CURRENT ISSUES IN TOBACCO CESSATION FOR THE PRACTICING PHYSICIAN Shahnaz Fatteh, M.D. Associate Clinical Professor and Director, Asthma, Allergy and Immunology Clinic Dr. Kiran C. Patel College of Osteopathic Medicine Nova Southeastern University
No Disclosures
OBJECTIVES Importance of Addressing Tobacco Use with Patients Pathophysiology of Tobacco Use Current Treatments / Medications New and Emerging Tobacco Products E-Cigarettes Public Policy Current issues pertaining to tobacco Meeting New Practice Standards for Addressing Tobacco Use How the Physician can Play a Key Role in Tobacco Cessation
WHY IS IT IMPORTANT TO ADDRESS TOBACCO USE WITH YOUR PATIENTS? Cigarette smoking is the chief, single avoidable cause of death in our society and the most important public health issue of our time. C. Everett Koop, M.D. U.S. Surgeon General, 1982-1989 From The Health Consequences of Smoking: Cancer. Surgeon General s Report, USDHHS, 1982
WHY IS IT THAT PHYSICIANS HAVEN T ROUTINELY DISCUSSED TOBACCO CESSATION WITH THEIR PATIENTS Discussion about tobacco may be time-consuming Physician may not feel they can make a difference Patients are unready to change Discussions can be unpleasant might be viewed by their patients as intrusive Sources: Vogt (2005). Addiction, 100(10): 1423-1431, Caplan, Lee, et.al. (2011), Journal of Community Health, 36(2): 238-243.
IF A CLINICIAN DOES NOT ADDRESS TOBACCO USE Patients may think that quitting smoking is not important if they don t hear it from their health providers
WHY SHOULD YOU PRIORITIZE THE TREATMENT OF TOBACCO USE? You can make a difference even with a brief intervention (3 minutes or less) For a patient not interested in quitting, a brief tobacco intervention can increase motivation and the possibility of future quit attempts Effective treatment and cessation resources exist. Source: Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Dept of Health and Human Services. Public Health Service. May 2008, p. 37.
Physicians can make a real difference in getting their tobaccodependent patients to quit
15.8% More than 70% of tobacco users indicate that they want to quit Source: Tobacco Free Florida
Source: Tobacco Free Florida
QUIT RATE CLINICAL PRACTICE GUIDELINE TREATING TOBACCO USE AND DEPENDENCE: MAXIMIZING TOBACCO TREATMENT AND ABSTINENCE IN THE HEALTH CARE SETTING Approx. 11% of tobacco users will quit on their own. Talking with the patient about their tobacco dependency for less than 3 minutes will increase the quit rate to 14.4%. Longer interventions and other elements in place in the clinical setting will more than double this quit rate. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Dept of Health and Human Services. Public Health Service. May 2008, p. 85. Relapse management Patient reinforcement counseling Counseling & medication Consistent pt. follow-up & assessment Patient reminder systems Telephone counseling services Multiple formats (verbal, written, video) Multidisciplinary team approach Longer Intervention (> 3 mins.) 14.4% Brief Intervention (< 3 mins.)
ASK BRIEF INTERVENTION CAN MAKE A DIFFERENCE ADVISE REFER
TOBACCO RELATED MORTALITY Tobacco use is the leading preventable cause of morbidity and mortality in the United States contributing to more than 480,000 deaths annually (Surgeon General s Report 2014) Secondhand smoke causes nearly 42,000 deaths from heart disease and lung cancer each year in the United States among nonsmokers. (Surgeon General s Report 2014) On average, smokers die more than 10 years earlier than nonsmokers
YOUTH AND TOBACCO 90% of smokers start smoking by age 18 Every day in the U.S., 3,200 kids under age 18 try their first cigarette (nearly 1.2 million per year) 2,500 youth and young adults become regular smokers daily (Surgeon General s Report 2012, 2014)
IN THE STATE OF FLORIDA SINCE THE INCEPTION OF TOBACCO FREE FLORIDA IN 2007... Adult smoking rate is 15.8% down from 21% in 2006. (2015) This reduction in adult smoking rate results in $17.7 billion in savings in tobacco-related health care costs (2007-2015) Youth smoking rate has decreased from 10.6% to 3.0% (2016) (Tobacco Free Florida 2015, 2016)
TOBACCO USE AND CHRONIC DISEASE Source: The Health Consequences of Smoking 50 Years of Progress: A Report of the Surgeon General, 2014
THE 50TH ANNIVERSARY SURGEON GENERAL S REPORT 2016 (SGR) HEALTH CONSEQUENCES CAUSALLY LINKED TO SMOKING Source: The Health Consequences of Smoking 50 Years of Progress: A Report of the Surgeon General, 2014
