T2 - IE 5 - Assisting Patients with Quitting (511)

How can you treat a patient with an addiction to nicotine (Physiological)?

How can you treat a patient with an addiction to nicotine (Physiological)?

Medications for cessation

How can you treat a patient with a habit of using nicotine (Behavioral)?

Behavior change program

What are the methods for quitting smoking?

Pharmacologic
▪ FDA-approved medications

Nonpharmacologic
▪ Counseling and other non-drug approaches

Counseling and medications are both effective, but the combination of counseling and medication is more effective than either alone.

What are some nonpharmacological therapies to help patients quit smoking?

Cold turkey: Just do it!

Unassisted tapering (fading)
- Reduced frequency of use
- Lower nicotine cigarettes
- Special filters or holders

Assisted tapering
- QuitKey (PICS, Inc.)
◼ Computer developed taper based on patient's smoking level
◼ Includes telephone counseling support

Acupuncture therapy

Hypnotherapy

Massage therapy

Formal cessation programs
- Self-help or group programs
- Individual, Telephone, or Web-based counseling

What are the effects of clinician intervention when helping patients quit smoking?

With help from a clinician, the odds of quitting approximately doubles.
- Patients who receive assistance are 1.7-2.2 times more likely to quit successfully for 5 or more months
- More clinicians helping = higher success rate

Why should clinicians address tobacco?

Failure to address tobacco use implies that quitting is not important.

Tobacco users expect to be encouraged to quit by health professionals

What are the 5 A's when helping patients quit smoking?

Ask
Advise
Assess
Assist
Arrange

What do you do in regards to the ASK category ?

Ask about tobacco use with a tone that conveys sensitivity, concern and is non-judgmental

Ex.
- "Do you smoke or use other types of tobacco or nicotine, such as e-cigarettes?"
- "Has there been any change in your smoking status?"

What do you do in regards to the ADVISE category ?

Advise tobacco users to quit (clear, strong, personalized)

Ex.
- "It's important for your health that you quit smoking, and I can help you."
- "Quitting smoking is the most important thing you can do to...[control your asthma, reduce your chance for another heart attack, better manage your diabetes, etc.]"
- "Quitting smoking is the single most important thing you can do to protect your health now and in the future."

What do you do in regards to the ASSESS category ?

Assess readiness to make a quit attempt

What do you do in regards to the ASSIST category ?

Assist with the quit attempt
- Not ready to quit: enhance motivation (the 5 R's)
◼ Relevance
◼ Risks
◼ Rewards
◼ Roadblocks
◼ Repetition
- Ready to quit: design a treatment plan
- Recently quit: relapse prevention

What do you do in regards to the ARRANGE category ?

Arrange follow-up care
- More follow ups = Higher quit rate

What are some important things to consider when patients are making the difficult decision to quit smoking?

Faced with change, most people are not ready to act.

Change is a process, not a single step.

Typically, it takes multiple attempts.

What are the stages smokers are in regarding their readiness to quit?

STAGE 1: Not ready to quit in the next month

STAGE 2: Ready to quit in the next month

STAGE 3: Recent quitter, quit within past 6 months

STAGE 4: Former tobacco user, quit > 6 months ago

Assessing a patient's readiness to quit enables clinicians to deliver relevant, appropriate counseling messages

For most patients, quitting is ?

A cyclical process, and their readiness to quit (or stay quit) will change over time.

Assess readiness to quit (or to stay quit) at each patient contact.

What are some characteristics of stage 1 for patients who want to quit smoking?

Not ready to quit

Not thinking about quitting in the next month

Some patients are aware of the need to quit.
▪Patients struggle with doubt about change.
▪Patients are not ready to change, yet.
▪Pros of continued tobacco use outweigh the cons.

GOAL: Start thinking about quitting.

What are some counseling strategies for stage 1 patients?

