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Comprehensive Overview ofNorth Carolina Tobacco Use and
Evidence Based Cessation Methods and Resources
June 2009 June 2009
Tobacco Prevention & Control BranchTobacco Prevention & Control BranchDivision of Public Health, DHHSDivision of Public Health, DHHS
Tobacco Use
The number one preventable cause of death The number one preventable cause of death in the United States and North Carolinain the United States and North Carolina
Estimated Preventable Causes of Death Estimated Preventable Causes of Death in North Carolina (2007)in North Carolina (2007)
Source: NC SCHS Health Profile of North Carolinians: 2009 Update Source: NC SCHS Health Profile of North Carolinians: 2009 Update North Carolina Department of Health and Human ServicesNorth Carolina Department of Health and Human Services
13,720
12,584
2,653
2,350
1,743
1,510
1,364
910
758
606
531
0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000
Tobacco
Diet/Phys. Inactivity
Alcohol
Microbial Agents
Toxic Agents
Medical Error
Motor Vehicles
Firearms
Uninsurance
Unsafe Sex
Illicit Drug Use
Estimated Number of Deaths
Tobacco Use Today
United StatesUnited States North North CarolinaCarolina
Deaths 438,000/yr.Deaths 438,000/yr. 13,720/yr. 13,720/yr.
Medical Medical (US state average)(US state average)
CostsCosts $1.89 billion $1.89 billion $2.46 billion $2.46 billion
Total Total costs $150 billion costs $150 billion $6.77 billion $6.77 billion
Source: Centers for Disease Control and Prevention. SAMMEC, 2000-2004Source: Centers for Disease Control and Prevention. SAMMEC, 2000-2004http://www.cdc.gov/tobacco/data_statistics/state_data/data_highlights/2006/00_pdfs/DataHighlights06table4.pdfhttp://www.cdc.gov/tobacco/data_statistics/state_data/data_highlights/2006/00_pdfs/DataHighlights06table4.pdf
Current Use Among NC Adults (aged >18 yrs), NC BRFSS, 2008
25.7 26.224.8
22.5 22.6 22.1 22.920.9
0
5
10
15
20
25
30
2001 2002 2003 2004 2005 2006 2007 2008
* Current smoking- everyday or some daysSource: NC BRFSS 2000-2006
Current Smoker Prevalence NC and US, 2005, 2006 & 2007 BRFSS
22.6 22.1 22.920.6 20.1 19.8
2005 2006 2007
Year
Perc
ent
NC
US
Percentage of Adults Who Smoke Cigarettes by Race/Ethnicity - NC BRFSS, 2008
21.1 22.3
13.7
34.9
14.9
0
5
10
15
20
25
30
35
40
White AfricanAmerican
Hispanic NativeAmerican
Other
Note: Current users report using either every day or on some days Source: NC State Center for Health Statistics NC BRFSS
Percentage NC Adults Reporting Current Smoking, by Education—NC BRFSS, 2008
29.6 27.9
21.0
9.7
0
10
20
30
40
50
< HS HS Graduate Some College CollegeGraduate
Education
Per
cent
Note: Current users report using either every day or on some days Source: NC State Center for Health Statistics NC BRFSS
14.013.2 12.7 12.5 12.4
11.5 11.2
14.014.314.915.115.715.917.1
17.718.5
19.520.620.921.3
0
5
10
15
20
25
Per
cen
tage
Percentage of Pregnant Women Percentage of Pregnant Women Reporting Smoking Status in NC – Reporting Smoking Status in NC –
North Carolina Birth Records, 1988-2007North Carolina Birth Records, 1988-2007
Source: NC Vital Records File from Odum Institute at UNC; Vital Statistics, 2007
Women Who Smoked 3 Months Before Pregnancy, During the Last 3 Months and After Pregnancy, NC PRAMS, 2006 and 2007
17.6
13.0
21.9
17.9
14.3
22.9
Before Pregnancy During the Last 3 Months After Pregnancy
Perce
nt
2006 2007
Current Smokers Among Middle & High School Students in North Carolina
15.0%
11.3%9.4%
5.8%4.5%
32.5%
28.1% 28.0%
20.9%19.4%
0.0%
7.0%
14.0%
21.0%
28.0%
35.0%
1999 2001 2003 2005 2007
Middle School High SchoolResults based on North Carolina Youth Tobacco Survey administered biannually since 1999
Percentage of Middle and High School Students Reporting Current Tobacco Use*, by Type – NC Youth Tobacco Survey: 2007
Note: *Smoking 1 or more cigarettes during the previous 30 days. Bidis (also known as beedis or beedies) are small brown cigarettes, often flavored, consisting of tobacco hand-rolled primarily produced in India and in some Southeast Asian countries.
Source: North Carolina Youth Tobacco Survey, 2007
9.1
4.53.9
2.3 2.2
26.6
19.0
13.0
8.6
3.1
0
5
10
15
20
25
30
Any Tobacco Cigarette Cigar Smokeless Tobacco Pipe
Per
cent
age
NC Middle School
NC High School
The Toll of Tobacco Use
In North Carolina: Total health care costs from
smoking: $2.46 billion Portion covered by state Medicaid
program: $769 million
Campaign for Tobacco-Free Kids, “The Toll of Tobacco in North Carolina” Fact Sheet accessed May 19, 2008 at http://www.tobaccofreekids.org/reports/settlements/toll.php?StateID=NC
Sticker Shock…In the United States more thanIn the United States more than
$75,000,000,000$75,000,000,000of annual healthcare costs are of annual healthcare costs are attributable directly to smoking.attributable directly to smoking.
