Healthcare Provider Toolkit
Kit Tools | Staged Patient Brochures | Special Patient Audiences Brochures | Counseling Protocol | Brief Motivational Interventions

Introductory Guide

INTRODUCTION

The influence your role as a healthcare practitioner carries in helping tobacco users quit cannot be overstated. Evidence produced by the U.S. Public Health Service in 2000 shows that a clinician’s advice to quit improves a patient’s success in maintaining abstinence. With the addition of a few minutes of counseling, this success rate doubles.

One-third of the 3,306,700 adults in Texas who smoke will try to quit this year. Regrettably, only one in 20 will be able to stay tobacco-free. Tobacco claims the lives of approximately 24,200 Texans every year, and every year, about 32,200 young Texans under age 18 become new, daily smokers. Of all Texas youth alive now, nearly 503,000 will ultimately die from tobacco-related diseases.

Adding to this challenge is the $884.7 million spent annually on marketing tobacco in Texas. Research has found that children are three times more sensitive to tobacco industry marketing efforts than adults, and that cigarette marketing carries more influence than peer pressure in underage experimentation with smoking.

As daunting as the task of smoking intervention may seem, current data underscores this fact: the coordinated efforts of healthcare administrators, insurers, purchasers and practitioners can boost cessation success.

The tools in this kit are designed to support your clinic’s own tobacco intervention efforts. They offer flexibility to meet the needs of different office practices and different patients, and their focus on brevity, as with the enclosed “Quick Guides,” seeks to accommodate the busiest practitioner.

Use only those tools that fit the specific needs of your office, and enlist the support of clinic staff in implementing a system that ensures that, for every patient at every clinic visit, tobacco use is queried and documented. Most important is your consistent support of your patients’ efforts to stay tobacco-free.

KIT TOOLS

Treating Tobacco Use and Dependence: Quick Reference Guide for Clinicians

This guideline produced by the U.S. Public Health Service in October 2000 provides all clinicians with the tools necessary to effectively identify and assess tobacco use, treat tobacco users willing to quit, treat tobacco users who are unwilling to quit and assist former tobacco users. It summarizes the science-based methodology, research and clinical judgment used in developing these recommendations.

You may obtain a more complete Clinical Practice Guide by calling any of the following Public Health Service clearinghouses’ toll-free numbers:

“As clinicians, you are in a frontline position to help your patients by asking two key questions: ‘Do you smoke?’ and ‘Do you want to quit?’”

—David Satcher, M.D. Ph.D.,
former U.S. Surgeon General

Agency for Healthcare Research and Quality (AHRQ)
1-800-358-9295
Centers for Disease Control and Prevention (CDC)
1-800-CDC-1311
National Cancer Institute (NCI)
1-800-4-CANCER

The full text version of the guideline is available online for free by visiting the Surgeon General’s Web site at: www.surgeongeneral.gov/tobacco/default.htm. Download a PDF.

Fax Referral Form

This form is a convenient tool for ensuring that patients who are ready to quit smoking get the help they need. Use this fax referral form to recommend patients for free counseling services from the American Cancer Society’s toll-free Quitline. Submit online. Download a PDF.

5 A’s and 5 R’s Quick Guide

Designed as a handy reference for you to assist patients willing to quit (5 A’s) and patients unwilling to quit (5 R’s), this laminated card summarizes the brief clinical interventions prescribed by the evidence-based work of the U.S. Public Health Service. The card’s strategies underscore a central theme: it is essential to provide at least a brief intervention to all tobacco users at each clinical visit.

Pharmacotherapy Quick Guide

This laminated card is a handy reference for you to review clinical guidelines for prescribing medications for smoking cessation (side 1) as well as options and dosages (side 2). This quick guide supports the U.S. Public Health Service’s assertion that, in addition to counseling, all smokers making a quit attempt should receive pharmacotherapy, except in the presence of special circumstances. Download a PDF: Front and Back.

