Intensive, Brief, and “Ultra Brief” Smoking Cessation Interventions

1. Intensive, Brief, and “Ultra Brief” Smoking Cessation Interventions Sandi Kazura, MD Medical Director Center for Tobacco Independence Maine Health January 17, 2008

2. Disclosures • 2006 – Honorarium for CME program development for Haymarket Medical, funded by Shire Pharmaceutical (prevention of substance abuse) • Research support from NIDA, NCI, Robert Wood Johnson Foundation, American Academy of Child and Adolescent Psychiatry, Brown University Collaborative on Translational Brain Research

3. Goals • Learn key evidence-based elements of practice-based smoking cessation interventions • Consider office teamwork approaches to enhance patient quit rates

4. Practice System Needs • Ways to • Identify smokers • Assess smokers • Motivate smokers to quit • Assist smokers with quitting • Evaluate how well the practice is doing with helping smokers

5. Identification • Who will do this? • When? • How ask?

6. How to ask • Straightforward, direct for most • However, “chippers” and occasional smokers may not identify themselves as smokers • Youth: Even low levels of smoking are important • Predicts future smoking • Can start the conversation • Highest yield of positive responses: • Have you ever smoked even a puff or two?

7. How to ask • Pregnant women are especially likely to have a difficult time disclosing tobacco use. • Best to ask using multiple choice format, e.g. • Which of the following statements best describes your cigarette smoking? • I smoke regularly now---about the same as before finding out I was smoking • I smoke regularly now, but I’ve cut down since I found out I was pregnant. • I smoke every once in a while • I have quit smoking since finding out I was pregnant • I wasn’t smoking around the time I found out I was pregnant, and I don’t currently smoke cigarettes

8. Assessment • Current use • Interest in quitting

9. Agree (dealing with motivation) • On a realistic goal • If not ready to quit, this could simply be an agreement for you to check in again at the next visit • Use empathy • Listening and repeating back what you understand • Explore pros and cons • “Quitting can be hard”

10. Assistance with Quitting • Counseling • Help identify triggers and barriers to quitting • Help with a personalized management plan • Medication • NRT: patch, gum, lozenge, spray, inhaler • Bupropion • Varenicline • Support • Professional & natural supports • Praise even small changes • Empathize with difficulty but be optimistic

11. Summarize - Three A’s Assess Agree Assist

12. Brief • 3 A’s • < 3 minutes • Medication, unless contraindicated • NRT patch may be easiest to explain

13. Intensify • Increase # of minutes (quit rate -OR compared to no contact) • Minimal: < 3 minute (1.3) • Low intensity: 3-10 minutes (1.6) • Higher intensity: > 10 minutes (2.3) • Increase # of messages • Messages over time • Number of clinicians, e.g. nurse plus doctor • Intensive behavioral counseling - typically provided by specialists (91 -300 minutes, OR = 3.2) • E.G. Tobacco Treatment Specialists - Certified (TTS-C)

14. Ultra Brief Options • Provide direct advice to quit • “I’m concerned about your smoking---it would be great if you quit” • Refer to Helpline • Passive - probably better than nothing alone, better as supplement to person-to-person counseling • Posters • Helpline # • Self-help materials

15. Office Systems • Include • Written mission statement (making a commitment to intervene) • Patient education resources • Automatic prompts to ask and counsel • Staff training • Office “champion” • Referral resources • Tracking system • Program evaluation (QA)

16. How will you do this in your practice setting?

17. Maine Tobacco Helpline1-800-207-1230 • Counseling • Medication - Free nicotine replacement (patch and gum) for those without insurance coverage • Support

18. Medications - Clinical Pearls • NRT - one common cause of failure is improper use • Varenicline • FDA “early communication” possible risk for • Suicidal thoughts • Aggressive & erratic behavior • Drowsiness • Inform patients, monitor • Bupropion • Think through potential issues in presence of psychiatric conditions • FDA Alert • Possible increased risk of suicidal thoughts and behavior • Monitor for worsening depression and/or suicidality

19. Web Resources • Smoking & Tobacco Use (Centers for Disease Control & Prevention) • www.cdc.gov/tobacco/ • Smoking Cessation Leadership • http://smokingcessationleadership.ucsf.org • Smoke Free Homes • www.kidslivesmokefree.org

20. Clinical Practice Guideline • Fiore MC, Bailey WC, Cohen SJ et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: Department of Health and Human Services. Public Health Service. June 2000. • Stay tuned! --- update scheduled for release 3/08 • Available free, on-line version, with technical support resources at • http://www.ahrq.gov/clinic/tobacco

21. Local Resources • Partnership for Tobacco Free Maine • www.tobaccofreemaine.org • Center for Tobacco Independence • Helpline: 1-800-207-1230 • Website: www.tobaccoindependence.org • Clinical Outreach – free consultation & technical support for your office • Contact: 662-7135

22. Upcoming Trainings • Check PTM and/or CTI websites for details • Basic • March 26, 2008 - South Portland • Intensive • April 28 & 29, 2008 • Basic training is a pre-requisite

23. Questions?Comments?