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Building a Smoking Cessation Program that Meets the Needs ofYour Patients and Your Practice
Edward Ellerbeck, MD, MPH
University of Kansas Medical Center
Departments of Internal Medicine and Preventive Medicine
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Disclosures
None
2
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Agenda
• Identify evidence-based principles of cessation treatment
–Case 1: Nauseated Mary
–Case 2: I’m not ready Sylvia
–Case 3: Sad Jackie
• Understand how to cover the costs of cessation
–Case 4: Broke Floyd
–Costs to the patient
–Reimbursement for providers
• Describe quality metrics related to smoking cessation and
the system changes needed to build and sustain effective
treatment
3
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Current smoking levels in the US
4
Kansas 17.2%
Missouri 22.1%
https://www.cdc.gov/statesystem/index.html
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Smoking remains the #1 cause of death
5https://www.cdc.gov/tobacco/infographics/health-effects/
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Smoking and poverty: Kansas BRFSS 2016
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Case #1: Nauseated Nancy
57 year-old,
Smoking history
• Smokes 20 cigarettes/day
• First cigarette ‘Honey, I have that first cigarette before I turn off the alarm clock’
Cessation history
• Tried patch; stopped on 3rd day after she started smoking again
• Tried nicotine gum; it made her nauseated and it didn’t seem to work
Thinking about quitting
• Her husband quit 2 years ago after a heart attack
• Heard ‘bad things’ about Chantix and doesn’t want to use that
7
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Given Nancy’s history, which of the following would be the best option for cessation pharmacotherapy?
8
A) Nicotine gum 4 mg – start with at least 10 pieces per day
B) Nicotine patch 21 mg daily
C) Nicotine patch 21 mg daily plus nicotine gum 2 mg start with at least 10 pieces per day
D) Varenicline 2 week starter pack followed by 3 full months of treatment
C
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9
Treatment Options Quit at 6-12 mos
Telephone Quitline 13%
Group Counseling 14%
Individual Counseling 17%
2-3 Sessions + Medication 28%
Bupropion + Counseling 24%
Patch + Counseling 27%
Varenicline + Counseling 33%
Combo Pharm + Counseling 26%-37%
Fiore et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. USDHHS, 2008.
What Works?
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Most effective agents
Varenicline
• OR for cessation 3.1 (2.5-3.8)
Combination patch with short acting NRT
• OR for cessation 3.6 (2.5-5.2)
10
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Behavioral Support
11
• Brief advice by provider (NNT=40)
• Tobacco Quitline (NNT=32)
• Fax OR Warm Handoff
• Text messaging• Text “quit” to 47848
• Apps• quitSTART, QuitGuide: https://smokefree.gov/tools-tips/apps
• Websites• https://smokefree.gov; becomanex.org
NNT – long term cessation; Schayck et al., 2017
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What Makes It Addictive?
12
How the drug makes you feel when you use it:
• It activates reward pathways in your brain
• Direct effects make you want to use it >>> occasionally
How you feel when you cannot use it:
• Craving, depression, and irritability
• Withdrawal makes you have to use it >>>regularly
• People with mental health issues such as depression, anxiety
http://science.education.nih.gov/supplements/nih2/addiction/guide/lesson3-1.htm
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What Makes Any Drug Addictive?
• How much you get & How fast you get it
• Bioavailability = Amount of drug that reaches the brain
• How your body handles the drug
• How quickly it is cleared from body
• Peaks and dips in blood levels set up an ideal “learning” cycle
13
Chronic use creates long-term brain changes
Sachs, DPL. Advances in Smoking Cessation Treatment. In Simmons, Ed. Current Pulmonology. Chicago, Year Book Medical Publishers, 1991:12;139-198; Niaura, 1999; Leshner, Am J Psychiatry, 1997
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Cigarettes: Perfectly designed to be addictive
Nicotine via cigarettes is absorbed through the lungs
Lung alveolar epithelium has the surface area of a tennis court
• Delivers a large amount of nicotine to the brain with every puff
Cigarettes have been alkalinized (ph-altered) to enhance nicotine absorption
Do the math - People take 12-15 puffs/cigarette
• 12 puffs/cig X 20 cigs/day X 365 day/yr = 87,000 puffs per year for the pack-a-day smoker
• 1 million puffs in 12 years
• Each puff provides a reward
Can you think of any more rewarding activity?
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Why does Nancy smoke so soon after waking?
