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Vn / ro cn1. Can we can paid?2. Should we simply refer out to quitlines and internet sites? Is there a role for us as physicians?3.What about the patient who does not want to quit?4. What do we have to offer for those who want to quit? What really works?5. How can we reduce relapses?

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Patient/Physician Partnership for Tobacco Cessation

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Learn a simple motivational intervention for behavioral changeOutline effective behavioral modification strategies for patients with nicotine addiction/dependence on smokingDescribe the pharmacologic interventions useful for smoking cessationDiscuss the issues in reimbursement for smoking cessation

ICD-9 Code: 305.1 (Tobacco Dependence)Medicare covers minimal counseling ( 10 min)Payment 12.46 and 20.17 dollars

For more information, see:http://www.endsmoking.org/resources/reimbursementguide/pdf/reimbursementguide-3rd-edition.pdf (General Coding) www.cms.hhs.gov/MLNGenInfo (Medicare)

Family Doctors can Help

VarietySome patients quit on their ownQuit lines have up to 30% success for those patients who use themThose with underlying mental health problems have a great deal of difficulty quitting. Those with chronic psychiatric problems die 20 years earlier than expected, mainly due to SA including tobacco. Need intensive treatment.

Smoking and Depression:A Common CombinationPersons with psychiatric conditions are twice as likely to smoke as general population11 in 3 smokers is depressed and smokes to self-medicate2,3Tailored psychotherapy or combined psycho- and pharmacotherapy more likely to result in abstinence4,5Bupropion indicated for treatment of depression and smoking cessationSources: 1el-Guebaly N, et.al. Psychiatr Serv. 2002;53:1166-1170; 2Rakel RE, Blum A. In: Rakel R, ed. Textbook of Family Practice. 6th ed. Philadelphia: WB Saunders; 2002:1523-1538; 3Anda RF, et.al. JAMA. 1990;264:1541-1545; 4Brown RA, et al. J Consult Clin Psychol. 2001;69:471-480; 5Hitsman B, et al. J Consult Clin Psychol. 1999;67:547-554.

SMOKING AND ALCOHOL

Part of the spectrum of addictionOne third of male smokers have an underlying alcohol problem. Unless you screen for this and deal with it, quitting either tobacco or the alcohol will be difficult. Use motivational approaches.Many young smokers also smoke marijuana. Ask about this and use motivational approaches.

Male Smokers with current or past alcohol problem

Current problem

Past problem

Total

Male

smokers

34.6%

(17)

18.7%

(9)

53.3%

Former

smokers

9.3%

(5)

ll.1%

(6)

20.2%

Nonsmokers

7.3%

(4)

12.7%

(7)

20%

32 physicians participatedPhysicians trained and given materials (video, booklets, charting and patient materials) Physician did intake and made an individual quit plan for each patientPhysicians saw patients 4 to 6 times, plus phone callsPatients and Physicians evaluated program

Only the 214 patients in Phase II have data re: length of quit success146 of the 214 (68%) quit68 (47%) quit for 1-2 mos37 (25%) quit for 3 mos41 (28%) quit for 4 mos 19.1% of entire group

What we learned1. Physicians are able to do intensive smoking interventions and have good results2. Physicians can use materials and provide practical advice3. Some physicians did not use NRT4. Patients felt that the relationship with their physicians was the most important factor in their success5. 20% quit for 4 months or more, and after the study, many others quit.

At end of studies patient who had not been successful indicated reasons why?They were also asked what else might have worked.They were asked to evaluate every intervention and indicate: had to have, lot of help, some help, little help, no help

Patient survey

Smoking cessation classes .

Nicotine Patch ...

Nicotine Gum

Zyban (pills) .

Nicotine Inhaler

Nicotine Nasal spray

Booklets to read

Partnership with your doctor

Office visits to your doctor ..

Phone calls from the doctors office..

Having a quit buddy ..

Free Telephone Quit Line .

Help from an internet web site .

Removed tobacco from home ..

Asked family & friends for support .

Was prepared for withdrawal signs ...

Was prepared to overcome triggers ...

Replaced urge to smoke with activity

Rewarded myself ...

