Many brave smokers will put their cigarettes down for the Great American Smokeout this Thursday and maybe even longer. “Yuma has the lowest smoker rates in Arizona, and we could conclude that those who do smoke are among the most addicted, the remaining are hardest to reach, which means that the people who do smoke need a lot of help,” said Christina Borrego, spokeswoman for Arizona Bureau of Tobacco Education & Prevention.

“They need to know how to do it right,” Borrego noted.

In support of employees and community members who will quit for at least that day, Yuma Regional Medical Center will hold a special celebration in the cafeteria from 11 a.m. to 1 p.m.

Hospital officials hope to inspire and encourage smokers to quit for one day and set a long-term plan to quit permanently.

“People have probably tried to quit but weren’t successful so what we’re doing at YRMC is encouraging them to try again,” said Apryl Brand, project coordinator for the hospital’s Smoking Cessation Project.

Although the Great American Smokeout celebration at the hospital is primarily focused on employees and their families, the public is welcomed.

Starting on that day, the hospital will start a smoking cessation support group from 5-6 p.m. at YRMC Cafeteria Dining Room A. It’s open to anyone interested in receiving help to quit tobacco use. Counselors trained by the American Cancer Society will be on hand.

“Research shows that support groups can influence someone’s health care a great deal,” Brand said. “They might meet someone at the support group, someone they can call when they need to and give each other encouragement.”

The Smoking Cessation Project has been meeting for a year to decide how to roll out a program. Members decided to do it in three phases: educating patients, helping employees and starting a support group.

The patient program will roll out soon, but the group has decided to kick off the employee program and support group on the day of the Great American Smokeout.

“We’re not there to condemn or coerce, just support people in their desire to quit,” Brand said.

As a chemotherapy nurse, Brand has seen the effect smoking has had on patients and their families.

“I have seen the sadness to families whose member have been diagnosed with lung cancer and COPD (chronic obstructive pulmonary disease),” she said.

“And then there’s second-hand. It smoke shows up as asthma and pneumonia in people who use tobacco and their children. People need to do this primarily for themselves and then their families.”

Brand noted 700 Yumans are diagnosed with cancer each year and that 30 percent of all cancer deaths come from tobacco use.

Statistics also note that smoking costs about $195 billion in annual health care costs and lost productivity in the workplace.

In addition, the American Cancer Society indicates that 87 percent of lung cancers are attributed to smoking. Tobacco-related diseases affect 443 Americans and are responsible for 1 in 5 deaths in the U.S.

“Now that’s a lot of people,” Brand said. “We hope to cut down those numbers so people can live a healthy life.”

She noted the challenges in quitting. “Cigarettes have a lot of chemicals, hazardous, toxic chemicals, that are added to addict people physiologically and psychologically. People have told me it’s worse than cocaine and alcohol.”

She’s also perturbed with the rising popularity of smokeless tobacco, which allows smokers to get their nicotine fix while working in smokeless facilities.

On a recent trip to Circle K, an employee told her he regularly uses smokeless tobacco at work.

“As a nurse, I just had to tell him (about the risks). I don’t meant to preach, but I have to educate people. It’s part of my oath to do no harm and educate people.”

She also worries that “kids are probably using this and their parents don’t even know it.”

The Smoking Cessation Project hopes to educate people about the risks associated with all types of tobacco use, including cancer of the mouth, throat, bad teeth and bad gums.

The group is working closely with the Arizona Smokers’ Helpline — www.ASHline.org — which offers personal coaching, prescription medication and free over-the-counter items such as nicotine gum, lozenges and patches to help smokers quit.

In addition, most insurance plans, including the Arizona Health Care Cost Containment System (AHCCCS) covers medication.

With the hope that many smokers will quit for the Great American Smokeout and beyond, Brand offered a piece of advice to nonsmokers.

“We need to go easy on people trying to quit. Their nerves are on the line. We need to support them by understanding that they are going through a lot.”

Smokers who suffer a stroke that causes a lesion at the insular cortex are more than 5 times more likely to stop their nicotine habit than those whose stroke did not result in such a lesion, according to a new study. In addition, the researchers found that preparedness to change also influenced successful smoking cessation poststroke.

