You hold the key to success!
How to get results with Tobacco Cessation
Sandy Wartgow
Chronic Disease Prevention and
Health Promotion
Carson City Health and Human
Services
Kelli Goatley-Seals
Chronic Disease Prevention
Program
Washoe County Health District
Topics to be Covered
• The toll of tobacco in the U.S. and Nevada
• Electronic cigarettes and other tobacco products
• Medicare Access and CHIP Reauthorization Act/
Merit-based Incentive Payment System
• ICD 10 and CPT codes for tobacco
• Brief Tobacco Use Intervention
• Nevada Quitline cessation resources
Current Climate in Nevada
• Nevada recently celebrated 10 years since the Nevada Clean
Indoor Air Act passed to offer more protection from exposure to
secondhand smoke
• In 2015 the Nevada State cigarette tax was raised by $1.00 a pack
bringing the average cost of a pack of cigarettes to $6.44 in Nevada
• Current Adult smokers: 16.9% (2014 BRFSS)
• Adults reporting daily smoking: 11.4% (ATS, 2016)
• Males are more likely to smoke than females (20% vs. 13.8%)
(BRFSS 2014)
• High school smoking prevalence is 7.2% (YRBS 2015)
• 45.8% of those who smoke in Nevada reported trying to quit in the
last 12 months (ATS 2016)
The Toll of Tobacco
• Smoking is the leading cause of preventable death and kills
480,000 people each year in the U.S., more than alcohol,
AIDS, motor vehicle crashes, illegal drugs, murders, and
suicides combined.*
• Tobacco use kills 1,300 people every day in the U.S.**
• Secondhand smoke is the third leading cause of preventable
death in the U.S., killing an estimated 53,000 nonsmokers
each year.**
*Campaign for Tobacco-free Kids
**U.S. Centers for Disease Control and Prevention
The Toll of Tobacco in Nevada
• The tobacco industry spends
over $78.7 million each year
to market their products in
Nevada.
• In Nevada, the combined
monetary toll of tobacco use
per each smoker’s lifetime is
calculated at $1,413,733.
• In Nevada, $1.08 billion is
spent in annual health care
costs directly caused by
smoking.
*Campaign for Tobacco Free Kids as of 2/6/15
https://wallethub.com/edu/the-financial-cost-of-smoking-bystate/9520/ lifetime cost
The Cost of Smoking
 If a person smokes one pack a
day, over one year’s time it
costs them $2,350 in Nevada.
 In 20 years that’s $47,012!
Enough money for a down
payment on a house, to buy a
car, or to help pay for a child’s
college education.
 Use the “teachable moment”
to help people realize the costs
of smoking.
Smoking
damages
ALL
OF
THE BODY
Tobacco and Our Lungs
 Causes lung cancer
 Causes Chronic Obstructive Pulmonary Disease
(COPD, including Chronic Bronchitis and
Emphysema)
 Exacerbates asthma
Tobacco and Our Hearts
 Increases blood
pressure and heart
rate
 Causes hardening
and narrowing of
the arteries
 Reduces oxygen
that reaches the
body’s tissues
Nicotine-PHYSICAL Addiction
Nicotine-PHYSICAL
Addiction
Dopamine
Pleasure, appetite
suppression
Norepinephrine
Arousal, appetite
suppression
Acetylcholine
Nicotine
Nicotine
Vasopressin
Vasopressin
Serotonin
Serotonin
Beta-endorphin
Beta-endorphin
Arousal, cognitive
enhancement
Memory improvement
Mood modulation,
appetite suppression
Reduction of anxiety and
tension
Benowitz, 1999
10
Secondhand Smoke
Secondhand smoke
contains over
7,000 chemicals,
70 of which are
known to cause
cancer.
https://www.cdc.gov/tobacco/data_statisti
cs/fact_sheets/secondhand_smoke/health_
effects/
Secondhand Smoke and Children
 Children are particularly susceptible to health risks
from secondhand smoke because their immune system
is less protective
 They breathe in more air relative to body weight (thus
for same exposure, will absorb more tobacco toxins)
 Their exposure is involuntary.
 Most children of smokers are exposed in the home or
car.
 Exposure rates increase in children who live in poverty
and households with low educational levels.
Effects of Secondhand Smoke
on Child Health
Early Childhood Harm
There is no risk-free level of exposure to secondhand smoke.
– Secondhand smoke causes numerous health problems in
infants and children, including more frequent and severe
asthma attacks, respiratory infections, ear infections, and
sudden infant death syndrome (SIDS).
–
Smoking during pregnancy results in more than 1,000
infant deaths annually.
https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/
Other Tobacco Products California Ad
Electronic Cigarettes and Other Tobacco Products
Other Tobacco Products, or OTPs, commonly refer to any
tobacco product that is not a cigarette.
