Tobacco Education and the Oregon Tobacco Quit Line Introduce myself. You are an important health resource to communities. Everyday you speak with people about health choices, including whether, how and when to quit tobacco. We wanted to share some information to help in those conversations. A 101 for Health Care Providers

Why Quit Tobacco? Tobacco use is the leading preventable cause of death and disability in Oregon. Each year, it kills nearly 7,000 people. Secondhand smoke kills an estimated 800 Oregonians each year. The best thing a tobacco user can do for his or her health is to quit tobacco. First off, let’s start with some data. Obligatory public health jokes here. We know that most Oregonians don’t use tobacco. Only 17% of adults smoke, but tobacco users are disproportionately from communities of color or are people with low incomes and education. Once someone quits, his or her health starts to improve immediately. Data from Oregon Tobacco Facts & Laws, January 2011 http://public.health.oregon.gov/PreventionWellness/TobaccoPrevention/Documents/tobfacts.pdf

People Want to Quit Quitting Can Be Hard ~ 70% of Oregon’s smokers want to quit. Common Motivators to Quit Personal health, wellness and fitness Children Social stigma Financial Quitting Can Be Hard We also know that most people want to quit. According to the most recent data from the Oregon Behavioral Risk Factor Survey, almost 70% of current smokers want to quit. We know from focus groups that people have really good reasons for quitting. They want to quit, they can tell you why they want to quit, “It’s an expensive habit”, etc… but quitting can still be hard. Perceptions of quitting? What are some common perceptions you have heard in your practice? – it’s hard, I’ll gain weight, all my friends smoke, etc. Smoking is social, it’s a habit, it calms me down… Most people have already tried to quit before. Tobacco users tend to view quitting as something they will do on their own and the reason they haven’t quit yet is because they don’t have enough willpower. It took a long time for people in state focus groups to realize that the reason it is hard for them to quit is because they are addicted (or to view nicotine as an addictive substance). Perceptions of quitting?

But People Can Quit! Counseling, Medication, and a Quit Plan help Tobacco users who receive effective treatment are 2 - 3 times more likely to quit and remain quit. Sometimes it take several attempts, but each attempt is important and valuable. Evidence-based ways to help people – what are some of the other things you think would help? Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guideline. U.S. Department of Health and Human Services. Public Health Service. http://www.surgeongeneral.gov/tobacco/

Physician Advice to Quit By merely asking patients if they use tobacco and, as their physician, advising them to quit, their chances of quitting double over the next year. There is no other clinical practice that has more impact on reducing illness, preventing death, and increasing quality of life.

Best Practices: The 5As Ask - Systematically identify all tobacco users at every visit. Advise - Strongly urge all tobacco users to quit. Assess - Determine willingness to make a quit attempt. Assist - Aid the patient in quitting. Help the patient with a quit plan. Arrange - Make provisions for referral or follow-up by you or your staff.

Best Practices: 2As and an R Ask - Identify all tobacco users at every visit. Advise - Strongly urge all tobacco users to quit. Arrange - Make provisions for referral or follow-up by you or your staff. www.askadviserefer.org Or, the shorter version, for when you have less time. This system was developed by dental hygienists.

Resources Clinical Practice Guidelines: Treating Tobacco Use and Dependence – Quick Reference Guide for Physicians www.surgeongeneral.gov/tobacco/tobaqrg.htm Rx for Change: Clinician-Assisted Tobacco Cessation Course http://rxforchange.ucsf.edu/ 5A’s Approach Brief Intervention

Referral Options The Oregon Tobacco Quit Line Community-Based Cessation Programs Online Cessation Resources So now you are ready to ask, advice, and refer all your tobacco using patients, but what are you going to refer them to? We will spend most of our time today talking about the Quit Line, but I will briefly cover the other options at the end.

The Oregon Tobacco Quit Line Why a Tobacco Quit Line? Quit Line Services Referring to the Quit Line Let’s start with the Oregon Tobacco Quit Line – and it does exactly what it says on the tin. It is a phone and web-based program that provides support for people trying to quit tobacco. This is a service provided by the Oregon Health Authority (part of the Tobacco Prevention and Education Program). The Quit line has been helping people quit tobacco for more than a decade. We’ll talk about why QLs are a good idea, what kinds of services we have available in Oregon, and how to make referrals to the QL.

