Maine Tobacco-Free Behavioral Health Summit

Thank You for Joining Us!

Agenda10:30a: The Case for Tobacco-Free Behavioral Health Facilities

11:30a: Policy Development and Implementation

12:30p: Lunch

1:00p: Clinical Treatment Training and Support

1:45p: Lessons Learned from the Field Discussion

About Us

BEC has a mission to reduce exposure to secondhand smoke and promote tobacco-free policies in behavioral health facilities, colleges/universities, hospitals, and multi-unit

housing by providing resources and technical assistance.

The Breathe Easy Coalition of Maine is able to provide resources and technical assistance to

support policy change through a grant from the Maine CDC Partnership for a Tobacco-Free Maine.

About You

Introductions• Name

• Organization

• BH: What is your organization doing to address tobacco or what do you hope to do to address tobacco?

• PH: How can your organization support behavioral health organizations to address tobacco?

Resources to Support Policy Change

► Policy support and technical assistance available for free through the Breathe Easy Coalition and Healthy Maine Partnerships.

► Tobacco Policy Toolkit – Coming Soon!

The Case for Addressing Tobacco in Behavioral

Health Facilities

Reasons for Addressing Tobacco Use

► Tobacco use remains the leading cause of preventable disease and death.

► There is no risk-free level of exposure to secondhand smoke – even brief exposure causes damage the can lead to serious disease and death.

► Creating tobacco-free areas changes the social norm around tobacco use and promotes tobacco-free living.

► Cigarette butts are the most littered item in the US and the filter can take up to 25 years to biodegrade.

No Risk-Free Level of Exposure

► The US Surgeon General has repeatedly stated that there is no safe level of exposure to secondhand smoke. Even brief exposure causes damage that can lead to serious disease and death.

► What is secondhand smoke?

Defined as the tobacco smoke exhaled by smokers or given off by the burning end of tobacco, which is inhaled involuntarily or passively by someone who is smoking.

No Risk-Free Level of Exposure

► The EPA has classified secondhand smoke as a Group A Carcinogen, Secondhand smoke contains thousands of chemicals – at least 69 which are known to cause cancer in humans.

► Exposure to secondhand smoke increases a nonsmoker’s risk of developing heart disease by 25-30% and for developing lung cancer by 20-30%.

Addressing More Than You’re Traditional Tobacco Products

► The CDC reports that increased risk “could be due to an increase in marketing, availability, and visibility of these tobacco products and the perception that they may be safer alternatives to cigarettes.”

► Best ways to address this:

► Education and prevention programming

► Strong, comprehensive tobacco-free policies

Creating Tobacco-Free Policies and Encouraging Tobacco-Free Lifestyles will:

Reducing exposure to secondhand smoke

Reducing the prevalence of tobacco use

Increasing the number of tobacco users who quit

Reducing the initiation of tobacco use among young people

Reducing tobacco-related morbidity and mortality, including

acute cardiovascular events

Tobacco Use and Behavioral Health

► People with serious mental illnesses are dying at least 25 years earlier than the general population.

88% of the deaths and 83% of premature years of life lost in people with serious mental

illness are due to “natural causes”:

• Cardiovascular Disease

• Diabetes

• Respiratory Diseases

• Infectious Diseases

► Increased morbidity and mortality are largely due to treatable medical conditions that are caused by modifiable risk factors such as smoking, obesity, substance abuse, and inadequate access to medical care.

Parks, J., Svendsen, D., Singer, P. & Foti, M.E., Morbidity and Mortality in People with Serious Mental Illness, National Association of State Mental Health Program

Directors, Medical Directors Council ( 2006)

Tobacco Use and Behavioral Health

► While smoking rates in the general population are declining, smoking rates for those with mental disorders continue to be twicethat of the general population.

Lasser, et al. Smoking and mental illness: A population-based prevalence study (2000)

Statistics to Consider

► 44% of cigarettes in the US are smoked by people with a serious mental illness.

► 75% of smokers have a past or current problem with mental illness or addiction.

