PTC3 Smoking Cessation

Types of Tobacco

• Smoking Tobacco

→ Cigarettes

→ Cigars

→ Pipes

→ Hookah

→ Vipes

→ Involve the combustion of dried tobacco leaves creating dangerous chemicals that are then absorbed by the lungs

• Smokeless Tobacco

→ Chewing tobacco

→ Dissolvable smokeless tobacco products

→ Snus

→ Moist Snuff/Dipp

→ Consumed either orally or nasally

• Both smoking and smokeless tobacco contain nicotine, the addicting c• Smoking Tobacco

→ Cigarettes

→ Cigars

→ Pipes

→ Hookah

→ Vipes

→ Involve the combustion of dried tobacco leaves creating dangerous chemicals that are then absorbed by the lungs

• Smokeless Tobacco

→ Chewing tobacco

→ Dissolvable smokeless tobacco products

→ Snus

→ Moist Snuff/Dipp

→ Consumed either orally or nasally

• Both smoking and smokeless tobacco contain nicotine, the addicting component

• The nicotine levels vary between products, but there is no safe form of tobacco

Smoking Tobacco

Tobacco smoking is the act of burning dried or cured leaves of the tobacco plant and inhaling the smoke. Combustion uses heat to create new chemicals that are not found in the unburned tobacco, such as tobacco-specific nitrosamines (TSNAs) and benzopyrene, and allow them to be absorbed through the lungs

Smokeless Tobacco

Smokeless tobacco is usually consumed orally or nasally without burning. Smokeless tobacco increases the risk of cancer and leads to nicotine addiction similar to that produced by cigarette smoking

Tobacco is the leading cause of preventable deaths in the U.S. today. (True/False)

True, it causes more than 480,000 deaths each year and secondhand smoke causes more than 40,000 deaths a year. They will usually die from a tobacco related death and it affects all the health systems. Smoking causes 1 in every 4 deaths from cardiovascular disease and 1 of every 3 cancer deaths is linked to smoking.

What can smoking cause?

Cancers (lung or oral), sudden infant death, type 2 diabetes, increases the risk of a stroke, COPD

Second hand smoke has less adverse effects compared to actually smoking the product. (True/False)

False, it actually causes the same adverse reactions. There is no safe level of exposure of second half smoke

Smoking increases the risk of lung cancer _______ times, and increases the risk of coronary disease ________ times.

24; 4

Sudden infant death syndrome (SIDS)

• The unexplained death of a seemingly healthy baby; can be caused by second hand smoke

Second Hand Smoke

The smoke or aerosol from burning tobacco products, like cigarettes, hookah, or vapes

Third hand smoke

• Tobacco residue from tobacco products that is left behind after smoking and builds up on surfaces and furnishings

• Full of carcinogens that causes adverse health outcomes

What is the effect of using smokeless tobacco products?

Oral cancers, dental problems, pancreas cancer and esophagus cancer

The overall rate of smoking in the US, the rate of smokeless tobacco use, and the rate of use of e-cigarettes

15%; 2%; 15%

Tobacco use remains high in what populations?

• Young adults

• Rural areas• People with disabilities

• LBTQ+ Communities

• Low income

• Low education

• Those with mental illness or substance use disorders

• Racial/ethnic minorities

• Military veterans

Nearly 9 out of 10 cigarette smokers first tried smoking by age...

...18. It is reported that 16.5% of high school students used any tobacco products.

Tobacco dependence

• Chronic disease characterized by multiple failed attempts to quit before long-term cessation is achieved

- complex, addictive behavior

• Quitting tobacco and nicotine is extremely difficult

What are the benefits of quitting tobacco?

• In just 20 minutes, blood pressure and heart rate decrease to their base line and in 8 hours, their blood oxygen level return to baseline levels

• It increases the health of the heart, lungs, brain, DNA, and mouth

• Combining counseling and medication doubles the chances of quitting

Tobacco cessation involves multiple __________ attempts.

quit (but they learn each time!)

5 A's Model

• Ask about tobacco use

→ "Do you use any tobacco products?"

• Advise to quit

→ "It is important that you quit smoking (or using tobacco now) and I can help you"

→ "Continuing to smoke makes your asthma worse, and quitting may dramatically improve your health"

• Assess willingness to make a quit attempt

→ "Would you like to be a non tobacco user?"

