9/2/15
Smoking Cessation Interventions
for the Medically/Economically
Underserved Populations
Susan Chaney, EdD, RN, FNP-C, FAANP
Susan Sheriff, PhD, RN, CNE
Texas Nurse Practitioners 27th Annual Conference
September 26, 2015
OBJECTIVES
•  Review the etiology, health benefits of cessation,
and nurse practitioner interventions for smoking
cessation for medically/economically
underserved populations.
•  Describe a multifaceted approach to smoking
cessation for medically/economically
underserved populations.
•  Examine nicotine and non-nicotine, first line and
second line medications for smoking cessation.
INTRODUCTION
Ø  Tobacco use is the leading cause of
preventable morbidity, mortality, and
health expense in the United States,
responsible for more than 480,000
deaths annually, or 1 of 5 deaths.
Ø  Smoking results in more deaths each
year in the U.S. than AIDS, alcohol,
cocaine, heroin, homicide, suicide,
motor vehicle crashes, and fires –
combined.
Ø  Smoking is responsible for 90% of
lung cancer deaths, and approximately
80% of chronic obstructive pulmonary
disease deaths.
(Centers for Disease Control & Prevention [CDC], 2015a)
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ETIOLOGY OF TOBACCO DEPENDENCE
v  The etiology of tobacco dependence is multidimensional with
physiological, psychological, and social/behavioral factors
v  Physiological factors include raising brain levels of dopamine
v  Psychological factors evolve from positive feedback provided
by pleasurable sensations
v  Social/behavioral factors include the following:
§  Smoking becomes a habit or an automatic and intrinsic
part of daily activities.
§  Smoking can be used as self-medication to reduce
unpleasant sensations that occur with tobacco
withdrawal or stress
v The highest state prevalence rates of smoking were in
Kentucky (29.0%), the Midwest (20.6%) and the South
(19.7%)
v Tobacco use costs more the $289 billion annually in U.S.
DEFINING THE UNDERSERVED POPULATION
v The federal Medically Underserved Area (MUA) and
Medically Underserved Population (MUP) designations
identify areas and populations that have limited access
to primary care services.
v MUAs include groups of census tracts that have a
population-to-provider ratio indicating a shortage.
v MUPs may include groups of persons who face
economic, cultural or linguistic barriers to health care
and reside in a specific geographic area.
(Department of Health, n.d.)
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UNDERSERVED
POPULATION:
BARRIERS TO HEALTH
Greater risk for limited access to healthcare resources
• 
•  Low socioeconomic status (SES) associated with increased
mortality rates and greater prevalence of risk behaviors, including
smoking
•  Financial barriers → medical conditions may reach an advanced
stage before the individual seeks care
•  Increased prevalence of mental health issues (depression, anxiety,
substance use/abuse)
•  Increased prescription medication use
•  Below national rates of leisure-time physical activity
•  Less likely to have completed recommended screenings for gender/
age
(Alverson & Kessler, 2010; Harley et al., 2014)
EPIDEMIOLOGY OF TOBACCO USE:
v  Adult smoking rates in theADULT
U.S. are 18.1%: All time low!
v  The highest rates of smoking in adults: American Indians/ Alaska
Natives, and adults who live below poverty level.
v  Cigarette smoking is more common in men (20.5%) than women
(15.8%).
