Tobacco Cessation

Tobacco Cessation Ask your patients if they use tobacco. Act to help them quit. The Problem • Tobacco use is a chronic disease. • 24% of American men and 19% of American women smoke. • Smoking-related diseases claim 440,000 American lives each year. • Smoking costs the United States approximately $97.2 billion each year in health-care costs and lost productivity. Ask and Act The Problem • Smoking is directly responsible for 87% of lung cancer cases and causes most cases of emphysema and chronic bronchitis. • 22% of high school seniors smoke daily. • Male smokers incur $15,800 more lifetime medical expenses and 4 days lost from work per year. • Female smokers incur $17,500 more in lifetime medical expenses and 2 days lost from work per year. Ask and Act The Problem • Only 70% of family physicians currently ask their patients if they use tobacco. • Only 40% take further action. Ask and Act Why don’t doctors ask? • • • • Too busy. Lack of expertise. No financial incentive. Feeling that most smokers can’t or won’t quit. Ask and Act Why don’t doctors ask? • Don’t want to appear judgmental. • Respect for patient’s privacy. • Negative message might scare patients away. • Health professional smokes. Ask and Act Opportunity for physicians • 70% of smokers see a physician each year. • 70% of smokers want to quit. • Physician’s advice to quit is an important motivator. • Patients are more satisfied with their health care if their provider offers smoking cessation interventions even if they’re not yet ready to quit. Ask and Act Physicians are crucial to successful cessation • Tobacco-cessation counseling by clinicians is effective in improving tobacco quit rates among adults and has been recommended for adolescents. • 3% quit/year if you do nothing • 6% quit for 6 months with 3 minute counseling or practice system USPHSR, 2000 Ask and Act Ask and Act • Ask every patient about tobacco use • Act to help them quit – On- or off-site counseling – Quitlines – Patient education materials – Self-help guides or Websites – Cessation classes – Pharmacotherapy Ask and Act Make system changes to identify all tobacco users and document interventions: • Incorporate into vital signs. • Use chart stickers or computer prompts to document status: current, quit or never smoker. • Develop templates for EHRs. Ask and Act Make system changes to identify all tobacco users and document interventions: • Let patients know you can help -posters, lapel pins, brochures. • Ask office staff for ideas how to “Ask and Act”. • Develop incentives for staff interventions with patients-teams, time off or special recognition. Ask and Act Make system changes to identify all tobacco users and document interventions: • Offer tobacco cessation group visits and place sign-up sheets in the waiting room. • Maintain tobacco cessation patient registry. • Plan for follow-up calls by office staff after tobacco quit date. Ask and Act Stages of change Precontemplation Don’t want to quit Contemplation Want to quit sometime Preparation Will quit in next 30 days Action Am quitting now Relapse Maintenance Termination Adapted from Knight, 1997 Ask and Act The 5 Rs: how do you encourage a patient who’s not ready to quit? – Relevance – Risks – Rewards – Roadblocks – Repetition Ask and Act Develop a Treatment Plan • • • • Help create a quit plan Provide practical counseling Provide social support Recommend pharmacotherapy • Provide supplementary materials Ask and Act Quitlines • It only takes 30 seconds to refer a patient to a toll-free tobacco-cessation quitline. • Quitlines are staffed by trained cessation experts who tailor a plan and advice for each caller. • Calling a quitline can increase a smoker’s chance of successfully quitting. Ask and Act Quitlines • 1-800-QUIT-NOW callers are routed to a state-run quitline or the National Cancer Institute quitline. • Quitline referral cards are free for AAFP members. Go to askandact.org. Ask and Act Advantages of Quitlines • Accessibility. • Appeal to those who are uncomfortable in a group setting. • Smokers are more likely to use a quitline than a face-to-face program. • No cost to patient. • Easy intervention for healthcare professionals. Ask and Act Types of Counseling Practical counseling – Teach problem-solving skills. – Identify danger situations for smoker. – Suggest coping skills to use with danger situations and how to avoid temptation. – Provide basic information about smoking dangers, withdrawal symptoms and addiction. Ask and Act Types of Counseling Intra-treatment support – Talk about treatment options. – Communicate care and concern. – Encourage patient to talk about quitting process. Ask and Act Types of Counseling Extra-treatment support – Help patient learn how to ask for social support. – Help patient identify additional support options. – Arrange for outside support. Ask and Act Pharmacotherapy – Who should receive it? • Nearly all smokers trying to quit, except those with medical contraindications, adolescents and those who smoke fewer than 10 cigarettes per day. Ask and Act Recommended first-line pharmacotherapies • Varenicline • Buproprion SR • Nicotine gum • Nicotine inhaler • Nicotine nasal spray • Nicotine patch • Nicotine lozenge Ask and Act Factors clinicians should consider when choosing first-line pharmacotherapies – Clinician familiarity with medications – Contraindications for selected patients – Patient preference – Previous patient experience – Patient characteristics (history of depression, weight