► 27% - the percentage of an average monthly budget spent on cigarettes by people on public assistance.

► 1.5% - the proportion of patients seeing an outpatient psychiatrist who receive treatment for tobacco addition.

Sources: JAMA; National Comorbidity Study; National Association of State Mental Health Program Directors; Tobacco Control; American Journal of Addiction

Addressing Tobacco: An Opportunity

Myths vs. Opportunities

Myth #1: Tobacco dependence is less harmful than other additions.

► Those with alcohol, drug and/or other behavioral health diagnosis are more likely to die from their tobacco use than from their other co-occurring conditions.

1. Hser, Y. I., McCarthy, W. J., & Anglin, M. D. (1994). Tobacco use as a distal predictor of mortality among long-term narcotics addicts. Preventive Medicine, 23, 61–69.

Myths vs. Opportunities

There is greater mortality from tobacco use than from alcohol, illicit drugs, HIV, suicide, homicide, and motor vehicle accidents combined.

Myths vs. Opportunities

Myth #2: Recovery from other addictions should come first.

► Studies of smoking and alcohol treatment indicate that concurrent treatment does not jeopardize abstinence from alcohol and other non-nicotine drugs.

3. Prochaska, Delucchi, & Hall. (2004). A Meta-Analysis of Smoking Cessation Interventions With Individuals in Substance Abuse Treatment or Recovery. Journal of Consulting and Clinical Psychology, 2004, Vol. 72, No. 6, 1144–1156

Myths vs. Opportunities

Myth #3: Tobacco use is just a bad habit that people can address on their own.

► As with other addictions, tobacco dependence is a chronic relapsing condition often requiring multiple, assisted quit attempts before long-term abstinence is achieved.

► A combination of behavioral counseling and use of approved tobacco treatment medications have been found to significantly increase quit rates.

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

Myths vs. Opportunities

Myth #4: Persons with mental illness and substance abuse disorders do not want to quit smoking or they’ve given up enough. Why take away their last pleasure?

► Roughly 70% of all tobacco users want to quit. Roughly 50% will make at least one quit attempt each year. This population should be afforded the same opportunity and encouragement to quit tobacco as any other segment of the population.

► People who achieve abstinence from tobacco report greater satisfaction in their lives. Recovery from tobacco dependence can ease financial burden, improve health, strengthen relationships and potentiate other positive life changes.

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

• 5. L. Shahab & R West, “Do ex-smokers report feeling happier following cessation? Evidence from a cross-sectional survey”, Nicotine Tob Res. 2009 May;11(5):553-7.

Myths vs. Opportunities

Myth #5: Quitting tobacco is too stressful for someone whose mental health

status is already fragile.

► Studies have demonstrated that individuals with psychiatric disorders can be aided in quitting smoking without threat to their mental health recovery.

► People who use tobacco use found to experience more stress than non-users.

► Experiences in psychiatric hospitals have demonstrated that tobacco-free

hospitals have resulted in fewer instances of seclusion and incidences of restraint as well as reduction in coercion and threats among patients and staff.

6. Prochaska, J., “Failure to Treat Tobacco Use in Mental Health and Addiction Treatment Settings: A Form of Harm Reduction?”. Drug Alcohol Depend. 2010 August 1; 110(3): 177–182.7. Parrot, A.C. “Does Cigarette Smoking Cause Stress?”, American Psychologist, Vol 54(10), Oct 1999, 817-820.8. Tobacco-Free Living in Psychiatric Settings: A Best-Practices Toolkit Promoting Wellness and Recovery, 2007

DHHS Rider E Requirements around Tobacco

New Rider E Contract Requirements being added as contracts are renewed.

All agencies providing Mental Health or Substance Abuse Services under this agreement shall have a current

written tobacco policy addressing:

► Inclusion of tobacco assessment and need for treatment in all plans of care;

► Annual screening of individuals receiving MH/SA services for tobacco use and dependence using best practice

assessment protocols, tools, and procedures;

► Referral of individuals receiving MH/SA services to evidence-based tobacco cessation treatment; and

► Use of tobacco in agency facilities, on agency property, and at all locations in which services are delivered. At

a minimum, these policies shall comply with state tobacco laws (MSRA 22 §1580 A and §1541-1550).

