Upload
others
View
4
Download
0
Embed Size (px)
Citation preview
CURRENT ISSUES IN TOBACCO CESSATION
FOR THE PRACTICING PHYSICIAN
Shahnaz Fatteh, M.D. Associate Clinical Professor and
Director, Asthma, Allergy and Immunology Clinic
Dr. Kiran C. Patel College of Osteopathic Medicine
Nova Southeastern University
No Disclosures
OBJECTIVES
Importance of Addressing Tobacco Use with Patients
Pathophysiology of Tobacco Use
Current Treatments / Medications
New and Emerging Tobacco Products – E-Cigarettes
Public Policy – Current issues pertaining to tobacco
Meeting New Practice Standards for Addressing Tobacco Use
How the Physician can Play a Key Role in Tobacco Cessation
“Cigarette smoking is the chief, single avoidable cause of death in our society and the most important public health issue of our time.”
C. Everett Koop, M.D.
U.S. Surgeon General, 1982-1989
From “The Health Consequences of Smoking: Cancer.” Surgeon General’s Report, USDHHS, 1982
WHY IS IT IMPORTANT TO ADDRESS
TOBACCO USE WITH YOUR PATIENTS?
WHY IS IT THAT PHYSICIANS HAVEN’T ROUTINELY
DISCUSSED TOBACCO CESSATION WITH THEIR
PATIENTS
Discussion about tobacco may be time-consuming
Physician may not feel they can make a difference
Patients are unready to change
Discussions can be unpleasant – might be viewed
by their patients as intrusive
Sources: Vogt (2005). Addiction, 100(10): 1423-1431, Caplan, Lee, et.al. (2011), Journal of Community
Health, 36(2): 238-243.
IF A CLINICIAN DOES NOT ADDRESS
TOBACCO USE…
Patients may think that
quitting smoking is not
important if they don’t hear it
from their health providers
WHY SHOULD YOU PRIORITIZE THE TREATMENT
OF TOBACCO USE?
You can make a difference even with a brief
intervention (3 minutes or less)
For a patient not interested in quitting, a brief
tobacco intervention can increase motivation and
the possibility of future quit attempts
Effective treatment and cessation resources exist.
Source: Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: U.S. Dept of Health and Human Services. Public Health
Service. May 2008, p. 37.
Physicians can make
a real difference in
getting their tobacco-
dependent patients to
quit
Source: Tobacco Free Florida
More than
70% of tobacco users indicate that they want to quit
15.8%
Source: Tobacco Free
Florida
CLINICAL PRACTICE GUIDELINE – TREATING TOBACCO USE AND DEPENDENCE:
MAXIMIZING TOBACCO TREATMENT AND
ABSTINENCE IN THE HEALTH CARE SETTING
Relapse management
Patient reinforcement counseling
Counseling & medication
Consistent pt. follow-up & assessment
Patient reminder systems
Telephone counseling services
Multiple formats (verbal, written, video)
Multidisciplinary team approach
Longer Intervention (> 3 mins.)
14.4% Brief Intervention (< 3 mins.)
Approx. 11% of tobacco users will quit on their own. Talking with the
patient about their tobacco dependency for less than 3 minutes will
increase the quit rate to 14.4%. Longer interventions and other elements in
place in the clinical setting will more than double this quit rate.
QU
IT R
ATE
Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Dept of Health and Human Services. Public Health Service. May 2008, p. 85.
BRIEF INTERVENTION
CAN MAKE A DIFFERENCE
ASK
ADVISE
REFER
TOBACCO RELATED MORTALITY
• Tobacco use is the leading preventable cause of morbidity and mortality in the United States contributing to more than 480,000 deaths annually (Surgeon General’s Report 2014)
• Secondhand smoke causes nearly 42,000 deaths from heart disease and lung cancer each year in the United States among nonsmokers. (Surgeon General’s Report 2014)
• On average, smokers die more than 10 years earlier than nonsmokers
YOUTH AND TOBACCO
• 90% of smokers start smoking by age 18
• Every day in the U.S., 3,200 kids under age 18
try their first cigarette (nearly 1.2 million per
year)
• 2,500 youth and young adults become regular
smokers daily
(Surgeon General’s Report 2012, 2014)
IN THE STATE OF FLORIDA…SINCE
THE INCEPTION OF TOBACCO FREE
FLORIDA IN 2007...
Adult smoking rate is 15.8% down from 21% in 2006. (2015)
This reduction in adult smoking rate results in $17.7 billion in savings in tobacco-related health care costs (2007-2015)
Youth smoking rate has decreased from 10.6% to 3.0% (2016)
(Tobacco Free Florida 2015, 2016)
TOBACCO USE AND CHRONIC DISEASE
Source: The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014
THE 50TH ANNIVERSARY SURGEON GENERAL’S REPORT 2016 (SGR)
HEALTH CONSEQUENCES CAUSALLY LINKED TO SMOKING
Source: The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014
Early Death fires (1%)
illicit drugs (1%)
homicide (3%)
car accidents (4%)
suicide (4%)
AIDS (4%)
alcohol (15%)
tobacco (68%*)
*combination of tobacco use (61%) + second-hand smoke (7%) AMERICAN CANCER SOCIETY
QUITTING TOBACCO USE
Non-pharmacologic
Counseling
Pharmacologic
FDA-approved medications
Counseling and medications are
both effective, but the combination of
counseling and medication is more
effective than either alone.
