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Treating Tobacco Use
and Dependence
October 26, 2017
Great Plains Quality Improvement Network
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Treating Tobacco Use and Dependence: Agenda
Brief history and developmental process
Facts about Tobacco
Clinical Interventions
Clinical Practice Guidelines
Motivational Interviewing
Cessation Steps
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PHS Guideline Statements
“There is no clinical intervention available today that can reduce illness, prevent death, and increase quality of life more than effective tobacco treatment interventions”
“Tobacco is the single greatest preventable cause of disease and premature death in the America
today.”
PHS Guidelines, 2000
Smoking in Perspective – U.S.
480,000 die each year
15.1% of adult smoke
16 million people suffer from smoking-related illness
8% of high school students smoke (1.6 million)
2,300 kids (under 18) try smoking each day
Adds $170 billion in direct health costs each year
$151 billion in lost productivity
$9.1 billion – annual marketing costs for tobacco industry ($25 million each day)
Nebraska spends $744 for every person in the state for smoking-attributable healthcare costs and lost productivity
Tobacco Free Kids.org; 10/17
Resource: Tobacco Free Kids https://www.tobaccofreekids.org/proble
m/toll-us
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How One Becomes Addicted
Unique aspects of nicotine
Reaches brain within 5 heart beats
(within 5 seconds)
Can either be stimulating or calming
Nicotine affects both reward and
withdrawal pathways
Nicotine stimulates norepinephrine &
serotonin systems
Results in dopamine secretion
Nicotine also interacts with
acetylcholine receptors.
Pavlovian Pairings
Nicotine to brain within seconds
Immediately paired with environment stimulus
Pairings causes environmental cues to trigger a craving for nicotine
Examples: drinking a cup of coffee, driving in a car, after meals, with alcohol
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Pavlovian Pairings With “hits” of nicotine over time (Base on an average of 10 drags (hits) per cigarette)
Pairings per
Day
Pairings per
Month
Pairings per
Year
¼ pack
(5 cig.’s)
50 1,500 18,250
½ pack
(10 cig.’s)
100 3,000 36,500
1 pack
(20 cig.’s)
200 6,000 73,000
Clinical Practice Guidelines
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Please think about your office system as it is
now? And how you want it to be.
Create a Culture that Promotes
Tobacco Cessation
Develop Culture
Provide magazines with NO tobacco adds
No smoking on clinic grounds during work hours – including staff
Provide visual cues throughout the office
Provide ongoing training & education to staff
Identify an Office Champion
Leadership for cessation efforts
Recommends & implements system changes
Treating Tobacco Dependence Practice Manual; 2017 American Academy of Family Physicians
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Evaluate Your Current System
How does function regarding tobacco cessation?
Can anything be done differently to be more effective
in helping patients stop using tobacco?
Treating Tobacco Dependence Practice Manual; 2017 American Academy of Family Physicians
Evaluate Patient Flow
Patient checks in Cues: Lapel Pins
Patient sits in waiting room Cues: Posters, brochures & quit line
cards
Height & weight taken in
hallway Cues: Posters, lapel pins
Remaining vital signs checked
in exam room RN or MA: Ask patient about tobacco use & document it
Cues: Posters, brochures & quit line cards
Patient meets with provider Provider:
Advise patient to quit Assess willingness to quit
Coach and/or refer for quit plan development Prescribe pharmacotherapy if needed
Patient meets with coach RN or MA: Develop a quit plan
Cues: Posters, lapel pins
Patient stops at billing/scheduling station Staff: Schedule follow-up appointment
Cues: Posters, lapel pins
Patient leaves
Treating Tobacco Dependence Practice Manual; 2017 American Academy of Family Physicians
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Identify Barriers
Common Barriers
Need for better model or system
Lack of time
Perceived lack of payment for intervention
Lack of experience/training
Enforcing no smoking policies with staff
Inappropriate expectations about treating tobacco cessation
Treating Tobacco Dependence Practice Manual; 2017 American Academy of Family Physicians
New System
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Ask about tobacco use.
Identify and document tobacco use status for every patient at
every visit.
Advise to quit.
In a clear, strong and personalized manner urge every tobacco
user to quit.
Assess willingness to make a quit attempt.
Is the tobacco user willing to make a quit attempt at this time?
Assist in quit attempt.
For the patient willing to make a quit attempt, offer medication
and provide or refer for counseling or additional treatment to
help the patient quit. For patients unwilling to quit at the time,
provide interventions designed to increase future quit attempts.
Arrange follow-up.
For the patient willing to make a quit attempt, arrange for follow-
up contacts, beginning within the first week after the quit date.
For patients unwilling to make a quit attempt at the time, address
tobacco dependence and willingness to quit at next clinic visit.
