10/25/2017 Treating Tobacco Use and Dependence October 26, 2017 Great Plains Quality Improvement Network 1 Treating Tobacco Use and Dependence: Agenda Brief history and developmental process Facts about Tobacco Clinical Interventions Clinical Practice Guidelines Motivational Interviewing Cessation Steps 2 1
10/25/2017 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 Resource: Tobacco Free Kids tobacco industry ($25 million each day) https://www.tobaccofreekids.org/proble Nebraska spends $744 for every person in m/toll-us the state for smoking-attributable healthcare costs and lost productivity Tobacco Free Kids.org; 10/17 2
10/25/2017 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 3
10/25/2017 Pavlovian Pairings With “hits” of nicotine over time (Base on an average of 10 drags (hits) per cigarette) Pairings per Pairings per Pairings per Day Month Year ¼ pack 50 1,500 18,250 (5 cig.’s) ½ pack 100 3,000 36,500 (10 cig.’s) 1 pack 200 6,000 73,000 (20 cig.’s) Clinical Practice Guidelines 4
10/25/2017 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 5
10/25/2017 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 Patient meets with provider Cues: Lapel Pins Provider: Advise patient to quit Assess willingness to quit Patient sits in waiting room Coach and/or refer for quit plan development Cues: Posters, brochures & quit line Prescribe pharmacotherapy if needed cards Patient meets with coach Height & weight taken in RN or MA: Develop a quit plan hallway Cues: Posters, lapel pins Cues: Posters, lapel pins Patient stops at billing/scheduling station Remaining vital signs checked Staff: Schedule follow-up appointment in exam room Cues: Posters, lapel pins RN or MA: Ask patient about tobacco use & document it Cues: Posters, brochures & quit line Patient leaves cards Treating Tobacco Dependence Practice Manual; 2017 American Academy of Family Physicians 6
10/25/2017 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 7
10/25/2017 Model for Treating Tobacco Use and Dependence – “5 As” 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 15 tobacco dependence and willingness to quit at next clinic visit. Treating Tobacco Use and Dependence: 2008 PHS Update. Content last reviewed June 2015. AHRQ, Rockville, MD. Enhancing the Motivation to Quit – “5 Rs” 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 16 Treating Tobacco Use and Dependence: 2008 PHS Update. Content last reviewed June 2015. AHRQ, Rockville, MD. 8
10/25/2017 The "5 A's" Model for Treating Tobacco Use and Dependence 17 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 9
10/25/2017 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 10
10/25/2017 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 11
10/25/2017 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? 12
10/25/2017 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. 13
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