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Evidence-Based Smoking Cessation Counseling for HIV-Infected Patients. Julia H. Arnsten, MD, MPH Chief, Division of General Internal Medicine Associate Professor of Medicine, Epidemiology, and Psychiatry Albert Einstein College of Medicine Montefiore Medical Center. - PowerPoint PPT Presentation
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Evidence-Based Smoking Cessation Counseling for
HIV-Infected Patients
Julia H. Arnsten, MD, MPHChief, Division of General Internal Medicine
Associate Professor of Medicine, Epidemiology, and PsychiatryAlbert Einstein College of Medicine
Montefiore Medical Center
Submitted by the NY/NJ AETC
Background
• More than 50% of HIV-infected patients smoke• Smoking poses unique health risks to HIV-
infected patients– pulmonary infections
– oropharyngeal lesions
– AIDS-defining and non-AIDS-defining malignancies.
• “Graying” of HIV-infected population necessitates screening for and prevention of chronic disease– Coronary heart disease
– Diabetes
– Obesity
Prevalence of Current Smoking in HIV-Infected Persons in 5 Cross-Sectional Studies
2001 – 2005
0
10
20
30
40
50
60
70
80
PCHIS(n=548)
SF General(n=228)
Houston(n=348)
HCSUS(n=2,864)
NYC(n=428)
PCHIS = SF, LA, IL, NJ, NY, MI; HCSUS = 8 metropolitan areas
Prevalence of smoking among HIV-infected patients in NYC
Burkhaler et al, Tobacco use and readiness to quit smoking in low-income HIV-infected persons, Nicotine Tob Res, 2005; 7(4):511-22.
• 428 HIV+ Medicaid recipients, NYC– Age: 22-75
– 59% males
– 53% African Americans, 30% Latinos
– HS education or less : 87%
• 67% current smokers (mean = 16 cig/day)• 19% former smokers, 16% never smokers• Current smokers
– Greater use of illicit substances (ever and current)
– Lower perceived health risk of continued smoking
Adult smoking rates
NYC
2003 21.5%
2004 18.9%
USA
2003 21.6%
2004 20.7%
HIV Patients are Living Longer
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1994 1995 1996 1997 1998 1999 2000 2001 2002
% o
f to
tal
HIV
/AID
S d
isch
arge
s
0-19 20-29 30-49 50+
Distribution of HIV/AIDS Discharges by Age-group, 1994-2002 (NYS)
Source: SPARCS (Statewide Planning and Research Cooperative System)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1993 1994 1995 1996 1997 1998 1999 2000 2001
%
0-19 20-29 30-49 50+
Source: NYS Medicaid Claims Database
Distribution of Medicaid recipients with HIV/AIDS by age group, 1993-2001 (NYS)
Living Longer = Changing Morbidity and Mortality
Cancer
Lung disease
Cardiovascular disease
Cancer rates before and after HAART
AIDS-Defining and Non AIDS-Defining Malignancies (non-ADM) Before and
After HAARTBedimo, R et al. Trends in AIDS-defining and non-AIDS-defining malignancies
among HIV-infected patients: 1989-2002. Clin Inf Dis 2004;39:1380-1384
0
5
10
15
20
25
30
35
40
89-96 97-02
ADM non-ADM
Ca s
es p
er 1
000
p at-
year
s
0
25
50
75
100
125
150
1994 1995 1996 1997 1998 1999 2000 2001 2002
Pe
r 1
00
,00
0 H
IV/A
IDS
dis
ch
arg
es
HAART
Cancers of the larynx and oropharynx
0
20
40
60
80
100
120
140
160
1993 1994 1995 1996 1997 1998 1999 2000 2001
Pe
r 1
00
,00
0 r
eci
pie
nts
with
HIV
/AID
S
Oropharynx Larynx
HAART
0
100
200
300
400
500
600
700
800
1994 1995 1996 1997 1998 1999 2000 2001 2002
Per
100
,000
HIV
/AID
S d
isch
arge
s
Lung, Trachea
Source: SPARCS
Cancers of the lung/tracheaCancers of the lung/trachea
Lung disease
Chronic Bronchitis and Emphysema
0
200
400
600
800
1000
1200
1400
1994 1995 1996 1997 1998 1999 2000 2001 2002
per 1
00,0
00 H
IV/A
IDS
dis
char
ges
Chronic Bronchitis Emphysema
Source: SPARCS database, NYSDOH
Cardiovascular disease
Myocardial infarction
0
0.5
1
1.5
2
2.5
3
3.5
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Ra
te p
er
10
00
pa
tien
t-yr
s
Holmberg et al. Trends in rates of Myocardial infarction among patients with HIVN Engl J Med 2004; 350:730-731
0
100
200
300
400
500
600
700
800
1994 1995 1996 1997 1998 1999 2000 2001 2002
per 1
00,0
00 H
IV/A
IDS
disc
harg
es
Acute Myocardial Infarction
Source: SPARCS database, NYSDOH
Risk Factors Are Additive The total severity of multiple low-level risk factors often exceeds that of a single severely elevated risk factor.
