Addressing Tobacco It Takes a Village

Transcription

1 Addressing Tobacco It Takes a Village Charles J. Bentz MD, FACP Medical Director: Tobacco Cessation & Prevention Legacy Health

2 Legacy Health 32 clinics 9500 employees 5 hospitals Children s hospital 320 employed physicians 2800 medical staff 1.3 billion in gross revenue Oregon and SW Washington

3 How can we do a better job. treating tobacco use and dependence?

4 Economic Disadvantage: Income / Education MMWR May 28, 2004

5 Barriers are the problem 1869 under-served smokers Open label, self-selection of free nicotine patch alone or in combination with Committed Quitters. 85% picked up free patches. 75% of participants elected a psychosocial treatment Outcomes: 13% of biochemical confirmed abstinence at 1 year Minority patients showed greater initial interest, less utilization Conclusion: Free, accessible cessation treatment offered in primary care settings was accepted and used by the majority of unselected smokers of diverse racial/ethnic origins. Barriers, rather than lack of interest, may keep minority smokers from using cessation treatments. Fiore MC, et al. Preventive Medicine. 38(4):412-20, 2004

6 Tobacco Industry 70% of African Americans prefer menthol cigarettes Target promotion to segregated black, urban markets in 1960 s Rate of advertising directly related to smoking rate Tobacco industry African Americanized the menthol cigarette

7 Tobacco Industry Bates# /0144, 1984

8 Tobacco Industry Bates# /7705, 1990

9 It continues Tobacco industry s aim is to keep African Americans engaged as consumers The truth is that the tobacco industry is killing 45,000 African Americans yearly The cancer death rate for African-American males would drop by nearly two-thirds if their exposure to tobacco smoke was eliminated

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12 Its Hard to Quit Actor Bill Talman of TV's Perry Mason, died of lung cancer at the age of 53, shortly after he made this 1968 anti-smoking advertisement. His widow, Peggy Talman, died from lung cancer on January 16, 2002 at PSVMC at the age of 73 after many years of continued smoking.

13 Chronic Administration of Nicotine: Effects on the Brain Human smokers have increased nicotine receptors in the prefrontal cortex. Nonsmoker Smoker Image courtesy of George Washington University / Dr. David C. Perry Perry et al. J Pharmacol Exp Ther 1999;289:

14 Nicotine Withdrawal Symptoms Anxiety 87% Irritability, frustration 87% Decreased heart rate 80% Difficulty Concentrating 73% Increased appetite, wt gain 73% Restlessness 71% Cigarette cravings 62% Depression, dysphoria No prior history depression 31% Prior history of depression 75% Data from Hughes JR, Hatsukami DK: Signs and symptoms of tobacco withdrawal. Arch Gen Psych 43: , 1986; Hughes JR, Hatsukami DK, Pickens RW, et al: Effect of nicotine on the tobacco withdrawal syndrome. Psychopharmacology 83:82-87, 1984.

15 Medications Help People Quit Nicotine Replacement (NRT) Five types: gum, patch, nasal spray, inhaler, lozenge Bupropion (Zyban) Antidepressant Varenicline (Chantix ) Nicotine receptor blocker Second Line Agents: Nortriptyline: antidepressant Clonidine: blood pressure Future Agents: Nicotine Vaccine

16 Medication vs. Behavior * Behavioral change for triggers, stressors, coping mechanisms, habit patterns, etc

17 What is Success? Spontaneous Quit Rates 2-3% 1 year Office-based counseling Minimal (< 3 minutes) 4% Brief (3-10 minutes) 5% Counseling (>10 minutes) 8-10% Interactive internet 5-10% Interactive telephone 10-25% Group classes 15-25% Classes with medication 25-35% Inpatient Residential 45-50% Public Health Service Guideline 2000, Hughes et al, CA cancer journal clinic, :143, Providence Tobacco Cessation & Prevention Program, Mayo Clinic Residential Cessation Program

18 Disparity Racial Cultural Social Norms Values / Beliefs Lifestyle Behavior Economic Narcissus, by Michelangelo Caravaggio, ca

19 Cessation Interventions: Mismatch? Research in cessation has been performed primarily in white, middle-class populations Behavioral interventions have been developed for white, middle-class smokers Genetic, socio-cultural, and pharmacologic determinants of smoking may differ Benowitz NL JAMA, Volume 288(4), 24/31 July 2002, p