→ If they are not ready, use the 5 Rs model

• Assist in quit attempt

→ Use counseling and pharmotherapy to help them quit and connect them to resources like ahect?

• Arrange follow up

→ Schedule follow-up contact preferable within the first week after the quit date

→ "Let's follow up in a couple of weeks so we can talk about how you are doing."

Fives R's Model

1. Relevance

• Indicate how quitting personally relevant to him or her

• "How is quitting most personally relevant to you?"

2. Risks

• Identify potential negative consequences of tobacco use that are relevant

• "What do you know about the risks of smoking regarding your health? What worries you about your smoking?"

3. Rewards

• Identify potential benefits of stopping tobacco use

• "Do you know how stopping smoking would affect your risk of cancer?"

4. Roadblocks

• Identify barriers or impediments to quitting

• "What would be difficult about quitting for you

5. Repetition

• Repeat 5 A's

or

• Repeat intervention at a later date

2 A's and an R

• Ask

→ Every patient about tobacco use

• Advice

→ The patient to quit

• Refer

→ The patient to quit resource

Key considerations for treating tobacco dependence

• Behavioral counseling can benefit all patients

• Medication can help patients quit and can be used with most patients, though special considerations may apply for some individuals

• Combining behavioral counseling and medication is more effective than either treatment alone

• Follow-up is key to monitoring patients for treatment adherence, side effects, and efficacy, along with providing support and continued assistance

Electronic Nicotine Delivery Systems (ENDS)

• Electronic cigarettes, e-cigarettes, vaping devices, or vape pens, are battery-powered devices used to smoke or "vape" a flavored solution which usually contains nicotine• There has been an exponential increase in recent years

E-Cigarette Anatomy

• There's a battery that heats up a liquid that contains nicotine to generate a aerosol vapor

E-liquids =

Nicotine (addictive; variable amounts that are comparable to cigarettes) + flavorings (safe, but appealing to youth) + Humectants (Propylene glycol, glycerol)

E-cigarettes increases the risk of...

...of ever using combustible tobacco cigarettes, and if they were already using cigarettes, they start dual using

E-cigarettes are currently approved by the FDA as a quit-smoking aid. (True/False)

False, it is not approved. The U.S. Preventive Services Task Force, a group of health experts that makes recommendations about preventive health care, concluded that the evidence is insufficient to recommend e-cigarettes for smoking cessation in adults, including pregnant women. HOWEVER, e-cigarettes may help non-pregnant adult smokers if used as a complete substitute for all cigarettes and other smoked tobacco products. TO DATE, THE FEW STUDIES ON THE ISSUE ARE MIXED. Evidence from two randomized controlled trials found that e-cigarettes with nicotine can help smokers stop smoking in the long term compared with placebo (non-nicotine) e-cigarettes. A recent CDC study found that many adults are using e-cigarettes in an attempt to quit smoking. However, most adult e-cigarette users do not stop smoking cigarettes and are instead continuing to use both products ("dual use"). Because smoking even a few cigarettes a day can be dangerous, quitting smoking completely is very important to protect your health.

The Stages of Change Model

Pre-contemplation → Contemplation → Preparation → Action → Maintenance

The Stages of Change Model: Pre-contemplation

• The individual has no interest in changing their behavior• They have not acknowledged that their is a problem behavior that needs to be changed

The Stages of Change Model: Contemplation

• Individuals acknowledge that they have a problem but may not be ready to change

The Stages of Change Model: Preparation

• When a person intends to change behavior and is preparing to change, but has not yet taken action.

• Ex. Planned a date to quit and booked themselves for a class

The Stages of Change Model: Action

• Active modification of behavior• "I now take a walk instead of smoking."

The Stages of Change Model: Maintenance

• When a person has successfully implemented a behavioral change for more than 6 months.

Roadblocks for Tobacco Users

• Lack of confidence

→ Many tobacco users have tried to quit before without success

• Ambivalence regarding the importance of the change

→ Some tobacco users rely on anecdotal evidence to suggest the smoking isn't really dangerous

• Feeling unprepared to make a change

→ There are many steps to take that can increase the likelihood that a quit attempt will be successful , but many tobacco users do not know what to do

Motivational interviewing

A collaborative, person-centered form of guiding to elicit and strengthen motivation for change

Underlying Theory of MI

• Patients are ambivalent about making changes (if they weren't, they would have already quit)

• When WE advocate for change, it will evoke "resistance" from the patient (they'll argue back)

• Resistance predicts lack of change

• Getting to patient to talk about making the change makes it more likely that she/he will do it

Pathway to Sucess:

1. Engage- The process of establishing a mutually trusting and respectful helping relationship

2. Focus

3. Evoke

4. Plan

MI uses active listening to engage the patient

• OARS:

→ Open-questions (elicit exploration of topics)

→ Affirmations/Appreciations (focusing on client strengths, efforts, patients, etc.)