Why a Tobacco Quit Line? We know it works: It fits the need: Quit Lines significantly increase quit rates compared to minimal or no counseling Quit Lines + medication significantly increase quit rates compared to use of medication alone. It fits the need: Quit Lines increase a participant’s chance of quitting Quit Lines offer a variety of services according to individual need. Backing up a bit, why would anyone want to refer to a tobacco quit line? A random phone number and who knows what is on the other end!? Evidence-based practice recommended by US Public Health Services, Clinical Practice Guidelines

Why a Tobacco Quit Line? It’s easy to access: 1-800-QUIT-NOW (784-8669), www.quitnow.net/oregon/ Español: 1-855-DÉJELO-YA (335356-92), www.quitnow.net/oregonsp/ TTY: 1-877-777-6534 It’s available when people need it: You can sign up and talk with a live counselor 24 hours a day Unlimited access to the web program There are lots of ways to connect with the Quit Line (and we’ll talk a little more about referral systems later). 1-800-QUIT-NOW and 1-855-DEJELO YA are the English/Spanish US national access numbers. There is English and Spanish web access available to Quit Line registration and WebCoach programs. Quit Coaches are available 24 –7. Having a service available when people need it, or are ready to act on an impulse to quit, or because something finally tipped them over the edge into making a decision to quit, is important. You don’t want that person to lose motivation because they had to wait several days or weeks to get a doctor’s appointment, or in some areas, wait several months until the local group cessation program or support group starts a new cycle.

What does the Quit Line do? The Oregon Tobacco Quit Line provides free counseling and medication to help people quit. Available to all Oregonians regardless of income or insurance status Staffed by real people, who are friendly and non-judgmental Counseling is available over the phone or online Coaching is available in 170+ languages including Spanish, Russian, Chinese, Korean, Vietnamese, and American Sign Language. Okay, so hopefully I’ve convinced you that Quit Lines are a good idea in general, let’s talk more about the specific services that we offer here in Oregon. The Quit line has been helping people quit tobacco for more than a decade.

How does the Quit Line Work? Registration Counseling Calls with Quit Coach Motivational Interviewing Problem-solving and coping skills Personalized Quit Plans Nicotine Replacement Therapy (patch or gum) mailed directly to house Quit Guide and other materials The process is really similar for the online program: registration, then going through creating a personalized quit plan online. This is self-directed, but covers much of the same topics that counseling calls over the phone would. An online participant can email or start an online chat with a quit coach at any point. These emails or chat conversations are much shorter (about 5 minutes) than a counseling call over the phone, which would take 20 or 30 mins.

Or, let’s look at how the Quit Line works in another way.

What is Quit Line counseling like? Coaches will help callers create their own plan, think through their own triggers, and problem solve their own solutions. Many of the coaches are former tobacco users themselves and understand the challenges of quitting. If you would like to listen in on a typical Quit Line counseling call, we have a recording of an adult participant and a youth participant from a training in September. If anyone would like that file, Sarah can provide it.

Who is eligible for the Quit Line? Only Three Criteria Must be at least 13 to enroll in counseling (and at least 18 to receive nicotine replacement therapy products) Must live in Oregon Must be ready to set a quit date in the next 30 days. If callers are younger than 13, we cannot legally provide services to them in Oregon and they will not be able to enroll. We cannot provide NRT products to anyone under the age of 18, as per FDA regulations. While teenagers can legally purchase these products over the counter, they must have a doctor’s prescription to do so. Participants must live in Oregon – although we are just looking for physical residency. Not legal residency. And must be ready to set a quit date in the next 30 days. If the participant isn’t ready to quit yet, they can still receive materials in the mail that will help them make that decision, and they can still ask questions about the QL and available services. They will be encouraged to call back when they are ready.

What services are available? Uninsured 4 counseling calls 2 weeks of Nicotine Replacement Therapy (patch and/or gum) Insured – with Quit Line benefit Whatever their own health plan covers, typically 4-5 counseling calls. Insured – without Quit Line benefit 1 counseling call 2 weeks of Nicotine Replacement Therapy Quit Line benefits are based on insurance status. We ask about insurance status and insurance plan during registration. Many people with insurance, including many covered by Medicaid plans, have Quit Line benefits through their own health plans and are not covered under the state Quit Line. Insurance status is tricky. We try to ensure that everyone who calls the Quit Line receives at least one counseling call and we try to connect them to other resources. For example, the Quit Line refers veteran callers to the 1-855-QUIT VET hotline and to TRICARE.

