Rx for CHANGEClinician-Assisted Tobacco Cessation
for Surgical Patients
Developed through a collaboration of the American Society for Anesthesiologists and the Rx for Change: Clinician-Assisted Tobacco Cessation program.
Funded by the National Cancer Institute and the Robert Wood Johnson Foundation.
TRAINING OVERVIEW
Epidemiology of Tobacco Use Benefits of Quitting for Surgical Patients Tobacco Dependence and Medications for
Quitting Changing Behavior – How You Can Help
EPIDEMIOLOGY of TOBACCO USE
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., former U.S. Surgeon General
“CIGARETTE SMOKING…
Adapted from NCI Smoking and Tobacco Control Monograph 8, 1997, p. 13. Data from U.S. Department of Agriculture. Reprinted with permission. Thun et al. 2002. Oncogene 21:7307–7325.
0
2
4
6
8
10
12
14
1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
Poun
ds o
f tob
acco
per
cap
ita
Cigarettes
Cigars
Chewing tobacco
Snuff
Pipe/roll your own
ADULT PER-CAPITA CONSUMPTION of TOBACCO, 1880–2005
All forms of tobacco
are harmful
.
Year
TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2006
Trends in cigarette current smoking among persons aged 18 or older
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2005 NHIS. Estimates since 1992 include some-day smoking.
Perc
ent
70% want to quit
0
10
20
30
40
50
60
1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999 2003
Male
Female 23.9%18.0%
20.8% of adults are
current smokers
Year
TRENDS in TEEN SMOKING, by ETHNICITY—U.S., 1977–2007
Trends in cigarette smoking among 12th graders: 30-day prevalence of use
0
10
20
30
40
50
1977 1982 1987 1992 1997 2002 2007Year
Institute for Social Research, University of Michigan, Monitoring the Future Projectwww.monitoringthefuture.org
Perc
ent
White
Hispanic
Black
PUBLIC HEALTH versus “BIG TOBACCO”
The biggest opponent to tobacco control efforts is the
tobacco industry itself.
Nationally, the tobacco industry is outspending our state tobacco control funding.
For every $1 spent by the states, the tobacco industry spends $18 to market its products.
TOBACCO INDUSTRY ADVERTISING
$13.11 billion spent in the U.S. in 2005 $35.9 million a day 95% increase over 1998 figures
0
5
10
15
1970 1997 1998 1999 2000 2001 2002 2003 2004 2005
Bill
ions
of d
olla
rs s
pent
YearFederal Trade Commission. (2007). Cigarette Report for 2004 and 2005.
New marketing restrictions
The TOBACCO INDUSTRY For decades, the tobacco industry publicly denied the
addictive nature of nicotine and the negative health effects of tobacco.
April 14, 1994: Seven top executives of major tobacco companies state, under oath, that they believe nicotine is not addictive: http://www.jeffreywigand.com/7ceos.php (video)
Tobacco industry documents indicate otherwise Documents available at http://legacy.library.ucsf.edu
The cigarette is a heavily engineered product. Designed and marketed to maximize bioavailability
of nicotine and addictive potential Profits over people
ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, 1997–2001
Centers for Disease Control and Prevention. (2005). MMWR 54:625–628.
32%28%23%9%8%
<1%
TOTAL: 437,902 deaths annually
Cardiovascular diseases
137,979
Lung cancer 123,836Respiratory diseases 101,454Second-hand smoke* 38,112Cancers other than lung
34,693
Other 1,828
Percentage of all smoking-attributable deaths*
* In 2005, it was estimated that nearly 50,000 persons died due to second-hand smoke exposure.
COMPOUNDS in TOBACCO SMOKE
Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde
Nicotine Nitrosamines Lead Cadmium Polonium-210
An estimated 4,800 compounds in tobacco smoke, including 11 proven human carcinogens
Gases Particles
Nicotine is the addictive component of tobacco products, but it does NOT cause the ill health effects of tobacco use.
2004 REPORT of the SURGEON GENERAL:HEALTH CONSEQUENCES OF SMOKING
Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general.
Quitting smoking has immediate as well as long-term benefits, reducing risks for diseases caused by smoking and improving health in general.
Smoking cigarettes with lower machine-measured yields of tar and nicotine provides no clear benefit to health.
