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Tobacco Use and EvidenceBased Cessation Methods:
Systems Changes in Primary Care
December 2008
Tobacco Prevention & Control Branch
Division of Public Health, DHHS
Tobacco Use
The number one preventable cause of death
in the United States and North Carolina
Estimated Preventable Causes
of Death in NC
13,500
Tobacco
12,500
Diet/Phys. Inactivity
2,600
2,300
1,700
1,300
Alcohol
Microbial Agents
Toxic Agents
Motor Vehiciles
900
600
500
Firearms
Sexual Behavior
Illicit Drug Use
0
2,000
4,000
6,000
8,000
10,000 12,000
14,000 16,000
Estimated Number of Deaths
Source: North Carolina State Center for Health Statistics (NC SCHS), 2002;
NC Medical Journal, July/August, 2002, Vol63, #4. Makdad, 2004 and NC Mortality, 2006
2004 Surgeon General’s
Report - The Health
Consequences of Smoking
Smoking harms nearly every organ of the body
 Cessation has immediate and long-term benefits
 Smoking low tar cigarettes provides no health
benefits
 List of smoking-caused diseases includes AAA,
AML, pneumonia, cataracts, periodontitis, and
cancers of pancreas, stomach, cervix, kidney

Tobacco dependence as
a chronic disease
“Tobacco dependence shows many
features of a chronic disease… A
failure to appreciate the chronic
nature of tobacco dependence may
undercut clinicians’ motivation to
treat tobacco use consistently.”
Dr. Michael Fiore, Chair of Treating Tobacco Use and
Dependence 2008 Update, Clinical Practice Guidelines
Help for the busy practice….
North Carolina
Tobacco Use Quitline
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1-800-QUIT-NOW (1-800-784-8669)
8a.m. – 3a.m., 7 days a week; Toll-free; Confidential
All North Carolinians - youth and adult
Proactive – Quit coaches can call tobacco users back upon
request, or make 1st call
Fax referral
Multiple language Quit Coaches
Administered by the Tobacco Prevention and Control Branch
Funded by the NC Division of Public Health, NC Health and
Wellness Trust Fund, Blue Cross Blue Shield of NC
Become an Ex
www.becomeanex.org
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For tobacco users who would use a web-based
cessation program
Fun, edgy, interactive website
Useful at any stage of change
Personalized quit plan to “Relearn life without
cigarettes”
Breaks quitting down into manageable pieces
Free and in English and Spanish
Cessation: What Works

Behavioral support
 Treats
the psychological and habit
aspects

Pharmacotherapy
 Treats
nicotine addiction
Works best when combined
5 A’s For Patients Willing to Quit
Ask about tobacco use
 Advise patient to quit
 Refer (1-800-QUIT-NOW or local prgm)
 Assess readiness to quit
 Assist in quit attempt
 Arrange follow-up

Health Care Provider’s
Quick Intervention

ASK about tobacco use
 Every
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ADVISE to quit
 In
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visit – make it a vital sign!
clear, personalized statements;
REFER patient to the NC Tobacco Use Quitline or
other evidence based tobacco cessation resources
 Let
the NC Tobacco Use Quitline help with the time
consuming work. They are experts at quit coaching and
will help Assess, Assist, and Arrange)
Step 1: Ask
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Systematically ask every patient about tobacco use
at every visit.
 Start Ask process with Vital Signs
 Create a reminder system (stamp, sticker,
EMR)
Determine if patient is current, former, or never
tobacco user.
Determine what form of tobacco is used.
Determine frequency of use.
Document tobacco use status in the medical
record.
Step 2: Advise
In
a clear, strong, and personalized
manner, urge every tobacco user to quit.

