Intensive, Brief, and “Ultra Brief” Smoking Cessation Interventions Sandi Kazura, MD Medical Director Center for Tobacco Independence Maine Health January 17, 2008 Disclosures 2006 – Honorarium for CME program development for Haymarket Medical, funded by Shire Pharmaceutical (prevention of substance abuse) Research support from NIDA, NCI, Robert Wood Johnson Foundation, American Academy of Child and Adolescent Psychiatry, Brown University Collaborative on Translational Brain Research Goals Learn key evidence-based elements of practice-based smoking cessation interventions Consider office teamwork approaches to enhance patient quit rates Practice System Needs Ways to Identify smokers Assess smokers Motivate smokers to quit Assist smokers with quitting Evaluate how well the practice is doing with helping smokers Identification Who will do this? When? How ask? How to ask Straightforward, direct for most However, “chippers” and occasional smokers may not identify themselves as smokers Youth: Even low levels of smoking are important Predicts future smoking Can start the conversation Highest yield of positive responses: • Have you ever smoked even a puff or two? How to ask Pregnant women are especially likely to have a difficult time disclosing tobacco use. Best to ask using multiple choice format, e.g. • Which of the following statements best describes your cigarette smoking? I smoke regularly now---about the same as before finding out I was smoking I smoke regularly now, but I’ve cut down since I found out I was pregnant. I smoke every once in a while I have quit smoking since finding out I was pregnant I wasn’t smoking around the time I found out I was pregnant, and I don’t currently smoke cigarettes Assessment Current use Interest in quitting Agree (dealing with motivation) On a realistic goal If not ready to quit, this could simply be an agreement for you to check in again at the next visit Use empathy Listening and repeating back what you understand Explore pros and cons “Quitting can be hard” Assistance with Quitting Counseling Help identify triggers and barriers to quitting Help with a personalized management plan Medication NRT: patch, gum, lozenge, spray, inhaler Bupropion Varenicline Support Professional & natural supports Praise even small changes Empathize with difficulty but be optimistic Summarize - Three A’s Assess Agree Assist Brief 3 A’s < 3 minutes Medication, unless contraindicated NRT patch may be easiest to explain Intensify Increase # of minutes (quit rate -OR compared to no contact) Minimal: < 3 minute (1.3) Low intensity: 3-10 minutes (1.6) Higher intensity: > 10 minutes (2.3) Increase # of messages Messages over time Number of clinicians, e.g. nurse plus doctor Intensive behavioral counseling - typically provided by specialists (91 -300 minutes, OR = 3.2) E.G. Tobacco Treatment Specialists - Certified (TTS-C) Ultra Brief Options Provide direct advice to quit “I’m concerned about your smoking---it would be great if you quit” Refer to Helpline Passive - probably better than nothing alone, better as supplement to person-to-person counseling Posters Helpline # Self-help materials Office Systems Include Written mission statement (making a commitment to intervene) Patient education resources Automatic prompts to ask and counsel Staff training Office “champion” Referral resources Tracking system Program evaluation (QA) How will you do this in your practice setting? Maine Tobacco Helpline 1-800-207-1230 Counseling Medication - Free nicotine replacement (patch and gum) for those without insurance coverage Support Medications - Clinical Pearls NRT - one common cause of failure is improper use Varenicline FDA “early communication” possible risk for • Suicidal thoughts • Aggressive & erratic behavior • Drowsiness • Inform patients, monitor Bupropion Think through potential issues in presence of psychiatric conditions FDA Alert • Possible increased risk of suicidal thoughts and behavior • Monitor for worsening depression and/or suicidality Web Resources Smoking& Tobacco Use (Centers for Disease Control & Prevention) www.cdc.gov/tobacco/ Smoking Cessation Leadership http://smokingcessationleadership.ucsf.org Smoke Free Homes www.kidslivesmokefree.org Clinical Practice Guideline Fiore MC, Bailey WC, Cohen SJ et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: Department of Health and Human Services. Public Health Service. June 2000. Stay tuned! --- update scheduled for release 3/08 Available free, on-line version, with technical support resources at http://www.ahrq.gov/clinic/tobacco Local Resources Partnership for Tobacco Free Maine www.tobaccofreemaine.org Center for Tobacco Independence Helpline: 1-800-207-1230 Website: www.tobaccoindependence.org Clinical Outreach – free consultation & technical support for your office • Contact: 662-7135 Upcoming Trainings Check PTM and/or CTI websites for details Basic March 26, 2008 - South Portland Intensive April 28 & 29, 2008 Basic training is a pre-requisite Questions? Comments?