Tobacco Use and Evidence- Based Cessation Methods: Systems Changes in Primary Care

1. Tobacco Use and Evidence- Based Cessation Methods:Systems Changes in Primary Care December 2008 Tobacco Prevention & Control Branch Division of Public Health, DHHS

2. Tobacco Use The number one preventable cause of death in the United States and North Carolina

3. Estimated Preventable Causes of Death in NC 13,500 12,500 2,600 2,300 1,700 1,300 900 600 500 Source: North Carolina State Center for Health Statistics (NC SCHS), 2002; NC Medical Journal, July/August, 2002, Vol63, #4. Makdad, 2004 and NC Mortality, 2006

4. 2004 Surgeon General’s Report - The Health Consequences of Smoking • Smoking harms nearly every organ of the body • Cessation has immediate and long-term benefits • Smokinglow tar cigarettes provides no health benefits • List of smoking-caused diseases includes AAA, AML, pneumonia, cataracts, periodontitis, and cancers of pancreas, stomach, cervix, kidney

5. Tobacco dependence as a chronic disease “Tobacco dependence shows many features of a chronic disease… A failure to appreciate the chronic nature of tobacco dependence may undercut clinicians’ motivation to treat tobacco use consistently.”Dr. Michael Fiore, Chair of Treating Tobacco Use and Dependence 2008 Update, Clinical Practice Guidelines

6. Help for the busy practice….

7. North Carolina Tobacco Use Quitline • 1-800-QUIT-NOW (1-800-784-8669) • 8a.m. – 3a.m., 7 days a week; Toll-free; Confidential • All North Carolinians - youth and adult • Proactive – Quit coaches can call tobacco users back upon request, or make 1st call • Fax referral • Multiple language Quit Coaches Administered by the Tobacco Prevention and Control Branch Funded by the NC Division of Public Health, NC Health and Wellness Trust Fund, Blue Cross Blue Shield of NC

8. Become an Exwww.becomeanex.org • For tobacco users who would use a web-based cessation program • Fun, edgy, interactive website • Useful at any stage of change • Personalized quit plan to “Relearn life without cigarettes” • Breaks quitting down into manageable pieces • Free and in English and Spanish

9. Cessation: What Works • Behavioral support • Treats the psychological and habit aspects • Pharmacotherapy • Treats nicotine addiction Works best when combined

10. 5 A’s For Patients Willing to Quit • Ask about tobacco use • Advise patient to quit • Refer (1-800-QUIT-NOW or local prgm) • Assessreadiness to quit • Assist in quit attempt • Arrange follow-up

11. Health Care Provider’s Quick Intervention • ASK about tobacco use • Every visit – make it a vital sign! • ADVISEto quit • In clear, personalized statements; • REFERpatient to the NC Tobacco Use Quitline or other evidence based tobacco cessation resources • Let the NC Tobacco Use Quitline help with the time consuming work. They are experts at quit coaching and will help Assess, Assist, and Arrange)

12. Step 1: Ask • Systematically ask every patient about tobacco use at every visit. • Start Ask process with Vital Signs • Create a reminder system (stamp, sticker, EMR) • Determine if patient is current, former, or never tobacco user. • Determine what form of tobacco is used. • Determine frequency of use. • Document tobacco use status in the medical record.

13. Step 2: Advise • In a clear, strong, and personalized manner, urge every tobacco user to quit. • “Mr. Jones, I know you are concerned about your family history of heart disease; your risk for having a heart attack can be reduced if you quit smoking” • Employ the teachable moment: link visit findings with advice.

