Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division of Public Health, DHHS
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Tobacco Use The number one preventable cause of death in the United States and North Carolina
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Estimated Preventable Causes of Death in North Carolina (2007) Source: NC SCHS Health Profile of North Carolinians: 2009 Update North Carolina Department of Health and Human Services
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Tobacco Use Today United States North Carolina United States North Carolina Deaths 438,000/yr. 13,720/yr. Medical (US state average) Costs $1.89 billion $2.46 billion Total costs $150 billion $6.77 billion Source: Centers for Disease Control and Prevention. SAMMEC, 2000-2004 http://www.cdc.gov/tobacco/data_statistics/state_data/data_highlights/2006/00_pdfs/DataHighlights06table4.pdf
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Current Use Among NC Adults (aged >18 yrs), NC BRFSS, 2008 * Current smoking- everyday or some days Source: NC BRFSS 2000-2006
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Percentage of Adults Who Smoke Cigarettes by Race/Ethnicity - NC BRFSS, 2008 Note: Current users report using either every day or on some days Source: NC State Center for Health Statistics NC BRFSS
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Percentage NC Adults Reporting Current Smoking, by EducationNC BRFSS, 2008 Note: Current users report using either every day or on some days Source: NC State Center for Health Statistics NC BRFSS
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Percentage of Pregnant Women Reporting Smoking Status in NC – North Carolina Birth Records, 1988-2007 Source: NC Vital Records File from Odum Institute at UNC; Vital Statistics, 2007
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Results based on North Carolina Youth Tobacco Survey administered biannually since 1999
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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
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The Toll of Tobacco Use In North Carolina: n nTotal health care costs from smoking: $2.46 billion n nPortion 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
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Sticker Shock… In the United States more than $75,000,000,000 of annual healthcare costs are attributable directly to smoking. National Institute on Drug Abuse Research Report Series, What is the Extent and Impact of Tobacco Use?, July 2006
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http:///www.cdc.gov/tobacco/ Surgeon Generals Report on Secondhand Smoke July 2006
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2006 SGR: Major Conclusions The debate is over. nSecondhand smoke is a serious health hazard and causes early death and disease in North Carolinians who do not smoke. nThe scientific evidence indicates there is no risk-free level of exposure to secondhand smoke nVentilation does not protect people from being exposed to SHS, only elimination of all smoking protects SHS (supported by ASHRAE) American Society of Heating, Refrigerating, American Society of Heating, Refrigerating, and Air Conditioning Engineers and Air Conditioning Engineers
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2006 SGRs Major Conclusions n SHS exposure of adults causes u Immediate adverse affects on the cardiovascular system u Coronary heart disease 30,000 deaths/yr 30,000 deaths/yr u Lung 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.
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CDC recently reviewed the literature and issued this commentary: All patients at risk of coronary heart disease or with known coronary artery disease should be advised to avoid all indoor environments that permit smoking. Source: British Medical Journal, 2004
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Helena, Montana Study n Smoking ban for 6 months n Reduced incidence of admissions for myocardial infarction of 40% during ban n MI admissions increased when ban rescinded Sargent, RP, et al. BMJ, 328:977-980, 2004. Sargent, RP, et al. BMJ, 328:977-980, 2004. n Replicated in studies: u France (15%) u Scotland (17%) u Ireland (14%) u Indiana (59%) u New York State (3,813 fewer MI admissions)
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Cardiovascular Risks of Second Hand Smoke n MI risk from tobacco smoke exposure is biologically feasible n Small exposures (30 minutes) can induce changes in vessels in people at risk n Short term reductions in exposure reduces heart attacks Pechacek,T., Babb, S. Commentary: How Acute and Reversible Are The Cardiovascular Risks of Second Hand Smoke? BMJ, 328:980-983, April 24, 2004.
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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 measurement BMJ, Jun 2004; 10.1136/bmj.38146.427188.55
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2006 SGRs Major Conclusions n Infants and children are at increased risk for u SIDS (Sudden Infant Death Syndrome) u acute respiratory infections u ear problems u more severe asthma u decreased lung growth u increased cases of bronchitis, pneumonia, and ear infections
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More sticker shock… Secondhand Smoke Costs - NC $289,000,000 This is a conservative estimate – does not consider: n lost productivity n impact on quality of life n long-term care and disability services Clinical Informatics Department, Blue Cross and Blue Shield of North Carolina North Carolinas Secondhand Smoke Healthcare Cost Burden, Pfannenschmidt and Wansink, Clinical Informatics Department, Blue Cross and Blue Shield of North Carolina
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Effects on Youth Effects of secondhand smoke/active smoking n Increases asthma significantly (15%) increase n $1.34 million/yr excess medical costs 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. 2004 Effects of secondhand smoke n Cognitive declines (decreases reading, math and block design) n Lower scores on reading and visuo-spatial testing Yolton, 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
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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.
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2004 Surgeon Generals Report The Health Consequences of Smoking
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2004 Surgeon Generals Report - The Health Consequences of Smoking n Doom and Gloom n Smoking harms nearly every organ of the body n Cessation has immediate and long-term benefits n Smoking low tar cigarettes provides no health benefits n List of smoking-caused diseases includes COPD, pneumonia, cataracts, periodontitis, AAA, and cancers of lung, pancreas, stomach, cervix, kidney
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2004 SGR – Smoking and Youth Children and adolescents who smoke have: n physical fitness n lung function n lung growth n respiratory illness n chronic cough and wheeze
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2004 SGR – Smoking and Pregnancy Smoking during pregnancy n Low birth weight n Stillbirth n Sudden Infant Death Syndrome u Risk doubles - smoking after birth u Risk 3-4 times greater - smoking before and after n Nicotine u blood flow to fetus u found in breast milk
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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
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Tobacco dependence as a chronic disease n Permanent abstinence is the goal u Congratulate smaller successes n Quitting consists of multiple relapses and remission n Few quit for good on first attempt n Each attempt is a learning experience n No single ideal intervention n Relapse is risk for weeks, months, years u Requiring ongoing interventions n Clinicians can feel ineffective, lose motivation
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"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?) 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
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It takes on average, 6 to 7 attempts to quit for good…
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Addiction
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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 GABAReduction of Anxiety and Tension Nicotine Stimulates Release of Many Different Neurotransmitters
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Characteristics of Nicotine lead to Reinforcement of Use & Addiction n High concentrations of nicotine within 7-10 seconds n Half-life = 90-120 min. n Able to respond quickly to additional doses n Euphoria without Intoxication n Behavior reinforced multiple times daily
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Nicotine Addiction: A Brain Disease Up-Regulation Increased numbers of Nicotinic receptors
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Withdrawal Syndrome or "Abstinence Syndrome" Pathophysiologic disturbances which result when a drug to which an organism is physically dependent is stopped.
