Tobacco Use Cessation: A Brief Primary Care

InterventionPresented by

Katherine M. Dollar, PhD

VISN 2 Center for Integrated Healthcare

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Acknowledgments

Materials for this intervention are based on the 5As framework described and presented in Hunter et al., (2009). As noted elsewhere, materials were also adapted from Robinson & Reiter (2007) and Shipley (2009). Sessions 3 and 4 were adapted from the participant work book developed by the VA Cooperative Studies Program #519 prepared by Miles McFall, Ph.D. and Andrew Saxon, M.D. All sessions are consistent with Clinical Practice Guidelines, 2008 update and the VA/DOD 2004 Clinical Practice Guidelines, and 2010 update (draft). For questions please contact Dr. Katherine Dollar at katherine.dollar@va.gov or Dr. Margaret Dundon at margaret.dundon@va.gov

CIH sharepoint site with materials: https://vaww.visn2.portal.va.gov/sites/natl/cih/default.aspx

VA Tobacco Cessation sharepoint site: https://vaww.portal.va.gov/sites/tobacco/default.aspx

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Objectives At the conclusion of the program, participants

will be able to:

• Discuss the benefits, risks, and appropriate use of pharmacological and behavioral interventions for tobacco cessation.

• Describe stepped-care models of service delivery in general and for tobacco cessation.

• Verbally demonstrate the essential elements of conducting a brief (mid-level) intervention for tobacco cessation within primary care.

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Clinical Practice Guideline (2008)

• Encourage all patients attempting to quit to use effective stop-smoking medications

• Except where contraindicated or where there is insufficient evidence of effectiveness: pregnant women, smokeless users, light smokers, adolescents

• For a free guideline, call 800-311-3435, or download: www.ahrq.gov/path/tobacco.htm#clinic Fiore, et al., 2008, Treating Tobacco Use and

Dependence. USDHHS.7

Interventions

• Pharmacological agents: Prescription and OTC

• Behavior change interventions• Combination (Most effective. As

treatment intensity increases, so does success)

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Non-Prescription Medicines

Medicine Months $/Month Successto Use (generic) Multiplier

Nicotine 2–6 $80 (50) 2xPatch

2 mg Nicotine 3–6 $120 (95) 2xgum or lozenge

4 mg Nicotine 3–6 $120 (95) 3xgum or lozenge

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Prescription Medicines

Medicine Months $/Month Successto Use (generic) Multiplier

Nicotine 3–6 $115 2xNasal Spray

Nicotine 3–6 $150 2xInhaler

Zyban/Wellbutrin 2–6 $220 (30) 2x(Bupropion ER)

Chantix 3–6 $160 3x(Varenicline)

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NRT Dosing Goal is to provide client’s usual amount of

nicotine Smoking-machine values are too low.

Humans get about twice as much nicotine, averaging 2 mg nicotine per cigarette rather than 1 mg

Adjust NRT dose based on client’s reaction. If cravings and withdrawal symptoms, use more NRT. If dizzy or nauseous, use less NRT

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Using Gum or Lozenges:Patient Ed for Med Use Example Gum. Chew slowly until a peppery taste

emerges, then “park” between cheek and gum. After about a minute, repeat. Chew and park for 30 minutes.

Lozenge. Allow to dissolve over 20–30 minutes. Minimize swallowing. Do not chew or swallow the lozenge. Occasionally move lozenge from one side of the mouth to the other.

Both. Do not eat or drink (except water) for 15 minutes before or during use. 12

Varenicline and VA Considered second-line smoking cessation medication in

VA, to be used only for those patients who failed an appropriate trial of nicotine replacement therapy, Zyban, or combination therapy within the past year

Prior to starting varenicline, patients should be screened for feelings of hopelessness, which may increase the risk of suicide once the medication is started. Patients should also be screened for current suicidal ideation or intent as well as a history of past suicide attempts

Patients with suicidal or assaultive thoughts, ideation or behaviors within the past 12months are not candidates for varenicline until judged to be stable by a mental health professional. Providers should strongly consider closer monitoring of mental health symptoms for patients with prior suicidality

At each renewal (or at other times, per provider discretion), thoughts of harm to self or others should be evaluated

