smoking pattern
Typical Smoking Pattern

Nicotine level before bedtime

1 -1.5 hours

First 2 hours

nicotine treatment products
Nicotine Treatment Products
  • Nicotine Gum 2mg & 4mg
  • Nicotine Patch 5mg, 7mg, 10mg, 14mg, 15mg, 21mg
  • Nicotine Inhaler
  • Nicotine Spray
  • Nicotine Lozenge
  • bupropion
combination nicotine therapy
Combination Nicotine Therapy
  • Use of a “passive” and “ad libitum” NRT product
    • Increases long-term abstinence rates than use of only one NRT
    • More studies are being completed on combination therapy
a suggested formula pack a day smoker
A Suggested FormulaPack-a-day smoker
  • Simultaneous use of Zyban, Patch, and Gum
  • Can use Inhaler, Lozenge or Spray
  • Patch: 21mg 4-8 weeks, 14mg 4 weeks, 7mg 4 weeks
  • Gum: 1 piece every 30 minutes first 2 hours of day
  • bupropion: 3 months
psychological addiction
Psychological Addiction
  • Tobacco use is a learned behavior
  • Tobacco use is a triggered behavior
  • Tobacco use is an automatic behavior
  • 40% smokers have an underlying depressive disorder
  • Used to decreased anxiety and increased stimulation
psychological addiction cont
Psychological Addiction (cont.)

Smokers are the experts of a behavior:

20 cigarettes X 10 puffs per cig = 200 puffs/day

200 puffs X 365 days = 73,000 puffs/year

73,000 puffs/year X 20 years = 1,460,000 puffs

What have you done more than 1,460,000 times?

social factors
Social Factors
  • Smokers know smokers
  • Smoking is an important part of socializing, especially at work sites
  • Many smokers started smoking because of social factors as adolescents - those reasons often continue to be present in adulthood
prochaska diclemente s model of the stages of change
Prochaska & DiClemente's Model of The Stages of Change
  • Allows more realistic goals for change
  • Reduces patient and physician frustration
  • Physician is in-step with the patient rather than in conflict
  • Provides framework for physician to intervene instead of “one intervention fitting all”
stages of change model
Stages of Change Model


Relapse Contemplation

Action Preparation


key concepts of the stages of change model
Key Concepts of the Stages of Change Model
  • Smokers move through different stages in attempting to quit
  • Change is a process that takes time rather than being a single event (The average smoker averages 7 quit attempts before total abstinence)
  • At different stages, smokers need different intervention processes to affect change


  • 40% of smokers
  • Not intending to change in
  • the foreseeable future
  • Un-informed or under-informed about the consequences of smoking

Stages of Change


Relapse Contemplation

Action Preparation


  • “Worn out quitter” – lack of efficacy to change
  • People in this stage exhibit:
    • Avoidance, don’t talk, read or think about
    • quitting
    • Rationalization to help them avoid
    • Rebellion: “nobody can tell me what to do”


Stages of Change


Relapse Contemplation

Action Preparation


  • 40% of smokers
  • Thinking about quitting in
  • the next 6 months
  • Very ambivalent, weighing
  • pros and cons of quitting
  • People in this stage:
    • Feel very stuck
    • Are waiting for the “right” reason(s) to quit
    • Need information and incentives


Stages of Change


Relapse Contemplation

Action Preparation


  • 10% of smokers
  • Thinking about quitting in
  • the next month
  • Engage in a preparation
  • behavior (i.e. cutting back
  • # of cigs, switching brands)
  • Action
  • 10% of smokers
  • They have quit in the last month – total abstinence
  • They are actively using strategies to avoid relapsing
  • to the behavior


  • This stage may last from 6 months to EOL
  • After 12 months of abstinence, on the average, 43% relapse to continuous smoking
  • Only 15% of smokers relapse all the way back to pre-contemplation
  • People in this stage need help with preventing
  • relapse
  • -Formulate an action plan for relapse -Reinforce decision to stay smoke-free

Stages of Change


Relapse Contemplation

Action Preparation



Clinicians should not expect that patients who are in pre-contemplative or contemplative stages will agree to a cessation attempt

  • The goal is to help them move to the next stage by increasing their motivation to stop

Assisting patients in the cessation process, relapse stage, and ex-users stage is chronic disease service

  • Patients in these stages require follow-up as they would for hypertension, diabetes, glaucoma, or any other chronic disease or condition
chronic disease management
Chronic Disease Management
  • Chronic diseases are prolonged conditions that often do not improve and are rarely completely cured
  • Chronic diseases are the leading causes of death and disability in US
  • Although most common and most costly of health problems – they are also the most preventable
somebody has to do something it s amazing it has to be us jerry garcia the grateful dead
“Somebody has to do something…it’s amazing it has to be us”Jerry Garcia “The Grateful Dead”

