Fundamentals of Tobacco Interventions
Copyright Copying or distribution of these materials is permitted providing the following is noted on all electronic and print versions: © CAMH/TEACH No modification of these materials can be made without prior written permission of CAMH/TEACH. 2
Disclaimer The recipient of the funding is in compliance with the CMA and the CPA guidelines / recommendations for interaction with the pharmaceutical industry. 3
Disclaimer These materials (and any other materials provided in connection with this presentation) as well as the verbal presentation and any discussions, set out only general principles and approaches to assessment and treatment pertaining to tobacco cessation interventions. They do not constitute clinical or other advice as to any particular situations and do not replace the need for individualized clinical assessment and treatment plans by health care professionals with knowledge of the specific circumstances. 4
Disclaimer: TEACH Curriculum Development The TEACH Curriculum and slides were developed and compiled with funding from the Government of Ontario, Ministry of Health Promotion. Content of slides are primarily based on evidence based guidelines including: • US Guidelines Treating Tobacco Use and Dependence: Clinical Practice Guideline 2008 Update. US Department of Health and Human Services, Public Health Service • The Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT) • Rethinking Stop-Smoking Medications: Treatment Myths and Medical Realities OMA Position Paper, January 2008. • The development or delivery of the TEACH curriculum was not influenced or funded in any part by tobacco industry. TEACH has not received funding from the tobacco industry. The development of the TEACH curriculum has not been influenced by pharmaceutical industry. TEACH project did receive a $10 000 unrestricted grant from Pfizer, to develop video vignettes that are used in our training. Information presented on pharmacotherapy refers to generic products only, and recommendations are based on existing research, including the US guidelines. An algorithm is provided to help practitioners determine if and which pharmacotherapy is appropriate for a smoker. 5
Modules 1 • 2 • 3 1 2 3 6 Environment Behaviour Medication
Learning Objectives At the end of this course, you will be able to: 1 2 3 7 • • Describe why clinicians should implement tobacco cessation interventions Summarize smoking prevalence in Canada by gender and among some special populations Enhance clients’ motivation to quit smoking Implement a structured, adaptable cognitive behavioral approach to smoking cessation Understand the effects of tobacco and nicotine on the brain List the pharmacotherapies that increase the odds of quitting Discuss or recommend cessation medications with your clients Integrate cessation interventions into your clinical practice
Learning Assessment 1 • • • 8 Please complete Learning Assessment 1 This is a self-reflection tool, designed to gauge whether your responses change throughout the workshop Keep the assessment for your own reflection.
1 ENVIRONMENT
Environment 1 Learning Objectives At the end of Module 1 you will be able to: 1. 2. 3. 10 Describe why clinicians should implement tobacco cessation interventions Summarize smoking prevalence in Canada by gender and among some special populations Integrate cessation interventions into your clinical practice
Optional Exercise 11
“Fast facts” on Tobacco Use in Canada • • • 12 Tobacco kills 1 in 5 Canadians, or 45, 000 people every year (more than deaths due to traffic accidents, suicides, homicides, drug abuse and HIV-AIDS combined) (Physicians for a Smoke. Free Canada, 2003) Economic impact of smoking estimated at $17 billion every year (Rehm et al. , 2006) 90% of people who smoke became addicted before age 18 (Fiore et al. , 2008) Tobacco-related disease accounts for at least 500, 000 hospital days each year in Ontario alone (MHP, 2009) 17. 5% of Canadians age 15 and over are current smokers (CTUMS, 2010) Rates of smoking are much higher among sub-populations: e. g. , 90% - people with schizophrenia, 90% - people with opioid dependence (Kalman, Morisette and George, 2005; NIDA, 2008)
Why should health professionals get involved? • • 13 Tobacco is the leading cause of preventable death in the developed world 70% of smokers want to quit, and the remaining 30% would likely choose to not start, or would not want their child to smoke (Fiore et al. , 2008) Just 3 -5% of unassisted quit attempts are successful, compared with up to 20% success for those receiving cessation counselling and medications (Fiore, Baker et al. , 2008) Outcomes of evidence-based cessation interventions are comparable with other chronic disease management (hypertension, asthma, diabetes) (West and Shiffman, 2007)
Understand tobacco dependence as a chronic, relapsing disease and the need for a paradigm shift 14
Gender-Specific Smoking Prevalence across the World Canada 19% 17% Mexico 37% 12% Men Women Sweden Russian Fed Iceland 19% 70% 25% 27% France Germany Portugal 37% Belarus 37% 41% 26% 64% 27% US Italy 31% China 26% Spain Iran 24% 33% 59% 21% 36% 19% 24% 4% Philippines 31% 2% Egypt 39% India 25% Kenya 9% 24% 28% 1% 1% 1% Brazil South Africa 20% 25% Australia 13% 8% Chile 28% 42% 22% 31% Shafey et al. The Tobacco Atlas, 2009. 15
