Slide 1 UNIVERSITY OF HAWAI I CANCER CENTER Reducing Tobacco Use and Nicotine Dependence in Clinical Settings Pebbles Fagan, Ph.D., M.P.H. Associate Professor and Program Director Cancer Prevention and Control Program University of Hawaii Cancer Center Hawaii (Oahu) Chapter Oncology Nursing Society Conference Up In Smoke: Tobacco Related Cancers and Implications for Practice August 16, 13 Slide 2 Goals for Today Increase knowledge on smoking prevalence rates among Hawaii s populations. Increase knowledge on evidence-based strategies to help smokers quit. Increase awareness of resources to help patients quit smoking. Slide 3 Comprehensive Approach to Reducing the Toll of Tobacco Caused Cancers Fully funded tobacco comprehensive tobacco control programs Increasing the price of tobacco products Enacting comprehensive smoke-free policies Controlling access to tobacco products Reducing tobacco advertising and promotion Implementing anti-tobacco media campaigns Encouraging and assisting tobacco users to quit.
Slide 4 Healthy People Increase tobacco screening in health care setting. Increase tobacco cessation counseling in health care setting. Increase comprehensive Medicaid insurance coverage of evidence-based treatment for nicotine dependency. Slide 5 SMOKING AND CANCER RATES Slide 6 Adult Current Smoking by Gender, BRFSS 25 15 National-11 Hawaii-11 5 Males Females
Slide 7 Adult Current Smoking by Race/Ethnicity, BRFSS 35 3 25 15 5 National-11 Hawaii-11 Hawaii- Slide 8 Adult Current Cigarette Smoking by Education, BRFSS 3 25 15 5 National -11 Hawaii-11 Slide 9 Adult Current Smoking by Poverty Status, BRFSS 35 3 25 15 National-11 Hawaii- 5 At or above poverty Below poverty -13% 131-185% 186+
Slide Lung Larynx Nasopharynx Oropharynx Hypopharynx Pancreas Esophagus Oral cavity Nasal cavity and paranasal sinuses Tobacco-Caused Cancers Tobacco is a human carcinogen. Cigarettes, smokeless, cigars, pipes, and bidis can causes up to 18 different cancers. Myeloid leukemia (bone marrow) Colorectum Ovary Stomach Liver Uterine cervix Urinary bladder Kidney (body and pelvis) Ureter *Hepatoblastoma (parental smoking) Secretan et al 9, Lancet Oncology, (11), 33-34 Slide 11 Lung Cancer Incidence and Mortality, - 5* 9 8 7 6 5 4 3 *Rates are per, and age-adjusted to U.S. standard population. Hawaii Tumor Registry -5 National Hawaii Slide 12 9 8 7 6 5 4 3 Lung Cancer Incidence and Mortality by Race Ethnicity and Gender, Hawaii -5 Native Hawaiian White Chinese Filipino Japanese Males- incidence Female-incidence Male-mortality Female-mortality
Slide 13 Predicted Rates of Lung Cancer Among Smokers Consuming CPD or 3 CPD Haiman, Strom, Wilkens, et al, NEJM, 6 Slide 14 ALA Hawaii Report Card 13 Cigarette tax: A Smokefree air laws: A Tobacco prevention and control program Funding: C Cessation coverage: C Takes into consideration Medicaid, state employee health plan, and quitline Slide 15 Benefits of Quitting People who stop smoking greatly reduce their risk of dying prematurely. Benefits are greater for people who stop at earlier ages, but cessation is beneficial at all ages. Smoking cessation lowers the risk for lung and other types of cancer. The risk for developing cancer declines with the number of years of smoking cessation. Risk for coronary heart disease, stroke, and peripheral vascular disease is reduced after smoking cessation. Coronary heart disease risk is substantially reduced within 1 to 2 years of cessation. Cessation reduces respiratory symptoms, such as coughing, wheezing, and shortness of breath. The rate of decline in lung function is slower among persons who quit smoking. Women who stop smoking before or during pregnancy reduce their risk for adverse reproductive outcomes such as infertility or having a low-birth-weight baby.