16
Cigars, Little Cigars, Cigarillos
•
•
•
•
•
•
Little cigars or cigarillos resemble
cigarettes.
According to tobacco industry documents,
they were intended to replace cigarettes
as cigarette advertising became
increasingly restricted, and taxes on
cigarettes (but not cigars) continued to
increase.
Come in flavored varieties, including
cherry, chocolate, vanilla, peach rum,
raspberry, Menthol and sour apple.
Flavorings may appeal to youth and young
people.
Flavorings in cigars are not regulated by
the federal government (FDA).
Preferred by African American and
Hispanic youth.
Dissolvable Tobacco Products
• Camel Orbs: mint-sized; dissolve in
about 10- 15 minutes; contains
about 1 milligram of nicotine,
almost as much as one cigarette.
• Camel Strips: resemble Listerine
breath strips; dissolve in about 2- 3
minutes; contains about 0.6 mg of
nicotine.
• Camel Sticks: resemble toothpicks;
dissolves in about 20-30 minutes;
contains about 3.1 mg per stick,
similar to the nicotine content in
about two cigarettes.
Chewing Tobacco and Snuff
• Chewing tobacco, another form of spit
tobacco, comes in three types: loose leaf,
plugs, and twists. Loose leaf is shredded
tobacco leaves made into strips; plugs are
pressed into small, soft blocks flavored with
licorice and sugar and then dried; and twists
are dried and twisted into hard spirals.
• Snuff is moist, finely chopped tobacco that is
placed between the cheek and gum and
doesn’t require chewing.
• In 2016, 2.8% of Nevadan’s surveyed
reported using smokeless tobacco.*
* 2016 Nevada Adult Tobacco Survey
Snus
• A moist powder smokeless tobacco
product.
• Placed between the cheek and gum.
• It doesn’t require the user to spit.
• Produced using steam heat and not fire,
which results in lower levels of
nitrosamines, a known cancer-causing
agent.
• Contains more nicotine than cigarettes.
• Negative health effects are similar to
smokeless tobacco use and include
developing lesions in the mouth, gum
recession and cancer of the mouth or
tongue.
Hookah
• Hookahs are also known as water
pipes.
• Commonly used by youth and young
adults and perceived to be safe.
• Using water as a filter does not
change the level of nicotine in the
smoke compared to pipes without a
water filtration process.
• Hookah smoke contains 36 times
more tar than cigarette smoke.
• Smoking hookah fills your body with
8 times more Carbon Monoxide.
Hookah Continued
• Each hookah session equals 100 more
times the smoke volume compared to
a single cigarette.
• A typical hookah session involves more
frequent puffs and deeper inhalation
over a longer period of time than
traditional cigarette use.
• CDC estimates 1.6 million young people
used hookahs in 2014. The agency said
those numbers have tripled since 2011.
• The 2016 NV ATS shows 74.9% of those
reporting hookah use used before age
24, with 53.1% using before age 20.
Electronic Cigarettes
• Nicotine delivery device first developed in China in 2004.
• When the user puffs on the inhaler, the battery heats the liquid
nicotine into an aerosol of liquid, flavorings and nicotine.
• Includes a battery component, an atomizer and tank filled with
liquid nicotine, and a mouthpiece.
• Commonly known as e-cigarette, e-cig, vape pen, or vapor.
• Using an e-cigarette is commonly referred to as vaping.
E-juice
A traditional single cigarette yields about
1mg of absorbed nicotine. A 15 ml bottle
of e-juice can be the equivalent of 4
packs of cigarettes, but this varies since
some e-cigarettes can be shut on and off.
E-cigarette Prevalence
•
In 2016, 24.2% of adults in Nevada had ever tried an e-cigarette even one time.*
•
About 21% of Nevada adults believe that e-cigarettes are safer than regular
cigarettes. *
•
Commonly cited reasons for use by e-cigarette users include: the perception
that they are healthier/less toxic than traditional cigarettes, aid in tobacco
craving/withdrawal symptoms, smoking cessation facilitator, and relapse
avoidance.
•
In 2015, the NV Youth Risk Behavior Survey found
students in NV use e-cigarettes more than combustible
cigarettes with 26.1% of high school and 11.3% of
middle school students reporting use.
•
The increases in current use of e-cigarettes offset the
decreases in other tobacco products, resulting in no
change in overall current tobacco use among youths.