“Mr. Jones, I know you are concerned about your
family history of heart disease; your risk for
having a heart attack can be reduced if you quit
smoking”
Employ
the teachable moment: link
visit findings with advice.
Step 3: Refer
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Is patient is ready to quit within 30 days?
Provide information about the NC Tobacco Use
Quitline
Proactive Referral for those ready to set a quit date
 Request written permission to fax contact
information to the Quitline
Follow-up at next visit – repeat process if necessary
Patients not ready to quit should be given the
Quitline number and/or other cessation resources
Quitline can Assess, Assist, Arrange
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Quitline helps patient ready to set a Quit Date, and
 Develop a quit plan
 Make up to three follow-up calls
 Discuss pharmacotherapy, refer back to HCP
 Encourage those not ready to set a quit date to
call back
Four call program is evidence-based
Patient can call the Quitline anytime
Fax Referral Program
Efficient method for referring patients who
want to quit to effective cessation services
 Physician referral of patients to cessation
programs is associated with higher rates of
participation than simply telling patients they
should stop smoking
 Alleviates some of the problems posed by
limited time and resources
 Takes the burden of initiating services off of
the patient
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How Fax Referral Works
1.
2.
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5.
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Patient has been identified as a tobacco user willing to
discuss quitting/ready to set a quit date
HCP educates patient on services of NC Tobacco Use
Quitline
Patient completes fax referral form providing consent for
HCP to release information to initiate proactive call.
•
Patient must provide contact information and sign the
fax referral form.
HCP must complete Provider Information on fax referral
form, including Name of Clinic
Based on times provided by patient, Quitline staff will
contact patient to begin Quitline calls.
Quitline can provide feedback to HCP on status of patient
•
Accepted Services, Refused Services, Not Reached
•
Must check HIPAA box on fax form and provide
clinic fax number, contact name and contact number
Effectiveness of Quitlines
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Smokers who use tobacco cessation Quitlines
double their chances of staying quit
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Proactive telephone counseling is more effective compared
to interventions without personal contact, such as self-help
materials. (meta-analysis of 27 studies of the efficacy of
telephone quitlines)
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Zhu, et al., 2002. Evidence of real-world effectiveness of a telephone
quitline for smokers. New England Journal of Medicine
Borland, et al., 2001. The effectiveness of callback counseling for
smoking cessation: a randomized trial. Addiction
Stead, et al., 2003—Cochrane Database of Systemic Reviews
Combining NRT with Quitline use increases quit rates