The Smoking Environment in Canada • • 17. 5% of Canadians (~5 million) 15 years or older are current smokers 26 % are former smokers 54% never smoked 55. 1% of daily smokers have their 1 st cigarette within 30 minutes of waking up. 75% within the hour! CTUMS, 2010 16
Mortality Due to Tobacco • • • 35, 000 -48, 000 Canadians die from smoking per year – 100 infants/year 1 in 5 deaths are due to smoking – Five times those due to car accidents, suicides, other drug abuse, murder and HIV combined! 1 in 2 smokers die from smoking related diseases. – 20% of smokers develop lung cancer – 80% of lung cancer caused by smoking WHO Report on the Global Tobacco Epidemic 17 http: //www. who. int/tobacco/mpower_report_full_2008. pdf
Differences by Province Smoking Prevalence (Ages 15+) CTUMS 2010 Wave 1 data 61% 36% 20% 19% 17% 12% 18 20% 21% 24% Territory data obtained using 2009 Canadian Community Health Survey; Provincial data obtained using CTUMS 2010 Wave 1 data. 16% 21% 19%
Current Canadian Adult Smokers (15+) by Province, 1999 & 2009 9% Ontario, Alberta, Nova Scotia, and PEI reduced by 9% in 10 years 19 CTUMS, 1999 and 2009 Annual data
Tobacco Use in Ontario 20
Gender Differences Male Female Smoking rates 19% 16. 0% Cigarettes per 15. 8 12. 9 day Current teen 14. 9% 10. 9% smokers (15 -19) Men aged 23 -24 have the highest smoking rate (28. 9%) 21 CTUMS, 2009 Annual data
Levels of Interventions • • • 22 Minimal / Brief Contact – Delivered during the course of a regular health care encounter in less than 3 minutes. i. e. : 5 A’s Intensive Interventions – Multi-session counselling programs involving extensive contact with a health care provider/counsellor – Inpatient programs (Mayo Clinic) Self Help Fiore MC et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence. 2008; Pbert et al. , 2008; USDHHS, 2008
Brief Cessation Interventions: The “ 5 As” – Ask about tobacco use – Advise to quit – Assess willingness to make a quit attempt – Assist in quit attempt – Arrange follow-up Fiore et al. 2008. 23
Quitting Smoking at any Age Can Increase Life Expectancy Increased Life Expectancy Age stop smoking by Life years gained <30 years 10 <40 years 9 <50 years 6 <60 years 3 Quitting smoking before the age of 30, normal life expectancy Doll R et al. 2007 24
Effective Amount of Contact Time Total Contact Time Estimated Abstinence Rate None 11. 0 % 1 – 3 minutes 14. 4 % 4 – 30 minutes 18. 8 % 31 – 90 minutes Optimal Intervention Time 26. 5 % 91 – 300 minutes 28. 4 % > 300 minutes 25. 5 % Need to consider resources available Fiore et al. , 2000 25
Environment Summary 1 You are now able to describe the prevalence of tobacco use on a national and international level by gender and among some special populations, explaining why clinicians play a critical role in implementing tobacco cessation interventions. 26
2 BEHAVIOUR
Behaviour 2 Learning Objectives At the end of Module 2 you will be able to: 1. 2. 3. 28 Enhance clients’ motivation to quit smoking Implement a structured, adaptable cognitive behavioural approach to smoking cessation Integrate cessation interventions into your clinical practice
Assessing Tobacco Dependence
Assessment • Components of Assessments – History of smoking and quit attempts – Level of nicotine dependence – Withdrawal – Reasons for smoking, reasons for wanting to quit – Social environment – Co morbidities – psychiatric, and/or other substance use – Intrinsic motivation and self-confidence – Client’s goals, views of treatment, preference for treatment Abrams et al, 2007 30
All Smokers Benefit From Proactive Assistance to Quit § Motivation to quit does not predict response to treatment § Motivation can increase when effective treatment is offered § Smokers with low motivation can achieve high continuous abstinence rates § Irrespective of motivation, all smokers should be actively offered assistance to quit 31
What is Motivational Interviewing? 2002: “A directive, client-centred style of counselling that helps clients to explore and resolve their ambivalence about changing. ” 1 2009: “Is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change. ” 2 1. 32 Miller and Rollnick (2002). Motivational Interviewing (2 nd ed), p. 25 2. Miller (2009). Ten Things that MI is Not
The Spirit of Motivational Interviewing • • 33 Ambivalence is a normal human condition Underlying spirit: collaborative, evocative, supporting autonomy
Change as a Process 34
The Stages of Change ? Precontemplation Contemplation Action Maintenance 35 Prochaska and Di. Clemente, 1984 Preparation
Stages of Change • • People do not move in a linear fashion through the cessation process Stages are arbitrary May misguide clinicians to diagnose clients at a certain level – too rigid BUT: if you consider these points when using the model it can be one of many helpful tools to use West (2005) 36
Change is not something you do to people, but with people. 37
DSM-IV Diagnostic Criteria for Nicotine Dependence In the DSM-IV 3 or more of the following criteria are required for a diagnosis of Nicotine Dependence: 1. Tolerance 2. Withdrawal. Requires daily use for at least several weeks. A minimum of 4 withdrawal symptoms are required. The withdrawal symptoms must “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. ” 3. The substance is used in larger amounts or over a longer period than was initially intended. 38