fires (1%) Early Death illicit drugs (1%) homicide (3%) car accidents (4%) suicide (4%) AIDS (4%) alcohol (15%) tobacco (68%*) *combination of tobacco use (61%) + second-hand smoke (7%) AMERICAN CANCER SOCIETY
QUITTING TOBACCO USE Non-pharmacologic Counseling Pharmacologic FDA-approved medications Counseling and medications are both effective, but the combination of counseling and medication is more effective than either alone. Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.,
PHARMACOTHERAPY FDA-APPROVED MEDICATIONS for CESSATION Nicotine polacrilex gum Nicorette (OTC) Generic nicotine gum (OTC) Nicotine lozenge Nicorette Lozenge (OTC) Nicorette Mini Lozenge (OTC) Generic nicotine lozenge (OTC) Nicotine transdermal patch NicoDerm CQ (OTC) Generic nicotine patches (OTC, Rx) Nicotine nasal spray Nicotrol NS (Rx) Nicotine inhaler Nicotrol (Rx) Bupropion SR (Zyban, generic) Varenicline (Chantix)
PHARMACOTHERAPY FDA-APPROVED MEDICATIONS for CESSATION Certain Combinations of Cessation Medications have been shown to be effective Combining a long-acting NRT (patch) with a short-acting NRT (gum, lozenge or inhaler) is more effective than using a single type of NRT Nicotine Patches have also been effective in combination with use of Bupropion (Zyban)
BRIEF TOBACCO INTERVENTION AND DOCUMENTATION Since addressing tobacco use with your patients does make a difference in their motivation to quit Did you know Most Insurances allow billing for cessation interventions and counseling. CPT Code: 99406 smoking and tobacco use counseling visit 3-10 minutes CPT Code: 99407 smoking and tobacco use counseling intensive visit greater than 10 minutes
E-CIGARETTES THE NEW TREND THE FACTS Battery powered devices that heat a liquid into an aerosol that is inhaled by user Different types/sizes of e-cigarettes - also known as e-cigs, e-hookahs, vapes, vape pens, mods, and tank systems Liquid most often has nicotine, flavoring, and other additives. E-cigs can also be used to deliver marijuana and other illegal drugs E-cigs are NOT FDA-approved cessation aid and are NOT proven to be safe. Source: U.S. Dept. of Health and Human Services. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General, 2016.
E-CIGARETTES THE NEW TREND THE FACTS, continued Most commonly used tobacco product among youth. More than ¼ of youth in middle and high school have tried e-cigs. In Florida, teen cigarette smoking has decreased, but high school e-cig use has increased by 72% in just two years from 10.8% in 2014 to 18% in 2016. (Tobacco Free Florida) Thousands of flavors such as strawberry, pina colada, blue raspberry are appealing to youth. Source: U.S. Dept. of Health and Human Services. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General, 2016.
E-CIGARETTES THE NEW TREND IT S JUST WATER VAPOR, RIGHT? WRONG E-cig aerosol is not harmless. Most contain nicotine which is addictive and disrupts growth of developing brain of youth, especially in the area of attention, learning, impulse control Health effects very concerning long term safety of e-cig use or exposure to secondhand aerosol not known. Not a water vapor, but an aerosol containing ingredients such as Nicotine causes addiction Ultrafine particles can be inhaled deep into the lungs Source: U.S. Dept. of Health and Human Services. E- Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General, 2016.
E-CIGARETTES THE NEW TREND THE FACTS, continued Diacetyl used in some flavors, chemical linked to bronchiolitis obliterans ( popcorn lung ) Volatile Organic Compounds such as benzene, and several heavy metals such as nickel, lead and tin Propylene Glycol while this is present in many foods, and considered safe to eat, inhaling could cause lung irritation/asthma Carcinogenic substances including formaldehyde found in some aerosols. Source: U.S. Dept. of Health and Human Services. E- Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General, 2016.
EVER HEARD OF JUULS? Very Popular Brand of E-cigs with youth and young adults Designed to look like a flash drive which is charged in the computer One Pod of e-liquid equals one pack of cigarettes or 200 puffs.
JUULing Middle School and High School students are using these on campus, easy to hide since it fits in palm and can be charged in computer. Several flavors including mango, cool mint, crème brulee, fruit medley, cool cucumber, classic tobacco.
