A Clinician’s Overview of Tobacco Treatment
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Barry Make, MD
Professor, Pulmonary Division
Department of Medicine
Director Emphysema Program
National Jewish Medical and Research Center
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Epi Mazzei, RN, BSN
Tobacco Treatment Specialist
National Jewish Medical and Research Center
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Learning Objectives:
• Discuss role of physicians in tobacco cessation
• Review key findings of the Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence
• Describe tobacco cessation pharmaceutical products and recommendations for pharmacotherapy, including combination treatment
• Identify recommended strategies for providing tobacco cessation in an office setting
Introduction
Medical professionals understand the adverse consequences of smoking and the benefits of quitting (see Table 1 ). Moreover, clinicians know that tobacco usage, predominantly cigarette smoking, is the leading preventable cause of death in the United States . In addition, 70% of current smokers report they would like to quit.6 However, a paradox exists in the medical community: Although clinicians recognize that they can influence their patients to stop smoking, they are often reticent to address smoking cessation with patients for a number of reasons, including time constraints, lack of knowledge about the best approach, fear of patients’ negative response to their efforts, and reimbursement issues.
Approximately 46 million U.S. adults smoke,4 and roughly 440,000 Americans die annually from complications due to tobacco usage.5 The economic impact is staggering as well, with $75 billion spent annually in direct health care expenses for medical complications due to smoking.5 Fortunately, it is within our power as clinicians to alter these statistics. Solid evidence demonstrates that counseling, behavioral therapy, and pharmacotherapy, administered in a primary care setting improve smokers’ ability to successfully quit and remain abstinent for one year or more.6,7 Given this, physicians have an incentive to treat smoking dependence to improve patient quality of life and prevent the development of tobacco related diseases.
In addition, agencies that address physician practice quality have recommended the adoption of evidence-based tobacco dependence treatment as part of routine patient care in clinical (inpatient and outpatient) settings. For example, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will soon begin collecting smoking cessation performance measures in hospital data sets for patients with a diagnosis of myocardial infarction, heart failure, and community acquired pneumonia.22
Evidence-based recommendations for smoking cessation are provided in the U.S. Public Health Service (PHS) Clinical Practice Guideline, Treating Tobacco Use and Dependence, issued in June 2000. This newsletter reviews key recommendations from the PHS Guideline and additional cessation strategies that clinicians can effectively implement within a clinical practice setting. Current pharmacotherapy options and practical information on counseling and behavioral strategies that promote smoking cessation are also offered. In addition, this newsletter addresses provider and patient resources for tobacco cessation and health insurance reimbursement issues.6
Strategies for Smoking Cessation Interventions
Smokers report that their physician’s advice to quit is an important motivator to stop smoking. Coupled with the fact that seven out of 10 smokers see a primary care physician every year, each office visit should be seen as an important opportunity for a smoking cessation intervention.6 Unfortunately, many medical professionals are not capitalizing on these opportunities as over one-third of current smokers report they have not been asked about their smoking status or advised to quit.6 A number of perceived barriers have been offered. Some physicians may assume that broaching the subject requires an extended amount of time. Many may feel they do not have the background knowledge or the resources readily available to effectively assist their patients. Still others may be hindered by a sense of futility with patients who don’t want to quit or a concern that they will generate hostility on the part of patients. The information included herein will address these issues and improve clinician self-efficacy for facilitating smoking cessation interventions.
