Smoking Cessation: Treating Tobacco Dependence

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1 Smoking Cessation: Treating Tobacco Dependence Pat Folan, RN Center for Tobacco Control Pulmonary Medicine NS-LIJ Health System NYS DOH Tobacco Control Program

2 Treating Tobacco Dependence Center for Tobacco Control Services Review of Clinical Practice Guideline, 2008 Update for Treating Tobacco Use and Dependence Reimbursement for counseling

3 Center for Tobacco Control Services Free Community Smoking Cessation Program, and follow up support group at our center in Great Neck Employee Program for all NS-LIJ Health System Employees including all cessation medications Medco also covers all cessation medications with no co-pay (OTC and RX for covered employees and dependents) Healthcare Provider education and support throughout Long Island Free 21 credit CME performance improvement project

4 Current Statistics Tobacco related illness is the leading cause of preventable death in the U.S., killing over 440,000 annually (CDC 2005) 70% of all tobacco users want to quit (CDC 2002) Quit attempts are 30% more successful with advice/support from a HCP (PHS Guideline: Treating Tobacco Use and Dependence 2008)

5 Prevalence 20.9% of adults smoke in the U.S. (CDC 2005) Prevalence rate is 18.3% in NYS (RTI 2006) Goal of Healthy People 2010 is to reduce smoking to 12% of adults by 2010 (USDHHS 2005)

6 The 5 A s Public Health Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and Dependence (2008) Developed by Agency for Healthcare Research and Quality (AHRQ) ASK ADVISE ASSESS ASSIST ARRANGE

7 The 5 R sr Relevance Risks Rewards Roadblocks Repetition USDHHS PHS Guideline 2008

8 The Pharmacological Approach to Treating Nicotine Dependence

9 Nicotine The main adverse effect of nicotine is addiction, which sustains tobacco use. Nicotine dependence leads to continued exposure to toxins in tobacco smoke.

10 Neurochemical Effects of Nicotine Nicotine Dopamine Norepinephrine Acetylcholine Glutamate Serotonin ß-endorphin Pleasure Appetite Suppression Arousal, Cognitive Enhancement Memory Mood Modulation Anxiety Reduction Benowitz NL. Primary Care. 1999; 26: 619.

11 First Line Therapies Buproprion SR Varenicline Nicotine gum-otc Nicotine inhaler Nicotine nasal spray Nicotine patch-otc Nicotine lozenge-otc Second Line Therapies Clonidine severe hypotension Nortriptyline fatal in overdose (These drugs are rarely used)

12 Cessation Medications Bupropion NRT Varenicline Bupropion and NRT

13 Bupropion Wellbutrin SR, Zyban Acts on receptor sites - nucleus accumbens Pregnancy Category (Class C)

14 Bupropion Dosing SR formulation (ZYBAN) 150 mg one daily for 3 days, then 150 mg twice a day XL formulation (Wellbutrin( XL) mg once a day (off label use) Start weeks before quit date. Duration of therapy is weeks

15 Bupropion Contraindications Seizure disorder or any potential for seizures Eating disorder MAO inhibitor in past 14 days

16 Side Effects Insomnia (35-40%) Less with XL formulation Dry mouth (10%) Seizure (1 in 1000) Depression, suicidal ideation, suicide attempt, and completed suicide

17 Varenicline Chantix Α4β2 2 nicotinic subtype acetylcholine receptor (nachr( nachr) ) partial agonist Also works as a nicotine antagonist- reduces the pleasurable effect of smoking

18 Starter Pack: Dosing 0.5 mg daily for 3 days 0.5mg twice daily for 4 days 1mg twice daily- maintenance dose Duration of therapy 12 weeks can continue 12 additional weeks if successfully quit Not recommended for use with NRT (may increase nausea and side effects)

19 Varenicline Decrease dose in renal impairment Side effects: nausea (30%) Lower dose, take with food, fluids 10% reported headache, insomnia, abnormal dreams depression, suicidal ideation, suicide attempt and completed suicide angioedema, Stevens-Johnson Syndrome, erythema multiforme traffic accidents, accidental injuries, loss of consciousness

20 Nicotine Replacement Therapy

21 Nicotine Replacement Therapy (NRT) Helps relieve withdrawal symptoms Provides lower nicotine levels than smoking Doubles chance of success versus placebo Safe, effective Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June 2000.