DSM-IV Diagnostic Criteria for Nicotine Dependence (2) 4. Unsuccessful efforts to cut down, regulate, or discontinue use. 5. A great deal of time spent obtaining the substance, using the substance, or recovering from its effects. 6. Important social, occupational, or recreational activities may be given up or reduced because of substance use. 7. Substance use continues despite the individual's realization that the substance is contributing to a psychological or physical problem. 39
DSM-IV Criteria Dependence Persistent desire or inability to stop Most smokers want to stop, fewer than 5% of unassisted attempts last a year or more Continued use despite harmful consequences Most smokers are aware of health risks and want to stop because of them, but feel unable to do so Withdrawal syndrome Experienced by majority of smokers Use of more of the drug or use for longer than intended 40 Fast Facts: Smoking Cessation, Robert West and Saul Shiffman, 2 nd edition 2007 Many smokers try to cut down but cannot maintain reduction; many learning to smoke believe they will stop before the damage is done but few manage to do so
DSM-IV Criteria Dependence (2) Important activities forgone because of the drug Tolerance; diminished effect with continued use In the case of nicotine, tolerance is mainly to the aversive effects A lot of time spent obtaining the drug, using it or recovering from its effects 41 Heavily dependent smokers may give up or interrupt activities in non-smoking areas Criterion related mainly to illicit drugs or those that impair function (intoxicating drugs) Fast Facts: Smoking Cessation, Robert West and Saul Shiffman, 2 nd edition 2007
Daily Diary - Baseline Think back to the last week starting today and make a note when you engaged in the current behaviour(s). 42
Assessing Our Clients • 43 Importance of Assessing – Builds alliance / relationship – basic ingredient of treatment – Big picture of client – Identifies co-occurring issues – Opportunity to educate client – “teachable moments” – Ongoing process – Collaborative approach
Assessments Seven Key Components 1. Level of nicotine dependence/ severity of withdrawal 2. Motivation 3. Past quit attempts and smoking history 4. Co- morbidities 5. Reasons for smoking, environment, triggers, reasons for quitting 6. Social environment supports and barriers 7. Smokers’ preference 44
Assessment Components 1. Level of nicotine dependence/ withdrawal • • • 45 Withdrawal symptoms, what happens when they don’t smoke or are unable to smoke? How much do they smoke presently? Menu of tools (addressed in the next section)
Withdrawal Symptoms • Withdrawal symptoms can predict lapse and relapse after cessation attempt (Killen & Fortman, 1997; Shiffman et al, 1997) • Can help determine if client needs a withdrawal management plan including pharmacotherapy The Tobacco Dependence Treatment Handbook, 2007 46
Nicotine Withdrawal Symptoms: Symptoms Duration Prevalence Irritability / Aggression < 4 weeks 50% Depression < 4 weeks 60% Restlessness <4 weeks 60% Poor concentration < 2 weeks 60% Increase appetite > 10 weeks 70% Light-headedness < 48 hours 10% Night-time awakenings < 1 week 25% Constipation > 4 weeks 17% Mouth ulcers > 4 weeks 40% Urges to smoke > 2 weeks 70% Slide Source: TEACH, CAMH, 2009 47
Assessment Components 2. Motivation • • 48 What brought this person in? Urgent issues (i. e. pregnant, COPD, transplant lists) May need to modify assessment depending on client’s situation Reasons for wanting to quit (why now? ) – External or internally motivated
Assessment Components 3. Past quit attempts and smoking history • 49 When did they start smoking, using tobacco products? Daily smoking? – How long? How much? How many quit attempts? – Longest time quit? – What have they tried? Review use of medications and supports
Assessment Components 4. Co-morbidities Other substance use / mental health issues – Can have an impact on treatment planning – Do they see a connection between their other issues and smoking? • Medical issues / medications – Will these have an impact on quit attempts? – Sometimes small adjustments in medication can shift a client’s attitude towards taking NRT – Are they motivators or stressors? 50
Assessment Components 5. Environment, triggers, reasons for smoking – Identify high-risk situations and triggers to smoking – What led to relapse? – What does their environment look like? 51
Helping to Define Triggers (5) Asking the Client: “ Can you identify 3 times in your daily routine when you are 100% certain that you will smoke? ” 1. 2. 3. 52 ________________________________
Assessment Components 6. Social Supports and Barriers • What supports do they have in place? • What is smoking status of friends, family, colleagues? • • • 53 What in their environment perpetuates their smoking? Is this a good time to quit or reduce? How does stress affect their smoking? Their quitting?
Assessment Components 7. Smoker’s Preference • • 54 What are the client’s goals around smoking? Resources / coping skills – Client’s perception of self-efficacy – Learnings from past quits, – What are their preferences, expectations, timelines around treatment? – What other stress management techniques do they utilize? – What are the client’s strengths?
