Tobacco Treatment and E-cigarettes: A Clinical Practice ...Electronic cigarettes Dual Use Most adult...

Tobacco Treatment and E-cigarettes: A

Clinical Practice Guideline Update

Allison Gorrilla, MPHOutreach SpecialistUniversity of Wisconsin School of Medicine and Public HealthUW Center for Tobacco Research and Intervention

November 3rd, 2017

Disclosure

Allison Gorrilla has no relevant disclosures

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Understand the changing face of tobacco use in Wisconsin

Review and provide an update to the 2008 Clinical Practice Guidelines: Treating Tobacco Use and Dependence recommendations

Including how to address e-cigarette use

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UW-Center for Tobacco Research and

Intervention

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Who We Are:

Research/Outreach and policy organization focusing on treating nicotine dependence

What We Do:

Manage the Wisconsin Tobacco Quit Line

Provide education and TA to support systematic treatment of tobacco dependence

UW-CTRI Outreach Specialists

Northwestern

Kris Hayden

Eau Claire, WI

Northeastern

Roger Dier

Oshkosh, WI

Southern

Amy Skora

Madison, WI

Southeastern

Allison Gorrilla

Milwaukee, WI

Smoking Prevalence Among Adults

18 and Older, United States, 1965-2015

Source: NHIS

2015 = 17%

#The Need Continues

Almost 50 million Americans continue to use tobacco

Half of smokers will die from tobacco-related disease if they don’t quit

On average, smokers are robbed of 13-14 years of life compared to non-smokers

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#The Need Continues

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More than 480,000 deaths/year nationally.

More than 8,000 deaths/year in Wisconsin.

1 out of every 5 deaths in Wisconsin and America are directly caused by smoking.

The Changing Face of Tobacco Use

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Tobacco is not an equal opportunity killer

The highest rates of tobacco use and tobacco-related health disparities are concentrated in our most vulnerable, underserved communities

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Tobacco Use Disparities in Wisconsin

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The low socioeconomic status/Medicaid

The least educated

Those with co-morbid mental health or

addictive disorders

Certain racial and ethnic minorities (e.g.:

Native Americans) LGBT community

Tobacco Use Disparities in Wisconsin

Tobacco Use Disparities in Wisconsin

Urban vs. Rural tobacco use

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Tobacco Use Disparities in Wisconsin

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Tobacco Use Disparities in Wisconsin

Understanding the Barriers

Access barriers

Insurance coverage

Financial constraints

Reduced access to quality health care

Belief Barriers

Willpower is sufficient for successful quitting

Cessation medications are ineffective, dangerous,

addicting, or too costly

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Understanding the Barriers

Tobacco industry targeting of certain communities

High-density of tobacco retailers in certain zip-

codes

Targeting of menthol products to African-

Americans and the LGBT community

Steep discounts at point-of-sale and through

mailed coupons in certain zip-codes.

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Meeting the Need

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The Guideline

2008 - Updated Guideline published

Literature from 1975 – 2007

Approximately 8,700 total articles

Key Guideline Recommendations

Tobacco dependence is a chronic disease that often

requires repeated intervention

All tobacco users should be screened for tobacco use,

advised to quit, and be offered an intervention

Effective tobacco dependence treatments consist of

Brief coaching/counseling

At least one of the 7 FDA-approved medications

System-level changes that integrate evidence-based cessation

treatment as the standard of care

Innovations in Cessation

Combining counseling and medication

Varenicline and combination NRT as particularly effective medication options

Pre-quit use of NRT + reduction counseling

Long-term NRT

Using Quit Lines as treatment extenders

E-cigarettes

Counseling and medication

The combination of counseling and medication is more effective than either alone

Cessation Medications

2 non-nicotine prescription-only pills:

Bupropion SR (Zyban or Wellbutrin)

Varenicline(Chantix)

5 nicotine replacement

therapies:

Nicotine patch

Nicotine gum

Nicotine lozenge

Nicotine nasal spray

Nicotine inhaler

Seven FDA-approved medications reliably increase long-term

abstinence rates

Recommended Treatment

Varenicline

Combination NRT

Patch + gum

Patch + lozenge/mini-lozenge

Patch + inhaler

+

Discuss medication options

Review patient’s hx of medication use, address concerns

Recommend medication based on effectiveness, patient preferences, cost, contraindications

