Pamela Graef Luckett, MCC, LPC, CTTS Tobacco Quitline

Transcription

1 Pamela Graef Luckett, MCC, LPC, CTTS Tobacco Quitline

2 Nicotine Dependence Sponsored by IQH Funded by the Mississippi State Dept. of Health Office of Tobacco Control

3 2 s and an Ask Advise Refer

4 A: Ask Ask all patients about tobacco Ascertain tobacco use status: Every patient Every visit Use a Vital Sign stamp Involve the entire healthcare team

5 How much tobacco do you use? How soon after waking do you use tobacco? Have you ever tried to stop? What happened?

6 How much do you smoke most days? Basically determined in the answer to two questions: How soon after waking do you first use tobacco? Addiction levels are higher when more than cigarettes are smoked most days and use begins within 5 minutes of waking * FTND survey

7 A : Advise In a clear, strong, & personalized manner, urge every tobacco user to quit. Clear: I think that it is important for you to quit using tobacco now, and I will be happy to help you. Strong: As your clinician, I need you to know that quitting is the most important thing you can do to protect your health. Personalized: Tie tobacco use to current health status and risks, economics, and impact on others.

8 How much does it cost to More than one pack? use tobacco? $5.00 per pack x one pack per day for 7 days = $35.00 per week $35.00 per week x 4 weeks a month = $ per month DO THE MATH!!! $ per month x 12 months a year = $ per year

9 Readiness to Quit Ask every tobacco user if he or she is willing to make a quit attempt at this time. If a parent/guardian, ask, too. If willing, provide assistance. Refer to specialist if intensive treatment is more appropriate or preferred. If not willing, provide a motivational intervention.

10 0-3 LOW MOTIVATION NOT READY TO QUIT Motivation to Quit 4-7 MODERATE MOTIVATION MAY BE READY TO QUIT 8-10 HIGH MOTIVATION READY TO QUIT

11 Assist motivated tobacco Users Help patient set a QUIT DATE Within 30 days Incorporate patient preferences Use meaningful upcoming dates if available Help patient prepare Inform family and friends Remove tobacco and related temptation cues Review quit history Anticipate challenges Consider pharmacotherapy Self Help Materials Give Key Advice Abstinence not even a single puff or dip after quitting Alcohol Highly associated with relapse Anticipate Discuss challenges and triggers Other Smokers Quit with others; develop strategies to cope

12 Nicotine Dependence and the Course of Treatment First 24 to 48 hours most difficult Withdrawal symptoms peak, then fall First 2 weeks: Highest relapse risk First 3 months: Most relapses have occurred Duration of medication use Long term relapses indicate need for chronic management

13 Considerations Motivation varies over time Factors that influence motivation Important life events Changes in physical functioning Recommendation from trusted health care provider Recent findings in the news So, timing of intervention is important Also, match your treatment content to patient s readiness level

14 Nicotine Patch Proper Use Upside Downside Proper Use Stop tobacco 1 per day, on awakening 6-12 weeks Tapering option Effect within 1-2 hours Simple 3 dose levels No new drug Eliminates tar and CO Little concern re: concurrent use with tobacco Systemic and skinrelated S/E s Health risks CV Disease Max dose may be insufficient for some

15 Nicotine Polacrilex Proper use Upside Downside Stop tobacco 2 mg and 4 mg Insufficient use Absorbed via oral mucosa Mint / Fruit Chewing increases S/E s Chew and park for 30 minutes Easily tailored Taste can be unpleasant Up to 20 (4 mg) or 30 (2 mg) pieces per day Oral substitute Use prn No food or drink for 15 minutes before use

16 Nicotine Lozenge Newer less data and clinical experience Up to 20 per day; 5 per 6 hour period 4mg: smoke within 30 minutes of awakening 2mg: smoke after 30 minutes Absorbed via oral mucosa Usage Stop all tobacco No eating or drinking 15 minutes before use 12 weeks

17 Nicotine Inhaler Proper Use Stop tobacco 6-16 /day 12 weeks; can extend Can taper, not necessary D/C if not quit in 4 weeks Upside Easy to tailor Oral Substitute Downside Lower level of dosing many not be ideal for heavier users

18 Bupropion QD 3 days, then BID 3 months Tapering at end of treatment not necessary Proper Use Ease of Use Initially can use tobacco concurrently Antidepressants effect Upside h/o Seizure d/o, Bulimia, Anorexia Nervosa, MAOI or other form of Bupropion Can take 1-2 weeks to reach adequate blood levels Downside

