Treating Tobacco Use and Dependence

Treating Tobacco Use and Dependence Aaron Swanson, MPH Iowa Department of Public Health Division of Tobacco Use Prevention and Control Tobacco Use in Iowa  Approximately 4,500 tobacco-related deaths annually (Campaign for Tobacco Free Kids, 2007)  20% of high school students are current smokers (2004 Iowa Youth Tobacco Survey)  18% of adults are current smokers. (2006 IA Adult Tobacco Survey)  Annual health care costs directly caused by smoking $1 billion (Campaign for Tobacco Free Kids, 2006)  Portion covered by Medicaid - $301 million (Campaign for Tobacco Free Kids, 2005) Smoking and Health Established cause of:   Risk factor for:    COPD Cancers  esophageal, laryngeal, lung, tracheal, oral, pancreatic, etc. hypertension, MI, stroke      Cardiovascular Disease  Diabetes Peptic ulcer disease Asthma Impotence Infertility Osteoporosis Low birth weight babies The Health Consequences of Smoking: A Report of the Surgeon General; 2004 Spit Tobacco and Health  Not a safe substitute to smoking cigarettes.  Smokeless tobacco contains 28 known carcinogens.  Oral health problems strongly associated with smokeless tobacco use are leukoplakia and recession of the gums.  The amount of nicotine absorbed from smokeless tobacco is 3 to 4 times the amount delivered by a cigarette. Centers for Disease Control and Prevention; National Cancer Institute Secondhand Smoke (SHS) • • • SHS exposure causes disease and premature death in children and adults who do not smoke. Children exposed to secondhand smoke are at an increased risk for SIDS, acute respiratory infections, ear problems, and more severe asthma. There is no risk-free level of exposure to secondhand smoke. 2006 Surgeon General’s Report on Secondhand Smoke Nicotine Addiction       Immediate reinforcement of drug taking behavior Physical – cravings, withdrawal symptoms Psychological – “situational use” “Euphoria” without “intoxication” Behavior reinforced multiple times daily Relapse is common - not an indication of personal failure by the patient or the clinician Mayo Clinic – Nicotine Dependence Center 2000 USPHS Guidelines Available Online http://www.surgeongeneral.gov/tobacco Individual copies available    AHRQ 1-800-358-9295 CDC 1-800-CDC-1311 NCI 1-800-4-CANCER USPHS Clinical Practice Guidelines Major Conclusions/Recommendations  Tobacco dependence is a chronic condition  A tobacco-user identification system should be implemented in every clinic  Cessation counseling delivered by health care providers is effective  Treatments are cost-effective  Pharmacotherpay is effective, and all patients should be encouraged to use except in special circumstances http://www.ahrq.gov/path/tobacco.htm Effective clinical interventions exist  ASK about tobacco use  ADVISE to quit  REFER patient to cessation resources American Dental Hygienists Association – http://www.askadviserefer.org Step 1: Ask  <1 min  Systemically ask every patient/client about tobacco use at every visit. Determine if patient/client is current, former, or never tobacco user. Document number of cigarettes smokes per day.  Document number of years smoked.  Document number of previous quit attempts  Step 2: Advise 1 min  In a clear, strong, and personalized manner, urge every tobacco user to quit.  Employ the teachable moment: link visit findings with advice. “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.” Meeting the patient where they are at....      Precontemplation Contemplation Preparation Action Maintenance  Relapse Step 3: Refer  Assess willingness to quit  1 min If willing to quit: Develop Personalized Quit Plan  Refer to Quitline Iowa   If unwilling to quit:  Provide a motivational intervention  Arrange follow-up Helping patients build an individualized treatment plan The Spirit of Motivational Interviewing (MI)  COLLABORATION  Not confrontation  EVOCATION  Not education/advice  AUTONOMY  Not authority Miller, W.R. & Rollnick, S. (2002) Motivational Interviewing, Preparing People for Change. Principles of Motivational Interviewing  Express Empathy  Develop Discrepancy  Roll with Resistance  Support Self-efficacy Miller, W.R. & Rollnick, S. (2002) Motivational Interviewing, Preparing People for Change When Exchanging Information: “Elicit-Provide-Elicit”  Step One: Ask the client what he/she already knows about the topic you’d like to present.  Step Two: Ask the client’s permission to provide information, give an opinion/advice or express concerns.  Step Three: Ask for the client's thoughts about the information you have provided. Miller, W.R. & Rollnick, S. (2002) Motivational Interviewing, Preparing People for Change Examine the Pros and Cons Good Things About Smoking _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ Not So Good Things About Smoking _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ Not So Good Things About Stopping Smoking _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ Good Things About Stopping Smoking _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ Negotiating a Change Plan  Setting goals  “What do you think is the first step in your process right now?” “Here are a variety of possibilities that people have used successfully. Which do you think might work best for you?” “So what is it specifically that you plan to do? When?” “Is this what you want to do?”  Considering change options   Arriving at a plan   Eliciting commitment  Miller, W.R. & Rollnick, S. (2002) Motivational Interviewing, Preparing People for Change Identify Triggers and Coping Strategies  What are the times, places, and situations when the patient is most likely to smoke?  Maintain smoking record or journal.  What plans does the patient have to cope with cravings that are likely during those times, places, and situations?  Avoidance of triggers. For those ready to quit…STAR Set a quit date Tell family and friends Anticipate challenges Remove all reminders/temptations For the patient unwilling to quit Relevance  Risks  Rewards  Roadblocks  Repetition  Reinforcement strategies  Provide positive reinforcement for quitting or engaging in a healthy coping response.  Congratulate patient for successes.  Identify patient’s plans for reinforcement.  Identify a reward after a certain period of remaining smoke free.  Enhance natural rewards of being a non-smoker.  Image of being a non-smoker (e.g., “How does it feel to be a nonsmoker?”). Referral options for health care providers What is Quitline Iowa?     Toll-free tobacco cessation helpline: 1-800-QUIT NOW (784-8669) Effective, research-based cessation resource Available free of charge to all Iowans  Free two-week supply of either the nicotine patch or gum Monday – Thursday: 7:00 a.m. – 12:00 a.m. Friday: 7:00 a.m. – 9:00 p.m. Saturday – Sunday: 8:00 a.m. – 7:00 p.m. Hours of service:     Services in English & Spanish; interpreter service available for most other languages   TDD line: 1-888-229-2182 Offers follow-up counseling calls tailored to clients’ needs Fax Referral Program  Efficient method for referring patients who smoke to effective cessation services  Alleviates some of the problems posed by limited time and resources  Takes the burden of initiating services off of the patient  New fax number beginning 1/1/08: 800-261-6259  Form can be downloaded at http://www.idph.state.ia.us/tobacco/common/pdf/quitline_fa x_referral.pdf Medicaid Program for Smoking Cessation  Initial prescription:   14 nicotine patches AND/OR 110 pieces of nicotine gum  Subsequent prescriptions:   Four-week supply of nicotine patches (at one unit/day) AND/OR 330 pieces of nicotine gum  Maximum allowed duration of therapy – 12 weeks within a 12 month period Medicaid – conditions of coverage  Diagnosis of nicotine dependence from a health care provider  Referral to Quitline Iowa for counseling  PA forms can be downloaded at http://www.iowamedicaidpdl.com  Confirmation of enrollment in a Quitline Iowa program  Must be 18 years of age or older to receive benefit Thank You!! Aaron Swanson, MPH Iowa Department of Public Health Division of Tobacco Use Prevention and Control 515-281-5491 aswanson@idph.state.ia.us