The list of diseases caused by smoking has been expanded. U.S. Department of Health and Human Services. (2004). The Health
Consequences of Smoking: A Report of the Surgeon General.
FOUR MAJOR CONCLUSIONS:
HEALTH CONSEQUENCES of SMOKING
Cancers Acute myeloid leukemia Bladder and kidney Cervical Esophageal Gastric Laryngeal Lung Oral cavity and pharyngeal Pancreatic
Pulmonary diseases Acute (e.g., pneumonia) Chronic (e.g., COPD)
Cardiovascular diseases Abdominal aortic aneurysm Coronary heart disease Cerebrovascular disease Peripheral arterial disease
Reproductive effects Reduced fertility in women Poor pregnancy outcomes
(e.g., low birth weight, preterm delivery)
Infant mortality Other effects: cataract,
osteoporosis, periodontitis, poor surgical outcomes
U.S. Department of Health and Human Services. (2004). The Health Consequences of Smoking: A Report of the Surgeon General.
ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTS—U.S., 1995–1999
0 10 20 30 40 50 60 70 80
Annual lost productivity
costs (1995–1999)
Medical expenditures
(1998)
Billions of dollars
Men, $55.4 billion
Ambulatory care, $27.2 billion
Prescription
drugs, $6.4
billion
Women, $26.5 billion
Nursing home,
$19.4 billion
Other care, $5.4 billion
Centers for Disease Control and Prevention. (2002). MMWR 51:300–303.
Hospital care, $17.1 billion
Societal costs: $7.18 per pack
USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.
There is no safe level of
second-hand
smoke.
Second-hand smoke causes premature death and disease in nonsmokers (children and adults)
Children: Increased risk for sudden infant death syndrome
(SIDS), acute respiratory infections, ear problems, and more severe asthma
2006 REPORT of the SURGEON GENERAL: INVOLUNTARY EXPOSURE to TOBACCO SMOKE
Respiratory symptoms and slowed lung growth if parents smoke Adults:
Immediate adverse effects on cardiovascular system Increased risk for coronary heart disease and lung cancer
Millions of Americans are exposed to smoke in their homes/workplaces Indoor spaces: eliminating smoking fully protects nonsmokers
Separating smoking areas, cleaning the air, and ventilation are ineffective
FINANCIAL IMPACT of SMOKING
Packsper day
Buying cigarettes every day for 50 years @ $4.32 per packMoney banked monthly, earning 4% interest
Dollars lost, in thousands
$755,177
$503,451
$251,725
0 200 400 600 800
$251,725
$503,451
$755,177
0
5
10
15
30 40 50 60
Year
s of
life
gai
ned
Age at cessation (years)
Prospective study of 34,439 male British doctors
Mortality was monitored for 50 years (1951–2001) On average, cigarette
smokers die approximately 10 years younger than do
nonsmokers.
Among those who continue smoking, at least half will
die due to a tobacco-related disease.
SMOKING CESSATION: REDUCED RISK of DEATH
Doll et al. (2004). BMJ 328(7455):1519–1527.
QUITTING: HEALTH BENEFITS
Lung cilia regain normal functionAbility to clear lungs of mucus increasesCoughing, fatigue, shortness of breath decrease
Excess risk of CHD decreases to half that of a
continuing smokerRisk of stroke is reduced to that of people who have never smoked
Lung cancer death rate drops to half that of a
continuing smokerRisk of cancer of mouth,
throat, esophagus, bladder, kidney, pancreas
decrease
Risk of CHD is similar to that of people who have never smoked
2 weeks to
3 months1 to 9
months
1year
5years
10years
after15 years
Time Since Quit Date Circulation improves,
walking becomes easier Lung function increases
up to 30%
BENEFITS of QUITTING for SURGICAL PATIENTS
WHY SHOULD SURGICAL PROVIDERS ADDRESS TOBACCO USE?
Quitting Smoking Improves Surgical
Outcomes
Surgery May Promote Quitting
Smoking
TOBACCO CESSATION IMPROVES SURGICAL OUTCOMES
Quitting reduces the incidence of: Cardiovascular complications Respiratory complications Wound-related complications
SHORT-TERM CARDIOVASCULAR BENEFITS OF SMOKING CESSATION
Nicotine Half life, approximately 1–2 hours Decreases in heart rate and systolic blood
pressure within 12 hours
Carbon monoxide Half life, approximately 4 hours Carboxyhemoglobin level near normal at 12
hours
Preoperative abstinence decreases the frequency of intraoperative ischemia*
*Woehlck et al. (1999). Anesth Analg 89:856-860.