Tools / Scales to Consider – – – 55 Fagerstrom Test for Nicotine Dependence Heaviness of Smoking Index Beck Inventory of Depression Beck Anxiety Inventory Why you Smoke Scale Reasons for Quitting Questionnaire Minnesota Withdrawal Scale QSU – Questionnaire of Smoking Urges Cigarette Withdrawal Scale Coping with Temptations Inventory (CWTI) Smoking Consequences Questionnaire
Behaviour Change Roadmap: THE 4 POINT PLAN
4 steps to stopping destructive behaviours and leading a healthier life: 1. 2. 3. 4. 57 STRATEGIZE TAKE ACTION OPTIMIZE PREVENT RELAPSE (PERSEVERE)
Setting the Stage • Important aspects to consider – Quitting is a process – Automatic behavior: not always a conscious process – A pack/day = 110, 000 hand to mouth repetitions/year – Linked with many behaviors: meals, alcohol, waking up, coffee, environment – group homes, smoking rooms in hospitals – Linked with social relationships: breaks at work, parties, friends houses 58
Step 1: STRATEGIZE
1. Strategize – Can take 1 session or can happen over several – Involves developing a quit plan: → Tracking smoking → Quit date → Triggers, coping skills, plan for high-risk events → Problem solving and coping skills → Support plan → Pharmacotherapy plan 60
Strategize: Psychological • • 61 Identify all positive supports – Personal - partner, family, friends, colleagues – Professional – physician, pharmacist, dentist, nurse, etc – Other support – Smokers’ Helpline, groups, websites, self-help Identify all negative influences – Other smokers (partner, family) – People who don’t want client to quit smoking – Unhelpful “encouragement” to quit
Strategize – Cognitive/Affective • • • 62 Personal relationship with cigarettes Describe cigarettes as friend or lover Can experience sense of loss when quitting Help reframe this thinking… abusive friend or lover Acknowledge these emotions
Strategize – Behavioural • • • 63 Relaxation strategies Physical activity Groups Rewarding accomplishments Tracking sheets / Self-monitoring – Increase awareness of smoking behaviour – Identify triggers, challenges – Suggest which cigarettes will be easy and which will be more difficult – Begins to break the automatic smoking behaviour and possibly reduces the number of cigarettes smoked
Strategize - Environmental • 64 Smoke-free environments – Make home and vehicle smoke-free – Explore areas of home to restrict smoking behaviour if entire home cannot go smokefree – Work environment – avoiding smoking areas – Other
Strategize - Biological • 65 Pharmacotherapy • If client is interested in medications, refer to physician/pharmacist or provide information • How much do they know about what is available? • What are the pros and cons of pharmacotherapy? • Who will help monitor this part of the quit plan?
Reasons for Change Making a commitment to meeting your goal is important to your success. Sometimes, it’s easy to forget why you’re making the change, so write down your reasons and use this as a reminder to yourself when things seem tough! The most important reasons why I want to change are: 1 ______________________________ _ 2 ______________________________ _ 3 ______________________________ _ 66
Decision to Change Worksheet Changing my current behaviour Benefits Costs 67 Continuing to behave in the same way
Strategize – Set a Goal • Setting a quit date: • Provides specific date/goal to work toward • Prevents delay in quitting • Allows time to reduce, practice, refine quit plan • At a minimum, plan to meet with client 1 – 2 weeks before quit date and 1 – 2 weeks after quit date 68
Goal Statement The behaviour I want to/need to change is: What is your goal now? START DATE: ACHIEVEMENT DATE: 69
Readiness Ruler People usually have several things they would like to change in their lives – this may be only one of those things. Answer the following three questions with respect to the goal you have set. How important is it to change this behaviour? 0 1 2 3 4 5 6 7 8 9 10 How confident are you that you could make this change? 0 1 2 3 4 5 6 7 8 9 10 How ready are you to make this change? 0 70 1 2 3 4 5 6 7 8
For Reflection: “Readiness Ruler” What are 3 reasons you are at _____ and not zero? 1. 2. 3. 71
Hands-On Practice! • • 72 Think of a behaviour that you would like to change – something you are comfortable sharing with a small group Examples could include: exercising more, healthy eating, etc. Take a few minutes to complete the Reasons for Change, Decisional Balance, and Goal Statement/Readiness Ruler Then get together in groups of 3 -4 people to discuss: (1) What was this exercise like? (2) What impact did this exercise have on your understanding of the issue you are considering changing? (3) How might you use these tools with your clients?
STRATEGIZE Identifying Barriers and Risky Situations
Identifying Barriers and Solutions to Change Possible Barriers: 74 Proposed Solutions: © CAMH/TEACH Project
Step 2: TAKE ACTION
Take Action • Discuss problems and potential strategies Changes in mood – what support is needed? • Withdrawal symptoms – re-assess pharmacotherapy plan • Low motivation – decisional balance, review reasons to quit • Weight gain – recommend physical activity, healthy eating, additional support • Lapses/slips – explore • 76
Take Action (2) • • • 77 Continue identifying triggers, stressful situations Continue self-monitoring Maintain smoke-free environments Can be one session or several sessions Reset quit/reduce date if needed Congratulate your client for coming back
Triggers and Consequences • • • 78 Identify high-risk situations Describe high-risk situation Describe types of triggers usually associated with the situation Describe the types of consequences associated with the situation How often does this type of situation occur?
