**Chronic Care Management Plan**

**Tobacco Cessation Overview**

Cigarette smoking is the greatest cause of preventable death and
disability in the US. Tobacco kills more Americans each year than
alcohol, illicit drugs, suicide, AIDS, and accidents combined. More than
3,000 children in the US begin smoking each day and 90 percent of adult
smokers initiated smoking before the age of 18 and 70 percent were daily
smokers before this age. Evidence indicates that the likelihood of
nicotine addiction is greatest during adolescence. Cigarette use and its
consequences impact employability. Smoking cessation treatments via the
use of TUPP counseling and medications are cost-effective healthcare
practices. In terms of life-years saved per dollar spent, effective
counseling and medications for smoking cessation have been found to be
among the most cost effective healthcare practices. In fact, tobacco
dependence treatment is more cost effective than the treatment of
hypertension, diabetes and hyperlipidemia. Finally, national surveys on
youth smoking strongly suggest that smoke-free workplaces and homes are
associated with significantly lower rates of adolescent smoking.

Nicotine Dependence/Addiction:

-   The most common form of drug addiction is nicotine dependence, which
    causes more death and disease than all other addictions combined.

-   Nicotine is the addictive component in cigarettes, and smokers
    experience cravings similar to those experienced by heroin and
    cocaine addicts.

-   The average cigarette contains approximately 9 mg of nicotine.

Nicotine Withdrawal:

-   Quitting is difficult since the nicotine addict will experience
    withdrawal symptoms.

-   These symptoms peak by day 3 and gradually diminish thereafter.

-   Symptoms include: increased cravings, hunger, irritability,
    restlessness, difficulty concentrating, mood disturbance and urge to
    smoke.

How Smoking Harms the Body:

Rapid Addiction:

-   Significant symptoms of addiction, sometimes after smoking only a
    few cigarettes, due to nicotine receptors in the brain.

Immune System Effects:

-   More sick visits to the doctor due to increased vulnerability to
    illnesses.

-   Slowed wound healing resulting in longer recovery time from minor
    and serious injuries.

-   More frequent ear and sinus infections, colds, and pneumonia.

Lung Effects:

-   Difficulty breathing due to airway constriction.

-   Wheezing, persistent cough, asthma attacks, and increased phlegm
    production.

-   Lower exercise tolerance.

Heart and Blood Vessel Effects:

-   Increased fatty deposition in blood vessels leading to early heart
    disease.

-   Clot formation and narrowing of blood vessels, increasing the risk
    of stroke or heart attack.

-   Faster heart rate and compromised blood flow to the heart.

-   Increased blood pressure, leading to organ damage.

Mouth and Stomach Effects:

-   Bad breath

-   Gum disease

-   Tooth decay

-   Heartburn

-   Acid reflux

-   Ulcer disease

Effects on the Brain:

-   Decreased blood flow to the brain, resulting in increased risk of
    stroke.

-   Increased stress.

-   Alteration of brain chemistry, leading to increased cravings.

Other Effects:

-   Vitamin deficiencies and their associated symptoms.

-   Pre-cancerous gene mutations.

-   Dangerous drug interactions.

Benefits of Quitting:

Quitting produces fast, major health benefits, some within minutes from
smoking that last cigarette.

-   At 20 minutes after last cigarette: blood pressure decreases; pulse
    rate drops; and body temperature of hands and feet increases.

-   At 8 hours after quitting: carbon monoxide level in blood drops to
    normal; and oxygen level in blood increases to normal.

-   At 24 hours after quitting: chance of a heart attack decreases.

-   At 48 hours after quitting: nerve endings start regrowing; and
    ability to smell and taste is enhanced.

-   After 2 weeks to 3 months: circulation improves; walking becomes
    easier; lung function increases.

-   After 1 to 9 months: coughing, sinus congestion, fatigue, shortness
    of breath decreases.

-   After 1 year: excess risk of coronary heart disease is decreased to
    half that of a smoker.