SMOKING CESSATION REDUCES POSTOPERATIVE COMPLICATIONS
0
10
20
30
40
50
60
Any Wound CardiacType of Complication
Perc
ent
ControlIntervention
120 orthopedic patient randomized to tobacco intervention or control, 6–8 weeks prior to surgery
~80% of intervention patients were able to quit or reduce smoking
Møller et al. (2002). Lancet 359:114–117.
WHY SHOULD SURGICAL CARE CLINICIANS BOTHER?
Quitting Smoking Improves Surgical
Outcomes
Surgery May Promote Quitting
Smoking
SURGERY PROMOTES TOBACCO CESSATION
Opportunity for providers to intervene Contact with healthcare system Forced abstinence in smoke-free facilities
Major medical interventions improve quit rates Occurs even in the absence of tobacco
interventions May also improve the effectiveness of tobacco
interventions
SMOKING CESSATION AFTER SURGERY
0
20
40
60
80
100
Self-help Outpatientcessationprograms
Major non-cardiac surgery
Coronarybypass surgery
Lung cancersurgery
Perc
ent a
bstin
ent a
t 1
year
BARRIERS TO PERIOPERATIVE SMOKING CESSATION
“Quitting just before surgery increases pulmonary complications.”
“Nicotine replacement therapy is dangerous.”
“Surgical patients are already too stressed.”
“Patients don’t want to hear about their smoking—they have enough to worry about.”
RECENT SMOKING CESSATION DOES NOT INCREASE PULMONARY COMPLICATIONS
0
5
10
15
20
25
ContinuedSmokers
RecentQuitters
Past Quitters Non-Smokers
OverallPneumonia
300 patients for lung cancer resection
“Recent” quitters: >1 week, <2 months
“Past” quitters: >2 months
Barrera et al. (2005). Chest 127:1977–1983.
(n=13) (n=39) (n=184) (n=64)
Perc
ent
NICOTINE REPLACEMENT THERAPY AND WOUND HEALING
0
5
10
15
20
25
30
Infection Dehiscience
Non-abstinent
Abstinent, active patch
Abstinent, placebo
48 smokers randomized to continuous smoking or abstinence, with or without nicotine replacement
Standardized wounds over a 12-week period
Sorensen et al. (2003). Ann Surg 238:1–5.
Perc
ent
PERIOPERATIVE STRESS IN SURGICAL PATIENTS
0
1
2
3
4
Preop Postop POD1 POD2 POD7
Perc
eive
d St
ress
Smokers
Non-smokers
Warner et al. (2004). Anesthesiology 199:1125–1137.
141 smokers, 150 non-smokers for elective surgery
Perceived stress measured from before surgery up to one week postoperatively (POD=postop day)
Smoking status does not affect changes in perceived stress
No evidence for significant cigarette cravings
Time
WHAT DO PATIENTS WHO SMOKE EXPECT?
Essentially all smokers are aware of general health hazards Most are not aware of how it might affect
their surgery – and want to know! They want information and options Almost all will not be offended if you
discuss their smoking… But they do not want a sermon
Warner et al., unpublished observations.
THE REAL BARRIERS TO INTERVENTION
“I don’t know how.”“I don’t have time.”
“It’s not my job.”
TOBACCO DEPENDENCE:A 2-PART PROBLEM
Tobacco Dependence
Treatment should address the physiological and the behavioral
aspects of dependence.
Physiological Behavioral
Treatment Treatment
The addiction to nicotine
Medications for cessation
The habit of using tobacco
Behavior change program
TOBACCO DEPENDENCE and MEDICATIONS for QUITTING
WHAT IS ADDICTION?”Compulsive drug use,
without medical purpose, in the face of negative
consequences”Alan I. Leshner, Ph.D.
Former Director, National Institute on Drug AbuseNational Institutes of Health
NICOTINE DISTRIBUTION
Henningfield et al. (1993). Drug Alcohol Depend 33:23–29.
01020304050607080
0 1 2 3 4 5 6 7 8 9 10Minutes after light-up of cigarette
Plas
ma
nico
tine
(ng/
ml) Arterial
Venous
Nicotine reaches the brain within 11 seconds.
