Beating Joe Camel: The American Society of Anesthesiologists Smoking Cessation Initiative The public health consequences of cigarette smoking are well-known and cannot be overstated. Despite this fact, the prevalence of cigarette smoking in the U.S. population continues to be significant (approximately 25%), and is even higher in adolescents (approaching 30-35%). Many smokers require surgery and anesthesia, either to treat the consequences of smoking-related disease (e.g., lung cancer) or for other pathology. We see the consequences of smoking in the lives of our patients every day. You may feel frustrated that your patients will do this to themselves, and worry about complications such as wound infections and pneumonia. Well, the good news is that most patients want to quit, and that there are now resources available for you to quickly and easily help them do so….

The ASA Smoking Cessation Initiative Beating Joe Camel… Why bother? Barriers The ASA Smoking Cessation Initiative How to help in three minutes or less How to get paid for helping (under some circumstances) Here is what we will discuss today

Quitting Smoking Improves Surgical Outcomes Why bother? Quitting Smoking Improves Surgical Outcomes Surgery May Promote Quitting Smoking First, why bother addressing your patient’s smoking behavior? There are at least two reasons to bother. First, quitting smoking may improve the immediate outcomes of anesthesia and surgery. Second, and maybe even more importantly, surgery itself may promote smoking cessation. So first, how can quitting smoking improve outcomes?

Tobacco Cessation Improves Surgical Outcomes Cardiovascular complications Respiratory complications Wound related complications Examples of complications that can be ameliorated by smoking cessation include cardiovascular, respiratory, and wound-related complications. You probably have thought about the first two, but may not have considered the last. We’ll look at each of these.

Short Term Cardiovascular Benefits of Smoking Cessation Nicotine Half life of ~1-2 h Decreases in heart rate and systolic blood pressure in 24 hrs Carbon Monoxide Half life of ~4 hours Level near normal at 12 hrs Preoperative abstinence decreases the frequency of intraoperative ischemia* Although there are many constituents of cigarette smoke which could affect cardiovascular function, nicotine and carbon monoxide are probably most prominent. Fortunately, the effects of both dissipate relatively quickly, so that even brief preoperative abstinence (e.g., the morning of surgery) may be beneficial. This idea is supported by a study by Woehlck and colleagues, who studied the association between recent smoking (as assessed by exhaled carbon monoxide levels) and ST segment depression during general anesthesia in patients without ischemic heart disease who were undergoing vascular surgery (Anesth Analg 89: 856-60, 1999). They found that patients who smoked shortly before surgery had more episodes of ST segment depression than nonsmokers, prior smokers, or chronic smokers who did not smoke before surgery. Thus, smokers can be told that quitting even for brief periods of time before surgery *Woehlck et al, Anesth Analg 89: 856, 1999

Smoking Cessation Reduces Postoperative Complications 120 Orthopedic patients randomized to tobacco intervention or control, 6-8 weeks prior to surgery ~80% of intervention patients were able to quit or reduce smoking In this study, 120 orthopedic surgery patients were randomized to receive an intervention to help them stop smoking beginning 6-8 before their surgery, or usual care. The intervention was very successful, with ~80% of patients receiving the intervention able to quit or significantly reduce their smoking. Those patients who received an intervention to help them stop smoking experienced a dramatic decrease in the overall complication rate following orthopedic surgery, mainly caused by a decrease in the rate of wound-related complications such as wound infection. There was some evidence of a decrease in cardiac complications, but the numbers of events were not sufficient to make any conclusions. This study shows the real benefits of stopping smoking to immediate postoperative outcomes. We do not know the length of abstinence needed to reduce risk, but there are reasons to think that even brief abstinence may be beneficial. For example, we know that tissue oxygenation is an important determinant of wound healing, and that acute smoking decreases tissue oxygenation. Brief abstinence should thus increase tissue oxygenation, and improve wound healing. Moller, Lancet 359:114, 2002

Quitting Smoking Improves Surgical Outcomes Why bother? Quitting Smoking Improves Surgical Outcomes Surgery May Promote Quitting Smoking So there are good reasons for surgical patients to quit smoking in the perioperative period. However, in addition to improving surgical outcomes, the scheduling of surgery is a great opportunity for patients to quit for good. This will have beneficial effects that last far beyond the perioperative period, as the average smoker adds 6-8 years to their life if they can quit smoking. What is the evidence that surgery itself promotes tobacco cessation?