→ Reflections of client POV (nondirective, then directive)

→ Summaries (capture "essence", link topics, transition conversation)

OARS: Open-ended questions

• Questions that allow respondents to answer however they want, they feel like they are being listened to

• What are the reasons you are interested in quitting tobacco?

→ How might you go about choosing a quit date that would work for you?

→ You were successful quitting in the past. What did you do then?

→ Tell me about why you are considering quitting?

OARS: Affirmations

• Providing reinforcement for the patients' positive ideas and behaviors

• Expressing appreciation for their efforts

• Praising patients in order to increase their confidence in their ability to follow through on their change plans

OARS: Reflective Listening

• A key part of listening is trying to understand the individual's situation and perspective

• Reflective listening allows you to check in an make sure that you are successful with this

Complex Reflections

• A response that goes beyond what the client has directly stated or implied, adding content or emphasis to focus on meanings or feelings that the client did not directly express

• I feel like what you are trying to do is....

OARS: Summaries

Short recaps of what has already been said; used to remind the audience of the points already addressed

Focusing

• An ongoing process of seeking and maintaining direction

• Needs to start with LISTENING

• Elicit pt's view of the situation/problem and can of their concerns, needs, desires

→ REFLECT their experience--Don't try to "fix" it

• Ask a focusing question (eg., "How can I help?")

→ LISTEN for their ideas before making your own suggestions

→ Discuss potential options together

Ambivalence

• Most clinicians are uncomfortable when patients are "sitting on the fence" and normally we would want to push them to one side

• But, if we make the "fence" uncomfortable to sit on, pts will want to get off the fence themselves

Dancing w/ Discord

• In MI, we believe "resistance" results from the interpersonal interactions between clinician and pt, not some personality flaw of the pt

• You interaction should feel like a dance, not a wrestling match→ And the clinician is sort of leading

Try Changing Your Approach

• Try LISTENING instead of LECTURING

• Express EMPATHY, not ACCUSATION

• Focus on the BENEFITS of change, rather than the CONSEQUENCES of not changing

Evocation

• A process intended to help resolve ambivalence in the direction of change

• Try to elicit from the pt what they want

The Staging Ruler

• On a scale of 1 - 10, how important is making this change to you?

→ Why did you choose 5, and not 3?

→ What would it take to move you from a 1 to a 2?

• On a scale of 1 - 10, how confident are you that you could make this change if you decided that you wanted to?

Planning

• The process of being "with" someone while s/he forms a change plan that will work

• To facilitate fully informed, deeply contemplated and internally-motivated choices

• ...Not necessarily to change behavior right away

Choosing Goals

• Your goal for the interactions should be based on the person's current stage of change

• Don't waste time throwing suggestions at people who aren't ready to hear them

• Rather, work on building motivation so that next time they might accept your advice

MI for Tobacco Cessation

• Motivational interviewing can be utilized to make tobacco cessation counseling more effective:

→ Flexible

→ Saves Time

→ Facilitates active pt participation

→ Can be used even with "resistant" patients to encourage behavior change

→ Complements other interventions

Motivational interviewing will generally be most effective when combined with other evidence-based interventions:

1. Pharmacotherapy

2. Skill building

3. Engaging Social Suport

Bupropion SR 150

• Cautions/Warnings:

→ Not for use if:

▪ Currently use monoamine

▪ Use bupropion in any other form

▪ Have a history of seizures

▪ Have a history of eating disorders

▪ See FDA package insert warning regarding suicidality and antidepressant drugs when used in children, adolescents, and young adults

• Side Effects:

→ Insomnia

→ Dry mouth

• Dosage:

→ Days 1 - 3: 150 mg q AM

→ Days 4 - end: BID

• Use:

→ Start 1 - 2 weeks before quit date; use 2 to 6 months

• Availability (check insurance):

→ Prescription only

▪ Generic

▪ Zyban

▪ Wellbutrin SR

Nicotine Gum (2mg or 4mg)

• Cautions/Warnings:

→ Caution with dentures

→ Do not eat or drink 15 minutes before or during use

• Side Effects:

→ Mouth soreness

→ Stomach ache

• Dosage:

→ 1 piece q 1 - 2 hrs

→ 6 - 15 pieces per day

→ If ≤ 24 cigs: 2 mg

→ If ≥ 25 cigs/day or chewing tobacco: 4 mg

• Use:

→ Up to 12 weeks or prn

• Availability (check insurance):

→ OTC only:

▪ Generic

▪ Nicorettej

Nicotine Inhaler

• Cautions/Warnings:

→ May irritate mouth/throat at first (but improves with use)

• Side Effects:

→ Local irritation of mouth and throat

• Dosage:

→ 6 - 16 cartridges/day

→ Inhale 80 times/cartridge

→ May save partially-used cartridge for next day

• Use:

→ Up to 6 months, taper at end

• Availability (check insurance):

→ Prescription only

▪ Nicotrol inhaler

Nicotine Lozenge (2mg or 4mg)

• Cautions/Warnings:

→ Do not eat or drink 14 minutes before or during use

→ One lozenge at a time

→ Limit 20 in 24 hrs

• Side Effects:

→ Hiccups

→ Cough

→ Heart burn

• Dosage:

→ If smoke/chew ≥ 30 minutes after waking: 2 mg

→ If smoke/chew ≤30 minutes after waking: 4 mg

→ Weeks 1 - 6: 1 q 1-2hrs

→ Weeks 7 - 9: 1 q 2-4hrs

→ Weeks 10 - 12: 1 q 4-8 hrs

• Use:

→ 3 - 6 months

• Availability (check insurance):

→ OTC only

▪ Generic

▪ Commit

Nicotine Patch

• Cautions/Warnings:

→ Do not use if you have severe eczema or psoriasis

• Side Effects:

→ Local skin reaction

→ Insomnia

• Dosage:

→ If ≥ 10 cigs/day: 21 mg 4 wks, 14 mg 2-4 wks, 7mgs 2 - 4 wks

→ If ≤ 10 cigs/day: 14 mg 4 wks, then 7 mgs 4 wks

• Use:

→ 8 - 12 wks

• Availability (check insurance):

→ OTC or Rx

▪ Generic

▪ Nicoderm CQ

▪ Nicotrol

Varenicline

• Cautions/Warnings:

→ Use with caution in pts:

▪ w/ significant renal impairment

▪ w/ serious psychiatric illness

▪ Undergoing dialysis

▪ FDA Warnings: Varenicline pts have reported depressed mood, agitation, changes in behavior, suicidal ideation, and suicide

▪ See www.fda.gov for further updaTes regarding recommended safe use of Varenicline

• Side Effects:

→ Nausea

→ Insomnia, Abnormal, vivid, or strange dreams

• Dosage:

→ Days 1-3: 0.5 mg q AM

→ Days 4-7: 0.5 mg BID

→ Days 8-end: 1 mg BID

• Use:

→ Start 1 week before quit date; use 3 - 6 months

• Availability (check insurance):

→ Rx only:

▪ Chantix

Combinations: 1) Patch + bupropion 2) Patch + gum 3) Patch + Lozenge + Inhaler

• Cautions/Warnings:

:→ Only patch + bupropion is currently FDA approved

→ Follow instructions for individual medications

• Side Effects:

→ See individual medications

• Dosage

:→ See individual medications

• Use:

→ See individual medications

• Availability (check insurance):

→ See individual medications

My pt can't afford medications and doesn't have insurance to cover it. What can I do?

• Instruct the patient to set aside all the money they would have spent on tobacco once they quit. After initial use of medication they will be able to afford medication going forward

.• Many clinics that serve people with no health insurance will provide treatment for tobacco dependence, including medication. Check for ones in your area and have them available for staff and patients as a referral source.

• As a clinician, you can call the tobacco quit line and ask about any sources of free or reduced cost medication for your patients. Try 1-800-QUIT-NOW, which works nationwide and seamlessly routes you to the quitline in the State you are calling from.

• If your patient qualifies for Medicaid or Medicare, these programs cover some tobacco dependence treatment medications. Get this information for your State and have available for staff and patients.

• Most pharmaceutical companies have programs to provide medications to those who cannot afford them. Contact the pharmaceutical companies directly or check with Partnership for Prescription Assistance at www.pparx.org or 1-888-4PPA-NOW.