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MiCMRC Educational Webinar
Tobacco Dependence TreatmentUSING THE CLINICAL PRACTICE GUIDELINES TO HELP PATIENTS
QUIT TOBACCO
July 12, 2017
MiCMRC Care Management Educational Webinar:Tobacco Dependence Treatment
Expert Presenter:
Patricia Heiler, MPH, CHES, ASQ-CQIAPublic Health Consultant, Tobacco SectionMichigan Department of Health and Human Services
USING THE CLINICAL PRACTICE GUIDELINES TO HELP
PATIENTS QUIT TOBACCO
Tobacco Dependence Treatment
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Tobacco Dependence IS a Chronic Disease
Similar to diabetes, heart failure, hypertension, hyperlipidemia
Expectation for remission and relapse Provide ongoing treatment:
advice/counseling support appropriate pharmacotherapy
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Nicotine is a Drug of Addiction
After inhaling, nicotine reaches the brain in
7-10 seconds “Euphoria” without being “Stoned” Immediate REINFORCEMENT of drug-taking behavior Nicotine activates reward pathways in the brain Moment to moment titration of dose to achieve the
desired effects Young people are uniquely vulnerable to the effects of
nicotine and more susceptible to addiction since the brain is not fully mature until approximately age 25
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Clinicians Can Make a Difference!
70% of smokers want to quit smoking, 50% try to quit each year. < 10% succeed
< 1/3 of smokers who try to quit use proven cessation treatments
80% of tobacco users in the United States see a health care provider each year
< 1/2 who saw a health professional in the past year reported receiving advice to quit
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The 5 “A’s” Intervention
ASK about Tobacco Use (Tobacco as a vital sign)
ADVISE to stop
ASSESS willingness to make an attempt
ASSIST in the stop attempt
ARRANGE for a follow-up visit
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Ask
Systematically identify all tobacco users at every visit
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Advise
Strongly urge all tobacco users to quit in a clear, strong, and personalized manner:
Clear – Important, cutting down not enough
Strong – Most important thing you can do to protect your health
Personalized – link to current symptoms and health concerns, social and or economic situations
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Assess
Determine willingness to make a quit attempt at the time
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Assist
Aid the patient in quitting Pharmacological–if not contraindicated Set a quit date Counseling
Skills training-Anticipate Challenges Problem solving
Social Support Intra-treatment social support Extra-treatment social support
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Assist Stage- Motivational InterviewingFor the Patient Unwilling to Quit
Express empathy “How important do you think it is for you to quit?” “What might happen
if you quit?”
Develop discrepancy “It sounds like you are very devoted to your family/ friends/job. How do
you think your smoking is affecting your children/relationships/work?”
Roll with resistance “Sounds like you are feeling pressured about your smoking.” “Would you
like to hear about strategies that can help you address your concerns when you quit?”
Support self-efficacy “So you were fairly successful the last time you quit.”
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Assist- Provide practical counseling
When was the last time you used tobacco? When was the last time you tried to quit? Review past quit experience Success Triggers for relapse
Anticipate triggers, challenges Alcohol – can lead to relapse Other smokers – limit exposure May I share some information?
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Assist- Medication
Seven first-line medications shown to be effective and recommended for use by the Guideline Panel:
Bupropion SR Nicotine Gum Nicotine Inhaler Nicotine Lozenge Nicotine Nasal Spray Nicotine Patch Varenicline
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Assist- What is an Electronic Cigarette?
o Allows user to inhale aerosol containing nicotine and/or other substances.
o Disposable or rechargeable and/or refillable.
o Contain a cartridge filled with liquid nicotine, flavorings and glycerin or propylene glycol.
o When coil heats, it converts the contents of the cartridge into aerosol.
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Assist- Tobacco Quitlines
Work in conjunction with clinician or health care worker intervention
Can provide the treatment intensity that often cannot be provided in an office setting due to time constraints
Increase access to treatment and reduce barriers Can provide assistance in multiple languages
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Assist- The Michigan Tobacco Quitline
1-800-QUIT-NOW (784-8669) 1-877-777-6534 (TTS) Counseling appointments available 24 hours/day Quitline provides: Referrals to local programs One time counseling Intensive counseling proactive sessions Unlimited reactive calls for one year Free NRT to qualified callers Self-help materials Free text messaging and online program Cultural and language specific services
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Assist- Michigan Tobacco Quit Line Services
All Michigan Callers Receive Information & Referral, Text Messaging
Medicaid & Veterans Counseling
4 sessions for general enrollees 9 sessions for prenatal
Medicare, Uninsured, Prenatal, Cancer Patients & County Health Plan Counseling (same as above) Nicotine patch, gum or lozenge
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Assist- Who Qualifies for Michigan Tobacco Quitline Counseling?
Medicaid, including MOMS Medicare Veterans Uninsured People with a Cancer Diagnosis Prenatal County Health Plans Youth 13-17 (no insurance information is collected)
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Assist- The Quitline Refers
Eligibility for Quitline services varies by insurance status
Anyone can call the Quitline Individuals will be referred to the appropriate service if they
are ineligible for Quitline services
Referring patients to the Quitline makes your job easier
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Assist- Michigan Quitline: Prenatal Protocol
Specially trained counselors dedicated to working with prenatal callers
Prenatal enrollees will receive 9 counseling calls-5 prior to delivery and 4 post-partum
Prenatal enrollees receive incentives for participation
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Assist- MI Tobacco Quitline: Online Services
• Michigan.quitlogix.org is tied to the Michigan Tobacco Quitline
• If enrollment form is completed online, phone intake will be shorter
• Dashboard• Calendar• Quit Plan Online• Track NRT orders from Quitline• Chats and forums• Success stories
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Assist- MI Tobacco Quitline: Text Messaging
Library of over 300 messages
2-way messaging Messages related to
support and relapse prevention
Tips, motivation, and encouragement
Messages customized by tobacco type
Messages assessing mood, craving, and tobacco status
Coaching call appointment reminders(as appropriate on the day prior to appointment)
NRT shipment status updates
Congratulatory messages Re-engagement messages Must opt-in at intake
Over 55% of Michigan participants have opted into the text messaging program.