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.,
Nicotine polacrilex gum
Nicorette (OTC)
Generic nicotine gum (OTC)
Nicotine lozenge
Nicorette Lozenge (OTC)
Nicorette Mini Lozenge (OTC)
Generic nicotine lozenge (OTC)
Nicotine transdermal patch
NicoDerm CQ (OTC)
Generic nicotine patches (OTC, Rx)
Nicotine nasal spray
Nicotrol NS (Rx)
Nicotine inhaler
Nicotrol (Rx)
Bupropion SR (Zyban, generic)
Varenicline (Chantix)
FDA-APPROVED MEDICATIONS for CESSATION
PHARMACOTHERAPY
FDA-APPROVED MEDICATIONS for CESSATION
PHARMACOTHERAPY
Certain Combinations of Cessation Medications have been
shown to be effective
Combining a long-acting NRT (patch) with a short-acting
NRT (gum, lozenge or inhaler) is more effective than
using a single type of NRT
Nicotine Patches have also been effective in combination
with use of Bupropion (Zyban)
BRIEF TOBACCO INTERVENTION
AND DOCUMENTATION
Since addressing tobacco use with your patients
does make a difference in their motivation to
quit…Did you know……
Most Insurances allow billing for cessation
interventions and counseling.
CPT Code: 99406 – smoking and tobacco
use counseling visit – 3-10 minutes
CPT Code: 99407 – smoking and tobacco
use counseling – intensive visit – greater than
10 minutes
E-CIGARETTES – THE NEW TREND
THE FACTS
Battery powered devices that heat a liquid into an
aerosol that is inhaled by user
Different types/sizes of e-cigarettes - also known
as e-cigs, e-hookahs, vapes, vape pens, mods,
and tank systems
Liquid most often has nicotine, flavoring, and
other additives.
E-cigs can also be used to deliver marijuana and
other illegal drugs
E-cigs are NOT FDA-approved cessation aid and
are NOT proven to be safe.
Source: U.S. Dept. of Health and
Human Services. E-Cigarette Use
Among Youth and Young Adults: A
Report of the Surgeon General,
2016.
E-CIGARETTES – THE NEW TREND
THE FACTS, continued
Most commonly used tobacco product among
youth.
More than ¼ of youth in middle and high
school have tried e-cigs.
In Florida, teen cigarette smoking has
decreased, but high school e-cig use has
increased by 72% in just two years—from
10.8% in 2014 to 18% in 2016. (Tobacco
Free Florida)
Thousands of flavors such as strawberry,
pina colada, blue raspberry are appealing
to youth.
Source: U.S. Dept. of Health and
Human Services. E-Cigarette Use
Among Youth and Young Adults:
A Report of the Surgeon General,
2016.
E-CIGARETTES – THE NEW TREND
IT’S JUST WATER VAPOR, RIGHT?—WRONG…
E-cig aerosol is not harmless.
Most contain nicotine which is addictive and disrupts growth
of developing brain of youth, especially in the area of
attention, learning, impulse control
Health effects very concerning –long term safety of e-cig
use or exposure to secondhand aerosol not known. Not a water vapor, but an aerosol containing ingredients such as
Nicotine – causes addiction
Ultrafine particles – can be inhaled deep into the lungs
Source: U.S.
Dept. of
Health and
Human
Services. E-
Cigarette Use
Among Youth
and Young
Adults: A
Report of the
Surgeon
General,
2016.
E-CIGARETTES – THE NEW TREND
THE FACTS, continued
Diacetyl – used in some flavors, chemical linked to
bronchiolitis obliterans (“popcorn lung”)
Volatile Organic Compounds such as benzene, and
several heavy metals such as nickel, lead and tin
Propylene Glycol – while this is present in many foods,
and considered safe to eat, inhaling could cause lung
irritation/asthma
Carcinogenic substances including formaldehyde
found in some aerosols.
Source: U.S.
Dept. of
Health and
Human
Services. E-
Cigarette Use
Among Youth
and Young
Adults: A
Report of the
Surgeon
General,
2016.
EVER HEARD OF JUULS?
Very Popular Brand of E-cigs
with youth and young adults
Designed to look like a flash
drive which is charged in
the computer
One Pod of e-liquid equals
one pack of cigarettes or 200
puffs.
JUULing…
Middle School and High School
students are using these on
campus, easy to hide since it fits
in palm and can be charged in
computer.
Several flavors including mango,
cool mint, crème brulee, fruit
medley, cool cucumber, classic
tobacco.
