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Objective:

Tuality Health Alliance
Policy # IV-2

Subject: Tobacco Cessation

Page 1 of 7
Objective: To ensure implementation of a standardized tobacco cessation program for all, Tuality Health Alliance (THA) members who wish assistance with their tobacco cessation efforts. The THA Quality Improvement (QI) Department will monitor member participation, compliance, and quit rates annually. The THA Tobacco Cessation Coordinator will provide outcomes information to Primary Care Physicians (PCP). The Case Manager will conduct medical record audit and data collection. A. Tobacco use includes all forms of tobacco: smoking cigarettes, cigars or pipes, as well as using snuff or chewing tobacco. B. Adults who have not used tobacco for at least 6 months and who have an easily visible mark on their chart to that effect should have usage reassessed at nearly every visit. Everyone without a tobacco use mark on the chart or those with a mark indicating use within the past 6 months should be asked at nearly every visit about current use and the answer documented for the provider. This frequency of use assessment should be established as a clinic policy and should be done by a staff person, preferably the one who rooms the patient. C. The two most common ways to indicate tobacco use status are with an appropriate label on the chart or with a vital sign in the progress notes. D. Adolescents should have usage reassessed at nearly every visit, regardless of whether there is a chart notation of non-use, due to their risk of beginning tobacco use at any time. M:\Share\THA\POLICIES\Current Policies\Coinciding Word Policies\4-2 Tobacco Cessation.doc Tuality Health Alliance
Policy # IV-2

Subject: Tobacco Cessation

Page 2 of 7
E. Tobacco cessation is particularly important during pregnancy. It is recommended that clinics have a particularly consistent identification and cessation program for pregnant women and preconception visits. F. Tobacco cessation is also very important in those individuals with heart disease or other risk factors for heart disease. ADVISE- (to quit) The Physician’s Role: A. Patients not intending to Quit in Next 6 Months A user not ready to consider quitting within the next 6 months is called a pre-contemplator and is helped most when a provider avoids confrontation while conveying both the message that quitting is important and the desire to be helpful when the user is ready to consider quitting. A simple informational pamphlet about the problems attending tobacco use and an expression of the provider's desire to be helpful are far more productive than an attempt to scare or argue unwilling users into quitting.
B. Patient Not Intending to Quit in Next Month The contemplator is considering quitting within the next 1 to 6 months. Contemplators are accepting of supportive and respectful urging to quit and encouragement to start thinking about a serious plan for doing so. Persuasive written, audio, or video information about the pros and cons of quitting may be appropriate for contemplators C. For RECENT QUITTERS 1. The Relapse rate is high in the first year. 2. Suggest Relapse prevention strategies. 3. Medical record documentation of advice given and update 4. Most tobacco relapses occur within the first three months after cessation. Telephone calls, clinic visits, can be appropriate times to accomplish intervention for relapse prevention. 1 Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2001 Aug. 27 p. [41 references] M:\Share\THA\POLICIES\Current Policies\Coinciding Word Policies\4-2 Tobacco Cessation.doc Tuality Health Alliance
Policy # IV-2

Subject: Tobacco Cessation

Page 3 of 7
Minimal relapse prevention should be part of every primary care encounter with the patient who has recently quit. Encourage the person to continue tobacco free. D. Establish Second Hand Smoke Exposure for All Patients and Inform patients of their increased risk of disease due to second- hand smoke exposure. Encourage a smoke-free living and working environment for patients, and assist the exposed patient to communicate with other household members about decreasing smoking in the house. Encourage the patient to support smoking cessation efforts among other household members who use tobacco. A. Assessment of interest in quitting and timing of that interest should be done after the main reasons for the visit have been addressed, and should precede any advice about quitting. This allows a 1 to 3 minute tobacco discussion accommodating both the users’ needs and the provider's time limits. B. It is recognized that this discussion may not be possible or appropriate at each visit. The goal should be to discuss tobacco cessation at nearly every visit. C. Remember that progress from one stage of readiness to quit to If the patient is willing to make a quit attempt at this time provide assistance. If the patient will participate in an intensive treatment program, refer to Tuality Health Education Center’s Tobacco Cessation Program. If the patient is unwilling to quit at this time, a motivational intervention should be provided. IV. ASSIST-with Quitting Help the patient with a Quit Plan. A. "The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline" emphasizes that three treatment elements in particular are effective for smoking cessation intervention: M:\Share\THA\POLICIES\Current Policies\Coinciding Word Policies\4-2 Tobacco Cessation.doc Tuality Health Alliance
Policy # IV-2

