Download Addressing Family Tobacco Use

Improving Children's Health by Addressing
Family Tobacco Use
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…dedicated to eliminating children’s exposure to tobacco
and secondhand smoke
Today’s Goals
• To train clinicians in:
– Effective ways to educate parents and caregivers on
the effects tobacco use has on children.
– Counseling strategies to promote smoke-free homes
and cars.
– The role of medications in cessation.
– Creating and implementing practice systems to
identify and treat tobacco use and exposure.
The Health Effects of Tobacco Use
Asthma
Otitis Media
Fire-related Injuries
SIDs
Bronchiolitis
Meningitis
Childhood
Infancy
In utero
Low Birth Weight
Stillbirth
Neurologic Problems
Influences
to Start
Smoking
Adolescence
Nicotine Addiction
Adulthood
Cancer
Cardiovascular Disease
COPD
47 Years After the 1st Surgeon General’s
Report –
People Still Smoke!
• 21% of US adults are smokers
• More than 30% of U.S. children live with at least
one smoker
Why Do People Use Tobacco?
• Nicotine is physically addictive
– Tolerance develops
– Withdrawal symptoms occur
• Nicotine is a potent drug, causing dopaminergic
activation and CNS stimulation
• Use is reinforced by social cues and habits
Youth Are
Especially Susceptible
• For many youth, symptoms of dependence
develop before daily use begins, and can begin
within a day after inhalation!
• There is no minimum requirement of number
smoked, frequency, or duration of use!
That First Puff…
• The nicotine in 1-2 puffs occupies 50% of nicotinic
receptors in the brain
• A single dose increases
– Noradrenaline synthesis in the hippocampus
– Neuronal potentiation lasting > month (meaning that
neurons discharge action potentials at lower
threshold)
What Can We Do?
Principles of Tobacco Dependence
Treatment
• Nicotine is addictive
• Tobacco dependence is a chronic
condition
• Effective treatments exist
• Every person who uses tobacco should be
offered treatment
Smokers Want to Quit
• 70% of tobacco users report wanting to quit
• Most have made at least one quit attempt
• Cite health expert advice as important
• Regardless of type! THIS MEANS YOU!
Counseling 101
• Patients and families expect you to discuss tobacco
use
• If counseling is delivered in a non-judgmental
manner, it is usually well-received
• Even small “doses” are effective - and cumulative!
• Strength of Evidence = A
The Theory…
Assessing Stage of Readiness
Precontemplation
Contemplation
Ready for Action
Relapse
Action
Maintenance
Behavior change occurs in stages – not all at once
Your Goal: Help the Tobacco User Take the
Next Step
Help a precontemplator become a contemplator…
…a contemplator start to make plans…
…someone who relapsed become “ready for
action”…
And so on….
Counseling IS Effective
• As little as 3 minutes doubles quit attempts and
successes
• Intensive counseling is more effective
– Dose-response relationship
• Most effective:
– Problem-solving skills
– Support from clinician
– Social support outside of treatment
Brief Intervention
• Minimal interventions lasting less than 3 minutes
increase overall tobacco use abstinence rates.
– Strength of Evidence = A
• Every tobacco user should be offered at least a
minimal intervention, whether or not he or she is
referred to an intensive intervention.
The 5 As
Ask
“2As and an R”
Ask
Advise
Assess
Advise
Assist
Arrange
Refer
2 As and an R: ASK
• Ask about tobacco use and SHS exposure at every
visit
• Make asking routine, consistent, and systematic
– Use standardized documentation
– Document as a “vital sign”
• Just asking can double quit attempts
How Do You Ask?
• Don’t lead: “You don’t smoke, do you?”
• Depersonalize the question: “Does anyone living in your
home use tobacco in any way?” “Who is it?” “Where do
they smoke?” “Is that inside the house?”
• Explore: “You say no one smokes around your son. What
does that mean?”