NON-CIGARETTE TOBACCO PRODUCTS
AND FUTURE USE OF CIGARETTES IN
YOUTH JAMA Pediatr. 1/2/18,
Watkins, Glantz, Chaffee
Population of 10,384 youth respondents
By using any of these products, youth more likely to use cigarettes one year later
E-cigarette, hookah, non-cigarette combustible tobacco, or smokeless tobacco use
Use of more than one of these products even more likely
PUBLIC HEALTH INITIATIVES
TOBACCO 21
Increasing legal age to purchase tobacco to 21 years old
95% of adult smokers begin smoking before age 21; raising legal age
to 21 has been shown to reduce youth initiation of tobacco
Will decrease nicotine addiction in teens and long-term use,
therefore saving lives (Institute of Medicine Report, 2015)
5 states (California, Oregon, New Jersey, Maine, and Hawaii have
raised their tobacco sales age to 21. Over 250 cities, counties,
communities have adopted Tobacco 21, including New York City, San
Antonio, Washington DC, to name a few.
PUBLIC HEALTH INITIATIVES
TOBACCO-FREE PARKS / BEACHES
Reduce secondhand smoke exposure
Reduce litter/cigarette butts on beaches
and in parks
Difficult to adopt laws due to preemption in
Florida—state government limits or eliminates
local governments authority to pass local
tobacco control laws, including adopting
smokefree areas
PUBLIC HEALTH INITIATIVES
SMOKE-FREE MULTI-UNIT HOUSING
HUD – Public Housing Authorities must have smoke-free
policies by July 31, 2018. Policies must prohibit smoking
in all indoor areas, individual living units, common areas,
office buildings, outdoor areas within 25 feet of buildings.
Protects residents from secondhand smoke exposure.
Secondhand smoke can seep through walls, ventilation
systems into non-smoker’s apartments
Cost savings – 2-7 times more time and money to turn
over an apartment in which smoking has occurred
Prevent smoking-related fires—can save on insurance
INTERESTED IN GETTING INVOLVED?
Contact your local Area Health Education
Center (AHEC) for free tobacco cessation
services for your patients and training for you,
your providers and your staff,
Call 877-848-6696
Join your county’s Tobacco Free Partnership
Advocate Tobacco 21 Efforts / Smokefree
Parks/Beaches in your community
INTERESTED IN GETTING INVOLVED?
Get involved in your local chapters of the American Lung
Association, American Cancer Society, American Heart
Association, etc.
Be aware of State/National Tobacco Awareness days:
Tobacco Free Florida Week (usually in May)
Lung Force Task Force– (American Lung
Association)
Great American Smokeout - 3rd Thursday in
November (American Cancer Society)
Kick Butts Day – March 21, 2018 (Campaign for
Tobacco-Free Kids)
Tobacco use harms
nearly every organ in the
body and is the leading
preventable cause of
death in the United
States, killing more than
480,000 people each
year. (CDC)
More than 70 % of tobacco
users say they want to quit…
and health providers can play
a unique and important role in
helping them succeed
Having an appropriate 3-4
minute conversation with a
patient followed by a referral
to cessation programs can
double or even triple the
quit rate.
Tobacco use kills more
people than AIDS, illicit drug
use, fires, alcohol, suicide,
murder, and car accidents
combined. (CDC)
It is inconsistent with sound medical practice
to provide health care and —
at the same time—
remain silent (or inactive) about a
major health risk. (Lightwood and Glantz, 1997, Rx for Change)
Source: CDC 2017,
Treating Tobacco Use
and Dependence 2008
Update, Rx for
Change
BRIEF INTERVENTION –
Where Can You Refer Your Patients?
ASK
ADVISE
REFER
ADDRESSING TOBACCO USE CAN HELP
PHYSICIANS AND HEALTH CARE
FACILITIES
MIPS
H.E.D.I.S. Measure
Joint Commission Tobacco Measures
SYSTEMS CHANGE – DEFINITION
Specific strategies that are
implemented to support changes in
health care organizations leading to
universal, evidence-based interventions
with all tobacco users
Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008. PAGE 67.
Tobacco Systems Change Strategies
1. Implement a Tobacco-User Identification System in Every Clinic
2. Provide Education, Resources, and Feedback to Promote Provider Intervention
3. Dedicate Staff to Provide Tobacco Dependence Treatment and Assess Its Delivery in Staff Performance Evaluations
4. Develop and promote Policies that Support and Provide Inpatient and Outpatient Tobacco Dependence Services
5. Include Tobacco Dependence Treatments (Both Counseling and Medication) Identified as Effective in the Guideline as Paid or Covered Services for All Subscribers or Members of Health Insurance Packages
IF YOUR PATIENT IS
READY TO QUIT…
HEALTH CARE PROVIDER FAX REFERRAL FORM TO TOBACCO FREE FLORIDA
IT’S WORKING! Evaluations of AHEC Tobacco Cessation Programs
from outside evaluator:
Highly effective program
High satisfaction rates from participants
Quit rates higher than most programs
Smoking prevalence among Florida adults was
15.8% in 2015 down from 21.0% in 2006.
Source: Tobacco Free Florida Fact Sheet