CHRONIC CARE MANAGEMENT PLAN

### TOBACCO CESSATION

Goals

1.  Enhance employability by helping the student to quit smoking.

2.  Educate students on the health risks associated with tobacco use.

3.  Reduce tobacco related health consequences.

4.  Optimize cessation counseling and pharmacotherapy whenever
    appropriate.

5.  Implement smoking cessation therapy and regularly scheduled
    follow-up visits.

+----+-----+----------------------------------------------------------+
| #  |     |                                                          |
|  C |     |                                                          |
| AR |     |                                                          |
| EE |     |                                                          |
| R  |     |                                                          |
| PR |     |                                                          |
| EP |     |                                                          |
| AR |     |                                                          |
| AT |     |                                                          |
| IO |     |                                                          |
| N  |     |                                                          |
| PE |     |                                                          |
| RI |     |                                                          |
| OD |     |                                                          |
+----+-----+----------------------------------------------------------+
| #  | #   | #                                                        |
|  Y |  NO |                                                          |
| ES |     |                                                          |
+----+-----+----------------------------------------------------------+
| #  | #   | # Establish a Sm                                         |
|    |     | oking Cessation Action Plan for each student who smokes. |
+----+-----+----------------------------------------------------------+
| #  | #   | # I                                                      |
|    |     | dentify students who are underage smokers (\< 18 years). |
+----+-----+----------------------------------------------------------+
| #  | #   | # Remind un                                              |
|    |     | derage smokers of the consequences for breaking the law. |
+----+-----+----------------------------------------------------------+
| #  | #   | # Obtain a smo                                           |
|    |     | king history by assessing the frequency and number of ci |
|    |     | garettes used daily, as well as the length of time since |
|    |     |  onset of smoking. Remember to inquire regarding the use |
|    |     |  of smokeless tobacco such as chewing tobacco and snuff. |
+----+-----+----------------------------------------------------------+
| #  | #   | Plan visit schedule based on student's desire to quit,   |
|    |     | but more often for students who choose pharmacotherapy   |
|    |     | (at least monthly).                                      |
+----+-----+----------------------------------------------------------+
| #  | #   | Clinical assessment for appropriate pharmacotherapy      |
|    |     | choice for cessation.                                    |
+----+-----+----------------------------------------------------------+
| #  | #   | Mandatory TUPP/smoking cessation enrollment if student   |
|    |     | desires to quit or has been prescribed any form of       |
|    |     | pharmacotherapy.                                         |
+----+-----+----------------------------------------------------------+
| #  | #   | Discuss methods of coping with stressors.                |
+----+-----+----------------------------------------------------------+
| #  | #   | Encourage students to reduce or eliminate tobacco        |
|    |     | exposure.                                                |
+----+-----+----------------------------------------------------------+
| #  | #   | Review medical history for chronic medical conditions    |
|    |     | such as asthma, diabetes, sleep apnea, hypertension,     |
|    |     | allergic rhinitis, etc. that are directly impacted by    |
|    |     | smoking.                                                 |
+----+-----+----------------------------------------------------------+
| #  | #   | Educate students on the health impacts of smoking and    |
|    |     | tobacco use.                                             |
+----+-----+----------------------------------------------------------+
| #  | #   | Review previous cessation history (i.e. question         |
|    |     | regarding quitting attempts in the past, the number of   |
|    |     | attempts, length of cessation, cessation technique -     |
|    |     | "cold turkey", nicotine patch, nicotine gum, bupropion,  |
|    |     | varenicline, etc.)                                       |
+----+-----+----------------------------------------------------------+
| ** |     |                                                          |
| CA |     |                                                          |
| RE |     |                                                          |
| ER |     |                                                          |
| D  |     |                                                          |
| EV |     |                                                          |
| EL |     |                                                          |
| OP |     |                                                          |
| ME |     |                                                          |
| NT |     |                                                          |
| PE |     |                                                          |
| RI |     |                                                          |
| OD |     |                                                          |
| ** |     |                                                          |
+----+-----+----------------------------------------------------------+
| #  | #   | Monitor adherence issues                                 |
|    |     |                                                          |
|    |     | -   Cessation counseling/TUPP participation              |
|    |     |                                                          |
|    |     | -   Pharmacotherapy regimen                              |
|    |     |                                                          |
|    |     | -   Avoidance of smoking while using nicotine            |
|    |     |     replacement therapy                                  |
|    |     |                                                          |
|    |     | -   Avoidance of other nicotine containing products      |
|    |     |                                                          |
|    |     | -   Self-monitoring                                      |
|    |     |                                                          |
|    |     | -   Environmental control - avoidance of tobacco         |
|    |     |     exposure                                             |
|    |     |                                                          |
|    |     | -   Stress management                                    |
|    |     |                                                          |
|    |     | -   Exercise/Physical activity                           |
|    |     |                                                          |
|    |     | -   Rest                                                 |
|    |     |                                                          |
|    |     | -   Nutrition                                            |
|    |     |                                                          |
|    |     | -   Alcohol, other drug use                              |
|    |     |                                                          |
|    |     | -   Withdrawal symptoms                                  |
+----+-----+----------------------------------------------------------+

