102
Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 June 2009 Tobacco Prevention & Control Tobacco Prevention & Control Branch Branch Division of Public Health, DHHS Division of Public Health, DHHS

Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Embed Size (px)

Citation preview

Page 1: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Comprehensive Overview ofNorth Carolina Tobacco Use and

Evidence Based Cessation Methods and Resources

June 2009 June 2009

Tobacco Prevention & Control BranchTobacco Prevention & Control BranchDivision of Public Health, DHHSDivision of Public Health, DHHS

Page 2: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Tobacco Use

The number one preventable cause of death The number one preventable cause of death in the United States and North Carolinain the United States and North Carolina

Page 3: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Estimated Preventable Causes of Death Estimated Preventable Causes of Death in North Carolina (2007)in North Carolina (2007)

Source: NC SCHS Health Profile of North Carolinians: 2009 Update Source: NC SCHS Health Profile of North Carolinians: 2009 Update North Carolina Department of Health and Human ServicesNorth Carolina Department of Health and Human Services

13,720

12,584

2,653

2,350

1,743

1,510

1,364

910

758

606

531

0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000

Tobacco

Diet/Phys. Inactivity

Alcohol

Microbial Agents

Toxic Agents

Medical Error

Motor Vehicles

Firearms

Uninsurance

Unsafe Sex

Illicit Drug Use

Estimated Number of Deaths

Page 4: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Tobacco Use Today

United StatesUnited States North North CarolinaCarolina

Deaths 438,000/yr.Deaths 438,000/yr. 13,720/yr. 13,720/yr.

Medical Medical (US state average)(US state average)

CostsCosts $1.89 billion $1.89 billion $2.46 billion $2.46 billion

Total Total costs $150 billion costs $150 billion $6.77 billion $6.77 billion

Source: Centers for Disease Control and Prevention. SAMMEC, 2000-2004Source: Centers for Disease Control and Prevention. SAMMEC, 2000-2004http://www.cdc.gov/tobacco/data_statistics/state_data/data_highlights/2006/00_pdfs/DataHighlights06table4.pdfhttp://www.cdc.gov/tobacco/data_statistics/state_data/data_highlights/2006/00_pdfs/DataHighlights06table4.pdf

Page 5: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Current Use Among NC Adults (aged >18 yrs), NC BRFSS, 2008

25.7 26.224.8

22.5 22.6 22.1 22.920.9

0

5

10

15

20

25

30

2001 2002 2003 2004 2005 2006 2007 2008

* Current smoking- everyday or some daysSource: NC BRFSS 2000-2006

Page 6: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Current Smoker Prevalence NC and US, 2005, 2006 & 2007 BRFSS

22.6 22.1 22.920.6 20.1 19.8

2005 2006 2007

Year

Perc

ent

NC

US

Page 7: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Percentage of Adults Who Smoke Cigarettes by Race/Ethnicity - NC BRFSS, 2008

21.1 22.3

13.7

34.9

14.9

0

5

10

15

20

25

30

35

40

White AfricanAmerican

Hispanic NativeAmerican

Other

Note: Current users report using either every day or on some days Source: NC State Center for Health Statistics NC BRFSS

Page 8: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Percentage NC Adults Reporting Current Smoking, by Education—NC BRFSS, 2008

29.6 27.9

21.0

9.7

0

10

20

30

40

50

< HS HS Graduate Some College CollegeGraduate

Education

Per

cent

Note: Current users report using either every day or on some days Source: NC State Center for Health Statistics NC BRFSS

Page 9: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

14.013.2 12.7 12.5 12.4

11.5 11.2

14.014.314.915.115.715.917.1

17.718.5

19.520.620.921.3

0

5

10

15

20

25

Per

cen

tage

Percentage of Pregnant Women Percentage of Pregnant Women Reporting Smoking Status in NC – Reporting Smoking Status in NC –

North Carolina Birth Records, 1988-2007North Carolina Birth Records, 1988-2007

Source: NC Vital Records File from Odum Institute at UNC; Vital Statistics, 2007

Page 10: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Women Who Smoked 3 Months Before Pregnancy, During the Last 3 Months and After Pregnancy, NC PRAMS, 2006 and 2007

17.6

13.0

21.9

17.9

14.3

22.9

Before Pregnancy During the Last 3 Months After Pregnancy

Perce

nt

2006 2007

Page 11: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Current Smokers Among Middle & High School Students in North Carolina

15.0%

11.3%9.4%

5.8%4.5%

32.5%

28.1% 28.0%

20.9%19.4%

0.0%

7.0%

14.0%

21.0%

28.0%

35.0%

1999 2001 2003 2005 2007

Middle School High SchoolResults based on North Carolina Youth Tobacco Survey administered biannually since 1999

Page 12: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Percentage of Middle and High School Students Reporting Current Tobacco Use*, by Type – NC Youth Tobacco Survey: 2007

Note: *Smoking 1 or more cigarettes during the previous 30 days. Bidis (also known as beedis or beedies) are small brown cigarettes, often flavored, consisting of tobacco hand-rolled primarily produced in India and in some Southeast Asian countries.

Source: North Carolina Youth Tobacco Survey, 2007

9.1

4.53.9

2.3 2.2

26.6

19.0

13.0

8.6

3.1

0

5

10

15

20

25

30

Any Tobacco Cigarette Cigar Smokeless Tobacco Pipe

Per

cent

age

NC Middle School

NC High School

Page 13: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

The Toll of Tobacco Use

In North Carolina: Total health care costs from

smoking: $2.46 billion Portion covered by state Medicaid

program: $769 million

Campaign for Tobacco-Free Kids, “The Toll of Tobacco in North Carolina” Fact Sheet accessed May 19, 2008 at http://www.tobaccofreekids.org/reports/settlements/toll.php?StateID=NC

Page 14: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Sticker Shock…In the United States more thanIn the United States more than

$75,000,000,000$75,000,000,000of annual healthcare costs are of annual healthcare costs are attributable directly to smoking.attributable directly to smoking.