Varenicline Dosing• Start one week before the quit date

- Day 1 to 3 0.5 mg white tablet 1x a day - Day 4 to 7 0.5 mg white tablet 2x a day

• On Quit Date STOP SMOKING and take 1.0 mg blue tablet 2x a day for 11 weeks

If not smoking at the end of twelve weeks, may continue for an additional 12 weeks

May stop abruptly. No need to taper. Take Varenicline after eating and with a full glass of water (to

lessen the chance of nausea; VHA Clinical Practice Guidance for Tobacco Use Cessation Treatment, 2010)

Behavioral Interventions

• Higher quit rates compared to no counseling

• Higher quit rates than medication alone• Unclear if difference between individual

and group interventions (Lancaster & Stead, 2005; Ranney, Melvin, Lux, McClain, & Lohr, 2006)

• It is clear that some patients prefer group and others 1:1, so we need to offer both, with 1:1 same day access

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Success Rates

• Having at least 4 individual brief (10-15 minute) appointments substantially improves abstinence rates (2-3 sessions: 16%; 4-8 sessions: 21%)

CPG 2008 Update

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A Stepped Care Approach

• Matches the intensity of services to patients level of need

• Population-based• All individuals receive basic intervention• Interventions are intensified for individuals

with difficulty sustaining progress• Allows for increased flexibility and meeting

specific patient needs• Success with multiple health behaviors

(weight management, diabetes care, hypertension)

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Level One Support

• Support for quitting starts with the primary care provider (PCP). Pt. simply talks with PCP about quitting. CRs will prompt periodically, but anytime is ok. Meds and brief advice can be given

• If not successful, a higher level of care is indicated (i.e., level two or level three support)

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Level Two Support: IPC BHP

• Level two support also starts with PCP. PCP links patient with IPC Behavioral Health Provider (BHP) for same-day, brief intervention and planning

• Brief (15-20 min.) individual visits x 4 • If needed, the IPC staff will help pt. access

medications to increase chances of success

• Follow-up will happen in 2-3 brief additional visits, some of which can be on the telephone

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Level Three Support: Specialty Programs

• The most intensive level of support• Often group format (e.g. QuitSmart™, ALA,

ACS…)• Consider referring if previous unsuccessful

quit attempts in integrated primary care• Most important: patient preference. The

steps or not linear, or required to be sequential!

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Ask the Experts

Please consult with experts and other team members, as needed, for support and continued treatment recommendations

Specialty TUC program staff may be excellent resources

New Health Behavior Coordinators also likely to be good resources

Coordinate efforts: educate the Level 1 and 3 staff about Level 2 offerings

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Level 2 Intervention

PC staff (preferably PCP) refer patient to BHP in Primary Care for brief intervention

See: “Tobacco Use Cessation: A Brief Primary Care Intervention- Step by Step Guide” (full and summary versions available)

See also: companion patient handouts and brochures

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Tobacco Use Cessation: A Brief Primary Care Intervention

Step by Step Guide

Overview of Full Intervention: (Ideally, meet with patient for 15 to 30 minutes at least 4 times in person or by phone)

Appointment 1: Preparing for the Quit Attempt Appointment 2: On or before the Quit Date Appointment 3: Approximately 1 week after the

Quit Date (Maintenance) Appointment 4: Approximately 1 Month after the

Quit Date (Strategies for Relapse Prevention)

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Appointment 1 Appointment 1 Overview: Preparing for the Quit

Attempt

1.1. Introduction and Verify Patient Interested in Assistance with Quitting

If No: Use Discontinuation script If Yes: Assessment of Tobacco Use If Ambivalent: Use MI language to discuss reasons for

quitting, benefits of cessation, and treatment options Ask if they would like to set a goal to quit smoking

If Yes: Assessment of Tobacco Use If No: Discontinuation script

1.2. Assessment of Tobacco Use Provide with tobacco cessation brochure and "Tobacco

Cessation: How to Change” handout (If time is limited, schedule 30 minute follow-up appointment. If time permits, begin assessment of tobacco use.)