• Don’t judge – check your body language, tone of voice,
the phrasing of the question
2 As and an R: ADVISE
• Strongly advise every tobacco user to quit
• Provide information about cessation to all
tobacco users
• Strongly urge smoke free homes and cars
• Look for “teachable moments”
• Personalize health risks
• Document your advice
What Do You Say?
• Clear: “I advise you to quit smoking.”
• Strong: “Eliminating smoke exposure of your son is the most
important thing you can do to protect the health of your
child.”
• Personalized: Emphasize the impact on health, finances, the
child, family, or patient.
•
•
“Smoking is bad for you (and your child/family). I can help you quit.”
“Tobacco smoke is bad for you and your family. You should make your
home and car smoke free.”
Be Specific…
• Having a smoke free home means no smoking
ANYWHERE inside the home or car!
• It DOES NOT mean smoking:
–
–
–
–
–
–
Near a window or exhaust fan
In the car with the windows open
In the basement
Inside only when the weather’s bad
Cigars, pipes, or hookahs
On the other side of the room
2 As and an R: REFER
• To quit line, 1-800-QUIT-NOW
• To community and Internet resources
• Give every tobacco user something that contains
information about quitting, the harms of tobacco
use, etc.
What Do You Say?
• “You should call this number. It’s a free service – and
the person on the other end of the telephone line
can help you get ready to quit.”
• “You should learn as much as you can about quitting
– the more you know, the more successful you’ll be.”
Quitlines
• It only takes 30 seconds to refer a patient to a toll-free
tobacco use cessation quitline.
• Quitlines are staffed by trained cessation experts who
tailor a plan and advice for each caller.
• 1-800-QUIT-NOW callers are routed to state-run
quitlines
Advantage of Quitlines
• Accessibility
• Appeal to those who are uncomfortable in a group
setting
• Smokers more likely to use a quitline than face-toface program
• No cost to patient
• Easy intervention for healthcare professionals
– Fax-back referral services
Medications
Work!
Pharmacotherapy
• Clinicians should encourage all patients attempting to
quit to use effective medications for tobacco
dependence treatment.
– Except where contraindicated or for specific
populations for which there is insufficient evidence
of effectiveness (i.e., pregnant women, smokeless
tobacco users, light smokers, and adolescents).
Factors to Consider…
• Clinician familiarity with medications
• Contraindications
• Patient preference
• Previous patient experience
• Patient characteristics (history of depression, weight gain
concerns, etc.)
First-line Pharmacotherapies
• Buproprion SR
• Nicotine Replacement Therapies (NRT)
– Nicotine gum
– Nicotine inhaler
– Nicotine nasal spray
– Nicotine patch
– Nicotine lozenge
• Varenicline
First-line Pharmacotherapies
• Varenicline (Chantix®) agonizes and blocks α4β2
nicotinic acetylcholine receptors.
• Buproprion SR (Zyban®) mechanism for smoking
cessation unknown; inhibits neuronal uptake of
norepinephrine, serotonin and dopamine.
• NRT: binds to CNS and peripheral nicotiniccholinergic receptors.
Varenicline (Chantix®)
• $4.00 - $4.22 per day
• Start 0.5 mg daily for 1-3 days, then increase to twice
daily for 1-4 days
• Increase to 1 mg twice daily on quit date.
• Most common side effects are nausea and vivid dreams
• Monitor for psychiatric symptoms
• Do not combine with NRT!
