Intensive_ Brief_ and “Ultra Brief” Smoking Cessation Interventions

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					Intensive, Brief, and “Ultra
 Brief” Smoking Cessation
           Sandi Kazura, MD
               Medical Director
      Center for Tobacco Independence
                 Maine Health
              January 17, 2008
 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
 Learn  key evidence-based elements of
  practice-based smoking cessation
 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
 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
                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
 Current  use
 Interest in quitting
       (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
     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
3  A’s
 < 3 minutes
 Medication, unless contraindicated
     NRT patch may be easiest to explain
   Increase # of minutes (quit rate -OR compared to no
       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
       Posters
       Helpline #
       Self-help materials
                 Office Systems
   Include
       Written mission statement (making a commitment to
       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

 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
       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)
 Smoking     Cessation Leadership
 Smoke     Free Homes
        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
 Available free, on-line version, with technical
  support resources at
             Local Resources
 Partnership    for Tobacco Free Maine
 Center    for Tobacco Independence
     Helpline: 1-800-207-1230
     Website:
     Clinical Outreach – free consultation &
      technical support for your office
       • Contact: 662-7135
            Upcoming Trainings
 Check     PTM and/or CTI websites for
 Basic
     March 26, 2008 - South Portland
 Intensive
     April 28 & 29, 2008
     Basic training is a pre-requisite

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