HOW TO OBTAIN REIMBURSEMENT

Numerous sources exist to provide healthcare practitioners and their administrative staff with information on how to code for reimbursement. Here are two:

PACT (Professional Assisted Cessation Therapy) produces a guide that contains advice for practitioners who wish to maximize benefits for smoking cessation, navigate around coverage deficiencies and advocate effectively for adequate coverage. Its Reimbursement for Smoking Cessation Therapy: A Healthcare Practitioner’s Guide can be viewed and retrieved, with its regular updates, on the PACT Web site for smoking cessation professionals, www.endsmoking.org.
The U.S. Public Health Service’s Clinical Practice Guideline also contains in its Appendix B coding information regarding the diagnosis of and billing for tobacco dependence treatment. The full text is available online at www.surgeongeneral.gov/
tobacco/default.htm.

Telephone “quitlines” have emerged as a successful method for tobacco users in Texas and nationwide. In fact, a randomized trial in 2000 to evaluate the American Cancer Society’s telephone counseling based in Austin, Texas, showed that “quitlines” garner double the success of self-help booklets and other cessation programs.

American Cancer Society’s 877-YES-QUIT Cards

Doctors, nurses, medical assistants, receptionists or others in your office are encouraged to hand these cards to patients ready to quit smoking or thinking about quitting. The enclosed stand also makes the cards freely available to patients in your office’s waiting and exam rooms. Convenient, tailored to each caller and confidential, the Quitline provides critical support to those who need it. The gray box titled Counseling Protocol summarizes the Quitline’s five steps. Download a PDF.

Tobacco User Identification Stickers For Patient Folders

These stickers can be placed on the patient’s chart so the tobacco user can be easily identified. Download a PDF.

“Yes You Can!” Quit Smoking Displays

For Brochures
For Quit Cards
Visual Aid

Download a PDF: Front and Back.

STAGED PATIENT BROCHURES

The following three patient take-home brochures address three distinct stages in the quitting process, allowing you to deliver appropriate materials for your patients’ smoking status.

Yes! I’m Ready to Quit.

This brochure contains, among other relevant suggestions and techniques, a personalized quit plan sheet that acts as a “contract” for your patient to set a quit date and write a quit plan. Download a PDF.

Maybe. I’m Thinking About Quitting.

This brochure acknowledges the difficulties in quitting an addiction and presents the many benefits and rewards of not smoking. A short worksheet helps your patients identify their personal reasons for quitting. Download a PDF.

No, I’m Not Ready to Quit.

This brochure acknowledges how a smoker feels and lists reasons why some people smoke. Risks and rewards are listed, including a “Healing Time Line” that charts the body’s healing from 20 minutes after the last cigarette to 10 years of smoke-free life. Download a PDF.

BROCHURES FOR SPECIAL PATIENT AUDIENCES

Smoking and My Baby

Quitting at any point in pregnancy can yield benefits. This brochure outlines the numerous risks to both the woman and the fetus, and builds on the increased motivation to quit during pregnancy. Download a PDF.

You’re Never Too Young to Get Addicted

This brochure finds ways to appeal to the fastest growing population of new smokers: teens. Every day, more than 3,000 young people under the age of 18 try their first cigarette. Designed to appeal to the special concerns and interests of teens, this brochure provides background information, tips for quitting and referral to the American Cancer Society’s Quitline at 1-877-YES-QUIT. Download a PDF.

Resources and Further Reading for Healthcare Providers

This list includes resources specifically for healthcare practitioners in Texas, plus Continuing Medical Education (CME) programs that provide training in the treatment of tobacco dependence. Download a PDF.

Resources and Further Reading for Patients

This list of Web addresses provides patients with sources for additional help and information. The convenient size makes them ideal for distribution to patients. Visit here.

COUNSELING PROTOCOL

Session	Schedule	Objectives
Initial Call	Intake and scheduling	Assess the caller’s willingness to quit and collect demographic information
1	Immediately following intake or within 7 days, depending on the caller	Determine the caller’s level of addiction, set a quit date and schedule next two sessions. Describe the counseling program and give pharmacotherapy information.
2	2 days before the quit date	Build on the caller’s initial motivation to call and engage actively in the counseling process. Also, help the caller prepare for the quit date with action and thought strategies.
3	1 day after the quit date	Help prevent relapses, which occur most frequently the day after the quit date. Address the caller’s withdrawal or relapse concerns and provide continued support and reinforcement.
4	About 1 week after session 3	Provide a booster to prevent a relapse. Assess the caller’s quit status and encourage his or her success. Engage in further training to prevent relapses. Encourage callers to not give up if they have a slip.
5	About 2 weeks after session 4	Make a final check-in, assessing progress and providing additional encouragement. Remind the caller this is the last session and answer any remaining questions. Reinforce caller for their success.