NCI-supported studies have demonstrated that a few brief, simple methods routinely used by clinic teams can significantly increase patient smoking quit rates when compared with self-help methods


If 75% of U.S. Clinicians routinely identified and assisted their tobacco-using patients and achieved only a 10% long-term quit rate (more than 6 months of abstinence), there would be at least 2 million more ex-users each year


“Every patient” means everyone age 8 and older, including the parents or guardians of patients who are minors. This is easier than trying to second-guess who is using tobacco



    • Clinic teams should treat tobacco use prevention and cessation advice as a brief, routine activity during every visit

Children and youth may start to use tobacco if their abstinence is not reinforced

  • Patients who use tobacco may need time to prepare themselves before committing to stopping
  • Ex-users need support to stay tobacco-free
  • Never-user adults need reinforcement never to start and encouragement to help others become tobacco-free
what can clinicians do
What Can Clinicians Do?
  • More than 70% of smokers contact a physician
  • each year and each smoker averages more than 4
  • visits per year
  • Many patients cite physician advice as an
  • important motivator for making an attempt to
  • quit
  • Research consistently shows that most tobacco
  • users want to stop (between 70-80%) and would
  • welcome assistance from their physician
  • A 1998 study found that physicians offered
  • counseling in only 21% of visits
standard of care
Standard of Care
  • Ask every patient’s smoking status and note in chart by using vital sign concept
  • Offer smoking assistance to all smokers
  • Provide pharmacotherapy if appropriate to the needs of the smoker
reasons for lack of clinician involvement
Reasons For Lack of ClinicianInvolvement
  • Lack of Time
  • Frustration over low quit rates, high relapse
  • Limited Training in Counseling
  • Limited Training about using Nicotine Replacement Products/bupropion
  • Lack of policy
lack of time doesn t have to be a problem
Lack of Time Doesn’t Have To Be a Problem
  • Even brief advice from a physician has been shown to increase quit rates
  • In 1996 the AMA endorsed the evidenced based Smoking Cessation Guidelines for brief intervention put out by The Agency for Healthcare Research and Quality (AHRQ)
the five a s
The Five A’s
  • Ask
  • Advise
  • Assess
  • Assist
  • Arrange

Clinical studies show that all five steps, used routinely, result in much higher levels of patient agreement to make a quit attempt and actual quit rates, than if only two or three steps are taken


There are two first visit steps foreverypatient:

    • ASK every patient about tobacco use
    • ADVISE user patients to stop using tobacco and commend patients who are tobacco-free
the 5 a s brief intervention
The 5 A’s: Brief Intervention
  • Ask:Systematically identify smoking status

Vital SignsBlood Pressure___________________________ Pulse____________ Weight________________

Temperature_____Respiratory Rate________

Tobacco use: (circle one) Current Former NeverType: (circle one) Cigarette Pipe Cigar Chewing Tobacco

the 5 a s brief intervention cont
The 5 A’s: Brief Intervention (cont.)
  • Advise:all patients who smoke. Advice should be:
    • Clear “I think it is important for you to quit smoking now and I can help you. Cutting down while you are ill is not enough.”
    • Strong “As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future.”
    • Personalized Connect to current health, family health, etc.
the 5 a s brief intervention cont61
The 5 A’s: Brief Intervention (cont.)
  • Assess:if the patient is ready to quit

Are they ready to set a quit date within the next month?

    • If patient will make a quit attempt, either refer to an intensive intervention such as the quit line, in-house program, or provide assistance
    • If the patient will not attempt to quit, provide a motivational intervention
for those willing to quit
For those willing to Quit
  • Assist:Help the patient make a quit plan
    • Recommend pharmacological therapies as appropriate
    • Set a quit date, ideally in next 2 weeks
    • Determine a method, cut down, cold turkey, nicotine fading
    • Remove tobacco from their environment
    • Identify trigger situations and make a plan for how they will cope
    • Avoid high risk situations
    • Get support, tell family and


the 5 a s brief intervention cont63
The 5 A’s: Brief Intervention (cont.)