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Smoking Cessation …is the easiest thing I ever did; I ought to know because I have done it a thousand times. - Mark Twain
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Withdrawal Symptoms n n 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. n n Cravings, which may relate to certain triggers, can occur for months to years. n n Craving will pass without a cigarette n n The relaxing effect that nicotine provides may not be due to physical relaxation; rather, it may be the elimination of early withdrawal symptoms.
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Withdrawal Symptoms Psychological/Behavioral: giving up a habit Psychological/Behavioral: giving up a habit Physical: absence of nicotine Physical: absence of nicotine Nicotine craving is a major obstacle to success Nicotine craving is a major obstacle to success Depression Depression Irritability; anger Irritability; anger Trouble concentrating; restlessness Trouble concentrating; restlessness Sleep disturbances; tiredness Sleep disturbances; tiredness Headache Headache Increased appetite Increased appetite Repeat exposure to nicotine creates tolerance Repeat exposure to nicotine creates tolerance Higher doses required to create same stimulation Higher doses required to create same stimulation http://teens.drugabuse.gov/drnida/drnida_nic1.asp#long_periods http://teens.drugabuse.gov/drnida/drnida_nic1.asp#long_periods
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Teens Underestimate the Addiction… n Most high school smokers believe they will not be smoking in 5 years, however 73% remain daily smokers 5-6 years later (CDC longitudinal studies)
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Addiction and Youth may be more sensitive to nicotine, especially in combination with other chemicals found in tobacco. Adolescents may be more sensitive to nicotine, especially in combination with other chemicals found in tobacco. Depending on age of initiation, this may increase the likelihood of tobacco addiction. Combined with social influences, this puts young people at greater risk for becoming addicted. Source: (National Institute on Drug Abuse: Tobacco Addiction Series)
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Cessation: What Works n Behavioral support Treats the psychological and habit aspects Treats the psychological and habit aspects n Pharmacotherapy Treats nicotine addiction Treats nicotine addiction Works best when combined
Efficacy of Physician Advice to Quit Abstinence Rate % Abstinence Rate % n No advice 7.9 n Physician Advice 10.2 u Patients expect healthcare providers to ask about tobacco use and advise them to quit Source: Treating Tobacco Use and Dependence, USDHHS, Public Health Service, 2000
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5 As For Patients Willing to Quit n Ask about tobacco use n Advise patient to quit Refer (1-800-QUIT-NOW or local prgm) Refer (1-800-QUIT-NOW or local prgm) n Assess readiness to quit n Assist in quit attempt n Arrange follow-up
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Ask n Ask about tobacco use at every visit n Systematically identify all tobacco users n Make identification/documentation a vital sign n Create a universal identification system (stickers, computer reminders, etc.)
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Create a Reminder System Include tobacco use in other medical / dental advice Use an identification system Use an identification system Stamp, Sticker, EMR Stamp, Sticker, EMR Tobacco Use and Exposure Tobacco Use: (circle one): Current Former Never Secondhand Smoke Exposure: YES NO Tobacco use is the single most preventable cause of death in the US.
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Advise n Clear, Strong, Personalized Quitting smoking... u...is the single best thing you can do for your health u...will reduce your risk of … n Employ the teachable moment: Link visit findings with advice. Link visit findings with advice.
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Assess n Willingness to make quit attempt in next 30 days n I want to quit NOT I need to quit
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Examples n Very specific reasons to quit smoking: I want to quit smoking so I can go shopping without stopping 10 times. I want to quit smoking so I can go shopping without stopping 10 times. I want to quit smoking so I will not have a stroke like my dad. I want to quit smoking so I will not have a stroke like my dad. I want to quit smoking so my dogs will not get emphysema. (real quote) I want to quit smoking so my dogs will not get emphysema. (real quote) I want to quit so I wont smell like an ashtray I want to quit so I wont smell like an ashtray
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Stages of Change n Pre-contemplation n Contemplation n Preparation n Action n Maintenance
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5Rs for Patients Not Ready To Make a Quit Attempt n Relevance n Risks n Rewards n Roadblocks n Repetition
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Assist n Develop a quit plan n STAR: - Set a quit date (within 2 weeks) - Tell family, friends, coworkers - Anticipate challenges to quitting - Remove tobacco products from environment environment
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Arrange n Schedule follow-up u in person u via telephone u NC Tobacco Use Quitline n 4 visits/calls is evidence based n Congratulate progress/success n Identify problems/anticipate challenges n Evaluate pharmacotherapy use/problems
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Help for the busy practice….
