UCSF Celebrates UCSF Celebrates World No Tobacco DayWorld No Tobacco Day

Participating OrganizationsParticipating OrganizationsHabit Abatement ClinicHabit Abatement ClinicTobacco Education CenterTobacco Education Center–– (TEC, at Mt. Zion)(TEC, at Mt. Zion)

Rx for ChangeRx for ChangeTobacco Free NursesTobacco Free NursesSmoking Cessation Smoking Cessation Leadership CenterLeadership CenterTobacco Documents Tobacco Documents ArchiveArchiveTobacco Documents Tobacco Documents LibraryLibrary

Chinese Smokers StudyChinese Smokers StudyLatino WebLatino Web--based studybased studyAmerican Heart AssociationAmerican Heart AssociationAmerican Lung AssociationAmerican Lung AssociationAmerican Cancer SocietyAmerican Cancer SocietyNightingalesNightingalesUCSF Center for Tobacco UCSF Center for Tobacco Control Research & Control Research & EducationEducationUCSF Division of Thoracic UCSF Division of Thoracic OncologyOncology

UCSF Celebrates UCSF Celebrates World No Tobacco DayWorld No Tobacco Day

Expanding the ClinicianExpanding the Clinician’’s Role s Role in Tobacco Cessation:in Tobacco Cessation:

Impact of the Rx for Change ProgramImpact of the Rx for Change Program

Mary Anne KodaMary Anne Koda--Kimble, PharmDKimble, PharmD

Professor and Dean, School of PharmacyProfessor and Dean, School of PharmacyUniversity of California at San FranciscoUniversity of California at San Francisco

is the chief, single, avoidable is the chief, single, avoidable cause of death cause of death in our society in our society

and the most important public and the most important public health issue health issue

of our time.of our time.””C. Everett Koop, M.D., former U.S. Surgeon General

““CIGARETTE SMOKINGCIGARETTE SMOKING……

1982

Training Future CliniciansTraining Future Clinicians

Robin Corelli, Karen Hudmon, Lisa Kroon, California Faculty

Rx for Change:Rx for Change:Vision and Curriculum GoalsVision and Curriculum Goals

State-of-the-art training programTURN-KEY, SHARED PROGRAMEasily integrated into existing course structuresSupported by evidence-based research• USPHS Clinical Practice Guideline, 2000

• Peer reviewed by national experts

Rx for Change:Rx for Change:External ReviewersExternal Reviewers

Neal Neal BenowitzBenowitz, MD, MDBruce Berger, PhD, RPhBruce Berger, PhD, RPh

Li Cheng, PhDLi Cheng, PhDTimothy Cline, PhDTimothy Cline, PhD

Carlo Carlo DiClementeDiClemente, PhD, PhDStanton Stanton GlantzGlantz, PhD, PhDTalineTaline KhroyanKhroyan, PhD, PhD

Alexander Alexander ProkhorovProkhorov, MD, PhD, MD, PhDFrank Vitale, MAFrank Vitale, MA

Tobacco cessation curriculum for PharmD students• California graduates qualified to intervene with all

tobacco users • Hands-on, skills-oriented training

6- to 12-hour modular program• Didactic lecture material

• Emphasis on behavior change

• Interactive, hands-on workshop

Rx for Change: OverviewRx for Change: Overview

Rx for Change:Rx for Change:Core ModulesCore Modules

Epidemiology of Tobacco Use (20 minutes)

Pharmacology of Nicotine & Principles of Addiction (45 minutes)

Drug Interactions with Smoking (5 minutes)

Assisting Patients with Quitting (90 minutes)

Aids for Quitting (60 minutes)

Role Playing: Case Scenarios (120 minutes)

Pfizer National Distribution Nicotine transdermal patchesNicotine nasal spray (placebo)Nicotine oral inhaler (placebo)

IMPACT!IMPACT!

Percent of total responses

Students’ pre- and post-training self-ratings for five components of comprehensive tobacco cessation counseling:

Ask, Advise, Assess, Assist, and Arrange (n = 493).

0% 20% 40% 60% 80% 100%

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Poor Fair Good Very good Excellent

Ask about tobacco use

Advise to quit

Assess readiness to

quit

0 20 40 60 80 100

2.01 (0.95)

3.61 (0.78)

2.10 (0.95)

3.82 (0.82)

Meansa (SD)

1.84 (0.93)

3.74 (0.82)

1.82 (0.95)

3.71 (0.87)

2.71 (1.16)

3.81 (0.82)

Assist with quitting

Arrange follow-up

All preAll pre-- versus postversus post--training training differences, differences, p p < 0.001< 0.001

Corelli et al., Preventive Medicine, 2005.