Surgery Promotes Tobacco Cessation Opportunity to intervene Contact with healthcare system Forced abstinence Major medical interventions improve quit rates Occurs even in the absence of tobacco interventions May also improve the effectiveness of tobacco interventions It’s important to understand that over 75% of smokers actually want to quit. Most have gotten the message that smoking is bad for them, and most of them have already made multiple quit attempts. But it is very difficult to quit, because nicotine is a highly addictive drug. So smokers need encouragement, and need help – and most will not be offended if you ask them about their smoking and offer to help them quit. Surgery provides the smoker with multiple contacts with healthcare providers throughout the surgical experience, with multiple opportunities to intervene. Having surgery generally requires at least 5 contacts with providers – the preoperative surgical visit, admission to the surgical facility, the preoperative interview with the anesthesiologist, dismissal from the surgical facility, and the postoperative surgical visit. The tobacco control literature shows that multiple messages from multiple providers are effective in helping smokers quit. In addition, all smokers must remain abstinent in surgical facilities, so the question is not whether they will be abstinent from smoking in the perioperative period, but for how long. Also, even if we do nothing, undergoing a major medical or surgical intervention increases the rate of spontaneous quitting as I will show you in the following slide. Going through surgery represents a “teachable moment” for smoking cessation, when people are much more likely to consider how to improve their health. This can make tobacco interventions more effective. This is good, because again, it is very difficult for most people to quit smoking.

Smoking Cessation After Surgery Under the best of circumstances about 5% of smokers successfully quit on their own with each attempt. With treatment in the best of outpatient stop-smoking clinics, this rate can approach 25% with each attempt. This may seem low, but remember that multiple attempts are often required, and that the majority of smokers eventually are successful in quitting – there are currently more ex-smokers in the US than active smokers. Simply having major non-cardiac surgery will approximately double the chances of quitting without any other help. Major procedures clearly linked to smoking-related diseases, such as coronary bypass surgery and lung cancer surgery, will further increase the rate of spontaneous quitting – although it is a testimony to the addictive properties of cigarettes that some patients cannot quit even after losing a lung to cancer.

Perioperative Smoking Cessation Barriers Quitting just before surgery increases pulmonary complications Nicotine replacement therapy is dangerous Surgical patients are already too stressed Patients don’t want to hear about their smoking – they have enough to worry about Here are some stated barriers to helping patients stop smoking for surgery. Quitting just before surgery increases pulmonary complications Nicotine replacement therapy is dangerous Surgical patients are already too stressed Patients don’t want to hear about their smoking – they have enough to worry about Fortunately, none of these barrier are valid, as we will review in the next few slides.

Recent Smoking Cessation Does Not Increase Pulmonary Complications 300 patients for lung cancer resection “Recent” quitters: >1 week, < 2 months “Past” quitters: > 2 months Some earlier studies have been interpreted as showing that quitting smoking a short time before surgery actually increases the risk of pulmonary complications. This is admittedly a difficult area to study, as all studies are retrospective with considerable potential for bias. However, the authors of these earlier studies in fact did not make this conclusion, and most of the more recent studies do not support the concept that recent quitting increases pulmonary risk. For example, this retrospective observational study showed that recent quitting does not increase the rate of pulmonary complications. It is true that it likely takes a period of weeks or months before the lungs have sufficiently recovered from the effects of chronic smoke exposure for patients to enjoy a decrease in risk. However, concerns over pulmonary complication should not discourage patients from quitting even immediately before surgery, especially given the potential for benefit in cardiovascular and wound-related complications, and the benefit of exploiting the “teachable moment” of surgery. Barrera et al, Chest 127:1977, 2005