These policies shall be reviewed annually with all staff and updated as necessary. Updates shall be submitted to the DHHS

program administrator upon update.

MaineCare Coverage for Tobacco

Tobacco Cessation Services

Effective August 1, 2014, there were a number of substantial changes to MaineCarecoverage of tobacco cessation services. These changes result from a combination of state and federal legislation (LD 386, An Act to Reduce Tobacco-Related Illness and Lower Health Care Costs in MaineCare, and the Affordable Care Act, respectively) promoting access to these benefits. MaineCare providers should be aware of these changes and of increased member eligibility for tobacco cessation products and services.

As of August 1, 2014, tobacco cessation pharmacological products, including patches, inhalers, sprays, gum, lozenges, and oral medications, will be available to all MaineCaremembers, as well as to participants in Maine’s Drugs for the Elderly (DEL) program. No co-payments may be collected for these products, and no annual or lifetime limitations will be imposed.

Effective August 1, 2014, those annual limits will be eliminated, and the service will be reimbursable for all members.

Tobacco Cessation Services

Prior to August 1, 2014, tobacco cessation counseling was reimbursable for some members up to a limit of three sessions per year. The following sections of the MaineCare Benefits Manual will be updated to eliminate the limitations:

Section 9, Indian Health Services; Section 31, Federally Qualified Health Centers; Section 90, Physician Services; Section 103, Rural Health Centers; and, Section 25, Dental Services (one per year)

Effective August 1, 2014, in addition to full coverage of tobacco cessation products, MaineCare will now cover tobacco cessation counseling for all MaineCare members. Tobacco cessation counseling will now be covered under Section 65, Behavioral Health Services. No co-payments or other cost-sharing may be imposed on these services. There will no longer be limitations placed on the number of annual tobacco cessation counseling sessions available to MaineCare members.

Tobacco Cessation Services

The following codes may be used:

S9453: Smoking cessation classes, non-physician provider (Section 9, Indian Health Services; Section 31, Federally Qualified Health Centers; and Section 103, Rural Health Clinics);

99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than three (3) minutes and up to 10 minutes (Section 90, Physician Services; Section 65, Behavioral Health Services);

99407: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (Section 90, Physician Services; Section 65, Behavioral Health Services);

99411: Preventive medicine, group counseling; 30 minutes (Section 65, Behavioral Health Services);

99412: Preventive medicine, group counseling; 60 minutes (Section 65, Behavioral Health Services); and,

D1320: Tobacco Counseling for the Control and Prevention of Oral Disease (Section 25, Dental Services)

Please call Provider Services with questions at: 1-866-690-5585.

Notice of MaineCare Reimbursement Methodology Change

AGENCY: Department of Health and Human Services, Office of MaineCare Services AFFECTED SERVICES: Chapter 101, MaineCare Benefits Manual, Chapters II & III, Section 65, Behavioral Health Services NATURE OF PROPOSED CHANGES: The Department seeks to add tobacco cessation counseling as a covered service with the following four Current Procedural Terminology (CPT) codes: 99406 (smoking and tobacco use cessation counseling; individual, greater than 3 minutes up to 10 minutes), 99407 (smoking and tobacco use cessation counseling; individual, greater than 10 minutes), 99411 (preventive medicine, group counseling; 30 minutes) and 99412 (preventive medicine, group counseling; 60 minutes). The above change has a retroactive application with an effective date of August 1, 2014, authorized under 22 MRSA Sec. 42(8). The Department will hold a hearing for the proposed rulemaking and will be publishing a notice which includes information on the hearing date and location. Rates for CPT codes 99406 ($8.67), 99407 ($16.81), 99411 ($11.54) and 99412 ($15.04) are based on 70% of the 2009 Medicare rate.

