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Smoking cessation efforts in your practice: Has Chantix helped chip away at the smoking population?
In my cardiology practice approximately a third of patients seen to have a real willingness and desire to quit and are making active efforts to reduce their smoking with an aim towards cessation. Another third seemed content to "keep it under control" with responses such as I don't really inhale and I've cut way down from what I used to smoke. And the final third seen to enjoy smoking so much that they have no interest in discussing strategies for cessation and justify its ongoing use with responses such as "It’s the only pleasure I have" or "I don't have any other risk factors" or "I don't have any other vices"
In my practice strategies of nicotine replacement therapy have been only marginally successful and a handful of patients have replaced smoking addiction with nicotine addiction unable to give up nicotine gum after several years.
Chantix has been very useful strategy as a mono therapy; the success rate with my patient's has been similar to what has been reported in the clinical trials for this drug with about half of patient's succeeding at smoking cessation at 6 months. In my experience the best success seems to be with heavier smoker's - those smokers with greater than one pack per day cigarette smoking are the most able to reduce and ultimately quit
The warnings related to Chantix issues with depression have raised concerns amongst patients. The heightened press reports caused many patient s to resist Chantix as an aid to smoking cessation and a small number of patients have struggled heartburn and GI upset issues.
I have not experienced any issues with reimbursement by pharmacy benefits managers after the first several months after Chantix was first introduced. I am however unable to find any resources for nonpharmacologic therapies such as behavioral modification or counseling for smoking cessation and would welcome suggestions other physicians might have that they have access to further own patient's.
Our actual reimbursement from payers for smoking counseling using codes 99406 and 99407 ranges $10.06 to $50.01 depending on the payer as an add on to the office visit.
What challenges doother clinicans face with regard to use of pharmacologic therapies for smoking cessation? Do clinicans have success in referring patient for nonpharmacologic therapies and have success with hypnosis or other nonpharmacologic strategies? Any success using dual therapy either nicotine gum or patch ,Chantix or bupropion? Have insurers in your area reimbursed the smoking counseling codes?
Other resources
Letter to Our New President: It's Time to Break the Habit by Melinda Beck
No Smoking Please on 60 minutes
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Dr Bilazarian performs coronary and peripheral interventions at Lahey Clinic and Massachusetts General Hospital. He has been an investigator in the interventional laboratory for new devices including drug-eluting stents, distal protection devices, imaging devices (OCT and InfraRed), and anticoagulant pharmacotherapy.
Dr Bilazarian is an active participant in clinical trials in congestive heart failure, hypertension, coronary disease prevention, prediabetes management, anemia, atrial fibrillation, and anticoagulation/antiplatelet therapies in the outpatient setting. He has authored numerous papers and book chapters in clinical cardiology. He was appointed as a physician advisor to the circulatory device panel of the FDA in 2008.
- Integration of new data and guidelines on inpatient and outpatient practice in clinical and interventional cardiology
- Practice approaches to the extra clinical issues in dealing with managed care insurers
- Strategies for navigating the restrictions of pharmacy benefits managers (PBMs) on pharmacologic therapies for our patients
- Experiences with restrictions on testing and imaging
CommentsCommentaires
I find that the most useful adjunct to persuading a patient to utilize Chantix is to give them the "calculator" that I keep in every office exam room AND distribute to every smoker AND NON-SMOKER who are admitted to the hospital. My thinking is that with 1 in 3 patients smoking in our area, everyone has a friend or family member who could use the information. The calculator is a chart that allows the patient to plot their individual expenditures or their entire household expenditures at one month, 6 months, 1 year, 5 years, 10 years and 20 years of tobacco use. I then point out that the cost of a college education for their children, a good automobile, dental care, or puchase of medication would be a more worthy expendiure.
When a patient tells me they "can't afford" Chantix, I present them with the cost of 1 year of tobacco expenditures and give them the devastating answer to why they are struggling in poverty. I point out that at the third week of tobacco cessation, the patient is actually making money. I also found two pharmacies in town that will sell Chantix by the week which is a great help.
When patients tell me they've heard of terrible nightmares that occurr with Chantix use, I then point out that there is no greater nightmare than learning you have lung cancer with brain mets, stroke or need an AICD at age 50. When they say they are afraid of nausea, I offer Phenergan or Zofran, admitting that this recommendation is against the grain of the common practice of stopping medications with side effects that we have been socialized as physicians to follow. However, as Dr. Tonstadt once told me, "smoking is different. It's going to kill them so you have to use other meds to keep them on Chantix". I always tell them to cut the dose in half or 1/4's if necessary and take it on a full stomach.
As for the numerous "lawsuits" that are going to be forthcoming with Chantix, I always point out my conversation with Dr. Tonstadt , (one of the earliest trialists with this compound ) that I had in Stockholm a few years ago BEFORE Chantix came to America. I told her that once it landed here, it would suddenly "cause" all manner of side effects. It would cause smokers to "grow two heads" for instance and "cause" all kinds of bizarre illness BECAUSE the U.S. is BURLEY territory and NOTHING that interferes with that addiction effectively WILL EVER be allowed to stay on the market here without a fight. Prediction is coming true. I always shake my head when ANYONE brings a suit against Chantix. Why not sue the tobacco company for promoting addiction which requires Chantix? Why not sue the tobacco companies and MAKE THEM REMOVE THE NICOTINE???
Thanks for your video Blogg on this very important topic. I'd also like to plug the idea of the U.S. becoming a SMOKE -FREE NATION like so many others such as India and Ireland. We should be panting to catch up with such forward thinking.
Especially in this economic environment, President Obama could pass this into law WITH NO EXPENDITURE except for the cost of a bit of ink and in 5 years, reduction in illnesses due to 2nd hand smoke combined with fewer new starts would MAKE enough money to drive a much needed national Prevention program.
Melissa
Do you use behavioral modification programs? Quit works or Chantix has their own program? I have found B-mod programs to be a must! when treating nicotine addiciton. Quit rates are always higher (double in most studies) when using both methods.
I have found Chantix (varenicline) very effective. Chantix is to my mind a landmark therapy that has re-doubled my attempts to have patient stop smoking. I put both the patient and spouse on the drug. The cessation seems much more effective if the spouse is involved. It is effective for many but not all. Patients should be encouraged to continue to attempt to quitting if they have early lapses after quit day.
The most common side effects I’ve seen include nausea, sleep problems, strange dreams, constipation, and gas. I’ve not seen the reported suicidal ideation or suicidal behavior.
The cost savings of smoking cessation is seems more important to the patients if they are tempted to restart.
I’ve even used Chantix once when a pregnant woman (with Ob’s approval) said she cannot stop smoking on her own and that the benefits of stopping smoking outweigh the risks Chantix presents to the unborn child.