1. Beating Joe Camel: The American Society of Anesthesiologists Smoking Cessation Initiative

2. Beating Joe Camel… Why bother? Barriers The ASA Smoking Cessation Initiative How to help in three minutes or less… (and get paid for doing it….)

3. Why Bother? Quitting Smoking Improves Surgical Outcomes Surgery May Promote Quitting Smoking

4. Tobacco Cessation Improves Surgical Outcomes Cardiovascular Complications Respiratory Complications Wound-related Complications

5. Short-term Cardiovascular Benefits of Smoking Cessation Nicotine  half life of ~1-2 h  decreases in heart rate and systolic blood pressure within 12 hours Carbon monoxide  half life of ~4 hours  carboxyhemoglobin level near normal at 12 hours Preoperative abstinence decreases the frequency of intraoperative ischemia* *Woehlck et al, Anesth Analg 89: 856, 1999

6. Smoking Cessation Reduces Postoperative Complications 120 Orthopedic patient randomized to tobacco intervention or control, 6- 8 weeks prior to surgery ~80% of intervention patients were able to quit or reduce smoking Moller, Lancet 359:114, 2002

7. Why bother? Quitting Smoking Improves Surgical Outcomes Surgery May Promote Quitting Smoking

8. 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

9. Smoking Cessation After Surgery

10. Barriers to Perioperative Smoking Cessation 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

11. Recent Smoking Cessation Does Not Increase Pulmonary Complications 300 patients for lung cancer resection “Recent” quitters: >1 week, < 2 months “Past” quitters: > 2 months Barrera et al, Chest 127:1977, 2005 (n=13) (n=39)(n=184) (n=64)

12. Nicotine Replacement Therapy and Wound Healing 48 smokers randomized to continuous smoking or abstinence, with or without nicotine replacement Standardized wounds over a 12 week period Sorensen et al, Ann Surg 238:1, 2003

13. Perioperative Stress in Smokers Warner et al, Anesthesiology 199:1125, 2004 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 Also no evidence for significant cigarette cravings

14. 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 Warner et al, unpublished observations

15. The Real Barriers to Intervention “I don’t know how” “I don’t have time” “It’s not my job”

16. 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) Warner et al, Anesth Analg 99:1766,2004

17. 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 brief tobacco interventions

18. ASA Smoking Cessation Initiative – Vision and Goals Vision  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

19. 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

20. 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

21. 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

22. 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 Most providers, and most patients, know nothing about quitlines….

23. ASK every patient about tobacco use Ask even if you already know the answer  Reinforces message that you as a physician think that their tobacco use is significant

24. ADVISE all smoker 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

25. 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

26. ASA “Quitcard”

27. ASA Patient Brochure

28. Other resources for your patients Tobacco treatment specialists  Available in many practice settings  Often hospital-based Websites  www.smokefree.gov www.smokefree.gov Insurers  E.g., Blue Cross/Shield, BluePrint for Health stop smoking program

29. CMS Reimbursement for Tobacco Interventions 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 HCPCS Codes  G0375 Smoking and tobacco-use cessation counseling visit; intermediate, > 3 minutes up to 10 minutes  G0376 Smoking and tobacco-use cessation visit; intensive, > 10 minutes

30. CMS Reimbursement for Tobacco Interventions 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 Two attempts (of up to 4 sessions) allowed every 12 months No credentialing requirements as of yet

31. ASA Smoking Cessation Initiative Task Force – Pilot program Identify approximately 10 practices nationally Identify a champion within each practice to promote the Ask-Advise-Refer strategy Implement strategy for ~3 months, beginning Sept 2007 Survey practices after this period to determine feasibility and gather feedback

32. 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 you need to do this effectively

33. What about Joe Camel?