Notice of MaineCare Reimbursement Methodology Change

REASON FOR PROPOSED CHANGES: In accordance with 22 MRSA §3174-WW, which requires that comprehensive tobacco cessation treatment be covered for all MaineCare members over the age of eighteen and those who are pregnant, tobacco cessation counseling services are being added to Section 65, Behavioral Health Services. This proposed change seeks to cover tobacco cessation treatment for all members, regardless of age who wish to cease the use of tobacco.ESTIMATE OF ANY EXPECTED INCREASE OR DECREASE IN ANNUAL AGGREGATE EXPENDITURES: The Department anticipates that this rulemaking will not have a measureable impact on expenditures.ACCESS TO PROPOSED CHANGES AND COMMENTS TO PROPOSED CHANGES: The public may review the proposed methodology changes and written comments at any Maine DHHS office in every Maine County. To find out where the Maine DHHS offices are, call 1-800-452-1926. For a fee, a paper copy of the rule may be requested by calling (207) 624-4050.

CONTACT INFORMATIONFOR RECEIPT OF COMMENTS: Elizabeth S. Bradshaw

AGENCY NAME: Office of MaineCare ServicesADDRESS: 242 State Street, 11 State House Station

Augusta, Maine 04333-0011TELEPHONE: (207) 624-4054 FAX: (207) 287-1864TTY: 711 Maine Relay (Deaf or Hard of Hearing)

Developing Tobacco-Free Policies

Breathe Easy, You’re In Maine!

► Maine law protects people from secondhand smoke in:

Indoor workplaces

Indoor public places

Restaurants/bars, including outdoor dining areas

State Parks, beaches and historical sites

Vehicles when children under 16 are present

Tobacco Policy Adoption

Maine Workplace Smoking Laws state that:

► Smoking of tobacco products is prohibited in all

enclosed areas where work is performed, in all

common areas, such as reception areas, break

rooms, cafeterias, hallways and meeting rooms,

and in private offices.

► Smoking is prohibited in employer owned or

leased vehicles and in employee-owned

vehicles when used in the course of work.

MSRA 22 §1580 A and §1541-1550

Tobacco Policy Adoption

Creation of 100% tobacco-free environment policies will:

► Build on Maine’s comprehensive smoke-free laws to address all

tobacco products.

► Change the social norm of tobacco products.

► Encourage and support tobacco-free lifestyles.

Tips for Creating a Tobacco Policy

1. Ensure a comprehensive approach to addressing tobacco products and supporting the members of your organization’s community to be tobacco-free.

2. Use the tobacco policy change as an opportunity to develop a shared vision of wellness that engages all members of your organization’s community.

3. Be positive about tobacco policy change. Remember – the policy is about the tobacco, not about the user.

A Timeline for Tobacco Policy Adoption

Plan a date for policy change and start steps 6-12 months* prior to date.

1. Establish a policy committee.

2. Develop a policy.

3. Train staff and educate consumers.

4. Prepare for policy launch.

5. Implement your policy.

6. Maintain long-term success.

*best practice timeline that can be adjusted based on organization readiness.

Phase 1: Create a Policy Committee

Establish a work group (or give as task to wellness team) to lead your tobacco policy transition – include administrators, clinicians, facility staff and clients. Try to include tobacco users to get broad perspective.

• Identify who will be responsible for coordinating policy implementation.

• Set the specific date for the new policy to take effect.

Phase 2: Develop Policy Language

► Background/Purpose section about why you are creating a tobacco-free environment.

Explaining the harmful effects of secondhand smoke, dangers of tobacco use and how going

tobacco-free meets the organization’s mission.

► Definition of what tobacco products are covered in the policy.

Best Practice: Tobacco use is defined as the smoking or use of all cigarettes, cigars, snuff, smokeless

tobacco, snus, electronic cigarettes, and other non-FDA approved nicotine delivery devices.

► Explanation of where tobacco use is prohibited.

Best Practice: Tobacco use is prohibited in all indoor and outdoor areas of a property at all times.