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Health Care Providers Quick Intervention n ASK about tobacco use n ADVISE to quit n REFER to NC Tobacco Use Quitline, Become An Ex, other resource n PRESCRIBE as appropriate
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REFER n Quitline information to all n Consider fax referral u Patients ready to quit within 30 days n Consider cessation medications n Provide Quitline number to patients not ready to quit n Other resources such as BecomeAnEx n Follow-up at next/every visit
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North Carolina Tobacco Use Quitline n 1-800-QUIT-NOW (1-800-784-8669) n 8a.m. – 3 a.m., 7 days a week; Toll-free; Confidential n All North Carolinians - youth and adult n Proactive – Quit coaches can call tobacco users back upon request, or make 1 st call n Fax referral n Multiple language Quit Coaches Administered by: Tobacco Prevention and Control Branch Funded by: NC Division of Public Health, NC Health and Wellness Trust Fund
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Quitline can Assess, Assist, Arrange n Quit coach helps set Quit Date, and u Develop quit plan u Make follow-up calls u Discuss pharmacotherapy u Mail targeted resources n Patients can call the Quitline anytime
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What happens on first call with the Quitline nIntake specialist determines readiness to quit nFirst call - plan for 5 -10 minutes to enroll nTransfer to Quit Coach for those ready nQuitline can call patients back 4 visits is an evidence based intervention 4 visits is an evidence based intervention nIf not ready to set quit date, Encouraged to call back when ready, and offered enrollment for: Encouraged to call back when ready, and offered enrollment for: Cessation materials (mailed) Cessation materials (mailed) Web Coach access Web Coach access
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Caller would like to speak to a Quit Coach One Call Program: n n Conversation with the Quit Coach for support n n Support materials for quitting n n Referral to local resources n n Medication information n n Help to develop a plan, including setting a quit date n n Access to Web Coach Four Call Program: n One Call program, plus n Quit Coach will call back -- A quit date is set -- Dates and times are made for three more calls from a Quit Coach n Three attempts, then letter is sent
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Caller does not want to talk to a Quit Coach Caller will be offered: n Messages to promote quitting n Support materials for quitting n Referral to local resources n Encouragement to call again
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Other Quitline Features Web Coach Progress tracking Progress tracking Coaching e-mails Coaching e-mails Discussion Forums Discussion Forums Click to Call Available on Web Coach Available on Web Coach
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Fax Referral to Quitline Helps With… Referral to effective cessation services Referral to effective cessation services Providers limited time and resources Providers limited time and resources The burden of patient initiating services The burden of patient initiating services NOTE: Provider referral to a cessation program is associated with higher rates of participation than simply telling patients they should stop using tobacco NOTE: Provider referral to a cessation program is associated with higher rates of participation than simply telling patients they should stop using tobacco
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Quitline Outcomes Report n Tool to follow patient progress with your advice to quit / utilize Quitline services n Most useful in clinic setting with dedicated fax machine/staff to retrieve reports n Outcomes Report information: u Accepted services u Declined services u Unreachable
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Take patients 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.
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How Fax Referral Works 1. 1. Patient has been identified as a tobacco user 2. 2. Patient educated on services of Quitline 3. 3. Patient wants to quit tobacco use within 30 days 4. 4. Patient would like a quit coach to call at time/date they select 5. 5. HCP completes Provider Information, including Hospital-Clinic Name, Contact Name and Number. 6. 6. Patient completes Patient Information and signs form, providing consent for HCP to release information Patient must provide contact information and sign and initial the fax referral form. 7. 7. Quitline can provide Fax Referral Outcomes Report: Accepted Services, Refused Services, Not Reached If you do not want the Outcomes Report contact the Tobacco Prevention and Control Branch at 919-707-5415 8. 8. Quitline will begin contact attempts to enroll patient in program based on time and date provided by patient
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More Cessation Resources www.becomeanex.org
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Become an EX www.becomeanEX.org n Web-based cessation program for adults n Fun, edgy, interactive n Personalized quit plan to: u Relearn life without cigarettes Relearn habit Relearn habit Relearn addiction Relearn addiction Relearn support Relearn support n Free and in English and Spanish
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Two booklets created by American Legacy Foundation in cooperation with Mayo Clinic – Ex Easy Read Booklet and Fotonovella
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Women and Children Resources
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Resources for Youth PROJECT ASPIRE – A smoking prevention interactive experience for youth: www.mdanderson.org/aspire www.mdanderson.org/aspire My Last Dip – An on line program for age 14 - 25 who use spit or smokeless tobacco: www.mylastdip.com
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Healthy Start Foundation n Two brochures can be ordered u If You Smoke And Are Pregnant http://www.nchealthystart.org/catalog/pregnancy.htm http://www.nchealthystart.org/catalog/pregnancy.htm u Oh Baby! We Want To Keep You Safe From Secondhand Smoke http://www.nchealthystart.org/catalog/parenting.htm#c006 www.nchealthystart.org
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You quit. Two quit. www.youquittwoquit.com u Informational website for Pregnant women Pregnant women New mothers New mothers Family and friends Family and friends Health professionals Health professionals UNC Center for Maternal and Infant Health Funded by North Carolina Health and Wellness rust Fund
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Tobacco Cessation Training for HCPs Working with Women The Guide is available on the Division of Public Health / Womens Health Branch webpage: http://whb.ncpublichealth.com/provPart/pubmanbro.htm#top For more information on the Womens Health and Tobacco Use Program, contact: Judy Ruffin Judy.ruffin@ncmail.net 919-707-5712
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Pharmacotherapy – First Line n Nicotine Replacement Therapy - Patch - Patch - Gum - Gum - Lozenge - Lozenge - Inhaler - Inhaler - Nasal Spray - Nasal Spray n Zyban (bupropion) n Chantix (varenicline)
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Over the Counter Medications Nicotine Patch n Dose: 21mg, 14mg or 7mg per 24 hours u 1 pack/day, start with higher dose, taper u duration 8 weeks u step down after 4 wks in 2 wk increments u Nicotrol is used for 16 hours, off at night n Adverse effects: local skin reaction, insomnia, vivid dreams n Contraindications: Recent MI, unstable angina, arrhythmia n Cost: 7mg box - $37 14mg box - $47 14mg box - $47 21mg box - $48 21mg box - $48
Over the Counter Medications Nicotine Gum n Dose: up to 24 pieces per day u x 12 weeks (longer if needed) u 2mg for 25 cigarettes per day u Chew, chew, park u Avoid acidic beverages n Consider using on a fixed schedule n Long term patch and gum use are effective n Adverse Effects: Mouth soreness, hiccups, jaw ache, dyspepsia n Contraindications: As for patch n Cost: 2mg box (100-170 pieces) ~ $45 (generic) 4mg box (100-110 pieces) ~ $63 (generic) 4mg box (100-110 pieces) ~ $63 (generic)
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Over the Counter Medications Nicotine Lozenge (Commit) n Dose u 2mg (1st cig. >30 min. after awake) u 4mg (1st cig.