The study results were not surprising, given that research has already shown that biological and psychological factors help explain smoking cessation in patients with stroke, said the study’s lead author, Rosa Suňer Soler, PhD, from the Neurology Department, Josep Trueta Hospital, Girona, Spain.

Biologically, the insular cortex may play an important role in emotional decision-making, and in terms of psychology, smoking behavior may be explained by stages, processes, and levels of change, Dr. Suňer told Medscape Medical News. “Before you stop smoking, you must be aware that you have a problem and take the decision to stop smoking.”
The analysis included 110 patients who were smokers when they suffered an acute stroke and were admitted to a stroke unit between January 2005 and July 2007. Researchers recorded sociodemographic and other variables, as well as information on smoking, including number of cigarettes smoked per day and level of nicotine dependence. In addition, they categorized patients according to their stage of preparedness to quit smoking before the stroke: precontemplation, contemplation, preparation, action (stopped smoking for less than 6 months), or maintenance (smoke-free for at least 6 months)

From computed tomography or magnetic resonance imaging scans, investigators classified lesions affecting the insular cortex by hemisphere (right or left side) and subtype (ischemic or hemorrhagic) and measured the volume of the cerebral infarct or hemorrhage.

Patients were evaluated at 3, 6, and 12 months after the stroke. Smoking abstinence was confirmed by recording expired carbon monoxide levels. Patients also assessed their difficulty in giving up smoking and their urge to restart the habit.

Patients smoked on average 27.6 cigarettes per day, had a mean score of 6.1 points in the Fagerström Test of nicotine dependence, and had started smoking at a mean age of 17.1 years. Of the sample, 85.5% said that before the stroke, they were not considering stopping smoking in the near future.

In 24.5% of the patients, the stroke-related lesion affected the insular cortex. At discharge, 69.1% of patients indicated they had given up smoking during hospitalization, including 88.9% of the patients with an insular cortex lesion and 62.7% of those without (P = .05).

At 1 year, 70.4% of participants with insular cortex lesions had stopped compared with 30.1% of those without (P < .001).

Having a lesion at the insular cortex was associated with significantly increased odds of quitting smoking (odds ratio, 5.42; 95% confidence interval, 1.95 – 15.01; P = .001).

According to Dr. Suňer, the insular cortex may regulate the experience of conscious urges and cravings with other specific brain areas. Disruption of hypocretin transmission in the insular cortex may also help explain decreased tobacco consumption in smokers with damage to this brain region, she added.

Having the intention to stop smoking before the stroke also increased the odds of successfully quitting the habit (odds ratio, 7.29; 95% confidence interval, 1.89 – 28.07; P = .004). In addition, patients who stopped smoking had a lessened perception of difficulty in stopping smoking.

“Considering our results, we must adjust therapeutic interventions to stages of change in patients” and help them to quit if they have raised a concern about smoking, said Dr. Suňer. She suggested that physicians systematically ask patients who smoke what stage they are at in terms of quitting.

Smoking Dangers

The study also showed that only a third of the patients associated stroke with their smoking habit. “It shows how little knowledge people have of the true dangers of smoking,” said Dr. Suňer. “We explain to our acute stroke patients the risk factors and the importance of prevention, but there must also be more information campaigns among the general population.”

As well as emphasizing this lack of awareness that smoking is a stroke risk factor, the study also highlights the fact that willingness and consideration to stop the habit before the stroke help patients quit afterward, said Joseph Broderick, MD, chair of neurology, University of Cincinnati, Ohio, and a member of the American Academy of Neurology, when asked to comment.

“It is also remarkable that despite a life-changing event such as a stroke, so many patients continue to smoke,” Dr. Broderick told Medscape Medical News.

Dr. Broderick questioned whether language disruption, which often accompanies insular damage in the dominant hemisphere, plays a role in smoking cessation.

“The volume of brain injury was similar for the smokers and those who successfully stopped,” he noted. “I wonder whether language impairment per se could be associated with increased likelihood of stoppage, rather than an effect upon emotional and reward processing in the brain.”

Practice administrator Glenn Jennings, M.B.A., lost both his parents to smoking-related illnesses and his father-in-law to lung cancer, so he and his wife, family physician Carrie Burns, M.D., already were advocates of not smoking well before their Baytown, Texas, practice participated in the AAFP’s Office Champions Tobacco Cessation Pilot Project.