Including parking lots and vehicles being used in the course of work.

► Outline of compliance expectations and enforcement parameters for staff, vendors, visitors and patients.

Phase 3: Train Staff and Educate Clients

Educate clients on tobacco policy decision – why your organization is addressing tobacco, what the policy states, what resources are available to support those who use tobacco.

Train staff around the tobacco policy – how to enforce the tobacco policy, how to discuss tobacco use and to conduct screening and provide treatment.

Communication is key for policy success – start early with training and education that create a positive message around going tobacco-free.

Phases 4-5: Going Tobacco-Free

Prepare signage and place in key locations throughout facility prior to the policy change taking effect.

Control the message and make being tobacco-free positive! Hold a kick-off celebration with education about tobacco and resources for quitting.

Begin enforcing the tobacco policy from implementation.

Phase 6: Enforce Policy & Maintain Long-Term Change

Communication is key to successful policy adoption:

• Post signage throughout facility stating policy.

• Inform new staff orientation and clients on intake.

• Be consistent with messaging and have clear understanding of who is responsible for enforcement.

• Treat like any other policy that is in place for staff or clients.

• Do check-ins with key staff about how implementation is going – send out additional reminders, add signage or enforcement as necessary to successfully reduce tobacco use on campus.

Why Address Tobacco Through Policy and Environmental Change

Remember:

► Tobacco use continues to be the leading cause of preventable disease and death.

► There is no risk-free level of exposure to secondhand smoke –even brief exposure causes damage that can lead to serious disease and death.

► Creating smoke-free and tobacco-free areas changes the social normalcy of tobacco use and promotes tobacco-free living.

► Non-smokers who are exposed to secondhand smoke increase their risk of developing heart disease by 25-30% and for developing lung cancer by 20-30%.

Resources to Support Your Policy Change Efforts

Support for Tobacco Policy Change

► Template Policies and information: www.BreatheEasyMaine.org/behavioralhealth

► Free Policy Technical Assistance from BEC and Healthy Maine Partnerships

Support Tobacco Policy Change

► Tobacco Policy Toolkit – Coming Soon!

► Template Resources Including:

► Policy Language

► Frequently Asked Questions

► Letters to Clients, Staff and Neighbors

► Assessment Tools

► Enforcement Guidance

Thank you for joining us!

For More Information:www.BreatheEasyMaine.org/BehavioralHealth

Breathe.Easy.Maine@gmail.com

(207)874-8774

Connect with us on social media:

www.facebook.com/BreatheEasyMaine

www.twitter.com/BreatheEasyME

Tobacco Treatment Information and Supports

Developed by

MaineHealth Center For Tobacco Independence

On behalf of

Maine CDC, DHHS

Partnership For A Tobacco-Free Maine

Tobacco Treatment and the

Behavioral Health

Population

Disclosures

The presenters of the PTM Clinical Outreach Program do not have any significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or providers of commercial services discussed in these presentations.

No commercial support of this training program.

Any discussion of off-label use of medications will be so indicated.

CEU certificates for completion of the training only.

Goals for Session

Review tobacco use in Maine

Discuss evidence-based

treatments

Emphasize your important

role with patients/clients

Offer Maine tobacco

treatment resources

Prevalence and Trends in Adult Tobacco Use

2011 vs. 2012Smoking Nationwide

(States and DC)

0

5

10

15

20

25

30

Yes

2011

2012

Smoking in Maine

0

5

10

15

20

25

30

Yes

2011

2012

Med

ian

%

Perc

en

t

21.2%

19.6%

22.8%

20.3%

High School Students Smoking Rates

Maine and U.S., 1993-2011

10%

20%

30%

40%

1993 1995 1997 1999 2001 2003 2005 2007 2009 2011

Maine

U.S.

Youth Risk Behavior Surveillance System (YRBSS)

Exhibit 1. Tobacco Use in the Past Month, People Ages 12 and Older, 2008

Substance Abuse and Mental Health Services Administration (2011). Tobacco use cessation during

Substance abuse counseling. Advisory, Volume 10. Issue 2

Tobacco Prevalence Among Adults by SUD

Compared to General Population

Public Health Impact

50% of smokers will die early from tobacco related disease – 480,000 people annually in U.S.

