Treating Tobacco Use and Dependence
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1 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
2 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 Resource: Tobacco Free Kids m/toll-us Tobacco Free Kids.org; 10/17 2
3 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
4 Pavlovian Pairings With hits of nicotine over time (Base on an average of 10 drags (hits) per cigarette) ¼ pack (5 cig. s) ½ pack (10 cig. s) 1 pack (20 cig. s) Pairings per Day Pairings per Month Pairings per Year 50 1,500 18, ,000 36, ,000 73,000 Clinical Practice Guidelines 4
5 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
6 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 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 Remaining vital signs checked in exam room RN or MA: Ask patient about tobacco use & document it Cues: Posters, brochures & quit line cards 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 6
7 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
8 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 followup 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. Treating Tobacco Use and Dependence: 2008 PHS Update. Content last reviewed June AHRQ, Rockville, MD. 15 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 Treating Tobacco Use and Dependence: 2008 PHS Update. Content last reviewed June AHRQ, Rockville, MD. 16 8
9 The "5 A's" Model for Treating Tobacco Use and Dependence Treating Tobacco Use and Dependence: 2008 PHS Update. Content last reviewed June AHRQ, Rockville, MD. 17 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 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 10
11 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
12 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 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? not confident at all 0 10 confident extremely 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
13 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 AHRQ, Rockville, MD. 13
14 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 AHRQ, Rockville, MD. 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 AHRQ, Rockville, MD
15 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 15
16 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 16
17 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 17
18 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 18
19 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? 19
20 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 20
21 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 21
22 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: 22
23 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 only engage in smoking the cigarette NOTHING ELSE! 23
24 Key Guideline Web Links Guideline Materials UW-CTRI training for Providers Providers>Videos for Providers> (Clinic Videos, Hospital Videos, Dental Videos, Motivational Interviewing, Pharmacy Videos, Quit Line Videos Tobacco Free Kids American Academy of Family Physicians 47 Andy Link, MS Tobacco Cessation Specialist
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