Nicotine Replacement Therapy and Wound Healing 48 smokers randomized to continuous smoking or abstinence, with or without nicotine replacement Standardized surgical wounds over a 12 week period Many surgeons, recognizing the effects of smoking on wound healing, have concerns about using nicotine replacement therapy in the perioperative period. Although more study is needed, the best evidence suggests that nicotine, in the doses provided by nicotine replacement such as nicotine patches, should have little effect on wound healing. In this study, the healing of experimental punch biopsy wounds was examined over a 12 week period in smokers who were randomized to either continuous smoking or abstinence, the latter assisted with or without nicotine patch (placebo controlled). For the outcome of wound infection, abstinence dramatically decreased the wound infection rate, a benefit that was maintained when active nicotine patches were used. Thus, it appears that nicotine replacement therapy does not negate the benefits of smoking abstinence on wound healing. Certainly nicotine replacement would seem preferable to patients going home after surgery and resuming their smoking – which many patients do. Nicotine replacement therapy will at least double smokers’ chances of quitting successfully, so should be considered as a tool to help patients maintain perioperative abstinence. Sorensen et al, Ann Surg 238:1, 2003

Perioperative Stress in Smokers 141 smokers, 150 non-smokers for elective surgery Perceived stress measured from before surgery up to one week postoperatively Smoking status does not affect changes in perceived stress No evidence for significant cigarette cravings Many smokers view cigarettes as a tool to manage stress. Should we take away this stress management tool at a time when smokers are going through the major stresses associated with surgery? In this study of both smokers and non-smokers scheduled for elective surgery, changes in perceived stress over the perioperative period were measured beginning in the preoperative period, extending through the first 7 days postoperatively. Non-smokers were studied to control for the effects of the surgical experience itself. First note that smokers report increased stress throughout, consistent with prior results in ambulatory smokers in general. Next note that stress decreases over the perioperative period as patients get through the surgery, as you might expect. These changes in stress over the perioperative period did not differ between smokers and nonsmokers. If abstinence from smoking, which many patients maintained throughout this period, caused increase stress due to nicotine withdrawal or other symptoms, you would expect to see increases in stress in the first days after surgery – but this did not happen. The authors also found little evidence of increases in cravings for cigarettes in smokers over this time. The results suggest that for most smokers, abstinence does not contribute to perceived stress in the perioperative period, perhaps because of all the other things happening to them, and the fact that they are not in their normal environment which provides “cues” to initiate smoking. Thus, smokers can be reassured that they will be able to maintain abstinence without experiencing significant distress. Warner et al, Anesthesiology 199:1125, 2004

What do smokers expect? Essentially all smokers are aware of general health hazards Most are not aware of how it might affect their surgery – and want to know! They want information and options Almost all will not be offended if you discuss their smoking… But they do not want a sermon So what do smokers facing surgery expect from their physicians? This information was gathered in a series of interviews with smokers facing surgery. The results show that physicians should not be shy in addressing their patients’ smoking behavior – they want to know the consequences of their smoking for their surgery, so that they can make their own decisions. Warner et al, Am J Prev Med 35:S486, 2008

The Real Barriers to Intervention “I don’t know how” “I don’t have time” “It’s not my job” Here are the real barriers to helping surgical patients quit smoking. The first two barriers are important, and the ASA is developing means to help overcome them as the next slides will show. Regarding the last, I hope that I have provided you reasons to think that this can be a part of our responsibility as anesthesiologists. Not only can we improve immediate postoperative outcomes, but we have a chance to make a lasting difference in the long-term health of our patients – so we need to take advantage of these opportunities.