9/24/201
815
Nancy’s cigarettes
• Deliver ~2 mg/cigarette
• With 20 cigarettes/day, Mary absorbs about 40 mg of nicotine daily
• While she sleeps, her nicotine is being metabolized rapidly (half-life of 2 hours)
• When she wakes up, the nicotine in her body is almost gone
• That first cigarette is particularly ‘enjoyable’
–It stimulates empty nicotine receptors Producing extra pleasure
Preventing withdrawal
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Nicotine patch
7, 14, 21 mg/24 hrs
Doubles quit rates OR 1.9 (1.7-2.2)
Onset of action 2-4 hours
Can dose according to level of smoking
• < 10 cpd – 7-14 mg
• 10-20 cpd – 14-21mg
• > 20 cpd – 21 mg +
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Speed matters
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18
Nicotine gum and lozenges
Regular dosing is critical (Take enough!)• > 25 CPD or 1st cigarette within 30 minutes = 4 mg
• 10 pieces/day = 10-20 mg/day
• Use every 1-2 hours + acute cravings
Buccal absorption – 50% (1-2 mg delivery)• Onset of action – 15 minutes
• Acidic beverages reduce absorption
Chewing• Chew about 15 times
• Note flavor of pepper or tingling
• Stop chewing
• Put gum between cheek and gums
• Chew again when tingling is gone
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Remember Nancy?
Why did Nancy get nauseated when she was chewing the gum?
She was chewing it too fast
and getting a lot of nicotine in her stomach
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Case #2: I’m not ready Sylvia
45 y/o s/p melanoma resection
Smoking history
• ½ PPD since age 15
• First cigarette with her coffee after showering– ~40 minutes after waking
– Smoking allowed in the home
• Enjoys smoking – relaxing, relieves stress at work
• Husband also smokes
• Not really interested in quitting
Do you:
A) Use your motivational interviewing skills to elicit her personal motives for quitting
B) Discuss available treatment options for smoking cessation
B
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You don’t need to be an expert inMotivational Interviewing
Funding Source: R01 CA133068Cancer Center Collaborators: Richter, Ellerbeck
6 month abstinence:- Motivational interviewing 6%- Health Education 15%
(p = 0.04)
Catley, PhD
Am J Prev Med. 2015
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755 AA ‘light’ smokers
• 6 month quit rate– Health Education: 16.7%
– MI: 8.5%
Kick it at Swope II
NollenCox
Addiction 2006; 101:883-91)
P < 0.001
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Lester’s already failed twice – what are the chances that a third intervention will work?
Disease Management for Smokers
in Rural Primary Care
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KanQuit: Impact of PTX on quit rates of smokers that failed PTX during a previous 6 month cycle
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Cycle 1 Cycle 2 Cycle 3 Cycle 4
PTX No PTX
Cupertino et al. Arch Intern Med. 2009 Nov 9;169(20)1928-30
N = 726
N=464
N=202
N=262N=181
N=81
N=96
N=44
N=24
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Case #3: Sad Jackie
43 year old woman preparing to undergo hysterectomy for cervical cancer
PMH: PTSD; depression with suicide attempt 2 years ago –reasonable control now on citalopram and bupropion
Smoking history:
• 1 PPD; 1st cigarette 15 minutes after awaking (in the garage or on the porch)
• Lives with 17 y/o daughter who wants her to quit
• Smokes in her car when alone, but not in the house
25
Which of the following would be the preferred treatment:
A) Nicotine patch 21 mg daily
B) Nicotine lozenge 4 mg – at least 10 daily
C) Varenicline starter pack followed by maintenance pack
C
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Tobacco #1 Killer of People with Mental Illness
Life expectancy 25 years < general population
Deaths are caused by Smoking
Heart disease
Cancer
NOT suicide
480,000 annual deaths attributed to tobacco in the U.S.
Nearly half occur in patients with mental illness.
Manderscheid & Colton, 2006
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Tobacco Use & Mental Illness
Increased odds of smoking
• 2.7 overall6
• 5.3 for patients with schizophrenia7
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Lancet. 2016 Jun 18;387:2507-20
Two cohorts:
• Psychiatric (n = 4116)
• Non-psychiatric (n = 3984
Randomized to:
• Varenicline
• Nicotine patch
• Bupropion
• Placebo
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EAGLES – psychiatric outcomes - Usually transient
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EAGLES – C-SSRS
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Adjusted odds ratios for continuous abstinence from weeks 9-24 after quit date (EAGLES study)
Treatment Non-psychiatric cohort
AOR cessation
Psychiatric cohort
AOR cessation
Varenicline vs placebo 2.99 (2.33-3.83) 3.61 (3.07-4.24)
Bupropion vs placebo 1.87 (1.46-2.39) 2.07 (1.75-2.45)
Nicotine patch vs
placebo
1.96 (1.51-2.55) 2.15 (1.82-2.54)
Varenicline vs bupropion 1.74 (1.41-2.14) 1.75 (1.52-2.01)
Varenicline vs patch 1.62 (1.32-1.99) 1.68 (1.46-1.93)
Anthenelli RM. Lancet 2016
For psychiatric cohort treated with
varenicline:
NNH = 36
NNT = 10
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https://www.fda.gov/Drugs/DrugSafety/ucm532221.htm
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Case #4: Broke Floyd
56 year old with bladder cancer
History of head and back injury; mild cognitive impairment. Currently on Medicare and Medicaid.