National Institute on Drug Abuse Research Report Series, What is the Extent and Impact of Tobacco Use?, July 2006
http:///www.cdc.gov/tobacco/
Surgeon General’s Report on Secondhand Smoke
July 2006
2006 SGR: Major Conclusions
The debate is over.The debate is over.
Secondhand smoke is a serious health hazard and causes early death and Secondhand smoke is a serious health hazard and causes early death and disease in North Carolinians who do not smoke. disease in North Carolinians who do not smoke.
The scientific evidence indicates there is The scientific evidence indicates there is no risk-free levelno risk-free level of exposureof exposure to secondhand smoketo secondhand smoke
Ventilation does not protect people from being exposed to SHS , only Ventilation does not protect people from being exposed to SHS , only elimination of all smoking protects SHS (supported by ASHRAE)elimination of all smoking protects SHS (supported by ASHRAE)
American Society of Heating, Refrigerating, American Society of Heating, Refrigerating, and Air Conditioning Engineersand Air Conditioning Engineers
2006 SGR’s Major Conclusions
SHS exposure of adults causesSHS exposure of adults causes Immediate adverse affects on the Immediate adverse affects on the
cardiovascular systemcardiovascular system Coronary heart diseaseCoronary heart disease
30,000 deaths/yr 30,000 deaths/yr Lung cancerLung cancer
estimated 3000 deaths/yr estimated 3000 deaths/yr
CDC. Annual smoking-attributable mortality, years of potential life lost, and economic costs – United States,1995-1999. Morbidity and Mortality Weekly Report 2002. 51(14):300-303.
CDC recently reviewed the literature and issued this commentary:
All patients at risk of coronary heart All patients at risk of coronary heart disease or with known coronary artery disease or with known coronary artery disease should be advised to avoid all disease should be advised to avoid all indoor environments that permit indoor environments that permit smoking.smoking.
Source: British Medical Journal, 2004Source: British Medical Journal, 2004
Helena, Montana Study Smoking ban for 6 monthsSmoking ban for 6 months Reduced incidence of admissions for myocardial Reduced incidence of admissions for myocardial
infarction ofinfarction of 40% 40% during banduring ban MI admissions increased when ban rescindedMI admissions increased when ban rescinded
Sargent, RP, et al. BMJ, 328:977-980, 2004.Sargent, RP, et al. BMJ, 328:977-980, 2004. Replicated in studies: Replicated in studies:
France (15%)France (15%) Scotland (17%)Scotland (17%) Ireland (14%)Ireland (14%) Indiana (59%)Indiana (59%) New York State (3,813 fewer MI admissions)New York State (3,813 fewer MI admissions)
Cardiovascular Risks of Second Hand Smoke MI risk from tobacco smoke exposure is MI risk from tobacco smoke exposure is
biologically feasiblebiologically feasible Small exposures (30 minutes) can induce Small exposures (30 minutes) can induce
changes in vessels in people at riskchanges in vessels in people at risk Short term reductions in exposure reduces Short term reductions in exposure reduces
heart attacks heart attacks
Pechacek,T., Babb, S. Commentary: How Acute and Reversible Are The Pechacek,T., Babb, S. Commentary: How Acute and Reversible Are The Cardiovascular Risks of Second Hand Smoke? BMJ, 328:980-983, April 24, Cardiovascular Risks of Second Hand Smoke? BMJ, 328:980-983, April 24, 2004.2004.
Working 8hours where smoking isallowed has thesame healthrisks as activesmoking.
Second Hand Smoke – Health Risk in Workplaces
Whincup, P et. al., Passive smoking and risk of coronary heart disease and stroke: prospective study with cotinine measurementBMJ, Jun 2004; 10.1136/bmj.38146.427188.55
2006 SGR’s Major Conclusions
Infants and children are at Infants and children are at increased risk forincreased risk for SIDS (Sudden Infant Death Syndrome)SIDS (Sudden Infant Death Syndrome) acute respiratory infections acute respiratory infections ear problemsear problems more severe asthma more severe asthma decreased lung growth decreased lung growth increased cases of bronchitis, increased cases of bronchitis,
pneumonia, and ear infectionspneumonia, and ear infections
More sticker shock…Secondhand Smoke Costs - NCSecondhand Smoke Costs - NC
$289,000,000$289,000,000
This is a conservative estimate – does not consider:This is a conservative estimate – does not consider: lost productivity lost productivity impact on quality of lifeimpact on quality of life long-term care and disability serviceslong-term care and disability services
North Carolina’s Secondhand Smoke Healthcare Cost Burden, Pfannenschmidt and Wansink, Clinical Informatics Department, Blue Cross and Blue Shield of North CarolinaClinical Informatics Department, Blue Cross and Blue Shield of North Carolina
Effects on Youth
Effects of secondhand smoke/active smokingEffects of secondhand smoke/active smoking Increases asthma significantly (15%) increaseIncreases asthma significantly (15%) increase $1.34 million/yr excess medical costs$1.34 million/yr excess medical costsSturm, J. et al: Effects of Tobacco Smoke Exposure on Asthma Prevalence and Medical Care Use in NC Sturm, J. et al: Effects of Tobacco Smoke Exposure on Asthma Prevalence and Medical Care Use in NC
Middle School Children. American Journal of Public Health, 94(2):308-313. Feb. 2004Middle School Children. American Journal of Public Health, 94(2):308-313. Feb. 2004
Effects of secondhand smokeEffects of secondhand smoke Cognitive declines (decreases reading, math and Cognitive declines (decreases reading, math and
block design)block design) Lower scores on reading and visuo-spatial testingLower scores on reading and visuo-spatial testingYolton, K. et al: Exposure to Environmental Tobacco Smoke and Cognitive Abilities among U.S.