National Institute on Drug Abuse Research Report Series, What is the Extent and Impact of Tobacco Use?, July 2006

Page 15: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division
Page 16: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

http:///www.cdc.gov/tobacco/

Surgeon General’s Report on Secondhand Smoke

July 2006

Page 17: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

2006 SGR: Major Conclusions

The debate is over.The debate is over.

Secondhand smoke is a serious health hazard and causes early death and Secondhand smoke is a serious health hazard and causes early death and disease in North Carolinians who do not smoke. disease in North Carolinians who do not smoke.

The scientific evidence indicates there is The scientific evidence indicates there is no risk-free levelno risk-free level of exposureof exposure to secondhand smoketo secondhand smoke

Ventilation does not protect people from being exposed to SHS , only Ventilation does not protect people from being exposed to SHS , only elimination of all smoking protects SHS (supported by ASHRAE)elimination of all smoking protects SHS (supported by ASHRAE)

American Society of Heating, Refrigerating, American Society of Heating, Refrigerating, and Air Conditioning Engineersand Air Conditioning Engineers

Page 18: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

2006 SGR’s Major Conclusions

SHS exposure of adults causesSHS exposure of adults causes Immediate adverse affects on the Immediate adverse affects on the

cardiovascular systemcardiovascular system Coronary heart diseaseCoronary heart disease

30,000 deaths/yr 30,000 deaths/yr Lung cancerLung cancer

estimated 3000 deaths/yr estimated 3000 deaths/yr

CDC. Annual smoking-attributable mortality, years of potential life lost, and economic costs – United States,1995-1999. Morbidity and Mortality Weekly Report 2002. 51(14):300-303.

Page 19: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

CDC recently reviewed the literature and issued this commentary:

All patients at risk of coronary heart All patients at risk of coronary heart disease or with known coronary artery disease or with known coronary artery disease should be advised to avoid all disease should be advised to avoid all indoor environments that permit indoor environments that permit smoking.smoking.

Source: British Medical Journal, 2004Source: British Medical Journal, 2004

Page 20: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Helena, Montana Study Smoking ban for 6 monthsSmoking ban for 6 months Reduced incidence of admissions for myocardial Reduced incidence of admissions for myocardial

infarction ofinfarction of 40% 40% during banduring ban MI admissions increased when ban rescindedMI admissions increased when ban rescinded

Sargent, RP, et al. BMJ, 328:977-980, 2004.Sargent, RP, et al. BMJ, 328:977-980, 2004. Replicated in studies: Replicated in studies:

France (15%)France (15%) Scotland (17%)Scotland (17%) Ireland (14%)Ireland (14%) Indiana (59%)Indiana (59%) New York State (3,813 fewer MI admissions)New York State (3,813 fewer MI admissions)

Page 21: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Cardiovascular Risks of Second Hand Smoke MI risk from tobacco smoke exposure is MI risk from tobacco smoke exposure is

biologically feasiblebiologically feasible Small exposures (30 minutes) can induce Small exposures (30 minutes) can induce

changes in vessels in people at riskchanges in vessels in people at risk Short term reductions in exposure reduces Short term reductions in exposure reduces

heart attacks heart attacks

Pechacek,T., Babb, S. Commentary: How Acute and Reversible Are The Pechacek,T., Babb, S. Commentary: How Acute and Reversible Are The Cardiovascular Risks of Second Hand Smoke? BMJ, 328:980-983, April 24, Cardiovascular Risks of Second Hand Smoke? BMJ, 328:980-983, April 24, 2004.2004.

Page 22: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Working 8hours where smoking isallowed has thesame healthrisks as activesmoking.

Second Hand Smoke – Health Risk in Workplaces

Whincup, P et. al., Passive smoking and risk of coronary heart disease and stroke: prospective study with cotinine measurementBMJ, Jun 2004; 10.1136/bmj.38146.427188.55

Page 23: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

2006 SGR’s Major Conclusions

Infants and children are at Infants and children are at increased risk forincreased risk for SIDS (Sudden Infant Death Syndrome)SIDS (Sudden Infant Death Syndrome) acute respiratory infections acute respiratory infections ear problemsear problems more severe asthma more severe asthma decreased lung growth decreased lung growth increased cases of bronchitis, increased cases of bronchitis,

pneumonia, and ear infectionspneumonia, and ear infections

Page 24: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

More sticker shock…Secondhand Smoke Costs - NCSecondhand Smoke Costs - NC

$289,000,000$289,000,000

This is a conservative estimate – does not consider:This is a conservative estimate – does not consider: lost productivity lost productivity impact on quality of lifeimpact on quality of life long-term care and disability serviceslong-term care and disability services

North Carolina’s Secondhand Smoke Healthcare Cost Burden, Pfannenschmidt and Wansink, Clinical Informatics Department, Blue Cross and Blue Shield of North CarolinaClinical Informatics Department, Blue Cross and Blue Shield of North Carolina

Page 25: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Effects on Youth

Effects of secondhand smoke/active smokingEffects of secondhand smoke/active smoking Increases asthma significantly (15%) increaseIncreases asthma significantly (15%) increase $1.34 million/yr excess medical costs$1.34 million/yr excess medical costsSturm, J. et al: Effects of Tobacco Smoke Exposure on Asthma Prevalence and Medical Care Use in NC Sturm, J. et al: Effects of Tobacco Smoke Exposure on Asthma Prevalence and Medical Care Use in NC

Middle School Children. American Journal of Public Health, 94(2):308-313. Feb. 2004Middle School Children. American Journal of Public Health, 94(2):308-313. Feb. 2004

Effects of secondhand smokeEffects of secondhand smoke Cognitive declines (decreases reading, math and Cognitive declines (decreases reading, math and

block design)block design) Lower scores on reading and visuo-spatial testingLower scores on reading and visuo-spatial testingYolton, K. et al: Exposure to Environmental Tobacco Smoke and Cognitive Abilities among U.S.