gain concerns, etc.) Ask and Act First-line pharmacotherapies • Varenicline-agonizes and blocks α4β2 nicotinic acetylcholine receptors. • Buproprion SR-mechanism for smoking cessation unknown; inhibits neuronal uptake of norepinephrine, serotonin and dopamine. • NRT-binds to various CNS and peripheral nicotinic-cholinergic receptors. Ask and Act First-line pharmacotherapies Varenicline – average cost per day is $4.00. Start .5mg daily for three days, then increase to twice daily for four days. On the eighth day, stop smoking and increase to 1mg twice daily. Most common side effects are nausea and vivid dreams. Ask and Act First-line pharmacotherapies Buproprion SR-average cost per day is $4.33. Start 150mg once daily for three days, then twice per day for seven to twelve weeks. Plan quit date around day seven of treatment. Common side effects include insomnia and headaches. Ask and Act First-line pharmacotherapies Nicotine gum-average cost per day is $9.33 for 2mg and $10.33 for 4mg dose. Patients who smoke less than 15 cigarettes per day chew one 2mg piece every one to two hours and those who smoke more than 15 a day chew 4mg piece every one to two hours. Common side effects are jaw pain and mouth soreness. Ask and Act First-line pharmacotherapies Nicotine inhaler-average cost per day is $9.50. Start with six to sixteen 10mg cartridges per day for three months, then taper over six to twelve weeks. Common side effects are mouth and throat irritation. Ask and Act First-line pharmacotherapies Nicotine nasal spray-average cost per day is $16.00. Start one or two .5mg doses in each nostril every hour for three to six months, then taper over four to six weeks. Common side effects are nose and eye irritation. This is the most addictive form of nicotine replacement therapy. Ask and Act First-line pharmacotherapies Nicotine patch-average cost per day is $4.00 for 21mg patch, $3.40 for 14mg patch and 7mg patch. For patients who smoke more than 10 cigarettes a day start at 21mg every twenty-four hours for six to eight weeks, then step down to 14mg for two to four weeks, then 7 mg for two to four weeks. Common side effects are skin irritation or sleep issues if worn at night. Ask and Act First-line pharmacotherapies Nicotine lozenge-average cost per day is $8.88. Start one lozenge every one to two hours for the first six weeks, then one lozenge every two to four hours for three weeks, then one lozenge every four to eight hours. For patients who smoke their first cigarette within thirty minutes of awakening, use 4mg dose and other use 2mg dose. Common side effects or mouth soreness and dyspepsia. Ask and Act Pharmacotherapies for lighter smokers – Consider reducing the dose of firstline nicotine replacement therapy (NRT). – No adjustments are necessary when using bupropion SR. Ask and Act Recommended second-line pharmacotherapies (off label use) – Clonidine-mechanism for smoking cessation unknown; stimulates α2adrenergic receptors (centrally-acting antihypertensive) – Nortripyline-mechanism for smoking cessation unknown; inhibits norepinephrine and serotonin uptake Ask and Act What should be considered for patients concerned with weight gain? – Bupropion SR and nicotine replacement therapies (especially gum) may delay, but not prevent, weight gain. – The average weight gain from tobacco cessation is 5 pounds, more common in women. Ask and Act Should pharmacotherapy be avoided in patients with a history of cardiovascular disease? • Nicotine replacement therapy-caution for drug class if MI within two weeks, severe arrhythmias or cardiovascular disease. • Buproprion SR-caution if recent MI or hypertension. • Varenicline-no contraindications or cautions in patients with a history of cardiovascular disease. Ask and Act What about pregnant smokers? – Counseling is best choice. – Risks of premature birth or stillbirth caused by smoking may be higher than the potential risk of birth defects caused by NRT use. – Buproprion SR and varenicline are both pregnancy category C. – Nicotine replacement therapy is pregnancy category D, except for gum and lozenges, which are pregnancy category C. Ask and Act Can pharmacotherapies be used long-term? – Yes. – Helpful with smokers with persistent withdrawal systems. – Long-term use of NRT does not present a known health risk. – FDA approved the use of bupropion SR for long-term maintenance. – Varenicline is recommended for 12 week course;may repeat for another 12 weeks. Ask and Act Can pharmacotherapies be combined? – Yes. – Evidence that combining nicotine patch with gum or nasal spray increase longterm abstinence rates. – Combining nicotine patch with buproprion is more effective than patch alone but not buproprion alone Ask and Act Treatment follow-up • Congratulate success! • Schedule counseling intervention within first 3 months. • Encourage the patient to talk about the process. – – – – Reasons patient wants to quit Worries about quitting (weight, stress) Success the patient has achieved Difficulties encountered Ask and Act Patient variables associated with lower success rates – High nicotine dependence. – History of psychiatric comorbidity. – High stress level. – Severe withdrawal during previous quit attempts. – Smokes heavily, and/or has first cigarette of the day within 30 minutes after waking in the morning. Ask and Act Patient variables associated with lower success rates – History of depression, schizophrenia, alcoholism, or other chemical dependency. – Stressful life circumstances or