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Prescription Medications Nicotine Inhaler n Dose: 4mg nicotine u 80 puffs=4mg nicotine u Best effects with frequent puffing/at least 6 cartridges per day (can use 6-16 cartridges/day) u Use for up to 6 months Reduce frequency over the last 6-12 weeks of tx Reduce frequency over the last 6-12 weeks of tx n Avoid acidic beverages n Adverse Effects: mouth/throat irritation, coughing, rhinitis n Contraindications: as for patch n Cost: 1 box (168 10mg cartridges) - $196
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Prescription Medications Nicotine Nasal Spray n Dose: 1 dose = 1 mg (0.5mg per nostril) u 1-2 doses per hour initially u Increase as needed for symptom relief u 8 min/40 max doses per day for 3-6 months u Do not sniff, swallow or inhale u Head titled slightly back n Adverse Effects: Nasal irritation, congestion; transient changes in smell, taste n Contraindications: as for patch n Cost: $49 per bottle (100 doses)
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NRT and Cardiovascular Disease n Not an independent risk factor for acute myocardial events n Use with caution in patients who: are within 2 weeks of MI are within 2 weeks of MI have serious arrhythmias have serious arrhythmias have serious or worsening angina have serious or worsening angina pectoris pectoris
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Prescription Medications Zyban, Wellbutrin (bupropion SR 150) n Begin 1-2 weeks before quit date n Dose: 150 mg in a.m. for 3 days 150 mg twice daily for 7 to 12 weeks 150 mg twice daily for 7 to 12 weeks n May consider long-term tx for 6 months post quit n Adverse Effects: Insomnia, dry mouth n Contraindications: history of seizure d/o, eating d/o, recent MAO inhibitor use in past 14 days n Cost: 1 box of 60 tablets u $97/month (generic) u $197-$210 (brand name)
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Prescription Medications Chantix (varenicline) n Stimulates nicotine receptors. Also blocks nicotine at receptor site n Start Chantix 1 week before quit date n Dose: 0.5 mg daily for 3 days 0.5mg twice daily for 4 days 0.5mg twice daily for 4 days 1.0mg twice daily for 3 months 1.0mg twice daily for 3 months n May decrease dosage (1mg/day) if significant side effects n Adverse Effects: nausea, insomnia, abnormal/vivid dreams n New warning label Jan. 2008– observe for neuro- psychiatric symptoms (post marketing data) n Cost: 1 box of 56 - $131 (~30 day supply) Research shows that at 1 year, 21% of those on Chantix are still abstinent compared to 8% with a placebo
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More on Pharmacotherapy n Combined therapy improves abstinence rates u Patch + gum, nasal spray, or inhaler u Patch plus buproprion (FDA approved) n Do not combine NRT with Chantix n Buproprion and gum or lozenge may delay weight gain n NRT for smokers not willing to quit – promising but warrants further research
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Pregnancy and Pharmacotherapy n Abstinence early produces greatest benefits n Quitting at any point yields benefits n Person to person intervention should be offered to pregnant and post partum women u Should exceeds minimal advice to quit n Inconclusive evidence that cessation medications increase abstinence rates
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Treating Tobacco Use and Dependence: Children and Adolescents Recommendations n Clinicians screen children and adolescents for tobacco use n Consider counseling and behavioral interventions that are effective with adults n Offer smoking cessation advice and interventions to parents
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Insurance Coverage for Cessation Medications n Medicaid now covers ALL cessation pharmacotherapy u Nicotine patch, gum, lozenge, nasal spray, inhaler u Zyban u Chantix n No Prior Authorization needed n Prescription required, even for OTC
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Counseling Coverage in NC nMedicaid added two CPT codes Jan. 1, 2009 u99406 – 3-10 minutes u99407 – > 10 minutes May be billed the same day as an E/M or Health Check visit May be billed the same day as an E/M or Health Check visit Use ICD-9 Code: 305.1 (tobacco abuse) Use ICD-9 Code: 305.1 (tobacco abuse) Unbundled – can use a second ICD-9 code Unbundled – can use a second ICD-9 code nMedicare, BCBSNC, and State Health Plan also reimburse these codes
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Who can bill Medicaid? In addition to physicians, nurse practitioners, and health departments, these codes can be billed incident to the physician by the following professional specialties: u Licensed psychologists and psychological associates u Licensed clinical social workers u Licensed professional counselors u Licensed marriage and family counselors u Certified nurse practitioners u Certified clinical nurse specialists u Licensed clinical addictions specialists or u Certified clinical supervisors
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Medicaid Coverage for Treatment nFor more information see Medicaid Bulletins: u http://www.dhhs.state.nc.us/dma/bulletin.htm uJan 2009: http://www.dhhs.state.nc.us/dma/bulletin.htm u uOct.2008: http://www.ncdhhs.gov/dma/bulletin/1008bulletin.htm
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More Cessation Counseling Reimbursement Codes n nOther codes: u u99401-04; 15-60 minutes (dedicated visit) u u99354 can be added to regular visit (must document counseling) u99411 u99411 is used for group counseling (per participant) MD, PA or FNP on premises, must talk to group RN (etc.) may facilitate session
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Helpful Web Sites and Links: n www.tobaccopreventionandcontrol. ncdhhs.gov/cessation n www.tobaccopreventionandcontrol. ncdhhs.gov/FaxForm.pdf n www.QuitLineNC.com n www.QuitNowNC.org
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Learning More / CE Options n Counseling for Change: An On-line Tobacco Cessation Course - Northwest AHEC u Contact Nedra Edwards Hines 336-713-7727; nedwards@wfubmc.edu 336-713-7727; nedwards@wfubmc.edu u $20 fee for course credits; free to view n Medscape: Treating Tobacco Use and Dependence http://www.medscape.com/viewarticle/570604 u Free u Approved for 1hour CE u AMA PRA Category 1 Credit(s) u Requires registration to Medscape n TobaccoFreePatients.com http://www1.tobaccofreepatients.com/TopicReq? u Based on NCI educational program u Available free for study and review u $15 per credit hour / letter of completion
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Take-Home Message for Health Care Providers n Brief cessation counseling is effective n Longer cessation counseling is more effective n Pharmacotherapy can double quit rates n Pharmacotherapy should be offered to all - few exceptions n Evidence-based resources are available
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You only have two minutes n Ask every everyone about tobacco use n Advise to quit with a clear, strong, personalized message n Refer to u NC Tobacco Use Quitline 1-800-QUIT-NOW (1-800-784-8669) 1-800-QUIT-NOW (1-800-784-8669) u Become An Ex www.becomeanex.org www.becomeanex.org n Pharmacotherapy – for most
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Tobacco Prevention and Control Branch Division of Public Health North Carolina Department of Health and Human Services Main Ph: 919-707-5400 Fax: 919-870-4844 www.tobaccopreventionandcontrol.ncdhhs.gov
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Comprehensive Overview of North Carolina Tobacco Use and Evidence Based Cessation Methods and Resources June 2009 Tobacco Prevention & Control Branch Division of Public Health, DHHS
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Tobacco Use The number one preventable cause of death in the United States and North Carolina
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Estimated Preventable Causes of Death in North Carolina (2007) Source: NC SCHS Health Profile of North Carolinians: 2009 Update North Carolina Department of Health and Human Services
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Tobacco Use Today United States North Carolina United States North Carolina Deaths 438,000/yr. 13,720/yr. Medical (US state average) Costs $1.89 billion $2.46 billion Total costs $150 billion $6.77 billion Source: Centers for Disease Control and Prevention. SAMMEC, 2000-2004 http://www.cdc.gov/tobacco/data_statistics/state_data/data_highlights/2006/00_pdfs/DataHighlights06table4.pdf