19 VARENICLINE o Approved in May 2006 o o o o o o o Used as part of a cessation program Oral medication intended ONLY for tobacco cessation 1 mg twice per day, 12 week treatment Additional weeks improve quit compliance Recommended only for adult use Dose adjustment for severe renal impairment Most common adverse side effects: - Nausea - Insomnia - Headache - Abnormal dreams

20 E-Cigarettes Not currently regulated by the FDA Many made overseas with little or no quality regulations Latest evaluations show they may have potential to cause a faster absorption of nicotine than regular cigarettes Are still a nicotine delivery system Of the chemicals found, one is diethlene glycol that is used in antifreeze FDA plans to start regulating e-cigarettes as a tobacco product category item

21 E-Cigarette Information Not currently regulated by the FDA Many made overseas with little or no quality regulations Latest evaluations show they may have potential to cause a faster absorption of nicotine than regular cigarettes Are still a nicotine delivery system Of the chemicals found, one if diethylene glycol that is used in antifreeze FDA plans to start regulating e-cigarettes as a tobacco product category item

22 2013 Mississippi Social Climate Survey Electronic Cigarettes* Issues Smokers maintaining dependence May Increase risk of relapse among former smokers May frustrate treatment electronic cigarettes are not approved nor incorporated into clinical practice guidelines Use among nonsmokers raises concerns about them being at risk for nicotine dependence Youth initiation No current regulations on marketing Exposure of e-cigarettes aresol to non users *statistics taken from Mississippi Tobacco Data

23 Factors Associated with Readiness Psychological Factors Social Factors Nicotine Dependence

24 Nicotine Cardiovascular effects Vasoconstrictor Blood pressure Heart rate Weight suppression Attention and memory Endogenous opiods

25 Carbon Monoxide ( CO ) Colorless, odorless gas Replaces oxygen Arterial wall damage Cardiovascular disease risk

26 Carbon Monoxide Levels Smokers Levels = ppm Normal Air = 1-5 ppm EPA Warning = 9 ppm

27 I only smoke when.. There is nothing else to do I m trying to loose weight I am with others who smoke I only smoke when. I m having to work or study late I m stressed out I m having a drink with others

28 Quick Facts About Secondhand Smoke Tobacco kills nearly ½ million Americans each year Causes premature death and disease in children and adults who do not smoke Also known as Environmental Tobacco Smoke or ETS A mixture of the smoke given off by the burning of tobacco products and smoke exhaled by smokers.

29 5 minutes stiffens the aorta 20 minutes excess blood clotting 30 minutes increases build up of fat deposits in blood vessels. Secondhand Smoke - Effects on your heart According to the CDC all heart disease patients should avoid exposure to secondhand smoke. 2 hours increases the change of an irregular heart beat

30 Secondhand Smoke Ingredients

31 New Findings: THIRDHAND SMOKE Thirdhand smoke refers to the tobacco toxins that buildup over time one cigarette will coat the surface of a certain room [a second cigarette will add another coat, and so on]. The third-hand smoke is the stuff that remains [after visible or "second-hand smoke" has dissipated from the air]. You can't really quantify it, because it depends on the space. In a tiny space like a car the deposition is really heavy. Smokers [may] smoke in another room or turn on a fan. They don't see the smoke going into a child's nose; they think that if they cannot see it, it's not affecting [their children]. Smokers themselves are also contaminated smokers actually emit toxins [from clothing and hair].

32 Thirdhand Smoke Thirdhand smoke can rub off onto skin and even be ingested if food is eaten that s been exposed to smoke. It was also shown that dust could carry third-hand smoke to the lungs. Thirdhand smoke can't be eliminated by airing out rooms, opening windows, using fans or air conditioners, or confining smoking to only certain areas of a home. It remains long after smoking has stopped. The nicotine residue that is left behind on furniture, walls, and carpeting after a cigarette has been smoked in a room that can become airborne a second time The resulting particulates, a toxic mix of ozone and nicotine, are so small that they can easily penetrate into the deepest parts of the lung, and over time, scientists say, could contribute to breathing problems like asthma or even cancer.