major life changes (divorce, job change, marriage, etc.). Ask and Act Patient variables associated with higher success rates – High motivation. – Ready to change. – Moderate to high self efficacy. – Supportive social network. Ask and Act Patient variables associated with higher success rates – Tobacco user reports motivation to quit. – Tobacco user is ready to quit within a 1-month period. – Confidence in his or her ability to quit. – A smoke-free workplace, home and social environment. Ask and Act Managing withdrawal symptoms – Most intense usually during the first three to seven days. – May continue for several weeks at a declining level of intensity. – Can experience periodic cravings months after stopping. Triggers or cues that were associated with smoking can provoke the cravings. Ask and Act Managing withdrawal TIPS FOR PATIENTS – Exercise. – Reduce or avoid caffeine or other stimulants. – Relax before going to bed. – Don't eat, watch television or discuss problems in bed. – Make your bedroom quiet, and keep a bedtime routine. Ask and Act Managing withdrawal TIPS FOR PATIENTS – Drink plenty of water. – Use cough drops to relieve throat irritation. Ask and Act Managing withdrawal TIPS FOR PATIENTS If you’re having trouble concentrating: – Adjust your schedule to a lighter workload. – Lower expectations on the amount of work you can do. – Understand the amount of energy and time it takes to stop smoking. Ask and Act Managing withdrawal TIPS FOR PATIENTS If your appetite has increased: – Eat healthy snacks. – Don’t delay regular meals. – Drink more water. – Exercise regularly. Ask and Act Managing withdrawal TIPS FOR PATIENTS If you crave a cigarette: – Wait out the craving, which is usually less than five minutes. – Try deep breathing. – Use distractions. Ask and Act Benefit from a relapse • A relapse provides useful information – Information about the cause of the event • A formerly unknown stressful situation – How to correct it occurrence in the future • An action plan for that event • Relapse is a normal part of the recovery process Ask and Act Relapse prevention: maintenance therapy • Tobacco Dependence is a Chronic Disease • Both MDs and patients often have unrealistic expectations for treatment of chronic disease, too often using a short treatment course • Forces driving relapse (biological, psychological, emotional) continue to influence well beyond the period of active treatment • Long-term therapy to maintain remission (prevent relapse) should be encouraged Ask and Act Getting Paid • Effective March 22, 2005, Medicare covers tobacco cessation counseling for patients who smoke and have a tobacco-related disease or whose therapy is affected by tobacco use. Ask and Act Getting Paid • Effective January 2006, Medicare's prescription drug benefit covers smoking cessation treatments prescribed by a physician. – Over-the-counter treatments are not covered Ask and Act Billing for tobacco cessation counseling - HCPCS codes • G0375: Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes; national average payment $12.89 • G0376: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes; national average payment $25.39 Ask and Act Billing for tobacco cessation counseling - HCPCS codes • 8 visits allowed in 12 month period (4 sessions per attempt). • Counseling < 3 min covered under E&M code. • Can have an appropriate E/M service on same day, use modifier -25. • Face-to-face counseling time can be “incident to”. Ask and Act Billing for tobacco cessation counseling - HCPCS codes • Any qualified provider, such as physicians, clinical social workers, psychologists, hospitals, may bill for tobacco cessation. • May be billed as inpatient as long as tobacco cessation not primary diagnosis for admission. Ask and Act Billing for tobacco cessation counseling – ICD-9 codes • 305.1: Tobacco Use Disorder • V15.82: History of Tobacco Use • Provide other clinically relevant diagnosis code, such as cough 786.2 • Document time spent counseling for tobacco cessation Ask and Act U.S. health plan coverage of tobacco dependence treatments 1997 160 plans (74%) with 60 million members. Any TDT Zyban/bupropion OTC NRT NRT if counseling Phone Counseling 25% 18% 2003 88% 30% 7% 25% 33% 27% 10% 19% 42% 36% 1-on-1 Counseling Group Counseling 36% 21% Source: McPhillips-Tangum, et al. Prev Chron Disease July 2006 3(3). Ask and Act Private Insurers • Most insurers provide coverage for at least one type of pharmacotherapy for tobacco cessation and at least one type of behavioral intervention Ask and Act Private Insurers • Use billing codes in the categories of: – Preventive Medicine Treatments – Tobacco Dependence Treatment as Part of the Initial or Periodic Comprehensive Preventive Medicine Examination – Tobacco Dependence Treatment as Specific Counseling and/or Risk Factor Reduction. Ask and Act Medicaid coverage 2000-2005 # (%) Medicaid Programs (N=51) Zyban NRT Patch NRT Gum 2000 31 (61%) 23 (45%) 22 (43%) 2005 37 (72%) 33 (65%) 31 (61%) NRT Spray/Inhaler Face-to-Face Counseling Group Counseling Proactive Telephone (Does not include State Quit Lines) 23 (45%) 11 (24%) 10 (20%) 3 (6%) 29 (57%) 25 (49%) 18 (35%) 3 (6%) Source: MMWR Nov. 9 2001; MMWR Nov. 10, 2006, CDC Ask and Act Tobacco addiction is a chronic disease and deserves ongoing clinical treatment. Effective smoking cessation can reduce illness and improve patient quality of life. Every time, ask your patients if they use tobacco. Act to help them quit. Ask and Act www.askandact.org Ask and Act