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Current Use Among NC Adults (aged >18 yrs), NC BRFSS, 2008 * Current smoking- everyday or some days Source: NC BRFSS 2000-2006
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Percentage of Adults Who Smoke Cigarettes by Race/Ethnicity - NC BRFSS, 2008 Note: Current users report using either every day or on some days Source: NC State Center for Health Statistics NC BRFSS
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Percentage NC Adults Reporting Current Smoking, by EducationNC BRFSS, 2008 Note: Current users report using either every day or on some days Source: NC State Center for Health Statistics NC BRFSS
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Percentage of Pregnant Women Reporting Smoking Status in NC – North Carolina Birth Records, 1988-2007 Source: NC Vital Records File from Odum Institute at UNC; Vital Statistics, 2007
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Results based on North Carolina Youth Tobacco Survey administered biannually since 1999
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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
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The Toll of Tobacco Use In North Carolina: n nTotal health care costs from smoking: $2.46 billion n nPortion 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
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Sticker Shock… In the United States more than $75,000,000,000 of annual healthcare costs are attributable directly to smoking. National Institute on Drug Abuse Research Report Series, What is the Extent and Impact of Tobacco Use?, July 2006
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http:///www.cdc.gov/tobacco/ Surgeon Generals Report on Secondhand Smoke July 2006
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2006 SGR: Major Conclusions The debate is over. nSecondhand smoke is a serious health hazard and causes early death and disease in North Carolinians who do not smoke. nThe scientific evidence indicates there is no risk-free level of exposure to secondhand smoke nVentilation does not protect people from being exposed to SHS, only elimination of all smoking protects SHS (supported by ASHRAE) American Society of Heating, Refrigerating, American Society of Heating, Refrigerating, and Air Conditioning Engineers and Air Conditioning Engineers
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2006 SGRs Major Conclusions n SHS exposure of adults causes u Immediate adverse affects on the cardiovascular system u Coronary heart disease 30,000 deaths/yr 30,000 deaths/yr u Lung 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.
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CDC recently reviewed the literature and issued this commentary: All patients at risk of coronary heart disease or with known coronary artery disease should be advised to avoid all indoor environments that permit smoking. Source: British Medical Journal, 2004
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Helena, Montana Study n Smoking ban for 6 months n Reduced incidence of admissions for myocardial infarction of 40% during ban n MI admissions increased when ban rescinded Sargent, RP, et al. BMJ, 328:977-980, 2004. Sargent, RP, et al. BMJ, 328:977-980, 2004. n Replicated in studies: u France (15%) u Scotland (17%) u Ireland (14%) u Indiana (59%) u New York State (3,813 fewer MI admissions)
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Cardiovascular Risks of Second Hand Smoke n MI risk from tobacco smoke exposure is biologically feasible n Small exposures (30 minutes) can induce changes in vessels in people at risk n Short term reductions in exposure reduces heart attacks Pechacek,T., Babb, S. Commentary: How Acute and Reversible Are The Cardiovascular Risks of Second Hand Smoke? BMJ, 328:980-983, April 24, 2004.
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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 measurement BMJ, Jun 2004; 10.1136/bmj.38146.427188.55
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2006 SGRs Major Conclusions n Infants and children are at increased risk for u SIDS (Sudden Infant Death Syndrome) u acute respiratory infections u ear problems u more severe asthma u decreased lung growth u increased cases of bronchitis, pneumonia, and ear infections
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More sticker shock… Secondhand Smoke Costs - NC $289,000,000 This is a conservative estimate – does not consider: n lost productivity n impact on quality of life n long-term care and disability services Clinical Informatics Department, Blue Cross and Blue Shield of North Carolina North Carolinas Secondhand Smoke Healthcare Cost Burden, Pfannenschmidt and Wansink, Clinical Informatics Department, Blue Cross and Blue Shield of North Carolina
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Effects on Youth Effects of secondhand smoke/active smoking n Increases asthma significantly (15%) increase n $1.34 million/yr excess medical costs 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. 2004 Effects of secondhand smoke n Cognitive declines (decreases reading, math and block design) n Lower scores on reading and visuo-spatial testing Yolton, 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
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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.
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2004 Surgeon Generals Report The Health Consequences of Smoking
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2004 Surgeon Generals Report - The Health Consequences of Smoking n Doom and Gloom n Smoking harms nearly every organ of the body n Cessation has immediate and long-term benefits n Smoking low tar cigarettes provides no health benefits n List of smoking-caused diseases includes COPD, pneumonia, cataracts, periodontitis, AAA, and cancers of lung, pancreas, stomach, cervix, kidney
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2004 SGR – Smoking and Youth Children and adolescents who smoke have: n physical fitness n lung function n lung growth n respiratory illness n chronic cough and wheeze
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2004 SGR – Smoking and Pregnancy Smoking during pregnancy n Low birth weight n Stillbirth n Sudden Infant Death Syndrome u Risk doubles - smoking after birth u Risk 3-4 times greater - smoking before and after n Nicotine u blood flow to fetus u found in breast milk
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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
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Tobacco dependence as a chronic disease n Permanent abstinence is the goal u Congratulate smaller successes n Quitting consists of multiple relapses and remission n Few quit for good on first attempt n Each attempt is a learning experience n No single ideal intervention n Relapse is risk for weeks, months, years u Requiring ongoing interventions n Clinicians can feel ineffective, lose motivation
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"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?) 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
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It takes on average, 6 to 7 attempts to quit for good…
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Addiction
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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 GABAReduction of Anxiety and Tension Nicotine Stimulates Release of Many Different Neurotransmitters
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Characteristics of Nicotine lead to Reinforcement of Use & Addiction n High concentrations of nicotine within 7-10 seconds n Half-life = 90-120 min. n Able to respond quickly to additional doses n Euphoria without Intoxication n Behavior reinforced multiple times daily
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Nicotine Addiction: A Brain Disease Up-Regulation Increased numbers of Nicotinic receptors
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Withdrawal Syndrome or "Abstinence Syndrome" Pathophysiologic disturbances which result when a drug to which an organism is physically dependent is stopped.
