The Quit Clinic As an Anti-smoking Advocacy Tool - MAPTB

The Quit Clinic As an Anti-smokingAdvocacy ToolAssociate Professor Chanchai Sittipunt MDDivision of Pulmonary and Critical Care MedicineDepartment of Internal Medicine Faculty of MedicineChulalongkorn University Bangkok Thailand

Nicotine Addiction: Chronic DiseaseChronic intake of nicotinefrom cigarettesNicotine addiction is aChanges to theneural circuitscontrolling motivationchronic diseaseNicotine hunger Nicotine habit False beliefsA biologically driven“need” to smokewhen nicotine levelsin the brain are lowCues associated withsmoking triggernicotine-drivenreward seekingExperience of reliefof nicotine withdrawalsymptoms leads toexpectations of moregeneral moodenhancement

Long-Term Quit Rates Highest WithCombination Pharmacotherapyand Behavioral SupportBehaviorTherapyBrief AdviceNo TherapyMedication30%20%10%No Medicationor placebo15%10%5%Hughes JR. CA Cancer J Clin. 2000;50:143-151.

Cost-effectiveness of Smoking Cessationper life-year saved:Smoking Cessation $ 2,000 – 6,000R x of Hypertension $ 9,000 – 26,000R x of Hyperlipidemia $ 50,000 – 196,000Benowitz NL Prog Cardiovasc Dis 2003;46:91-111111

Treating smoking dependence versusmoderate hypertensionNumber needed to treatfor 1 incidentTreatment durationProtection gained fromtreatmentFrequency of sideeffectsCostReimbursementFrequency of practiceSmokingCessation14-283 monthsLoweredsusceptibility to 15-20diseaseLowLowNoneRarelyAntihypertensiveTreatment280ProlongedImproved heart andblood vessel functionCommonHighYesOften

Managing Smoking In 2007•Treat it as a chronic disease•Local guideline & “5 A’s” Model•Facilitating behavior changecounseling, behavior therapy•Optimize medication useappropriate medications•Know, support, utilize available resourcesTelephone quitlinesWorksite and community group intervention programsIndividual counseling programsWeb sites

Smokers Want to QuitPercentage Who Wantto Stop Smoking9080706050403020100Results of a Survey of 10,295 Smokers in 17 European Countries 1SweedenFinlandGreecePolandUnited KingdomNetherlandsIrelandRussiaFranceSpainBelgiumDenmarkPortugalLuxembourgGermanyAustriaItaly– In the US• 7 in 10 smokers profess a desire to quit 2• 41% of smokers in 2002 reported they had tried to quit during theprevious year 31. Boyle P et al. Eur J Pub Health. 2000;10:5–14. 2. CDC. MMWR. 2002;51:642–645. 3. CDC. MMWR. 2004;53:427–430.

Smoking Cessation: Dilemma• Effective tobacco dependence treatmentexists• Treatment is cost-effective• Smokers want to quit• But clinicians do not routinely use itWhy not?

Gaps in Smoking CessationsocietyActiveSmokersGovernmentHealth CareProvidersNGOSmokingcessationtreatment

Smokers Want to Quit? Asia• In the 1990s, the proportion of male ex-smokers whohad successfully quit ranged from 30% in Westernnations to:– 4% in China– 5% in India– 10% in Vietnam• Intention to quit is as high as 75% in the Westcompared with:– 14–16% in China– 31% in India– 51% in Hong Kong Chinese1. Abdullah ASM, Husten CG. Thorax. 2004;59:623-630. (Review); 2. Abdullah ASM, Yam HK. Am J Health Promot. 2005;19:346-354.