I did not use or do this

No help

A little help

Some help

Lot of help

Had to have this

82

2

2

3

8

0

42

7

9

21

8

12

78

5

7

5

1

1

56

7

4

8

16

7

73

2

7

8

3

5

89

2

1

2

2

0

18

11

25

22

19

3

3

2

13

29

35

15

3

1

21

28

34

10

27

5

23

20

13

8

69

8

5

7

6

1

87

54

1

1

3

0

81

5

9

2

0

0

24

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23

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24

16

17

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15

22

5

10

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31

17

19

5

17

16

22

16

21

7

24

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18

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7

WHAT HELPED PATIENTSRated some help, lot of help or had to have this

Partnership with you doctor: 81% 94% of those who quit 4 months and 67% of those who never quitOffice visits to doctor: 74% of all enrolleesPhone calls: 59% of those who were calledBooklets to read: 55% of those who read themNicotine Patch: 57% of those who used them, Bupropion: 74% of those who used this (82% of those who quit and 62% of those relapsed before 2 months)

Something hopefulEight months after the study half of the physicians said that patients who had previously failed tried again and succeeded.One said several did.Smoking was now viewed as a chronic disease and the patient-physician team could build on past successes and failuresSO WHAT YOU DO ARE LAY BUILDING BLOCKS. SMOKING CESSATION IS OFTEN NOT A ONE SHOT DEAL.

Aspects of Nicotine AddictionSources: 1Giovino GA, et.al. Epidemiol Rev. 1995;17:48-65; 2US Public Health Service. JAMA. 2000;283:3244-3254; 3Hughes JR. J Gen Intern Med. 2003;18:1053-1057.NicotineDependenceSocialPhysical/BiochemicalBehavioralPsychological

Assessing the Degree of Nicotine AddictionAsk about it:

How much do you smoke (how often, # of cigarettes/day)?When do you smoke the days first cigarette?Note: some patients may only smoke a few cigarettes a day and still be addicted, especially adolescents (craving and loss of control without much withdrawal).

What do you do next1. Tell them to quit2. Ask if they want to quit3. Ask if they have ever tried to quit before 4 Refer them to a quit line or website Marketing methods: 5-85. Tell them how bad cigarettes are for them (or give them a booklet). 6. Connect health effects to their health7. Talk about reasons to quit: cost, health, breath, etc.8. Convince them: one liners, demythologize9. Use some type of motivational assessment

Benefits of QuittingSubstantially reduces risk of all-cause mortality among patients with coronary heart disease1Significantly decreases mortality among those who have had a myocardial infarct2Substantially decreases cancer risk3Decreases risk of stroke4Improves airflow obstruction regardless of baseline lung function5 Sources: 1Critchley JA, Capewell S. JAMA. 2003;290:86-97; 2Wilson K, et.al. Arch Intern Med. 2000;160:939-944; 3U.S. Department of Health and Human Services. Health Benefits of Smoking Cessation. A Report of the US Surgeon General. Rockville, MD: U.S. Department of Health and Human Services; 1990; 4Wannamethee SG, et.al. JAMA. 1995;274:155-160; 5Scanlon PD, et al. Am J Resp Crit Care Med. 2000;161:381-390.

Assess MotivationAsk them to list: reasons they want to continue to smoke versus reasons they want to quit

Or use the 1 to 10 scale: One is I will never quit smoking. Ten is I will quit this week

Scale 1-10 on desire to quit, then 1-10 on their belief that then can quit

Interventions

PharmacologicBehavioralSelf-help materialsBrief AdviceCounselingExerciseNicotine-replacement therapyBupropionVarenicline

Multi-Component Interventions Increase Long-Term Quit RatesSource: Hughes JR. CA Cancer J Clin 2000;50:147.

NoTherapyBrief AdviceBehavioral TherapyPlacebo/No Medication5%10%15%First-Line Medication10%20%30%

FDA-Approved PharmacotherapyPatch (OTC)Gum (OTC)Lozenge (OTC)Inhaler (Prescription)Nasal Spray (Prescription)BupropionVareniclineNicotine-replacement Therapy (NRT)PrescriptionMedications

NRT, why so little???CostPhysician beliefsPatient fears and beliefsPrevious failuresPhysician survey:7/10 recommended it 2/10 did not (cost and Burpropion works better) 3/10 said their patients did not want it

Nicotine-Replacement Therapy (NRT)Reduces nicotine withdrawal symptoms (e.g., anxiety, cravings, hunger)1All forms are effective2Effectiveness appears independent of intensity of additional support programs2Compatible with all other cessation interventionsLimited evidence tha