The PHS Guideline states that tobacco dependence is a chronic disease that often requires repeated interventions. A crucial point is that repeated interventions may be required for long-term, significant positive behavior changes. The necessity for these repeated messages doesn’t indicate that smoking cessation counseling “falls on deaf ears,” or is due to a lack of clinician efficacy with tobacco treatment. Rather, the need for repeated communications emphasizes the extremely addictive nature of tobacco dependence that approximately 80% of tobacco users experience and acknowledges the difficulty of achieving behavioral change.23 As with any addiction, multiple quit attempts may be required for a successful outcome. However, each intervention that motivates, assists, or reinforces positive behavioral changes, either now or at some future time, is beneficial and has the potential to significantly improve and lengthen patients’ lives.24
There is a strong dose-response association between the intensity of counseling administered and its resultant efficacy. Longer intervention session times (over 10 minutes) and a greater number of intervention sessions have a significant positive effect on abstinence rates.6 But even brief smoking cessation interventions (three minutes or less) have been shown to improve smoking abstinence rates. Moreover, the rates of smoking abstinence increase with all types of clinicians (physician, psychologist, nurse, dentist, or counselor) administering the intervention.6 Thus, it is recommended that all health professionals actively advise smoking cessation for patients who currently smoke.
• • An expectant mother should be advised to completely quit smoking to lessen risks of complications with her pregnancy, premature birth, and a low birth weight baby.
• • A father with an asthmatic child who quits smoking will reap immediate health benefits for both himself and his child, since asthma is exacerbated by secondhand smoke.
• • A middle-aged man with mildly abnormal lung function who reports shortness of breath with exertion should be encouraged to quit smoking to improve and maintain lung function.
• • A younger individual should be encouraged to quit smoking to avoid premature skin aging and wrinkles, bad breath, yellowed teeth, and the smell of smoke on clothing.
Because the majority of tobacco users express ambivalence about quitting, a motivational intervention, which leads patients to explore and consider behaviors that are consistent with their own priorities and values, can be provided.25 The key to this intervention is to engage each individual patient in a discussion as to how quitting will impact their life based on their individual personality, lifestyle, and life goals. Research shows that motivational interventions are most likely to be effective when they are presented by a clinician who is empathetic, avoids confrontation, encourages patient autonomy (i.e., provides patients a choice of options), and endorses the patient’s self-efficacy (i.e., confirms their ability to promote self-change).9-11 A useful process to improve patient motivation to quit smoking encompasses the following 5Rs.
Tobacco Dependence Treatment
When a patient expresses willingness to make a quit attempt, the clinician should provide an intervention to assist in these efforts. Patients should be educated about current treatment options and involved in making therapeutic decisions. The clinician’s responsibilities to aid the quitting patient include counseling, behavior modification strategies, and recommendations for pharmacotherapy.26 Counseling and behavior therapies play a vital role in enabling the patient to anticipate and plan for psychological and social challenges and change, whereas pharmacotherapy can significantly mitigate the physical withdrawal symptoms of nicotine.
Counseling and Behavior Therapies
The Guideline recommends three counseling and behavior therapies: practical counseling, intra-treatment support, and extra-treatment support.
Practical counseling involves problem solving and skills training for the patient. The following are key elements :
- Help the patient develop a quit plan. This includes setting a quit date (generally within the next one-three weeks), telling family and friends to solicit their support, and removing tobacco products from the home and work environment.
- Help the patient identify situations or triggers that may increase the likelihood of smoking relapse. This may include being around other smokers, consuming alcohol, or feeling stressed.
- Help the patient develop coping and problem solving skills. Learning to anticipate and avoid, or modify, difficult situations; incorporating positive behaviors to reduce or deal with stress, and learning cognitive strategies to cope with nicotine cravings are skills the patient can develop with practice.
- Provide basic information about tobacco addiction and successful quitting. Include information about the addictive nature of nicotine, withdrawal symptoms, and the importance of not smoking, even a puff, once they quit.
Intra-treatment support is the provision of a supportive clinical environment. Conveying belief in the patient’s self-efficacy to quit and demonstrating a willingness to offer help and emotional support are key elements of this therapeutic strategy.
- All office staff should encourage the patient in the quit attempt and reinforce smoking cessation efforts.
- Communicate caring and concern, and a belief in the patient’s ability to successfully quit.
- Encourage the patient to discuss the quitting process. Ask about past quit attempts, barriers to quitting and any past successes. In addition, be open to the patient’s expression of fears or ambivalence about quitting.