14. Step 3: Refer • Is patient is ready to quit within 30 days? • Provide information about the NC Tobacco Use Quitline • Proactive Referral for those ready to set a quit date • Request written permission to fax contact information to the Quitline • Follow-up at next visit – repeat process if necessary • Patients not ready to quit should be given the Quitline number and/or other cessation resources

15. Quitline can Assess, Assist, Arrange • Quitline helps patient ready to set a Quit Date, and • Develop a quit plan • Make up to three follow-up calls • Discuss pharmacotherapy, refer back to HCP • Encourage those not ready to set a quit date to call back • Four call program is evidence-based • Patient can call the Quitline anytime

16. Fax Referral Program • Efficient method for referring patients who want to quit to effective cessation services • Physician referral of patients to cessation programs is associated with higher rates of participation than simply telling patients they should stop smoking • Alleviates some of the problems posed by limited time and resources • Takes the burden of initiating services off of the patient

17. How Fax Referral Works • Patient has been identified as a tobacco user willing to discuss quitting/ready to set a quit date • HCP educates patient on services of NC Tobacco Use Quitline • Patient completes fax referral form providing consent for HCP to release information to initiate proactive call. • Patient must provide contact information and sign the fax referral form. • HCP must complete Provider Information on fax referral form, including Name of Clinic • Based on times provided by patient, Quitline staff will contact patient to begin Quitline calls. • Quitline can provide feedback to HCP on status of patient • Accepted Services, Refused Services, Not Reached • Must check HIPAA box on fax form and provide clinic fax number, contact name and contact number

19. Effectiveness of Quitlines • Smokers who use tobacco cessation Quitlines double their chances of staying quit • Zhu, et al., 2002. Evidence of real-world effectiveness of a telephone quitline for smokers. New England Journal of Medicine • Borland, et al., 2001. The effectiveness of callback counseling for smoking cessation: a randomized trial. Addiction • Proactive telephone counseling is more effective compared to interventions without personal contact, such as self-help materials. (meta-analysis of 27 studies of the efficacy of telephone quitlines) • Stead, et al., 2003—Cochrane Database of Systemic Reviews • Combining NRT with Quitline use increases quit rates • Zhu, et al., 2000. Telephone counseling as adjuvant treatment for nicotine replacement therapy in a "real-world" setting.Preventive Medicine

20. Michael C. Fiore, MD, M.P.H., Panel Chair of Treating Tobacco Use and Dependence 2008 Update, Clinical Practice Guidelines Director, Center for Tobacco Research and Intervention, University of Wisconsin Medical School "In my view, a doctor isn't providing an appropriate standard of care …. if he or she doesn't ask two key questions —'Do you smoke?' and 'Do you want to quit?'— (Do you use tobacco? Do you want to quit?) and then work with that individual to make it happen.“

21. Efficacy of Physician Advice to Quit Abstinence Rate % • No advice 7.9 • Physician Advice 10.2 • Patients expect healthcare providers to ask about tobacco use and advise them to quit Source: Treating Tobacco Use andDependence, USDHHS, Public Health Service, 2008

22. Strategies for Implementation Create a Reminder System Expand the vital signs to include tobacco use Use an alternative universal identification system Stamp, Sticker, Add to the EMR Tobacco Use and Exposure Tobacco Use: (circle one): Current Former Never Secondhand Smoke Exposure: YES NO Tobacco use is the single most preventable cause of death in the US.

23. Pharmacotherapy • Nicotine Replacement Therapy - Patch - Gum - Lozenge - Inhaler - Nasal Spray • Zyban (bupropion) • Chantix (varenicline)

24. NRT and Cardiovascular Disease • Not an independent risk factor for acute myocardial events • Use with caution in patients who: • are within 2 weeks of MI • have serious arrhythmias • have serious or worsening angina pectoris

25. Cessation Counseling Reimbursement • Medicare, BCBSNC, SHP • ICD-9 Code: 305.1 (tobacco abuse) • File in addition to visit’s E&M code • Unbundled – can use a second ICD9 code • CPT Code: • 99406 – intermediate visit (3-10 minutes) • 99407 – intensive visit (> 10 minutes) • No modifier required • Medicaid adding two new CPT codes Jan. 1, 2009 • 3 - 10 minutes • >10 minutes • Look for in January 2009 Medicaid Bulletin • http://www.dhhs.state.nc.us/dma/bulletin.htm NC Prevention Partners, NC AFP Spring Family Physicians Weekend, April 18, 2008 ICD-9: Diagnosis code E&M: Evaluation and management code CPT: Current procedural terminology code