Nicotine enters brain
Stimulation of nicotine receptors
Dopamine release
DOPAMINE REWARD PATHWAYPrefrontal
cortex
Nucleus accumbens
Ventral tegmental
area
BIOLOGY of NICOTINE ADDICTION: ROLE of DOPAMINENicotine
stimulates dopamine release
Repeat administration
Tolerance develops
Discontinuation leads to
withdrawal symptoms.Pleasurable feelings
Nicotine addiction
is not just a bad habit.
Benowitz. (2008). Clin Pharmacol Ther 83:531–541.
Irritability/frustration/anger Anxiety Difficulty concentrating Restlessness/impatience Depressed mood/depression Insomnia Impaired performance Increased appetite/weight gain Cravings
NICOTINE PHARMACODYNAMICS: WITHDRAWAL EFFECTS
Hughes. (2007). Nicotine Tob Res 9:315–327.
Most symptoms manifest within the first 1–2 days, peak
within the first week, and subside within 2–
4 weeks.
HANDOUT
NICOTINE ADDICTION Tobacco users maintain a minimum serum
nicotine concentration in order to Prevent withdrawal symptoms Maintain pleasure/arousal Modulate mood
Users self-titrate nicotine intake by Smoking/dipping more frequently Smoking more intensely Obstructing vents on low-nicotine brand
cigarettesBenowitz. (2008). Clin Pharmacol Ther 83:531–541.
Nicotine polacrilex gum (OTC) – brand (Nicorette), genericNicotine lozenge (OTC) – brand (Commit), genericNicotine transdermal patch (OTC, Rx) – brand (NicoDerm
CQ, OTC), generic (OTC, Rx)Nicotine nasal spray (Rx) – brand (Nicotrol NS)Nicotine inhaler (Rx) – brand (Nicotrol Inhaler)Bupropion SR (Rx) – brand (Zyban), genericVarenicline (Rx) – brand (Chantix)
These are the only medications that are FDA-approved for smoking cessation.
FDA-APPROVED MEDICATIONS for SMOKING CESSATION
OTC = Over the counter
PHARMACOTHERAPY
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
Medications significantly improve success rates. * Includes pregnant women, smokeless tobacco users, light smokers, and adolescents.
“Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations* for which there is insufficient evidence of effectiveness.”
NRT: RATIONALE for USE
Reduces physical withdrawal from nicotine
Eliminates the immediate, reinforcing effects of nicotine that is rapidly absorbed via tobacco smoke
Allows patient to focus on behavioral and psychological aspects of tobacco cessation
NRT products approximately doubles quit rates.
PLASMA NICOTINE CONCENTRATIONS for NICOTINE-CONTAINING PRODUCTS
0
5
10
15
20
25
1/0/1900 1/10/1900 1/20/1900 1/30/1900 2/9/1900 2/19/1900 2/29/1900
Plas
ma
nico
tine
(mcg
/l)
Cigarette
Moist snuff
Nasal spray
Inhaler
Lozenge (2mg)
Gum (2mg)
Patch
0 10 20 30 40 50 60
Time (minutes)
Cigarette
Moist snuff
NICOTINE GUM Resin complex of nicotine and polacrilin Sugar-free chewing gum base Contains buffering agents to enhance buccal
absorption of nicotine Available:
2 mg, 4 mg; original, cinnamon, fruit, mint (various), and orange flavors
NICOTINE LOZENGE Nicotine polacrilex formulation
Delivers ~25% more nicotine than equivalent gum dose
Sugar-free mint (various), cappuccino or cherry flavor
Contains buffering agents to enhance buccal absorption of nicotine
Available: 2 mg, 4 mg
TRANSDERMAL NICOTINE PATCH
Nicotine is well absorbed across the skin Delivery to systemic circulation avoids hepatic
first-pass metabolism Plasma nicotine levels are lower and fluctuate less
than with smoking Available:
Brand or generic; nicotine delivery over 24 hours
21 mg, 14 mg, 7 mg
NICOTINE NASAL SPRAY Aqueous solution of nicotine in a 10-ml spray
bottle Each metered dose actuation delivers
50 mcL spray 0.5 mg nicotine
~100 doses/bottle Rapid absorption across nasal mucosa Available:
Rx only
NICOTINE INHALER Nicotine inhalation system consists of:
Mouthpiece Cartridge with porous plug containing 10 mg
nicotine and 1 mg menthol Delivers 4 mg nicotine vapor, absorbed across
buccal mucosa Available:
Rx only
BUPROPION SR Nonnicotine cessation aid Oral formulation Sustained-release antidepressant
Atypical antidepressant thought to affect levels of various brain neurotransmitters (dopamine, norepinephrine)
Clinical effects craving for cigarettes symptoms of nicotine withdrawal
VARENICLINE Nonnicotine cessation aid Partial nicotinic receptor agonist Oral formulation Binds with high affinity and selectivity at 42 neuronal nicotinic acetylcholine receptors
Stimulates low-level agonist activity Competitively inhibits binding of nicotine
VARENICLINE:CARDIOVASCULAR EFFECTS?