Children and Adolescents. Environmental Health Perspectives, 113(1):98-103. January 2005
Yolton, K. et al (2005). Exposure to Environmental Tobacco Smoke and Cognitive Abilities among US Children and Adolescents. Environmental Health Perspectives, Vol 113 (1), 98-103.
2004 Surgeon General’s Report 2004 Surgeon General’s Report
The Health Consequences of SmokingThe Health Consequences of Smoking
2004 Surgeon General’s Report - The Health Consequences of Smoking
“Doom and Gloom” Smoking harms nearly every organ of the body Cessation has immediate and long-term benefits Smoking low tar cigarettes provides no health
benefits List of smoking-caused diseases includes COPD,
pneumonia, cataracts, periodontitis, AAA, and
cancers of lung, pancreas, stomach, cervix, kidney
2004 SGR – Smoking and Youth
Children and adolescents who smoke have:Children and adolescents who smoke have:
physical fitnessphysical fitness lung function lung function lung growthlung growth respiratory illnessrespiratory illness chronic cough and wheezechronic cough and wheeze
2004 SGR – Smoking and Pregnancy
Smoking during pregnancy Smoking during pregnancy Low birth weightLow birth weight StillbirthStillbirth Sudden Infant Death SyndromeSudden Infant Death Syndrome
Risk doubles - smoking after birthRisk doubles - smoking after birth Risk 3-4 times greater - smoking before and afterRisk 3-4 times greater - smoking before and after
NicotineNicotine blood flow to fetusblood flow to fetus found in breast milkfound in breast milk
Tobacco dependence as a chronic disease
“Tobacco dependence shows many features of a chronic disease… A failure to appreciate the chronic nature of tobacco dependence may undercut clinicians’ motivation to treat tobacco use consistently.” Dr. Michael Fiore, Chair of Interagency Committee on Smoking and Health, 2000
Tobacco dependence as a chronic disease Permanent abstinence is the goalPermanent abstinence is the goal
Congratulate smaller successes Congratulate smaller successes Quitting consists of multiple relapses and Quitting consists of multiple relapses and
remissionremission Few quit for good on first attemptFew quit for good on first attempt Each attempt is a learning experienceEach attempt is a learning experience No single ideal interventionNo single ideal intervention Relapse is risk for weeks, months, yearsRelapse is risk for weeks, months, years
Requiring ongoing interventionsRequiring ongoing interventions Clinicians can feel ineffective, lose motivation Clinicians can feel ineffective, lose motivation
"In my view, a doctor isn't providing an appropriate
standard of care …. if he or she doesn't ask two key
questions
—'Do you smoke?' and 'Do you want to quit?'—
(Do you use tobacco? Do you want to quit?)(Do you use tobacco? Do you want to quit?)
and then work with that individual to make it
happen.“
—Michael C. Fiore, MD, M.P.H., Director Center for Tobacco Research and Intervention University of Wisconsin Medical School
It takes on average, 6 to 7 attempts to quit for good…
Addiction
NICOTINE
DOPAMINE Pleasure, Appetite Suppression
NOREPINEPHRINE Arousal, Appetite Suppression
ACETYLCHOLINE Arousal, Cognitive Enhancement
GLUTAMATE Learning, Memory Enhancement
SEROTONIN Mood Modulation,Appetite Suppression
BETA-ENDORPHIN Reduction of Anxiety and Tension
GABA Reduction of Anxiety and Tension
Nicotine Stimulates Release of Many Different Neurotransmitters
Characteristics of Nicotine lead to Reinforcement of Use & Addiction
High concentrations of High concentrations of nicotine within 7-10 nicotine within 7-10 secondsseconds
Half-life = 90-120 min.Half-life = 90-120 min. Able to respond quickly Able to respond quickly
to additional dosesto additional doses ““Euphoria” without Euphoria” without
“Intoxication”“Intoxication” Behavior reinforced Behavior reinforced
multiple times dailymultiple times daily
Nicotine Addiction:“A Brain Disease”
““Up-Regulation”Up-Regulation” Increased Increased numbersnumbers of Nicotinic receptors of Nicotinic receptors
Withdrawal Syndrome or "Abstinence Syndrome"
Pathophysiologic disturbances which result Pathophysiologic disturbances which result when a drug to which an organism is when a drug to which an organism is
physically dependent is stopped.physically dependent is stopped.
Smoking Cessation
“…“…is the easiest thing I ever did; I ought to is the easiest thing I ever did; I ought to know because I have done it a thousand know because I have done it a thousand times”.times”.
- - Mark TwainMark Twain
Withdrawal Symptoms Symptoms may begin within a few hours of last use, but
typically within the first few days, and begin to subside within a few weeks.
Cravings, which may relate to certain “triggers” , can occur for months to years.
Craving will pass without a cigarette
The “relaxing” effect that nicotine provides may not be due to physical relaxation; rather, it may be the elimination of early withdrawal symptoms.