What are we doing now? Survey responses from 329 anesthesiologists and 299 general surgeons Proportions that “always” performed intervention Actual patient perceptions may differ (e.g., ~30% of patients recall being advised) What are we doing now? These are the results of a national survey of general surgeons and anesthesiologists that examined their practices and attitudes towards smoking cessation. At the moment, we do not consistently address our patients’ smoking behavior….which is not surprising. The survey showed that many had an interesting in providing this service to their patients, but let’s be honest - none of us were trained to do so, and most of have very little extra time. Is there something we can do that is practical and effective? Warner et al, Anesth Analg 99:1766,2004

ASA Smoking Cessation Initiative: Rationale Smoking cessation improves perioperative outcomes Sustained abstinence produced by this teachable moment produces an average 6-8 years of life gained Demonstrate to the public that anesthesiologists are perioperative physicians who care about patient health Recent CMS changes make it possible to bill for tobacco interventions lasting three or more minutes In 2006, the ASA convened a task force to provide recommendations regarding how anesthesiologists could help their patients quit smoking. Here are some of the reasons that the Task Force outlined for why it is important for the ASA to be involved. As we have seen, smoking cessation can improve immediate perioperative outcomes. If we can get patients to quit smoking for good, the average smoker will gain 6-8 years of life. If we are effective advocates for tobacco control, this could demonstrate to the public that anesthesiologists are perioperative physicians who care about patient health beyond just putting folks to sleep and waking them up. Finally, recent changes by the Center for Medicare Services make it possible to bill for brief tobacco interventions.

ASA Smoking Cessation Initiative Vision and Goals Every smoker cared for by an anesthesiologist will receive assistance in quitting as an integral part of care Goal Increase the involvement of ASA members in smoking cessation efforts, thus increasing abstinence rates for their patients who smoke Here are the vision and goal for the ASA initiative, as recommended by the Task Force and as approved by the ASA House of Delegates.

ASA Smoking Cessation Initiative Strategies Encourage all anesthesiologists to consistently apply the ASK, ADVISE, and REFER technique Develop anesthesiologists who can serve as leaders for local efforts to provide tobacco intervention services in perioperative practice Educate the public regarding the importance of perioperative smoking cessation Create partnerships with other healthcare professionals to promote a comprehensive perioperative strategy for patients who smoke The Task Force is pursuing four strategies. First, all anesthesiologists will be encouraged to consistently apply the Ask, Advise, and Refer technique which we will describe in the following slides, a simple, quick, and effective technique that can be applied with minimal training or knowledge. Second, some anesthesiologists may want to go beyond this simple technique and serve as leaders for local efforts to provide tobacco intervention services in perioperative practice, and we want to provide support to these individuals. Third, we want to educate the public regarding the importance of perioperative smoking cessation. Finally, we hope to create partnerships with other healthcare professionals to promote a comprehensive perioperative strategy for patients who smoke.

What should we do for smokers who need surgery? ASK Assess tobacco use at every visit ADVISE Strongly urge all tobacco users to quit REFER To a tobacco quitline or other resources First some background. It has been recognized for many years now that physicians can play an important role in helping patients quit smoking, as interventions by physicians increase quit rates. There have been efforts to train especially primary care physicians in tobacco control and how to intervene, hoping that these physicians will incorporate these interventions as a part of their practices. For the most part, these efforts have failed, because most physicians do not have the expertise or the time to provide extending counseling to their patients. Thus, the tobacco control community has moved towards getting physicians to apply this ask-advise-refer technique, rather than expecting physicians to do it all themselves. The idea is that we can simply and quickly ask our patients about their smoking and advise them to quit, but that none of us are tobacco control experts. Thus, we get our patients referred to the experts who can help them quit smoking – and fortunately, the services of these experts are now readily available to all Americans through tobacco “quitlines” and other resources.

Free via telephone to all Americans Staffed by trained specialists What are Quitlines? Free via telephone to all Americans Staffed by trained specialists Up to 4-6 personalized sessions Some offer free nicotine replacement therapy Up to 30% success rates for patients who complete sessions What are these quitlines, anyway? They provide free services to all Americans through a single toll-free number to help smokers quit and stay off cigarettes. They are staffed by trained specialists with extensive experience in providing tobacco counseling. They take the time to work with smokers to develop a personalized plan that is right for them, offering multiple extended counseling sessions. Some offer free nicotine replacement therapy that is mailed to the smokers. They are quite effective, with up to 30% success rates for patients who complete sessions. However, most physicians, and most smokers, know almost nothing about them, so they are not being utilized by most smokers who want to quit. Most providers and patients know nothing about quitlines….