(CDC, 2015a)
EPIDEMIOLOGY
•  In the U.S., smoking prevalence remains highest among those with
less than a high school education (28.4%), those with no health
insurance (28.6%), and those living below the federal poverty level
(27.9%)
•  Medicaid enrollees currently smoke cigarettes at a 60% higher rate
than the national average, and racial/ethnic minorities and women
are disproportionately represented in this population
•  The homeless population reflects an even greater disparity, with
approximately 70% tobacco prevalence (over 3x national average)
•  Smokers with lower incomes are also less likely to use evidencebased smoking cessation treatments such as pharmacotherapy and
counseling than smokers with higher incomes
(Bock et al., 2014; America Lung Association [ALA], 2014b; Okuyemi et al., 2006; Fu et al., 2014)
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BENEFITS OF
CESSATION
Timeline of Improvement
BENEFITS OF CESSATION
Long-Term Effects
•  Within a few hours → the level of carbon monoxide in the blood
begins to decline, increasing the blood’s ability to carry oxygen
•  Within a few weeks → improved circulation, produce less phlegm,
less coughing/wheezing
•  Within several months → substantial improvements in lung function
•  Within a few years → lower risks for chronic disease processes
•  Heart rate and blood pressure begin to normalize (abnormally high
with smoking)
•  Improved sense of smell, and food will taste better
**ONE cigarette = 11 minutes taken from your life!**
•  Reduced risk of developing some lung diseases (including COPD, one
of the leading causes of death in the United States)
•  Lowered risk for lung cancer and many other types of cancer
•  Reduced risk for heart disease, stroke, and peripheral vascular disease
•  Reduced heart disease risk within 1-2 years of quitting
•  Reduced respiratory symptoms, such as coughing, wheezing, and
shortness of breath
Ø  symptoms may not disappear, but do not continue to progress at the same
rate among people who quit compared with those who continue to smoke
•  Reduced risk for infertility in women of childbearing age
•  Smoking cessation during pregnancy reduces the risk of having a low
birth weight baby, pre-term labor, and associated complications
(CDC, 2015b)
(CDC, 2015b)
BARRIERS TO SMOKING
CESSATION
v  Language, Acculturation, & Literacy
v  Nicotine Dependence (Current Use)
•  Multiple self-report tools available for free
•  Higher level of dependence and increased use of mentholated
cigarettes
•  Smoke higher number of cigarettes per day
v  Motivation to Quit
•  Lowest in low-SES population
•  Over 60% of smokers express a desire to quit, but most are
unwilling to make a serious quit attempt within the next 6 months
•  Low-SES smokers are also less likely to achieve cessation for
≥6 months compared to higher SES individuals
(Businelle et al., 2010)
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HISTORY
BARRIERS TO CESSATION
(CONTINUED)
•  Family and patient medical history
v  Increased Stressors (Coping Mechanism)
•  Higher unemployment rate, lower income, increased financial
burdens, poorer health status, higher rates of separation/divorce
v  Co-morbid Psychiatric Issues
•  Increased prevalence of substance use/abuse,
•  Higher rates of anxiety, depression, and mental illness
v  Disparities in advertising to low SES communities
•  Communities with more tobacco retailers
•  Advertisement sizes larger, lower mean price, closer to schools
(within 1000 feet), and more likely to promote mentholated
cigarettes
–  Heart disease, respiratory disease, or cancer
•  HPI: sputum, cough, shortness of breath,
exercise tolerance
•  Social and dietary history: alcohol, coffee,
use of illicit substances
•  Depression screen
–  Depression is 2x more common in smokers
(Seidberg, Caughey, Rees, & Connolly, 2010)
SMOKING HISTORY
Ø  How manyQUESTIONNAIRE
packs of cigarettes do you smoke per day?
Ø  What brand of cigarettes do you smoke?
Ø 
Ø 
Ø 
Ø 
Ø 
Ø 
Ø 
Ø 
Ø 
How many previous attempts to quit smoking?
What method did you use in your previous attempts?
How long did your previous attempts at quitting last?
What barriers did you face during smoking cessation?
How old were you when you started smoking?
How many years have you been smoking?
How many members of your family smoke?
Do one or both of your parents smoke?
Are you motivated to quit now? If so, do you have confidence in
your ability to do so?
(Chaney & Sheriff, 2008)
WITHDRAWAL SYMPTOMS OF NICOTINE
Weight Gain
Cravings
Restlessness
Difficulty Concentrating
Headaches
Irritability
↓HR & BP
Drowsiness
Increased Appetite
Increased Skin Temperature
Depression
Insomnia
Anxiety
GI Disturbances
(CDC, 2014b; Chaney & Sheriff, 2012)
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EXAM & DIAGNOSIS
Physical Examination:
Ø Monitor VS, particularly BP which adds an additional risk
of heart disease if elevated; tobacco use: current, former,
never; weight
Ø Examine ears, nose, sinuses, mouth, and pharynx, noting
signs of inflammation due to irritation from tobacco
Ø Perform complete exam of lungs
Ø Perform complete exam of heart & peripheral vascular system
DIAGNOSIS
•  Can bill as primary reason for visit
•  ICD-9: 305.1 Tobacco use disorder
•  May bill as secondary to another problem
Diagnostic Tests:
Ø Spirometry & pulmonary function tests
Ø Urine samples
Ø Screen for lipid disorders to determine
additional risk factors for heart disease
BARRIERS TO ACCESSING
TOBACCO CESSATION
TREATMENT
• 
• 
• 
• 
Required Co-payments
Prior Authorization Requirements
Limits on Duration of Treatment
Annual & Lifetime Limits on Quit
Attempts
•  “Stepped Care Therapy” Requirements
•  Requirements for Cessation Counseling
& the unintended effects on the underserved
Know how your patient is affected by:
v Coverage
v Affordability
v Premiums/Penalties
v Preventive/Screening Services
v Medicaid Expansion
v Tobacco Cessation
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ACA: PREMIUMS &
PENALTIES
THE AFFORDABLE CARE ACT
(ACA)
v Coverage for ALL
–  Over 16 million people gained coverage, dropping the uninsured
rate, with the largest changes seen in African Americans and
those with low-SES
–  Coverage for pre-existing conditions (Ex: COPD, Lung CA)
v Affordable Plans
–  Targeted for low-SES, but high premiums present affordability gap
for middle-income Americans
–  Less than half (42%) of the uninsured can afford premiums of just
$100/month
(U.S. Department of Health & Human Services [USDHHS],
2015; Transamerica Center for Health Studies, n.d.)