2,200 Maine adults die each year as a result of their own smoking

Close to 300 Maine adults die each year from second hand smoke

79,000 Maine children are exposed to second hand smoke in the home

More deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and homicides combined

Campaign For Tobacco-Free Kids

CDC Fact Sheet, 2011

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/

17

81

4119 14

30

440

0

50

100

150

200

250

300

350

400

450

Comparative Causes

of Annual Deaths in U.S.

Source: CDC

AIDS Alcohol Motor Homicide Drug Suicide Smoking

Vehicle Induced

Est. 200,000

per year for

people with

mental

illness and

SA

17

8141

19 14 30

480

Health Consequences

Causally Linked to Smoking

U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress:

A Report of the Surgeon General. 2014

Tobacco Treatment and Substance

Abuse

Continued smoking is associated with worse drug

treatment outcomes

Smoking cessation is predictive of improved sobriety

Tobacco treatment interventions found to be associated with 25% increased likelihood of long-term abstinence from alcohol and illicit drugs

Tobacco treatment enhances sobriety from alcohol and other drugs

(Prochaska, 2010)

Frosch et al., 2000

Bobo et al., 1998; Hughes, 1993; Shoptaw et al., 1996

Prochaska et al. 2004

Smoking and Depression

Frequently Co-occur

Smokers exhibit higher rates of depression symptoms (1,2, 3)

Chronic episodes of depression associated with increased smoking prevalence in both men & women (4, 5)

Persons with chronic depression have greater difficulty with quitting (6,7)

Depression symptoms may emerge with quitting

1. Acton et al. 2001; 2. Farrell et al., 2001; 3. Tsoh et al., 2003; 4. Breslau et al, 1998

5. Breslau et al., 1993; 6. Berlin & Covey, 2006; 7,. Niaura et al. 2001

Can Quitting Tobacco Worsen Mental

Illness Symptoms?

Short answer – yes, it can

• This is a short term issue for most

• Mental well-being and long-term outlook is good for most

• Withdrawal - symptoms usually peak in the first week after stopping

tobacco, usually return to baseline by a month (Hughes, 2007)

• Tobacco treatment medications can help

Berlin, Chen, Covey (2009) did not find increases in

depression, anxiety, or suicidal ideation symptoms in

abstainers with past history of depression

• However, depression, anxiety, and suicidal ideation increased

in those with failed quits

Stress-relief and Happiness

after Quitting Smoking

Happier afterquitting

Less happyafter quitting

About thesame

“I feel happier now than when I was smoking”

“I feel about the same now as when I was smoking”

“I feel less happy now than when I was smoking”

L. Shahab & R West, “Do ex-smokers report feeling happier following

cessation? Evidence from a cross-sectional survey”, 2009

Smoking Effect on Medications

Smoking enhances activity of the CYP1A2 liver enzyme which metabolizes some medications

Smoking may speed up the rate at which some medications are metabolized

This results in lowered blood levels of these medications for those who smoke

Blood levels of medications may rise when the person quits smoking and dosing may require adjustments

This effect is caused by hydrocarbons in the tobacco smoke – not by nicotine

The Caffeine Connection Smoking speeds up the process by which

caffeine is metabolized

This reduces the half-life of caffeine to just 3-6 hours as opposed to 6-8 hours

When a person quits smoking, the blood caffeine levels increase by as much as 250%

Increased caffeine levels:

- can cause anxiety, insomnia, irritability

- these mirror and aggravate nicotine

withdrawal symptoms

Consider tapering caffeine intake

prior to quitting smoking

If Only…

Tobacco Dependence

and Smoking Behavior

7-10 seconds to reach the

brain

Immediate rewards

Many of the long-term

negative effects are not

immediately apparent

Lack of intoxication

Relative ease of obtaining

and using (compared to

illicit drugs)

Can I Really Make a Difference?