1

2

3

4

5

Pre-training Post-training

Not at all confident

Extremely confident

Changes in confidence for cessation counseling:12-item scale,Cronbach alpha = 0.92

Ave

rage

item

sco

re

p < 0.001

Confidence to CounselConfidence to Counsel

n = 493

Corelli et al., Preventive Medicine, 2005.

Will increase the NUMBER of patients they counsel for cessation.

87%

Improved the QUALITYof their cessation counseling.

97%

Percentage of student pharmacists

Effect of Formal Training Effect of Formal Training

Corelli et al., Preventive Medicine, 2005.

Do you believe that students at other U.S. schools of pharmacy would benefit from receiving the

same, or similar, training?

0 50 100

NO

YES 99.2%

Disseminating Rx for Change: Disseminating Rx for Change: Student PharmacistsStudent Pharmacists’’ ViewsViews

PercentageCorelli et al., Preventive Medicine, 2005.

Dissemination of Rx for ChangeDissemination of Rx for Change

“Disseminating a Tobacco Curriculum for Pharmacy Schools”National Cancer Institute: 1 R25 CA 90720 to Karen Hudmon

CALIF: 6 schools700 students annually

USA: 89 schools 95% trained faculty9,000 students annually

Dissemination of Rx for Change Dissemination of Rx for Change US Schools of PharmacyUS Schools of Pharmacy

5/31/2005

71/85 (84%) of schools trained have implemented

0

5000

10000

15000

20000

1998-1999 1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005

Pharmacy Medicine Dentistry Nursing Total

Num

ber

of s

tude

nts

trai

ned

Academic year

National Estimates:National Estimates:Number of Students TrainedNumber of Students Trained

rxforchange.ucsf.edurxforchange.ucsf.edu

Rx for ChangeRx for ChangeCurrent & Future Current & Future

DirectionsDirectionsOngoing dissemination• Nursing: UCSF, other collaborators (Georgetown, Washburn)• Medicine: UCSF• Dentistry: UCSF, Baylor University

Future dissemination• Physician Assistant programs• Others: Respiratory Therapy, Occupational Therapy• International

International dissemination•• Guatemala, Argentina (Spanish translation)Guatemala, Argentina (Spanish translation)•• England England •• JapanJapan

Practicing Clinicians

Courtesy of Mell Lazarus and Creators Syndicate. Copyright 2000, Mell Lazarus.

Amsterdam Airport

UCSF Celebrates UCSF Celebrates World No Tobacco DayWorld No Tobacco Day

What to Do with a Patient What to Do with a Patient Who SmokesWho Smokes

Steven A. Schroeder, MDSteven A. Schroeder, MD

World No Tobacco DayWorld No Tobacco DayMay 31, 2005May 31, 2005

TobaccoTobacco’’s Deadly Tolls Deadly Toll

440,000 deaths in the U.S. each year440,000 deaths in the U.S. each year4.8 million deaths world wide each year4.8 million deaths world wide each year10 million deaths estimated by year 203010 million deaths estimated by year 20308.6 million disabled from tobacco in the U.S. alone8.6 million disabled from tobacco in the U.S. alone

17

8141

19 14 30

440

0

50

100

150

200

250

300

350

400

450

Comparative Causes of Annual Deaths in the United States

Num

ber o

f Dea

ths

(thou

sand

s)

Source: CDC

AIDS Alcohol Motor Homicide Drug Suicide SmokingVehicle Induced

Also suffer from mental illness and/or substance abuse

*

*

Annual U.S. Deaths Attributable to Smoking, 1995–1999

Centers for Disease Control and Prevention. MMWR 2002;51:300–303.

53,000Second-hand smoke

98,000Respiratory diseases

31,000Cancers other than lung

125,000Lung cancer

149,000Cardiovascular diseases

2,000Other

34%

28%22%

9%

7%

<1%

TOTAL: more than 440,000 deaths annually

Health Consequences of SmokingHealth Consequences of Smoking

CancersCancers–– LungLung–– Laryngeal, pharyngeal, oral cavity, Laryngeal, pharyngeal, oral cavity,

esophagusesophagus–– PancreaticPancreatic–– Bladder and kidneyBladder and kidney–– Cervical and endometrial Cervical and endometrial –– GastricGastric–– Acute myeloid leukemiaAcute myeloid leukemia