* 2016 Nevada Adult Tobacco Survey
E-cigarette Safety and Quality
• 2009 FDA studied 2 brands of e-cig and found:
– Carcinogens and heavy metals found in juice and aerosol
– Quality control was inconsistent or non-existent
– Nicotine free e-cigs contained nicotine
– Nicotine levels varied, sometimes twice as high as FDA
approved devices
– Not recognized as quit smoking devices
• Nicotine is highly addictive and is a vasoconstrictor meaning it
instantly narrows blood vessels:
– Increases heart rate by 10-20 beats per minute
– Considered a neurological-toxin and is used as an insecticide
• The liquid used in e-cigarettes, when ingested or absorbed
through the skin, can cause vomiting, seizures or death.
E-cigarette Safety and Quality
• Poison centers reported
2,405 e-cigarette calls from
Sept. 2010 to Feb. 2014. The
total number of poisoning
cases is likely higher than
reflected in this study,
because not all exposures
might have been reported
to poison centers.
• Calls to poison centers
involving e-cigarette liquids
containing nicotine rose
from one per month in Sept.
2010 to 215 per month in
Feb. 2014.
• According to the CDC, more
than half (51.1%) of the calls
to poison centers due to ecigarettes involved young
children 5 years and under,
and about 42 percent of the
poison calls involved people
age 20 and older.
National Poison Control Center
Nevada Poison Center E-juice
45
40
13
35
30
25
20
15
10
5
0
11
31
10
2013
(22
Total)
2014
(44
Total)
Blue indicates under age 5
E-cigarette Aerosol
E-cigarettes appeal to youth and adults in part
due to the wide variety of flavors.
A study from Nevada’s Desert Research
Institute looked at how flavoring compounds in
e-liquid affect the chemical composition and
toxicity of e-cigarette aerosol. Findings include:
• Review of studies demonstrating formation of toxic aldehydes in
e-cigarette aerosol due to propylene glycol and glycerol.
• Thermal decomposition of flavoring compounds in e-cigarettes
dominates formation of aldehydes during vaping, producing levels
that exceed occupational safety standards.
• Production of aldehydes was found to be exponentially dependent
on concentration of flavoring compounds.
Khlystov, A and Samburova V. (2016). Flavoring Compounds Dominate Toxic Aldehyde Production during
E-Cigarette Vaping. Environmental Science & Technology. http://pubs.acs.org/doi/abs/10.1021/acs.est.6b05145
Secondhand Aerosol
• E-cigarettes do not just emit “harmless water vapor.”
Secondhand e-cigarette aerosol contains nicotine, ultrafine
particles and low levels of toxins that are known to cause
cancer.
• Exposure to fine and ultrafine particles may exacerbate
respiratory ailments like asthma, and constrict arteries which
could trigger a heart attack.
• At least 10 chemicals identified in e-cigarette aerosol (in
mainstream or secondhand e-cigarette aerosol) are classified as
carcinogens and reproductive toxins.
Data from Americans for Nonsmokers’ Rights Fact Sheet http://no-smoke.org/pdf/ecigarette-secondhand-aerosol.pdf
Second-hand e-cig smoke compared to regular cigarette smoke http://www.eurekalert.org/pub_releases/2014-08/uosc-ses082814.php
Secondhand Aerosol continued
• E-cigarettes contain and emit propylene glycol (PG), a chemical
that is used as a base in e-cigarette solution and is one of the
primary components in the aerosol emitted by e-cigarettes.
– Short term exposure causes eye, throat, and airway irritation.
– Little known about long-term exposure PG.
– Material Safety Data Sheet from Dow Chemical states
“inhalation exposure to PG mist should be avoided.”
• Even though propylene glycol is FDA approved for use in some
products, the inhalation of propylene glycol is not. Some
studies show that heating propylene glycol changes its chemical
composition, producing small amounts of propylene oxide, a
known carcinogen.
Data from Americans for Nonsmokers’ Rights Fact Sheet http://no-smoke.org/pdf/ecigarette-secondhand-aerosol.pdf
Second-hand e-cig smoke compared to regular cigarette smoke http://www.eurekalert.org/pub_releases/2014-08/uosc-ses082814.php
E-cigarette Marketing and Commercial Appeal
•The e-cigarette companies advertise their products as a
better-smelling, cheaper, and guilt-free alternative to
smoking. They are also marketed as a way to circumvent
some smoking bans. Now, there are an estimated 8,500
vape shops in the U.S., doing $1.2 billion in sales.
•E-cigarettes are promoted heavily online and are more
widely searched than NRTs (nicotine replacement
therapy).
•There is concern that e-cigarettes may appeal to youth
because of their high-tech design, easy availability online
or via mall kiosks, and the wide array of flavors of
cartridges.
•Youth exposure to TV ads for e-cigarettes
increased by 256 percent from 2011 to 2013,
exposing 24 million U.S. kids to these ads,
according to a study published in the journal
Pediatrics.