33 Cotinine levels in children National Health and Nutrition Examination Survey (NHANES) Hypothesized and found that among 4,782 children ages 6 to 18 years, in households that do not allow smoking in their own home, children who live in apartments have a 140% higher cotinine level than children living in detached homes, This relationship persists when controlling for poverty and race/ethnicity 33

34 Pediatric Visit Creates a Teachable Moment for Smoking Cessation Many parents see their child s health care provider more often than their own Interventions in the pediatric office setting have been successful: Decreased number of cigarettes smoked and home nicotine levels Increases in parent-reported smoke-free homes and quit rates (Rosen et al Pediatrics 2012) 34

35 Best Idea to Pass on To Parents Who Use Tobacco Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke.

36 Reimbursement Codes ICD-9 code for tobacco cessation counseling through Medicare and some Blue Cross policies code Medicaid in Mississippi covers all pharmacotherapy including over the counter medications as well as Chantix and Zyban. Must be considered as one of the 5 allowable prescriptions, and must include a prescription

37 What to expect when you connect with the quitline:

38 The Quitline s FREE Service Include: Telephone counseling for tobacco users who want to quit. This consists of one individualized coaching and support call. Callers will receive personalized advices on how to quit, information on medications, and assistance with choosing a quit date and creating a quit plan. State residents may call the Quit Line back as often as they like. Four weeks of free medication (nicotine patch or nicotine gum), and self help materials. A secure website where tobacco users can interact with others trying to quit, get support, develop personalized quit plans and track results. Information on those concerned about a tobacco user. Referrals to local quit tobacco resources and services.

39 Tobacco Quitline Stats Healthcare providers are the highest % of referrals to the quitline most months, at least 30% Quit rates are calculated by a survey of participants at 7 months post enrollment, 30 day point prevalence each month is a designated cohort of callers Average quit rate is 40% with approximately 48-50% of callers responding to the survey

40 Provider Referral Program Why a Fax/Referral Program? Healthcare providers are busy, don t always have time for a lengthy discussion about tobacco use Need a quick, reliable, easy way to connect patients/clients to qualified cessation professional Documentation of referral is in compliance with JCAHO regulations

41 Steps to Referral When a patient is ready to quit, have the patient sign the Fax Referral/Consent form and fax it to the Tobacco Quitline. Any current health conditions may be outlined on the Fax/Referral form and the provider may provide clearance for the use of NRT products on the form as well. The Quitline staff will discuss pharmacotherapy choices, if appropriate, for relief from withdrawal symptoms and to aid with quitting. The Provider may receive Progress Reports, as well as review, and file the Fax/Referral Form in patient s medical record for discussion at next visit. The Quitline staff will make a proactive contact with the referral within one business day of receipt of the Fax/Referral Form

42 Sample Fax Referral Form

43 Using Online Referral Option Easy to follow Instructions Free online registration

44 Online Referral Process Add a Referral Successful Registration

45 Successful completion of online referral Listing of individual provider referrals

46 Register for FREE specialized tobacco cessation program QUITNOW Intake screening to ensure the most appropriate level of treatment Bi-lingual services available for Spanish speaking callers No charge, professional cessation counseling over the phone and online. 8 weeks of the NRT patch or gum at no charge to qualified callers All counselors are Master s level, behavioral health professionals Referrals to Community programs provided through the ACT Center

47 Tobacco user assessment includes these topics: Past quit attempts Tobacco use status/history Presence of support system and likelihood of receiving support Presence of tobacco and other tobacco users in environment(s) Causes for relapse Motivation for quitting Current stress level Presence of medical conditions (including pregnancy)

48 Tobacco Quitline QUIT-NOW Counseling Services for Smokers and Spit/Chew Tobacco Users at no charge Hours of Operation 24-hour answering service Live counseling o 7am 9pm Monday Thursday o o 7am 7pm, Friday and 9:00 am 5:30 pm Saturday

49 Region 1 Mental Health Center Tri-Lakes Medical Center, Batesville Delta Regional Medical Center, Greenville University of MS Medical Center, Jackson King s Daughter Medical Center, Brookhaven Southwest Mississippi Regional Medical Center, McComb North Mississippi Medical Center, Iuka North Mississippi Medical Center, Tupelo Greater Meridian Health Center, Meridian Memorial Hospital, Gulfport ACT CENTER On-site treatment programs are available at convenient locations across Mississippi. This project offers intensive assistance for overcoming tobacco addiction to residents of all 15 communities and outlying areas. The program includes: o initial visit, o o 6 treatment sessions, medications, follow-up appointments, all at no cost to the participants.

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