Children and Adolescents. Environmental Health Perspectives, 113(1):98-103. January 2005

Page 26: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Yolton, K. et al (2005). Exposure to Environmental Tobacco Smoke and Cognitive Abilities among US Children and Adolescents. Environmental Health Perspectives, Vol 113 (1), 98-103.

Page 27: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

2004 Surgeon General’s Report 2004 Surgeon General’s Report

The Health Consequences of SmokingThe Health Consequences of Smoking

Page 28: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

2004 Surgeon General’s Report - The Health Consequences of Smoking

“Doom and Gloom” 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 COPD,

pneumonia, cataracts, periodontitis, AAA, and

cancers of lung, pancreas, stomach, cervix, kidney

Page 29: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

2004 SGR – Smoking and Youth

Children and adolescents who smoke have:Children and adolescents who smoke have:

physical fitnessphysical fitness lung function lung function lung growthlung growth respiratory illnessrespiratory illness chronic cough and wheezechronic cough and wheeze

Page 30: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

2004 SGR – Smoking and Pregnancy

Smoking during pregnancy Smoking during pregnancy Low birth weightLow birth weight StillbirthStillbirth Sudden Infant Death SyndromeSudden Infant Death Syndrome

Risk doubles - smoking after birthRisk doubles - smoking after birth Risk 3-4 times greater - smoking before and afterRisk 3-4 times greater - smoking before and after

NicotineNicotine blood flow to fetusblood flow to fetus found in breast milkfound in breast milk

Page 31: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

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 Interagency Committee on Smoking and Health, 2000

Page 32: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Tobacco dependence as a chronic disease Permanent abstinence is the goalPermanent abstinence is the goal

Congratulate smaller successes Congratulate smaller successes Quitting consists of multiple relapses and Quitting consists of multiple relapses and

remissionremission Few quit for good on first attemptFew quit for good on first attempt Each attempt is a learning experienceEach attempt is a learning experience No single ideal interventionNo single ideal intervention Relapse is risk for weeks, months, yearsRelapse is risk for weeks, months, years

Requiring ongoing interventionsRequiring ongoing interventions Clinicians can feel ineffective, lose motivation Clinicians can feel ineffective, lose motivation

Page 33: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

"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?)(Do you use tobacco? Do you want to quit?)

and then work with that individual to make it

happen.“

—Michael C. Fiore, MD, M.P.H., Director Center for Tobacco Research and Intervention University of Wisconsin Medical School

Page 34: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

It takes on average, 6 to 7 attempts to quit for good…

Page 35: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Addiction

Page 36: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

NICOTINE

DOPAMINE Pleasure, Appetite Suppression

NOREPINEPHRINE Arousal, Appetite Suppression

ACETYLCHOLINE Arousal, Cognitive Enhancement

GLUTAMATE Learning, Memory Enhancement

SEROTONIN Mood Modulation,Appetite Suppression

BETA-ENDORPHIN Reduction of Anxiety and Tension

GABA Reduction of Anxiety and Tension

Nicotine Stimulates Release of Many Different Neurotransmitters

Page 37: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Characteristics of Nicotine lead to Reinforcement of Use & Addiction

High concentrations of High concentrations of nicotine within 7-10 nicotine within 7-10 secondsseconds

Half-life = 90-120 min.Half-life = 90-120 min. Able to respond quickly Able to respond quickly

to additional dosesto additional doses ““Euphoria” without Euphoria” without

“Intoxication”“Intoxication” Behavior reinforced Behavior reinforced

multiple times dailymultiple times daily

Page 38: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Nicotine Addiction:“A Brain Disease”

““Up-Regulation”Up-Regulation” Increased Increased numbersnumbers of Nicotinic receptors of Nicotinic receptors

Page 39: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Withdrawal Syndrome or "Abstinence Syndrome"

Pathophysiologic disturbances which result Pathophysiologic disturbances which result when a drug to which an organism is when a drug to which an organism is

physically dependent is stopped.physically dependent is stopped.

Page 40: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Smoking Cessation

“…“…is the easiest thing I ever did; I ought to is the easiest thing I ever did; I ought to know because I have done it a thousand know because I have done it a thousand times”.times”.

- - Mark TwainMark Twain

Page 41: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Withdrawal Symptoms Symptoms may begin within a few hours of last use, but

typically within the first few days, and begin to subside within a few weeks.

Cravings, which may relate to certain “triggers” , can occur for months to years.

Craving will pass without a cigarette

The “relaxing” effect that nicotine provides may not be due to physical relaxation; rather, it may be the elimination of early withdrawal symptoms.