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Smoking Cessation …is the easiest thing I ever did; I ought to know because I have done it a thousand times. - Mark Twain
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Withdrawal Symptoms n n 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. n n Cravings, which may relate to certain triggers, can occur for months to years. n n Craving will pass without a cigarette n n The relaxing effect that nicotine provides may not be due to physical relaxation; rather, it may be the elimination of early withdrawal symptoms.
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Withdrawal Symptoms Psychological/Behavioral: giving up a habit Psychological/Behavioral: giving up a habit Physical: absence of nicotine Physical: absence of nicotine Nicotine craving is a major obstacle to success Nicotine craving is a major obstacle to success Depression Depression Irritability; anger Irritability; anger Trouble concentrating; restlessness Trouble concentrating; restlessness Sleep disturbances; tiredness Sleep disturbances; tiredness Headache Headache Increased appetite Increased appetite Repeat exposure to nicotine creates tolerance Repeat exposure to nicotine creates tolerance Higher doses required to create same stimulation Higher doses required to create same stimulation http://teens.drugabuse.gov/drnida/drnida_nic1.asp#long_periods http://teens.drugabuse.gov/drnida/drnida_nic1.asp#long_periods
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Teens Underestimate the Addiction… n Most high school smokers believe they will not be smoking in 5 years, however 73% remain daily smokers 5-6 years later (CDC longitudinal studies)
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Addiction and Youth may be more sensitive to nicotine, especially in combination with other chemicals found in tobacco. Adolescents may be more sensitive to nicotine, especially in combination with other chemicals found in tobacco. Depending on age of initiation, this may increase the likelihood of tobacco addiction. Combined with social influences, this puts young people at greater risk for becoming addicted. Source: (National Institute on Drug Abuse: Tobacco Addiction Series)
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Cessation: What Works n Behavioral support Treats the psychological and habit aspects Treats the psychological and habit aspects n Pharmacotherapy Treats nicotine addiction Treats nicotine addiction Works best when combined
Efficacy of Physician Advice to Quit Abstinence Rate % Abstinence Rate % n No advice 7.9 n Physician Advice 10.2 u Patients expect healthcare providers to ask about tobacco use and advise them to quit Source: Treating Tobacco Use and Dependence, USDHHS, Public Health Service, 2000
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5 As For Patients Willing to Quit n Ask about tobacco use n Advise patient to quit Refer (1-800-QUIT-NOW or local prgm) Refer (1-800-QUIT-NOW or local prgm) n Assess readiness to quit n Assist in quit attempt n Arrange follow-up
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Ask n Ask about tobacco use at every visit n Systematically identify all tobacco users n Make identification/documentation a vital sign n Create a universal identification system (stickers, computer reminders, etc.)
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Create a Reminder System Include tobacco use in other medical / dental advice Use an identification system Use an identification system Stamp, Sticker, EMR Stamp, Sticker, EMR Tobacco Use and Exposure Tobacco Use: (circle one): Current Former Never Secondhand Smoke Exposure: YES NO Tobacco use is the single most preventable cause of death in the US.
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Advise n Clear, Strong, Personalized Quitting smoking... u...is the single best thing you can do for your health u...will reduce your risk of … n Employ the teachable moment: Link visit findings with advice. Link visit findings with advice.
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Assess n Willingness to make quit attempt in next 30 days n I want to quit NOT I need to quit
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Examples n Very specific reasons to quit smoking: I want to quit smoking so I can go shopping without stopping 10 times. I want to quit smoking so I can go shopping without stopping 10 times. I want to quit smoking so I will not have a stroke like my dad. I want to quit smoking so I will not have a stroke like my dad. I want to quit smoking so my dogs will not get emphysema. (real quote) I want to quit smoking so my dogs will not get emphysema. (real quote) I want to quit so I wont smell like an ashtray I want to quit so I wont smell like an ashtray
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Stages of Change n Pre-contemplation n Contemplation n Preparation n Action n Maintenance
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5Rs for Patients Not Ready To Make a Quit Attempt n Relevance n Risks n Rewards n Roadblocks n Repetition
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Assist n Develop a quit plan n STAR: - Set a quit date (within 2 weeks) - Tell family, friends, coworkers - Anticipate challenges to quitting - Remove tobacco products from environment environment
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Arrange n Schedule follow-up u in person u via telephone u NC Tobacco Use Quitline n 4 visits/calls is evidence based n Congratulate progress/success n Identify problems/anticipate challenges n Evaluate pharmacotherapy use/problems
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Help for the busy practice….