“What the project did was raise our level of awareness in our office, give us some tools and make us do some thinking about how we could be more effective,” said Jennings, who served as the practice’s office champion. “We became more effective as an office in identifying people who needed to quit smoking and adding new procedures.”

Jennings’ experience with the pilot is far from unique. Forty-nine participating practices were asked to review patient charts before and after the 13-month pilot, which was based largely on the AAFP’s evidence-based Ask and Act program. The percentage of patient charts with documentation of tobacco use status increased from 82.1 percent to 90.2 percent during that period, while the percentage of charts with documentation that patients were offered cessation assistance increased from 47.8 percent to 72.1 percent.

Each practice was required to name an office champion to lead the project and a physician champion to ensure that the office champion had the support of staff. The office champions were required to complete a training program, identify and implement system changes to better integrate tobacco cessation activities into daily office routines, and create a culture that encourages cessation.

According to the pilot’s final report (19-page PDF; About PDFs), practices successfully implemented 85 percent of the changes identified in their implementation plans, and 98 percent of practices expressed confidence that the changes they did make could be sustained.

Many of the changes were based on a practice toolkit provided by the AAFP that includes the following resources:
quit-smoking posters;
a smoking cessation group visits guide;
billing and coding information for smoking cessation-related services;
patient education materials;
lapel pins; and
“prescription pads” that list helpful information for patients before, during and after they quit smoking.
Jennings said Burns’ office had patient education materials and quitline cards in the waiting room and every exam room. In addition, medical assistants reviewed a stop-smoking booklet with patients and gave copies to patients who indicated they were ready to quit. The medical assistants followed up with those patients a week after their appointments to check their progress.

A quitter is defined by Merriam-Webster dictionary as one who gives up too easily. Sometimes quitting isn’t as easy as it seems. Sometimes quitting isn’t always a negative thing. Army Staff Sgt. Latasha Wade, Headquarters and Headquarters Company, 3rd Maneuver Enhancement Brigade, knows how difficult it can be to quit. Quit smoking, that is. “I smoked for 16 years,” Wade said. “I quit smoking when I met my husband. At that time he had been cigarette free for two years and he didn’t want to relapse being around a smoker. So I quit smoking five months after we started dating.”

Wade quit gradually.

“I was hiding it from my husband while we were dating and eventually I got tired of hiding it and I quit,” Wade said. “The advice I would give someone who wants to quit smoking would be to find something to motivate them to quit. Be it for health reasons, saving money or their significant other.”

Among current U.S. adult smokers, 70 percent report that they want to quit completely, and millions have attempted to quit smoking, according to the Centers for Disease Control and Prevention.

“I consistently smoked for 10 years,” Army Staff Sgt. Kevin Hoffman of the 98th Maintenance Company said. “I thought, this isn’t helping me any, and I had a new son. It was also getting expensive anyways, so I quit. It took about six months.”

His first attempt to stop smoking cold turkey failed, so he took another approach and quit gradually.

“I started smoking again for a couple weeks and I was like, ‘naw, this is just wrong.’ So then I just started slowly stopping and then one day I just threw the pack of cigarettes I had left away and I refused to smoke from then on.”

Hoffman said the reasons to quit go beyond your own health.

“You need to quit for the people that you love if not for yourself,” he said.

Here on Joint Base Elmendorf-Richardson, for Soldiers, Airmen, civilians and family members who would like to quit using tobacco products, the opportunity to quit is locally available.

A great way to start is to attend a tobacco cessation class.

“If they are ready to quit smoking today, what we normally do is invite them to attend the class,” said Janice Fulton, a health educator, at the JBER Health and Wellness Center, or HAWC. “The research over time has shown that on doing tobacco cessation in a group setting with that kind of support just increases your chances for success.

“If you’re determined to absolutely, positively quit today, we will definitely sit down and talk with you. If you want to do medications, then we’ll refer you to one of the providers involved with the tobacco cessation program who are able to prescribe the tobacco cessation medications.”

“Sometimes the folks that attend the class bring a family member like a spouse who’s going to be their support system in their cessation efforts, so they’re perfectly welcome to come to the class also and hear the information,” Fulton said.