Page 42: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Withdrawal Symptoms • Psychological/Behavioral: giving up a habitPsychological/Behavioral: giving up a habit• Physical: absence of nicotinePhysical: absence of nicotine

Nicotine craving is a major obstacle to successNicotine craving is a major obstacle to successDepressionDepressionIrritability; angerIrritability; angerTrouble concentrating; restlessnessTrouble concentrating; restlessnessSleep disturbances; tirednessSleep disturbances; tirednessHeadacheHeadacheIncreased appetiteIncreased appetite

• Repeat exposure to nicotine creates toleranceRepeat exposure to nicotine creates tolerance• Higher doses required to create same stimulationHigher doses required to create same stimulation

http://teens.drugabuse.gov/drnida/drnida_nic1.asp#long_periodshttp://teens.drugabuse.gov/drnida/drnida_nic1.asp#long_periods

Page 43: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Teens Underestimate the Addiction…

Most high school smokers believe they Most high school smokers believe they will not be smoking in 5 years, however will not be smoking in 5 years, however 73% remain daily smokers 5-6 years later 73% remain daily smokers 5-6 years later (CDC longitudinal studies)(CDC longitudinal studies)

Page 44: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Addiction and Youth

Adolescents may be more sensitive to nicotine, may be more sensitive to nicotine, especially in combination with other chemicals especially in combination with other chemicals found in tobacco. found in tobacco.

Depending on age of initiation, this may increase the Depending on age of initiation, this may increase the likelihood of tobacco addiction. Combined with likelihood of tobacco addiction. Combined with social influences, this puts young people at greater social influences, this puts young people at greater risk for becoming addicted. risk for becoming addicted.

Source: (National Institute on Drug Abuse: Tobacco Addiction Series)

Page 45: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Cessation: What Works

Behavioral supportBehavioral support Treats the psychological and habit Treats the psychological and habit

aspectsaspects Pharmacotherapy Pharmacotherapy

Treats nicotine addictionTreats nicotine addiction

Works best when combinedWorks best when combined

Page 46: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf

Page 47: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Efficacy of Physician Advice to Quit

Abstinence Rate %Abstinence Rate % No advice No advice 7.9 7.9 Physician AdvicePhysician Advice 10.2 10.2

Patients expect healthcare providers to ask Patients expect healthcare providers to ask about tobacco use and advise them to quitabout tobacco use and advise them to quit

Source: Treating Tobacco Use andSource: Treating Tobacco Use and Dependence, USDHHS, Public Health Service, 2000Dependence, USDHHS, Public Health Service, 2000

Page 48: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

5 A’s For Patients Willing to Quit

AskAsk about tobacco use about tobacco use AdviseAdvise patient to quit patient to quit

Refer (1-800-QUIT-NOW or local prgm)Refer (1-800-QUIT-NOW or local prgm) AssessAssess readiness to quitreadiness to quit AssistAssist in quit attempt in quit attempt ArrangeArrange follow-up follow-up

Page 49: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Ask

Ask about tobacco use at every visitAsk about tobacco use at every visit Systematically identify all tobacco usersSystematically identify all tobacco users Make identification/documentation a vital Make identification/documentation a vital

signsign Create a universal identification system Create a universal identification system

(stickers, computer reminders, etc.)(stickers, computer reminders, etc.)

Page 50: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Create a Reminder System

Include tobacco use in other medical / dental adviceInclude tobacco use in other medical / dental advice Use an identification system Use an identification system Stamp, Sticker, EMR Stamp, Sticker, EMR

Tobacco Use and ExposureTobacco Use: (circle one): Current Former Never

Secondhand Smoke Exposure: YES NOTobacco use is the single most preventable cause of death in the US.

Page 51: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Advise

Clear, Strong, PersonalizedClear, Strong, Personalized

““Quitting smoking ...Quitting smoking ... ...is the single best thing you can do for ...is the single best thing you can do for

your health” your health” ...will reduce your risk of …”...will reduce your risk of …”

Employ the teachable moment: Employ the teachable moment: Link visit findings with advice. Link visit findings with advice.

Page 52: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Assess

Willingness to make quit attempt in next 30 Willingness to make quit attempt in next 30 daysdays

““I want to quit” NOT “I need to quit” I want to quit” NOT “I need to quit”

Page 53: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Examples Very specific reasons to quit smoking:Very specific reasons to quit smoking:

“ “I want to quit smoking so I can go shopping I want to quit smoking so I can go shopping without stopping 10 times.”without stopping 10 times.”

“ “I want to quit smoking so I will not have a I want to quit smoking so I will not have a stroke like my dad.”stroke like my dad.”

“ “I want to quit smoking so my dogs will not I want to quit smoking so my dogs will not get emphysema.” (real quote)get emphysema.” (real quote)

I want to quit so I won’t smell like an ashtray I want to quit so I won’t smell like an ashtray

Page 54: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Stages of Change

Pre-contemplationPre-contemplation ContemplationContemplation PreparationPreparation ActionAction MaintenanceMaintenance

Page 55: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

5R’s for Patients Not Ready To Make a Quit Attempt

RelevanceRelevance RisksRisks RewardsRewards RoadblocksRoadblocks RepetitionRepetition

Page 56: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Assist

Develop a quit planDevelop a quit plan STAR:STAR:

- - SSet a quit date (within 2 weeks)et a quit date (within 2 weeks)

- - TTell family, friends, coworkersell family, friends, coworkers

- - AAnticipate challenges to quittingnticipate challenges to quitting

- - RRemove tobacco products fromemove tobacco products from environmentenvironment

Page 57: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Arrange Schedule follow-up Schedule follow-up

in personin person via telephonevia telephone NC Tobacco Use QuitlineNC Tobacco Use Quitline

4 visits/calls is evidence based4 visits/calls is evidence based Congratulate progress/successCongratulate progress/success Identify problems/anticipate challengesIdentify problems/anticipate challenges Evaluate pharmacotherapy use/problemsEvaluate pharmacotherapy use/problems

Page 58: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Help for the busy practice….