Assist:Provide Problem Solving

  • Abstinence: Even a single puff can set you back
  • Past Quit Experience: What helped, what hurt
  • Depression: Consider supportive counseling while trying to quit plus bupropion or other antidepressants
the 5 a s brief intervention cont64
The 5 A’s: Brief Intervention (cont.)
  • Alcohol: Consider limiting or abstaining, alcohol can cause relapse
  • Other smokers in the household: Encourage housemates to quit or not smoke around them, contract for smoke-free areas
the 5 a s brief intervention cont65
The 5 A’s: Brief Intervention (cont.)
  • Arrange: Set up Follow-up contact
    • Make another appointment or f/u via telephone
    • Contact within the first 2 weeks after quitting is most effective
      • Contact can be from anyone
    • Problem Summary list for PCP
organization helps to keep interventions brief
Organization HelpsTo Keep Interventions Brief
  • Delegate follow-up calls among clinical staff
  • Add smoking status to vital signs for a chart prompt
  • Have “How to Quit” literature available
  • Let your patients know that staff is available to assist them
reasons for lack of clinician involvement67
Reasons For Lack of ClinicianInvolvement
  • Lack of Time
  • Frustration over low quit rates, high relapse
  • Limited Training in Counseling
  • Limited Training about using Nicotine Replacement Products/bupropion
  • Lack of Policy
clinician frustration working with patients who don t want to quit
Clinician Frustration:Working with patients who don’t want to quit.
  • According to a recent study only one third of physicians had positive expectations regarding the outcome of counseling or their influence on patient behavior in general
  • McIlvain et al. Fam Med 2002
the monster of grim prospects
The Monster of Grim Prospects

Physicians and patients have low expectations

Physicians use few counseling techniques, often relying on advice alone and use few office supports

reasons for lack of clinician involvement70
Reasons For Lack of Clinician Involvement
  • Lack of Time
  • Frustration over low quit rates, high relapse
  • LimitedTrainingin Counseling
  • Limited Training about using Nicotine Replacement Products/bupropion
interventions with pre contemplators
Interventions with Pre-Contemplators
  • Goals of this stage:
    • To increase their awareness of how smoking effects them
    • To enhance self- efficacy
the 5 r s
The 5 R’s
  • Risk:Provide information about the consequences of smoking and the need for change
  • Relevance:How is this information relevant to their situation?
  • Reward:What are the benefits of quitting?
  • Roadblocks:What are the barriers to quitting?
  • Repetition:Repeat this intervention with each office visit until they move to contemplation of quitting
example of the 5 r s with a pulmonary patient
Example of The 5 R’s with a Pulmonary Patient

You are seeing a patient, Mr. P, a 60-year-old man who has recently been diagnosed with COPD. He has been smoking 1ppd for over 35 years and has never stopped smoking. Mr. P feels that he has “already done the damage” to his lungs and there is no point in quitting now.

example of the 5 r s with a pulmonary patient cont
Example of The 5 R’s with a Pulmonary Patient (cont.)
  • Risk:Smoking has an additive effect, the more you smoke, the more breathing problems occur for you, over time
  • Relevance:Because you have COPD:

“If you continue to smoke, your inhaler medication will not work as well as if you did not smoke”“If you continue to smoke, you will have more episodes of respiratory distress than

if you quit”

example of the 5 r s with pulmonary patient cont
Example of The 5 R’s with Pulmonary Patient (cont.)
  • Rewards:What is in it for them if they quit

“You will be able to enjoy your present level of activity longer if you quit smoking”

“The best way to slow the progression of the disease is by quitting smoking”

Get specific: fishing, walking, etc. Ask them what they would miss

example of the 5 r s with pulmonary patient cont76
Example of The 5 R’s with Pulmonary Patient (cont.)
  • Roadblocks:Feels damage is already done

“No matter your current health status, your quality of life improves after quitting smoking”

  • Repetition:Repeat 4 R’s at each visit until patient is ready to quit
enhance self efficacy with pre contemplators
Enhance Self-Efficacy withPre-Contemplators

Self-Efficacy:Confidence in one’s ability to perform a given behavior

“One half of all people who have ever smoked have now quit”

“Many people in your situation have tried and succeeded to quit”“There are many things available to help you quit when you are ready”