Smoking history
• Smokes 1 PPD with 1st cigarette 10 minutes after awaking
• Interested in quitting, but ‘Doc – I just can’t afford it
33
Do you:
A) Initiate Wellbutrin SR 150 mg BID, since it will be covered by his insurance
B) Prescribe a 21 mg nicotine patch (qs 1 month with 1 refill)
C) Refer to social worker for help with getting smoking cessation treatment
B
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Tobacco Cessation Treatment: Coverage Improving
Insurance Counseling Medications Attempts/yr
Medicare 4 sessions All prescription meds 2
Kansas Medicaid unlimited All FDA approved unlimited
Marketplace 4 sessions All FDA approved 2
Employer-sponsored 4 sessions All FDA approved 2
Grandfathered plans No requirements
American Lung Association:
http://www.lung.org/our-initiatives/tobacco/cessation-and-prevention/tobacco-cessation-treatment-what-is-covered.html
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KANCARE Medication coverage*
PRODUCT TREATMENT DURATION DAILY LIMIT
Chantix® (varenicline) 24 weeks 2 tablets
Zyban® (bupropion) 12 weeks 2 tablets
Nicotine Inhaler 24 weeks 16 cartridges
Nicotine Patches 12 weeks 1 patch
Nicotine Nasal Spray 12 weeks 80 sprays (4 mL)
Nicotine Lozenges 12 weeks 20 lozenges
Nicotine Gum 12 weeks 24 pieces
*As of 2018 no preauthorization. Cover up to 4
attempts/year.
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Document diagnosis: F17.200, Nicotine dependence unspecified, uncomplicated
Codes for smoking cessation counseling 99406: 3-10 minutes of counseling* (RVU 0.40)
99407: >10 minutes of counseling* (RVU 0.78)
http://www.aafp.org/patient-care/public-health/tobacco-nicotine/coding-reference.html
Reimbursement
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37
3%
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But not every brand of NRT is covered
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CASE #5: IMPROVING CESSATION IN MY CLINIC
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40
https://bphc.hrsa.gov/qualityimprovement/performancemeasures/
qualitycare.html
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2017 National Data
41
87.5%
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Ask, Advise, Assess, Refer: AAAR
ASK
ADVISE
ASSIST
REFER
Ask every patient if they use tobacco
Advise every tobacco user to quit
Assist every smoker in selecting and using
a medication to help them quit
Refer all smokers for counseling
Medications and counseling can double or triple quit rates
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What happened to adding smoking status to the vital signs?
Incorporating smoking status in the vital signs increases the rate of
counseling in the clinic 3-fold and the rate of cessation 2-fold.
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44
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Ask: Empowering your MA
ASK 2.0
Collect smoking as part
of the vital signs
MA inserts: .smokehx
# CPD: ___
Smoke within 30 minutes of waking: Yes/No
Previously tried for cessation:
__varenicline
__ bupropion
__ nicotine patch
__ nicotine lozenge
__ nicotine gum
Previously used tobacco quitline: Yes/No
Smoking allowed in the home: Yes/No
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Advise
ASK
ADVISE
3x
CESSATION
2x2x
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OFFICE SYSTEMS – Assist
ASK
ADVISE
ASSIST
REFER
What works?
% quit at 1 year
Telephone quitline…………………….13%
Group counseling……………………..14%
Individual counseling………………….17%
Bupropion + counseling……………….24%
Patch + counseling…………………….27%
Varenicline + counseling……..……….33%
Combination + counseling*…..…26%-37%
*Combinations include nicotine patch plus nicotine gum or lozenge or bupropion
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Refer internally for counseling
Train an MA or nurse to function as your ‘tobacco treatment specialist’
Ask all of your smokers to talk to your ‘tobacco treatment specialist’
REFER 1.0
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Refer to telephone quitlines
REFER
RR of quitting: 1.37
Stead LF. Telephone counseling for smoking cessation. Cochrane Database Syst Rev 2013
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Refer to text messaging programs
REFER
Scott-Sheldon LA; JMIR 2016
Text messaging programs significantly increase odds of successful cessation
(OR 1.38 (1.22-1.55))
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OFFICE SYSTEMS – Reimbursement
• Patients with a tobacco-related illness (treatment)–99406: 3-10 minutes of counseling* (RVU 0.40)
–99407: >10 minutes of counseling* (RVU 0.78)
• -25 modifier labels it as a separate reimbursable service
*Use ICD10 F17.200 Nicotine dependence
http://www.aafp.org/patient-care/public-health/tobacco-nicotine/coding-reference.html
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How to Get What Works Into Routine Care?A provider-centric example
1. MA rooms pt
Asks/records
tob use status
2. Tob user status
communicated
to Provider
3. Provider
Advises
to quit
4. Provides
brief Ed. on
benefits for
recovery/ 20
prevention
5. Provider
orders cess.