Bupropion SR (Zyban®)
• $3.62 - $6.04 per day
• Start 150 mg once daily for 3 days, then twice per
day for 7-12 weeks
• Plan quit date around day 7 of treatment
• Common side effects include insomnia and dry
mouth
• May be combined with NRT
Nicotine Gum
• $3.28 - $6.57 per day for 2 mg
• $4.31 - $6.51 per day for 4mg
• Weeks 1-6: one every 1-2 hours
Weeks 7-9: one every 2-4 hours
Weeks 10-12: one every 4-8 hours
• Common side effects are jaw pain and mouth soreness
Nicotine Inhaler
• $5.29 per day
• 6-16 cartridges per day, initially one every 1-2 hours
• Common side effects are mouth and throat irritation
Nicotine Nasal Spray
• $3.57 per day
• 1-2 doses (sprays) per hour
• Common side effects are nose and eye irritation
• Most addictive form of NRT
Nicotine Patch
• $1.90 - $3.89 per day
• >25 cigarettes per day: 21 mg every 24 hours for 4
weeks, then 14 mg for 2 weeks, then 7 mg for 2 weeks
• Common side effects
• Skin irritation
• Sleep problems if worn at night
Nicotine Lozenge
• $3.66 - $5.25 per day
• Weeks 1-6: one every 1-2 hours
Weeks 7-9: one every 2-4 hours
Weeks 10-12: one every 4-8 hours
• If first cigarette smoked within thirty minutes of
awakening, use 4 mg; others use 2 mg.
• Common side effects include mouth soreness and
dyspepsia
Second-line Pharmacotherapies*
• Clonidine: mechanism for smoking cessation unknown;
stimulates α2-adrenergic receptors (centrally-acting
antihypertensive)
• Nortripyline: mechanism for smoking cessation unknown;
inhibits norepinephrine and serotonin uptake
*”off label”
Pharmacotherapy for
Lighter Smokers
• Medications have not been shown to be beneficial to
light smokers
• If NRT is used, consider reducing the dose
• No adjustments are necessary when using Bupropion
SR or Varenicline
Patients Concerned with Weight Gain
• Bupropion SR and NRT (especially gum and 4 mg
lozenge) may delay, but not prevent weight gain
• The average weight gain after quitting is less than 10
pounds, more common in women
Patients with History of Depression
• Bupropion SR
• Nortriptyline
• NRT
Patients with Mental Illness
• Most will need medication
• Patients with bipolar disorder or eating disorders should
not use Bupropion SR
• Patch effective for those with schizophrenia
• Varenicline safety not established
• Quitting can increase the effect of some psychiatric
medications
• Check for relapse to mental illness with changes in
smoking status
Patients with Cardiovascular Disease
• No association between the nicotine patch and acute
cardiovascular events even in patients who continue
to smoke while on the patch
• NRT packaging recommends caution in patients with
acute cardiovascular disease
Pregnant Smokers
• Counseling is best choice
• Risks of premature birth or stillbirth caused by
smoking may be higher than the potential risk of
birth defects caused by NRT use
• Bupropion SR and Varenicline are pregnancy
category C
• Prescription NRT is pregnancy category D
Long-term Pharmacotherapy
• Helpful with smokers with persistent withdrawal
systems
• Long-term use of NRT does not present a known
health risk
• Bupropion SR approved for for up to 6 months
• Varenicline recommended for 12 weeks. May repeat
for 12 more.
Combining Medications
• Patch + gum or nasal spray = increases long-term
abstinence
• Patch + inhaler are effective
• Patch + Bupropion SR is more effective than patch
alone
• Patch + nortriptyline increases long-term abstinence
• Combining Varenicline with NRT is not recommended
Combining Counseling and Medications
• The combination of counseling and medication is more
effective for smoking cessation than either medication or
counseling alone. Therefore…both counseling and
medication should be provided to patients trying to quit
smoking.
– Strength of Evidence = A
Role Playing Exercises
The Rules
• Role playing exercises can help you become
“comfortable” with new language
• Role playing exercises DON’T work if you DON’T say
the words out loud
• Be silly. Have fun!
Break into Pairs
• Take turns as the “clinician” and “patient” or “parent”
Clinical Practice
Change
What Exactly is Clinical Practice Change?
• A change (hopefully an improvement) in the SYSTEM
of care practiced in the clinical setting
• The system is designed to produce the results it
produces
– If you’re not happy with the results, you need to
change the system
Key Components
• A clinical leader
• An administrative leader
• Support of Management
• A little bit of knowledge
• The desire to help children and families
Systems Changes Support the “Ask” Step
• All patients
– Should be asked if they use tobacco, and
– Should have their tobacco use status documented
on a regular basis.