ASK every patient about tobacco use Ask even if you already know the answer Reinforces the message that as a physician you think their tobacco use is significant So here is what the Task Force is encouraging all anesthesiologists to do. Always, Always ask….if you don’t care about your patients’ smoking, why should they?

ADVISE all smokers to quit Why quit for surgery? – Talking Points Quit for as long as possible before and after surgery Day of surgery especially important – “fast” from both food and cigarettes Benefits of quitting to wound healing, heart and lungs Great opportunity to quit for good Many people don’t have cravings Need to be smoke free in the hospital anyway Almost all smokers know that smoking is bad for them, and know that they should quit. But you can emphasize points that are unique to the time of surgery. Even if they are not ready to quit for good, they can likely reduce their risks by at least temporarily quitting around the time of surgery. Because fasting from food Is already a well-established part of the clinical routine, ask them to fast from cigarettes as well. Emphasize how this will help them heal better, and improve the function of their heart and lungs. And remember that about three-quarters of smokers want to quit – so remind them that this is a great opportunity for them to quit for good because most people don’t have cravings for cigarettes immediately after surgery, and they need to be smoke-free in the hospital anyway.

REFER smokers to quitlines or other resources What are quitlines? – Talking Points Quitlines are free Talk with a specialist, not a recording Free stop smoking medications may be available Can call anytime, even after surgery Can help you stay off cigarettes even if you have already quit Can also use proactive fax referral 1-800-QUIT-NOW Finally, refer patients to quitlines or other resources. The Task Force has developed materials to help you do this, including a convenient card with the quitline number and other information and a brochure that goes into more detail about the importance of quitting and how quitlines work. These materials can be ordered FREE on the ASA Web site at www.asahq.org/stopsmoking. Here are some points that can be emphasized regarding the quitlines when talking with patient: Quitlines are absolutely free. You talk with a specialist, not a recording. These specialists provide multiple, extending counseling sessions at times that are convenient for you. Free stop smoking medications may be available. You can call anytime, even after surgery. They can help you stay off cigarettes even if you have already quit. You can also refer patients to quitlines via faxed referrals, if you want to set this up in your preoperative clinic. The national toll-free number is 1-800-QUIT-NOW. If you do not have time to explain about the quitlines, you can simply give the patient a referral card or brochure.

ASA Quitline Card The ASA has created “Quitcards” that can be distributed to patients.

ASA Patient and Provider Brochures The ASA also has created a brochure that gives reasons why patients should quit, and in another page (not shown) extensive information about the quitlines. There is also a brochure for you that will explain more about how to help you patients quit smoking. Both are available for FREE at www.asahq.org/stopsmoking.

Other Patient Resources Tobacco treatment specialists Available in many practice settings Often hospital-based Web sites www.smokefree.gov www.asahq.org/stopsmoking Insurers E.g., Blue Cross/Shield, BluePrint for Health stop smoking program There are other resources available to help patients quit smoking. In many practice settings, there are tobacco treatment specialists who can provide counseling services to patients. Often these are offered as part of a hospital-based program. We suggest that you take some time to find out whether these services are available in your setting, and how you can get patients into these programs. There are also many web-based resources available; this is one website that has links to many others. In general, tobacco intervention services are among the most cost-effective of healthcare services. In recognition of this fact, many insurers will offer stop-smoking services to their enrollees.

Tobacco Intervention CMS Reimbursement Who is covered? Patients who use tobacco and have a disease or adverse health effect found by the US Surgeon General to be linked to tobacco use Patients who take certain therapeutic agents whose metabolism or dosage is affected by tobacco use as based on FDA-approved information CPT® Codes 99406 Smoking and tobacco-use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 Smoking and tobacco-use cessation counseling visit; intensive, greater than10 minutes So we’ve talked about the ask-advise-refer strategy, which provides a simple “baseline” level of intervention to help surgical patients stop smoking. You may be interested in doing more. For example, there are many opportunities to incorporate more extensive interventions in preoperative clinics, and to partner with other members of the surgical team such as surgeons or perioperative nurses. For those interested in providing more extensive counseling, there is now the potential to be separated reimbursed for these services. For Medicare patients, CMS has recently added reimbursement for tobacco interventions. Eligible patients include those who use tobacco and have a disease or adverse health effect found by the US Surgeon General to be linked to tobacco use. This is a very broad definition, and can include hypertension or chronic cough, so that most patients in the Medicare age group would be covered. Two codes are available depending on the length of counseling.