Subject: Tobacco Cessation

Page 4 of 7
B. Nicotine Replacement Therapy Combining nicotine patches with other self-administered forms of nicotine replacement therapy as well as Cessation classes and support groups may be more effective than a single form of nicotine replacement therapy. Nicotine replacement therapy, Chantix (oral medication) and Zyban (bupropion) can be very helpful to selected patients. It is most effective if the patient agrees to completely stop tobacco use with the start of nicotine replacement therapy or 1 week after starting Zyban (bupropion) and the patient agrees to participate in a follow-up program of some type. Nicotine replacement therapy includes nicotine transdermal patches. C. Combination therapy If patients use nicotine replacement therapy or Zyban, it is important for them to become completely tobacco- free. Ongoing use of tobacco predicts failure long-term. One strategy is to encourage patients to make their tobacco-free program more intense with each use of tobacco after their quit date. They can add an exercise program, call a help line, ask for a friend's help, read a pamphlet, or contact THA’s Tobacco Cessation Coordinator for other options. Offer other resources such as self-help brochures and materials from drug companies, community support systems, THA Tobacco Cessation Coordinator, or tobacco cessation classes offered at Tuality Health Education Center. a. Set a quit date-ideally, the quit date should be within 2 b. Provide a supportive clinical environment while encouraging the patient in his or her quit attempt. c. Recommend the use of pharmacotherapies. d. Wants Extra Help in Remaining Tobacco-Free A former user who is having some trouble remaining tobacco-free may want or need more help than the provider can supply in the 2 to 3 minutes available to discuss this topic. Common difficulties include weight gain, stress, withdrawal symptoms, or social/ habit/ psychological needs. M:\Share\THA\POLICIES\Current Policies\Coinciding Word Policies\4-2 Tobacco Cessation.doc Tuality Health Alliance
Policy # IV-2

Subject: Tobacco Cessation

Page 5 of 7
Congratulate on Quitting/Encourage In-Office or Referral Those who have quit using tobacco within the last month (particularly within the past week) are at a very high risk for resuming use. Reinforcement and follow-up can be crucial during this period. The first 6 months after quitting are the transition between the Action and Maintenance stages. This time period (especially the first 2 weeks), is when one is at the highest risk for relapse, are the most challenging. Encourage the patient to avoid temptations to use tobacco again. Smoking cessation often takes 3 to 4 attempts before long-term success is achieved. The provider can do counseling and a referral to Tuality Health Education Center for Tobacco Cessation classes and support groups may be completed. Follow-up options include a face-to-face, telephoned or mailed postal or electronic expression of support and willingness to help. The timing of follow-ups should be discussed with the patient; generally, the follow-up should come at the time when it will be most needed or wanted. Notify THA Tobacco Cessation Coordinator of the following: 1. Member 2. Member Date of Birth 3. Primary Care Physician 4. Target Quit Date 5. Prescription Medications, if any THA-OHP- Referral with pre-approval into Tuality Healthcare Tobacco Cessation Program is recommended with the following therapies to increase the probability of success. 1. Nicotine Replacement Therapy (NRT) a. NicoDerm CQ b. Formulary medications do not require prior authorization. Member enrolls into “Committed M:\Share\THA\POLICIES\Current Policies\Coinciding Word Policies\4-2 Tobacco Cessation.doc Tuality Health Alliance
Policy # IV-2

Subject: Tobacco Cessation

Page 6 of 7
Quitters” Behavioral Modification program using 1-800-770-0708. Please inform member to tell counselor that he or she is a THA member for tracking purposes. 2. Non-Nicotine Therapy-Requires prior authorization. for website interactive support for tobacco cessation needs. a. Prior authorization is required. Initially a 6 week course of therapy will be approved followed by an additional 6 weeks if the member has quit. An additional 12 weeks (at 6 week intervals) may also be approved if the member can demonstrate that he/she has been able to remain tobacco free during therapy. When the Tobacco Cessation Coordinator is notified of any THA member contacting the “Quit Line” for assistance in cessation activities, the Tobacco Cessation Coordinator will notify the PCP by fax of the encounter. be done annually as data is made available through encounter and claims data, State audits, Case Manager audits, and PCP information. M:\Share\THA\POLICIES\Current Policies\Coinciding Word Policies\4-2 Tobacco Cessation.doc Tuality Health Alliance
Policy # IV-2

Subject: Tobacco Cessation

Page 7 of 7
Formulated: September 1998 Revised: January THA Plan Director
THA Medical Director
M:\Share\THA\POLICIES\Current Policies\Coinciding Word Policies\4-2 Tobacco Cessation.doc

Source: http://www.tualityhealthalliance.org/pdf/OHP/4-2%20PO%20Tobacco%20Cessation.pdf

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Perspectives: A View of Family Medicine in New Jersey Fibromyalgia: Practical Treatments for the Family Physician Richard N. Podell, MD Source: Perspectives: A View of Family Medicine in New Jersey (Written for Perspectives (4Q05), a journal of the New Jersey Academy of Family Physicians, and reprinted with permission.) Richard N. Podell, MD, Clinical Professor in the Department

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