ACA: MEDICAID EXPANSION
(AS OF JANUARY 1, 2014)
Goals & Regulations
•  Household income of 133%
of FPL or less → now eligible
•  133% FPL= $16,243/year
(individual), or $33,465/year (family
of four)
•  Federal government will pay for
100% of coverage
•  Minorities and low-SES most
affected by expansion
Unintended Effects
• States are able to set their out-ofpocket costs with copays, coinsurance, and deductibles
• 23 states opted out of the
Medicaid expansion, including
Texas
• *TEXAS = 15% of FPL*
–  Family of 3 earning >$3,700/
year are “too rich” to qualify
–  Coverage gap, low-SES
unaffected
(ALA, 2014b)
Goals & Regulations
Annual fee for NO insurance
Surcharge: Insurers and
employers can charge tobacco users
up to 1.5 times the regular premium
Insurers in small group market must
remove surcharge for a tobacco user
who agrees to enroll in a program to
help them quit
●
●
●
(ALA, n.d.b)
Unintended Effects
•  Over 25% of the uninsured
population said that paying the
tax penalty and health expenses
costs less than paying for
insurance
•  Average smoker may spend up
to 20% of their annual income in
premiums
Annual Fee for the Uninsured
2014: $95/adult, $47.50/child for up to $285/family,
OR 1% of household income, whichever is greater
2015: $325/adult, $162.50/child for up to $975/family,
OR 2% income, whichever is greater
2016: $695/adult, $374.50/child for up to $2,085/family,
OR 2.5% of income, whichever is greater
ACA: TOBACCO CESSATION
Goals & Regulations
• ‘A’ grade by USPSTF = covered
by most health plans
• 2010: Comprehensive cessation
free for pregnant women
• 2014: Medicaid programs no
longer able to exclude tobacco
cessation medications from their
prescription drug coverage
Unintended Effects
•  No definition for treatments
included (meds/counseling)
•  Guidance for what plans should
include, not actual policy
•  Coverage ≠ Preferred!
•  Providers often unaware of
covered services available to
offer
(ALA, n.d.a; ALA, 2014a)
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Treatment Guidelines: 5As
•  Ask: tobacco use at every encounter
•  Advise: advise all smokers to quit
•  Assess: identify smokers willing to make a quit
attempt
•  Assist: medication, counseling, exercise
•  Arrange: frequent follow-up visits
–  Consider referral to intensive program
• 
• 
• 
• 
• 
• 
• 
• 
COUNSELING SESSION
TOPICS
Week 1: Safely using NRT: dosage, times, side effects
Week 2: Pairing participants with a “quit buddy”
Week 3: Exciting things to do in place of smoking
Week 4: Knowing your triggers and how to overcome
Week 5: Avoiding people and places that sabotage success
Week 6: Getting support from family and friends
Week 7: Hearing success stories from ex-smokers
Week 8: Being successful in long-term maintenance
(Chaney & Sheriff, 2012)
EXERCISE
INTERVENTIONS
•  Weight gain has been identified as a barrier to
smoking cessation among women. Regular exercise
can prevent the normal weight gain seen when women
stop smoking.
•  Exercise program of 45 minutes of aerobic walking for
3 x a week in the community
•  After 12 months, the experimental groups of walkers
were able to quit smoking and continue to exercise.
(Chaney, Sheriff, & Merritt, 2015)
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JUSTIFICATION
•  Exercise training may help to improve
long-term maintenance of smoking
cessation in women. Few studies have
examined exercise.
