CURRENT ISSUES IN TOBACCO CESSATION

FOR THE PRACTICING PHYSICIAN

Shahnaz Fatteh, M.D. Associate Clinical Professor and

Director, Asthma, Allergy and Immunology Clinic

Dr. Kiran C. Patel College of Osteopathic Medicine

Nova Southeastern University

No Disclosures

OBJECTIVES

Importance of Addressing Tobacco Use with Patients

Pathophysiology of Tobacco Use

Current Treatments / Medications

New and Emerging Tobacco Products – E-Cigarettes

Public Policy – Current issues pertaining to tobacco

Meeting New Practice Standards for Addressing Tobacco Use

How the Physician can Play a Key Role in Tobacco Cessation

“Cigarette smoking is the chief, single avoidable cause of death in our society and the most important public health issue of our time.”

C. Everett Koop, M.D.

U.S. Surgeon General, 1982-1989

From “The Health Consequences of Smoking: Cancer.” Surgeon General’s Report, USDHHS, 1982

WHY IS IT IMPORTANT TO ADDRESS

TOBACCO USE WITH YOUR PATIENTS?

WHY IS IT THAT PHYSICIANS HAVEN’T ROUTINELY

DISCUSSED TOBACCO CESSATION WITH THEIR

PATIENTS

Discussion about tobacco may be time-consuming

Physician may not feel they can make a difference

Patients are unready to change

Discussions can be unpleasant – might be viewed

by their patients as intrusive

Sources: Vogt (2005). Addiction, 100(10): 1423-1431, Caplan, Lee, et.al. (2011), Journal of Community

Health, 36(2): 238-243.

IF A CLINICIAN DOES NOT ADDRESS

TOBACCO USE…

Patients may think that

quitting smoking is not

important if they don’t hear it

from their health providers

WHY SHOULD YOU PRIORITIZE THE TREATMENT

OF TOBACCO USE?

You can make a difference even with a brief

intervention (3 minutes or less)

For a patient not interested in quitting, a brief

tobacco intervention can increase motivation and

the possibility of future quit attempts

Effective treatment and cessation resources exist.

Source: Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update.

Clinical Practice Guideline. Rockville, MD: U.S. Dept of Health and Human Services. Public Health

Service. May 2008, p. 37.

Physicians can make

a real difference in

getting their tobacco-

dependent patients to

quit

Source: Tobacco Free Florida

More than

70% of tobacco users indicate that they want to quit

15.8%

Source: Tobacco Free

Florida

CLINICAL PRACTICE GUIDELINE – TREATING TOBACCO USE AND DEPENDENCE:

MAXIMIZING TOBACCO TREATMENT AND

ABSTINENCE IN THE HEALTH CARE SETTING

Relapse management

Patient reinforcement counseling

Counseling & medication

Consistent pt. follow-up & assessment

Patient reminder systems

Telephone counseling services

Multiple formats (verbal, written, video)

Multidisciplinary team approach

Longer Intervention (> 3 mins.)

14.4% Brief Intervention (< 3 mins.)

Approx. 11% of tobacco users will quit on their own. Talking with the

patient about their tobacco dependency for less than 3 minutes will

increase the quit rate to 14.4%. Longer interventions and other elements in

place in the clinical setting will more than double this quit rate.

QU

IT R

ATE

Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Dept of Health and Human Services. Public Health Service. May 2008, p. 85.

BRIEF INTERVENTION

CAN MAKE A DIFFERENCE

ASK

ADVISE

REFER

TOBACCO RELATED MORTALITY

• Tobacco use is the leading preventable cause of morbidity and mortality in the United States contributing to more than 480,000 deaths annually (Surgeon General’s Report 2014)

• Secondhand smoke causes nearly 42,000 deaths from heart disease and lung cancer each year in the United States among nonsmokers. (Surgeon General’s Report 2014)

• On average, smokers die more than 10 years earlier than nonsmokers

YOUTH AND TOBACCO

• 90% of smokers start smoking by age 18

• Every day in the U.S., 3,200 kids under age 18

try their first cigarette (nearly 1.2 million per

year)

• 2,500 youth and young adults become regular

smokers daily

(Surgeon General’s Report 2012, 2014)

IN THE STATE OF FLORIDA…SINCE

THE INCEPTION OF TOBACCO FREE

FLORIDA IN 2007...

Adult smoking rate is 15.8% down from 21% in 2006. (2015)

This reduction in adult smoking rate results in $17.7 billion in savings in tobacco-related health care costs (2007-2015)

Youth smoking rate has decreased from 10.6% to 3.0% (2016)

(Tobacco Free Florida 2015, 2016)

TOBACCO USE AND CHRONIC DISEASE

Source: The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014

THE 50TH ANNIVERSARY SURGEON GENERAL’S REPORT 2016 (SGR)

HEALTH CONSEQUENCES CAUSALLY LINKED TO SMOKING

Source: The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014

Early Death fires (1%)

illicit drugs (1%)

homicide (3%)

car accidents (4%)

suicide (4%)

AIDS (4%)

alcohol (15%)

tobacco (68%*)

*combination of tobacco use (61%) + second-hand smoke (7%) AMERICAN CANCER SOCIETY

QUITTING TOBACCO USE

Non-pharmacologic

Counseling

Pharmacologic

FDA-approved medications

Counseling and medications are

both effective, but the combination of

counseling and medication is more

effective than either alone.

Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.

Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.,

Nicotine polacrilex gum

Nicorette (OTC)

Generic nicotine gum (OTC)

Nicotine lozenge

Nicorette Lozenge (OTC)

Nicorette Mini Lozenge (OTC)

Generic nicotine lozenge (OTC)

Nicotine transdermal patch

NicoDerm CQ (OTC)

Generic nicotine patches (OTC, Rx)

Nicotine nasal spray

Nicotrol NS (Rx)

Nicotine inhaler

Nicotrol (Rx)

Bupropion SR (Zyban, generic)

Varenicline (Chantix)

FDA-APPROVED MEDICATIONS for CESSATION

PHARMACOTHERAPY

FDA-APPROVED MEDICATIONS for CESSATION

PHARMACOTHERAPY

Certain Combinations of Cessation Medications have been

shown to be effective

Combining a long-acting NRT (patch) with a short-acting

NRT (gum, lozenge or inhaler) is more effective than

using a single type of NRT

Nicotine Patches have also been effective in combination

with use of Bupropion (Zyban)

BRIEF TOBACCO INTERVENTION

AND DOCUMENTATION

Since addressing tobacco use with your patients

does make a difference in their motivation to

quit…Did you know……

Most Insurances allow billing for cessation

interventions and counseling.

CPT Code: 99406 – smoking and tobacco

use counseling visit – 3-10 minutes

CPT Code: 99407 – smoking and tobacco

use counseling – intensive visit – greater than

10 minutes

E-CIGARETTES – THE NEW TREND

THE FACTS

Battery powered devices that heat a liquid into an

aerosol that is inhaled by user

Different types/sizes of e-cigarettes - also known

as e-cigs, e-hookahs, vapes, vape pens, mods,

and tank systems

Liquid most often has nicotine, flavoring, and

other additives.

E-cigs can also be used to deliver marijuana and

other illegal drugs

E-cigs are NOT FDA-approved cessation aid and

are NOT proven to be safe.

Source: U.S. Dept. of Health and

Human Services. E-Cigarette Use

Among Youth and Young Adults: A

Report of the Surgeon General,

2016.

E-CIGARETTES – THE NEW TREND

THE FACTS, continued

Most commonly used tobacco product among

youth.

More than ¼ of youth in middle and high

school have tried e-cigs.

In Florida, teen cigarette smoking has

decreased, but high school e-cig use has

increased by 72% in just two years—from

10.8% in 2014 to 18% in 2016. (Tobacco

Free Florida)

Thousands of flavors such as strawberry,

pina colada, blue raspberry are appealing

to youth.

Source: U.S. Dept. of Health and

Human Services. E-Cigarette Use

Among Youth and Young Adults:

A Report of the Surgeon General,

2016.

E-CIGARETTES – THE NEW TREND

IT’S JUST WATER VAPOR, RIGHT?—WRONG…

E-cig aerosol is not harmless.

Most contain nicotine which is addictive and disrupts growth

of developing brain of youth, especially in the area of

attention, learning, impulse control

Health effects very concerning –long term safety of e-cig

use or exposure to secondhand aerosol not known. Not a water vapor, but an aerosol containing ingredients such as

Nicotine – causes addiction

Ultrafine particles – can be inhaled deep into the lungs

Source: U.S.

Dept. of

Health and

Human

Services. E-

Cigarette Use

Among Youth

and Young

Adults: A

Report of the

Surgeon

General,

2016.

E-CIGARETTES – THE NEW TREND

THE FACTS, continued

Diacetyl – used in some flavors, chemical linked to

bronchiolitis obliterans (“popcorn lung”)

Volatile Organic Compounds such as benzene, and

several heavy metals such as nickel, lead and tin

Propylene Glycol – while this is present in many foods,

and considered safe to eat, inhaling could cause lung

irritation/asthma

Carcinogenic substances including formaldehyde

found in some aerosols.

Source: U.S.

Dept. of

Health and

Human

Services. E-

Cigarette Use

Among Youth

and Young

Adults: A

Report of the

Surgeon

General,

2016.

EVER HEARD OF JUULS?

Very Popular Brand of E-cigs

with youth and young adults

Designed to look like a flash

drive which is charged in

the computer

One Pod of e-liquid equals

one pack of cigarettes or 200

puffs.

JUULing…

Middle School and High School

students are using these on

campus, easy to hide since it fits

in palm and can be charged in

computer.

Several flavors including mango,

cool mint, crème brulee, fruit

medley, cool cucumber, classic

tobacco.