Withdrawal Symptoms • Psychological/Behavioral: giving up a habitPsychological/Behavioral: giving up a habit• Physical: absence of nicotinePhysical: absence of nicotine
Nicotine craving is a major obstacle to successNicotine craving is a major obstacle to successDepressionDepressionIrritability; angerIrritability; angerTrouble concentrating; restlessnessTrouble concentrating; restlessnessSleep disturbances; tirednessSleep disturbances; tirednessHeadacheHeadacheIncreased appetiteIncreased appetite
• Repeat exposure to nicotine creates toleranceRepeat exposure to nicotine creates tolerance• Higher doses required to create same stimulationHigher doses required to create same stimulation
http://teens.drugabuse.gov/drnida/drnida_nic1.asp#long_periodshttp://teens.drugabuse.gov/drnida/drnida_nic1.asp#long_periods
Teens Underestimate the Addiction…
Most high school smokers believe they Most high school smokers believe they will not be smoking in 5 years, however will not be smoking in 5 years, however 73% remain daily smokers 5-6 years later 73% remain daily smokers 5-6 years later (CDC longitudinal studies)(CDC longitudinal studies)
Addiction and Youth
Adolescents may be more sensitive to nicotine, may be more sensitive to nicotine, especially in combination with other chemicals especially in combination with other chemicals found in tobacco. found in tobacco.
Depending on age of initiation, this may increase the Depending on age of initiation, this may increase the likelihood of tobacco addiction. Combined with likelihood of tobacco addiction. Combined with social influences, this puts young people at greater social influences, this puts young people at greater risk for becoming addicted. risk for becoming addicted.
Source: (National Institute on Drug Abuse: Tobacco Addiction Series)
Cessation: What Works
Behavioral supportBehavioral support Treats the psychological and habit Treats the psychological and habit
aspectsaspects Pharmacotherapy Pharmacotherapy
Treats nicotine addictionTreats nicotine addiction
Works best when combinedWorks best when combined
http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf
Efficacy of Physician Advice to Quit
Abstinence Rate %Abstinence Rate % No advice No advice 7.9 7.9 Physician AdvicePhysician Advice 10.2 10.2
Patients expect healthcare providers to ask Patients expect healthcare providers to ask about tobacco use and advise them to quitabout tobacco use and advise them to quit
Source: Treating Tobacco Use andSource: Treating Tobacco Use and Dependence, USDHHS, Public Health Service, 2000Dependence, USDHHS, Public Health Service, 2000
5 A’s For Patients Willing to Quit
AskAsk about tobacco use about tobacco use AdviseAdvise patient to quit patient to quit
Refer (1-800-QUIT-NOW or local prgm)Refer (1-800-QUIT-NOW or local prgm) AssessAssess readiness to quitreadiness to quit AssistAssist in quit attempt in quit attempt ArrangeArrange follow-up follow-up
Ask
Ask about tobacco use at every visitAsk about tobacco use at every visit Systematically identify all tobacco usersSystematically identify all tobacco users Make identification/documentation a vital Make identification/documentation a vital
signsign Create a universal identification system Create a universal identification system
(stickers, computer reminders, etc.)(stickers, computer reminders, etc.)
Create a Reminder System
Include tobacco use in other medical / dental adviceInclude tobacco use in other medical / dental advice Use an identification system Use an identification system Stamp, Sticker, EMR Stamp, Sticker, EMR
Tobacco Use and ExposureTobacco Use: (circle one): Current Former Never
Secondhand Smoke Exposure: YES NOTobacco use is the single most preventable cause of death in the US.
Advise
Clear, Strong, PersonalizedClear, Strong, Personalized
““Quitting smoking ...Quitting smoking ... ...is the single best thing you can do for ...is the single best thing you can do for
your health” your health” ...will reduce your risk of …”...will reduce your risk of …”
Employ the teachable moment: Employ the teachable moment: Link visit findings with advice. Link visit findings with advice.
Assess
Willingness to make quit attempt in next 30 Willingness to make quit attempt in next 30 daysdays
““I want to quit” NOT “I need to quit” I want to quit” NOT “I need to quit”
Examples Very specific reasons to quit smoking:Very specific reasons to quit smoking:
“ “I want to quit smoking so I can go shopping I want to quit smoking so I can go shopping without stopping 10 times.”without stopping 10 times.”
“ “I want to quit smoking so I will not have a I want to quit smoking so I will not have a stroke like my dad.”stroke like my dad.”
“ “I want to quit smoking so my dogs will not I want to quit smoking so my dogs will not get emphysema.” (real quote)get emphysema.” (real quote)
I want to quit so I won’t smell like an ashtray I want to quit so I won’t smell like an ashtray
Stages of Change
Pre-contemplationPre-contemplation ContemplationContemplation PreparationPreparation ActionAction MaintenanceMaintenance
5R’s for Patients Not Ready To Make a Quit Attempt
RelevanceRelevance RisksRisks RewardsRewards RoadblocksRoadblocks RepetitionRepetition
Assist
Develop a quit planDevelop a quit plan STAR:STAR:
- - SSet a quit date (within 2 weeks)et a quit date (within 2 weeks)
- - TTell family, friends, coworkersell family, friends, coworkers
- - AAnticipate challenges to quittingnticipate challenges to quitting
- - RRemove tobacco products fromemove tobacco products from environmentenvironment
Arrange Schedule follow-up Schedule follow-up
in personin person via telephonevia telephone NC Tobacco Use QuitlineNC Tobacco Use Quitline
4 visits/calls is evidence based4 visits/calls is evidence based Congratulate progress/successCongratulate progress/success Identify problems/anticipate challengesIdentify problems/anticipate challenges Evaluate pharmacotherapy use/problemsEvaluate pharmacotherapy use/problems
Help for the busy practice….