Triggers and Consequences Worksheet High-risk situation: ____________ 1. Briefly describe one of your most serious high-risk situations. 2. Describe as specifically as possible the types of triggers usually associated with this situation. 3. Describe as specifically as possible the types of consequences usually associated with this situation (immediate and delayed consequences, and positive and negative consequences). 4. How often did this type of situation occur in the past year? What percentage of your total behaviour over the past year occurred in this type of situation? _______% 79
Triggers and Coping Skills – Sample Plan Triggers Coping Skills Smoke with colleague every day at breaks After meals Chew gum after meals, get up from table right away Stress at work gets too much on some days 80 Tell colleague I am quitting Plan to take walks when stress is high
3 Options to Cope with Triggers 1. Avoid the triggers or situations 2. Change the trigger or 3. situation Find an alternative or substitute for the cigarette in response to the trigger or situation 81
Example: Getting together with friends on Saturday night • Avoid the triggers or situations – Miss this event while I’m trying to quit smoking • Change the trigger or situation – Ask friends to smoke outside b/c I am quitting • Find an alternative or substitute for the cigarette – When someone lights up, get support from other friends – Get up and get glass of water or move to another part of – 82 the room Might use nicotine gum or inhaler
Change Plan Worksheet The changes I want to make are… The most important reasons why I want to make these changes are…. . The steps I plan to take in changing are… The ways other people can help me are… I will know that my plan is working if… Some things that could interfere with my plan are. . . 83
Step 3: OPTIMIZE YOUR PLAN
Doing a 360: Asking for Feedback • • SOCIAL SUPPORTS (FAMILY MEMBERS, FRIENDS, COLLEAGUES) PROFESSIONALS ( MD, RN, PHARMACIST, OTHERS) • • • 85 FEEDBACK ON MY PLAN? THINGS MISSING? WATCH FOR SABOTEURS AND ENLIST SUPPORTERS
Step 4: PREVENT RELAPSE (Persevere) “ A Slip is Not a Fall ”
Relapse Prevention • 75% relapse within 4 – 52 weeks 87 Song et al. , (2009) A meta-analysis of 49 trials involving cognitive-behavioural coping strategies for smoking relapse prevention interventions indicates motivated quitters benefit from coping skills training after the first week of quitting
A Perspective for Clients A Lifetime of smoking AGE 13 AGE 53 25 cig/day x 40 years = 365, 000 cigarettes 4, 380, 000 hand to mouth repetitions 40 years of smoking 88 Quit attempt
If I were to relapse. . . …it would most likely be in the following situation: What coping strategies could I use to avoid this relapse? 89
Prevent Relapse • If the client has quit or reduced • • • 90 Congratulate on changes made Review benefits Identify future challenges and plan to cope Pharmacotherapy Engagement
Prevent Relapse (2) • 91 If client had slips/relapsed: – Assess what happened – What can be done differently? – What worked?
Example: Getting Together with Friends on Saturday Night • Avoid the triggers or situations – Miss this event while I’m trying to quit smoking • Change the trigger or situation – Ask friends to smoke outside b/c I am quitting • Find an alternative or substitute for the cigarette – When someone lights up, get support from other friends – Get up and get glass of water or move to another part of the room – Might use nicotine gum or inhaler 92
Prevent Relapse (3) • • Pharmacotherapy – long term use for those that would benefit Staying engaged in treatment / counselling / groups when possible What other supports will remain available beyond treatment? Planning for relapse – What situations/triggers might lead to a slip or relapse? – Is there a plan on how to deal with those situations? 93
Revisiting the Decision to Change Worksheet When you started the change process, you completed a “Decisional Balance” of anticipated costs and benefits of changing and of continuing the behaviour in the same way. Now that you have made some changes, complete the decisional balance again noting the actual costs and benefits that you have experienced, as well as things that you didn’t anticipate as costs or as benefits. Then go back and compare your responses with your previous Decisional Balance. Changing my current behaviour Benefits Costs 94 Continuing the behaviour in the same way
Readiness Ruler Now that you have successfully made some changes, where would you rate the importance of sustaining these changes? How confident do you feel now in maintaining change? How ready are you to continue the journey of change? After you have completed this sheet, go back and compare your responses with the one you completed previously. How important is it to change this behaviour? 0 1 2 3 4 5 6 7 8 9 10 How confident are you that you could make this change? 0 1 2 3 4 5 6 7 8 9 10 How ready are you to make this change? 0 95 1 2 3 4 5 6 7 8
Concluding Thoughts on Relapse Prevention • • • 96 Follow-up calls – Evaluation and counselling calls How can the client re-engage quickly in treatment if he/she relapses? What are the red flags/warning signs that a client might relapse? – “One won’t hurt” – “I’m sure I can smoke socially now that I’ve quit” – “I’m stressed. Just this once to help me get through this” – “I’ve been quit for long enough that I have control over this”
Current Motivation and Next Steps Where were you when you started this process, and where are you now? What do you need to do to continue to make positive changes? What is your next step? 97
Additional resources that can support me… 98
Even people who quit intermittently have substantial health benefits over those who continue to smoke. 99
Behaviour Summary 2 In your practice you are now equipped to enhance clients’ motivation to quit smoking and implement a structured, adaptable cognitive behavioural approach to smoking cessation, while better understanding the physiological responses to the addictive properties of tobacco. 100
3 MEDICATION
Medication 3 Learning Objectives At the end of Module 3 you will be able to: 1. 2. 3. 4. 102 Understand the effects of tobacco and nicotine on the brain List pharmacotherapies that increase the odds of quitting Discuss or recommend cessation medications with your clients Integrate cessation interventions into your clinical practice
Smoking as an Addiction
What are Tobacco and Nicotine? • Tobacco - plant that contains nicotine – Two kinds: Traditional and Commercial • Nicotine - one of the major addictive components in tobacco Nicotine is not known to lead to any diseases such as COPD or cancer. It is the 4, 000 other chemicals in cigarette smoke that contributes to these diseases. 104
Tobacco and Carcinogens • More than 60 carcinogens are in cigarette smoke • A minimum of 16 carcinogens are in unburned tobacco Hecht (2003); Freiman et al. (2004); US Surgeon General’s Report 1989. 105
Tobacco is a legal product. . . Nicotine Insecticide Stearic Acid Candle Wax Toluene Industrial Solvent Ammonia Toilet Cleaner Cadmium Batteries Hexamine Barbeque Lighter Butane Lighter Fluid Paint Methanol Rocket Fuel 106 Carbon Monoxide Arsenic Poison Methane Sewar Gas Acetic Acid Vinegar
Anatomy of a Cigarette Side stream smoke – 800 x toxic Tobacco: Leaf Reconstituted Puffed 107 Filter: Hold back tar Mild: more holes in filter Paper: burn rings, titanium oxide accelerant
108
‘‘Why do people smoke. . . to relax; for the taste; to fill the time; something to do with my hands. . But, for the most part, people continue to smoke because they find it too uncomfortable to quit’’ Philip Morris, 1984 109 Philip Morris. Internal presentation. 1984, 20 th March; Kenny et al. Pharmacol Biochem Behav. 2001; 70: 531 -549.
