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1 Never Quit Quitting Training Healthcare Providers to Integrate Cessation Counseling and Referral into Office Practice Lisa Krugman, MPH, MSW Washtenaw County Public Health

2 Washtenaw County Smokers (HIP 2005) 15% of adult residents currently smoke (18% of adult women smoke) High risk group: Certain zip codes Ypsilanti ( ): 8): 25% currently smoke W. Washtenaw county y( (Chelsea, Dexter and Manchester): 21% currently smoke Rest of County: 9% currently smoke High risk group: Income level l <$35,000: 30% currently smoke $35,000-$74,999: $74,999: 16% currently smoke

3 Tobacco Use is the #1 Preventable Cause of Death in the U.S.

4 Health Effects of Tobacco Use Smoking effects every part of your body Smokers are 2-4x more likely to develop coronary heart disease than non-smokers Smoking causes about 90% of lung cancer deaths Smoking can cause cancer of the bladder, larynx, kidney, lung, pancreas and stomach, oral cavity (US Dept. Health and Human Services, 2006)

5 Smoking and Mental Illness 75% of people with either addictions or mental illness smoke, compared to 22% of the general population People with serious mental illness die 25 years younger than the general population largely from conditions caused by smoking (Source: Nat l Assoc. of State Mental Program Directors, 2007)

6 Alcohol, Drug Abuse and Tobacco Use Smokers who also abuse alcohol or drugs are dying at 4 times the rate of the general public who smoke 43% of all cigarettes are bought by people who abuse alcohol or other drugs

7 MYTHS AND DATA RELATED TO SMOKING CESSATION AND ALCOHOL ABSTINENCE Myth: Smoking is more benign than alcoholism More people with alcoholism die from smoking- related diseases than from alcohol-related illness (Hurt et al. 1996) Comorbid smoking and alcoholism result in synergistic exacerbation of health risks (Bien and Burge 1990; York and Hirsch 1995; Hinds et al. 1979) (Source: Gulliver, et. Al. Alcohol Research & Health, 2006)

8 MYTHS AND DATA RELATED TO SMOKING CESSATION AND ALCOHOL ABSTINENCE Myth: Smokers with comorbid alcoholism have either no interest or no ability to quit smoking The majority (up to 80 percent) of individuals in addiction treatment are interested in quitting smoking (cf. Prochaska et al. 2004) Inclusion of smoking cessation treatment into other addiction programs does not negatively affect rates of treatment completion or motivation for abstinence (Sharp et al. 2003; Monti et al.1995) (Source: Gulliver, et. Al. Alcohol Research & Health, 2006)

9 MYTHS AND DATA RELATED TO SMOKING CESSATION AND ALCOHOL ABSTINENCE Myth: Smoking cessation will impede successful alcohol use outcomes Participation in smoking cessation efforts while engaged in other substance abuse treatment has been associated with a 25 percent greater likelihood of long-term abstinence from alcohol and other drugs (Prochaska et al. 2004) Data indirectly suggest that continued smoking increases the risk of alcohol relapse among alcohol-dependent smokers (Taylor et al. 2000) (Source: Gulliver, et. Al. Alcohol Research & Health, 2006)

10 MYTHS AND DATA RELATED TO SMOKING CESSATION AND CRISIS Myth: Cutting out smoking will only worsen the crisis Our immediate concern is the crisis, as the person recovers, we will provide an environment that promotes wellness. Ultimately it is the consumers choice to quit, we can not make them but we can educate and provide resources.

11 Meet Brenda Meet Brenda Brenda is 27-years old She has smoked since age 12 She smokes on average one pack (20 cigarettes) every day Brenda is a recovering alcoholic (2 months) Brenda has a history of major depressive episodes

12 Brenda Meet Brenda Receives Services from an SA Provider Not N t in crisis i She is not sure if she wants to quit She lives with her sister who is a smoker

13 What can you do? Many patients cite a healthcare providers advice as an important motivator to making a quit attempt Clients look to you as role models Other interventions: Signage, Quit kits, Posters

14 What is The 5 A s Approach? Evidence-based clinical counseling approach 5-15 minutes brief counseling intervention Can double or triple quit rates (30-70%)

15 Ask The Five A s: Best Practice for Advise Assess Assist Arrange Smoking Cessation

16 The 5 A s: Ask (1 minute) ASK every patient Do you smoke? or Have you smoked in the past year? DOCUMENT - Current smoker and number of cigarettes per day - Former smoker with quit date - Never smoked

17 The 5 A s: Advise (3 minutes) Advise all smokers to seriously consider making a quit attempt using a clear and personalized message Advice as brief as 3 minutes is effective!

18 Advise: Clear, Strong and Personalized I think it is important for you to quit smoking now. I can help. Quitting smoking will not only make you healthier but will help you to stay sober. I know you are struggling financially and quitting smoking could save you $1,825 per year.

19 The 5 A s: Assess: Is the patient ready to quit? (1-3 minutes) Are you ready to set a quit date within the next 30 days? If yes, proceed to assist If no, goal is to move patient from not thinking about quitting to at least thinking about it: What is preventing you from making a quit attempt?

20 The 5 R s: For Patients who do not want to quit Risk: Provide information about the health effects of smoking Relevance: How is this information relevant to their situation? Reward: What are the benefits of quitting? i Roadblocks: What are the barriers to quitting? Repetition: Repeat this intervention ti with each office visit until they move to contemplation of quitting

21 The 5 A s: Assist (3 minutes) Identify trigger situations (drinking alcohol, friends who smoke) Provide social support ( we can help you quit ) Arrange social support in smoker s environment (identify quit buddy, identify support person) Provide cessation materials Identify quit smoking method (cold turkey vs. NRT use, if appropriate)

22 Nicotine Replacement Therapy Nicotine patch (NRT) Nicotine gum or lozenge Nicotrol inhaler (Rx) Nicotine nasal spray (Rx) Other quit smoking medications: Wellbutrin (bupropion)/ Zyban Chantix

23 Depression ession and Tobacco Use 40% of smokers have some kind of depression Consider the anti-depressant bupropion p (wellbutrin, Zyban) as quit smoking aid. (Source: American Cancer Society)

24 Depression ession and Tobacco Use Having a history of depression is associated with more severe withdrawal symptoms including more severe depression. Some studies have found that many people with a history of major depression will have a new major depressive episode after quitting If mild depression occurs, it will usually begin within the first day, continue for the first couple of weeks, and go away within a month (Source: National Cancer Institute)

25 The 5 A s: Arrange Arrange follow up and support Continue encouragement

26 You Can Make a Difference! ence! Ask every patient Do you smoke? Advise smokers with clear, strong and personalized language the importance of quitting Assess willingness to quit (also assess for depression) For those willing to quit Assist with quit plan and resources Arrange for follow-up

27 Icandoit!

28 Want to learn more? Earn continuing medical education credit by taking an online tobacco treatment training program:

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