Zhu, et al., 2000. Telephone counseling as adjuvant treatment for nicotine
replacement therapy in a "real-world" setting. Preventive Medicine
Michael C. Fiore, MD, M.P.H., Panel Chair of Treating Tobacco Use and
Dependence 2008 Update, Clinical Practice Guidelines
Director, Center for Tobacco Research and Intervention, University of
Wisconsin Medical School
"In my view, a doctor isn't providing an
appropriate standard of care …. if he or she doesn't
ask two key questions
—'Do you smoke?' and 'Do you want to quit?'—
(Do you use tobacco? Do you want to quit?)
and then work with that individual to make it
happen.“
Efficacy of Physician Advice to
Quit
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Abstinence Rate %
No advice
7.9
Physician Advice
10.2
 Patients
expect healthcare providers to ask
about tobacco use and advise them to quit
Source: Treating Tobacco Use and Dependence, USDHHS, Public Health Service, 2008
Strategies for Implementation
Create
a Reminder System
Expand the vital signs to include tobacco use
Use an alternative universal identification system
Stamp, Sticker, Add to the EMR
Tobacco Use and Exposure
Tobacco Use: (circle one): Current Former Never
Secondhand Smoke Exposure: YES
NO
Tobacco use is the single most preventable cause of death in the US.
Pharmacotherapy
Nicotine Replacement Therapy
- Patch
- Gum
- Lozenge
- Inhaler
- Nasal Spray
 Zyban (bupropion)
 Chantix (varenicline)
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NRT and Cardiovascular Disease
Not an independent risk factor for acute
myocardial events
 Use with caution in patients who:
 are within 2 weeks of MI
 have serious arrhythmias
 have serious or worsening angina
pectoris
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Cessation Counseling Reimbursement
 Medicare, BCBSNC, SHP
ICD-9 Code: 305.1 (tobacco abuse)
 File in addition to visit’s E&M code
 Unbundled – can use a second ICD9 code
CPT Code:
 99406 – intermediate visit (3-10 minutes)
 99407 – intensive visit (> 10 minutes)
• No modifier required
 Medicaid adding two new CPT codes Jan. 1, 2009
 3 - 10 minutes
 >10 minutes
 Look for in January 2009 Medicaid Bulletin
o
http://www.dhhs.state.nc.us/dma/bulletin.htm
ICD-9: Diagnosis code
E&M: Evaluation and management code
CPT: Current procedural terminology code
NC Prevention Partners, NC AFP
Spring Family Physicians
Weekend, April 18, 2008
More Cessation Counseling
Reimbursement Codes
Other codes:
99401-04; 15-60 minutes (dedicated visit)
99354 can be added to regular visit (must
document counseling)
99411 is used for group counseling (per
participant)
MD, PA or FNP on premises, must talk to
group
RN (etc.) may facilitate session
Over the Counter Medications
Nicotine Patch
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Dose: 21mg, 14mg or 7mg per 24 hours
1
pack/day, start with higher dose, taper
 duration 8 weeks
 step down after 4 wks in 2 wk increments
 Nicotrol is used for 16 hours, off at night
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Adverse effects: local skin reaction, insomnia,
vivid dreams
Contraindications: Recent MI, unstable angina,
arrhythmia
Cost: 7mg box - $37
14mg box - $47
21mg box - $48
Over the Counter Medications
Nicotine Gum
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Dose: up to 24 pieces per day
 x 12 weeks (longer if needed)
 2mg for <25 cigarettes per day
 4mg for >25 cigarettes per day
 Chew, chew, park
 Avoid acidic beverages
Consider using on a fixed schedule
Long term patch and gum use are effective
Adverse Effects: Mouth soreness, hiccups, jaw ache,
dyspepsia
Contraindications: As for patch
Cost: 2mg box (100-170 pieces) ~ $45 (generic)
4mg box (100-110 pieces) ~ $63 (generic)
Over the Counter Medications
Nicotine Lozenge (Commit)
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Dose
 2mg (1st cig. >30 min. after awake)
 4mg (1st cig. <30 min. after awake)
 9 (min) to 20 (max) lozenges/day
 x 12 weeks (longer if needed)
Allow to dissolve in mouth
Avoid acidic beverages
Adverse Effects: Nausea, hiccups, heartburn
 4mg dose - headache, cough
Contraindications: as for patch
Cost: 2mg box (72 lozenges) - $34
4 mg box (72 lozenges) - $39
(9 lozenges/day =1 box/wk = $136-$156/mo)
Prescription Medications
Nicotine Inhaler
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Dose: 4mg nicotine
 80 puffs=4mg nicotine
 Best effects with frequent puffing/at least 6 cartridges
per day (can use 6-16 cartridges/day)
 Use for up to 6 months
 Reduce frequency over the last 6-12 weeks of tx
Avoid acidic beverages
Adverse Effects: mouth/throat irritation, coughing, rhinitis
Contraindications: as for patch
Cost: 1 box (168 10mg cartridges) - $196
Prescription Medications
Nicotine Nasal Spray
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Dose: 1 dose = 1 mg (0.5mg per nostril)
 1-2 doses per hour initially
 Increase as needed for symptom relief
 8 min/40 max doses per day for 3-6 months
 Do not sniff, swallow or inhale
 Head titled slightly back
Adverse Effects: Nasal irritation, congestion;
transient changes in smell, taste
Contraindications: as for patch
Cost: $49 per bottle (100 doses)
Prescription Medications
Zyban, Wellbutrin (bupropion SR 150)
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Begin 1-2 weeks before quit date
Dose: 150 mg in a.m. for 3 days
150 mg twice daily for 7 to 12 weeks
May consider long-term tx for 6 months post quit
Adverse Effects: Insomnia, dry mouth
Contraindications: history of seizure d/o, eating d/o, recent
MAO inhibitor use in past 14 days
Cost: 1 box of 60 tablets
 $97/month (generic)
 $197-$210 (brand name)
Prescription Medications
Chantix (varenicline)
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Stimulates nicotine receptors. Also blocks nicotine at
receptor site
Start Chantix 1 week before quit date
Dose: 0.5 mg daily for 3 days
0.5mg twice daily for 4 days
1.0mg twice daily for 3 months
May decrease dosage (1mg/day) if significant side effects
Adverse Effects: nausea, insomnia, abnormal/vivid dreams
New warning label Jan. 2008– observe for neuropsychiatric symptoms (post marketing data)
Cost: 1 box of 56 - $131 (~30 day supply)
Research shows that at 1 year, 21% of those on Chantix are still abstinent
compared to 8% with a placebo
More on Pharmacotherapy
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Evidence exists that combined therapy improves
abstinence rates
 For patients unable to use a single type
of first line agent
Patch + gum, nasal spray, or inhaler
Patch plus bupropriopn
Patch plus buproprion is FDA approved
Do not combine NRT with Chantix
Buproprion and gum may delay weight gain
Buproprion and lozenge may delay weight gain
NRT for smokers not willing to quit – promising
but warrants further research
Pregnancy and Pharmacotherapy
Abstinence early produces greatest benefits
 Quitting at any point yields benefits
 Person to person intervention should be
offered to pregnant and post partum women
that exceeds minimal advice to quit and is
more extended
 Inconclusive evidence that cessation
medications increase abstinence rates
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NC DMA Cessation
Medication Coverage
Medicaid now covers ALL cessation
pharmacotherapy
 Nicotine patch, gum, lozenge, nasal
spray, inhaler
 Zyban
Chantix
No Prior Authorization needed
Prescription required, even for OTC
You only have two minutes
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Ask every everyone about tobacco use
Advise to quit with a clear, strong, personalized
message
Refer to the Quitline or other resources
 NC Tobacco Use Quitline