Model for Treating Tobacco Use and Dependence – “5 As”
Treating Tobacco Use and Dependence: 2008 PHS Update. Content last reviewed June 2015. AHRQ, Rockville, MD.
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RELEVANCE: Tailor advice and discussion to each
patient
RISKS: Discuss risks of continued smoking
REWARDS: Discuss benefits of quitting
ROADBLOCK: Identify barriers to quitting
REPETITION: Reinforce the motivational message at every visit
Enhancing the Motivation to Quit – “5 Rs”
Treating Tobacco Use and Dependence: 2008 PHS Update. Content last reviewed June 2015. AHRQ, Rockville, MD.
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The "5 A's" Model for Treating Tobacco Use and Dependence
Treating Tobacco Use and Dependence: 2008 PHS Update. Content last reviewed June 2015. AHRQ, Rockville, MD.
Opportunities to Intervene
Capitalize on moments to discuss healthier choices
New patient visits
Annual physicals; Women’s wellness exams
Well-child visits (e.g., discuss smoking in the home and car)
Problem-oriented office visits for the many diseases caused or affected by tobacco use (e.g., upper respiratory conditions, diabetes, hypertension, asthma)
Follow-up visits after hospitalization for a tobacco-related illness or the birth of a child
A recent health scare
Assess patients Readiness to Change.
Treating Tobacco Dependence Practice Manual; 2017 American Academy of Family Physicians
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Stages of Change
Precontemplation – Not interested in quitting
Contemplation – Considering changing
Preparation – Making plans to change soon, next 30 days
Action – Taking action to change behavior
Maintenance – Six months of behavior change
Relapse – Resumption of negative behavior
Treating Tobacco Dependence Practice Manual; 2017 American Academy of Family Physicians
Motivational Interviewing
A directive, client-centered counseling style for increasing intrinsic motivation by helping clients
explore and resolve ambivalence.
Dr. William Miller & Dr. Stephen
Rollnick
www.motivationalinterviewing.com
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Features of Motivational Interviewing
Patient-centered
Ask open-ended questions
Creates ambivalence & discrepancy
Patient moves themselves along the Stages of Change
model
Patient changes their talk
There is an information exchange
Important Aspects of Motivational Interviewing
Open-ended Questions
Reflective Listening
Summarization
Affirmation
Giving Advice
Elicit-Provide-Elicit
Negotiating a Change Plan
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Basic Principles of
Motivational Interviewing
Express empathy
Develop discrepancy
Roll with resistance
Support self-efficacy
Treating Tobacco Use and Dependence: 2008 PHS Update. Content last reviewed June 2015. AHRQ, Rockville, MD.
Important/Confident/Motivated
If you decide to change, how (IMPORTANT, CONFIDENT, MOTIVATED) are you that you could do it?
On a scale of 0 to 10, what number would you give yourself?
0…………………………………………10
not confident extremely
at all confident
A. Why are you at X and not at 1?
B. What would need to happen for you to get from x to y?
C. How can I help you get from x to y?
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Summary
Talk less than your patient
Reflect twice for every question asked
Use complex reflections more than 1/2 of the time
Ask mostly open ended questions
Avoid getting ahead of client’s readiness (offering change talk, unwelcome advice)
First-Line Pharmacotherapies
Seven first-line medications shown
to be effective and recommended
for use by the Guideline Panel:
Nicotine Patch
Nicotine Lozenge
Nicotine Gum
Nicotine Nasal Spray
Nicotine Inhaler
Bupropion SR - (Zyban)
Chantix
Treating Tobacco Use and Dependence: 2008 PHS Update. Content last reviewed June 2015. AHRQ, Rockville, MD.
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Factors to Consider When Choosing a
Pharmacotherapy
Clinician familiarity with the medications
Contraindications for selected patients
Patient Preference
Previous patient experiences with a specific agent
(positive or negative)
Patient characteristics (concern about weight gain,
history of depression)
Is combination of pharmacotherapy appropriate
Treating Tobacco Use and Dependence: 2008 PHS Update. Content last reviewed June 2015. AHRQ, Rockville, MD.
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Specific Populations - Recommendations
• The recommendations in Guideline have been shown to
be effective in a variety of populations.
• Interventions outlined in this Guideline are recommended
for all individuals who use tobacco, except…
• When medication use is contraindicated
• In specific populations which medication has not
been shown to be effective (pregnant women,
smokeless tobacco users, light smokers and
adolescents).
Treating Tobacco Use and Dependence: 2008 PHS Update. Content last reviewed June 2015. AHRQ, Rockville, MD.