Okay, are there any questions so far about how the Quit Line works, who is elgible, and the kinds of services we provide? Going to switch gears and talk about promoting the QL and referring to the QL now.

Promoting the Quit Line Quit Line Materials Provider Referrals #1 way people hear about the Quit Line People may already be familiar with the past media campaigns (television spots: ghost and artery; upcoming campaign will include online advertising, bus ads, print ads and more).

Quit Line Materials Posters, palm cards, and counter cards are available to download online: http://www.smokefreeoregon.com/quit/quit-resources Materials are available in English, Spanish, Russian, Chinese, Korean and Vietnamese

Online Promotion Web Banners Click-to-Call Buttons Online options. Can put these web banners or buttons on your organization’s website to help connect your patients/clients with the QL. These tools can be downloaded from www.smokefreeoregon.com/quit/quit-resources/

Referring to the Quit Line Fax Referrals Simple form (English or Spanish) Download and fill out with patient Fax or (snail) mail to Quit Line The Quit Line calls your patient directly and asks if they would like to enroll in services. If they accept, they can begin counseling immediately. Download the fax referral forms and FAQs online at www.smokefreeoregon.org/quit/quit-resources/ Anyone can use the fax referral process

Fax Referral Reports Questions about making referrals to the Quit Line? The referring provider also receives a report back letting them know if the patient was reached and if they enrolled or declined services.

Referring to the Quit Line Electronic Referrals If clinic or health system utilizes an Electronic Health/Medical Record, may be able to send electronic referrals to the Quit Line. Options: Use EHR to generate fax referral form – fax or email Use EHR to identify tobacco users – data transfer If you are interested in this option, please contact Beth Sanders directly for more information.

Any questions about promotion or referral systems? Quit Lines are not for everyone – a state quitline typically reaches 1-2% of the state’s tobacco users, with promotion and lots of media, up to 6-10%. SO what about the other 90%?

Community-Based Resources Freedom From Smoking American Lung Association Standardized curriculum, trained facilitators Self-help, group program, online options www.lungoregon.org/quit/index.html Nicotine Anonymous Non-profit, 12-step based program www.nicotine-anonymous.org Health Plan Programs Freedom From Smoking is the best program if you are looking to start your own program on-site. Many health plans in Oregon offer group cessation programs, including Kaiser, Providence, Tuality, and Adventist Health and accept members of the general public. The state tries o maintain a listing of these resources (may provide local list of options for a given county).

Online Cessation Resources Become an Ex (American Legacy Foundation) http://becomeanex.org You Can Quit Smoking Now (DHHS) www.smokefree.gov/ Freedom From Smoking (American Lung Association) www.ffsonline.org Live Chat with a Quit Counselor (National Cancer Institute) https://cissecure.nci.nih.gov/livehelp/welcome.asp There are several evidence-based (and free!) cessation programs available online.

Online Programs for Specific Populations TeenQuit and The Truth® -- teen tobacco users www.teenquit.com and www.truth.org My Last Dip – smokeless tobacco users www.mylastdip.com Ucanquit2 – military members, families and veterans www.ucanquit2.org Many of these web-based programs have downloadable or orderable materials for providers or educators.

Free phone text-based cessation program For teens and young adults (age 13 and up) Offered by the DHHS Sample Message: Having a rough day & need a positive message sent your way? We could all use a little boost sometimes. Text BOOST to: (202) 618-4419 Learn more and sign up at: http://smokefree.gov/smokefreetxt Smokefree TXT is a cessation resource. It is a mobile texting service designed for teens and young adults. It is offered through the US Department of Health and Human Services and is free for all to use (usual text messaging rates will apply).

Other Resources for Providers How-To Guide for Treating Patients who Use Tobacco (University of Wisconsin) http://www.ctri.wisc.edu/HC.Providers/Howtoguide.pdf Become a Tobacco Aware Practice: Using an Organization and Team-Based Approach (American Academy of Family Physicians) www.aafp.org/online/en/home/clinical/publichealth/tobacco/cme/webcasts/tobaccoawarepractice.html Selected highlights – I have a whole resource guide with various CME options, toolkits, etc.

Questions?