Beating Joe Camel: The American Society of Anesthesiologists

Smoking Cessation Initiative

Beating Joe Camel: The American Society of Anesthesiologists

Smoking Cessation Initiative

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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)

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Why bother?

Surgery May Promote Quitting Smoking

Quitting Smoking Improves Surgical

Outcomes

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Tobacco Cessation Improves Surgical Outcomes

• Cardiovascular complications

• Respiratory complications

• Wound related complications

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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 MonoxideH

alf life of ~4 hours

Level near normal at 12 hrs

• Preoperative abstinence decreases the frequency of intraoperative ischemia*

*Woehlck et al, Anesth Analg 89: 856, 1999

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Smoking Cessation Reduces Postoperative Complications

0

10

20

30

40

50

60

Any Wound Cardiac

Complication

%

Control

Intervention• 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

Moller, Lancet 359:114, 2002

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Why bother?

Quitting Smoking Improves Surgical

Outcomes

Surgery May Promote Quitting Smoking

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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

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Smoking Cessation After Surgery

0

20

40

60

80

100

% q

uit

tin

g a

t o

ne

year

Self-help OutpatientCessationPrograms

Major Non-cardiacSurgery

CoronaryBypassSurgery

LungCancerSurgery

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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

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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

0%

5%

10%

15%

20%

25%

ContinuedSmokers

RecentQuitters

PastQuitters

NonSmokers

Overall

Pneumonia

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Nicotine Replacement Therapy and Wound Healing

0 %

5 %

1 0 %

1 5 %

2 0 %

2 5 %

3 0 %

I n f e c t i o n r a t e

N o n - a b s t i n e n t

A b s t i n e n t , a c t i v e p a t c h

A b s t i n e n t , p l a c e b o

•48 smokers randomized to continuous smoking or abstinence, with or without nicotine replacement•Standardized surgical wounds over a 12 week period

Sorensen et al, Ann Surg 238:1, 2003

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Perioperative Stress in Smokers

0

1

2

3

4

Preop Postop POD1 POD2 POD7

Pe

rce

ive

d S

tre

ss Smokers

Nonsmokers•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

Warner et al, Anesthesiology 199:1125, 2004

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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, Am J Prev Med 35:S486, 2008

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The Real Barriers to Intervention

“I don’t know how”

“I don’t have time”

“It’s not my job”

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What are we doing now?

0%

20%

40%

60%

80%

100%

Ask Advise Assist

Anesthesiologists

Surgeons• 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

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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

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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

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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

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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

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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 patients know nothing about quitlines….

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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

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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

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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

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ASA Quitline Card

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ASA Patient and Provider Brochures

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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

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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

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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

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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

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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

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Rates That Anesthesiologists Performed Ask-Advise-Refer Elements

0

2 0

4 0

6 0

8 0

1 0 0

A s k A d v i s e R e f e r

B a s e l i n e

P i l o t p r o j e c t

% “

freq

uent

ly o

r al

way

s”

“Baseline” data from 2004 national survey of ASA members, Warner et al, A&A, 99:1766, 2004

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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

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What about Joe Camel?