Slide 16 Cancer Patients and Quitting Smoking Smoking among cancer patients decreased survival increased risk of developing a second primary cancer greater side effects of treatment a poor treatment response higher risk of heart and lung conditions poorer quality of life Benefits of quitting better recover better treatment responses, including fewer side effects Better healing from surgery and wounds lower risk of secondary cancer Slide 17 Cancer Patients and Quitting Smoking Most patients with a smoking-related cancer stop smoking or make a serious quit attempt at diagnosis. Doctors and nurses caring for cancer patients who are still smoking play a key role in helping that person to successfully stop. At a recent conference of the American Society of Clinical Oncology in June 13, speakers agreed that once diagnosed with cancer, all patients who smoke should be referred to smoking cessation clinics/assistance. A study carried out by thoracic surgeons showed that a large proportion of cancer patients did not believe that smoking would affect how successful their treatment was. Few research studies conducted to examine the effects of smoking cessation among cancer patients. Slide 18 QUITTING AND CLINICAL PRACTICE
Slide 19 Treating Tobacco Use Dependence Clinical Practice Guidelines, 1996,, 8 Over 8, publications reviewed Tobacco Dependence Guidelines Panel of 37 experts were charged with identifying effective, experimentally validates tobacco dependence treatments and practices Slide Sponsors Agency for Healthcare Research and Quality Centers for Disease Control and Prevention National Cancer Institute National Heart, Lung, and Blood Institute National Institute on Drug Abuse Robert Wood Johnson Foundation American Legacy Foundation University of Wisconsin School of Medicine and Public Health s Center for Tobacco Research and Intervention Slide 21 Generating Evidence The recommendations were made as a result of a systematic review and meta-analysis of 11 specific topics identified by the Panel: proactive quitlines; combining counseling and medication relative to either counseling or medication alone; varenicline; various medication combinations; long-term medications; cessation interventions for individuals with low socioeconomic status/limited formal education; cessation interventions for adolescent smokers; cessation interventions for pregnant smokers; cessation interventions for individuals with psychiatric disorders, including substance use disorders; providing cessation interventions as a health benefit; and systems interventions, including provider training and the combination of training and systems interventions. The strength of evidence that served as the basis for each recommendation is indicated clearly in the Guideline update.
Slide 22 Recommendations Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective in this Guideline. Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. Slide 23 Recommendations Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist that can significantly increase rates of long-term abstinence. It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting. Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use the counseling treatments and medications recommended in this Guideline. Slide 24 Recommendations Effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempting to quit smoking except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates: Bupropion SR Nicotine gum Nicotine inhaler Nicotine lozenge Nicotine nasal spray Nicotine patch Varenicline
Slide 25 Recommendations Clinicians also should consider the use of certain combinations of medications identified as effective in this Guideline. Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication. Telephone quitline counseling is effective with diverse populations and has broad reach. Therefore, both clinicians and health care delivery systems should ensure patient access to quitlines and promote quitline use. Slide 26 Recommendations If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments shown in this Guideline to be effective in increasing future quit attempts. Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in this Guideline as covered benefits. Slide 27 Advice to Quit Smoking 7% of smokers see a physician annually 3% see a dentist annually PAs, nurses, physical and occupational therapists, pharmacists, counselors, and other clinicians 7% of smokers want to quit Your advice is a strong motivator to quit