DO
◼ Strongly advise to quit
◼ Provide information
◼ Ask noninvasive questions; identify reasons for tobacco use
◼ Raise awareness of health consequences/concerns
◼ Demonstrate empathy, foster communication
◼ Leave decision up to patient

DON'T
◼ Persuade (Pushy)
◼ "Cheerlead"
◼ Tell patient how bad tobacco is, in a judgmental manner
◼ Provide a treatment plan

Counseling strategies for stage 1 patients flow chart:

What are some characteristics of stage 2 for patients who want to quit smoking?

Ready to quit in the next month

Patients are aware of the need to, and the benefits of, making the behavioral change.

Patients are getting ready to take action.

GOAL: Achieve cessation.

What are the three key elements for counseling stage 2 patients?

Assess tobacco use history

Discuss key issues

Facilitate quitting process
- Practical counseling (problem solving/skills training)
- Social support delivered as part of treatment

In stage 2, what should you address regarding patient tobacco use history?

Current use: type(s) of tobacco, amount

Past use: duration, recent changes

Past quit attempts:
◼ Number, date, length
◼ Methods/medications used, adherence, duration
◼ Reasons for relapse

In stage 2, what key issues should you discuss?

Reasons/motivation to quit

Confidence in ability to quit

Triggers for tobacco use

Weight Gain

Withdrawal symptoms

Living with a smoker

Alcohol and socializing

Smoking after meals

Boredom

In stage 2, how should you counsel patients about the key issue of weight gain?

Discourage strict dieting while quitting

Encourage healthful diet and meal planning

Suggest increasing water intake or chewing sugarless gum

Recommend selection of nonfood rewards

When fear of weight gain is a barrier to quitting:
- Consider pharmacotherapy with evidence of delaying weight gain (bupropion SR or 4-mg nicotine gum or lozenge)
- Assist patient with weight maintenance or refer patient to specialist or program

In stage 2, how should you counsel patients about the key issue of withdrawal symptoms?

Most WS pass within 2-4 weeks after quitting

Cravings can last longer, up to several months or years
- Can be improved with cognitive or behavioral coping strategies

Refer to Withdrawal Symptoms Information Sheet
- Symptom, cause, duration, relief

Most symptoms manifest within the first 1-2 days, peak within the first week, and subside within 2-4 weeks.

In stage 2, how should you counsel patients about the key issue of living with another smoker ?

Discuss importance and negotiate where and when he/she will smoke, but do not make demands

Surprise the smoker with a gift at the end of your first month of quitting as a thank you

In stage 2, how should you counsel patients about the key issue of Alcohol and Socializing?

Explore alternative ways to socialize

Avoid going to a bar

If they do go, advise patients:
◼ Don't drink alcohol, or limit drinks to one or two
◼ Have a plan and practice it
◼ Visualize yourself saying "No thank you, I don't smoke" several times before going out

In stage 2, how should you counsel patients about the key issue of smoking after meals? (How can you avoid it)

Immediately get up from the table

Brush teeth
- While doing so, look in the mirror and confirm commitment to quitting—"I can do this!"

Take a short walk

Call a supportive friend

In stage 2, how should you counsel patients about the key issue of smoking due to boredom? (How to avoid it)

Advise patients to:
◼ Always carry a book/newspaper/crossword puzzle
◼ Plan ahead, avoiding long periods of inactivity
◼ Learn to enjoy doing nothing from time to time
◼ Restart an old hobby or start to exercise

In stage 2, how should you facilitate the quitting process for smoking?

Discuss methods for quitting
◼ Discuss pros and cons of available methods
◼ Pharmacotherapy: a treatment, not a crutch!
◼ Importance of behavioral counseling

Set a quit date

Recommend Tobacco Use Log
◼ Helps patients to understand when and why they use tobacco
◼ Identifies activities or situations that trigger tobacco use
◼ Can be used to develop coping strategies to overcome the temptation to use tobacco

Provide medication counseling

Discuss concept of "slip" versus relapse
◼ "Let a slip slide."