They don’t want to quit

70% of tobacco users would like to quit (1)

They will resent being asked

Patients report greater satisfaction with providers who

address behavioral health issues (2)

It won’t do any good

Brief interventions lead to increased quit attempts and

increased success with quit attempts (1)

It’s too time-consuming to address this with each patient

Minimal interventions lasting less than 3 minutes increase

overall tobacco abstinence rates (1)

We can help!

1. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville,

MD:

U.S. Dept. of Health and Human Services. Public Health Service. May 2008

2. Conroy MB, Majchrzak NE et al, 2005, “The association between patient-reported receipt of tobacco intervention

at a primary care visit and smokers' satisfaction with their health care.”

Guideline Findings

Tobacco use is chronic and relapsing

Interventions, even brief interventions, are effective

Physicians and other healthcare providers are similarly effective in delivering tobacco counseling

The combination of counseling + medications have greater efficacy than either alone

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

Replacement Smoker

Tobacco Dependence:

A Pediatric Onset Disorder

Nearly 9 out of 10 smokers started smoking by

age 18

Rare to begin smoking after age 25

99% started by age 26

Progression from occasional to daily smoking

almost always occurs by age 26

2012 Surgeon General's Report—Preventing Tobacco Use Among Youth and Young Adults

Light Smoking

Highest rates of light smoking among teens and young adults

Defined as less than 10 cpd.

Also called “social" smokers, occasional smokers, or “chippers”

YRBS, 1997-2009

0

5

10

15

20

25

30

35

40

1997 2001 2003 2005 2007 2009

HS Smoking Rate

% of HS Studentswho Smoke >10Cigarettes Daily

Most light smokers believe they can and will quit easily.

Regrettably, this is often not the case.

Teens Continue to Smoke

90% of H.S. students who were daily smokers continued to smoke

four years later

50% of students who were “occasional” smokers were smoking

four years later

Health Psychology, March 2004

About 3 out of 4 teen smokers

end up smoking into adulthood

Report of the U.S. Surgeon General

2012

Brief Interventions:

The 5 A’s

ADVISE quitting

ASK about tobacco use, every time

ASSESS interest in quitting

ARRANGE follow-up

ASSIST by offering help when ready to try

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

Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service. May 2008

Ask Have you smoked or

used tobacco in the

past 6 months?

Have you ever used

tobacco?

Are you exposed to

second hand smoke?

Document tobacco

use status

Vital SignsBlood pressure:___________

Pulse:___________________

Weight: __________________

Temperature: _____________

Respiratory Rate:___________

Tobacco Use (circle one):

Current Former Never

Type(s) of tobacco used:

Advise

In a clear, personalized manner urge every tobacco

user to quit

Clear: “Quitting smoking (or other tobacco use) is the

most important thing you can do to help control your

high blood pressure.”

Personalized: Tie risks from their tobacco use to their

current symptoms or concerns

Assess

Willingness to quit

What are your thoughts about your tobacco use?

Have you ever tried to cut down or stop in the past? How did

that go?

What worked?

What seemed to help?

What problems did you have with this?

Assist Inform of best treatments available

e.g., Dispel myths about NRT

Follow USPHS Guidelines

Provide treatments and discuss resourcesMedications, HelpLine, other resources

Build on any past quit attemptsCongratulate any abstinence

Use this experience as basis for new attempt

For Those Ready to QuitQuit Plan

Quit Plan

Offer praise, endorse their

interest in quitting

Set a “Stop Date”

(w/in 2 weeks, ideally)

Look at routines, problem-

solve

Discuss medication options

Provide self-help materials

Identify any other resources

Identify challenges and

barriers

Plan for urges and

cravings

Develop new coping skills

Find new ways to spend

time

For Those Not Ready to Quit

Explore in non-judgmental manner

Convey genuine interest

Explore both sides of any ambivalence, paying

particularly close attention to any concerns

about tobacco use

Ask for permission to offer information

Let patient know you will raise a question

again at his/her next appointment

First-Line Tobacco Treatment Medications

Nicotine Replacement Therapies (NRT)