Slide 28 Brief Intervention Pocket Cards: 5As Slide 29 Algorithm for Treating Tobacco Use YES Does the patient now use tobacco? NO YES Is patient willing to quit? NO YES Did patient once use tobacco? NO Provide appropriate tobacco dependence treatments Provide motivation to quit Prevent relapse Encourage continued abstinence Slide 3 INCREASE AWARENESS OF RESOURCES FOR QUITTING
Slide 31 Telephone and Web-based Counseling Quitlines 1-8-QUITNOW Clearthesmoke.org Web-based support Smokefree.gov Tobaccofree.gov Legacy EX Campaign http://www.becomeanex.org Re-learning your life without cigarettes Slide 32 1-8-QUIT-NOW- Hawaii Web-based coaching Live coaching 7 days per week 3am-9pm Free nicotine replacement therapy (patch and gum) Private insurance- up to 2 weeks supply Medicaid- up to 4 weeks No insurance- up to 8 weeks Slide 33 Hawaii Tobacco Quitline: clearthesmoke.org
Slide 34 Self-Help and Quitting Clearing the Air For people at all stages of quitting Pathways to Freedom For African Americans interested in quitting Guia para Dejar de Fumar For Spanish speaking persons interested in quitting Clear Horizons Ages 5 and over For people thinking about quitting Forever Free For people trying to stay quit Slide 35 HEALTH INSURANCE, MEDICAID AND SMOKING CESSATION Blind Pregnant Poor Disabled Slide 36 Affordable Care Act and Tobacco Cessation All plans in the Health Insurance Marketplace are required to cover tobacco cessation treatment. Specific coverage varies by plan. ACA requires new plans to cover clinical preventive services that receive an A or B for efficacy from the U.S. Preventive Services Taskforce. However, comprehensive coverage is not required.
Slide 37 Quitting Smoking Among Adults by Health Plan: NHIS, 8 7 6 5 4 3 Private Medicaid Medicare Military Other Public Plan Uninsured Interest in Quitting Recent Cessation Received Advice Used Counseling and/or Meds Source: CDC MMWR, Nov 11, 11 Slide 38 State Medicaid Coverage for Tobacco Dependence Treatment,, 5, 9 4 35 3 25 15 5 9 5 complete some medication pregnant women or counseling only none Recent Source: CDC MMWR, October 22, Slide 39 Medicaid and Smoking Cessation In, all state Medicaid programs were required to begin covering a comprehensive tobacco cessation benefit for pregnant women. In 14, Section 252 of the ACA specifies that as of January 1, 14, tobacco cessation medications will be removed from the list of optional medications and required for inclusion in states prescription drug benefit.
Slide 4 Hawaii Med-QUEST: Medicaid Coverage Medications *NRT Gum *NRT Patch +NRT Lozenge +NRT Nasal Spray +NRT Inhaler +Buproprion (Zyban) +Varenicline (Chantix) Counseling +Individual +Group +Phone (1-8-QUIT-NOW) Slide 41 WHAT ABOUT ELECTRONIC CIGARETTES? Slide 42 Electronic Cigarettes Nicotine delivery devices. Not regulated by the FDA or anyone else. Not an approved evidence-based practice. Many other drugs tested by FDA and are not considered first line, clonidine and nortriptyline. Only recommended because of contraindications or patient cannot take first line.
Slide 43 Harm Reduction and E-Cigarettes Complete abstinence and treating chronic dependence is the goal. Are smokers using them to quit? Are smoking using them for harm reduction? Are smokers continuing to smoke e-cigs after quitting cigarettes? Are smoker switching back from e-cigs to cigs? Are the successful in achieving long-term abstinence or reduction in cpd? Slide 44 Take Home Messages Lung cancer is still the leading cause of cancer deaths in the US and Hawaii. Smoking is lower in Hawaii than other states, but disparities exist. Providers should assist all patients with quitting and use evidence-based practice to do so. Its important to make patients aware that smoking can impact secondary cancer risk, treatment, survivorship, and quality of life. Tobacco cessation treatment should be integrated into routine care of cancer patients. Because of multiple complex issues that patients have to deal with, more intensive treatment is likely warranted. How to help patients http://www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/tobacco/index.html