Reduce fertility in women, poor Reduce fertility in women, poor pregnancy outcomes, low birth pregnancy outcomes, low birth weight babies, sudden infant weight babies, sudden infant death syndromedeath syndrome

Cardiovascular diseasesCardiovascular diseases–– SubclinicalSubclinical atherosclerosisatherosclerosis–– Coronary heart diseaseCoronary heart disease–– StrokeStroke–– Abdominal aortic aneurysmAbdominal aortic aneurysm

Respiratory diseasesRespiratory diseases–– Acute respiratory illnesses, e.g., Acute respiratory illnesses, e.g.,

pneumoniapneumonia–– Chronic respiratory diseases, Chronic respiratory diseases,

e.g., COPDe.g., COPD

CataractCataract

PeriodontitisPeriodontitis

U.S. Department of Health and Human Services.The Health Consequences of Smoking: A Report of the Surgeon General, 2004.

Ways to Help Smokers QuitWays to Help Smokers Quit

Raise prices (taxes)Raise prices (taxes)Clean indoor airClean indoor airCreate counterCreate counter--marketingmarketingProvide cessation aids (counseling and Provide cessation aids (counseling and pharmacotherapy)pharmacotherapy)–– Directly by clinician in individual or group session Directly by clinician in individual or group session

(office or hospital)(office or hospital)–– Through tollThrough toll--free telephone free telephone quitlinesquitlines

Reasons for Not Helping Patients QuitReasons for Not Helping Patients Quit

1.1. Too busyToo busy2. Lack of expertise2. Lack of expertise3. No financial incentive3. No financial incentive4. Most smokers can4. Most smokers can’’t/wont/won’’t quitt quit5. Stigmatizing smokers5. Stigmatizing smokers6. Respect for privacy6. Respect for privacy7. Negative message might scare away patients7. Negative message might scare away patients8. I smoke myself8. I smoke myself

Responses to Patient Who SmokesResponses to Patient Who Smokes

Unacceptable: Unacceptable: ““I donI don’’t have time.t have time.””

AcceptableAcceptable–– Refer to a quit lineRefer to a quit line–– Establish systems in your office and hospitalEstablish systems in your office and hospital–– Become a cessation expertBecome a cessation expert

Nicotine Addiction CycleNicotine Addiction Cycle

Reprinted with permission. Benowitz. Med Clin N Am 1992;2:415–437.

Nicotine AddictionNicotine Addiction

Tobacco users maintain a minimum serumTobacco users maintain a minimum serumnicotine concentration in order tonicotine concentration in order to–– Prevent withdrawal symptomsPrevent withdrawal symptoms–– Maintain pleasure/arousalMaintain pleasure/arousal–– Modulate moodModulate mood

Users selfUsers self--titrate nicotine intake bytitrate nicotine intake by–– Smoking more frequentlySmoking more frequently–– Smoking more intenselySmoking more intensely–– Obstructing vents on lowObstructing vents on low--nicotine brand cigarettesnicotine brand cigarettes

LongLong--Term (Term (≥≥6 Months) Quit Rates for 6 Months) Quit Rates for Available Cessation MedicationsAvailable Cessation Medications

0

5

10

15

20

25

30

Nicotine gum Nicotine patch Nicotinelozenge

Nicotine nasalspray

Nicotineinhaler

Bupropion

Active drugPlacebo

Data adapted from Silagy et al. Cochrane Database Syst Rev, 2002 and Hughes et al., Cochrane Database Syst Rev, 2000

Perc

ent q

uit 19.7

14.4

11.5

8.4

17.2

8.9

23.9

11.8

17.1

9.1

19.3

10.2

Combination Therapy: Patch Plus Combination Therapy: Patch Plus Bupropion SRBupropion SR

15.6%

16.4%

30.3%

35.5%

0% 5% 10% 15% 20% 25% 30% 35% 40%

Placebo

Nicotine patch

Bupropion

Nicotine patchplus bupropion

Jorenby et al. N Engl J Med 1999;340(9):685–691.

Percentage of patients quit at 12 months after cessation

Effects of Clinician InterventionsEffects of Clinician Interventions

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline.Rockville, MD: USDHHS, PHS, 2000.