Extra-treatment support recognizes that patients need social support in their environments during a quit attempt. Important elements include:
- Assist the patient in identifying others who will be supportive of the quit attempt.
- Encourage the patient to solicit the support of these non-smoking family, friends, and co-workers.
- Provide resources, including information on quitlines, website programs and resources, community programs, and self-help materials.
Many states provide a free telephone smoking cessation service for their residents. Callers can access tobacco treatment counselors who answer questions, provide education on tobacco dependence, guidance and support through the quitting process, and educational materials and information on local resources. Quitlines offer counseling that is convenient and confidential and can reach a large number of smokers. Telephone counseling has been shown to significantly improve the success of long-term abstinence compared to self-help materials alone. 37
Pharmacotherapy
The use of pharmacotherapy approximately doubles a patient’s chance of quitting.6 As a result, the Guideline recommends that pharmacotherapy be prescribed for all patients attempting to quit, unless special circumstances warrant otherwise (e.g., pregnancy, medical contraindications, adolescent patients, patients smoking fewer than 10 cigarettes/day). Clinicians should encourage patients to use one or a combination of approved pharmacotherapies. Six first-line medications and two second-line medications have been shown to significantly increase abstinence rates long term.6,27
The first-line medications have been approved by the FDA for tobacco dependence treatment. These medications include one non-nicotine medication and five nicotine replacement therapy medications.
Buproprion hydrochloride SR is the first non-nicotine medication to be approved by the FDA for smoking cessation. Its mechanism of action is presumed to be mediated by blocking neural re-uptake of dopamine and/or norepinephrine. It is contraindicated in patients with a seizure disorder, a current or prior diagnosis of eating disorders, use of a MOA inhibitor within the previous 14 days, or use of another medication that contains buproprion. Because buproprion is also effective for depression, it should be considered for smokers with current or past history of depression. Available only by prescription, it is indicated for tobacco treatment as Zyban® and for depression as Wellbutrin®. Buproprion SR can be combined with nicotine replacement therapy.6
Nicotine Replacement Therapy
The remaining five first-line FDA medications approved for smoking cessation are nicotine replacement therapies (NRT). These products contain another form of nicotine, with markedly different delivery and absorption, whereby the addictive properties are not reinforced. Moreover, they do not contain any of the carcinogens or toxic gases found in cigarette smoke. The use of an NRT provides an overall lower dose of nicotine than tobacco products, which can suppress the physical withdrawal symptoms.6
Nicotine replacement therapy is available with passive or active dosing. The nicotine transdermal patch is the exclusive NRT product with passive dosing, producing relatively steady doses in the body. The other five NRT products – nicotine gum, lozenge, inhaler, and nasal spray – have active dosing, allowing the patient to adjust dosing on an acute basis. Initially, active NRT products are recommended for use on a regular schedule as underuse can lead to smoking relapse.
No one first-line medication has been shown to be more efficacious than another, so first-line pharmacotherapies should be prescribed based on presence of contraindications, patient preference, patient characteristics (e.g., concerns with weight gain, history of depression), and clinician familiarity with the medications.6,12 Some studies suggest that patient adherence is higher with the nicotine patch.12 Table 2 provides more information on medications and details the recommended dosages, side effects, correct techniques for usage, and approximate daily costs. Additional prescribing information is available at http://www.surgeongeneral.gov/tobacco/prescrib.htm.