4β2 nicotinic receptor not known to have non-CNS effects
No evidence for effects on vascular function
More data needed
VARENICLINE: WARNING In 2008, Pfizer added a warning label
advising patients and caregivers: Patients should stop taking varenicline and contact their healthcare provider immediately if agitation, depressed mood, or changes in behavior that are not typical for them are observed, or if the patient develops suicidal ideation or suicidal thoughts.
LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS
0
5
10
15
20
25
30
Nicotine gum Nicotinepatch
Nicotinelozenge
Nicotinenasal spray
Nicotineinhaler
Bupropion Varenicline
Active drugPlacebo
Data adapted from Cahill et al. (2008). Cochrane Database Syst Rev; Stead et al. (2008). Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev
Perc
ent q
uit 18.0
15.8
11.3
9.9
16.1
8.1
23.9
11.8
17.1
9.1
19.0
10.3 11.2
20.2
$0
$1
$2
$3
$4
$5
$6
$7
$8
Trade $6.58 $5.26 $3.89 $5.29 $3.72 $7.40 $4.75Generic $3.28 $3.66 $1.90 - - $3.62 -
Gum Lozenge Patch Inhaler Nasal spray Bupropion SR Varenicline
COMPARATIVE DAILY COSTS of PHARMACOTHERAPY
$/da
y
Average $/pack of cigarettes, $4.32
PHARMACOTHERAPY: USE in PREGNANCY
The Clinical Practice Guideline makes no recommendation regarding use of medications in pregnant smokers
Insufficient evidence of effectiveness; concerns with safety
Category C: varenicline, bupropion SR Category D: prescription formulations of NRT“Because of the serious risks of smoking to the
pregnant smoker and the fetus, whenever possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit.” (p. 165)
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
CHANGING BEHAVIOR – HOW YOU CAN HELP
TOBACCO CESSATION REQUIRES BEHAVIOR CHANGE
Fewer than 5% of people who quit without assistance are successful in quitting for more than a year.
Few patients adequately PREPARE and PLAN for their quit attempt.
Many patients do not understand the need to change behavior
Patients think they can just “make themselves quit”
Behavioral counseling is a key component of treatment for tobacco use and dependence.
Often, patients automatically smoke in the following situations:
Behavioral counseling helps patients learn to cope with these difficult situations without having a cigarette.
When drinking coffee While driving in the car When bored While stressed While at a bar with friends
After meals During breaks at work While on the telephone While with specific friends or
family members who use tobacco
CHANGING BEHAVIOR (cont’d)
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Estim
ated
abs
tinen
ce a
t 5+
mon
ths
1.0 1.11.7
2.2
n = 29 studies
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
With help from a clinician, the odds of quitting approximately doubles.
Compared to patients who receive no assistance from a clinician, patients who receive assistance are 1.7–2.2 times as likely to quit successfully for 5 or more months.
CLINICIANS CAN MAKE a DIFFERENCE
Esti
mat
ed a
bsti
nenc
e ra
te a
t 5+
mon
ths
0
10
20
30
None One Two Three or more
Number of Clinician Types
1.0
1.8(1.5,2.2)
2.5(1.9,3.4)
2.4(2.1,3.4)
n = 37 studies
The NUMBER of CLINICIANS CAN MAKE a DIFFERENCE, too
Compared to smokers who receive assistance from no clinicians, smokers who receive assistance from two or more clinicians are 2.4–2.5 times as likely to quit successfully for 5 or more months.