E-hookah = E-cigarettes
Mods: refers to Modification: Mods can refer to both the actual e-cigarette, also
known as a personal vaporizer, or PV. There can also be mods for other parts of ecigarette hardware, such as an atomizer tank mod.
E-cigs for Marijuana and Other Drug Use
•
•
•
•
•
Various surveys indicate increasing number of people, including teens, are filling
e-cigs with marijuana concentrates like THC oil, hemp oil, hash wax (dabs, honey).
Concentrates can deliver a more potent high than using marijuana via traditional
smoking methods, with some concentrates containing 40 to 80% THC (regular
marijuana contains THC levels of 15 to 20%).
The THC concentrations of vaporized hash oil and waxes (dabs) can exceed that
of dried cannabis by four to 30 times.
Numerous videos on YouTube demonstrating how to use e-cigarettes to smoke
marijuana derivatives.
Some web forum discussions around smoking meth using e-cigs.
E-cigarette Legal Status and Regulation
• FDA has authority over e-cigs as tobacco products and FDA’s
finalized rule went into effect August 2016
– Marketing restrictions
– Mandated ingredient listing
– Age restricted access
• Regulation in Nevada
– 2015 legislative session restricted the sale of e-cigarettes to minors
– E-cigarettes are not included in the NCIAA (the Nevada law prohibiting
smoking in many indoor areas of employment)
– There are no additional taxes on e-cigarettes and liquid nicotine (ejuice)
– There are no regulations limiting flavors at the state or federal level
– No tobacco retailer license required to sell in e-cigs in Nevada
E-cigarette Public Health Concerns
• Re-normalizes the image of smoking
o Allowed in places where smoking is not allowed
o Unrestricted advertising
o Mimics the smoking behavior
• May increase “dual” use
• May be a gateway to cigarettes and other tobacco
products.
• Long term health effects are
unknown
How You Can Help
Incorporate strategies in your area of influence
– Add a cessation referral option in your EMR system
– Create policies to incorporate brief intervention in your practice
– Ensure quit cards are available to staff that interact with
patients
– Utilize ICD 10 codes and CTP codes
MACRA/MIPS
Medicare Access and CHIP Reauthorization Act/ Merit-based Incentive Payment System
• Started in January 2017 - payment adjustments begin in 2019
• MIPS combines 3 existing quality and value reporting
programs into one: the Physician Quality Reporting System
(PQRS); the Value-Based Modifier (VBM); and the EHR Meaningful
Use (MU) program. MIPS also adds 4th component for
improvement activities. Most providers will initially participate in
Medicare through MIPS.
– Quality (formerly PQRS)
– Advancing Care Information
(formerly EHR Meaningful Use)
– Clinical Practice Improvement
Activities (new)
– Cost (formerly Value-based
Modifier)
– Provides incentive payments for
participation in eligible APMs
MACRA/MIPS
Medicare Access and CHIP Reauthorization Act/ Merit-based Incentive Payment System
Quality
(replaces PQRS)
Advancing Care
Information (ACI)
(replaces EHR
Meaningful Use)
Improvement
Activities (new)
Cost
(based on claims
data)
60% of the total score
in year 1
(Decreases to 50% in
2018; 30% in 2019
and thereafter)
25% of the total score
in year 1
15% of the total score
in year 1
0% of the total score
in year 1
(Increases to 10% in
2018; 30% in 2019
and thereafter)
*In 2017, any provider who reports on one quality measure for at least one patient will receive at least 3 points on
the measure and avoid a payment adjustment in 2019.
MACRA/MIPS
Medicare Access and CHIP Reauthorization Act/ Merit-based Incentive Payment System
How is the new Quality category different from PQRS? https://qpp.cms.gov/measures/quality
– Each provider must report 6 individual measures or a specialty measure set (one must be an
outcome measure, or if no outcome measure is available, a high-value measure)
Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times
within 24 months AND who received cessation counseling intervention if identified as a tobacco user
How will the Improvement Activities category work? https://qpp.cms.gov/measures/ia
Performance in this category is calculated based on the provider’s attestation to completing 2 highweighted activities or 4 medium-weighted activities for a minimum of 90 days. Some examples of
improvement activities include care coordination, beneficiary engagement and patient safety activities
Implementation of condition-specific chronic disease self-management support programs
Provide condition-specific chronic disease self-management support programs or coaching or link
patients to those programs in the community
Tobacco Use
Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and
treatment interventions, including tobacco use screening and cessation interventions (refer to NQF
#0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for
tobacco dependence
ICD 10-Tobacco
Code
Definition
Nicotine/Tobacco Dependence
F17.21
F17.210
F17.213
F17.211
F17.22
F17.220
F17.223
Nicotine Dependence, cigarettes
Nicotine Dependence, cigarettes, uncomplicated
Nicotine Dependence, cigarettes, with withdrawal
Nicotine Dependence, cigarettes, in remission
Nicotine Dependence, chewing tobacco
Nicotine Dependence, chewing tobacco, uncomplicated
Nicotine Dependence, chewing tobacco, with withdrawal
F17.221
Nicotine Dependence, chewing tobacco, in remission
F17.29
Nicotine Dependence, other tobacco product
F17.290
Nicotine Dependence, other tobacco product uncomplicated
F17.293
Nicotine Dependence, other tobacco product, with withdrawal
F17.291
Nicotine Dependence, other tobacco product, in remission
F17.20
Nicotine Dependence, unspecified
Document diagnosis every visit!