22 Increase in nicotine concentration ( ng/ml ) Plasma nicotine concentrations for smoking and NRT Minutes Source: Balfour DJ & Fagerström KO. Pharmacol Ther : Cigarette Gum 4 mg Gum 2 mg Inhaler Nasal spray Patch

23 Nicotine Patch Features Transdermal delivery system provides regulated, constant level of nicotine Convenient and well tolerated, with low dependency potential

24 Nicotine Patch Dosing 1 patch/day worn for 16 or 24 hours daily Available doses range from mg/patch Dosing according to amount smoked Step 1 patch Step 2 patch Step 3 patch Smoking 1 PPD or more Smoking ½ to 1PPD Smoking less than ½ PPD Step down every 6 weeks

25 Nicotine Patch Side effects Local: skin irritation, rash More marked reactions with 24-hour patch Rotate sites, hydrocortisone cream may help Systemic: insomnia, sleep disturbances, dyspepsia To limit sleep disturbances, remove the patch 1 hour before bedtime

26 Nicotine Gum / Lozenge Features Nicotine absorbed via buccal mucosa Available in 2 mg and 4 mg strengths 4 mg strength more effective for highly addicted (>25 cigarettes per day) smokers Self-titration

27 Nicotine Gum or Lozenge Dosing Use at least 9 pieces/day during first 6 weeks Technique critical to correct use Chew or moisten and then park Avoid alcohol and caffeinated beverages Side effects Local: irritation of tongue, mouth and throat, ulceration of oral mucosa, jaw-muscle ache Systemic: indigestion, nausea, dizziness

28 Nicotine Inhaler Dosing Individualized-self titration Initial treatment can range from weeks For best results, use up to 16 cartridges/day for first 3 to 6 weeks If needed, gradual reduction can begin after initial treatment period Rx: 1box = 168 cartridges

29 Nicotine Nasal Spray Intranasal delivery with fast, effective relief of withdrawal symptoms Designed for ad libitum use with dose flexibility Particularly beneficial for highly dependent smokers or those not responding to other treatments Rx only: 1 box = 4 bottles

30 Dosing Nicotine Nasal Spray 1 spray each nostril (2 sprays = 1 mg nicotine) Do not exceed 5 doses/hr or 40 doses/day (usually much less is needed) Side effects Nasal irritation, runny nose, throat irritation, watering eyes, sneezing and coughing Tolerability occurs after a couple days

31 Combination Therapy There is evidence that combining the nicotine patch with bupropion SR, or the nicotine patch with nicotine gum, nasal spray or inhaler increases long-term abstinence rates. Fiore MC, Jaen CR, Baker, TB, et al. Treating Tobacco Use and Dependence.. Clinical Practice Guideline 2008 Update. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.

32 Long-term Pharmacotherapy Goal of long-term pharmacotherapy is to replace smoking Long-term use of NRT and bupropion is likely to be much safer than smoking but efficacy has not yet been demonstrated Experience with long term bupropion use for depression suggests it is well tolerated

33 Is NRT suitable for cardiovascular pts? No evidence of increased CV risk with NRT NRT delivers plasma cotinine levels far below those produced by smoking NRT causes less vasospasm than smoking There is no data to support that NRT causes acute cardiovascular events

34 AHA s Position Statement on NRT NRT has been shown to be safe and effective in helping people stop using cigarettes when used as part of a comprehensive smoking cessation program. NRT has been shown to be safe in most people with Heart Disease. accessed 07/25/2009

35 Billing for Smoking and Tobacco-Use Cessation Counseling 2009

36 Billing Codes for Tobacco Cessation Counseling CPT Code Billing Code Definition Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes Counseling for 3 minutes or less is considered part of the evaluation & management (E&M) service and cannot be billed as an additional service.

37 Coverage Coverage Frequency 2 tobacco cessation attempts are covered annually Each attempt has maximum of 4 sessions 8 counseling sessions in a 12 months period Eligibility for Coverage Patient has adverse health affect from tobacco use or Patient treated with a therapeutic agent whose metabolism or dosing is affected by tobacco use

38 Required Documentation Patient history must be sufficient to demonstrate coverage conditions were met Diagnosis code must reflect Condition that is adversely affected by tobacco use Condition being treated with a therapeutic agent whose metabolism or dosing is affected by tobacco use Time spent Intervention recommended

39 Other Reimbursement Some public and private sector Managed Care Organizations also provide smoking cessation benefits Benefits vary nationwide check patient s health insurance provider benefits; ask about coverage

40 Cessation Medication Medicaid Benefit Package NYS Covered Meds Nicotine Nasal Spray, Zyban, Nicotine Inhalers, Varenicline, Nicotine patches and gum 2 courses of therapy per patient per year 1 course = 90 day supply Combination Therapy permitted- must have Rx for all meds. NYS,

41 NYS Medicaid Coverage Smoking cessation counseling for Medicaid eligible pregnant women (1/1/09) 6 sessions in 12 month period By MDs, PAs, NPs, midwives At hospital outpatient depts., diagnostic and treatment centers, and federally qualified health centers. NYS DOH Office of Health Insurance Programs, 2009

42 Multi-State Collaborative for Health Systems Change Mission Statement: We are a collaborative of tobacco control programs working to facilitate sustainable changes in healthcare systems within our states and nationally in order to reduce tobacco use and prevalence.

43 Task Group Insurance and Reimbursement Increase in provision of comprehensive cessation benefits to all members Increase reimbursement for provision of evidence-based direct cessation services Information sharing: Medicaid reimbursement for counseling and pharmacotherapy

44 Members New York Wisconsin Iowa New Hampshire Massachusetts Rhode Island Minnesota Vermont Colorado Maine Washington Oregon Ohio

45 THANK YOU! Pat Folan, RN Center for Tobacco Control

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