1.3. Develop Plan for Quitting. Use “Tobacco Cessation: How to Change” handout to provide written plan

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1.1. Introduction and Verify Patient Interest in Assistance with Quitting

"I’m the behavioral health provider for the clinic and I’m (a social worker/a health psychologist/a psychology intern….) It sounds like (medical provider’s name) is concerned about your tobacco use. One of my roles in the clinic is to work with (medical provider's name) to help people stop using tobacco. S/he asked me to help you with quitting tobacco. Is that something you would like? … Do you have 15 or 20 minutes today so we can get started?

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 Tobacco Use Intervention

Decision TreeThey (PCP) asked me to help you with

quitting tobacco. Is that something you would like to do?

Yes: Tobacco Use

Assessment

No: Discontinuation

Script

Would you like to set a goal to

quit smoking?

Ambivalent:MI Language, Reasons for

Quitting, Benefits, Tx Options

Yes: Tobacco Use

Assessment

No: Discontinuation

Script

If “No”: Discontinuation Script

"It doesn’t sound like you are interested in quitting right now, but if you ever change your mind and want to consider quitting, (your medical provider) and I will be happy to help you quit. We can help you right here in the clinic or we can refer you to a more intensive treatment program. We both consider quitting tobacco to be the most important change you can make for your health. I can give you this brochure with information about our programs and the benefits of quitting tobacco. You can contact me or any of these numbers on the brochure if you want help with quitting.”

  Offer brochure with your contact information if

desired and conclude session.

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If AMBIVALENT: Using MI language, discuss reasons for quitting, benefits of cessation,

and treatment options

"Would you be interested in talking about reasons for quitting and hearing more about treatment options? (If yes, continue) Let’s start by reviewing your reasons for quitting tobacco.“

Using MI language, elicit reasons why the patient would like to stop tobacco and why they might want to continue use (pros and cons).  

"What are some of the good things about quitting tobacco? Why would you like to stop using it? “

"I know that there are also reasons why people continue to “smoke”/”chew”…. What are some of the things that might stop you from quitting?"

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Discuss patient's responses and provide additional information about

health benefits of quitting

Although there are some things that people enjoy about using tobacco, the health benefits that you get from quitting are dramatic. Would you like hear more specific information about health benefits? (if yes- provide brochure.) If you would like, you can take this with you today. It provides information about the benefits of quitting tobacco, the types of programs we have, and other numbers you can call for assistance. For example, some of the benefits include fresher smelling breath and clothes, and improved ability to do everyday tasks (climbing stairs, walking…)

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MI Language

Provide overview of treatment options (brochure if available)

Assess readiness to change: Give patient readiness ruler, explain scale and

ask them to rate their current level of readiness to change

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Readiness RulerAssessing Importance and Confidence

Importance How important is it to you to quit tobacco ?On a scale of 0 to 10, with 0 being not important & 10 being very important…

0 1 2 3 4 5 6 7 8 9 10 Not at all Somewhat Very

ConfidenceHow confident are you that you could stop smoking/using…, if you decided to? On a scale of 0 to 10, with 0 being not confident at all & 10 being very confident?

0 1 2 3 4 5 6 7 8 9 10 Not at all Somewhat Very

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MI (Cont) "On a scale of 1 to 10, with 1 meaning not that important

and 10 meaning very important, how important do you think it is for you to quit smoking?”

  "On a scale of 1 to 10, with 1 meaning not at all confident

and 10 meaning completely confident, how confident do you feel about quitting?

"Why are you at a __instead of a (lower number here) __?" and/or "What would need to happen to make your ____increase to (slightly higher number)___?

Given everything that we have talked about today, including the benefits of quitting, the types of treatment we can offer, and your readiness to change, would like to set a goal to quit smoking?

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1.2. Tobacco Use Assessment

Gather pattern of use (what, when, exactly how much, and why)

What kind of tobacco do you use? How much tobacco do you use? How often do you use tobacco? Everyday or on the weekends?