Pharmacological Approaches to Smoking Cessation Treatment
Biological Aspects of Addiction – A biological need for a drug that arises because of physiological adaptation to the presence of a drug in the body and brain – Body becomes dependent on the drug to be able to function normally – Stopping the drug leads to a withdrawal syndrome which is unpleasant and motivates person to continue using – Not the complete picture 111 Fast Facts: Smoking Cessation, Robert West and Saul Shiffman, 2 nd ed, 2007
Percentage Still Abstinent Quitting Smoking Unaided: Analysis of 4 Studies 3 - 5% Long-term smoking abstinence in those who try to quit unaided = 3%– 5% 112 Hughes JR et al. (2004)
Guideline #7 for Treating Tobacco Addiction “Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication”. Fiore et al. 2008 113
Guidelines for Treating Tobacco Addiction Clinicians should encourage the use of medication by all patients attempting to quit smoking except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i. e. , pregnant women, smokeless tobacco users, light smokers, and adolescents). Six (in Canada) first-line medications that reliably increase quit rates: – Bupropion SR – Nicotine gum – Nicotine inhaler – Nicotine lozenge – Nicotine patch – Varenicline Consider the use of certain combinations of medications. USDHHS, 2008; Fiore MC & Jaén CR. , 2008 114
Costs of Smoking vs. Pharmacotherapy One Week Supply: Approx. Cost/Week Name-brand patch No-name patch $22. 00 Nicorette gum (10 pieces/day) $99. 00 (3 boxes at $33. 00) Nicorette inhaler (5 cartridges/day) $150 (3. 5 boxes at $42. 00) Cheap brand of cigarettes (7 packs) $40. 00 Name-brand cigarettes (7 packs) $66. 00 Contraband Cigarettes $7. 00 - $15. 00 Varenicline $60 starter kit; $70 for continuation pack Buproprion 115 $34. 00 $40. 00
Nicotine Replacement Therapy • • • 116 Provides the body with nicotine to help minimize withdrawal symptoms and cravings Eliminates toxic substances one gets from cigarettes Shown to almost double quit rates Most effective when combined with counselling Can be used to help “reduce” smoking – Can start before quit date
Who Should Not Use NRT? • • 117 Not everyone needs NRT Not everyone can afford NRT Studies show that NRT is not effective for those that smoke 10 cigarettes or less or are non-daily smokers Need to assess case by case – Discuss with client – Use tools to assess dependence
Medications for Quitting Smoking Medication Nicotine gum Nicotine lozenge Nicotine patch Nicotine inhaler Bupropion Varenicline Treatment length 1 -3 months 12 weeks 8 -12 weeks 12 -24 weeks 7 -12 weeks 12 -24 weeks • Mouth irritation • Irregular Main side effects • • heartbeat Upset stomac • Nausea h Hiccups • Heartburn • Hiccups 2 mg, 4 mg Dosage Effectiveness at six months or longer† (OR [CI]) 118 1. 66 (1. 521. 81) Irritation of throat and nasal passages sleep (insomnia, abnormal/viv id dreams) • • Headache • Sneezing • Site rash • Coughing • Dyspepsia (pruritis erythema, burning) • insomnia • Nausea • Dry mouth • Nausea • Sleep disturbances • Constipation • Flatulence 2 mg, 4 mg 7, 14, 21 mg 5, 10, 15 mg 6 -12 cartridges per day 150 -300 mg/day 0. 5 mg qd to 1 mg bid 3. 69 * (2. 74 -4. 96) 1. 81 (1. 63 -2. 02) 2. 14 (1. 44 -3. 18) 2. 06 (1. 77 -2. 40) 2. 83* (1. 91 -4. 19) Adapted from Le Foll & George (2007), Shiffman et al (2002) • Disturbed * 4 mg, effectiveness at 6 -weeks
Ask about tobacco use: How much do you smoke? 0 - ___ cigarettes per day ( cpd)? (one large pack = 25 cpd, one small pack = 20 cpd) Yes Algorithm for Tailoring Pharmacotherapy for Smoking Cessation 1, 2 Advise: As your physician, I am concerned about your tobacco use, and advise you to quit. Would you like my help? Motivational Interviewing Assess the 5 R’s: Relevance Rewards Risk Roadblocks Repetition No Cold Turkey No response Has bupropion/NRT failed? N Is weight gain a concern? N Want to quit within 7 days? Y = NRT (Gum, Patch, Lozenge or Inhaler) No Yes Low importance or confidence (≤ 5) High importance or confidence (>5) Assist in Quit Attempt: Would you like to quit abruptly? Have you tried quitting cold turkey? Yes No Yes: Pharmacotherapy options Has NRT failed? Y/N Is weight gain a concern? Y …History of seizures? N . . . History of mental illness? N …Eating disorder? N. . . Allergic to bupropion? N. . . Previous non-responder? N Want to quit within 7 days? N = Bupropion SR Has bupropion/NRT failed? Y Is weight gain a concern? N . . . History of seizures? N …History of mental illness? N …Eating disorder? N. . . Allergic to varenicline? N. . . Previous non-responder? N Want to quit within 7 days? N = Varenicline Choose the following combinations: 1. Two or more forms of NRT a. patch (15 mg) + gum (2 mg) b. patch + inhaler c. patch + lozenge 2. Bupropion + form of NRT a. Bupropion + patch b. Bupropion + gum No Varenicline with NRT Arrange Follow Up 1. Monitor carefully 2. Consider contraindications 3. Consider comorbidities and specific pharmacotherapy 