support, med
script
6. Provider refers
to Quitline or TXT
& puts
recommendations
in AVS
7. Schedules 1
month FU appt
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Alternatively, a TTS-Focused Work Flow
1. MA rooms pt
Asks/records
tob use status
2. Tob user status
communicated
to Provider/TTS
3. PROVIDER
Brief pep talk on
importance/benefi
ts of quitting
4. TTS or other caregiver:
a. Helps patient select support
b. Helps patient select preferred medication
Obtains script for med from providerc. Schedules follow up
d. Conducts follow up
Assesses status
Works with physician to change
meds
Changes support
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StopSmoking Smartphrase to Prompt/Document Care
Tobacco Cessation Management & Counseling:
Counseling points: Quitting tobacco improves overall health and cancer treatment outcomes. Counseling addressed problem-solving, skills training and using medication to meet goals toward quitting. The following plan was developed:
Plan
Based on our discussion, the patient has chosen to:
Behavior: (Choose all that apply)
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• Make the house tobacco-free
• Set a quit date for (date)
• Cut down tobacco use
• No behavioral goals at this time
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Plan
Based on our discussion, the patient has chosen to:
Medication: (Choose all that apply)
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• Varenicline (Chantix)
• Nicotine patch (*best in combination
with 1 short-acting NRT)
• Nicotine gum
• Nicotine lozenge
• Nicotine inhaler
• Nicotine nasal spray
• Bupropion SR (Zyban/Wellbutrin)
• No medications at this time
StopSmoking Smartphrase to Prompt/Document Care
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Plan
Based on our discussion, the patient has chosen to:
Behavior:_____
Medication:_____
Behavioral support: (Choose all that apply)
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• Tobacco quitline (1-800-QUIT-NOW)
• Text message program for quitting
(text ‘QUIT’ to 47848)
• Text message program to prepare to
quit (text ‘GO’ to 47848)
• Cessation "app" or website
(quitSTART; www.smokefree.gov)
• In-person cessation program
• No support at this time
StopSmoking Smartphrase to Prompt/Document Care
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Billing
Time spent counseling for tobacco cessation: {22086} minutes
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• 3-10
• more than 10
CCStopSmoking Smartphrase to Prompt/Document Care
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Summary and Conclusions
Smoking is the #1 preventable cause of death and disproportionately affects the poor and those with mental illness
Effective pharmacotherapy and counseling are available
• Both should be used
We need to design our systems of care to ensure access and delivery of these effective treatments
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NIH funded-study focused on smoking during pregnancy and postpartum
Goal: to understand how tobacco treatment is delivered to peripartum women and how we can support women in quitting
Recruiting clinics that serve pregnant women and/or their infants
• Please see the University of Kansas Medical Center table!
• Contact Dr. Taneisha Scheuermann 913-588-2641 ([email protected])
Helping Moms Quit
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KanCare materials
Kim Jordan
Survey of Cessation benefits
Tobacco Guideline for Behavioral Health
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References
Smoking cessation version 1.2016: Clinical practice guidelines in oncology. JNCCN; 2016; 14(11):1430-68
Safety and efficacy of smoking cessation pharmacotherapy. Lancet 2016 Jun 18; 387:2507-20
The Past, Present, and Future of Nicotine Addiction Therapy. AnnuRev Med 2016; 67:467-86
Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomized, placebo-controlled clinical trial. Lancet. 2016; 387: 2507-20.
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Case #6: Judy
JW is a 35 y/o woman who is interested in quitting. She smokes about 7 cigarettes/day. She tried the patch in the past and quit for three weeks, but with the stress at work, went back to smoking.
“One of my friends at work is using the e-cigarette. What do you think? Is it worth trying?”
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E-cigarette
Safety
- nicotine
- additives
Efficacy
- nicotine delivery?
- controlled trials?
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E-cigs – public health threat (epi and Harbinger)
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40% of male upperclassmen use
5 or more pods/week
1 pod = 1 cigarette
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