+----+-----+----------------------------------------------------------+
| ** |     |                                                          |
| CA |     |                                                          |
| RE |     |                                                          |
| ER |     |                                                          |
| TR |     |                                                          |
| AN |     |                                                          |
| SI |     |                                                          |
| TI |     |                                                          |
| ON |     |                                                          |
| PE |     |                                                          |
| RI |     |                                                          |
| OD |     |                                                          |
| ** |     |                                                          |
+----+-----+----------------------------------------------------------+
| #  | #   |                                                          |
|  Y |  NO |                                                          |
| ES |     |                                                          |
+----+-----+----------------------------------------------------------+
| #  | #   | Conduct a Wellness Center exit interview approximately   |
|    |     | two weeks before program completion.                     |
+----+-----+----------------------------------------------------------+
| #  | #   | Identify potential sources of primary health care, and   |
|    |     | specialty care if needed, in the work community.         |
+----+-----+----------------------------------------------------------+
| #  | #   | Obtain signed HIPAA authorizations for the transfer of   |
|    |     | student health records to identified health care         |
|    |     | providers.                                               |
+----+-----+----------------------------------------------------------+
| #  | #   | Assist the student in enrolling or maintaining           |
|    |     | enrollment in a public or private health insurance       |
|    |     | program.                                                 |
+----+-----+----------------------------------------------------------+
| #  | #   | Provide the student with a copy of the SF-93, SF-88,     |
|    |     | immunization records, and a copy of the chronic care     |
|    |     | management plan, including flow sheets.                  |
+----+-----+----------------------------------------------------------+
| #  | #   | Provide the student with an adequate amount of           |
|    |     | medication(s) and supplies at departure.                 |
+----+-----+----------------------------------------------------------+

**See Tobacco Cessation Management Flow Sheet for tracking patient
visit.**

**See Treatment Guideline for Nicotine Replacement Therapy for
additional guidance.**

**See "Strengthening Your TUPP" presentation for additional information
and guidance on suggested counseling and pharmacological interventions
from the National Health and Wellness Conference of April 2007.**