0

10

20

30

No clinician Self-helpmaterial

Nonphysicianclinician

Physicianclinician

Type of Clinician

Esti

mat

ed a

bsti

nenc

e at

5+

m

onth

s

1.0 1.1(0.9,1.3)

1.7(1.3,2.1)

2.2(1.5,3.2)

n = 29 studies

New Medications in the PipelineNew Medications in the PipelineRimonabantRimonabant–– CannabinoidCannabinoid receptor inhibitorreceptor inhibitor–– Blocks reinforcing effects of nicotineBlocks reinforcing effects of nicotine–– Also suppresses appetiteAlso suppresses appetite–– In phase III trialsIn phase III trials–– Will likely be expensiveWill likely be expensiveNicotine VaccineNicotine Vaccine–– Produces antibodies to nicotineProduces antibodies to nicotine–– Reduces nicotine levels in animalsReduces nicotine levels in animals

CYP246 InhibitorsCYP246 Inhibitors–– CYP246 is a hepatic enzyme that metabolizes nicotineCYP246 is a hepatic enzyme that metabolizes nicotine–– Higher blood nicotine levels per cigarette smokedHigher blood nicotine levels per cigarette smoked–– Could also increase potency of NRTCould also increase potency of NRT

JCAHO Core MeasuresJCAHO Core Measures

Community Acquired PneumoniaCommunity Acquired PneumoniaAcute MIAcute MICHFCHFPediatricsPediatrics

Adult Smoking Cessation Counseling Given to CAP Patients

38

21

8.3

3441

4643

47

0

10

20

30

40

50

60

Jan-March-03 N = 68

April-June-03 N = 45

July-Sept-03 N = 27

Obs

erve

d R

ate

UCSF UHC CM Hospitals National Rate for Qtr

0

20

40

60

80

100

Q3 2002 Q4 2002 Q1 2003 Q2 2003 Q3 2003

UCSF UHC JCAHO

Smoking Cessation Advice Given to AMI Patients

Adult Smoking Cessation Advice Given to CHF Patients who Smoke

020406080

100

Q32002

Q42002

Q12003

Q22003

Q32003

Quarter of InterestUCSF UHC JCAHO

Treating Tobacco Dependence : 2003Treating Tobacco Dependence : 2003

Providers•5 A’s Training/Education•Reimbursement •Physician Leadership

Cessation•Group Classes•Free Medications•Telephone Support•Self-Help Materials•Prov-RN

Clinics•5 A’s Training•EMR Resources•Dissemination (TAR)•Resources: Primary Care, Specialties, Pediatrics, OB/GYN

Health System•Research > $800K•Leadership: ATMCRWJF, CDC, AAHP•Formal HSI Program

Target Groups•Disease Management•PHS employees•Web-Based•Women & Children•Clinical Programs

Community•TOFCO•Oregon Quitline•Business Case

Hospital-Based•Inpatient Program•Behavioral Health/CD

Evaluation•C.O.R.E.•Utilization•Grant Writing

SMOKER(who wants to quit)

Smoking Prevalence in PHP vs. OregonSmoking Prevalence in PHP vs. Oregon

15%16%17%18%19%20%21%22%23%24%

'88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 2000

State of Oregon (BRFS) Providence Health Plan: Oregon

Gold CardGold Card

—

Quitline NumbersQuitline Numbers

11--800 NO BUTTS (California number)800 NO BUTTS (California number)

11--800 QUIT NOW (National number)800 QUIT NOW (National number)

Barriers to Successful CessationBarriers to Successful Cessation

Provider inattention/pessimismProvider inattention/pessimismCoCo--dependency and mental illnessdependency and mental illnessNo coverage for cessation drugsNo coverage for cessation drugsImproper use of the drugsImproper use of the drugsIgnorance of Ignorance of quitlinesquitlines

Strategies for Increasing Quit RatesStrategies for Increasing Quit Rates

Reframe expectations of successReframe expectations of successFocus on mental health/substance abuse populationFocus on mental health/substance abuse populationMarket Market quitlinesquitlines betterbetterDevelop newer drugsDevelop newer drugsCreate better systemsCreate better systemsProvide clinical championsProvide clinical champions

Power of InterventionPower of Intervention

⅓⅓ to to ½½ of the 46 million smokers will die from of the 46 million smokers will die from the habit. Of the 32 million who want to quit, 10 the habit. Of the 32 million who want to quit, 10 to 16 million will die from smoking.to 16 million will die from smoking.Increasing the 2.5% cessation rate to 10% Increasing the 2.5% cessation rate to 10% would save 2.4 million additional lives.would save 2.4 million additional lives.If cessation rates rose to 15%, 4 million If cessation rates rose to 15%, 4 million additional lives would be saved.additional lives would be saved.No other health intervention could make such a No other health intervention could make such a difference!difference!

UCSF Celebrates UCSF Celebrates World No Tobacco DayWorld No Tobacco Day