NON-CIGARETTE TOBACCO PRODUCTS AND FUTURE USE OF CIGARETTES IN YOUTH JAMA Pediatr. 1/2/18, Watkins, Glantz, Chaffee Population of 10,384 youth respondents By using any of these products, youth more likely to use cigarettes one year later E-cigarette, hookah, non-cigarette combustible tobacco, or smokeless tobacco use Use of more than one of these products even more likely
PUBLIC HEALTH INITIATIVES TOBACCO 21 Increasing legal age to purchase tobacco to 21 years old 95% of adult smokers begin smoking before age 21; raising legal age to 21 has been shown to reduce youth initiation of tobacco Will decrease nicotine addiction in teens and long-term use, therefore saving lives (Institute of Medicine Report, 2015) 5 states (California, Oregon, New Jersey, Maine, and Hawaii have raised their tobacco sales age to 21. Over 250 cities, counties, communities have adopted Tobacco 21, including New York City, San Antonio, Washington DC, to name a few.
PUBLIC HEALTH INITIATIVES TOBACCO-FREE PARKS / BEACHES Reduce secondhand smoke exposure Reduce litter/cigarette butts on beaches and in parks Difficult to adopt laws due to preemption in Florida state government limits or eliminates local governments authority to pass local tobacco control laws, including adopting smokefree areas
PUBLIC HEALTH INITIATIVES SMOKE-FREE MULTI-UNIT HOUSING HUD Public Housing Authorities must have smoke-free policies by July 31, 2018. Policies must prohibit smoking in all indoor areas, individual living units, common areas, office buildings, outdoor areas within 25 feet of buildings. Protects residents from secondhand smoke exposure. Secondhand smoke can seep through walls, ventilation systems into non-smoker s apartments Cost savings 2-7 times more time and money to turn over an apartment in which smoking has occurred Prevent smoking-related fires can save on insurance
INTERESTED IN GETTING INVOLVED? Contact your local Area Health Education Center (AHEC) for free tobacco cessation services for your patients and training for you, your providers and your staff, Call 877-848-6696 Join your county s Tobacco Free Partnership Advocate Tobacco 21 Efforts / Smokefree Parks/Beaches in your community
INTERESTED IN GETTING INVOLVED? Get involved in your local chapters of the American Lung Association, American Cancer Society, American Heart Association, etc. Be aware of State/National Tobacco Awareness days: Tobacco Free Florida Week (usually in May) Lung Force Task Force (American Lung Association) Great American Smokeout - 3 rd Thursday in November (American Cancer Society) Kick Butts Day March 21, 2018 (Campaign for Tobacco-Free Kids)
Tobacco use harms nearly every organ in the body and is the leading preventable cause of death in the United States, killing more than 480,000 people each year. (CDC) More than 70 % of tobacco users say they want to quit and health providers can play a unique and important role in helping them succeed Tobacco use kills more people than AIDS, illicit drug use, fires, alcohol, suicide, murder, and car accidents combined. (CDC) It is inconsistent with sound medical practice to provide health care and at the same time remain silent (or inactive) about a major health risk. (Lightwood and Glantz, 1997, Rx for Change) Source: CDC 2017, Treating Tobacco Use and Dependence 2008 Update, Rx for Change Having an appropriate 3-4 minute conversation with a patient followed by a referral to cessation programs can double or even triple the quit rate.
ASK BRIEF INTERVENTION Where Can You Refer Your Patients? ADVISE REFER
ADDRESSING TOBACCO USE CAN HELP PHYSICIANS AND HEALTH CARE FACILITIES MIPS H.E.D.I.S. Measure Joint Commission Tobacco Measures
SYSTEMS CHANGE DEFINITION Specific strategies that are implemented to support changes in health care organizations leading to universal, evidence-based interventions with all tobacco users Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008. PAGE 67.
Tobacco Systems Change Strategies 1. Implement a Tobacco-User Identification System in Every Clinic 2. Provide Education, Resources, and Feedback to Promote Provider Intervention 3. Dedicate Staff to Provide Tobacco Dependence Treatment and Assess Its Delivery in Staff Performance Evaluations 4. Develop and promote Policies that Support and Provide Inpatient and Outpatient Tobacco Dependence Services 5. Include Tobacco Dependence Treatments (Both Counseling and Medication) Identified as Effective in the Guideline as Paid or Covered Services for All Subscribers or Members of Health Insurance Packages
IF YOUR PATIENT IS READY TO QUIT
HEALTH CARE PROVIDER FAX REFERRAL FORM TO TOBACCO FREE FLORIDA
IT S WORKING! Evaluations of AHEC Tobacco Cessation Programs from outside evaluator: Highly effective program High satisfaction rates from participants Quit rates higher than most programs Smoking prevalence among Florida adults was 15.8% in 2015 down from 21.0% in 2006. Source: Tobacco Free Florida Fact Sheet