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Health Care Providers Quick Intervention n ASK about tobacco use n ADVISE to quit n REFER to NC Tobacco Use Quitline, Become An Ex, other resource n PRESCRIBE as appropriate
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REFER n Quitline information to all n Consider fax referral u Patients ready to quit within 30 days n Consider cessation medications n Provide Quitline number to patients not ready to quit n Other resources such as BecomeAnEx n Follow-up at next/every visit
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North Carolina Tobacco Use Quitline n 1-800-QUIT-NOW (1-800-784-8669) n 8a.m. – 3 a.m., 7 days a week; Toll-free; Confidential n All North Carolinians - youth and adult n Proactive – Quit coaches can call tobacco users back upon request, or make 1 st call n Fax referral n Multiple language Quit Coaches Administered by: Tobacco Prevention and Control Branch Funded by: NC Division of Public Health, NC Health and Wellness Trust Fund
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Quitline can Assess, Assist, Arrange n Quit coach helps set Quit Date, and u Develop quit plan u Make follow-up calls u Discuss pharmacotherapy u Mail targeted resources n Patients can call the Quitline anytime
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What happens on first call with the Quitline nIntake specialist determines readiness to quit nFirst call - plan for 5 -10 minutes to enroll nTransfer to Quit Coach for those ready nQuitline can call patients back 4 visits is an evidence based intervention 4 visits is an evidence based intervention nIf not ready to set quit date, Encouraged to call back when ready, and offered enrollment for: Encouraged to call back when ready, and offered enrollment for: Cessation materials (mailed) Cessation materials (mailed) Web Coach access Web Coach access
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Caller would like to speak to a Quit Coach One Call Program: n n Conversation with the Quit Coach for support n n Support materials for quitting n n Referral to local resources n n Medication information n n Help to develop a plan, including setting a quit date n n Access to Web Coach Four Call Program: n One Call program, plus n Quit Coach will call back -- A quit date is set -- Dates and times are made for three more calls from a Quit Coach n Three attempts, then letter is sent
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Caller does not want to talk to a Quit Coach Caller will be offered: n Messages to promote quitting n Support materials for quitting n Referral to local resources n Encouragement to call again
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Other Quitline Features Web Coach Progress tracking Progress tracking Coaching e-mails Coaching e-mails Discussion Forums Discussion Forums Click to Call Available on Web Coach Available on Web Coach
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Fax Referral to Quitline Helps With… Referral to effective cessation services Referral to effective cessation services Providers limited time and resources Providers limited time and resources The burden of patient initiating services The burden of patient initiating services NOTE: Provider referral to a cessation program is associated with higher rates of participation than simply telling patients they should stop using tobacco NOTE: Provider referral to a cessation program is associated with higher rates of participation than simply telling patients they should stop using tobacco
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Quitline Outcomes Report n Tool to follow patient progress with your advice to quit / utilize Quitline services n Most useful in clinic setting with dedicated fax machine/staff to retrieve reports n Outcomes Report information: u Accepted services u Declined services u Unreachable
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Take patients 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.
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How Fax Referral Works 1. 1. Patient has been identified as a tobacco user 2. 2. Patient educated on services of Quitline 3. 3. Patient wants to quit tobacco use within 30 days 4. 4. Patient would like a quit coach to call at time/date they select 5. 5. HCP completes Provider Information, including Hospital-Clinic Name, Contact Name and Number. 6. 6. Patient completes Patient Information and signs form, providing consent for HCP to release information Patient must provide contact information and sign and initial the fax referral form. 7. 7. Quitline can provide Fax Referral Outcomes Report: Accepted Services, Refused Services, Not Reached If you do not want the Outcomes Report contact the Tobacco Prevention and Control Branch at 919-707-5415 8. 8. Quitline will begin contact attempts to enroll patient in program based on time and date provided by patient
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More Cessation Resources www.becomeanex.org
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Become an EX www.becomeanEX.org n Web-based cessation program for adults n Fun, edgy, interactive n Personalized quit plan to: u Relearn life without cigarettes Relearn habit Relearn habit Relearn addiction Relearn addiction Relearn support Relearn support n Free and in English and Spanish
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Two booklets created by American Legacy Foundation in cooperation with Mayo Clinic – Ex Easy Read Booklet and Fotonovella
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Women and Children Resources
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Resources for Youth PROJECT ASPIRE – A smoking prevention interactive experience for youth: www.mdanderson.org/aspire www.mdanderson.org/aspire My Last Dip – An on line program for age 14 - 25 who use spit or smokeless tobacco: www.mylastdip.com
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Healthy Start Foundation n Two brochures can be ordered u If You Smoke And Are Pregnant http://www.nchealthystart.org/catalog/pregnancy.htm http://www.nchealthystart.org/catalog/pregnancy.htm u Oh Baby! We Want To Keep You Safe From Secondhand Smoke http://www.nchealthystart.org/catalog/parenting.htm#c006 www.nchealthystart.org
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You quit. Two quit. www.youquittwoquit.com u Informational website for Pregnant women Pregnant women New mothers New mothers Family and friends Family and friends Health professionals Health professionals UNC Center for Maternal and Infant Health Funded by North Carolina Health and Wellness rust Fund
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Tobacco Cessation Training for HCPs Working with Women The Guide is available on the Division of Public Health / Womens Health Branch webpage: http://whb.ncpublichealth.com/provPart/pubmanbro.htm#top For more information on the Womens Health and Tobacco Use Program, contact: Judy Ruffin Judy.ruffin@ncmail.net 919-707-5712
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Pharmacotherapy – First Line n Nicotine Replacement Therapy - Patch - Patch - Gum - Gum - Lozenge - Lozenge - Inhaler - Inhaler - Nasal Spray - Nasal Spray n Zyban (bupropion) n Chantix (varenicline)
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Over the Counter Medications Nicotine Patch n Dose: 21mg, 14mg or 7mg per 24 hours u 1 pack/day, start with higher dose, taper u duration 8 weeks u step down after 4 wks in 2 wk increments u Nicotrol is used for 16 hours, off at night n Adverse effects: local skin reaction, insomnia, vivid dreams n Contraindications: Recent MI, unstable angina, arrhythmia n Cost: 7mg box - $37 14mg box - $47 14mg box - $47 21mg box - $48 21mg box - $48
Over the Counter Medications Nicotine Gum n Dose: up to 24 pieces per day u x 12 weeks (longer if needed) u 2mg for 25 cigarettes per day u Chew, chew, park u Avoid acidic beverages n Consider using on a fixed schedule n Long term patch and gum use are effective n Adverse Effects: Mouth soreness, hiccups, jaw ache, dyspepsia n Contraindications: As for patch n Cost: 2mg box (100-170 pieces) ~ $45 (generic) 4mg box (100-110 pieces) ~ $63 (generic) 4mg box (100-110 pieces) ~ $63 (generic)
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Over the Counter Medications Nicotine Lozenge (Commit) n Dose u 2mg (1st cig. >30 min. after awake) u 4mg (1st cig.