• Strength of Evidence = A
You and Your Practice:
Effective Smoking
Cessation Counselors
• Every member of your practice – clinicians, office staff,
and receptionists – can play an important role in tobacco
control
The Barriers
• There’s never enough time to do the things you
already need to do
• You may not be reimbursed…
• Can derail efforts
• May not want to talk about it
The Assets
• You and your staff and colleagues
• Can be effective counselors
• Your patients and their families
• Expect to hear about tobacco
• The changing culture
• Is making it harder to use tobacco
But How?
• Clinical Staff
• Can ASK and ACT
• Administrative Staff
• Can keep materials stocked and administer
screening questionnaires
• Management
• Need to support the “cause”
Clinical Practice Change:
Best Practices
• Set goals
• Involve everyone
• Understand the current system
• Decide what needs changing
• Research those areas in detail
• Document changes
• Make it a continuous process
Plans Have Components
• How will success be measured?
• What are we doing?
• Who are the subject(s)?
• How will we start? Finish? Deliver advice?
• Where will it be done?
• When will it be done?
Monitor and Feedback
• Are procedures working as intended?
• Are staff completing assigned tasks?
• Is documentation evident?
• Are patient materials kept up to date?
• Does the team receive timely feedback and support for a
job well done?
Reimbursement
for Tobacco Use Cessation
Counseling
Medicare Benefits
• CMS pays for outpatient and hospitalized Medicare
beneficiaries who:
1- who use tobacco, regardless of whether they have signs
or symptoms of tobacco-related disease;
2- who are competent and alert at the time that counseling
is provided;
3- whose counseling is furnished by a qualified physician or
other Medicare-recognized practitioner.
Signs and Symptoms of tobacco-related disease: already
covered under Medicare Part B
Medicare Visits
• 2 individual tobacco cessation counseling attempts
per year; maximum of 4 intermediate OR intensive
sessions per attempt.
– Total: covering up to 8 sessions per year per beneficiary
who uses tobacco
• Intermediate cessation counseling = 3-10 minutes
per session
• Intensive cessation counseling =
more than 10 minutes per session.
CPT codes
• Counseling of a Symptomatic Patient
– 99406: 3-10 minutes
– 99407: More than 10 minutes
• Diagnosis Code 305.1: Non-dependent tobacco use disorder
• Diagnosis Code V15.82: History of tobacco use
Who Can Bill Medicare?
• Any qualified provider, such as physicians, clinical social
workers, psychologists, hospitals, may bill for tobacco
cessation counseling
Most Private Insurers Cover
• Most insurers provide coverage
for at least one type of pharmacotherapy for tobacco
cessation and at least one type of behavioral intervention
Billing Private Insurers
• Use billing codes in these categories:
• Preventive Medicine Treatments
• Tobacco Dependence Treatment as Part of the
Initial or Periodic Comprehensive Preventive
Medicine Examination
• Tobacco Dependence Treatment as Specific
Counseling and/or Risk Factor Reduction.
Medicaid Provides Benefits
• 47 of the 51 state/DC Medicaid programs cover
tobacco-dependence treatment for some enrollees
• 38 cover at least one form of tobacco-dependence
treatment for all enrollees (nicotine patch plus
bupropion slow release)
• 18 cover individual counseling for all enrollees
• 8 cover group counseling for all enrollees
• Only 8 programs offer coverage of all 2008 PHS
Guideline-recommended pharmacotherapy and
counseling for all enrollees.
Need more information?
The AAP Richmond Center
www.aap.org/richmondcenter
Audience-Specific Resources
State-Specific Resources
Cessation Information
Funding Opportunities
Reimbursement Information
Tobacco Control E-mail List
Pediatric Tobacco Control Guide
Summary
• Tobacco use and SHS exposure is a serious disease
• YOU can intervene
• Through counseling
• Pharmacotherapies
• Reimbursement
• Change your clinical practice to make it happen!
Questions?
Skull of a Skeleton with
Burning Cigarette
Antwerp 1885-1886
Van Gogh Museum
Amsterdam