Several controlled trials show that combination therapy with two first-line agents (e.g., buproprion SR + nicotine patch, nicotine patch + nicotine gum, etc.) is superior to the administration of a single therapy only. Combining the use of first-line agents should strongly be considered for those who have been unable to quit using a single type of pharmacotherapy or who are heavily addicted. When using combination therapy, it is recommended that one medication provide a long-acting effect (e.g., buproprion SR), whereas the other may be used as needed by the patient to achieve more rapid increases in blood levels in a manner similar to cigarette smoking (e.g., nicotine gum, inhaler, nasal spray, lozenge).13-17
No single approach of tobacco cessation is best for all tobacco users. A dual approach of behavior modification and pharmacotherapy has been shown to be the most effective. 6
Second-line medications — clonidine and nortriptyline — have been shown to be efficacious in treating nicotine dependence in some studies, but they are not recommended for first-line use because (a) the FDA has yet to approve them specifically for tobacco dependence treatment and (b) the possible side effects with these medications may be greater. Clonidine is traditionally prescribed for hypertension treatment, and abrupt discontinuation of the medication can cause nervousness, headache, and tremors along with a rapid blood pressure increase and elevated levels of catecholamines. Nortriptyline is typically used to treat depression, and overdose may cause significant cardiotoxic effects. Physicians should only consider prescribing second-line medications for patients attempting to quit when first-line medications cannot be used due to contraindications or when first-line medications have not proven effective in a patient’s cessation attempts.6 See Table 2 for more information on second-line medications.
Research and Tobacco Treatment
Although tobacco treatment has made significant advances in recent years, there are many tobacco users unable to quit, many of whom may have a higher level of addiction and don’t respond to currently available pharmacotherapy. Ongoing tobacco research includes efforts to gain more knowledge and understanding of nicotine and potentially other compounds in cigarette smoke that drive smoking behavior. As a result, several of the new medications being studied for tobacco dependence target specific brain sites. 29
- mecamylamine – a nicotine antagonist (formerly available as an antihypertensive) 30
- varenicline – a selective nicotine agonist 31
- rimonabant – a new class of drug that curbs nicotine cravings and appetite 32
In addition, clinical trials have recently begun with a nicotine vaccine which reduces the amount of nicotine that passes from the blood to the brain up to 65%, thereby preventing nicotine addiction. 33
Putting Smoking Cessation Interventions Into Practice
There are many opportunities in the office setting to encourage and support nonsmoking behavior. Clinical interventions are most effective when provided by more than one health professional in an office and when the interventions are incorporated into routine office procedures. A comprehensive office-based approach that involves all office staff and provides an environment conducive to smoking cessation in all patient care areas is recommended.36
The following key strategies can be implemented in most medical office settings with existing staff and resources. When possible it is beneficial to designate one staff member to be a tobacco cessation coordinator and be responsible for implementing these changes, and maintaining and enhancing these practices within the office setting.36
• Place smoking cessation visuals such as posters, brochures and information booklets in the reception area and exam rooms. Ensure that all exam rooms have the materials needed to assist patients with a quit attempt, including Quitline fax referral forms, self-help materials and other cessation resources.39
- Develop a systematic process to identify and track patients who smoke.
- Flag charts of patients who commit to making a quit attempt and ensure that arrangements are made for follow up (i.e. provide education on NRT, phone call on quit date, schedule follow up appointment).
- Train other office staff and utilize them to provide assistance or reinforcing messages throughout the patient flow within your setting (i.e. provide support, answer questions, arrange follow up phone calls).
Harm reduction is an approach to reduce the adverse effects of smoking in individuals who are unable or unwilling to quit smoking by reducing the number of cigarettes smoked and/or using an alternate source of nicotine.35 Although there is currently no evidence that reducing smoking actually reduces harm, there are a number of reduced harm strategies that have been proposed. In the order of least harmful, they are: substitution of least harmful alternatives (e.g., NRT), substitution of moderately harmful alternatives (e.g., smokeless tobacco), and substitution of most harmful alternatives (e.g., modified cigarettes; reduced smoking). Concerns regarding the promotion of harm reduction include: will this substitute for total abstinence or remaining abstinent, will it supplement (and sustain) ongoing use of conventional tobacco products, and will it encourage experimentation by children who would have avoided conventional tobacco products. 34
A key component of disseminating and facilitating smoking cessation assistance in an office setting involves clinician education. Fortunately, there is a wealth of information on tobacco treatment available to health care professionals. In many areas, state or community based public health agencies provide training programs and educational materials on tobacco cessation for providers, in addition to resource and referral information on local cessation programs.