Patch - 7,14 and 21 mg

Gum – 2 and 4 mg

Lozenge - 2 and 4 mg

Inhaler

Nasal spray

Buproprion SR 150mg (Zyban, Welbutrin)

Varenicline 0.5 & 1 mg (Chantix)

Instruct on Proper Use

Special Considerations

Bupropion

Do not use with history of seizures, heavy alcohol use, eating disorders, brain injury, or by patients who have used a MAO inhibitor within the past 14 days: Seizures can occur

Not recommended for those with anxiety spectrum disorders

Varenicline

Black box warnings

Not tested with population with co-occuring other addictions

Lack of evidence for use with adolescents

NRT

Consider combination/high dose NRT with heavy nicotine dependence

What about the e-cigarette?

Classified as a tobacco product in Maine

Contains nicotine of varying amounts

Safety of e-cigarette unknown

Effect on quitting other tobacco is unknown

Not sold or recommended as a tobacco treatment

medication

Arrange Schedule follow-up visit or phone call

Make referrals to the Maine Tobacco HelpLine

Youth HelpLine Number

Fax Referrals to: 207-662-5102

Local treatment options (Tobacco Treatment Services Guide)

Congratulate abstinent patients & support those who are

struggling to remain engaged in the quit process

The Maine Tobacco HelpLine

All Maine residents

4 call program

Outbound and ad-hoc calls

Proven outcomes

Effective, free, friendly & confidential

Intensive behavioral counseling

NRT at no cost for those who are

eligible

HelpLine Quit Rates

15%

26%

47%

0% 10% 20% 30% 40% 50%

1 Call

2-3 Calls

4 Calls

Overall Quit Rate = 28%

2011 Maine Tobacco HelpLine Evaluation Outcomes

Phone Translator?

Signature

Message?

Best time

Direct Referral Report Snapshot(FAX, E-mail or Electronic)

The HelpLine reaches 70% of those who are direct-referred

44% of those we reach participate in counseling

About 33% of those who are counseled will quit!

Quitting Tobacco is a Process … not a single event

Feedback Letter

Includes:

Patient’s status

Quit Date

NRT: type

Leonard Brown

Bufford Health Center

123 Main Street

Bufford , Me, 04999

Clinic Fax: 207-555-5555

Re: Marshall Lastname DOB: 08/27/161

Dear Leonard Brown,

You recently referred your patient Marshall Lastname

to the Maine Tobacco HelpLine. Today we are

reporting that as of 1/23/2012 this participant’s

status is “Accepted Services”:

Planned Quit Date: 2/15/2012

NRT: Patch

Thank you for talking to your patient about taking this

important step for their health.

If you have any questions about the Maine Tobacco

HelpLine, please call us at 207-662-7154

Beyond Brief Interventions

Treating tobacco dependence is a PROCESS…

Brief Interventions: Ask about

tobacco use and refer to the Maine

Tobacco HelpLine

Intensive Counseling: Ask about

tobacco use and build it into

treatment planning and delivery

Use the HelpLine as supplement

Further Training & Support

Clinical Outreach Systems Support Sessions

On-site training and support for entire office staff

FMI call (207) 662-7140

PTM Tobacco Intervention: Basic Skills Training

Conducted several times a year throughout the state

Intensive Tobacco Treatment Training Conference

Conducted annually in the spring

Completion of Basic Training is a prerequisite

www.tobaccofreemaine.org

Questions/Thoughts

On behalf of the

Partnership for a Tobacco-Free Maine,

Maine CDC, and Maine DHHS

thank you for your participation in the

Clinical Outreach Program

Toby Simon

Clinical Outreach Program

Center for Tobacco Independence

simont1@mainehealth.org

207-595-8660

Thank you for joining us!

For More Information:www.BreatheEasyMaine.org/BehavioralHealth

Breathe.Easy.Maine@gmail.com

(207)874-8774

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