8%
Grundy SM et al. J Am Coll Cardiol 1999;34:1348-1359.
BP 165/95 mm Hg BP 165/95 mm HgAge 56 years
BP 165/95 mm HgAge 56 years
LDL-C 155 mg/dL
BP 165/95 mm HgAge 56 years
LDL-C 155 mg/dLSmoker
13%
19%
27%
0
5
10
15
20
25
30
Mea
n A
bsol
ute
Ri s
k (%
)
Are physicians intervening in tobacco use?
Ellerbeck, Ahluwalia, et al. Direct observation of smoking cessation activities in primary care practice. J Fam Pract. 2001; 50:688-693
In 38 primary care practices:
Tobacco was discussed in 21% of encounters.
Discussion was:– more common in those practices (58%) with standard forms for
recording smoking status
– more common during new patient visits
– less common with older patients
– less common with physicians in practice more than 10 years
Barriers to treating tobacco dependence
“Not enough time.”
“Patients don’t want to hear about it.”
“I can’t help patients stop.”
“Not enough time”
“Minimal interventions lasting less than 3
minutes increase overall tobacco abstinence
rates.”
The PHS Guideline
(Strength of Evidence = A)
“Patients don’t want to hear about it”
• In several studies, smoking cessation interventions during physician visits were associated with increased patient satisfaction with care among smokers
• 1,898 patients who reported that they had been asked about tobacco use or advised to quit during the latest visit had 10% greater satisfaction rating and 5% less dissatisfaction than those not reporting such discussions Mayo Clin Proc. 2001;76:138-143
Proportion of Patients Reporting Positive Changes in Health Promoting Behavior
Following Diagnosis with HIVCollins et al, Health Psychology 2001; 20(5):351-360
0102030405060708090
100
Exercise Diet Smoking Alcohol-druguse
Proportion of Patients Interested in Quitting Smoking
Mamary et al, Cigarette smoking and the desire to quit among individuals living with HIV, AIDS Patients Care and STDs 2002; 16(1):39-42
0102030405060708090
100
Thinking aboutquitting
Interested in agroup
Interested in NRT
“I can’t help patients stop”
Effective clinical interventions exist
The Public Health Service Clinical Practice Guideline Treating Tobacco Use and Dependence was published in June, 2000 and offers effective treatments for tobacco dependence.
Summary Algorithm for Treating Tobacco Dependence
The 5 A’sFor Patients Willing To Quit
• ASK about tobacco use at every visit.• ADVISE to quit with a clear, strong, personalized
message.• ASSESS willingness to make a quit attempt within
the next 30 days.• ASSIST in quit attempt with a brief (3-5 min)
counseling intervention.• ARRANGE for follow-up (ANTICIPATE relapse).
ASK
VITAL SIGNS Blood Pressure: _______________________________ Pulse: ________________ Weight: _______________ Temperature: ________________________________ Respiratory Rate: _____________________________ Tobacco Use: Current Former Never (circle one)
EVERY patient at EVERY visit
ADVISE
• Once tobacco use status has been identified and documented, advise all tobacco users to quit
• Even brief advice to quit results in greater quit rates
• Advice should be:- clear - strong- personalized
“As your health care provider, I must tell you that the most important thing you
can do to improve your health is to stop smoking.”
ASSESS
After providing a clear, strong, and personalized message to quit, you must determine whether the patient is willing to quit at this time
“Are you willing to try to quit at this time? I can
help you.”