There needs to be an environment of support for people trying to quit, according to Rebecca Kleinschmidt, a Health Educator, who also works at the HAWC.

“If the environment they’re in doesn’t support those changes, it’s really difficult for people to stay tobacco free. There are a lot of different stages in the progress of change. Action is one of those, but if people are in the preparation stage and their not quite ready to change, but they’re thinking about it, they’re very welcome here. They don’t have to be actively quitting smoking in order to participate in our class.

“We get people who really need to build their confidence before they jump into trying to reduce or quit. This is a good place to learn some skills on how to build their confidence, how to set reasonable goals and learn tricks that will make them feel more powerful in this fight against tobacco.”

It’s normal for many tobacco users to try quitting several times before succeeding, according to Fulton.

“That’s typical,” Fulton said. “Most people will tell you they’ve tried 8-11 times before they finally quit and that’s ok. They can come back as often as they need to. That’s OK.

Kleinschmidt feels there is a decrease in smoking during the winter months.

“I think people, around the holidays and New Year’s, reflect upon changes that they want in their lives,” Kleinschmidt said. “In addition, because of policy changes and environmental changes, it’s more common that people have to smoke outside and in the cold winter months here, that’s sort of a barrier to people. So when they have to smoke outside when it’s so cold, it’s sort of a reminder too: ‘Do I really want to be doing this? Is this really worth it?’”

Smokeless tobacco is also addressed at the three-day class.

“Since I’ve been involved in the smoking cessation program I’ve seen an increase in smokeless tobacco use,” Fulton said. “There are a lot of folks who use both, smoke and use smokeless tobacco, and have a tendency to use smokeless tobacco when the weather prohibits them from going outside. We’ve seen those rates increasing over time.”

The first day of class covers methods of quitting, including pharmacotherapy. A medical staff member spends time with each participant talking about what medication they want to use, if any, and making sure there are no contraindications present.

The second day covers triggers of use, normal withdrawal symptoms, both physical and psychological, and addresses any issues the participants have experienced since the first class. This day also includes nutrition counseling. The HAWC dieticians address weight gain issues after tobacco.

Day three addresses stress management and techniques for dealing with daily stressors without resorting to tobacco use and relapse prevention.

“The training is not restricted to tobacco or nutrition,” Fulton said. “We can do other things like cold weather injury prevention, infectious disease, STDs or other health related training.

The HAWC can take that training to any unit, Army or Air Force, on JBER, according to Fulton.

“Our primary objective is to provide primary prevention, which is to help people with small lifestyle changes that reduce the risk of illness or disease,” Kleinschmidt said. “We also provide secondary prevention, which is for people who weren’t diagnosed with an illness or a disease, but their symptoms can be managed with lifestyle changes. For example, the diabetic patient can be given nutritional advice and be given help on becoming more active and they can really control their insulin levels and control their symptoms ultimately with lifestyle changes.

Tobacco cessation is just one area of emphasis for the HAWC. The center can build preventive health training programs for units on nutrition, fitness, cholesterol reduction, STD awareness and other issues upon request.

“We mainly go by what people want and what people need, but the top two causes of unintentional or preventable death are tobacco use and overweight due to poor nutrition and inactivity,” Kleinschmidt said. “Those are the two major things we focus on. So many people needlessly die because of those two issues that are lifestyle based.”

Did you know that in the past year, one in five Knox County teens has smoked a cigarette? The state also earned an “F” last year in tobacco prevention and cessation coverage. But TennCare and others are working to change that. In July, the state expanded TennCare’s coverage for smoking cessation agents from just teens and pregnant women, to all people enrolled trying to quit.

“The governor has been very vocal about wanting to improve the health status of Tennessee. And this is one step toward that goal,” said Kelly Gunderson, director of Communications with TennCare.

“If you think about the people that die every year from smoking-related illnesses, even those who are non-smokers. It’s just a huge huge impact on our state’s health,” said Sarah Harder with the Metropolitan Drug Commission.

Now the Tennessean reports the TennCare Pharmacy Advisory Committee is recommending that more anti-smoking agents be added to the preferred drug list.

“If you really go through and use a product to stop smoking. That you really do work with your physician and work out a plan that’s actually helpful and help you succeed in,” said Gunderson.