Smoking cessation paradoxSmoking is an addictionstopping is a matter ofwillpowerSmoking should beregarded as a medicalconditionbutis primarily a lifestylechoiceHelping patients to stopis part of the jobother things have ahigher priority

Smoking cessation paradoxOther things have higher priority53Helping patient stop is part of job87Stopping is primarily down to willpower92Smoking is addictive97Smoking is a medical condition81Smoking is a lifestyle choice690 20 40 60 80 100PercentPfizer-sponsored survey: Interviews with 2836 smoking and non-smokinggeneral practitioners in 16 countries

Barriers To Treating Smokers• I have too little time• I will alienate my patients• Treatment doesn’t work (smokers don’t quit)• I don’t know what to do• Smokers don’t want it, or can’t afford it• It’s not my job• It’s not cost-effective to treat tobacco(institutions)

Barriers To Treating SmokersReasons for smokers not engaging physicians•Rather try on my own first•Know smoking is bad or don’t want a lecture•Doctor really doesn’t care to help•Doctor isn’t knowledgeable about quitting•Poor rapport with doctor•Unpleasant past quitting attempts

Closing the Gaps in Smoking CessationAssisting GP toprovide basic carefor smokerssocietyHealth CareProvidersActiveSmokersCessationClinicProviding NGOeducationSystem interventionMotivating smokersProviding smokingcessation servicefor smokersGovernmentSmokingcessationtreatment

5 A’s A s Model of Brief Counseling• ASK• ADVISEOffice staffCore physician role• ASSESS• ASSIST• ARRANGERefer to in-houseor communityresource

Roles of Physicians• A physician:– Discusses smoking status with the patient– Informs the patient of the health consequences– Advises the patient to stop smoking– Possibly prescribes medication• If a patient is interested in giving up,– Assists with further counseling: nurses, pharmacist– Refer to quit smoking clinic– Follow up

Changing Roles of Primary CareThe case study from UK• 1960-1970: Explain the dangers• 1980-1990: Motivate quit attempts andprovide treatment (5As, NRT)• 2000-present: Motivate quit attempts andrefer to specialist service

Elements Needed to Manage TobaccoDependency Effectively• Clinicians trained in brief intervention• Referral sources available (Quitlines, clinics)• Cessation medications available and affordable• Practice systems in place Identify, document smoking status Easy, systematic way to make referrals Performance routinely monitored and rewarded• Take advantage of opportunities (no-smoking law?)

Set Up Smoking Cessation ClinicHealth care system, hospital vision/missionSWOT analysis external/internal factorsIdentify goal and target population, how torecruit smokersDecide on service providedDesign system, tools and data collectionFunding and how to maintain program

Smoking Cessation Clinic Models• Dedicated central clinics– Spain• Proactive Quitlines dispensing NRT– USA• Specialists within primary care– France– Japan• Mixed model (full-time clinics plus trainedprimary care staff)– UK (comprehensive NHS network since 2000)

King Chulalongkorn MemorialHospital Smoking Cessation Clinic1,300 beds hospitalProvide all level of care and affiliate with faculty ofmedicine Chulalongkorn universitySmoking cessation started as part of “ COPD” clinicManaged by Pulmonologists, fellows, trainees,nurses and technician8.00-15.00 daily, Monday-FridayWalk-in or referral from primary physicianFocus on brief intervention and counseling

Ask, Assess, and DocumentTobacco-Use StatusTobacco history isas important asother vital signsActive smoking is anactive problem andshould be prioritizedVital SignsBlood PressurePulse WeightTemperatureRespiratory RateTobacco Use: CurrentFormer Never

Active smokerNon smoker

ASK: Smoking statusOffice staff (medical assistant, nurse) Asks about smoking status Documents smoking status in chart Generates reminder to doctor toaddress patients tobacco use

Smoking Cessation RegistrationGeneral informationSmoking/ tobacco historypast experiencemotivation/ willingnessnicotine addiction assessmenttrigger factorsaddress/ how to contact

Assessment of Patients Important data for cessation plan amount of cigarettes/day past experiences Fagerstrom’s score for nicotine addiction contraindication for medication patient’s expectation cost/ socioeconomic status Exhaled CO Lung function test

Treatment Brief intervention byPulmonologist followed by nursestrained in counseling (20-25 minutes)Prescribe medications ( Bupropion,nortriptyline, nicotine supplement)Psychologist consultation as neededFollow up in 2 weeksTelephone follow up

Roles of Cessation Clinic• Referral center for smoking cessationtreatment (by physicians or self-referred)• Development of guidelines and systeminterventions to facilitate smokingcessation in heath care settings• Educating health care providers,students• Research in smoking cessation

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