Page 59: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Health Care Provider’s Quick Intervention

ASKASK about tobacco useabout tobacco use ADVISEADVISE to quitto quit REFERREFER to NC Tobacco Use Quitline, to NC Tobacco Use Quitline,

Become An Ex, other resourceBecome An Ex, other resource PRESCRIBEPRESCRIBE as appropriateas appropriate

Page 60: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

REFER Quitline information to allQuitline information to all Consider fax referralConsider fax referral

Patients ready to quit within 30 daysPatients ready to quit within 30 days

Consider cessation medicationsConsider cessation medications Provide Quitline number to patients Provide Quitline number to patients

not ready to quitnot ready to quit Other resources such as BecomeAnExOther resources such as BecomeAnEx Follow-up at next/every visitFollow-up at next/every visit

Page 61: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

North Carolina Tobacco Use Quitline

1-800-QUIT-NOW (1-800-784-8669)1-800-QUIT-NOW (1-800-784-8669) 8a.m. – 3 a.m., 7 days a week; Toll-free; Confidential8a.m. – 3 a.m., 7 days a week; Toll-free; Confidential All North Carolinians - youth and adultAll North Carolinians - youth and adult Proactive – Quit coaches can call tobacco users back Proactive – Quit coaches can call tobacco users back

upon request, or make 1upon request, or make 1stst call call Fax referralFax referral Multiple language Quit CoachesMultiple language Quit Coaches

Administered by: Tobacco Prevention and Control Branch Administered by: Tobacco Prevention and Control Branch Funded by: NC Division of Public Health, NC Health and Wellness Funded by: NC Division of Public Health, NC Health and Wellness

Trust FundTrust Fund

Page 62: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Quitline can Assess, Assist, Arrange Quit coach helps set Quit Date, andQuit coach helps set Quit Date, and

Develop quit planDevelop quit plan

Make follow-up callsMake follow-up calls

Discuss pharmacotherapyDiscuss pharmacotherapy

Mail targeted resourcesMail targeted resources

Patients can call the Quitline anytimePatients can call the Quitline anytime

Page 63: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

What happens on first call with the Quitline Intake specialist determines readiness to quit Intake specialist determines readiness to quit First call - plan for 5 -10 minutes to enrollFirst call - plan for 5 -10 minutes to enroll Transfer to Quit Coach for those ready Transfer to Quit Coach for those ready Quitline can call patients backQuitline can call patients back

4 visits is an evidence based intervention4 visits is an evidence based intervention If not ready to set quit date, If not ready to set quit date,

Encouraged to call back when ready, and Encouraged to call back when ready, and offered enrollment for:offered enrollment for: Cessation materials (mailed)Cessation materials (mailed) Web Coach access Web Coach access

Page 64: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Caller would like to speak to a Quit Coach One Call Program: 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:Four Call Program: One Call program, plusOne Call program, plus Quit Coach will call backQuit Coach will call back

-- A quit date is set-- A quit date is set-- Dates and times are -- Dates and times are made for three more made for three more

calls from a Quit calls from a Quit CoachCoach

Three attempts, then Three attempts, then letter is sentletter is sent

Page 65: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Caller does not want to talk to a Quit Coach

Caller will be offered:Caller will be offered: Messages to promote quittingMessages to promote quitting Support materials for quittingSupport materials for quitting Referral to local resourcesReferral to local resources Encouragement to call againEncouragement to call again

Page 66: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Other Quitline Features

Web CoachWeb Coach Progress trackingProgress tracking Coaching e-mailsCoaching e-mails Discussion ForumsDiscussion Forums

Click to CallClick to Call Available on Web CoachAvailable on Web Coach

Page 67: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Fax Referral to Quitline Helps With… Referral to effective cessation servicesReferral to effective cessation services Provider’s limited time and resourcesProvider’s limited time and resources The burden of patient initiating services The burden of patient initiating services NOTE: Provider referral to a cessation NOTE: Provider referral to a cessation

program is associated with higher rates of program is associated with higher rates of participation than simply telling patients participation than simply telling patients they should stop using tobaccothey should stop using tobacco

Page 68: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Quitline Outcomes Report

Tool to follow patient progress with your Tool to follow patient progress with your advice to quit / utilize Quitline servicesadvice to quit / utilize Quitline services

Most useful in clinic setting with dedicated Most useful in clinic setting with dedicated fax machine/staff to retrieve reportsfax machine/staff to retrieve reports

Outcomes Report information:Outcomes Report information: Accepted servicesAccepted services Declined servicesDeclined services UnreachableUnreachable

Page 69: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division
Page 70: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Take patient’s vital signs & ask about

tobacco use.

Advise to quit.

Give patient cessation resources: 1-800-QUIT-NOW (1-800-784-8669),

www.becomeanex.org,or other resource.

INTERVENE: Offer cessation medications if indicated, Quitline #, fax

referral option

Give patient cessation resources: 1-800-QUIT-NOW (1-800-784-8669),

www.becomeanex.org,or other resource.

Is the patient

ready to quit?

Does patient

want a quit coach to

call them?

The Quitline will make at least 5 attempts to call the patient.

NO

YES

NO

YES

NC Tobacco Use Quitline Fax Referral Flow Chart

Complete fax referral consent form & fax to

Quitline.

