MiCMRC Educational Webinar

Tobacco Dependence TreatmentUSING THE CLINICAL PRACTICE GUIDELINES TO HELP PATIENTS

QUIT TOBACCO

July 12, 2017

MiCMRC Care Management Educational Webinar:Tobacco Dependence Treatment

Expert Presenter:

Patricia Heiler, MPH, CHES, ASQ-CQIAPublic Health Consultant, Tobacco SectionMichigan Department of Health and Human Services

USING THE CLINICAL PRACTICE GUIDELINES TO HELP

PATIENTS QUIT TOBACCO

Tobacco Dependence Treatment

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Tobacco Dependence IS a Chronic Disease

Similar to diabetes, heart failure, hypertension, hyperlipidemia

Expectation for remission and relapse Provide ongoing treatment:

advice/counseling support appropriate pharmacotherapy

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Nicotine is a Drug of Addiction

After inhaling, nicotine reaches the brain in

7-10 seconds “Euphoria” without being “Stoned” Immediate REINFORCEMENT of drug-taking behavior Nicotine activates reward pathways in the brain Moment to moment titration of dose to achieve the

desired effects Young people are uniquely vulnerable to the effects of

nicotine and more susceptible to addiction since the brain is not fully mature until approximately age 25

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Clinicians Can Make a Difference!

70% of smokers want to quit smoking, 50% try to quit each year. < 10% succeed

< 1/3 of smokers who try to quit use proven cessation treatments

80% of tobacco users in the United States see a health care provider each year

< 1/2 who saw a health professional in the past year reported receiving advice to quit

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The 5 “A’s” Intervention

ASK about Tobacco Use (Tobacco as a vital sign)

ADVISE to stop

ASSESS willingness to make an attempt

ASSIST in the stop attempt

ARRANGE for a follow-up visit

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Ask

Systematically identify all tobacco users at every visit

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Advise

Strongly urge all tobacco users to quit in a clear, strong, and personalized manner:

Clear – Important, cutting down not enough

Strong – Most important thing you can do to protect your health

Personalized – link to current symptoms and health concerns, social and or economic situations

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Assess

Determine willingness to make a quit attempt at the time

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Assist

Aid the patient in quitting Pharmacological–if not contraindicated Set a quit date Counseling

Skills training-Anticipate Challenges Problem solving

Social Support Intra-treatment social support Extra-treatment social support

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Assist Stage- Motivational InterviewingFor the Patient Unwilling to Quit

Express empathy “How important do you think it is for you to quit?” “What might happen

if you quit?”

Develop discrepancy “It sounds like you are very devoted to your family/ friends/job. How do

you think your smoking is affecting your children/relationships/work?”

Roll with resistance “Sounds like you are feeling pressured about your smoking.” “Would you

like to hear about strategies that can help you address your concerns when you quit?”

Support self-efficacy “So you were fairly successful the last time you quit.”

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Assist- Provide practical counseling

When was the last time you used tobacco? When was the last time you tried to quit? Review past quit experience Success Triggers for relapse

Anticipate triggers, challenges Alcohol – can lead to relapse Other smokers – limit exposure May I share some information?

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Assist- Medication

Seven first-line medications shown to be effective and recommended for use by the Guideline Panel:

Bupropion SR Nicotine Gum Nicotine Inhaler Nicotine Lozenge Nicotine Nasal Spray Nicotine Patch Varenicline

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Assist- What is an Electronic Cigarette?

o Allows user to inhale aerosol containing nicotine and/or other substances.

o Disposable or rechargeable and/or refillable.

o Contain a cartridge filled with liquid nicotine, flavorings and glycerin or propylene glycol.

o When coil heats, it converts the contents of the cartridge into aerosol.

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Assist- Tobacco Quitlines

Work in conjunction with clinician or health care worker intervention

Can provide the treatment intensity that often cannot be provided in an office setting due to time constraints

Increase access to treatment and reduce barriers Can provide assistance in multiple languages

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Assist- The Michigan Tobacco Quitline

1-800-QUIT-NOW (784-8669) 1-877-777-6534 (TTS) Counseling appointments available 24 hours/day Quitline provides: Referrals to local programs One time counseling Intensive counseling proactive sessions Unlimited reactive calls for one year Free NRT to qualified callers Self-help materials Free text messaging and online program Cultural and language specific services

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Assist- Michigan Tobacco Quit Line Services

All Michigan Callers Receive Information & Referral, Text Messaging

Medicaid & Veterans Counseling

4 sessions for general enrollees 9 sessions for prenatal

Medicare, Uninsured, Prenatal, Cancer Patients & County Health Plan Counseling (same as above) Nicotine patch, gum or lozenge

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Assist- Who Qualifies for Michigan Tobacco Quitline Counseling?

Medicaid, including MOMS Medicare Veterans Uninsured People with a Cancer Diagnosis Prenatal County Health Plans Youth 13-17 (no insurance information is collected)

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Assist- The Quitline Refers

Eligibility for Quitline services varies by insurance status

Anyone can call the Quitline Individuals will be referred to the appropriate service if they

are ineligible for Quitline services

Referring patients to the Quitline makes your job easier

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Assist- Michigan Quitline: Prenatal Protocol

Specially trained counselors dedicated to working with prenatal callers

Prenatal enrollees will receive 9 counseling calls-5 prior to delivery and 4 post-partum

Prenatal enrollees receive incentives for participation

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Assist- MI Tobacco Quitline: Online Services

• Michigan.quitlogix.org is tied to the Michigan Tobacco Quitline

• If enrollment form is completed online, phone intake will be shorter

• Dashboard• Calendar• Quit Plan Online• Track NRT orders from Quitline• Chats and forums• Success stories

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Assist- MI Tobacco Quitline: Text Messaging

Library of over 300 messages

2-way messaging Messages related to

support and relapse prevention

Tips, motivation, and encouragement

Messages customized by tobacco type

Messages assessing mood, craving, and tobacco status

Coaching call appointment reminders(as appropriate on the day prior to appointment)

NRT shipment status updates

Congratulatory messages Re-engagement messages Must opt-in at intake

Over 55% of Michigan participants have opted into the text messaging program.

