1. I do not have any relevant financial relationships to disclose.

2. A PRACTICAL GUIDE TO HELPING PATIENTS STOP SMOKING E. H. Maynard, Jr. MD Benson Area Medical Center Benson, NC

3. Goals of Presentation 1. Review the scope of the problem of tobacco use 2. Review evidence-based interventions that work 3. Present a toolkit to help other practices get started with a smoking cessation program 4. Discussion of our practice’s experiences and challenges with initiating a smoking cessation program

4. The Problem of Smoking  21% of Americans smoke  45 million American adults smoke  1,200 children & adolescents become new smokers each day

5. Cost to Individuals  Smoking is a chronic disease often requiring repeated interventions and multiple attempts to quit  Smoking greatly increases risk of developing cancer, heart disease, stroke, pregnancy complications, lung disease, etc.  50% of smokers will die of smoking-caused disease  $5.11/pack

6. Cost to Society  $96 billion/year in smoking-related direct health costs  $97 billion/year in smoking-related indirect costs due to loss of productivity  The combined cost to society, individuals, and families is estimated at nearly $40/pack

7. It is Difficult for Smokers to Stop on Their Own  70% of smokers report wanting to quit  44% of smokers report trying to quit each year  Only 4-7% are successful on their own

8. We in the Healthcare Field Have Opportunities to Help  70% of smokers are seen by a physician each year  Smokers report physicians’ advice as an important motivator to quit

9. A Golden Opportunity for Success  Most smokers are interested in quitting  Healthcare providers are in frequent contact with smokers  Clinicians have high credibility with smokers  There are proven strategies that greatly increase the likelihood of successful smoking cessation

10. But…  Only 70% of insured smokers receive smoking cessation advice from their physician  Only 25% of Medicaid smokers reported receiving practical help with smoking cessation  Only 33% of adolescents receive counseling regarding tobacco use from their physicians  Only 39% of smokers reported that they were given specific help from their physicians regarding smoking cessation

11. Physicians say…  They are too busy  They have no financial incentive  They feel smokers cannot or will not quit  They don’t want to make patients angry  They don’t want to be judgmental  They will scare patients away if they discuss smoking cessation

12. Actually…  Even brief tobacco dependence treatment can be effective  Tobacco cessation counseling is effective at improving quit rates  Smokers are more satisfied with their healthcare if providers offer smoking cessation interventions even when the patients are not ready to stop smoking

13. Actually…  Many smoking cessation interventions are reimbursable  It is doubtful that there is any other intervention which could have a greater benefit to a smoker’s health than helping him/her quit smoking

14. A significant system failure “…it is difficult to identify any other condition that presents such a mix of lethality, prevalence, and neglect, despite effective and readily available interventions.” - Treating Tobacco Use and Dependence: 2008 Update US Department of Health and Human Services Public Health Service May 2008

15. Tobacco field Johnston County, NC

16. Tool #1 Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guidelines  Based on 8,700 research articles  Identifies effective, experimentally-validated tobacco treatments and practices  Provided detailed rationale for recommended practices

17. Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guidelines  Sponsored by:  Agency for Health Care Research and Quality  Centers for Disease Control and Prevention  National Cancer Institute  National Heart, Lung, and Blood Institute  National Institute on Drug Abuse  American Legacy Foundation  Robert Wood Johnson Foundation  University of Wisconsin School of Medicine and Public Health Center for Tobacco Research and Intervention

18. Recommendations summed up by the 5 As:  ASK about smoking status  ADVISE smokers to quit  ASSESS willingness to quit  ASSIST smoking cessation efforts  ARRANGE for ongoing follow-up

19. ASK: “Implement an office system to document tobacco use status for every patient at every clinic visit.” Possibilities  Incorporate into vital signs  Use chart stickers or computer prompts  Develop templates for electronic health records