Page 71: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

More Cessation Resources

www.becomeanex.org

Page 72: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Become an EX www.becomeanEX.org

Web-based cessation program for adultsWeb-based cessation program for adults Fun, edgy, interactive Fun, edgy, interactive Personalized quit plan to:Personalized quit plan to:

“ “Relearn life without cigarettes” Relearn life without cigarettes” Relearn habitRelearn habit Relearn addictionRelearn addiction Relearn supportRelearn support

Free and in English and SpanishFree and in English and Spanish

Page 73: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Two booklets created by American Legacy Foundation in cooperation with Mayo Clinic –

Ex Easy Read Booklet and Fotonovella

Page 74: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Women and Children Resources

Page 75: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Resources for Youth

PROJECT ASPIREPROJECT ASPIRE – A smoking prevention – A smoking prevention interactive experience for youth:interactive experience for youth: www.mdanderson.org/aspirewww.mdanderson.org/aspire

My Last Dip My Last Dip – An on line – An on line program for age 14 - 25 who program for age 14 - 25 who use spit or smokeless use spit or smokeless tobacco:tobacco: www.mylastdip.comwww.mylastdip.com

Page 76: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Healthy Start Foundation

Two brochures can be orderedTwo brochures can be ordered If You Smoke And Are PregnantIf You Smoke And Are Pregnant http://www.nchealthystart.org/catalog/pregnancy.htmhttp://www.nchealthystart.org/catalog/pregnancy.htm

Oh Baby! We Want To Keep You Safe Oh Baby! We Want To Keep You Safe From Secondhand Smoke From Secondhand Smoke http://www.nchealthystart.org/catalog/parenting.htm#c006 http://www.nchealthystart.org/catalog/parenting.htm#c006

www.nchealthystart.orgwww.nchealthystart.org

Page 77: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

You quit. Two quit. www.youquittwoquit.com

Informational website forInformational website for Pregnant womenPregnant women New mothersNew mothers Family and friendsFamily and friends Health professionalsHealth professionals

UNC Center for Maternal and Infant Health UNC Center for Maternal and Infant Health Funded by North Carolina Health and Wellness rust FundFunded by North Carolina Health and Wellness rust Fund

Page 78: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division
Page 79: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Tobacco Cessation Training for HCP’s Working with Women

The Guide is available on the Division of Public Health / Women’s Health Branch webpage: http://whb.ncpublichealth.com/provPart/pubmanbro.htm#top

For more information on the Women’s Health and Tobacco Use Program, contact:

Judy Ruffin

[email protected]

919-707-5712

Page 80: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division
Page 81: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Pharmacotherapy – First Line Nicotine Replacement TherapyNicotine Replacement Therapy

- Patch- Patch

- Gum- Gum

- Lozenge- Lozenge

- Inhaler- Inhaler

- Nasal Spray - Nasal Spray Zyban (bupropion)Zyban (bupropion) Chantix (varenicline)Chantix (varenicline)

Page 82: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Over the Counter Medications

Nicotine PatchNicotine Patch DoseDose: 21mg, 14mg or 7mg per 24 hours: 21mg, 14mg or 7mg per 24 hours

1 pack/day, start with higher dose, taper1 pack/day, start with higher dose, taper duration 8 weeksduration 8 weeks step down after 4 wks in 2 wk incrementsstep down after 4 wks in 2 wk increments Nicotrol is used for 16 hours, off at nightNicotrol is used for 16 hours, off at night

Adverse effectsAdverse effects: local skin reaction, insomnia, : local skin reaction, insomnia, vivid dreamsvivid dreams

ContraindicationsContraindications: Recent MI, unstable angina, : Recent MI, unstable angina, arrhythmiaarrhythmia

CostCost: 7mg box - $37: 7mg box - $37 14mg box - $47 14mg box - $47

21mg box - $4821mg box - $48

Page 83: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Nicotine Patch Dose Based on Smoking Rate

CPD = Cigarettes per day

10 cpd10 cpd 7 - 14 mg/d 7 - 14 mg/d

10 - 20 cpd 14 - 21 mg/d10 - 20 cpd 14 - 21 mg/d

21 - 40 cpd21 - 40 cpd 21 - 42 mg/d 21 - 42 mg/d

>40 cpd>40 cpd 42+ mg/d 42+ mg/d

Webinar – Pharmacologic Therapy for Tobacco Use and Dependence, J. Taylor Hays, MD, Mayo clinic Nicotine Dependence Center, Rochester, MNWebinar – Pharmacologic Therapy for Tobacco Use and Dependence, J. Taylor Hays, MD, Mayo clinic Nicotine Dependence Center, Rochester, MN

© © 2008 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH.2008 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED ALL RIGHTS RESERVED

2008 Update to CPGs do not recommend NRT for light smokers due to Insufficient evidence2008 Update to CPGs do not recommend NRT for light smokers due to Insufficient evidence

Page 84: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Over the Counter MedicationsNicotine GumNicotine Gum DoseDose: up to 24 pieces per day: up to 24 pieces per day

x 12 weeks (longer if needed)x 12 weeks (longer if needed) 2mg for <25 cigarettes per day2mg for <25 cigarettes per day 4mg for >25 cigarettes per day4mg for >25 cigarettes per day Chew, chew, parkChew, chew, park Avoid acidic beveragesAvoid acidic beverages

Consider using on a fixed scheduleConsider using on a fixed schedule Long term patch and gum use are effectiveLong term patch and gum use are effective Adverse EffectsAdverse Effects: Mouth soreness, hiccups, jaw ache, : Mouth soreness, hiccups, jaw ache,

dyspepsiadyspepsia ContraindicationsContraindications: As for patch: As for patch CostCost: 2mg box (100-170 pieces) ~ $45 (generic): 2mg box (100-170 pieces) ~ $45 (generic)

4mg box (100-110 pieces) ~ $63 (generic)4mg box (100-110 pieces) ~ $63 (generic)

Page 85: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Over the Counter Medications

Nicotine Lozenge (Commit)Nicotine Lozenge (Commit) DoseDose

2mg (1st cig. >30 min. after awake)2mg (1st cig. >30 min. after awake) 4mg (1st cig. <30 min. after awake)4mg (1st cig. <30 min. after awake) 9 (min) to 20 (max) lozenges/day9 (min) to 20 (max) lozenges/day x 12 weeks (longer if needed)x 12 weeks (longer if needed)