Health Care Provider’s Quick Intervention
ASKASK about tobacco useabout tobacco use ADVISEADVISE to quitto quit REFERREFER to NC Tobacco Use Quitline, to NC Tobacco Use Quitline,
Become An Ex, other resourceBecome An Ex, other resource PRESCRIBEPRESCRIBE as appropriateas appropriate
REFER Quitline information to allQuitline information to all Consider fax referralConsider fax referral
Patients ready to quit within 30 daysPatients ready to quit within 30 days
Consider cessation medicationsConsider cessation medications Provide Quitline number to patients Provide Quitline number to patients
not ready to quitnot ready to quit Other resources such as BecomeAnExOther resources such as BecomeAnEx Follow-up at next/every visitFollow-up at next/every visit
North Carolina Tobacco Use Quitline
1-800-QUIT-NOW (1-800-784-8669)1-800-QUIT-NOW (1-800-784-8669) 8a.m. – 3 a.m., 7 days a week; Toll-free; Confidential8a.m. – 3 a.m., 7 days a week; Toll-free; Confidential All North Carolinians - youth and adultAll North Carolinians - youth and adult Proactive – Quit coaches can call tobacco users back Proactive – Quit coaches can call tobacco users back
upon request, or make 1upon request, or make 1stst call call Fax referralFax referral Multiple language Quit CoachesMultiple language Quit Coaches
Administered by: Tobacco Prevention and Control Branch Administered by: Tobacco Prevention and Control Branch Funded by: NC Division of Public Health, NC Health and Wellness Funded by: NC Division of Public Health, NC Health and Wellness
Trust FundTrust Fund
Quitline can Assess, Assist, Arrange Quit coach helps set Quit Date, andQuit coach helps set Quit Date, and
Develop quit planDevelop quit plan
Make follow-up callsMake follow-up calls
Discuss pharmacotherapyDiscuss pharmacotherapy
Mail targeted resourcesMail targeted resources
Patients can call the Quitline anytimePatients can call the Quitline anytime
What happens on first call with the Quitline Intake specialist determines readiness to quit Intake specialist determines readiness to quit First call - plan for 5 -10 minutes to enrollFirst call - plan for 5 -10 minutes to enroll Transfer to Quit Coach for those ready Transfer to Quit Coach for those ready Quitline can call patients backQuitline can call patients back
4 visits is an evidence based intervention4 visits is an evidence based intervention If not ready to set quit date, If not ready to set quit date,
Encouraged to call back when ready, and Encouraged to call back when ready, and offered enrollment for:offered enrollment for: Cessation materials (mailed)Cessation materials (mailed) Web Coach access Web Coach access
Caller would like to speak to a Quit Coach One Call Program: Conversation with the Quit
Coach for support Support materials for
quitting Referral to local resources Medication information Help to develop a plan,
including setting a quit date Access to Web Coach
Four Call Program:Four Call Program: One Call program, plusOne Call program, plus Quit Coach will call backQuit Coach will call back
-- A quit date is set-- A quit date is set-- Dates and times are -- Dates and times are made for three more made for three more
calls from a Quit calls from a Quit CoachCoach
Three attempts, then Three attempts, then letter is sentletter is sent
Caller does not want to talk to a Quit Coach
Caller will be offered:Caller will be offered: Messages to promote quittingMessages to promote quitting Support materials for quittingSupport materials for quitting Referral to local resourcesReferral to local resources Encouragement to call againEncouragement to call again
Other Quitline Features
Web CoachWeb Coach Progress trackingProgress tracking Coaching e-mailsCoaching e-mails Discussion ForumsDiscussion Forums
Click to CallClick to Call Available on Web CoachAvailable on Web Coach
Fax Referral to Quitline Helps With… Referral to effective cessation servicesReferral to effective cessation services Provider’s limited time and resourcesProvider’s limited time and resources The burden of patient initiating services The burden of patient initiating services NOTE: Provider referral to a cessation NOTE: Provider referral to a cessation
program is associated with higher rates of program is associated with higher rates of participation than simply telling patients participation than simply telling patients they should stop using tobaccothey should stop using tobacco
Quitline Outcomes Report
Tool to follow patient progress with your Tool to follow patient progress with your advice to quit / utilize Quitline servicesadvice to quit / utilize Quitline services
Most useful in clinic setting with dedicated Most useful in clinic setting with dedicated fax machine/staff to retrieve reportsfax machine/staff to retrieve reports
Outcomes Report information:Outcomes Report information: Accepted servicesAccepted services Declined servicesDeclined services UnreachableUnreachable
Take patient’s vital signs & ask about
tobacco use.
Advise to quit.
Give patient cessation resources: 1-800-QUIT-NOW (1-800-784-8669),
www.becomeanex.org,or other resource.
INTERVENE: Offer cessation medications if indicated, Quitline #, fax
referral option
Give patient cessation resources: 1-800-QUIT-NOW (1-800-784-8669),
www.becomeanex.org,or other resource.
Is the patient
ready to quit?
Does patient
want a quit coach to
call them?
The Quitline will make at least 5 attempts to call the patient.
NO
YES
NO
YES
NC Tobacco Use Quitline Fax Referral Flow Chart
Complete fax referral consent form & fax to
Quitline.