Harder says if people are looking to quit, you can do more than chewing gum or wearing a nicotine patch.

“Using the therapy and the agents are going to give you the best chance to succeed in quitting and to keep you off the nicotine in the long run,” said Harder.

Smoking not only hurts the environment, it hurts wallets.

“For employers, for every smoker, it’s going to cost them $3,500 for their health care benefits and lost productivity and those sorts of things,” said Harder.

She adds that 46% of people in Knox County have tried cigarettes at least once.

Another disappointing blow for those trying to kick the tobacco puffing habit has come to light. Taking the popular smoking cessation drug Chantix, known for its ability to curb the intense craving for nicotine, has been found to increase the risk of heart attack and stroke by as much as 72 percent, whether or not they currently suffer from heart disease.

The findings of the new study recently published in the Canadian Medical Association Journal have prompted the U.S. Food and Drug Administration (FDA) to issue a statement that advising that “The known benefits of Chantix should be weighed against its potential risks when deciding to use the drug in smokers with cardiovascular disease.”
The conclusions of the new research come a little more than one week after the FDA reported that the use of Chantix among people with heart disease poses a small yet significant risk of heart attack and stroke based on the results of a study of 700 people.
Pfizer’s Chantix is the best-selling prescription drug for smoking cessation in spite of carrying an FDA required “black box” label due to known side effects including depression, suicidal thoughts, and nightmares. In addition, the drug is known to intensify psychiatric symptoms among those with a history of experiencing them prior to taking it.
Lead study author, Dr. Sonal Singh, assistant professor of medicine at Johns Hopkins University, pointed out that until now both the Pfizer and the FDA have failed to pursue signs of cardiovascular risk since the approval of Chantix for use in 2006. “The FDA should have already put it on their warning label. The risk is substantial, the risk is present in smokers without heart disease, and Pfizer knew about this for five years.”

Even though texting has its disadvantages (from having caused car accidents to aiding in ugly bullying of all kinds), there might be a new benefit to the cell phone function. A study by The Lancet, a medical journal, found that smokers that received texts with motivational messages are more likely to stop smoking.

Out of 5,800 participants, 2,915 smokers received encouraging texts from “txt2stop,” a mobile-based smoking intervention program. (The other 2,885 were in the control group that didn’t receive txt2stop messages.) For example, the smokers in the first group would receive messages that read, “TODAY is the start of being QUIT forever, you do it.”

So okay, the messages aren’t exactly grammatically sound, but the participants responded well to them. The Lancet reported for the group that received motivational messages, the success rate was 10.7 percent, while the second group which did not receive motivational messages had the success rate of 4.9 percent.

Smokers in that first group also texted the words “crave” and “lapse” to indicate when they’re having a tough time with smoking cessation. Txt2stop would then reply encouraging words and suggestions like, “Cravings last less than 5 minutes on average. To help distract yourself, try sipping a drink slowly until the craving is over.”

The conclusion? The Lancet reported, “The txt2stop smoking cessation programme significantly improved smoking cessation rates at 6 months and should be considered for inclusion in smoking cessation services.”

Recent legislative changes mean that medical practices can get paid for helping Medicare and privately insured patients quit smoking. “When physicians do the work and document this work, then you can bill and get it paid,” said Tom Houston, MD, a family physician at McConnell Heart Health Center in Columbus, Ohio, who has long worked on tobacco-related issues. And there most likely will be incentives beyond the usual fee for service, such as bonuses for meaningful use of electronic medical records and meeting quality metrics from private insurers.

So how do physicians get paid for counseling patients about quitting smoking?

The U.S. Dept. of Health and Human Services announced Aug. 25, 2010, that smoking cessation will be paid for under Medicare Parts A and B. Previously, the program paid for cessation only for patients who already developed a tobacco-related medical condition. This change was supported by the American Medical Association, and private insurers are expected to follow suit if they haven’t already done so.

“For practices, one of the biggest challenges is the patchwork of coverage that varies by payer, but more and more private insurers are expanding their coverage of tobacco dependence,” said Michael Fiore, MD, MPH, director of the Center for Tobacco Research and Intervention at the University of Wisconsin in Madison.