4. Consider dual purpose medications 5. If after 4 weeks no response, consider alternative 1 st line medications. * @ 4 weeks Partial response Consider combination pharmacotherapy, based on: 1. failed attempt with monotherapy 2. breakthrough cravings 3. level of dependence 4. multiple failed attempts 5. experiencing nicotine withdrawal Assess Readiness: Given everything going on in your life, on a scale of 0 -10, where 0 is lowest… How important is it for you to quit smoking? How confident are you that you can quit smoking? Developed by Peter Selby, MBBS, CCFP. This algorithm is based on: Bader, Mc. Donald, Selby, Tobacco Control, 2009: 18: 34 -42. Fiore MC et al. , Clinical Practice Guideline: Treating Tobacco Use and Dependence, May 2008. Gray, Therapeutic Choices: 5 th Ed. , 2007, Chapter 10: 147 -157. Reduce to Quit (RTQ) Step 1: (0 -6 weeks) - Smoker sets a target for no. of cigarettes per day to cut down and a date to achieve it by (at least 50% recommended) - Smoker uses gum to manage cravings Step 2: (6 weeks up to 6 months) - Smoker continues to cut down cigarettes using gum - Goal should be complete stop by 6 months - Smoker should seek advice from HCP if smoking has not stopped within 9 months Step 3: (within 9 months) - Smoker stops all cigarettes and continues to use gum to relieve cravings Step 4: (within 12 months) - Smoker cuts down the amount of gum used, then stops gum use completely (within 3 months of stopping smoking) *N. B. for 2 nd line medications (clonidine and nortriptyline), see guidelines.
Nicotine Patch • • 24 hour continuous dose of nicotine – 21, 14 and 7 mg patches (applied every 24 h) 16 hour continuous dose of nicotine – 15, 10, and 5 mg (applied every 16 h) Off-label use – higher than 21 mg dose for highly dependent smokers Potential side effects – May cause sleep disturbance or nightmares → Remove before bed – Skin irritation – Clear patch 120
How to Use the Patch • • 121 Apply to clean dry area above the waist, rotating site daily Remove old patch before applying new one Do not use lotion, moisturizing soap Touch only small corner of adhesive Ensure complete adherence of patch Wash hands in water after application Discard old patch out of reach of children, animals – can be harmful
Nicotine Gum • • • 122 Provides body with nicotine for 20 -30 minutes 2 & 4 mg doses Responds to the immediate urge to smoke Oral gratification Must be able to chew gum (i. e. no dentures, TMJ) Potential side effects – Upset stomach, hiccups → Chewing too fast: review proper use of gum
How to Use Nicotine Gum 2 mg Use in combination with patch as a breakthrough medication; typically if smoke <pack/day 4 mg Use in combination with patch or alone; typically if smoke > pack/day § Chew one piece at a time, no more than 1 per hour § Use every hour – if not in combination with patch § Up to 20 pieces per day as needed 123
How to Use Gum (2) • • • 124 Chew and park in between teeth and cheeks Absorbed via buccal mucosa Repeat chew every minute or so Each piece lasts approximately 30 minutes Do not chew within 30 minutes of caffeine/acidic products
“Reduce to Quit” (RTQ) Approaches Who? Goal? 50% reduction in daily cigarette consumption between 6 weeks and 4 months of treatment How? Self-titrate to the level of nicotine to reduce withdrawal symptoms. A reduction of cigarette consumption should be continued until complete cessation can be attempted When? 125 Smokers not ready or unable to quit abruptly Craving to smoke in order to prolong smokefree intervals for as long as possible
RTQ: Using NRT Gum How long? • If such a reduction has not been achieved by 4 months, the patient should be further counselled and/or re-evaluated. • A quit attempt should be made as soon as the patient feels ready – but not later than 6 months after the start of treatment. • Regular use of the gum beyond 12 months in the Quitting Gradually program is generally not recommended. How much? 126 Maximum of 20 pieces gum / day Shiffman, Ferguson, & Strahs, 2009
Nicotine Inhaler • • • Small, cigarette-shaped inhaler Satisfies sensory and ritualistic aspect of smoking One cartridge contains 10 mg of nicotine and 1 mg menthol Absorbed in oral cavity, throat and upper respiratory tract by “puffing” Potential side effects – throat & mouth irritation, headache, nausea, indigestion(<20%) 127
How to use the Nicotine Inhaler • Single cartridge equivalent to 4 -5 cigarettes - or 20 minutes of continuous use • • 128 Puff like cigar, not deeply into the lungs May notice a burning, warm or cool sensation when inhaling – OK unless it becomes bothersome Clean inhaler on a regular basis with soap and water Can use up to 6 cartridges/day – use as needed
Nicotine Lozenge • • 129 1 mg and 2 mg dosages Max of 15 mg / day should be used Slowly suck until strong taste is noticed Rest lozenge between cheek and gum Wait 1 minute or until taste fades Repeat sucking Each lozenge takes about 30 minutes to consume Use only 1 at a time