More Cessation Resources
www.becomeanex.org
Become an EX www.becomeanEX.org
Web-based cessation program for adultsWeb-based cessation program for adults Fun, edgy, interactive Fun, edgy, interactive Personalized quit plan to:Personalized quit plan to:
“ “Relearn life without cigarettes” Relearn life without cigarettes” Relearn habitRelearn habit Relearn addictionRelearn addiction Relearn supportRelearn support
Free and in English and SpanishFree and in English and Spanish
Two booklets created by American Legacy Foundation in cooperation with Mayo Clinic –
Ex Easy Read Booklet and Fotonovella
Women and Children Resources
Resources for Youth
PROJECT ASPIREPROJECT ASPIRE – A smoking prevention – A smoking prevention interactive experience for youth:interactive experience for youth: www.mdanderson.org/aspirewww.mdanderson.org/aspire
My Last Dip My Last Dip – An on line – An on line program for age 14 - 25 who program for age 14 - 25 who use spit or smokeless use spit or smokeless tobacco:tobacco: www.mylastdip.comwww.mylastdip.com
Healthy Start Foundation
Two brochures can be orderedTwo brochures can be ordered If You Smoke And Are PregnantIf You Smoke And Are Pregnant http://www.nchealthystart.org/catalog/pregnancy.htmhttp://www.nchealthystart.org/catalog/pregnancy.htm
Oh Baby! We Want To Keep You Safe Oh Baby! We Want To Keep You Safe From Secondhand Smoke From Secondhand Smoke http://www.nchealthystart.org/catalog/parenting.htm#c006 http://www.nchealthystart.org/catalog/parenting.htm#c006
www.nchealthystart.orgwww.nchealthystart.org
You quit. Two quit. www.youquittwoquit.com
Informational website forInformational website for Pregnant womenPregnant women New mothersNew mothers Family and friendsFamily and friends Health professionalsHealth professionals
UNC Center for Maternal and Infant Health UNC Center for Maternal and Infant Health Funded by North Carolina Health and Wellness rust FundFunded by North Carolina Health and Wellness rust Fund
Tobacco Cessation Training for HCP’s Working with Women
The Guide is available on the Division of Public Health / Women’s Health Branch webpage: http://whb.ncpublichealth.com/provPart/pubmanbro.htm#top
For more information on the Women’s Health and Tobacco Use Program, contact:
Judy Ruffin
919-707-5712
Pharmacotherapy – First Line Nicotine Replacement TherapyNicotine Replacement Therapy
- Patch- Patch
- Gum- Gum
- Lozenge- Lozenge
- Inhaler- Inhaler
- Nasal Spray - Nasal Spray Zyban (bupropion)Zyban (bupropion) Chantix (varenicline)Chantix (varenicline)
Over the Counter Medications
Nicotine PatchNicotine Patch DoseDose: 21mg, 14mg or 7mg per 24 hours: 21mg, 14mg or 7mg per 24 hours
1 pack/day, start with higher dose, taper1 pack/day, start with higher dose, taper duration 8 weeksduration 8 weeks step down after 4 wks in 2 wk incrementsstep down after 4 wks in 2 wk increments Nicotrol is used for 16 hours, off at nightNicotrol is used for 16 hours, off at night
Adverse effectsAdverse effects: local skin reaction, insomnia, : local skin reaction, insomnia, vivid dreamsvivid dreams
ContraindicationsContraindications: Recent MI, unstable angina, : Recent MI, unstable angina, arrhythmiaarrhythmia
CostCost: 7mg box - $37: 7mg box - $37 14mg box - $47 14mg box - $47
21mg box - $4821mg box - $48
Nicotine Patch Dose Based on Smoking Rate
CPD = Cigarettes per day
10 cpd10 cpd 7 - 14 mg/d 7 - 14 mg/d
10 - 20 cpd 14 - 21 mg/d10 - 20 cpd 14 - 21 mg/d
21 - 40 cpd21 - 40 cpd 21 - 42 mg/d 21 - 42 mg/d
>40 cpd>40 cpd 42+ mg/d 42+ mg/d
Webinar – Pharmacologic Therapy for Tobacco Use and Dependence, J. Taylor Hays, MD, Mayo clinic Nicotine Dependence Center, Rochester, MNWebinar – Pharmacologic Therapy for Tobacco Use and Dependence, J. Taylor Hays, MD, Mayo clinic Nicotine Dependence Center, Rochester, MN
© © 2008 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH.2008 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH. ALL RIGHTS RESERVED ALL RIGHTS RESERVED
2008 Update to CPGs do not recommend NRT for light smokers due to Insufficient evidence2008 Update to CPGs do not recommend NRT for light smokers due to Insufficient evidence
Over the Counter MedicationsNicotine GumNicotine Gum DoseDose: up to 24 pieces per day: up to 24 pieces per day
x 12 weeks (longer if needed)x 12 weeks (longer if needed) 2mg for <25 cigarettes per day2mg for <25 cigarettes per day 4mg for >25 cigarettes per day4mg for >25 cigarettes per day Chew, chew, parkChew, chew, park Avoid acidic beveragesAvoid acidic beverages
Consider using on a fixed scheduleConsider using on a fixed schedule Long term patch and gum use are effectiveLong term patch and gum use are effective Adverse EffectsAdverse Effects: Mouth soreness, hiccups, jaw ache, : Mouth soreness, hiccups, jaw ache,
dyspepsiadyspepsia ContraindicationsContraindications: As for patch: As for patch CostCost: 2mg box (100-170 pieces) ~ $45 (generic): 2mg box (100-170 pieces) ~ $45 (generic)
4mg box (100-110 pieces) ~ $63 (generic)4mg box (100-110 pieces) ~ $63 (generic)
Over the Counter Medications
Nicotine Lozenge (Commit)Nicotine Lozenge (Commit) DoseDose