“Quitlines” offer tremendous convenience and flexibility and appeal to people of all ages and smoking habits. Trained counselors answer calls and assist each person in forming a personalized quitting strategy. The counseling protocol for the American Cancer Society’s Quitline, 1-877-YES-QUIT (1-877-937-7848) incorporates five sessions of 15 to 30 minutes each, plus up to three additional sessions for callers who relapse. People who relapse are advised to review their reasons for wanting to quit and to bring their learning experience to bear on their next quit attempt.

When your patients first call 1-877-YES-QUIT (1-877-937-7848), they learn about smoking cessation programs and services in their community, receive a set of booklets that offer tips on quitting and schedule the first counseling session. An outline of the American Cancer Society’s 1-877-YES-QUIT (1-877-937-7848) counseling protocol appears above.

Common Patient Concerns	Sample Responses
I’m worried I won’t be able to handle the withdrawal effects.	Soon after you stop smoking your body lets you know that it is recovering from all the smoking you’ve done. Try to think of these uncomfortable feelings as “recovery effects”—a sign that your body is healing itself. Withdrawal effects last only a short time, usually two to three weeks. Let’s talk about the medications that exist to help ease the symptoms of withdrawal. Here is a short list of tips to help you get past cravings and tough situations.
I know I’ll gain weight and I don’t want those extra pounds.	People differ widely when it comes to gaining weight after they stop smoking. If you use food, especially food high in calories, as your primary way to cope with smoking urges, then your chances of gaining weight are much higher. Try using the non-food coping techniques offered by the American Cancer Society and increasing your daily exercise. Keep in mind, too, that the benefits of quitting far outweigh the pounds you might gain.
I’ve tried to quit many times—and failed. Why should it be different now?	Most people who have quit for good have tried many times before—just like you. They learn from their experiences and apply this to their new attempts. My staff and I will support you in your new quit attempt.
Why do I cough more after I stop smoking?	Your coughing episodes after you quit are a healthy indication that your defense systems in your lungs are beginning to recover. In just a few months, you’ll cough less and have more energy and fewer sinus problems.
Isn’t it bad to put nicotine replacement drugs in my body?	It’s not the nicotine that is so bad for you; it’s all the other chemicals you inhale when you smoke. Nicotine replacement therapy delivers just enough nicotine to ease your withdrawal symptoms, so you can focus on quitting for good. In fact, let’s make sure you’re using enough (gum, spray, etc.).
I cut back by switching to brands lower in tar and nicotine.	Regrettably, the damage to your health remains the same. A number of studies have shown that smokers tend to compensate for changing to “lighter” brands by inhaling more deeply. Let’s discuss your options for a quit-smoking plan that works for you.

BRIEF MOTIVATIONAL INTERVENTIONS

“If every doctor, nurse, dentist or other healthcare provider and health plan uses this tool in practice across America, we can double quit rates, from 1 to at least 2 million new quitters each year.”

—Michael C. Fiore, M.D., panel chair in reference to the Quick Reference Guide for Clinicians included in this kit.

The five major steps—the 5 A’s and 5 R’s—to intervention recommended by the current U.S. Public Health Service guideline enclosed in this kit are brief, requiring 3 minutes or less of direct clinician time.

All steps underscore the importance of patient autonomy (e.g., choice among options) and self-efficacy (e.g., by identifying previous successes in behavior change efforts). Patients should be encouraged to indicate why quitting is personally relevant, plus any motivational information should be made relevant to a patient’s disease status or risk, family or social situation, health concerns, age, gender and other important patient characteristics, such as personal barriers to cessation. Talking to the father of a young child with recurring respiratory problems, for example, presents counseling opportunities distinct from talking to a teenager who hopes to join an athletic team.