UCSF Celebrates World No Tobacco Day

Participating Organizations
Habit Abatement Clinic Tobacco Education Center
– (TEC, at Mt. Zion)

Rx for Change Tobacco Free Nurses Smoking Cessation Leadership Center Tobacco Documents Archive Tobacco Documents Library

Chinese Smokers Study Latino Web-based study American Heart Association American Lung Association American Cancer Society Nightingales UCSF Center for Tobacco Control Research & Education UCSF Division of Thoracic Oncology

UCSF Celebrates World No Tobacco Day

Expanding the Clinician’s Role in Tobacco Cessation: Impact of the Rx for Change Program

Mary Anne Koda-Kimble, PharmD
Professor and Dean, School of Pharmacy University of California at San Francisco

is the chief, single, avoidable cause of death in our society and the most important public health issue of our time.”
C. Everett Koop, M.D., former U.S. Surgeon General 1982

Training Future Clinicians

Robin Corelli, Karen Hudmon, Lisa Kroon, California Faculty

Rx for Change: Vision and Curriculum Goals
State-of-the-art training program
TURN-KEY, SHARED PROGRAM Easily integrated into existing course structures Supported by evidence-based research
• •

USPHS Clinical Practice Guideline, 2000 Peer reviewed by national experts

Rx for Change: External Reviewers
Neal Benowitz, MD Bruce Berger, PhD, RPh Li Cheng, PhD Timothy Cline, PhD Carlo DiClemente, PhD Stanton Glantz, PhD Taline Khroyan, PhD Alexander Prokhorov, MD, PhD Frank Vitale, MA

Rx for Change: Overview
Tobacco cessation curriculum for PharmD students
• •

California graduates qualified to intervene with all tobacco users Hands-on, skills-oriented training

6- to 12-hour modular program
• • •

Didactic lecture material Emphasis on behavior change Interactive, hands-on workshop

Rx for Change: Core Modules
Epidemiology of Tobacco Use (20 minutes) Pharmacology of Nicotine & Principles of Addiction (45 minutes) Drug Interactions with Smoking (5 minutes) Assisting Patients with Quitting (90 minutes) Aids for Quitting (60 minutes) Role Playing: Case Scenarios (120 minutes)

Pfizer National Distribution Nicotine transdermal patches Nicotine nasal spray (placebo) Nicotine oral inhaler (placebo)


Students’ pre- and post-training self-ratings for five components of comprehensive tobacco cessation counseling:
Ask, Advise, Assess, Assist, and Arrange (n = 493).
Poor Fair Good Very good Excellent

Meansa (SD) 2.71 (1.16) 3.81 (0.82)

Ask about Pre tobacco use Post Advise Pre to quit Post Assess Pre readiness to quit Post Assist Pre with quitting Post Arrange Pre follow-up

2.01 (0.95) 3.61 (0.78)

All pre- versus post-training differences, p < 0.001

2.10 (0.95) 3.82 (0.82)

1.84 (0.93) 3.74 (0.82)

1.82 (0.95) 3.71 (0.87) 0 0% 20 20%


Percent of total responses

40 40%

60 60%

80 80%

100 100%

Corelli et al., Preventive Medicine, 2005.

Confidence to Counsel
Extremely confident

5 4 3 2 1 Pre-training

p < 0.001
Changes in confidence for cessation counseling: 12-item scale, Cronbach alpha = 0.92
n = 493

Not at all confident

Average item score

Corelli et al., Preventive Medicine, 2005.

Effect of Formal Training
Percentage of student pharmacists
97% 87%

Improved the QUALITY of their cessation counseling.

Will increase the NUMBER of patients they counsel for cessation.
Corelli et al., Preventive Medicine, 2005.

Disseminating Rx for Change: Student Pharmacists’ Views
Do you believe that students at other U.S. schools of pharmacy would benefit from receiving the same, or similar, training?

0 50


Corelli et al., Preventive Medicine, 2005.


