| History |
The
Utah Healthcare Tobacco System & Treatment
Guidelines are based the Public Health Service
(PHS) Clinical Practice Guideline for Treating
Tobacco Use and Dependence. The PHS Guideline
was derived from a meta-analysis of 6000
research articles on treating tobacco use and
dependence in healthcare settings. Based
on this research, PHS compiled the most effective
treatment and referral methods into one 3-5
minute intervention called "the 5 A’s".
PHS also recommended that healthcare administrators,
insurers, managed care organizations, and
purchasers adopt systems changes that facilitate
the 5 A’s intervention. The Utah Tobacco
Prevention and Control Program and its
Utah partners in healthcare, public health and
advocacy contributed to the Utah Healthcare
Tobacco System & Treatment Guidelines. The Guidelines
are subject to constant revisions and improvement
as the research base expands and local
realities change.
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Utah Healthcare
Tobacco Treatment Guideline
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Utah
Healthcare Tobacco System Guideline
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Utah Healthcare Tobacco Treatment Guideline |
The
Utah Healthcare Tobacco Treatment Guideline is
based on "the 5 A's" intervention advocated
by the Public Health Service Clinical Practice
Guideline for Treating Tobacco Use and Dependence.
This guideline outlines the responsibilities of
clinicians and staff to treat and refer tobacco-using
clients. These activities may and should
be divided or shared among more than one member
of the clinic staff and usually only take 3-5
minutes of clinic time. For example,
a receptionist may provide the patient with an
intake form that asks if the patient uses tobacco,
a physician may advise the patient to quit and
prescribe pharmacotherapy, a nurse may help the
patient create a quit plan, and a case manager
may refer the patient to intensive counseling
and provide follow-up.
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Identify
and ensure documentation of tobacco use
status (current, former, never) for
every patient on his or her initial clinic
visit.
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Update
the tobacco-use status of all adolescents
at least annually.
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Update
the tobacco-use status of all adult tobacco-users
at least annually.
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Update
the tobacco-use status of all adult, former
tobacco-users who have used tobacco
in the last 5 years at least annually.
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to Top of 5As Section
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In a clear, strong, and personalized manner
advise every smoker to quit.
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Ask
each tobacco-using patient, "Are you ready
to try to quit using tobacco?"
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Provide
a motivational intervention to all patients unwilling
to quit: Discuss the Relevance of quitting
to the patient, Risks of tobacco use, Rewards
of quitting and solutions to Roadblocks.
Repeat at each visit.
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Review
past quit attempts to assess cessation strategies
which do and do not work for the patient.
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Diagnose
and treat underlying affective disorders, including
anxiety and depressive disorders, that
inhibit success of cessation treatments.
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Help
patients to set a quit date within 2 weeks.
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Help
the patient make plans to: |
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Tell
family and friends about their decision
to quit and request support. |
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Anticipate
and plan for challenges to the the quit
attempt, including nicotine withdrawal
symptoms, particularly in first few weeks. |
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Remove
tobacco from home, work & car. |
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Avoid
alcohol.
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Recommend
FDA-approved pharmacotherapies to patients that
desire to quit as indicated.
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Offer
FDA-approved pharmacotherapies to hospitalized
patients who use tobacco as indicated.
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Refer
the patient to the Utah Tobacco Quit Line (1-888-567-TRUTH), Utah
QuitNet (http://utahquitnet.com) or to another
group or individual cessation counseling
service providing 90-300 minutes of counseling
divided into at least 4 sessions.
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Distribute
tobacco cessation resources such as self-help
manuals and Quit Line referral cards.
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Schedule
follow-up, either in person or on the phone.
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Provide
relapse prevention intervention for all former
tobacco users, including congratulations
for quitting, strong encouragement to remain abstinent
and a brief discussion of the benefits derived
from quitting and how to solve any problems
encountered or anticipated threats to continued
abstinence.
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Provide
prescriptive relapse prevention interventions
to patients that indicateproblems with maintaining
abstinence.
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| Utah
Healthcare Tobacco System Guideline |
Clinicians
and staff are more likely to implement "the
5 A’s" intervention advocated by
the Public Health Service Clinical Practice Guideline
for Treating Tobacco Use and Dependence when
appropriate systems are in place to facilitate
tobacco dependence treatment. This guideline
outlines the responsibilities of healthcare administrators,
insurers, managed care organizations, and healthcare
purchasers to make tobacco dependence treatment
and referrals feasible for clinicians and staff.
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| Identification
of Tobacco-Using Patients |
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Have
a designated place to record tobacco use status
(current, former, never), such as a sticker
or stamp, on all patient charts or indicate smoking
status using computer reminder systems. |
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Hospitals
implement a system to identify and document the
current tobacco-use status of all hospitalized
patients. |
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Ask
pregnant women about tobacco-use status using
the multiple-choice format recommended by the
PHS.
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| Delegation
of Responsibilities |
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Identify
and assign staff or clinician(s) to implement
each of the 5 A’s.
(Different persons may be responsible for different
parts of the intervention.) |
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Include
tobacco dependence intervention in written protocol
or job descriptions and in the performance
evaluations of salaried clinicians and specialists.
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| Staff
and Clinical Education |
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Provide
training to clinicians and staff to implement
the 5 A's. On a regular basis, offer lectures/seminars/
in-services with continuing medical education (CME)
and/or other credit about tobacco dependence
treatment.
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Evaluate fidelity to 5 A model
and effectiveness of clinician and staff efforts. Drawing
on data from chart audits, electronic medical
records, and computerized patient databases,
evaluate the degree to which clinicians are
identifying, documenting, and treating patients
who use tobacco.
Provide feedback to clinicians about their performance.
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| Accessibility
of Cessation Resources |
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Evaluate
fidelity to 5 A model and effectiveness of clinician
and staff efforts. Drawing on data from chart
audits, electronic medical records, and computerized
patient databases, evaluate the degree to which
clinicians are identifying, documenting,
and treating patients who use tobacco.
Provide feedback to clinicians about their performance.
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Hospitals
make group or individual tobacco cessation counseling
available to all hospitalized tobacco-using
patients.
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Pharmacy
formularies include FDA-approved tobacco dependence pharmacotherapies.
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Reimburse
clinicians for tobacco dependence consultation
services; Pay physicians for treatment of
tobacco-use disorder (ICD9 code 305.1, ADA
code 1320)
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Inform
clinicians and specialists that they will be reimbursed
for using effective tobacco dependence treatments.
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Insurance
formularies include FDA-approved tobacco dependence pharmacotherapies,
including both Nicotine Replacement Therapy (NRT)
and Zyban.
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Insurers
and managed care organizations (MCO's) cover group
or individual counseling for members. Group
or individual counseling should last 90-300 minutes
and involve at least 4 sessions.
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Health
plans inform subscribers of the availability of
covered tobacco dependence treatments (both
counseling and pharmacotherapy) and encourage
patients to use these services.
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Employers
and other health care purchasers purchase health
plans that include cessation benefits.
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Ensure
compliance with JCAHO regulations mandating that
all sections of the hospital be entirely
smoke-free.
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Ensure
compliance to the Utah Clean Indoor Air Act, including: |
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Smoking
prohibited in all indoor areas of public
access and throughout all public buildings. |
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Outside
smoking designated areas for employees and
visitors not allowed within 25 feet
of building entrances, exits, air intakes,
or windows. |
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Smoking
and nonsmoking areas are designated with
signs. |
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