•  Men have more success with nicotine
replacement therapy (NRT) and staying
abstinent. They restart smoking
because they see a cigarette and want it.
(CDC, 2015b)
PHARMACOTHERAPEUTIC
S
•  All smokers should be offered medication,
except when contraindicated (pregnant women,
smokeless tobacco users, light smokers and
adolescents).
•  The 7 first-line medications include: Buproprion
SR, nicotine gum, nicotine inhaler, nicotine
lozenge, nicotine nasal spray, nicotine patch and
varenicline.
•  All 7 FDA approved medications have specific
contraindications, warnings, precautions and
concerns, and side effects.
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PHARMACOTHERAPEUTIC
S
•  Higher doses of nicotine gum, lozenge and patch have
been shown to be effective in highly dependent smokers.
•  Consider prescribing second-line agents, such as
Clonidine and Nortriptyline for patients unable to use
first-line agents.
•  Data show that Buproprion SR and NRTs (gum and
lozenge) delay, but do not prevent, weight gain.
•  NRTs are safe to use in cardiovascular patients except in
recent MI, serious arrhythmias or USA.
•  Combining first-line agents increases long-term
abstinence rates. (see recommendations)
PHARMACOLOGICAL
INTERVENTION
Five first-line:
Nicotine gum
Nicotine
Nicotine patch
replacement
Nicotine nasal spray
therapies
Nicotine inhaler
(NRT)
Nicotine lozenge
Bupropion SR (Zyban)
Varenicline (Chantix)
Category C: Buproprion and Varenicline
Category D: Nicotine gum, patch, nasal spray,
inhaler
(CDC, 2014b)
FIVE FIRST-LINE NRT:
Available:
• Exclusively as an over-the-counter medication
• 2 mg and 4 mg (per piece) doses
Dosage:
• 2 mg gum initially for patients smoking < 25 cigarettes/
day
• 4 mg for smoker > 25 cigarettes/day or failed with 2 mg
• Do not exceed 30 pieces per day for using 2 mg strength
• Do not exceed 20 pieces per day for using 4 mg strength
Duration:
• Usually for the first few months of quit attempt
• Should tailor the dosage and duration of the therapy to
fit the need of each patient
(USDHHS, 2014)
FIVE FIRST-LINE NRT:
Adverse Effects:
• Mouth soreness, hiccups, dyspepsia and jaw ache
Instructions:
• Patient should refrain from smoking while using the gum
• Chewed slowly until a “peppery” taste emerges, then
“parked” slowly between cheek and gum to facilitate
nicotine absorption through the oral mucosa
• Gum should be intermittently chewed and parked for about
30 minutes
(USDHHS, 2014)
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FIVE FIRST-LINE NRT:
Available: Both as an OTC and a prescription medication patch.
BRAND
DOSAGE
DURATION
(mg/h)
(WEEKS)
NICODERM &
HABITROL
21/24
14/24
7/24
4
then 2
then 2
PROSTEP
22/24
11/24
4
then 4
NICOTROL
15/16
10/16
5/16
4
then 2
then 2
FIVE FIRST-LINE NRT:
Adverse Effects:
• 50% of patients will have a local skin reaction,
usually mild
• Local treatment with hydrocortisone cream 1% or
triamcinolone cream 0.5% with rotation of sites are effective
Instructions:
• Patient should refrain from smoking while using the
patch
• Should place a new patch on a relatively hairless location
between the neck and the waist
• Patches should be applied as soon as patient awakens
on their quit day
(Papadakis & McPhee, 2013)
FIVE FIRST-LINE NRT:
FIVE FIRST-LINE NRT:
Available: Only as a prescription medication.
Available: Only as a prescription medication.
Dosage: 0.5mg delivery to each nostril (1 mg total ). Initial 1-2 dose
Dosage: A dose from the nicotine inhaler consists of a puff or inhalation.
Each cartridge delivers a total of 4 mg of nicotine over 80 inhalations.
Recommended dosage is 6–16 cartridges/day.
Duration: Recommended duration of therapy is up to 6 months. Instruct
patient to taper dosage during the final 3 months of treatment.
per
hours, increasing prn for symptom relief. Minimum
recommended treatment: 8 doses/day, with maximum limit of 40
doses/day (or 5 doses/hour)
Duration: 3-6 months
Adverse Effects: Bronchospasm, mouth/throat irritation, cough, H/
A,
rhinitis, sinusitis, and taste change
Precaution: Hypersensitivity to menthol, MI acute in 2 weeks,
pulmonary
diseases, asthma, and pregnancy
Instruction: Should not sniff, swallow, or inhale while administering
doses because this increases irritating effects
Adverse Effects: Local irritation in the mouth and throat was observed in
40% of patients using the nicotine inhaler. Coughing (32%) and rhinitis
(23%) also were common. Severity was generally rated as mild, and the
frequency of such symptoms declined with continued use.