2mg (1st cig. >30 min. after awake)2mg (1st cig. >30 min. after awake) 4mg (1st cig. <30 min. after awake)4mg (1st cig. <30 min. after awake) 9 (min) to 20 (max) lozenges/day9 (min) to 20 (max) lozenges/day x 12 weeks (longer if needed)x 12 weeks (longer if needed)
Allow to dissolve in mouthAllow to dissolve in mouth Avoid acidic beveragesAvoid acidic beverages Adverse EffectsAdverse Effects: Nausea, hiccups, heartburn: Nausea, hiccups, heartburn
4mg dose - headache, cough4mg dose - headache, cough ContraindicationsContraindications: as for patch: as for patch CostCost: 2mg box (72 lozenges) - $34 : 2mg box (72 lozenges) - $34 4 mg box (72 lozenges) - $394 mg box (72 lozenges) - $39 (9 lozenges/day =1 box/wk = $136-$156/mo)(9 lozenges/day =1 box/wk = $136-$156/mo)
Prescription Medications
Nicotine InhalerNicotine Inhaler DoseDose: 4mg nicotine: 4mg nicotine
80 puffs=4mg nicotine80 puffs=4mg nicotine Best effects with frequent puffing/at least 6 cartridges Best effects with frequent puffing/at least 6 cartridges
per day (can use 6-16 cartridges/day)per day (can use 6-16 cartridges/day) Use for up to 6 months Use for up to 6 months
Reduce frequency over the last 6-12 weeks of txReduce frequency over the last 6-12 weeks of tx Avoid acidic beveragesAvoid acidic beverages Adverse EffectsAdverse Effects: mouth/throat irritation, coughing, rhinitis: mouth/throat irritation, coughing, rhinitis ContraindicationsContraindications: as for patch: as for patch CostCost: 1 box (168 10mg cartridges) - $196: 1 box (168 10mg cartridges) - $196
Prescription Medications
Nicotine Nasal SprayNicotine Nasal Spray DoseDose: 1 dose = 1 mg (0.5mg per nostril): 1 dose = 1 mg (0.5mg per nostril)
1-2 doses per hour initially1-2 doses per hour initially Increase as needed for symptom reliefIncrease as needed for symptom relief 8 min/40 max doses per day for 3-6 months8 min/40 max doses per day for 3-6 months Do not sniff, swallow or inhaleDo not sniff, swallow or inhale Head titled slightly backHead titled slightly back
Adverse EffectsAdverse Effects: Nasal irritation, congestion; : Nasal irritation, congestion; transient changes in smell, tastetransient changes in smell, taste
ContraindicationsContraindications: as for patch: as for patch CostCost: $49 per bottle (100 doses): $49 per bottle (100 doses)
NRT and Cardiovascular Disease
Not an independent risk factor for acute Not an independent risk factor for acute myocardial eventsmyocardial events
Use with caution in patients who:Use with caution in patients who: are within 2 weeks of MIare within 2 weeks of MI have serious arrhythmiashave serious arrhythmias have serious or worsening anginahave serious or worsening angina
pectorispectoris
Prescription Medications
Zyban, Wellbutrin (bupropion SR 150)Zyban, Wellbutrin (bupropion SR 150) BeginBegin 1-2 weeks before quit date 1-2 weeks before quit date DoseDose: 150 mg in a.m. for 3 days: 150 mg in a.m. for 3 days 150 mg twice daily for 7 to 12 weeks150 mg twice daily for 7 to 12 weeks May consider long-term tx for 6 months post quitMay consider long-term tx for 6 months post quit Adverse EffectsAdverse Effects: Insomnia, dry mouth: Insomnia, dry mouth ContraindicationsContraindications: history of seizure d/o, eating : history of seizure d/o, eating
d/o, recent MAO inhibitor use in past 14 daysd/o, recent MAO inhibitor use in past 14 days CostCost: 1 box of 60 tablets : 1 box of 60 tablets
$97/month (generic)$97/month (generic) $197-$210 (brand name)$197-$210 (brand name)
Prescription Medications
Chantix (varenicline)Chantix (varenicline) Stimulates nicotine receptors. Also blocks nicotine at Stimulates nicotine receptors. Also blocks nicotine at
receptor sitereceptor site Start Chantix 1 week before quit dateStart Chantix 1 week before quit date DoseDose: 0.5 mg daily for 3 days: 0.5 mg daily for 3 days
0.5mg twice daily for 4 days0.5mg twice daily for 4 days 1.0mg twice daily for 3 months1.0mg twice daily for 3 months
May decrease dosage (1mg/day) if significant side effectsMay decrease dosage (1mg/day) if significant side effects Adverse EffectsAdverse Effects: nausea, insomnia, abnormal/vivid dreams: nausea, insomnia, abnormal/vivid dreams New warning label Jan. 2008– observe for neuro- New warning label Jan. 2008– observe for neuro-
psychiatric symptoms (post marketing data)psychiatric symptoms (post marketing data) CostCost: 1 box of 56 - $131 (~30 day supply): 1 box of 56 - $131 (~30 day supply)
Research shows that at 1 year, 21% of those on Chantix are still abstinent Research shows that at 1 year, 21% of those on Chantix are still abstinent compared to 8% with a placebocompared to 8% with a placebo
More on Pharmacotherapy Combined therapy improves abstinence ratesCombined therapy improves abstinence rates
Patch Patch ++ gum, nasal spray, or inhaler gum, nasal spray, or inhaler Patch plus buproprion (FDA approved)Patch plus buproprion (FDA approved)
Do not combine NRT with ChantixDo not combine NRT with Chantix Buproprion and gum or lozenge may delay Buproprion and gum or lozenge may delay
weight gainweight gain NRT for smokers not willing to quit – NRT for smokers not willing to quit –
promising but warrants further researchpromising but warrants further research