ASSIST• Help develop a quit plan• Provide practical counseling
– Identify events, internal states, or activities that increase the risk of smoking or relapse (e.g. drinking, other smokers).
– Identify and practice coping or problem-solving skills.– Provide basic information about smoking and successful quitting.
• Provide intra-treatment social support– Encourage the patient in the quit attempt.– Communicate caring and concern.– Encourage the patient to talk about the quitting process
• Help patient obtain extra-treatment social support• Recommend pharmacotherapy (ex. special circumstances)• Provide supplementary materials
Developing a quit plan• Set a quit date
• Review past quit attempts
• Anticipate challenges
• Remove tobacco products
• Avoid
– Alcohol use
– Exposure to tobacco
Counsel your patients to quit
“Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates”
The PHS Guideline
(Strength of Evidence = A)
“There is a strong dose-response relation between the session length of person-to-person contact and successful treatment outcomes. Intensive interventions are more effective than less intensive interventions and should be used whenever possible”
The PHS Guideline
(Strength of Evidence = A)
Brief Intervention
• 5-15 minute counseling session• Four components
– State your concern about your patient’s behaviors (smoking, use of alcohol/drugs, diet)
– Make explicit recommendation for change in behavior
– Discuss patient’s reaction– Review treatment options; negotiate plan
ARRANGE and ANTICIPATE
• Schedule a follow-up contact within one week after the quit date– Telephone contact– Quit lines
• The majority of relapse occurs in the first two weeks after quitting
• Preventing Relapse– Congratulate success– Encourage continued abstinence– Discuss with your patient:
• benefits of quitting• barriers
• If your patient has used tobacco, remind him or her that the relapse should be viewed as a learning experience
• Relapse is consistent with the chronic nature of tobacco dependence; not a sign of failure
Relapse
“How has stopping tobacco use helped
you?.”
Cell Phone Intervention Pilot Study: Houston, Texas
Lazev et al, Increasing access to smoking cessation treatment in a low-income, HIV-positive population: The feasibility of cellular telephones. Nicotine &
Tobacco Research, 2004; 6(2):281-286.
• Pilot study of a proactive cell phone smoking cessation intervention (n=20)
• Thomas St. Clinic – 4000 medically indigent patients (mostly Black and Hispanic)
• Six scheduled cell-phone delivered counseling sessions delivered over two weeks (1 d prior to quit date, on quit date, and 2, 4, 7, and 14 d post) – average 5 min
• 24 hr/7 d/week quit line, patient info also provided• Highly successful: 95% made a quit attempt and 75% were
abstinent at 1 and 2 weeks post quit date
A Nurse-Managed, Peer-Led Cessation Intervention for HIV-Positive Smokers
Wewers et al, Jour Assn of Nurses in AIDS Care 2000; 11(6):37-44
• Randomized trial of 15 participants
• Intervention = weekly counseling sessions plus NRT
• Control group = written materials
• Follow-up: 8 weeks, 8 months
• Outcomes = point abstinence and continuous abstinence
0102030405060708090
100
8 week 8 month
Intervent
Control
Treating patients who are not ready to make a quit attempt with Motivational Interviewing (a Form
of Brief Intervention)
• RELEVANCE: Tailor advice and discussion to each patient, avoid argument!
• RISKS: Outline specific risks of smoking.
• REWARDS: Outline the benefits of quitting.
• ROADBLOCKS: Identify barriers to quitting.
• REPETITION: Reinforce the motivational message at every visit, avoid argument!
Motivational Interviewing
Motivational interviewing is a directive, client-centered counseling style for eliciting
behavior change by helping clients to explore and resolve ambivalence.
Stephen Rollnick, William R. Miller, 1995
Rollnick, S., & Miller, W. R. What is motivational interviewing? Behavioural and Cognitive Psychotherapy. 1995;23:325-334.
Readiness to Change Model Precontemplation Relapse
Contemplation Maintenance
Preparation Action
Stages of Change in Two Populations of HIV-Infected Smokers, Compared to
General Population
0
10
20
30
40
50
60
70
Precont Contemp Prep
New York
Houston
Gen Pop
NY: Burkhaler et al, Tobacco use and readiness to quit smoking in low-income HIV-infected persons, Nicotine Tob Res, 2005; 7(4):511-22.Houston: Gritz et al, Smoking behavior in a low-income multiethnic HIV/AIDS population, Nicotine Tob Res, 2004; 6(1):71-77.