**See website: [http://www.askandact.com](http://www.askandact.com/)**

+--------+-----------+---+-----------+------+---+---------------------+
| > **C  |           |   |           |      |   |                     |
| HRONIC |           |   |           |      |   |                     |
| > CARE |           |   |           |      |   |                     |
| > MANA |           |   |           |      |   |                     |
| GEMENT |           |   |           |      |   |                     |
| > PLAN |           |   |           |      |   |                     |
| >      |           |   |           |      |   |                     |
|  FLOWS |           |   |           |      |   |                     |
| HEET** |           |   |           |      |   |                     |
| >      |           |   |           |      |   |                     |
| > **T  |           |   |           |      |   |                     |
| OBACCO |           |   |           |      |   |                     |
| >      |           |   |           |      |   |                     |
|  CESSA |           |   |           |      |   |                     |
| TION** |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
| **     |           | * |           |      | * |                     |
| Sex:** |           | * |           |      | * |                     |
|        |           | A |           |      | D |                     |
|        |           | g |           |      | a |                     |
|        |           | e |           |      | t |                     |
|        |           | : |           |      | e |                     |
|        |           | * |           |      | o |                     |
|        |           | * |           |      | f |                     |
|        |           |   |           |      | E |                     |
|        |           |   |           |      | n |                     |
|        |           |   |           |      | t |                     |
|        |           |   |           |      | r |                     |
|        |           |   |           |      | y |                     |
|        |           |   |           |      | : |                     |
|        |           |   |           |      | * |                     |
|        |           |   |           |      | * |                     |
+--------+-----------+---+-----------+------+---+---------------------+
| **Co-  |           |   |           |      |   |                     |
| Morbid |           |   |           |      |   |                     |
| C      |           |   |           |      |   |                     |
| onditi |           |   |           |      |   |                     |
| ons:** |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
| **Me   |           |   |           |      |   |                     |
| dicati |           |   |           |      |   |                     |
| ons:** |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
| **T    |           |   |           |      |   |                     |
| obacco |           |   |           |      |   |                     |
| Use    |           |   |           |      |   |                     |
| and    |           |   |           |      |   |                     |
| Freque |           |   |           |      |   |                     |
| ncy:** |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
| **     |           |   |           |      |   |                     |
| Number |           |   |           |      |   |                     |
| of     |           |   |           |      |   |                     |
| Months |           |   |           |      |   |                     |
| or     |           |   |           |      |   |                     |
| Years  |           |   |           |      |   |                     |
| Smo    |           |   |           |      |   |                     |
| ked:** |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
| **TUPP |           |   |           |      |   |                     |
| Pa     |           |   |           |      |   |                     |
| rticip |           |   |           |      |   |                     |
| ation: |           |   |           |      |   |                     |
| YES    |           |   |           |      |   |                     |
| NO**   |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
| **T    |           |   |           |      |   |                     |
| obacco |           |   |           |      |   |                     |
| Ces    |           |   |           |      |   |                     |
| sation |           |   |           |      |   |                     |
| Interv |           |   |           |      |   |                     |
| ention |           |   |           |      |   |                     |
| C      |           |   |           |      |   |                     |
| hosen: |           |   |           |      |   |                     |
| (      |           |   |           |      |   |                     |
| circle |           |   |           |      |   |                     |
| all    |           |   |           |      |   |                     |
| that   |           |   |           |      |   |                     |
| ap     |           |   |           |      |   |                     |
| ply)** |           |   |           |      |   |                     |
|        |           |   |           |      |   |                     |
| **Coun |           |   |           |      |   |                     |
| seling |           |   |           |      |   |                     |
| Ni     |           |   |           |      |   |                     |
| cotine |           |   |           |      |   |                     |
| Repla  |           |   |           |      |   |                     |
| cement |           |   |           |      |   |                     |
| T      |           |   |           |      |   |                     |
| herapy |           |   |           |      |   |                     |
| Other  |           |   |           |      |   |                     |
| Med    |           |   |           |      |   |                     |
| icatio |           |   |           |      |   |                     |
| n(s)** |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
| **Ni   |           |   |           |      |   |                     |
| cotine |           |   |           |      |   |                     |
| Repla  |           |   |           |      |   |                     |
| cement |           |   |           |      |   |                     |
| Th     |           |   |           |      |   |                     |
| erapy: |           |   |           |      |   |                     |
| i      |           |   |           |      |   |                     |
| nclude |           |   |           |      |   |                     |
| dose   |           |   |           |      |   |                     |
| and    |           |   |           |      |   |                     |
| frequ  |           |   |           |      |   |                     |
| ency** |           |   |           |      |   |                     |
| (      |           |   |           |      |   |                     |
| patch, |           |   |           |      |   |                     |
| gum,   |           |   |           |      |   |                     |
| in     |           |   |           |      |   |                     |
| haler, |           |   |           |      |   |                     |
| nasal  |           |   |           |      |   |                     |
| s      |           |   |           |      |   |                     |
| pray): |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
| **     | **NRT**   |   | **Medi    | *    |   | **                  |
| Date** |           |   | cations** | *Adh |   | Comments/Progress** |
|        |           |   |           | eren |   |                     |
|        |           |   |           | ce** |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
|        |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
|        |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
|        |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
|        |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
|        |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
|        |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
|        |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
|        |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
|        |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
|        |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
|        |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
|        |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
|        |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+
|        |           |   |           |      |   |                     |
+--------+-----------+---+-----------+------+---+---------------------+