Private insurance and Medicaid coverage will vary, but Medicare will pay for two attempts to stop smoking that involve a maximum of four cessation sessions each per year.

Practices can expect to receive $10 to $15 for shorter smoking cessation sessions and $25 to $30 for longer ones, and much of this should come from insurers. A trained office member usually provides smoking cessation counseling.

“Many offices are getting a nurse or medical assistant trained in motivation counseling, education and intervention,” Dr. Houston said.

Bonuses for incorporating smoking cessation into a practice beyond the usual fee for service also are possible. Using an EMR to tally the percentage of patients asked about tobacco use and delivering a cessation treatment is one of the quality reporting requirements to qualify for meaningful use incentive payments. Tackling tobacco-related issues is expected to become part of quality measures that allow physicians to receive bonuses within an accountable care organization.

Experts say the first step toward incorporating smoking cessation into medical care is developing a system that will tell physicians which patients use tobacco. This may be in the form of an alert attached to an EMR or require less technology, such as a sticker attached to a paper chart.

The next step is to assess a patient’s readiness to quit. Surveys have indicated that most smokers want to give up tobacco, but they may be unaware of their options beyond quitting cold turkey.

“The majority of smokers want to quit,” said Carol Southard, RN, a tobacco treatment specialist at Rush University Medical Center in Chicago. “We have a captive audience.”

When initiating counseling, questions to ask a patient include: What worked in the past? What didn’t? How much tobacco do you use? Do you smoke cigarettes or use other forms of tobacco? Would a prescription smoking cessation drug be appropriate? What about nicotine replacement therapies? What should your quit date be?

The information should be documented in a patient’s chart along with the time spent on this subject.

“This can be an estimate,” said Cindy Hughes, a coding and compliance specialist with the American Academy of Family Physicians. “This is not something that requires that they have a stopwatch in hand.”

The visit needs to be coded appropriately. The ICD-9 codes for patients without a tobacco-related illness are 305.1, nondependent tobacco use disorder, or V15.82, history of tobacco use.

For Medicare patients, the service should then be coded G0436 if the counseling is more than three minutes but less than 10. Smoking cessation counseling longer than 10 minutes should be coded G0437.

For patients with private insurance, the CPT code is 99406 for the shorter visit and 99407 for the longer one. Modifier 25 should be used if the evaluation and management codes characterize the focus of the visit.

“Be sure to make your staff aware of the ability to bill for this, and make sure it’s being reported appropriately,” Southard said.

Smoking cessation counseling shorter than three minutes is not a separate billable service.

Quitting smoking eight weeks or less before surgery doesn’t increase a patient’s risk of postoperative complications, say British researchers who reviewed nine previous studies. “Cigarette smoking has been implicated as a risk factor for postoperative complications across a spectrum of surgical specialties,” according to background information with the study. “Compared with nonsmokers, smokers who undergo surgery have longer hospital stays, higher risk of readmission, are more likely to be admitted to an intensive care unit, and have an increased risk of in-hospital mortality.”

The researchers also noted that existing evidence does not offer clear guidance on when it’s best to quit smoking before surgery.

“When all nine studies are combined, there is no beneficial or detrimental effect of quitting within eight weeks before surgery compared with continue smoking,” wrote Katie Myers and colleagues at Queen Mary University of London, Barts and the London School of Medicine and Dentistry in a news release.

But these findings need to be interpreted with caution, they added.

“Future studies should focus on patients with a very short duration of abstinence and should use biochemical validation of self-reported abstinence. In the meantime, until some new evidence of harm emerges, firm advice to stop smoking and an offer of smoking cessation treatment to those who need it can be provided to pre-surgical patients at any time,” the researchers concluded.

The article appears in the March 14 online edition of the journal Archives of Internal Medicine.

Two of the review co-authors said they have received research funds and act as consultants for companies that make smoking-cessation products.

While the review offers some valuable information, it does not provide a definitive answer, said the authors of an accompanying editorial.

“Physicians should ideally try to get their patients to stop smoking several months prior to their surgery. The appropriate advice regarding the optimal timing of smoking cessation for patients seen close to their scheduled surgery awaits further research,” wrote Clara K. Chow and P.J. Devereaux of the Population Health Research Institute at McMaster University in Hamilton, Canada.