Notes
Such as electronic
products, hookah, cigars,
cigarillos, bidi, snus, orbs
Try not to use unspecified
ICD 10-Tobacco
Maternal/Pregnancy
Try to use one of
the ones that
identifies trimester
USE additional F17 code to
identify type of tobacco
O99.330
Smoking (tobacco) complicating
pregnancy, unspecified trimester
O99.331
Smoking (tobacco) complicating
pregnancy, first trimester
USE additional F17 code to
identify type of tobacco
O99.332
Smoking (tobacco) complicating
pregnancy, second trimester
USE additional F17 code to
identify type of tobacco
O99.333
Smoking (tobacco) complicating
pregnancy, third trimester
USE additional F17 code to
identify type of tobacco
O99.334
Smoking (tobacco) complicating
childbirth
USE additional F17 code to
identify type of tobacco
O99.335
Smoking (tobacco) complicating
puerperium
USE additional F17 code to
identify type of tobacco
CPT Codes- Tobacco
Cessation Counseling
Z71.6
Tobacco Abuse Counseling
99406
Smoking/tobacco cessation counseling
3-10 mins
99407
Smoking/tobacco cessation counseling
Use additional codes of
Nicotine dependence
intermediate
Mod. 25 on
E&M code
intensive
>10 mins
99411
99412
99078
Smoking cessation –group counseling
prevention
Smoking cessation –group counseling
prevention
Physician or other qualified health care
professional qualified by education,
training, licensure to provide educational
services to patients in group setting
Mod. 25 on
E&M code
30 minutes
60 minutes
Note: G-codes no longer used for Medicare
ICD 10-Tobacco
Providers need to use these too!!!
Environmental /Secondhand Exposure
Z57.31
Z77.22
Occupational Exposure to Environmental
Tobacco Smoke
Contact with and/or (suspected) exposure to
environmental tobacco smoke: Exposure to
second-hand smoke (acute) (chronic); passive
smoking (acute)(chronic)
Excludes: Z77.22 exposure to
environmental tobacco smoke
Excludes: Z57.31 Occupational
exposure
Consider Casino and
Bar workers
Consider kids& family
of smokers other
related dx. Consider
those live in nonsmoke-free housing
Newborn/Pediatrics
P04.2
P96.81
Z81.2
Z71.89
Newborn (suspected to be) affected by
maternal use of tobacco, affected by in utero
exposure to tobacco smoke
Exposure to (parental)(environmental)tobacco
smoke in the perinatal period
Family history of tobacco abuse and
dependence
Counseling, other specified
Exposure from non-maternal tobacco
smoke affecting newborn
Pediatrics- use when children exposed
to environments of secondhand smoke
Pediatrics-OB/Gyn when counseling
parents and family on their smoking
effects on the patient
We need your help in coding as secondary diagnosis—
Every time you believe to be a factor in primary diagnosis!
ICD 10-Tobacco
Providers need to use these too!!!
Injuries/ Poisonings/ External Causes
T65.211
T65.212
T65.213
T65.221
T65.222
T65.223
T65.291
T65.292
T65.293
Toxic effect of chewing tobacco,
accidental (unintentional) or not
otherwise specified
Toxic effect of chewing tobacco,
intentional self-harm
Toxic effect of chewing tobacco, assault
Toxic effect of cigarettes, accidental
(unintentional) or not otherwise
specified
Toxic effect of cigarettes, intentional selfharm
Toxic effect of cigarettes, assault
Toxic effect of other tobacco and/or
nicotine, accidental (unintentional) or
not otherwise specified
Toxic effect of other tobacco and/or
nicotine, intentional self-harm
Toxic effect of other tobacco and/or
nicotine, assault
Swallowing, child eating,
etc.
Swallowing, child eating,
first time smoking
(overexposure)
Electronic products, ejuice poisoning(nicotine),
cigars, cigarillos, hookah,
snus, bidi, orbs
Gotta love ICD 10
Use your imagination here?
USE additional code for
exposure to second hand
tobacco smoke (Z57.31, Z77.22)
What is a Brief Intervention?