26. More Cessation Counseling Reimbursement Codes • Other codes: • 99401-04; 15-60 minutes (dedicated visit) • 99354 can be added to regular visit (must document counseling) • 99411 is used for group counseling (per participant) • MD, PA or FNP on premises, must talk to group • RN (etc.) may facilitate session

27. Over the Counter Medications Nicotine Patch • Dose: 21mg, 14mg or 7mg per 24 hours • 1 pack/day, start with higher dose, taper • duration 8 weeks • step down after 4 wks in 2 wk increments • Nicotrol is used for 16 hours, off at night • Adverse effects: local skin reaction, insomnia, vivid dreams • Contraindications: Recent MI, unstable angina, arrhythmia • Cost: 7mg box - $37 14mg box - $47 21mg box - $48

28. Over the Counter Medications Nicotine Gum • Dose: up to 24 pieces per day • x 12 weeks (longer if needed) • 2mg for <25 cigarettes per day • 4mg for >25 cigarettes per day • Chew, chew, park • Avoid acidic beverages • Consider using on a fixed schedule • Long term patch and gum use are effective • Adverse Effects: Mouth soreness, hiccups, jaw ache, dyspepsia • Contraindications: As for patch • Cost: 2mg box (100-170 pieces) ~ $45 (generic) 4mg box (100-110 pieces) ~ $63 (generic)

29. Over the Counter Medications Nicotine Lozenge (Commit) • Dose • 2mg (1st cig. >30 min. after awake) • 4mg (1st cig. <30 min. after awake) • 9 (min) to 20 (max) lozenges/day • x 12 weeks (longer if needed) • Allow to dissolve in mouth • Avoid acidic beverages • Adverse Effects: Nausea, hiccups, heartburn • 4mg dose - headache, cough • Contraindications: as for patch • Cost: 2mg box (72 lozenges) - $34 4 mg box (72 lozenges) - $39 (9 lozenges/day =1 box/wk = $136-$156/mo)

30. Prescription Medications Nicotine Inhaler • Dose: 4mg nicotine • 80 puffs=4mg nicotine • Best effects with frequent puffing/at least 6 cartridges per day (can use 6-16 cartridges/day) • Use for up to 6 months • Reduce frequency over the last 6-12 weeks of tx • Avoid acidic beverages • Adverse Effects: mouth/throat irritation, coughing, rhinitis • Contraindications: as for patch • Cost: 1 box (168 10mg cartridges) - $196

31. Prescription Medications Nicotine Nasal Spray • Dose: 1 dose = 1 mg (0.5mg per nostril) • 1-2 doses per hour initially • Increase as needed for symptom relief • 8 min/40 max doses per day for 3-6 months • Do not sniff, swallow or inhale • Head titled slightly back • Adverse Effects: Nasal irritation, congestion; transient changes in smell, taste • Contraindications: as for patch • Cost: $49 per bottle (100 doses)

32. Prescription Medications Zyban, Wellbutrin (bupropion SR 150) • Begin 1-2 weeks before quit date • Dose: 150 mg in a.m. for 3 days 150 mg twice daily for 7 to 12 weeks • May consider long-term tx for 6 months post quit • Adverse Effects: Insomnia, dry mouth • Contraindications: history of seizure d/o, eating d/o, recent MAO inhibitor use in past 14 days • Cost: 1 box of 60 tablets • $97/month (generic) • $197-$210 (brand name)