1-800-QUIT-NOW (1-800-784-8669) and/or
 Become


an Ex
www.becomeanex.org
Pharmacotherapy - recommend cessation
medication (few exceptions)
Fax referral form and other
resources

www.QuitLineNC.com

www.tobaccopreventionandcontrol
.ncdhhs.gov/cessation
What happens when you call the
Quitline
First call - plan for 5 minutes to enroll
Readiness to quit determined
Caller inquiring for others, information
gathering
Caller would like to speak to a Quit Coach
Live transfer to a Quit Coach for those ready
to quit
Caller would like to speak to a
Quit Coach
One Call Program:
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Conversation with the
Quit Coach for support
Support materials for
quitting
Referral to local resources
Medication information
Help to develop a plan,
including setting a quit
date
Access to Web Coach
Four Call Program:
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One Call program, plus
Quit Coach will call back
-- A quit date is set
-- Dates and times are
made for three more
calls from a Quit
Coach
Three attempts, then letter
is sent
NC Tobacco Use Quitline Web Coach
and Click to Call features
Web Coach
For those enrolled in Quitline
Progress tracking, coaching e-mails
Discussion Forums
Click to Call
Click icon, enter phone number, Quitline
calls within minutes
Feature available on Web Coach
Take-Home Message for Health
Care Providers
Ask, Advise, Refer (1-800-QUIT-NOW)
 Brief cessation counseling is effective
 Longer cessation counseling is more effective
 Pharmacotherapy can double quit rates
 Pharmacotherapy should be offered to all
- few exceptions
 Evidence-based resources are available

Continuing Education Options

Medscape: Treating Tobacco Use and Dependence
http://www.medscape.com/viewarticle/570604
 Free
 Approved
for 1hour CE
AMA PRA Category
1 Credit(s)™
 Requires

registration to Medscape
TobaccoFreePatients.com
http://www1.tobaccofreepatients.com/TopicReq?
 Based
on NCI educational program
 Available free for study and review
 $15 per credit hour or for letter of completion
Tobacco Prevention and Control Branch
Resources
For downloadable resources
Visit our web site:
www.tobaccopreventionandcontrol.ncdhhs.gov
CONTACT:
Donna Dayer, Tobacco Cessation Specialist
e-mail: [email protected]
Main number: 919-707-5400
Office: 919-707-5415