Pregnancy and Pharmacotherapy
Abstinence early produces greatest benefitsAbstinence early produces greatest benefits Quitting at any point yields benefitsQuitting at any point yields benefits Person to person intervention should be Person to person intervention should be
offered to pregnant and post partum womenoffered to pregnant and post partum women Should exceeds minimal advice to quitShould exceeds minimal advice to quit
Inconclusive evidence that cessation Inconclusive evidence that cessation medications increase abstinence ratesmedications increase abstinence rates
Treating Tobacco Use and Dependence: Children and Adolescents
RecommendationsRecommendations
Clinicians screen children and adolescents for tobacco Clinicians screen children and adolescents for tobacco useuse
Consider counseling and behavioral interventions that Consider counseling and behavioral interventions that are effective with adultsare effective with adults
Offer smoking cessation advice and interventions to Offer smoking cessation advice and interventions to parentsparents
Insurance Coverage for Cessation Medications
Medicaid now covers ALL cessation Medicaid now covers ALL cessation pharmacotherapypharmacotherapy Nicotine patch, gum, lozenge, nasal spray, Nicotine patch, gum, lozenge, nasal spray,
inhalerinhaler ZybanZyban ChantixChantix
No Prior Authorization neededNo Prior Authorization needed Prescription required, even for OTCPrescription required, even for OTC
Counseling Coverage in NC
Medicaid added two CPT codes Jan. 1, 2009Medicaid added two CPT codes Jan. 1, 2009 99406 – 3-10 minutes 99406 – 3-10 minutes 99407 – > 10 minutes99407 – > 10 minutes
May be billed the same day as an E/M or Health May be billed the same day as an E/M or Health Check visitCheck visit
Use ICD-9 Code: 305.1 (tobacco abuse)Use ICD-9 Code: 305.1 (tobacco abuse) Unbundled – can use a second ICD-9 codeUnbundled – can use a second ICD-9 code
Medicare, BCBSNC, and State Health Plan also Medicare, BCBSNC, and State Health Plan also reimburse these codesreimburse these codes
Medicaid Coverage for Treatment
For more information see Medicaid Bulletins:For more information see Medicaid Bulletins: Jan 2009:
http://www.dhhs.state.nc.us/dma/bulletin.htmhttp://www.dhhs.state.nc.us/dma/bulletin.htm Oct.2008:
http://www.ncdhhs.gov/dma/bulletin/1008bulletin.htm
More Cessation Counseling Reimbursement Codes Other codes:
99401-04; 15-60 minutes (dedicated visit) 99354 can be added to regular visit (must
document counseling) 9941199411 is used for group counseling (per
participant) MD, PA or FNP on premises, must talk to
group RN (etc.) may facilitate session
Helpful Web Sites and Links:
www.tobaccopreventionandcontrol.www.tobaccopreventionandcontrol.ncdhhs.gov/cessationncdhhs.gov/cessation
www.tobaccopreventionandcontrol.www.tobaccopreventionandcontrol.ncdhhs.gov/FaxForm.pdfncdhhs.gov/FaxForm.pdf
www.QuitLineNC.com www.QuitLineNC.com
www.QuitNowNC.orgwww.QuitNowNC.org
Learning More / CE Options Counseling for Change: An On-line Tobacco Cessation Counseling for Change: An On-line Tobacco Cessation
Course - Northwest AHEC Course - Northwest AHEC Contact Nedra Edwards HinesContact Nedra Edwards Hines
• 336-713-7727; [email protected]; [email protected] $20 fee for course credits; free to view$20 fee for course credits; free to view
Medscape: Treating Tobacco Use and DependenceMedscape: Treating Tobacco Use and Dependencehttp://www.medscape.com/viewarticle/570604http://www.medscape.com/viewarticle/570604
FreeFree Approved for 1hour CE Approved for 1hour CE AMA PRA Category 1 Credit(s)™ AMA PRA Category 1 Credit(s)™ Requires registration to MedscapeRequires registration to Medscape
TobaccoFreePatients.comTobaccoFreePatients.comhttp://www1.tobaccofreepatients.com/TopicReq?http://www1.tobaccofreepatients.com/TopicReq?
Based on NCI educational programBased on NCI educational program Available free for study and reviewAvailable free for study and review $15 per credit hour / letter of completion$15 per credit hour / letter of completion
Take-Home Message for Health Care Providers Brief cessation counseling is effectiveBrief cessation counseling is effective Longer cessation counseling is more effectiveLonger cessation counseling is more effective Pharmacotherapy can double quit ratesPharmacotherapy can double quit rates Pharmacotherapy should be offered to allPharmacotherapy should be offered to all
- few exceptions- few exceptions Evidence-based resources are availableEvidence-based resources are available
You only have two minutes AskAsk every everyone about tobacco use every everyone about tobacco use AdviseAdvise to quit with a clear, strong, to quit with a clear, strong,
personalized messagepersonalized message ReferRefer to to
NC Tobacco Use QuitlineNC Tobacco Use Quitline 1-800-QUIT-NOW (1-800-784-8669)1-800-QUIT-NOW (1-800-784-8669)
Become An ExBecome An Ex www.becomeanex.orgwww.becomeanex.org
PharmacotherapyPharmacotherapy – for most – for most
Tobacco Prevention and Control BranchDivision of Public Health
North Carolina Department of Health and Human Services
Main Ph: 919-707-5400Fax: 919-870-4844
www.tobaccopreventionandcontrol.ncdhhs.gov