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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
3
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
9
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
10
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
13
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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
33
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
42
Allison Gorrilla, MPH
UW-Center for Tobacco Research
and Intervention
414-333-3067
ctri.wisc.edu
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