Encourage medication adherence

Consider optional pre-quit nicotine patch use (2-3 weeks) with smoking reduction

Long-term NRT use is safe and effective

The 5A brief intervention

ASK about tobacco use at every visit

ADVISE all users to quit

ASSESS willingness to make a quit attempt

ASSIST quitting with evidence-based treatments

ARRANGE follow-up

Tobacco Cessation Brief Intervention Protocol

http://ctri.wisc.edu/page-factsheets.htm

http://ctri.wisc.edu/page-factsheets.htm

Wisconsin Tobacco Quit Line (WTQL)

The Clinical Practice Guideline identifies and endorses the power of individual, group and telephone counseling

Counseling from the Wisconsin Tobacco Quit Line can quadruple the chances of a tobacco user quitting for good

Launched in May 2001

Free, confidential, tailored phone-based program available 24/7

Quit Line Services

Quit Coach calls

1 outbound phone call Tobacco users can call whenever they need

Nicotine Replacement Therapy (NRT)

2 week starter kit of the patch, gum, or lozenge mailed to their home

18 yo and older; once per 12 months Online Web Coach; mobile app

Quit Kit self-help guide/materials

Information for others

Integrating the WTQL

Healthcare

professional role:

Provide brief

intervention: Urge tobacco user to quit

Ask if they are willing to quit

Ask if they are willing to talk

to the Quit Line

Prescribe cessation

medication(s), if appropriate

Quit Line role:

Used as a treatment

extender for

intensive counseling

and 2 weeks of NRT

Fax to Quit – Referral to the WTQL

Efficient way to connect tobacco users who are ready to quit directly to the Quit Line

After training by UW-CTRI, site receives a customized referral form

Staff fax the referral form for interested smoker to the Quit Line

Quit Line coach proactively calls the tobacco user

Referring site is kept in the loop (referral outcome report)

The Changing Landscape of

Tobacco Products: An Update on E-

cigarettes

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Electronic cigarettes

Electronic cigarettes (e-cigarettes) and other “vaping” devices are battery-operated products designed to deliver nicotine, flavor, and other chemicals

Electronic cigarettes

Safety

E-cigarette aerosol is not harmless; however, e-cigarette aerosol generally contains fewer toxicants than smoke from combustible tobacco products

Studies have found harmful elements in e-cigarettes such as heavy metals, volatile organic compounds, and cancer-causing agents

Based on current understanding, e-cigarettes are less dangerous than continued smoking if used by combustible tobacco smokers as a complete substitute for all combustible tobacco products

Electronic cigarettes

Dual Use

Most adult e-cigarette users also smoke conventional cigarettes

9.8%

2.5% 1.3%

36.5%

9.6%

1.2%0%

5%

10%

15%

20%

25%

30%

35%

40%

Current

Smokers

Former

Smokers

Never Smokers

2010

2013

Electronic cigarettes

Youth Use

A Clinical Approach to E-cigarettes

Studies on effectiveness of e-cigarettes as a cessation aid are few, with mixed and modest results

Some show cessation effectiveness about equal to NRT

Due to very limited cessation data, neither the PHS Guideline nor the Preventive Service Clinical Task Force has recommended E-cigarettes as a cessation aid

No long-term safety data

A Clinical Approach to E-cigarettes

When asked about e-cigarettes as a smoking cessation option clinicians can:

Focus on the known, very substantial risks of combustible cigarettes

Urge the patient to use evidence-based counseling and medications to quit

If the patient decides instead to try e-cigs, inform him or her that:

We don’t have information regarding long term health effects

Dual use should be avoided

They should ideally be used as a bridge off combustibles and ultimately off all tobacco agents and medications

In Summary

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Your clinic

Can fill the gap in access to and

knowledge of evidence-based

tobacco cessation treatments

Smoking Prevalence Among Adults

18 and Older, United States, 1965-2015

Source: NHIS

2015 = 17%

Questions

&

Discussion

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Allison Gorrilla, MPH

UW-Center for Tobacco Research

and Intervention

414-333-3067

agorrilla@ctri.wisc.edu

ctri.wisc.edu

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