There are a number of excellent web sites for health care professionals that include information on formal training programs, online education, and resources for patients.
Reimbursement Issues
Although smoking cessation interventions are considered the “gold standard” of preventive treatment because they are more cost-effective than more common medical interventions such as mammography screening or treatment of hypertension, health care systems do not universally provide reimbursement for smoking cessation treatment and counseling. Currently, only 36 states provide Medicaid coverage for tobacco treatment and only 10 of these cover counseling.38 Medicare is conducting a one-year program in seven states to evaluate which smoking cessation strategies help older Medicare beneficiaries quit smoking, but at this time it provides no benefit for counseling or drug therapies.40 Most private health plans provide limited benefits for tobacco treatment with great variability among benefit packages and insufficient reimbursement for providers and patients.
The tobacco treatment reimbursement scenario is rapidly evolving and clinicians and their staff should familiarize themselves with benefit options for the plans in which they participate. In plans where counseling is a covered benefit, providers can use the following diagnostic codes from the International Classification of Diseases, 9th revision, Clinical Modification (ICD9-CM):
- 305.1 Tobacco Use Disorder: This includes adverse patient health consequences due to the negative effects of tobacco use. This code excludes a history of tobacco use (V15.82).
- V15.82 History of Tobacco Use: This includes a patient’s past use of tobacco that may result in future health complications. Tobacco dependence (305.1) is excluded.
In plans where counseling is not a covered benefit, clinicians can submit for reimbursement of smoking cessation counseling provided to patients who have smoking-related diagnoses (bronchitis, diabetes, asthma, etc.), or who require a medical procedure related to smoking co-morbidity (spirometry, EKG, lipid profile, etc.). The ICD-9 codes for these diagnoses and procedures plus additional reimbursement guidelines are provided in Reimbursement for Smoking Cessation Therapy, A Healthcare Practitioner’s Guide, Third Edition .38
To maximize patients’ smoking cessation benefits, clinicians should utilize referrals to resources such as Quitlines, employer group cessation or wellness programs, and pharmaceutical company programs. Clinicians and office staff are also in a position to advocate with health plans for extended benefit coverage and provider reimbursement, and going forward, to work as change agents for improved coverage.38
Finally, a new set of “Health and Behavior” CPT codes, championed primarily by the American Psychological Association, appears to represent a new billing mechanism that can be utilized by certain health professionals for smoking cessation assessment and counseling when the patient has a diagnosed medical disorder for which smoking cessation would be medically advisable. The key difference in this billing strategy, as opposed to the ones presented above, is that the new Health and Behavior codes are used to reimburse psychological services that treat behavioral, social, and psychophysiological conditions related to the treatment or management of physical health problems, such as asthma or COPD. As of January 1, 2002, Medicare recognized these codes as eligible for reimbursement. Further information about these CPT codes and their appropriate use can be found at:http://www.apa.org/practice/cpt_2002.html.41
The PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence provides key evidence-based recommendations for clinicians. Physicians should implement a system in their practice to identify, track, and offer treatment to all tobacco users. The 5As , a brief intervention which encompasses these strategies, should be provided at each patient visit.
Clinicians should provide a supportive clinical environment for smoking cessation whereby all staff are empathetic and non-judgmental. For patients who are not willing to make a quit attempt, an intervention to increase motivation to quit (the 5Rs ) should be provided. For patients who are willing to make a quit attempt, a combination approach of pharmacotherapy plus counseling and behavior modification therapies is recommended. The use of pharmacotherapy approximately doubles a patient’s chance for successful quitting so pharmacotherapy options should be discussed with all patients attempting to quit, unless special circumstances warrant otherwise (e.g., pregnancy, medical contraindications, adolescent patients, patients smoking fewer than 10 cigarettes/day).The FDA has approved five nicotine replacement therapy products and one non-nicotine medication for smoking cessation. Individuals who are heavily addicted or have had multiple unsuccessful past quit attempts may benefit from a combination of pharmacotherapy.
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