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Prescription Medications Nicotine Inhaler n Dose: 4mg nicotine u 80 puffs=4mg nicotine u Best effects with frequent puffing/at least 6 cartridges per day (can use 6-16 cartridges/day) u Use for up to 6 months Reduce frequency over the last 6-12 weeks of tx Reduce frequency over the last 6-12 weeks of tx n Avoid acidic beverages n Adverse Effects: mouth/throat irritation, coughing, rhinitis n Contraindications: as for patch n Cost: 1 box (168 10mg cartridges) - $196
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Prescription Medications Nicotine Nasal Spray n Dose: 1 dose = 1 mg (0.5mg per nostril) u 1-2 doses per hour initially u Increase as needed for symptom relief u 8 min/40 max doses per day for 3-6 months u Do not sniff, swallow or inhale u Head titled slightly back n Adverse Effects: Nasal irritation, congestion; transient changes in smell, taste n Contraindications: as for patch n Cost: $49 per bottle (100 doses)
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NRT and Cardiovascular Disease n Not an independent risk factor for acute myocardial events n Use with caution in patients who: are within 2 weeks of MI are within 2 weeks of MI have serious arrhythmias have serious arrhythmias have serious or worsening angina have serious or worsening angina pectoris pectoris
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Prescription Medications Zyban, Wellbutrin (bupropion SR 150) n Begin 1-2 weeks before quit date n Dose: 150 mg in a.m. for 3 days 150 mg twice daily for 7 to 12 weeks 150 mg twice daily for 7 to 12 weeks n May consider long-term tx for 6 months post quit n Adverse Effects: Insomnia, dry mouth n Contraindications: history of seizure d/o, eating d/o, recent MAO inhibitor use in past 14 days n Cost: 1 box of 60 tablets u $97/month (generic) u $197-$210 (brand name)
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Prescription Medications Chantix (varenicline) n Stimulates nicotine receptors. Also blocks nicotine at receptor site n Start Chantix 1 week before quit date n Dose: 0.5 mg daily for 3 days 0.5mg twice daily for 4 days 0.5mg twice daily for 4 days 1.0mg twice daily for 3 months 1.0mg twice daily for 3 months n May decrease dosage (1mg/day) if significant side effects n Adverse Effects: nausea, insomnia, abnormal/vivid dreams n New warning label Jan. 2008– observe for neuro- psychiatric symptoms (post marketing data) n Cost: 1 box of 56 - $131 (~30 day supply) Research shows that at 1 year, 21% of those on Chantix are still abstinent compared to 8% with a placebo
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More on Pharmacotherapy n Combined therapy improves abstinence rates u Patch + gum, nasal spray, or inhaler u Patch plus buproprion (FDA approved) n Do not combine NRT with Chantix n Buproprion and gum or lozenge may delay weight gain n NRT for smokers not willing to quit – promising but warrants further research
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Pregnancy and Pharmacotherapy n Abstinence early produces greatest benefits n Quitting at any point yields benefits n Person to person intervention should be offered to pregnant and post partum women u Should exceeds minimal advice to quit n Inconclusive evidence that cessation medications increase abstinence rates
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Treating Tobacco Use and Dependence: Children and Adolescents Recommendations n Clinicians screen children and adolescents for tobacco use n Consider counseling and behavioral interventions that are effective with adults n Offer smoking cessation advice and interventions to parents
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Insurance Coverage for Cessation Medications n Medicaid now covers ALL cessation pharmacotherapy u Nicotine patch, gum, lozenge, nasal spray, inhaler u Zyban u Chantix n No Prior Authorization needed n Prescription required, even for OTC
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Counseling Coverage in NC nMedicaid added two CPT codes Jan. 1, 2009 u99406 – 3-10 minutes u99407 – > 10 minutes May be billed the same day as an E/M or Health Check visit May be billed the same day as an E/M or Health Check visit Use ICD-9 Code: 305.1 (tobacco abuse) Use ICD-9 Code: 305.1 (tobacco abuse) Unbundled – can use a second ICD-9 code Unbundled – can use a second ICD-9 code nMedicare, BCBSNC, and State Health Plan also reimburse these codes
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Who can bill Medicaid? In addition to physicians, nurse practitioners, and health departments, these codes can be billed incident to the physician by the following professional specialties: u Licensed psychologists and psychological associates u Licensed clinical social workers u Licensed professional counselors u Licensed marriage and family counselors u Certified nurse practitioners u Certified clinical nurse specialists u Licensed clinical addictions specialists or u Certified clinical supervisors
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Medicaid Coverage for Treatment nFor more information see Medicaid Bulletins: u http://www.dhhs.state.nc.us/dma/bulletin.htm uJan 2009: http://www.dhhs.state.nc.us/dma/bulletin.htm u uOct.2008: http://www.ncdhhs.gov/dma/bulletin/1008bulletin.htm
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More Cessation Counseling Reimbursement Codes n nOther codes: u u99401-04; 15-60 minutes (dedicated visit) u u99354 can be added to regular visit (must document counseling) u99411 u99411 is used for group counseling (per participant) MD, PA or FNP on premises, must talk to group RN (etc.) may facilitate session
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Helpful Web Sites and Links: n www.tobaccopreventionandcontrol. ncdhhs.gov/cessation n www.tobaccopreventionandcontrol. ncdhhs.gov/FaxForm.pdf n www.QuitLineNC.com n www.QuitNowNC.org
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Learning More / CE Options n Counseling for Change: An On-line Tobacco Cessation Course - Northwest AHEC u Contact Nedra Edwards Hines 336-713-7727; nedwards@wfubmc.edu 336-713-7727; nedwards@wfubmc.edu u $20 fee for course credits; free to view n Medscape: Treating Tobacco Use and Dependence http://www.medscape.com/viewarticle/570604 u Free u Approved for 1hour CE u AMA PRA Category 1 Credit(s) u Requires registration to Medscape n TobaccoFreePatients.com http://www1.tobaccofreepatients.com/TopicReq? u Based on NCI educational program u Available free for study and review u $15 per credit hour / letter of completion
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Take-Home Message for Health Care Providers n Brief cessation counseling is effective n Longer cessation counseling is more effective n Pharmacotherapy can double quit rates n Pharmacotherapy should be offered to all - few exceptions n Evidence-based resources are available
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You only have two minutes n Ask every everyone about tobacco use n Advise to quit with a clear, strong, personalized message n Refer to u NC Tobacco Use Quitline 1-800-QUIT-NOW (1-800-784-8669) 1-800-QUIT-NOW (1-800-784-8669) u Become An Ex www.becomeanex.org www.becomeanex.org n Pharmacotherapy – for most
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Tobacco Prevention and Control Branch Division of Public Health North Carolina Department of Health and Human Services Main Ph: 919-707-5400 Fax: 919-870-4844 www.tobaccopreventionandcontrol.ncdhhs.gov