decisional balance cont
Decisional Balance (cont.)
  • What are the drawbacks of the quitting
    • Uncomfortable physical withdrawal
    • Cravings
    • Weight gain
    • Not feeling like themselves for a while
    • Irritability
  • This is an opportunity to begin exploring methods of quitting…
decisional balance cont79
Decisional Balance (cont.)
  • Explore Reasons for Quitting
    • Smoking leads to more inflammation & more asthma attacks
    • Exposure to second-hand smoke, even while socializing, increases asthma complications
    • Asthmatics who smoke often feel that they have poorer health and complain about lack of energy compared to non-smoking asthmatics
    • Continuing to smoke will decrease the amount of activities she can do
reasons for lack of physician involvement
Reasons For Lack of PhysicianInvolvement
  • Lack of Time
  • Frustration over low quit rates, high relapse
  • LimitedTrainingin Counseling
  • Limited Training about using Nicotine Replacement Products/bupropion
  • Lack of Policy
nicotine treatment products81
Nicotine Treatment Products
  • Nicotine Gum 2mg & 4mg
  • Nicotine Patch 5mg, 7mg, 10mg, 14mg, 15mg, 21mg
  • Nicotine Inhaler
  • Nicotine Spray
  • Nicotine Lozenge
  • bupropion
lack of policy
Lack of Policy
  • Identifying all tobacco users
  • Process for providing/prescribing NRT/bupropion
  • Tobacco cessation bedside counseling
    • Help with preventing withdrawal symptoms
  • Follow-up
  • Smoke-free environment
relapse predictors
Relapse Predictors
  • Relapse is most likely to occur for three common reasons in addition to little or no preparation
    • Within first 2 weeks – inability to withstand nicotine withdrawal
    • 3-4 months – need for self-medication for anxiety or depressive symptoms
    • Anytime due to a stressful event
risks factors for relapse
Risks factors for Relapse
  • High nicotine addiction (Fagerstrom >7)
  • Smokes > 20-25 cigarettes per day
  • Multiple failed attempts (cannot quit for 7 days)
  • Less than 12th grade education
  • Low SES
  • Poor social support (widowed, lives with smokers)
  • Psychiatric Co-morbidity
  • Younger age < 45 years
minimal relapse prevention steps
Minimal Relapse Prevention Steps
  • Always congratulate the ex-user
  • Use open ended questions to help with problem solving (e.g., What has been easy? What has been hard?
  • Encourage active discussion of:
    • Benefits of quitting
    • Success (length of time or reduction of cigs)
    • Problems encountered threatening relapse (e.g. depression, weight gain, alcohol, other smokers)
relapse challenges
Relapse Challenges
  • Lack of Support
    • Schedule follow-up visits
    • Arrange telephone calls with patient
    • Ask patient to identify 3 support people
    • Refer to cessation counseling/support program
  • Negative mood or depression
    • Refer to Counselor/Psychologist
    • Prescribe medications if appropriate
relapse challenges cont
Relapse Challenges (cont.)
  • Strong/Prolonged withdrawal symptoms
    • Reassess the amount/use of NRT
    • Check for correct use of NRT
    • Extend use of NRT
  • Weight Gain
    • Encourage exercise program prior to quit date
    • Use pharmacotherapy know to delay or avoid weight gain (e.g., nicotine gum, bupropion)
    • Normalize weight gain 5-10 lbs – most people lose by one year anniversary
    • Refer to specialist or weight program
relapse challenges88
Relapse Challenges
  • Feelings of Deprivation/Lack of motivation
    • Encourage patient to reread/write down list of reasons why they wanted to quit
    • Encourage a reward schedule for successes
    • Normalize feelings
    • Check for slips – renew of withdrawal symptoms
    • Encourage to quit for 10 minutes at a time, don’t worry about tomorrow, next week or 5pm

ICD-9 Codes

292.0 Drug Withdrawal


Abstinence syndrome or symptoms

Withdrawal syndrome or symptoms

305.1 Tobacco Use Disorder

Tobacco Dependence

Excludes: History of tobacco use V15.82

V15.82 History of tobacco use

Excludes tobacco dependence

reimbursement cont
Reimbursement (cont.)

Counseling E/M codes

  • 15 minute encounter (PCP nurse)
    • First visit – 96150
    • Follow –up – 96152
  • 25 modifier at a preventive health visit
    • If time is spent counseling, add – 25 modifier to 99211-13 office visit and preventive health code and 305.1 ICD-9
    • For an ill visit, if > 15 minutes is spent counseling and is documented, the encounter can be up-coded (i.e., 99213 to 99214)
reimbursement cont91
Reimbursement (cont.)

Medicare Coverage – HCPCS G codes (Effective 7/2005, retroactive to 3/2005)

  • G0375 – 3-10 minutes counseling

(Intermediate) - $13

  • G0376 - >10 minutes counseling (Intensive) $24
  • Limitations:
    • Only patients with “high risk” conditions are eligible
      • (i.e., pneumonia, asthma, etc – must be coded too)
    • Up to 9 visit annually
    • Physician or “Medicare recognized provider”
    • Currently for outpatient settings only
    • Will not cover group formats, individual counseling only

U.S. Department of Health and Human Services. (2000). Treating tobacco use and dependence. Public Health Service.

feel free to contact me
Feel free to Contact Me

Linda A. Thomas, MS

Program Manager

Tobacco Consultation Service

University of Michigan Health System or