Understand what factors predispose use Gather history of cessation attempts (stop smoking

medications, what worked) Determine potential alternatives for stress

management. (In subsequent sessions, it may be beneficial to teach relaxation strategies- such as diaphragmatic breathing)

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1.3. Develop Plan for Quitting; use “Tobacco Cessation: How to Change” handout

Review information on patient handout “Tobacco Cessation: How to Change” about the factors that contribute to using tobacco

Help patient establish exact quit date and time Help patient develop plan for success by preparing

environment (also on pt. HO) Help the patient choose a method or combination of

methods to quit (document on handout) Recommend use of tobacco cessation medications

and provide information Facilitate medication process with the PCP,

pharmacy, etc ., as needed

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Appointment 2

Appointment 2 Overview: (On or before the quit date)

2.1. Review Benefits of Quitting 2.2. Review Quit Plan 2.3. Discuss Concerns/Fears (Confidence and

Motivation / Develop Plan to Address Concern) 2.4. Discuss Plan for Handling Urges 2.5. Introduce Relaxation Strategies - Such as

Diaphragmatic Breathing

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2.1. Review Benefits of Quitting

Suggest and highlight benefits that seem most relevant to the patient. Examples of benefits: Improved health and reduced risk of disease and

early death Food will taste better Improved sense of smell Easier breathing and less “smoker’s coughing” Save money to purchase things and vacations you

really want Elicit others from patient (“what do you see as

some of the benefits of quitting?”)

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2.2 Review Quit Plan

If patient did not bring a copy of plan from previous session, provide another copy to discuss

Using “Tobacco Cessation: How to Change” handout. Teach the patient 4 As of quitting (i.e., Avoid, Alter, use Alternatives, stay Active)

Revise as needed

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2.3. Discuss Concerns /Fears (Confidence and Motivation/Develop Plan to Address Concerns)

"Are there any other specific concerns that you have? It is good that we know some of your concerns before hand- that way we can come up with ways to address them." (Help to develop plan to address these concerns and review additional strategies.For example, help the patient consider how they will live differently. Ask questions.)

Will you stop carrying lighters in your pocket? Will you be able to drink alcohol without using

tobacco? How will you still take breaks at work without using

tobacco?

“It is often helpful to get the support of others when you are trying to quit. How would you feel about asking your significant other/spouse and coworkers to help you quit? Could you let your friends and coworkers know you are quitting?”

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2.4. Discuss Plan for Handling Urges

"The Goal is not to have a single puff or chew. Once a person quits tobacco, they often struggle with urges. Thus, it is important to have a plan for when you feel the urge to use tobacco. It can help to know that the urge will pass in just a few minutes whether you use tobacco or not. Remember that you can always look back at the plan that we have developed. The most common reason for returning to tobacco is stress. I am wondering what besides using tobacco you might do if you feel stressed and have urges to use/smoke/chew?"

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2.5. Introduce Additional Strategies such as Diaphragmatic Breathing

Consider other relaxation training (e.g., progressive muscle relaxation)

Consider cognitive strategies Recommend NRT (gum/lozenge) or other

meds –for withdrawal and cravings, if not included in initial plan

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Appointment 3

Appointment 3 Overview: Maintenance (approximately 1 week after quit date)

3.1 Assessment of Current Tobacco Use Status 3.2 Discuss Maintenance Strategies 3.3 Address Stress Management

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3.1. Assessment of Current Tobacco Use Status

Determine if patient has quit Ask the patient to describe his/her

smoking cessation experiences on Quit Date and subsequent days. Complete abstinence? If no: Discuss what happened, if they actually

made the quit attempt, how long it lasted, and what factors lead to starting again. Assess motivation and confidence for making another attempt- Encourage and return to planning phase (see materials in session 1 and 2)- ask the patient to consider different strategies, including NRT or other medications.

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3.2. Discuss Maintenance Strategies

Explain to the patient that despite great plans, slips and relapse often occur

Reinforce previous success Acknowledge that it is difficult and often

takes multiple attempts Do not become hopeless after a failed

attempt Frame as an opportunity for learning and

problem-solving

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3.3. Address Stress Management for Success

Consider teaching additional brief relaxation methods (e.g. deep breathing) that were not discussed in sessions 2, cognitive techniques, and encouraging physical activity.

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Appointment 4

4.1 Assessment of Current Tobacco Use Status Determine if patient has continued abstinence

4.2 Initiate a Brief Discussion of Positive Experiences Associated with Quitting Tobacco and Successful Methods Used to Quit

Encourage the patient to vigorously continue using coping strategies and medications that worked since Quit Date

4.3 Assess and Resolve Problems Encountered in Quitting Smoking and/or Anticipated Threats to Abstinence

4.4 Discuss the Difference between a Slip and a Relapse

4.5 Discuss Strategies for Managing and Preventing Relapse

Provide information about the most common high-risk situations for relapse

Query the patient about his/her highest risk smoking trigger that could lead to resumption of smoking after Quit Date

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Encounter Information This mid-level intervention is intended to be used by behavioral

health providers integrated in primary care clinics and should not be coded or documented as specialty care.