The Agency for Healthcare Research and Quality
(AHRQ) recommends brief interventions, which
include the following steps:
1. Ask (about tobacco use)
2. Advise (patient to quit)
3. Refer (educate patient on dangers of tobacco
use and referring client to 1-800-QUIT-NOW or
private insurance provider cessation program)
Why Use Brief Interventions?
• 70% of all smokers report wanting to quit smoking.
• Professional assistance or community health provider
advice increases quit rates by 30%.
• For many patients, you may be the only link they have to
health information like this.
ASK:
Step 1 (1 minute)
• Ask every patient about their tobacco use at every visit.
• Determine if the patient currently uses tobacco, formerly
used tobacco, or has never used tobacco.
• Determine what form of tobacco is used (ex: cigarettes, ecigarettes, smokeless tobacco, etc.)
• Determine how often tobacco is used.
• Document tobacco use status in the medical record.
ADVISE: Step 2
(1 minute)
• In a clear, strong, and personalized manner, urge every
tobacco user to quit using a non-judgmental approach.
• Tobacco users who have failed in previous quit attempts
should be told that most people make repeated quit
attempts before they are successful.
• Employ the teachable moment: link health issues with
advice.
Refer: Step 3
(1 minute)
• Determine if the patient is interested in quitting.
• Provide educational materials on quitting.
• For those clients interested in quitting, provide information
on the Nevada Tobacco Quitline 1-800-QUIT-NOW.
• Provide a referral using quit cards or online
www.nevadatobaccoquitline.com.
• Document this interaction with patient in medical record.
Key Messages: Quitting Tobacco
• Quitting often requires multiple
attempts (7-10)
• Counseling or medication increases
the chance of a quit attempt being
successful
• Combination of both counseling and
medication is the most effective
method of quitting (evidence-based)
• 1-800 QUIT NOW provides FREE help
quitting smoking and you don’t have
to even leave your home
www.nevadatobaccoquitline.com
Patients can create a profile
and log into the Quit-Now
system for more resources
Use Chrome or Firefox if
you experience problems
with other browsers
Three Link Chain of Addiction
There are three aspects to nicotine addiction:
1. Biological (Physical)
2. Psychological (Mental)
3. Sociocultural (Social)
Breaking Physical Addiction
One-Two Punch
Either counseling or medication
are effective when used alone,
but the combination of
counseling and medication is
more effective than either alone.
(US Depart. Of Health and Human Services, Public Health
Service. Treating Tobacco Use and Dependence: Clinical
Practice Guideline 2008 Update, May 2008).
Provider Resources
Referring Patients to the Quitline
• The Nevada Tobacco Quitline offers FREE telephone-based service to
Nevada residents 13 years or older
• Hours of Operation: Daily 4 am – 10 pm (PST)
• Free Nicotine Replacement Therapy (NRT) provided to uninsured
patients for 12 weeks, Medicaid patients for 8 weeks, and privately
insured clients for 2 weeks. Supply mailed to patient’s home; counseling
and support provided while people are becoming non-tobacco users.
• Fast, Free telephonic access to trained tobacco cessation experts that
can assist with quitting the use of all tobacco products including ecigarettes.
Advise patients to call from a phone with a 775 or 702 area code:
– 1-800-QUIT-NOW (1-800-784-8669)
– Services available in Spanish and other languages
– 1-855-DEJALO-YA (Spanish)
Free Materials
Quit cards: Double sided Sp/Eng
If you require quit cards, please email your
regional contact:
[email protected] Washoe County
[email protected] Southern Nevada
[email protected] all other areas of Nevada
Free Materials
Providers Guide to Nicotine/ Tobacco Billing and Coding
Code
F17.21
F17.210
F17.213
F17.211
F17.22
F17.220
F17.223
F17.221
F17.29
F17.290
F17.293
F17.291
F17.20
Z87.891
Z57.31
Z77.22
Z71.6
99406
Definition
Notes
Nicotine/Tobacco Dependence
Nicotine Dependence, cigarettes
Nicotine Dependence, cigarettes, uncomplicated
Nicotine Dependence, cigarettes, with
withdrawal
Nicotine Dependence, cigarettes, in remission
Nicotine Dependence, chewing tobacco
Nicotine Dependence, chewing tobacco,
uncomplicated
Nicotine Dependence, chewing tobacco, with
withdrawal
Nicotine Dependence, chewing tobacco, in
remission
Such as elec. products,
Nicotine Dependence, other tobacco product
hookah, cigars, cigarillos, bidi,
snus, orbs
Nicotine Dependence, other tobacco product
uncomplicated,
Nicotine Dependence, other tobacco product,
with withdrawal
Nicotine Dependence, other tobacco product, in
remission
Try not to use unspecified
Nicotine Dependence, unspecified,
Quit smoking how long ago?