Offer to assist throughout quit attempt
◼Follow up with the patient

Discuss coping strategies

Congratulate the patient

What are the myths and facts related to stress related tobacco use?

Myths:
◼ "Smoking gets rid of all my stress." (Does not actually help with stress)
◼ "I can't relax without a cigarette."

Facts:
◼ There will always be stress in one's life.
◼ There are many ways to relax without a cigarette.

People who smoke confuse the relief of withdrawal with the feeling of relaxation.

Stress management suggestions:
- Deep breathing, shifting focus, taking a break.

How can you discuss coping strategies for stage 2 patients?

Cognitive coping strategies
◼ Focus on changing the way a patient thinks
◼ Occur prior to the situation or "in the moment"

Behavioral coping strategies
◼ Involve specific actions to reduce risk for relapse
◼ Occur prior to the situation or "in the moment"

How can you teach and encourage coping?

Think in terms of "alternatives"

There is always some other way to think or something else to do in every situation (to avoid smoking)

Use a variety of techniques

Foster creativity

What are the steps to teach and encourage coping?

Ask
- Ex. "What could you do differently in this situation so you won't be prompted to want a cigarette?"

If they provide a reasonable alternative, be supportive

If they say "I don't know" or "I can't think of anything"
- Suggest a coping technique
- Make suggestions appropriate to their lifestyle

What are some Cognitive Coping Strategies?

Review commitment to quit

Distractive thinking

Positive self-talk

Relaxation through imagery

Mental rehearsal and visualization

Remind yourself that urges are brief.

What are some Behavioral Coping Strategies?

Control your environment
- Tobacco-free home and workplace
- Remove triggers to tobacco use
- Modify behaviors that you associate with tobacco

Substitutes for smoking
- Water, sugar-free chewing gum or hard candies (oral substitutes)

Minimize stress where possible, obtain social support, take a break, and alleviate withdrawal symptoms

What are some characteristics of stage 3 smokers?

Recent quitter

Actively trying to quit for good

Patients have quit using tobacco sometime in the past 6 months

Withdrawal symptoms occur.

Patients are at high risk for relapse.

GOAL: Remain tobacco-free for at least 6 months.

For stage 3 smokers, how can you evaluate the quit attempts?

Tailor interventions to match each patient's needs

Status of attempt
◼ Ask about social support
◼ Identify ongoing temptations and triggers for relapse
◼ Encourage healthy behaviors to replace tobacco use

Slips and relapse

Medication adherence, plan for termination (When to stop meds)
- Are the meds working?

For stage 3 smokers, how can you prevent relapse?

Congratulate success!

Encourage continued abstinence

Schedule additional follow-up as needed

What are some characteristics of stage 4 patients who want to quit smoking?

Former tobacco user

Tobacco-free for 6 months

Patients remain vulnerable to relapse.

Ongoing relapse prevention is needed

GOAL: Remain tobacco-free for life.

How do you counsel stage 4 patients?

Assess status of quit attempt

Congratulate continued success

Ask about and address slips and relapse

Plan for termination of pharmacotherapy

Review tips for relapse prevention

Continue to assist throughout the quit attempt

If your patient that smokes does not have time for an entire counseling session about quitting, what can you do?

Brief Counseling: Ask, Advise, Refer
- Brief interventions have been shown to be effective
- Can be achieved in less than 1 minute.

ASK about tobacco use

ADVISE tobacco users to quit

REFER to other resources
- Person referred to will do the assist and arrange aspect of the counseling
- refer to other resources, such as local group programs or the toll-free quitline

What are tobacco quitlines?

Tobacco cessation counseling, provided at no cost via telephone to all Americans

Staffed by highly trained specialists

Up to 4-6 personalized sessions (varies by state)

Some state quitlines offer pharmacotherapy at no cost (or reduced cost)

28.1% success rate for patients who use the quitline and a medication for cessation

When a patient calls a quitline what are they provided with?