Diagnostic Code: Tobacco Use Disorder (305.1) Procedure Code (CPT): Will depend on the length of

appointment as follows: 99407 = Smoking and tobacco use cessation counseling visit:

intensive, Greater than 10 minutes 99406 = Smoking and tobacco use cessation counseling visit:

intermediate, Greater than 3 minutes up to 10 minutes Although specific clinic names and note titles will vary by

individual clinics, appointments for this intervention should be entered in the standard clinic used for patients receiving behavior health services in primary care. Similarly, note titles should reflect services provided in primary care rather then specialty tobacco cessation programs.

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References Centers for Disease Control and Prevention. Cigarette smoking among adults – United States, 2006. (2007). Morbidity and Mortality Weekly Report, 56, 1157-1161.

Fiore, M. C., Bailey, W. C., Cohen, S. J., Dorfman, S. F., Goldstein, M. G., Gritz, E. R., . . . Wewers, M. E. (2008) Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD: U.S. Department of Health and Human Services.

Hajek, P., Stead, L. F., West, R., Jarvis, M., & Lancaster, T. (2009) Relapse Prevention Interventions for Smoking Cessation. Cochrane Database of Systematic Reviews. Retrieved from Cochrane Library database.

Hunter, C. L., Goodie, J. L., Oordt, M. S., & Dobmeyer, A. C. (2009). Integrated Behavioral Health in Primary Care: Step-By Step Guidance for Assessment and Intervention. Washington, DC: American Psychological Association.

Institute of Medicine. (2009) Combating Tobacco Use in Military and Veteran Populations. Washington, DC: The National Academies Press.

Lancaster, T., & Stead, L. F. (2005). Individual behavioral counselling for smoking cessation. Cochrane Database of Systematic Review. Retrieved from Cochrane Library database.

Miller, D. R., Kalman, D., Ren, X. S., Lee, A. F., Niu, Z., & Kazis, L. E. (2001). Office of Quality and Performance, Veterans Health Administration. Health Behaviors of Veterans in the VHA: Tobacco Use. 1999 Large Health Survey of VHA Enrollees. Washington, DC: Veterans Health Administration.

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References (Cont.)

Piasecki, T. M. (2006). Relapse to smoking. Clinical Psychology Review, 26, 196-215.

Ranney, L., Melvin, C., Lux, L., McClain, E., & Lohr, K. N. (2006). Systematic review: Smoking cessation intervention strategies for adults and adults in special populations. Annals of Internal Medicine, 145, 845-856.

Shiffman, S., & Ferguson, S. G. (2008) Nicotine patch therapy prior to quitting smoking: a meta-analysis. Addiction, 103, 557-563.

Shipley, R. H. (2009). QuitSmart® Leader Manual: Scientific Foundations and Implementation guidelines for the QuitSmart® Stop Smoking Method. Durham, NC: QuitSmart Stop Smoking Resources, Inc.

Tonstad, S., Tønnesen, P., Hajek, P., Williams, K. E., Billing, C. B., & Reeves, K. R. (2006). Effect of maintenance therapy with varenicline on smoking cessation: A randomized controlled trial. Journal of the American Medical Association, 296, 64-71.

U.S. Department of Health and Human Services. (2008). Treating Tobacco Use and Dependence. U.S. Department of Health and Human Services.

VHA Clinical Practice Guidance for Tobacco Use Cessation Treatment, 2010.

Westman, E. C., Behm, F. M., Simel, D. L., & Rose, J. E. (1997). Smoking behavior on the first day of a quit attempt predicts long-term abstinence. Archives of Internal Medicine, 157, 335-340.

Williams, K. E., Reeves, K. R., Billing, C. B., Jr., Pennington, A. M., & Gong, J. A. (2007). A double-blind study evaluating the long-term stafety of varenicline for smoking cessation. Current

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