Dissemination of Rx for Change
USA: 89 schools 95% trained faculty 9,000 students annually

“Disseminating a Tobacco Curriculum for Pharmacy Schools” National Cancer Institute: 1 R25 CA 90720 to Karen Hudmon

CALIF: 6 schools 700 students annually

Dissemination of Rx for Change US Schools of Pharmacy

71/85 (84%) of schools trained have implemented

National Estimates: Number of Students Trained
Pharmacy Medicine Dentistry Nursing Total

Number of students trained





1998-1999 1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005

Academic year


Rx for Change Current & Future Directions
Ongoing dissemination
Nursing: UCSF, other collaborators (Georgetown, Washburn) • Medicine: UCSF • Dentistry: UCSF, Baylor University

Future dissemination
Physician Assistant programs • Others: Respiratory Therapy, Occupational Therapy • International

International dissemination
Guatemala, Argentina (Spanish translation) • England • Japan

Practicing Clinicians

Courtesy of Mell Lazarus and Creators Syndicate. Copyright 2000, Mell Lazarus.

Amsterdam Airport

UCSF Celebrates World No Tobacco Day

What to Do with a Patient Who Smokes

Steven A. Schroeder, MD
World No Tobacco Day
May 31, 2005

Tobacco’s Deadly Toll
440,000 deaths in the U.S. each year 4.8 million deaths world wide each year 10 million deaths estimated by year 2030 8.6 million disabled from tobacco in the U.S. alone

Comparative Causes of Annual Deaths in the United States
Number of Deaths (thousands)
450 400 350 300 250 200 150 100 50 0
AIDS Alcohol Motor Homicide Drug Suicide Vehicle Induced Smoking


81 17 41 19 14 30

Source: CDC

Also suffer from mental illness and/or substance abuse

Annual U.S. Deaths Attributable to Smoking, 1995–1999
Cardiovascular diseases Lung cancer Respiratory diseases Second-hand smoke other than Cancers lung Other 149,000

125,000 28% 98,000 22% 9% 53,000 7% 31,000 2,000 <1%

TOTAL: more than 440,000 deaths annually
Centers for Disease Control and Prevention. MMWR 2002;51:300–303.

Health Consequences of Smoking
– Lung – Laryngeal, pharyngeal, oral cavity, esophagus – Pancreatic – Bladder and kidney – Cervical and endometrial – Gastric – Acute myeloid leukemia

Cardiovascular diseases
– – – – Subclinical atherosclerosis Coronary heart disease Stroke Abdominal aortic aneurysm

Respiratory diseases
– Acute respiratory illnesses, e.g., pneumonia – Chronic respiratory diseases, e.g., COPD

Reduce fertility in women, poor pregnancy outcomes, low birth weight babies, sudden infant death syndrome

Cataract Periodontitis

U.S. Department of Health and Human Services.The Health Consequences of Smoking: A Report of the Surgeon General, 2004.

Ways to Help Smokers Quit
Raise prices (taxes) Clean indoor air Create counter-marketing Provide cessation aids (counseling and pharmacotherapy)
– Directly by clinician in individual or group session (office or hospital) – Through toll-free telephone quitlines

Reasons for Not Helping Patients Quit
1. Too busy 2. Lack of expertise 3. No financial incentive 4. Most smokers can’t/won’t quit 5. Stigmatizing smokers 6. Respect for privacy 7. Negative message might scare away patients 8. I smoke myself

Responses to Patient Who Smokes
Unacceptable: “I don’t have time.” Acceptable
– Refer to a quit line – Establish systems in your office and hospital – Become a cessation expert

Nicotine Addiction Cycle

Reprinted with permission. Benowitz. Med Clin N Am 1992;2:415–437.