Personal history of nicotine dependence
Environmental /Secondhand Exposure
Occupational Exposure to Environmental Tobacco Excludes: Z77.22 exposure to
Smoke
environmental tobacco smoke
Excludes: Z57.31 Occupational
Contact with and/or (suspected) exposure to
exposure
environmental tobacco smoke: Exposure to
second-hand smoke (acute) (chronic); passive
smoking (acute)(chronic)
Cessation Counseling
Use additional codes of
Tobacco Abuse Counseling
Nicotine dependence
Smoking/tobacco cessation counseling 3-10 mins intermediate
99407
Smoking/tobacco cessation counseling >10 mins
intensive
99411
99412
99078
Smoking cessation –group counseling prevention
Smoking cessation –group counseling prevention
Physician or other qualified health care
professional qualified by education, training,
licensure to provide educational services to
patients in group setting
30 minutes
60 minutes
Other
Maternal/Pregnancy
O99.330
Smoking (tobacco) complicating pregnancy,
unspecified trimester
Try to use one of the ones that
identifies trimester
USE additional F17 code to identify type of
tobacco
O99.331
Smoking (tobacco) complicating pregnancy, first
trimester
USE additional F17 code to identify type of
tobacco
O99.332
Smoking (tobacco) complicating pregnancy, second
trimester
USE additional F17 code to identify type of
tobacco
O99.333
Smoking (tobacco) complicating pregnancy, third
trimester
USE additional F17 code to identify type of
tobacco
O99.334
Smoking (tobacco) complicating childbirth
USE additional F17 code to identify type of
tobacco
O99.335
Smoking (tobacco) complicating puerperium
USE additional F17 code to identify type of
tobacco
Newborn/Pediatrics
Consider Casino and
Bar workers
Consider kids& family
of smokers other
related dx. Consider
those live in nonsmoke-free housing
Mod. 25 on E&M
code
Mod. 25 on E&M
code
P04.2
Newborn (suspected to be) affected by maternal
use of tobacco, affected by in utero exposure to
tobacco smoke
P96.81
Exposure to (parental)(environmental)tobacco
smoke in the perinatal period
Exposure from non-maternal
tobacco smoke affecting newborn
Z81.2
Family history of tobacco abuse and dependence
Pediatrics- use when children
exposed to environments of
secondhand smoke
Z71.89
Counseling, other specified
Pediatrics-OB/Gyn when
counseling parents and family on
their smoking effects on the
patient
T65.211
Toxic effect of chewing tobacco, accidental
(unintentional) or not otherwise specified
T65.212
Toxic effect of chewing tobacco, intentional selfharm
T65.213
Toxic effect of chewing tobacco, assault
T65.221
Toxic effect of cigarettes, accidental (unintentional)
or not otherwise specified
Injuries/ Poisonings/ External Causes
T65.222
Toxic effect of cigarettes, intentional self-harm
T65.223
Toxic effect of cigarettes, assault
T65.291
Toxic effect of other tobacco and/or nicotine,
accidental (unintentional) or not otherwise
specified
T65.292
Toxic effect of other tobacco and/or nicotine,
intentional self-harm
T65.293
Toxic effect of other tobacco and/or nicotine,
assault
Swallowing, child eating, etc.
Use your imagination here?
Swallowing, child eating, first time
smoking (overexposure)
Electronic products, e-juice
poisoning(nicotine), cigars,
cigarillos, hookah, snus, bidi, orbs
USE additional code for exposure to second
hand tobacco smoke (Z57.31, Z77.22)
Thank You!
Questions
Sandy Wartgow
[email protected]
775-283-7201
Gethealthycarsoncity.org
Kelli Goatley-Seals
[email protected]
775-328-6160
Acknowledgments and Resources
Many of the slides in this presentation were developed from content contained in fact sheets, websites, and other
materials developed by the American Legacy Foundation, American Academy of Pediatrics, Campaign for Tobacco Free
Kids, Americans for Non Smoker’s Rights, Centers for Disease Control and Prevention and Public Health Law Policy
Center.
Resources:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
2016 Nevada Adult Tobacco Survey, Nevada Institute for Children’s Research & Policy.
American Cancer Society, Prevention and Early Detection. “Guide to Quitting Smoking,” Revised May 2009.
Americans for Nonsmokers’ Rights, Electronic (e-) Cigarettes and Secondhand Aerosol, 2014.
American Legacy Foundation. “Tobacco Fact Sheet: Electronic Cigarettes,” Revised June 2013.
American Society for Heating, Refrigeration, and Air Conditioning Engineering (ASHRAE Journal), June 2014.
