Download ASA Provider power point

Beating Joe Camel:
The American Society of Anesthesiologists
Smoking Cessation Initiative
Beating Joe Camel…
• Why bother?
• Barriers
• The ASA Smoking Cessation Initiative
• How to help in three minutes or less
• How to get paid for helping (under some
circumstances)
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Why bother?
Quitting Smoking
Improves Surgical
Outcomes
3
Surgery May Promote
Quitting Smoking
Tobacco Cessation Improves Surgical
Outcomes
• Cardiovascular complications
• Respiratory complications
• Wound related complications
4
Short Term Cardiovascular Benefits of
Smoking Cessation
• Nicotine
Half life of ~1-2 h
Decreases in heart rate and systolic blood pressure in 24
hrs
• Carbon Monoxide
Half life of ~4 hours
Level near normal at 12 hrs
• Preoperative abstinence decreases the frequency
of intraoperative ischemia*
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*Woehlck et al, Anesth Analg 89: 856, 1999
Smoking Cessation Reduces Postoperative
Complications
60
Control
Intervention
50
%
40
30
20
10
0
Any
Wound
Complication
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Moller, Lancet 359:114, 2002
Cardiac
• 120 Orthopedic patients
randomized to tobacco
intervention or control,
6-8 weeks prior to
surgery
• ~80% of intervention
patients were able to
quit or reduce smoking
Why bother?
Quitting Smoking
Improves Surgical
Outcomes
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Surgery May Promote
Quitting Smoking
Surgery Promotes Tobacco Cessation
• Opportunity to intervene
– Contact with healthcare system
– Forced abstinence
• Major medical interventions improve quit rates
– Occurs even in the absence of tobacco interventions
– May also improve the effectiveness of tobacco
interventions
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Smoking Cessation After Surgery
% quitting at one year
100
80
60
40
20
0
Self-help
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Outpatient Major Non- Coronary
Cessation
cardiac
Bypass
Programs
Surgery
Surgery
Lung
Cancer
Surgery
Perioperative Smoking Cessation Barriers
• Quitting just before surgery increases
pulmonary complications
• Nicotine replacement therapy is dangerous
• Surgical patients are already too stressed
• Patients don’t want to hear about their
smoking – they have enough to worry about
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Recent Smoking Cessation Does Not
Increase Pulmonary Complications
25%
Overall
Pneumonia
20%
15%
10%
5%
0%
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Continued
Smokers
Recent
Quitters
Past
Quitters
Non
Smokers
Barrera et al, Chest 127:1977, 2005
•300 patients for lung
cancer resection
•“Recent” quitters:
>1 week, < 2 months
•“Past” quitters:
> 2 months
Nicotine Replacement Therapy and
Wound Healing
30%
Non-abstinent
25%
Abstinent, active patch
20%
Abstinent, placebo
15%
10%
5%
0%
Infection rate
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Sorensen et al, Ann Surg 238:1, 2003
•48 smokers randomized
to continuous smoking or
abstinence, with or
without nicotine
replacement
•Standardized surgical
wounds over a 12 week
period
Perioperative Stress in Smokers
Perceived Stress
4
Smokers
Nonsmokers
3
2
1
0
Preop Postop POD1
13
POD2
POD7
Warner et al, Anesthesiology 199:1125, 2004
•141 smokers, 150 nonsmokers for elective surgery
•Perceived stress measured
from before surgery up to
one week postoperatively
•Smoking status does not
affect changes in perceived
stress
•No evidence for significant
cigarette cravings
What do smokers expect?
• Essentially all smokers are aware of general
health hazards
– Most are not aware of how it might affect their surgery
– and want to know!
• They want information and options
• Almost all will not be offended if you discuss their
smoking…
• But they do not want a sermon
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Warner et al, Am J Prev Med 35:S486, 2008
The Real Barriers to Intervention
“I don’t know how”
“I don’t have time”
“It’s not my job”
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What are we doing now?