Precontemplation
Goal is to raise doubt, increase perception/ consciousness of problemexpress concernstate the problem non-judgmentallyagree to disagreeadvise a trial of abstinence or cutting down importance of follow-up (even if still smoking/using drug
& alcohol ) less intensity is better
Samet, JH, Rollnick S, Barnes H. Arch Intern Med. 1996;156:2287-93.
ContemplationGoal is to tip the balance
elicit positive and negative aspects of smoking or drug & alcohol use
elicit positive and negative aspects of not smoking or using drugs & alcohols
summarize (patient could write these down)demonstrate discrepancies between values and actionsadvise a trial of abstinence or cutting down
PreparationGoal is to help determine the best course of action
working on motivation is not helpfulsupporting self-efficacy is (remind of strengths--i.e.
previous quits, periods of sobriety, coming to doctor)help decide on achievable goalscaution re: difficult road ahead relapse won’t disrupt relationship
ActionGoal is to help patient take steps to change
support and encouragementacknowledge discomfort (losses, withdrawal) reinforce importance of recovery
MaintenanceGoal is to help prevent relapse
anticipate difficult situations (triggers) recognize the ongoing strugglesupport the patient’s resolve reiterate that relapse won’t disrupt your relationship
RelapseGoal is to renew the process of contemplation
explore what can be learned from the relapseexpress concernemphasize the positive aspects of prior abstinence and of
current efforts to quit smoking or drug & alcohol usesupport self-efficacy
Ingredients of Effective Brief Interventions (FRAMES)
FEEDBACK of personal risk or impairment i.e. CHD, lung disease, state consequences or risks
emphasis on personal RESPONSIBILITY for change“…it’s up to you to decide…”
clear ADVICE to change identify the problem, explain why change is important,
advocate specific change
Ingredients of Effective Brief Interventions (FRAMES)
a MENU of alternativesa range of options
EMPATHIC counseling styleunderstanding and reflective
enhancement of SELF-EFFICACYreinforce it, state your belief they can do it
Physician’s Treatment Goals
• Maintain awareness of smoking (and other drug & alcohol issues)
• Ask, assess and advise about smoking• Consider smoking (and drug & alcohol problems) as
a mainstream medical issues• Counsel patients about behavior change at every
visit
SMOKING CESSATION FOR THE SECONDARY PREVENTION OF CORONARY HEART DISEASE
Critchley, J. Capewell, S. Cochrane Heart Group Cochrane Database of Systematic Reviews. 1, 2006
BACKGROUND
• Smoking is an established risk factor for coronary heart disease
• The impact of smoking cessation on risk for coronary heart disease is less well established
METHODS
• Meta-analysis to estimate the magnitude of risk reduction when a patient with CHD stops smoking
• Search: – Cochrane Register of Controlled Trials (CENTRAL),
MEDLINE, EMBASE, Science Citation Index, CINAHL, PsychLit, Dissertation Abstracts, BIDSISI Index to Scientific and Technical Proceedings, UK National Research Register
METHODS
• Selection: – Prospective cohort studies of patients with a diagnosis
of CHD, which include all-cause mortality as an outcome measure
– Smoking status measured at least twice to ascertain which smokers have quit
– Subjects followed-up for at least two years
RESULTS
• Twenty studies• Reduction in crude relative risk (RR) of mortality
for those who quit smoking compared with those who continued to smoke – RR 0.64, 95% confidence interval 0.58 to 0.71
• Reduction in non-fatal myocardial infarctions – RR 0.68, 95% confidence interval 0.57 to 0.82
RESULTSSIX HIGHEST QUALITY STUDIES
CONCLUSION
• Smoking cessation is associated with a substantial reduction in the risk of all-cause mortality among patients with CHD
• Risk reduction comparable with other secondary preventive therapies such as cholesterol lowering
• The risk reduction associated with smoking cessation consistent regardless of differences between the studies in terms of index cardiac events, age, sex, country, and time period
Recommended