Treating Tobacco Use and Dependence October 26, 2017 Great Plains - - PDF document

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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. 16

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

• r 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. 28

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 –
• nly 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 sodtown@gmail.com