Precaution: Hypersensitivity to menthol, MI acute in 2 weeks, pulmonary
diseases, asthma, and pregnancy.
Instruction: Keep in pocket in cold weather; avoid acidic beverages w/i
15” before or after use.
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FIVE FIRST LINE
NRT:
FIRST LINE:
Available: OTC
Available: As a prescription medication.
Dosage: 2-4 mg doses. The 2 mg dose is recommended for those who
smoke more than 30” after waking; 4mg dose within 30” of waking.
Dosage: Begin with 150mg Q Am for 3 days, then increase
to 150 mg BID, continued for 7-12 weeks following the
quit day, begin 1-2 weeks before quitting smoking.
Maintain therapy: 150mg BID up to 6 months.
Duration: Use at least 9 lozenges/day in the first 6 weeks; use for up to
12 weeks; with no more than 20 lozenges to be used per day.
Adverse Effects: Nausea, hiccups, heartburn; h/a and coughing with
higher dosages.
Precaution: Pregnancy, CVD (recent MI, severe arrhythmias and USA).
Instruction: should be allowed to dissolve in mouth, do not chew or
swallow it; avoid drinking anything but water w/i 15” before or after use;
Precaution: Pregnancy: should be used only if the increased
likelihood of smoking abstinence, with its potential
benefits, outweighs the risk of bupropion SR treatment
and potential concomitant smoking.
Contraindications: Seizure disorder, eating disorder, or those who have
used an MAO inhibitor in the past 14 days.
Adverse Effects: Insomnias (35-40%) and dry mouth (10%).
(Papadakis & McPhee, 2013)
FIRST LINE:
Available: by prescription
Dosage: Begin 1 week before quit date at 0.5mg daily x 3 d; 0.5mg BID
x 4 d; f/b 1mg BID x 3months. (NOTE: Instruct to quit smoking on day 8
when 1mgBID begins)
Duration: May be used for up to 6 months.
Adverse Effects: Nausea, insomnia, vivid dreams
Precaution: Pregnancy Cat. C
Instruction: To reduce nausea, take on a full stomach. To reduce
insomnia, take 2nd pill at supper rather than HS.
NOTE: In Feb. 2008, FDA added a warning regarding changes in
behavior, suicidal ideation, depression and suicide. Obtain a psychiatric
history and monitor for changes in mood or behavior.
SPECIAL SUB-POPULATIONS:
PREGNANCY
•  Cigarette smoke contains thousands of chemicals, many of
which may contribute to reproductive toxicity- of particular
concern are carbon monoxide, nicotine, and oxidizing
chemicals.
•  Because of the serious risks of smoking to the pregnant
smoker and the fetus, whenever possible pregnant
smokers should be offered person-to-person psychosocial
interventions that exceed minimal advice to quit.
•  As of October, 2010: ALL pregnant women with Medicaid
can receive comprehensive cessation for free
•  Nicotine products for cessation are generally not
recommended during pregnancy.
(ALA, 2014b)
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RELAPSE PREVENTION
q  Congratulate, encourage, and stress importance of
abstinence at every opportunity
q  Review benefits derived from cessation
q  Inquired about problems encountered and offer possible
solutions
q  Anticipated problems or threats to maintaining abstinence
q  Help patient identify sources of support
q  Emphasize that beginning to smoke (even a puff )will
increased urges and make quitting more difficult
q  Assess pharmacotherapy use and problems
q  Consider use or referral to more intensive treatment
(group or individual counseling)
CONCLUSIONS
Ø No single factor determines patterns of tobacco use.
These patterns are the results of complex interactions
of multiple factors, such as socioeconomic status,
cultural characteristics, acculturation, stress, biological
elements, targeted advertising, price of tobacco products,
and varying capacities of communities to mount effective
tobacco control initiatives.
Ø Rigorous surveillance and prevention research are needed
on the changing cultural, psychosocial, and environmental
factors that influence tobacco use to improve our
understanding of racial/ethnic smoking patterns and
identify strategic tobacco control opportunities.
(CDC, 2014b)
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