33. Prescription Medications Chantix (varenicline) • Stimulates nicotine receptors. Also blocks nicotine at receptor site • Start Chantix 1 week before quit date • Dose: 0.5 mg daily for 3 days 0.5mg twice daily for 4 days 1.0mg twice daily for 3 months • May decrease dosage (1mg/day) if significant side effects • Adverse Effects: nausea, insomnia, abnormal/vivid dreams • New warning label Jan. 2008– observe for neuro- psychiatric symptoms (post marketing data) • Cost: 1 box of 56 - $131 (~30 day supply) Research shows that at 1 year, 21% of those on Chantix are still abstinent compared to 8% with a placebo

34. More on Pharmacotherapy • Evidence exists that combined therapy improves abstinence rates • For patients unable to use a single type of first line agent • Patch + gum, nasal spray, or inhaler • Patch plus bupropriopn • Patch plus buproprion is FDA approved • Do not combine NRT with Chantix • Buproprion and gum may delay weight gain • Buproprion and lozenge may delay weight gain • NRT for smokers not willing to quit – promising but warrants further research

35. Pregnancy and Pharmacotherapy • Abstinence early produces greatest benefits • Quitting at any point yields benefits • Person to person intervention should be offered to pregnant and post partum women that exceeds minimal advice to quit and is more extended • Inconclusive evidence that cessation medications increase abstinence rates

36. NC DMA Cessation Medication Coverage • Medicaid now covers ALL cessation pharmacotherapy • Nicotine patch, gum, lozenge, nasal spray, inhaler • Zyban • Chantix • No Prior Authorization needed • Prescription required, even for OTC

37. You only have two minutes • Ask every everyone about tobacco use • Advise to quit with a clear, strong, personalized message • Refer to the Quitline or other resources • NC Tobacco Use Quitline • 1-800-QUIT-NOW (1-800-784-8669) and/or • Become an Ex • www.becomeanex.org • Pharmacotherapy - recommend cessation medication (few exceptions)

38. Fax referral form and other resources • www.QuitLineNC.com • www.tobaccopreventionandcontrol.ncdhhs.gov/cessation

39. What happens when you call the Quitline • First call - plan for 5 minutes to enroll • Readiness to quit determined • Caller inquiring for others, information gathering • Caller would like to speak to a Quit Coach • Live transfer to a Quit Coach for those ready to quit

40. One Call Program: Conversation with the Quit Coach for support Support materials for quitting Referral to local resources Medication information Help to develop a plan, including setting a quit date Access to Web Coach Four Call Program: One Call program, plus Quit Coach will call back -- A quit date is set -- Dates and times are made for three more calls from a Quit Coach Three attempts, then letter is sent Caller would like to speak to a Quit Coach

41. NC Tobacco Use Quitline Web Coach and Click to Call features Web Coach • For those enrolled in Quitline • Progress tracking, coaching e-mails • Discussion Forums Click to Call • Click icon, enter phone number, Quitline calls within minutes • Feature available on Web Coach

42. Take-Home Message for Health Care Providers • Ask, Advise, Refer (1-800-QUIT-NOW) • Brief cessation counseling is effective • Longer cessation counseling is more effective • Pharmacotherapy can double quit rates • Pharmacotherapy should be offered to all - few exceptions • Evidence-based resources are available

43. Continuing EducationOptions • Medscape: Treating Tobacco Use and Dependence http://www.medscape.com/viewarticle/570604 • Free • Approved for 1hour CE • AMA PRA Category 1 Credit(s)™ • Requires registration to Medscape • TobaccoFreePatients.com http://www1.tobaccofreepatients.com/TopicReq? • Based on NCI educational program • Available free for study and review • $15 per credit hour or for letter of completion

44. Tobacco Prevention and Control Branch Resources For downloadable resources Visit our web site: www.tobaccopreventionandcontrol.ncdhhs.gov CONTACT: Donna Dayer, Tobacco Cessation Specialist e-mail: donna.dayer@ncmail.net Main number: 919-707-5400 Office: 919-707-5415