Campaign for Tobacco Free Kids. “FDA and the States Must Regulate E-Cigarettes to Protect Public Health: Our Policy Regarding E-Cigarettes,” July 2013.
Campaign for Tobacco Free Kids. “New Study Finds Dramatic Rise in Youth Exposure to E-cigarette Ads on TV,” June 2, 2014.
Campaign for Tobacco Free Kids. “Electronic Cigarettes and Youth,” February 13, 2017.
Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. “Electronic Cigarette Use Among Middle and High School Students —
United States, 2011–2012,” Volume 62, Number 35, September 6, 2013.
Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. “Notes from the Field. Calls to Poison Centers for Exposures to Electronic
Cigarettes — United States, September 2010–February 2014”, Volume 63, Number 13, April 4, 2014.
Consumer Reports, “ E-cigarettes: Still many questions,” March 2014
Senator Richard J. Durbin (D-IL), Rep.Henry Waxman, Senators Rockefeller IV, Blumenthal. Markey, Brown, Reed, Boxer, Merkley, and Rep. Pallane Jr.(Report
written by staff), “Gateway to Addiction- A Survey of Popular Electronic Cigarette Manufacturers and Targeted Marketing to Youth”, April 14, 2014
London, William M. (2000, July 1) How addictive is cigarette smoking?
Public Health Law and Policy, Technical Assistance Legal Center. “Electronic Cigarettes: How They Are- and Could Be- Regulated,” July 2011.
http://no-smoke.org/pdf/ecigarette-secondhand-aerosol.pdf
http://health.nv.gov/PDFs/Tobacco/TobaccoBurdenDocument_FINAL.pdf
http://www.tobaccofreekids.org/facts_issues/toll_us/nevada
http://www.legacyforhealth.org/content/download/582/6926/file/LEG-FactSheet-eCigarettes-JUNE2013.pdf
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/
http://www.nytimes.com/2014/03/24/business/selling-a-poison-by-the-barrel-liquid-nicotine-for-e-cigarettes.html?partner=rss&emc=rss&smid=tw-nytimes&_r=1
www.aap.org/richmondcenter
E-cigarette References
•American Cancer Society, Prevention and Early Detection. “Guide to Quitting Smoking,” Revised May 2009
• Americans for Nonsmokers’ Rights, Electronic (e-) Cigarettes and Secondhand Aerosol, 2014.
• American Legacy Foundation. “Tobacco Fact Sheet: Electronic Cigarettes,” Revised June 2013.
• American Society for Heating, Refrigeration, and Air Conditioning Engineering (ASHRAE Journal), June 2014
• Campaign for Tobacco Free Kids. “FDA and the States Must Regulate E-Cigarettes to Protect Public Health: Our Policy
Regarding E-Cigarettes,” July 2013.
• Campaign for Tobacco Free Kids. “New Study Finds Dramatic Rise in Youth Exposure to E-cigarette Ads on TV,” June 2,
2014.
• Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. “Electronic Cigarette Use Among
Middle and High School Students — United States, 2011–2012,” Volume 62, Number 35, September 6, 2013.
• Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. “Notes from the Field. Calls to
Poison Centers for Exposures to Electronic Cigarettes — United States, September 2010–February 2014”, Volume 63,
Number 13, April 4, 2014.
• Cobb, N.K. and D.B. Abrams, E‐cigarette or drug‐delivery device?
• Consumer Reports, “ E-cigarettes: Still many questions,” March 2014
• Food and Drug Administration, FDA and public health experts warn about electronic cigarettes. 2009.
• Grana, R., N. Benowitz, and S. Glantz, Background Paper on Ecigarettes. Center for Tobacco Control Research and
Education, University of California, San Francisco and WHO Collaborating Center on Tobacco Control, 2013.
• Nevada Poison Center, A. Bronstein, February 4, 2015.
• Senator Richard J. Durbin (D-IL), Rep.Henry Waxman, Senators Rockefeller IV, Blumenthal. Markey, Brown, Reed, Boxer,
Merkley, and Rep. Pallane Jr.(Report written by staff), “Gateway to Addiction- A Survey of Popular Electronic Cigarette
Manufacturers and Targeted Marketing to Youth”, April 14, 2014
•Sussan TE, Gajghate S, Thimmulappa RK, Ma J, Kim J-H, et al. (2015) Exposure to Electronic Cigarettes Impairs Pulmonary
Anti-Bacterial and Anti-Viral Defenses in a Mouse Model. PLoS ONE 10(2): e0116861. doi:10.1371/journal.pone.0116861
• London, William M. (2000, July 1) How addictive is cigarette smoking?
• Public Health Law and Policy, Technical Assistance Legal Center. “Electronic Cigarettes: How They Are- and Could BeRegulated,” July 2011.