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Assist- MI Tobacco Quitline: Nicotine Replacement Therapy
All participants medically screened- some conditions require a medical consent form from physician
Patches, Gum and Lozenges offered to eligible groups
Shipped directly to the participant’s home Only available to those 18 and older No cost to the participant Prenatal must have signed approval from
physician
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Assist- MI Tobacco Quitline: Fax Referral
• Fax Referral Forms• Online at Michigan.quitlogix.org
• Quitline receives referral form- referrals can be made by a variety of types of providers and staff• Call within one business day • 3 attempts in the requested time frames or over a 10 day period
• Fax back to provider• When referral is received• When patient enrolls• When patient receives NRT• When patient completes the program• If patient is un-reachable• If patient declines to participate in the QuitLine
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Assist- Michigan Tobacco QuitlineFax Referral Form for Health Care Providers
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Arrange – schedule follow up
TimingQuit weekFirst month
Follow-up conversation
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Patricia HeilerPublic Health Consultant, Tobacco Section
Michigan Department of Health and Human Services
heilerp@michigan.gov(517)335-1265
www.michigan.gov/tobacco
Michigan Tobacco Quitline:https://michigan.quitlogix.org/
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The Effective Dentist: Motivational Interviewing Demonstration
https://www.youtube.com/watch?feature=player_detailpage&v=f8QSA_5PEFM
Smoking Cessation Leadership Center, An Introduction to Motivational Interviewing: Focus on Tobacco Use and Dependence https://smokingcessationleadership.ucsf.edu/webinar/co-hosted-american-academy-family-physicians-introduction-motivational-interviewing-focus
Rx for Change videos:http://www.rxforchange.ucsf.edu/curricula/ask_advise.php
Resources
American Cancer Society “Set Yourself Free” patient tool: http://www.cancer.org/myacs/highplainshawaiipacific/programsandservices/set-yourself-free-english
Campaign for Tobacco-Free Kids list of helpful tobacco-prevention materials:https://www.tobaccofreekids.org/research/factsheets/pdf/0159.pdf
American Lung Association list of helpful tobacco-prevention materials:http://www.lung.org/our-initiatives/tobacco/cessation-and-prevention/resource-library.html
The Centers for Disease Control and Prevention’s Health Care Provider resources: https://www.cdc.gov/tobacco/campaign/tips/partners/health/index.html
The Centers for Disease Control and Prevention’s Smoking & Tobacco Use Web site: http://www.cdc.gov/tobacco/quit_smoking/how_to_quit/resources/index.htm
http://www.cdc.gov/tobacco/basic_information/index.htm
Resources
The Florida Area Health Education Centers (AHEC) Network’s Twelve Facts to Help Dispel the Myths about Nicotine Replacement Therapies (NRTs) and Nicotine document
http://www.ahectobacco.com/wp-content/uploads/2013/03/NRTMythsandFacts.pdf
Smoking Cessation Leadership Center's webinar, Integrating Medications into Smoking Cessation Treatment: The Basics,
http://smokingcessationleadership.ucsf.edu/webinar/integrating-medications-smoking-cessation-treatment-basics
Smoking Cessation Leadership Center's webinar, Beyond the Basics: Pharmacotherapy for Smoking Cessation -
http://smokingcessationleadership.ucsf.edu/webinar/beyond-basics-pharmacotherapy-smoking-cessation
Rx for Change’s Pharmacologic Product Guide: FDA-Approved Medications for Smoking Cessation
http://www.aafp.org/dam/AAFP/documents/patient_care/tobacco/pharmacologic-guide.pdf
Resources
Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville (MD): US Department of Health and Human Services; 2008 May. Fiore MC, Jaén 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. http://www.ncbi.nlm.nih.gov/books/NBK63952
Centers for Disease Control and Prevention. A Practical Guide to Working with Health-Care Systems on Tobacco-Use Treatment. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006. http://www.cdc.gov/tobacco/quit_smoking/cessation/practical_guide/pdfs/practical_guide.pdf
Smoking Cessation Leadership Center Archived Webinars http://smokingcessationleadership.ucsf.edu/webinars/archive
Resources
Partnership for Prevention. Healthcare Provider Reminder Systems, Provider Education, and Patient Education: Working with Healthcare Delivery Systems to Improve the Delivery of Tobacco- Use Treatment to Patients—An Action Guide. The Community Health Promotion Handbook: Action Guides to Improve Community Health. Washington, DC: Partnership for Prevention; 2008. https://www.prevent.org/data/files/initiatives/tobaccousetreatment.pdf
The Conversations for Change videos are produced by the Behavioral Health and Wellness Program in the School of Medicine at the University of Colorado. Designed to help providers address tobacco cessation with patients and are to be viewed in order as part of a facilitated educational process. https://www.bhwellness.org/resources/videos
Treating Tobacco Use and Dependence Practice Manual: a systems change approach. Ask and Act A Tobacco Control Program; American Academy of Family Physicians, 2015.
http://www.aafp.org/dam/AAFP/documents/patient_care/tobacco/practice-manual.pdf
Resources
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