20 The Motel Syndrome Many group-practices are really solo-practices in disguise

21 Outsource Tobacco Cessation Ask: every patient about tobacco Act: refer them to the quit line

22 What happens when you call a Quit Line? Talk to an intake person for information and questions Referral to a trained counselor Develop a customized quit plan Information about medications Information / referral to cessation services in your area A tailored Tobacco Quit Kit is mailed that day 14.8% one-year quit rates Tobacco Control 2003;12:45-51

23 Bentz CJ, et al. Am J Prev Med, (1): Diagram of Quit Line Connection in Primary Care ASK Clinic ADVISE ASSESS Program Free & Clear or Local Programs Tobacco Use Documented in Chart Clinic Advice to quit and Stage of readiness to quit Documented in Chart Provider refers to Quit Line ARRANGE Oregon Quit Line After initial smoking cessation intervention, QuitLine staff refer patients to appropriate resources and return fax form to clinic Patient Patient completes Form. Form faxed to Quit Line. Quit Line contacts patient. Two Options for Connection with Quitline Patient Brochure given Patient contacts quitline at their convenience. ASSIST

24 Oregon Quit Line: Special Populations GLBT: Protocols recognize stress and heterosexism, sensitivity to language Hispanic: Awareness of collectivism and emphasis on family Emphasis on Simpatia, personal skills, and nationality African Americans: Awareness of metabolic and Menthol issues, as well as barriers to care Asians: Coaches who are fluent in the preferred Asian language, if possible Native Americans: Tailored communication to allow participants more time, stepping on words Addressing sacred tobacco where appropriate Training by Creek-Muskogee and Oglala Lakota Nations

25 Ideal Tobacco Benefit Coverage Access to evidence-based counseling individual, group, and phone counseling Access to FDA approved meds (including OTC) No linkage requirements Eliminate out-of-pocket costs Multiple episodes without lifetime limits Clinician reimbursement Sustained campaign to encourage utilization C A M P A I G N F O R T O B A C C O - F R E E K I D S, 1400 I Street NW Suite 1200 Washington, DC 20005,

26 Value Based Benefit Design removes barriers to the use of high-value services Lower out-of-pocket costs may act as an incentive for the employee to make good health care choices A healthy lifestyle Preventive services High-value services Self-management of disease Cranor CW et al. J Am Pharm Assoc. 2003;43: Highvalue services VBBD: Tailored Cost Sharing Lowvalue services

27 Oregon SB 734: Effective

28 Cessation vs. Policy Smoke-free policy requires and complements cessation

29 Oregon Tobacco Prevention & Education Program, Oregon Association of Hospitals & Health Systems, Acumentra Health, Oregon Nurses Association, Make It Your Business, Smoking Cessation Leadership Center, many hospitals, health systems, and professional associations in Oregon Step Up! Cessation benefits for all hospital employees Intensive intervention for all inpatients Pharmacist-assisted cessation classes Hospital tobacco-free campus policies Hospitals to step up and lead local businesses to curb tobacco use

30 Addressing Tobacco in Healthcare System Goals and Objectives All patients have tobacco use documented as part of routine care All tobacco users receive brief provider advice to quit All smokers have access to intensive cessation programs All smokers have coverage for tobacco cessation services Oregon SB 734: All participating health insurance plans cover cessation Counseling (face-to-face and telephonic) Evidence-based pharmacotherapy (including OTC) Quality Assurance sets goals, monitors interventions, and provides feedback to frontline staff Health System has a clear policy, supports training, and has financial incentives to support cessation efforts Tobacco-Free policies for hospitals and administrative buildings

31 Legacy Health Tobacco Cessation Program Dashboard Performance Hospitals Measure Definition EM GS MP MH SC Tobacco use % inpatients documented Receiving intervention: % inpatient smokers Post-Discharge follow-up % Referred to classes / QL Clinics Measure Definition Primary Care Specialty Teaching Tobacco use % patients Advice to quit % smokers Assistance RF % smokers RF Assistance Rx % smokers Rx Coverage/Benefit Covered Benefit (Measure) LHS employee Regence BC Health Plan #2 Counseling: Group Sessions Counseling: Telephonic Pharmacotherapy: NRT (OTC) Pharmacotherapy: Burpropion Pharmacotherapy: Varenicline Provider Reimbursement System Changes Policies and Staff Non-smoking Policy Dedicated Staff Education and Training Quality Improvement Specific Goals Measure Feedback to for Cessation Performance Front-line Staff Color Coding and Definitions Performance Measures < 50% 50% - 90% 90% - 100% Cessation Coverage/Benefit No coverage Partial coverage (co-payment) Full coverage (no co-payment) System Change Implementation None Partial Complete

32 Be the change you want to see in the world Mohandas K. Gandhi ( )

33 Questions