100%
Anesthesiologists
Surgeons
80%
60%
40%
20%
0%
Ask
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Advise
Assist
• Survey responses from 329
anesthesiologists and 299
general surgeons
• Proportions that “always”
performed intervention
• Actual patient perceptions
may differ (e.g., ~30% of
patients recall being
advised)
Warner et al, Anesth Analg 99:1766,2004
ASA Smoking Cessation Initiative:
Rationale
• Smoking cessation improves perioperative
outcomes
• Sustained abstinence produced by this teachable
moment produces an average 6-8 years of life
gained
• Demonstrate to the public that anesthesiologists
are perioperative physicians who care about patient
health
• Recent CMS changes make it possible to bill for
tobacco interventions lasting three or more minutes
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ASA Smoking Cessation Initiative Vision
and Goals
• Vision
– Every smoker cared for by an anesthesiologist will
receive assistance in quitting as an integral part of care
• Goal
– Increase the involvement of ASA members in smoking
cessation efforts, thus increasing abstinence rates for
their patients who smoke
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ASA Smoking Cessation Initiative
Strategies
• Encourage all anesthesiologists to consistently apply
the ASK, ADVISE, and REFER technique
• Develop anesthesiologists who can serve as leaders
for local efforts to provide tobacco intervention
services in perioperative practice
• Educate the public regarding the importance of
perioperative smoking cessation
• Create partnerships with other healthcare
professionals to promote a comprehensive
perioperative strategy for patients who smoke
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What should we do for smokers who need
surgery?
• ASK
Assess tobacco use at every visit
• ADVISE
Strongly urge all tobacco users to quit
• REFER
To a tobacco quitline or other resources
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What are Quitlines?
•
•
•
•
Free via telephone to all Americans
Staffed by trained specialists
Up to 4-6 personalized sessions
Some offer free nicotine replacement
therapy
• Up to 30% success rates for patients who
complete sessions
Most providers and patients know nothing about quitlines….
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ASK every patient about tobacco use
• Ask even if you already know the answer
– Reinforces the message that as a physician
you think their tobacco use is significant
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ADVISE all smokers to quit
• Why quit for surgery? – Talking Points
– Quit for as long as possible before and after surgery
• Day of surgery especially important – “fast” from
both food and cigarettes
– Benefits of quitting to wound healing, heart and lungs
– Great opportunity to quit for good
• Many people don’t have cravings
• Need to be smoke free in the hospital anyway
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REFER smokers to quitlines or other
resources
• What are quitlines? – Talking Points
–
–
–
–
–
Quitlines are free
Talk with a specialist, not a recording
Free stop smoking medications may be available
Can call anytime, even after surgery
Can help you stay off cigarettes even if you have
already quit
• Can also use proactive fax referral
• 1-800-QUIT-NOW
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ASA Quitline Card
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ASA Patient and Provider Brochures
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Other Patient Resources
• Tobacco treatment specialists
– Available in many practice settings
– Often hospital-based
• Web sites
– www.smokefree.gov
– www.asahq.org/stopsmoking
• Insurers
– E.g., Blue Cross/Shield, BluePrint for Health stop
smoking program
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Tobacco Intervention CMS Reimbursement
• Who is covered?
– Patients who use tobacco and have a disease or
adverse health effect found by the US Surgeon
General to be linked to tobacco use
– Patients who take certain therapeutic agents whose
metabolism or dosage is affected by tobacco use as
based on FDA-approved information
• CPT® Codes
– 99406 Smoking and tobacco-use cessation counseling
visit; intermediate, greater than 3 minutes up to 10
minutes
– 99407 Smoking and tobacco-use cessation counseling
visit; intensive, greater than10 minutes
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Tobacco Intervention CMS Reimbursement
• Cessation counseling attempt occurs when a
qualified physician or other Medicare recognized
practitioner determines that a beneficiary meets
the eligibility requirements and initiates treatment
• Two attempts, up to 4 sessions, allowed every 12
months
• No credentialing requirements
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ASA Smoking Cessation Initiative Task Force
Pilot Program
• Identified 14 practices nationally, both
private practices and academic
• Implemented Ask-Advise-Refer strategy
from Oct. – Dec. 2007
• Practices surveyed after this period to
determine feasibility and gather feedback
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Pilot Project Highlights
(n=94 responses)
• ~50% expressed increased self-efficacy
• ~75% agree that they would incorporate AAR
in their practice
• High acceptance of materials
• ~80% agree that the ASA should encourage
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% “frequently or always”
Rates That Anesthesiologists Performed
Ask-Advise-Refer Elements
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100
Baseline
Pilot project
80
60
40
20
0
Ask
Advise
Refer
“Baseline” data from 2004 national survey
of ASA members, Warner et al, A&A,
99:1766, 2004
Bottom Line…
• You can make a difference in the lives of
your patients who smoke
• You can help without being an expert in
tobacco control – and get paid for doing it
• The ASA is working to provide you with the
tools needed to do this effectively
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What about Joe Camel?
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