Tobacco Intervention CMS Reimbursement Cessation counseling attempt occurs when a qualified physician or other Medicare recognized practitioner determines that a beneficiary meets the eligibility requirements and initiates treatment Two attempts, up to 4 sessions, allowed every 12 months No credentialing requirements Here are some of the details regarding requirements for reimbursement. Cessation counseling attempt occurs when a qualified physician or other Medicare-recognized practitioner determines that a beneficiary meets the eligibility requirements above and initiates treatment with a cessation counseling attempt. There is no specific content mandated for the counseling session. For example, if the ask-advise-refer process requires more than 3 minutes, this would qualify as a counseling session. In other words, simply referring patients to the quitline would count, if you spend enough time explaining the rationale for quitting and how the quitlines operate. 8 sessions allowed every 12 months, and there are no credentialing requirements as of yet for those who provide the service. Current reimbursement rates are in the $15-$18 range for these codes, so no one will become rich doing this. However, about 1 in 10 Medicare patients smoke, so for high volume preoperative clinics, at least some additional revenue will be generated if counseling is systematically applied. More information about this reimbursement is available at the ASA website.

ASA Smoking Cessation Initiative Task Force Pilot Program Identified 14 practices nationally, both private practices and academic Implemented Ask-Advise-Refer strategy from Oct. – Dec. 2007 Practices surveyed after this period to determine feasibility and gather feedback The Task Force has conducted a pilot project to test the ASK-ADVISE-REFER technique in actual anesthesia practice. The idea was to see if this is a feasible approach, and to get feedback from the anesthesiology community before the launch of a national program. Fourteen practices were identified across the country, including a mix of academic and private practices. Each practice identified a “champion” to serve as an implementation leader to promote the ASK-ADVISE-REFER technique, using the materials provided by the ASA. The strategy was implemented in these practices from October to December 2007. After this period, the practices were surveyed to determine acceptance by anesthesiologists and to gather feedback.

Pilot Project Highlights (n=94 responses) ~50% expressed increased self-efficacy ~75% agree that they would incorporate AAR in their practice High acceptance of materials ~80% agree that the ASA should encourage Here are some highlights from the survey. About half of the respondents felt that they were now more confident in talking with their patients about their smoking, and about three-quarters planned to incorporate the ASK-ADVISE-REFER strategy into their practices. They liked the materials that the ASA had developed, and most agreed that this was something that the ASA should encourage. These results indicate that this approach certainly appears to be feasible in anesthesiology practices.

Rates That Anesthesiologists Performed Ask-Advise-Refer Elements % “frequently or always” Those anesthesiologists who participated in the pilot project reported if they “frequently or always” performed each element of the ASK-ADVISE-REFER strategy. Almost all asked about tobacco use, most advised patients to quit smoking, and overt half made referrals to quitlines. This compares very favorably with data gathered as part of a national survey of ASA members in the past, and suggests that the pilot project was effective in encouraging anesthesiologists to address their patients’ tobacco use. “Baseline” data from 2004 national survey of ASA members, Warner et al, A&A, 99:1766, 2004

You can make a difference in the lives of your patients who smoke Bottom Line… You can make a difference in the lives of your patients who smoke You can help without being an expert in tobacco control – and get paid for doing it The ASA is working to provide you with the tools needed to do this effectively Here is the bottom line….

What about Joe Camel? Poor Joe….this is meant to funny, but is really not - significant proportion of our smoking patients will end up like this. Thanks for helping the ASA devise effective tools that we can use as anesthesiologists to get Joe out of the lives of our patients…..