Allow to dissolve in mouthAllow to dissolve in mouth Avoid acidic beveragesAvoid acidic beverages Adverse EffectsAdverse Effects: Nausea, hiccups, heartburn: Nausea, hiccups, heartburn

4mg dose - headache, cough4mg dose - headache, cough ContraindicationsContraindications: as for patch: as for patch CostCost: 2mg box (72 lozenges) - $34 : 2mg box (72 lozenges) - $34 4 mg box (72 lozenges) - $394 mg box (72 lozenges) - $39 (9 lozenges/day =1 box/wk = $136-$156/mo)(9 lozenges/day =1 box/wk = $136-$156/mo)

Page 86: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Prescription Medications

Nicotine InhalerNicotine Inhaler DoseDose: 4mg nicotine: 4mg nicotine

80 puffs=4mg nicotine80 puffs=4mg nicotine Best effects with frequent puffing/at least 6 cartridges Best effects with frequent puffing/at least 6 cartridges

per day (can use 6-16 cartridges/day)per day (can use 6-16 cartridges/day) Use for up to 6 months Use for up to 6 months

Reduce frequency over the last 6-12 weeks of txReduce frequency over the last 6-12 weeks of tx Avoid acidic beveragesAvoid acidic beverages Adverse EffectsAdverse Effects: mouth/throat irritation, coughing, rhinitis: mouth/throat irritation, coughing, rhinitis ContraindicationsContraindications: as for patch: as for patch CostCost: 1 box (168 10mg cartridges) - $196: 1 box (168 10mg cartridges) - $196

Page 87: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Prescription Medications

Nicotine Nasal SprayNicotine Nasal Spray DoseDose: 1 dose = 1 mg (0.5mg per nostril): 1 dose = 1 mg (0.5mg per nostril)

1-2 doses per hour initially1-2 doses per hour initially Increase as needed for symptom reliefIncrease as needed for symptom relief 8 min/40 max doses per day for 3-6 months8 min/40 max doses per day for 3-6 months Do not sniff, swallow or inhaleDo not sniff, swallow or inhale Head titled slightly backHead titled slightly back

Adverse EffectsAdverse Effects: Nasal irritation, congestion; : Nasal irritation, congestion; transient changes in smell, tastetransient changes in smell, taste

ContraindicationsContraindications: as for patch: as for patch CostCost: $49 per bottle (100 doses): $49 per bottle (100 doses)

Page 88: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

NRT and Cardiovascular Disease

Not an independent risk factor for acute Not an independent risk factor for acute myocardial eventsmyocardial events

Use with caution in patients who:Use with caution in patients who: are within 2 weeks of MIare within 2 weeks of MI have serious arrhythmiashave serious arrhythmias have serious or worsening anginahave serious or worsening angina

pectorispectoris

Page 89: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Prescription Medications

Zyban, Wellbutrin (bupropion SR 150)Zyban, Wellbutrin (bupropion SR 150) BeginBegin 1-2 weeks before quit date 1-2 weeks before quit date DoseDose: 150 mg in a.m. for 3 days: 150 mg in a.m. for 3 days 150 mg twice daily for 7 to 12 weeks150 mg twice daily for 7 to 12 weeks May consider long-term tx for 6 months post quitMay consider long-term tx for 6 months post quit Adverse EffectsAdverse Effects: Insomnia, dry mouth: Insomnia, dry mouth ContraindicationsContraindications: history of seizure d/o, eating : history of seizure d/o, eating

d/o, recent MAO inhibitor use in past 14 daysd/o, recent MAO inhibitor use in past 14 days CostCost: 1 box of 60 tablets : 1 box of 60 tablets

$97/month (generic)$97/month (generic) $197-$210 (brand name)$197-$210 (brand name)

Page 90: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Prescription Medications

Chantix (varenicline)Chantix (varenicline) Stimulates nicotine receptors. Also blocks nicotine at Stimulates nicotine receptors. Also blocks nicotine at

receptor sitereceptor site Start Chantix 1 week before quit dateStart Chantix 1 week before quit date DoseDose: 0.5 mg daily for 3 days: 0.5 mg daily for 3 days

0.5mg twice daily for 4 days0.5mg twice daily for 4 days 1.0mg twice daily for 3 months1.0mg twice daily for 3 months

May decrease dosage (1mg/day) if significant side effectsMay decrease dosage (1mg/day) if significant side effects Adverse EffectsAdverse Effects: nausea, insomnia, abnormal/vivid dreams: nausea, insomnia, abnormal/vivid dreams New warning label Jan. 2008– observe for neuro- New warning label Jan. 2008– observe for neuro-

psychiatric symptoms (post marketing data)psychiatric symptoms (post marketing data) CostCost: 1 box of 56 - $131 (~30 day supply): 1 box of 56 - $131 (~30 day supply)

Research shows that at 1 year, 21% of those on Chantix are still abstinent Research shows that at 1 year, 21% of those on Chantix are still abstinent compared to 8% with a placebocompared to 8% with a placebo

Page 91: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

More on Pharmacotherapy Combined therapy improves abstinence ratesCombined therapy improves abstinence rates

Patch Patch ++ gum, nasal spray, or inhaler gum, nasal spray, or inhaler Patch plus buproprion (FDA approved)Patch plus buproprion (FDA approved)

Do not combine NRT with ChantixDo not combine NRT with Chantix Buproprion and gum or lozenge may delay Buproprion and gum or lozenge may delay

weight gainweight gain NRT for smokers not willing to quit – NRT for smokers not willing to quit –

promising but warrants further researchpromising but warrants further research

Page 92: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Pregnancy and Pharmacotherapy