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
WHAT SHOULD WE DO FOR SURGICAL PATIENTS ?
ASK about tobacco USE
ADVISE tobacco users to QUIT
REFER to other resources
ASSIST
ARRANGE
Patient receives assistance, with follow-up counseling
arranged, from other resources such as the
tobacco quitline
WHAT ARE “TOBACCO QUITLINES”?
Tobacco cessation counseling, provided at no cost via telephone to all Americans
Staffed by trained specialists Up to 4–6 personalized sessions (varies by
state) Some state quitlines offer nicotine
replacement therapy at no cost Up to 30% success rate for patients who
complete sessionsMost health-care providers, and most patients,
are not familiar with tobacco quitlines.
ASK EVERY PATIENT ABOUT TOBACCO USE
Ask even if you already know the answer Reinforces the message that tobacco
use is clinically significant, and quitting is important
ADVISE ALL PATIENTS WHO SMOKE TO QUIT: Talking Points
Why quit for surgery? Quit for as long as possible before and
after surgery Day of surgery is particularly important Advise patient to “fast” from food and
cigarettes Benefits of quitting to wound healing,
heart and lungs Great opportunity to quit for good
Many people don’t have cravings Need to be smoke free in the hospital anyway
REFER smokers to quitlines or other resources
What are quitlines? – talking points Quitlines are free Talk with a specialist, not a
recording Free stop smoking medications may
be available Can call anytime, even after surgery Can help you stay off cigarettes
even if you have already quit Can also use proactive fax referral 1-800-QUIT-NOW
Am. Society of Anesthesiologists: “QUIT CARD”
Amer. Society of Anesthesiologists: PATIENT BROCHURE
OTHER RESOURCES FOR YOUR PATIENTS
Tobacco treatment specialists Available in many practice settings Often hospital-based
Websites www.smokefree.gov www.asahq.org/patientEducation/smokingcessatio
n.htm Insurers
e.g., Blue Cross/Shield, BluePrint for Health program
OTHER WEB RESOURCES FOR PROVIDERS
General portal for information www.smokefree.gov
ASA-sponsored site providing information and resources for surgical patients and providers
www.asahq.org/patientEducation/smoking_cessationProvider.htm
Training materials for clinicians http://rxforchange.ucsf.edu
CMS REIMBURSEMENT FOR TOBACCO INTERVENTIONS
Who is covered? Patients who use tobacco and have a disease or
adverse health effect found by the U.S. Surgeon General to be linked to tobacco use
CPT codes 99406: Smoking and tobacco-use cessation
counseling visit; intermediate, > 3 minutes up to 10 minutes
99407: Smoking and tobacco-use cessation visit; intensive, > 10 minutes
CMS REIMBURSEMENT FOR TOBACCO INTERVENTIONS
Cessation counseling attempt occurs when a qualified physician or other Medicare-recognized practitioner determines that a beneficiary meets the eligibility requirements above and initiates treatment with a cessation counseling attempt
Two attempts (of up to 4 sessions) allowed every 12 months
No credentialing requirements as of yet
A COMPREHENSIVE APPROACH…
Every surgical patient has at least five points of contact when undergoing elective surgery Initial surgical visit (scheduling) Admission to facility Preop visit by anesthesia provider Discharge from facility Post-op surgical visit
Each provides an opportunity to provide reinforcing messages…if the surgical team can work together
Tobacco users expect to be encouraged to quit by health professionals.
Screening for tobacco use and providing tobacco cessation counseling are positively associated with patient satisfaction (Barzilai et al., 2001).
Barzilai et al. (2001). Prev Med 33:595–599.
Failure to address tobacco use tacitly implies that quitting is not important.
WHY SHOULD CLINICIANS ADDRESS TOBACCO?
HELPING PATIENTS QUIT IS a CLINICIAN’S RESPONSIBILITY
THE DECISION TO QUIT LIES IN THE HANDS OF EACH PATIENT.
TOBACCO USERS DON’T PLAN TO FAIL.
MOST FAIL TO PLAN.
Clinicians have a professional obligation to address tobacco use and can have an important role in helping patients
plan for their quit attempts.
DR. GRO HARLEM BRUNTLAND,
FORMER DIRECTOR-GENERAL of the WHO:
“If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.”
USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS.
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