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Integrating Tobacco Cessation into EHRs
EHRs allow for integration PHS guideline into practice work
flow and system level changes to reduce tobacco use
EHRs should
Encourage quitting
Advise about smoke-free environments
Connect patients and families to resources
Tobacco treatment template should be programed to
appear when patients present health issues related to
tobacco use
Include on an EHR template
Smoking status
Treating Tobacco Dependence Practice Manual; 2017 American Academy of Family Physicians
New Culture
Tobacco-use Registries
Group visits
Make assignment/team approach
E-visits
Create staff feedback mechanism
Payment
Treating Tobacco Dependence Practice Manual; 2017 American Academy of Family Physicians
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Payment – Coding
2014 ACA required insurance plans to cover many
preventive services including tobacco screening &
coaching
Medicare
Intermediate & Intensive
Medicaid
Private Insurance
Self-pay or Uninsured
Treating Tobacco Dependence Practice Manual; 2017 American Academy of Family Physicians
Staff Resistance to Change
Supported by the providers
Plan strategies for dealing with resistance
Strategies for short-term and long-term
Clear communication
Leadership needs to present changes in positive and
united voice
Develop an Implementation plan
Treating Tobacco Dependence Practice Manual; 2017 American Academy of Family Physicians
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Cessation Steps
Objectives
Be able to assess the smoker
Identify strengths & potential barriers
Conduct interview in a manner which advances stage of change and promotes self-efficacy
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Assessment Components
Medical/Psychiatric History
Nicotine Dependence/Smoking History
Quitting History
Social Environment
Beliefs/Stage of Change
Self-Efficacy
Medical History
Family History
Other risk factors
Current medications
Depression symptoms (past or current)
Smoking related illnesses
Smoke promoting (e.g. chronic pain)
What are current symptoms
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Assessing Nicotine Dependence
Smoking history
Smoking triggers
Negative consequences of smoking
Withdrawal
Self-Monitoring
Fagerstrom Tolerance Questionnaire
“Why I Smoke Test”
Smoking History: Not So Basic
First experience - have them explain (explore)
Why did they start
How soon to daily use
Family environment - supported or discouraged
Age when started
Years smoked
What is most/least liked about smoking
Current amount spent and what brand
Recent change in pattern? Why?
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Quit Attempt Information
Time: anything significant happening
Reason: Why do they want to quit - be specific
Method: if nothing specific, why not?
Relapse: did they relapse, if so, what happened?
Specifics on longest, most recent
Think - what would be different this time?
What worked? What did not work?
How the person attempt to quit?
If NRT, was it used correctly?
Other supports?
Self Monitoring of Smoking Behavior
Keep a written record of all cigarettes smoked
For patient to effectively change, they must first understand their own unique smoking habit
Serves to increase knowledge about factors cueing and maintaining smoking
self-monitoring is reactive- may result in a reduction of smoking rate
Patients are not to make changes in their smoking while self-monitoring
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Triggers & Stressors
Know their triggers & stressors
Know when, where, why, & how individual is
feeling for each cigarette
Each cigarette is a response to a trigger or stressor
Delay, Delay, Delay
Delaying a cigarette, even 30
seconds has substantial
impact on quitting
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S.T.A.R.T your engines…
Set a quit date
Tell family, friends, & co-workers
Anticipate & plan for challenges
(triggers)
Remove all tobacco products
Talk to your doctor about getting
help
Finish the race…
Use NRT or Prescription Drugs correctly
(be patient)
Drink plenty of water
Find help (local program or quit line)
Make plans for each situation or trigger
Keep busy
Lifestyle Balance:
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Getting Ready for Quit Day
Buy cigarettes by the pack only
Delay each use by substituting other behaviors
Smoke only in one place. DO NOT make it comfortable
When you decide to smoke, SMOKE. But that is all you
do.
Eliminate places where you smoke
Stop carrying tobacco products with you
Three Steps to Assist with Cessation
1. Record all cigarettes smoked in a
day – each cigarette is trigger
2. Delay – delaying a cigarette even
for small amounts of time has great
benefits
3. Limit smoking to only few places –
only engage in smoking the
cigarette – NOTHING ELSE!
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Key Guideline Web Links
Guideline Materials
https://www.ncbi.nlm.nih.gov/books/NBK63952/
www.ctri.wisc.edu
UW-CTRI – training for Providers
www.ctri.wisc.edu
Providers>Videos for Providers> (Clinic Videos, Hospital Videos, Dental Videos, Motivational Interviewing, Pharmacy Videos, Quit Line Videos
Tobacco Free Kids
https://www.tobaccofreekids.org/
American Academy of Family Physicians
http://www.aafp.org/patient-care/public-health/tobacco-nicotine.html
Andy Link, MS
Tobacco Cessation Specialist
402-417-5541