NON-CIGARETTE TOBACCO PRODUCTS

AND FUTURE USE OF CIGARETTES IN

YOUTH JAMA Pediatr. 1/2/18,

Watkins, Glantz, Chaffee

Population of 10,384 youth respondents

By using any of these products, youth more likely to use cigarettes one year later

E-cigarette, hookah, non-cigarette combustible tobacco, or smokeless tobacco use

Use of more than one of these products even more likely

PUBLIC HEALTH INITIATIVES

TOBACCO 21

Increasing legal age to purchase tobacco to 21 years old

95% of adult smokers begin smoking before age 21; raising legal age

to 21 has been shown to reduce youth initiation of tobacco

Will decrease nicotine addiction in teens and long-term use,

therefore saving lives (Institute of Medicine Report, 2015)

5 states (California, Oregon, New Jersey, Maine, and Hawaii have

raised their tobacco sales age to 21. Over 250 cities, counties,

communities have adopted Tobacco 21, including New York City, San

Antonio, Washington DC, to name a few.

PUBLIC HEALTH INITIATIVES

TOBACCO-FREE PARKS / BEACHES

Reduce secondhand smoke exposure

Reduce litter/cigarette butts on beaches

and in parks

Difficult to adopt laws due to preemption in

Florida—state government limits or eliminates

local governments authority to pass local

tobacco control laws, including adopting

smokefree areas

PUBLIC HEALTH INITIATIVES

SMOKE-FREE MULTI-UNIT HOUSING

HUD – Public Housing Authorities must have smoke-free

policies by July 31, 2018. Policies must prohibit smoking

in all indoor areas, individual living units, common areas,

office buildings, outdoor areas within 25 feet of buildings.

Protects residents from secondhand smoke exposure.

Secondhand smoke can seep through walls, ventilation

systems into non-smoker’s apartments

Cost savings – 2-7 times more time and money to turn

over an apartment in which smoking has occurred

Prevent smoking-related fires—can save on insurance

INTERESTED IN GETTING INVOLVED?

Contact your local Area Health Education

Center (AHEC) for free tobacco cessation

services for your patients and training for you,

your providers and your staff,

Call 877-848-6696

Join your county’s Tobacco Free Partnership

Advocate Tobacco 21 Efforts / Smokefree

Parks/Beaches in your community

INTERESTED IN GETTING INVOLVED?

Get involved in your local chapters of the American Lung

Association, American Cancer Society, American Heart

Association, etc.

Be aware of State/National Tobacco Awareness days:

Tobacco Free Florida Week (usually in May)

Lung Force Task Force– (American Lung

Association)

Great American Smokeout - 3rd Thursday in

November (American Cancer Society)

Kick Butts Day – March 21, 2018 (Campaign for

Tobacco-Free Kids)

Tobacco use harms

nearly every organ in the

body and is the leading

preventable cause of

death in the United

States, killing more than

480,000 people each

year. (CDC)

More than 70 % of tobacco

users say they want to quit…

and health providers can play

a unique and important role in

helping them succeed

Having an appropriate 3-4

minute conversation with a

patient followed by a referral

to cessation programs can

double or even triple the

quit rate.

Tobacco use kills more

people than AIDS, illicit drug

use, fires, alcohol, suicide,

murder, and car accidents

combined. (CDC)

It is inconsistent with sound medical practice

to provide health care and —

at the same time—

remain silent (or inactive) about a

major health risk. (Lightwood and Glantz, 1997, Rx for Change)

Source: CDC 2017,

Treating Tobacco Use

and Dependence 2008

Update, Rx for

Change

BRIEF INTERVENTION –

Where Can You Refer Your Patients?

ASK

ADVISE

REFER

ADDRESSING TOBACCO USE CAN HELP

PHYSICIANS AND HEALTH CARE

FACILITIES

MIPS

H.E.D.I.S. Measure

Joint Commission Tobacco Measures

SYSTEMS CHANGE – DEFINITION

Specific strategies that are

implemented to support changes in

health care organizations leading to

universal, evidence-based interventions

with all tobacco users

Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008. PAGE 67.

Tobacco Systems Change Strategies

1. Implement a Tobacco-User Identification System in Every Clinic

2. Provide Education, Resources, and Feedback to Promote Provider Intervention

3. Dedicate Staff to Provide Tobacco Dependence Treatment and Assess Its Delivery in Staff Performance Evaluations

4. Develop and promote Policies that Support and Provide Inpatient and Outpatient Tobacco Dependence Services

5. Include Tobacco Dependence Treatments (Both Counseling and Medication) Identified as Effective in the Guideline as Paid or Covered Services for All Subscribers or Members of Health Insurance Packages

IF YOUR PATIENT IS

READY TO QUIT…

HEALTH CARE PROVIDER FAX REFERRAL FORM TO TOBACCO FREE FLORIDA

IT’S WORKING! Evaluations of AHEC Tobacco Cessation Programs

from outside evaluator:

Highly effective program

High satisfaction rates from participants

Quit rates higher than most programs

Smoking prevalence among Florida adults was

15.8% in 2015 down from 21.0% in 2006.

Source: Tobacco Free Florida Fact Sheet