Nicotine Addiction
Tobacco users maintain a minimum serum nicotine concentration in order to
– Prevent withdrawal symptoms – Maintain pleasure/arousal – Modulate mood

Users self-titrate nicotine intake by
– Smoking more frequently – Smoking more intensely – Obstructing vents on low-nicotine brand cigarettes

Long-Term (≥6 Months) Quit Rates for Available Cessation Medications
30 25

Active drug Placebo
19.7 17.2 14.4 11.5

23.9 19.3 17.1 11.8

Percent quit

20 15 10 5 0





Nicotine gum Nicotine patch

Nicotine lozenge

Nicotine nasal spray

Nicotine inhaler


Data adapted from Silagy et al. Cochrane Database Syst Rev, 2002 and Hughes et al., Cochrane Database Syst Rev, 2000

Combination Therapy: Patch Plus Bupropion SR
Percentage of patients quit at 12 months after cessation
Nicotine patch plus bupropion Bupropion



Nicotine patch


Placebo 0% 5% 10%








Jorenby et al. N Engl J Med 1999;340(9):685–691.

Effects of Clinician Interventions
Estimated abstinence at 5+ months

n = 29 studies










0 No clinician Self-help material Nonphysician clinician Physician clinician

Type of Clinician
Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, 2000.

New Medications in the Pipeline
Rimonabant – Cannabinoid receptor inhibitor – Blocks reinforcing effects of nicotine – Also suppresses appetite – In phase III trials – Will likely be expensive Nicotine Vaccine – Produces antibodies to nicotine – Reduces nicotine levels in animals CYP246 Inhibitors – CYP246 is a hepatic enzyme that metabolizes nicotine – Higher blood nicotine levels per cigarette smoked – Could also increase potency of NRT

JCAHO Core Measures
Community Acquired Pneumonia Acute MI CHF Pediatrics

Adult Smoking Cessation Counseling Given to CAP Patients
UCSF 60 UHC CM Hospitals National Rate for Qtr

Observed Rate

50 40 30 20 10 0 Jan-March-03 N = 68 43 34


47 41


21 8.3
April-June-03 N = 45 July-Sept-03 N = 27

Smoking Cessation Advice Given to AMI Patients

100 80 60 40 20 0 Q3 2002 Q4 2002 Q1 2003

Q2 2003


Q3 2003

Adult Smoking Cessation Advice Given to CHF Patients w ho Smoke 100 80 60 40 20 0 Q3 2002 Q4 2002 Q1 2003 Q2 2003 Q3 2003 JCAHO

Quarter of Interest UCSF UHC

Treating Tobacco Dependence : 2003
•TOFCO •Oregon Quitline •Business Case

•Inpatient Program •Behavioral Health/CD

Health System
•Research > $800K •Leadership: ATMC RWJF, CDC, AAHP •Formal HSI Program

Target Groups
•Disease Management •PHS employees •Web-Based •Women & Children •Clinical Programs

(who wants to quit)

•Group Classes •Free Medications •Telephone Support •Self-Help Materials •Prov-RN

•5 A’s Training/Education •Reimbursement •Physician Leadership

Clinics Evaluation
•C.O.R.E. •Utilization •Grant Writing •5 A’s Training •EMR Resources •Dissemination (TAR) •Resources: Primary Care,
Specialties, Pediatrics, OB/GYN

Smoking Prevalence in PHP vs. Oregon
24% 23% 22% 21% 20% 19% 18% 17% 16% 15% '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 2000 State of Oregon (BRFS) Providence Health Plan: Oregon

Gold Card

Quitline Numbers
1-800 NO BUTTS (California number) 1-800 QUIT NOW (National number)

Barriers to Successful Cessation
Provider inattention/pessimism Co-dependency and mental illness No coverage for cessation drugs Improper use of the drugs Ignorance of quitlines

Strategies for Increasing Quit Rates
Reframe expectations of success Focus on mental health/substance abuse population Market quitlines better Develop newer drugs Create better systems Provide clinical champions

Power of Intervention
⅓ to ½ of the 46 million smokers will die from
the habit. Of the 32 million who want to quit, 10 to 16 million will die from smoking. Increasing the 2.5% cessation rate to 10% would save 2.4 million additional lives. If cessation rates rose to 15%, 4 million additional lives would be saved. No other health intervention could make such a difference!

UCSF Celebrates World No Tobacco Day

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