20. ADVISE: “In a clear, strong, and personalized manner, urge every smoker to quit smoking at every visit.”

21. ASSESS: “Assess every tobacco user’s willingness to make an attempt to quit at the time of each visit.”

22. Tool #2 PROGRESS NOTES Date:_/_/_ Patient Name: _______ DOB:_/_/_ Chart: _____ Ht:__ Wt:__ BMI:__ Temp:__ RR:__ Pulse:__ BP:_/_ Nurse/MA:__ Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No

23.  Help the patient develop a quit plan  Provide practical counseling and problem solving advice  Provide medication to help  Provide supplemental materials  Provide a supportive clinical environment ASSIST

24. Tool #3 Rx for Success to Stop Smoking

25. Provide Practical Counseling Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No  Abstinence from tobacco is essential  Build on past quit experiences  Anticipate triggers, challenges  Avoid alcohol  Encourage others in home to quit  Referral for formal counseling if needed

26. Tool #4 Success with Smoking Cessation- Practical Counseling for the Busy Clinician

27. Medication Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No Except when medically contraindicated, all smokers attempting to quit should be encouraged to use medication. First Line Drugs:  Bupropion SR  Nicotine replacement (gum, inhaler, lozenge, spray, patch)  Varenicline Second Line Drugs:  Clonidine  Imipramine

28. Tool #5 Comparison of Smoking Cessation Drugs

29. Provide a Supportive Clinical Environment Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No  Physician/Provider Commitment  Provide information that is culturally, racially, educationally, and age- appropriate  Serve as advocates for patients who want to quit smoking  Consider group visits

30. Tool #7 AAFP Guide to Group Visits for Smoking Cessation

31. ARRANGE Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No  Appropriate follow-up should be arranged for smokers trying to quit  Some form of patient follow-up during the first week after quit date  Address tobacco use at subsequent clinical visits  If tobacco use has recurred, consider more intensive treatments

32. For Those Reluctant to Quit… Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No “For patients not ready to make a quit attempt, clinicians should use a brief intervention designed to promote the motivation to quit.”

33. Motivational Interviewing Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No  Uncovers ambivalence about tobacco use  Uses this ambivalence to address interest in quitting  Expresses empathy  Develops discrepancies  Rolls with resistance  Supports self-efficacy

34. Tool #8 Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No Brief Guide to Motivational Interviewing

35. The 5 Rs Smoking Status? Current Past Never Advised to Quit? Yes No Willing to Quit? Yes No  Relevance  Risks  Rewards  Roadblocks  Repetition

36. Tool #9 Guide to the 5 Rs

37. Getting Paid  Medicare covers counseling and medications  Some state Medicaid programs cover some forms of counseling and medication  Smoking cessation counseling can increase E/M coding levels during problem-related visits  Private insurances vary but most cover some form of counseling and some medication

38. Tool #10 AAFP Guide to Appropriate Coding for Smoking Cessation

39. In Summary  Tobacco use should be assessed at every visit  Smoking cessation should be advised at every visit  Willingness to quit should be assessed for smokers  Those willing to quit should be supported with counseling, medication, supportive clinical environment, additional information  Those unwilling to quit should receive interventions to help motivate commitment to quit in the future  Tobacco use must be treated as a chronic illness with frequent surveillance and follow-up

40. Tobacco Field Johnston County, NC

41. Benson Area Medical Center

42. Staff smoking area at BAMC

43. Getting Started at Benson Area Medical Center  Recognize cultural differences  Gather a toolkit of information to assist clinicians in providing appropriate and helpful information  Create a supportive environment for smoking cessation  Choose an initial small target group to pilot project  Train advocates within the practice to assist smokers who want to quit

44. Results from pilot project at BAMC BeforeAfter % Smokers asked about smoking57%100% % Smokers counseled to quit50%93% % Smokers with documented quit attempt7%29% July 1, 2008- July 1, 2009

45. Tobacco Field Johnston County, NC