Abstinence early produces greatest benefitsAbstinence early produces greatest benefits Quitting at any point yields benefitsQuitting at any point yields benefits Person to person intervention should be Person to person intervention should be

offered to pregnant and post partum womenoffered to pregnant and post partum women Should exceeds minimal advice to quitShould exceeds minimal advice to quit

Inconclusive evidence that cessation Inconclusive evidence that cessation medications increase abstinence ratesmedications increase abstinence rates

Page 93: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Treating Tobacco Use and Dependence: Children and Adolescents

RecommendationsRecommendations

Clinicians screen children and adolescents for tobacco Clinicians screen children and adolescents for tobacco useuse

Consider counseling and behavioral interventions that Consider counseling and behavioral interventions that are effective with adultsare effective with adults

Offer smoking cessation advice and interventions to Offer smoking cessation advice and interventions to parentsparents

Page 94: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Insurance Coverage for Cessation Medications

Medicaid now covers ALL cessation Medicaid now covers ALL cessation pharmacotherapypharmacotherapy Nicotine patch, gum, lozenge, nasal spray, Nicotine patch, gum, lozenge, nasal spray,

inhalerinhaler ZybanZyban ChantixChantix

No Prior Authorization neededNo Prior Authorization needed Prescription required, even for OTCPrescription required, even for OTC

Page 95: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Counseling Coverage in NC

Medicaid added two CPT codes Jan. 1, 2009Medicaid added two CPT codes Jan. 1, 2009 99406 – 3-10 minutes 99406 – 3-10 minutes 99407 – > 10 minutes99407 – > 10 minutes

May be billed the same day as an E/M or Health May be billed the same day as an E/M or Health Check visitCheck visit

Use ICD-9 Code: 305.1 (tobacco abuse)Use ICD-9 Code: 305.1 (tobacco abuse) Unbundled – can use a second ICD-9 codeUnbundled – can use a second ICD-9 code

Medicare, BCBSNC, and State Health Plan also Medicare, BCBSNC, and State Health Plan also reimburse these codesreimburse these codes

Page 96: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Medicaid Coverage for Treatment

For more information see Medicaid Bulletins:For more information see Medicaid Bulletins: Jan 2009:

http://www.dhhs.state.nc.us/dma/bulletin.htmhttp://www.dhhs.state.nc.us/dma/bulletin.htm Oct.2008:

http://www.ncdhhs.gov/dma/bulletin/1008bulletin.htm

Page 97: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

More Cessation Counseling Reimbursement Codes Other codes:

99401-04; 15-60 minutes (dedicated visit) 99354 can be added to regular visit (must

document counseling) 9941199411 is used for group counseling (per

participant) MD, PA or FNP on premises, must talk to

group RN (etc.) may facilitate session

Page 98: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Helpful Web Sites and Links:

www.tobaccopreventionandcontrol.www.tobaccopreventionandcontrol.ncdhhs.gov/cessationncdhhs.gov/cessation

www.tobaccopreventionandcontrol.www.tobaccopreventionandcontrol.ncdhhs.gov/FaxForm.pdfncdhhs.gov/FaxForm.pdf

www.QuitLineNC.com www.QuitLineNC.com

www.QuitNowNC.orgwww.QuitNowNC.org

Page 99: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Learning More / CE Options Counseling for Change: An On-line Tobacco Cessation Counseling for Change: An On-line Tobacco Cessation

Course - Northwest AHEC Course - Northwest AHEC Contact Nedra Edwards HinesContact Nedra Edwards Hines

• 336-713-7727; [email protected]; [email protected] $20 fee for course credits; free to view$20 fee for course credits; free to view

Medscape: Treating Tobacco Use and DependenceMedscape: Treating Tobacco Use and Dependencehttp://www.medscape.com/viewarticle/570604http://www.medscape.com/viewarticle/570604

FreeFree Approved for 1hour CE Approved for 1hour CE AMA PRA Category 1 Credit(s)™ AMA PRA Category 1 Credit(s)™ Requires registration to MedscapeRequires registration to Medscape

TobaccoFreePatients.comTobaccoFreePatients.comhttp://www1.tobaccofreepatients.com/TopicReq?http://www1.tobaccofreepatients.com/TopicReq?

Based on NCI educational programBased on NCI educational program Available free for study and reviewAvailable free for study and review $15 per credit hour / letter of completion$15 per credit hour / letter of completion

Page 100: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Take-Home Message for Health Care Providers Brief cessation counseling is effectiveBrief cessation counseling is effective Longer cessation counseling is more effectiveLonger cessation counseling is more effective Pharmacotherapy can double quit ratesPharmacotherapy can double quit rates Pharmacotherapy should be offered to allPharmacotherapy should be offered to all

- few exceptions- few exceptions Evidence-based resources are availableEvidence-based resources are available

Page 101: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

You only have two minutes AskAsk every everyone about tobacco use every everyone about tobacco use AdviseAdvise to quit with a clear, strong, to quit with a clear, strong,

personalized messagepersonalized message ReferRefer to to

NC Tobacco Use QuitlineNC Tobacco Use Quitline 1-800-QUIT-NOW (1-800-784-8669)1-800-QUIT-NOW (1-800-784-8669)

Become An ExBecome An Ex www.becomeanex.orgwww.becomeanex.org

PharmacotherapyPharmacotherapy – for most – for most

Page 102: Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division

Tobacco Prevention and Control BranchDivision of Public Health

North Carolina Department of Health and Human Services

Main Ph: 919-707-5400Fax: 919-870-4844

www.tobaccopreventionandcontrol.ncdhhs.gov