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Assist- MI Tobacco Quitline: Nicotine Replacement Therapy

All participants medically screened- some conditions require a medical consent form from physician

Patches, Gum and Lozenges offered to eligible groups

Shipped directly to the participant’s home Only available to those 18 and older No cost to the participant Prenatal must have signed approval from

physician

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Assist- MI Tobacco Quitline: Fax Referral

• Fax Referral Forms• Online at Michigan.quitlogix.org

• Quitline receives referral form- referrals can be made by a variety of types of providers and staff• Call within one business day • 3 attempts in the requested time frames or over a 10 day period

• Fax back to provider• When referral is received• When patient enrolls• When patient receives NRT• When patient completes the program• If patient is un-reachable• If patient declines to participate in the QuitLine

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Assist- Michigan Tobacco QuitlineFax Referral Form for Health Care Providers

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Arrange – schedule follow up

TimingQuit weekFirst month

Follow-up conversation

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Patricia HeilerPublic Health Consultant, Tobacco Section

Michigan Department of Health and Human Services

heilerp@michigan.gov(517)335-1265

www.michigan.gov/tobacco

Michigan Tobacco Quitline:https://michigan.quitlogix.org/

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The Effective Dentist: Motivational Interviewing Demonstration

https://www.youtube.com/watch?feature=player_detailpage&v=f8QSA_5PEFM

Smoking Cessation Leadership Center, An Introduction to Motivational Interviewing: Focus on Tobacco Use and Dependence https://smokingcessationleadership.ucsf.edu/webinar/co-hosted-american-academy-family-physicians-introduction-motivational-interviewing-focus

Rx for Change videos:http://www.rxforchange.ucsf.edu/curricula/ask_advise.php

Resources

American Cancer Society “Set Yourself Free” patient tool: http://www.cancer.org/myacs/highplainshawaiipacific/programsandservices/set-yourself-free-english

Campaign for Tobacco-Free Kids list of helpful tobacco-prevention materials:https://www.tobaccofreekids.org/research/factsheets/pdf/0159.pdf

American Lung Association list of helpful tobacco-prevention materials:http://www.lung.org/our-initiatives/tobacco/cessation-and-prevention/resource-library.html

The Centers for Disease Control and Prevention’s Health Care Provider resources: https://www.cdc.gov/tobacco/campaign/tips/partners/health/index.html

The Centers for Disease Control and Prevention’s Smoking & Tobacco Use Web site: http://www.cdc.gov/tobacco/quit_smoking/how_to_quit/resources/index.htm

http://www.cdc.gov/tobacco/basic_information/index.htm

Resources

The Florida Area Health Education Centers (AHEC) Network’s Twelve Facts to Help Dispel the Myths about Nicotine Replacement Therapies (NRTs) and Nicotine document

http://www.ahectobacco.com/wp-content/uploads/2013/03/NRTMythsandFacts.pdf

Smoking Cessation Leadership Center's webinar, Integrating Medications into Smoking Cessation Treatment: The Basics,

http://smokingcessationleadership.ucsf.edu/webinar/integrating-medications-smoking-cessation-treatment-basics

Smoking Cessation Leadership Center's webinar, Beyond the Basics: Pharmacotherapy for Smoking Cessation -

http://smokingcessationleadership.ucsf.edu/webinar/beyond-basics-pharmacotherapy-smoking-cessation

Rx for Change’s Pharmacologic Product Guide: FDA-Approved Medications for Smoking Cessation

http://www.aafp.org/dam/AAFP/documents/patient_care/tobacco/pharmacologic-guide.pdf

Resources

Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville (MD): US Department of Health and Human Services; 2008 May. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008. http://www.ncbi.nlm.nih.gov/books/NBK63952

Centers for Disease Control and Prevention. A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006. http://www.cdc.gov/tobacco/quit_smoking/cessation/practical_guide/pdfs/practical_guide.pdf

Smoking Cessation Leadership Center Archived Webinars http://smokingcessationleadership.ucsf.edu/webinars/archive

Resources

Partnership for Prevention. Healthcare Provider Reminder Systems, Provider Education, and Patient Education: Working with Healthcare Delivery Systems to Improve the Delivery of Tobacco- Use Treatment to Patients—An Action Guide. The Community Health Promotion Handbook: Action Guides to Improve Community Health. Washington, DC: Partnership for Prevention; 2008. https://www.prevent.org/data/files/initiatives/tobaccousetreatment.pdf

The Conversations for Change videos are produced by the Behavioral Health and Wellness Program in the School of Medicine at the University of Colorado. Designed to help providers address tobacco cessation with patients and are to be viewed in order as part of a facilitated educational process. https://www.bhwellness.org/resources/videos

Treating Tobacco Use and Dependence Practice Manual: a systems change approach. Ask and Act A Tobacco Control Program; American Academy of Family Physicians, 2015.

http://www.aafp.org/dam/AAFP/documents/patient_care/tobacco/practice-manual.pdf

Resources