Caller is routed to language-appropriate staff

Brief Questionnaire
▪ Contact and demographic information
▪ Smoking behavior

Choice of services
▪ Individualized telephone counseling
▪ Referral to local programs, as appropriate

Quitlines have broad reach and are recommended as an effective strategy

Pharmacists, in regards to making a commitment to helping with smoking cessation, should?

Address tobacco use with all patients.

At a minimum, make a commitment to incorporate brief tobacco interventions as part of routine patient care.

Ask, Advise, and Refer

Describe tobacco use trends among adult males/females over the past 50 years

More males than females

Gradual decrease in smokers over the past 50 years

More than half of current smokers want to quit and try to quit

List the compounds in tobacco smoke that can cause harm to humans

Gases:
- Carbon monoxide
- Hydrogen cyanide
- Ammonia
- Benzene
- Formaldehyde

Particles
- Nicotine
- Nitrosamines
- Lead
- Cadmium
- Polonium-210

Nicotine is the addictive component of tobacco products, but it does NOT cause the ill health effects of tobacco use.

What are the health risks associated w/ smoking during pregnancy?

Congenital defects
Low birth weight
Preterm delivery
Infant mortality
Reduced fertility

List three health risks to infants, children, and adults due to second hand smoke

Cancer, respiratory, and cardiovascular diseases

Children
- Increase risk of SIDS, acute respiratory infections, ear problems, asthma
- Respiratory symptoms and slowed lung growth

Adults
- ADE on CV system
- Increased risk for CHD and lung cancer

Describe health consequences and deaths associated w/ tobacco use

Cardiovascular/metabolic disease, lung cancer, pulmonary disease, second hand smoke, cancers other than lung, other

Describe health benefits associated w/ tobacco cessation

Reduction in cumulative risk of death from lung cancer in men also reduces risk of death overall

Describe PK profile of nicotine (ADME)

Absorption:
- Absorption is pH dependent
- Acidic → ionized, poor absorption
- Alkaline → non ionized, easier absorption
- At physiological pH, easily absorbed

Distribution:
- Nicotine reaches brain within 10-20 seconds
- Higher presence in arterial than venous

Metabolism:
- 10-20% excreted unchanged in the urine
- Metabolized to 70-80% cotinine and ~ 10% other metabolites

Excretion
- Nicotine t½ =2 hr
- Cotinine t½ = 16 hr
- Occurs through kidneys (pH dependent, increases w/ acidic)
- Through breast milk

Describe the pharmacodynamic effects of nicotine on CNS and cardiovascular systems

CNS
- Pleasure,
- Arousal, improved vigilance
- Improved task performance
- Anxiety relief

Cardiovascular system
- Increased HR and BP
- Increase in cardiac output
-Coronary and cutaneous vasoconstriction

Which beverages can affect absorption of nicotine from buccal mucosa?

Coffee, juice, cola, can lower pH of mouth → reduce absorption of nicotine

What neurotransmitters are affected by nicotine and their effects

Describe the dopamine reward pathway + role in nicotine addiction

Nicotine enters brain → stimulate nicotine receptor → stimulate dopamine into prefrontal cortex

Stimulation of reward pathway → enhances behaviors that support smoking

List 6 symptoms of nicotine withdrawal + peak and duration

Identify 2 key factors that increase likelihood of stroke, myocardial infarction, and thromboembolism in smokers who use OC.

Women who are 35 years of age or older AND smoke at least 15 cigarettes per day are at significantly elevated risk. (This interaction does not decrease the efficacy of hormonal contraceptives)

Describe drug interaction between smoking + caffeine and be able to advise pt on how to adjust consumption when quitting smoking

Tobacco smoke induces CYP1A2 enzymes, which metabolize caffeine -> Increases caffeine clearance

Caffeine levels increase (~56%) upon quitting

Decrease caffeine intake by 50% when quitting; no caffeine after 1PM for individuals with a typical bedtime

Tobacco use can decrease the effectivity of dugs metabolized by?

CYP1A2