Dependence Potential of Nicotine Delivery Devices • • 130 Dependence potential tends to correlate with time to peak concentration Because the nicotine is delivered differently, more slowly and at lower doses in NRT, it is significantly less addictive then smoking Le Houezec, 2003
Dependence Potential of Nicotine Delivery Devices Reaches brain within 15 -20 secs for non-daily and less dependent and 30 secs for daily, dependent smokers 0 1 hr Gum, lozenge, inhaler peaks in 20 – 30 minutes 131 Rose et al. , 2010 2 hrs Patch peaks in 2 – 6 hrs
Effectiveness and Safety of NRT • • • Recent study of 2767 predominantly middle-aged smokers not ready to quit: half were given NRT (gum, inhaler or choice of therapy) and half were given placebo for up to 18 months Primary Outcome was six months of sustained abstinence from smoking Results overwhelmingly positive NRT was well tolerated Those using the NRT achieved six months of sustained abstinence & most lasted beyond 12 - 26 months Moore et al 2009; 132
Cardiac Disease and NRT • • • NRT is safer than smoking Cigarette smoke causes – Increase in heart rate – Blood pressure – Decreased clotting time – Polycythemia NRT has not been associated with any increase in cardiac events (heart attack, stroke) • Hubbard, R, et al. 2005 133
Long-Term Use of NRT • • 134 Most of the time people who use NRT to stop smoking gradually reduce or stop NRT medicine without difficulty May use NRT long-term if needed – Appropriate way of reducing the harm caused by smoking – Using NRT is always preferable to using tobacco products Long-term use of NRT products can help in reducing morbidity and mortality Preliminary evidence suggests that long-term use of oral NRT may be associated with certain kinds of cancer (Gemenetzidis et al. , 2009)
Assessing Readiness to discontinue NRT • • 135 Have you been in a situation in which you would normally smoke but have been able to refrain from smoking with ease? Have you ever forgotten to put on your patch or use your inhaler/gum/lozenge?
Pregnancy and Youth - NRT should be considered in pregnancy and for youth if the likelihood of smoking cessation justifies the potential risk of using it by the pregnant patient or youth who might continue to smoke. Benowitz et al, 2000 136
Bupropion • • 137 Originally designed to treat depression Shown to double one’s chances of quitting Shown to minimize weight gain associated with quitting smoking Contraindications – Seizure history – Active eating disorder – MAOI Medications – Using Bupropion, sensitivity to Bupropion
How To Use Bupropion • • • 138 Prescribed by Physician, Nurse Practitioner or Dentist Dose 150 mg once daily for 3 days, increase to 150 mg twice daily on day 4 8 hours between doses Take as early in evening as possible Monitor closely for changes in mood, suicidal ideations Can be used alone or in combination with NRT
Varenicline • • 139 Oral medication to quit smoking Reduces withdrawal and craving Prevents pleasurable effects of smoking Varenicline is a partial agonist (α 4 2 nicotinic acetylcholine receptor), which partially mimics the effect of nicotine
Varenicline: Drug Interactions / Precautions • • • 140 Concomitant use of nicotine replacement therapy – not expected to increase cessation – will increase adverse drug reactions Does not affect and is not affected by CYP 450 enzyme system Reduce dose in severe renal impairment
Important Safety Information Regarding Varenicline Boxed Warning: • Highlights important recommendations for healthcare professionals regarding information related to neuropsychiatric adverse events. • A warning regarding rare reports of hypersensitivity reactions, such as angioedema and serious skin reactions, including Stevens-Johnson syndrome and erythema multiforme. Unintentional Varenicline Exposure: • Recent retroactive study assessed cases where varenicline was unintentionally ingested, most common side effects were gastrointenstinal and neuropsychiatric • Vast majority did not require admission to hospital Varenicline and Psychiatric Side-Effects: • • 141 No clear evidence associated with depression or suicidal thoughts, however twofold increase of self harm cannot be ruled out. Varenicline may be associated with increased aggression and acts of violence towards others
2 nd Line Medications • • 142 Use at physicians discretion (first- line medications unsuccessful) Not approved as smoking cessation aids Clonidine – Anti-hypertensive – Helps to reduce withdrawal Nortriptyline – Antidepressant – Two studies demonstrated increased abstinence rates
The Future? • • • 143 Selegiline – Parkinson treatment Vaccines – prevent nicotine from reaching the brain Transcranial Magnetic Stimulation
Multiple Quit Attempts May Be Necessary – >70% of US smokers have attempted to quit 1 → Approximately 46% try to quit each year → Only 7% who try to quit are abstinent 1 year later – Similar percentages in countries with established tobacco control programs (UK, Australia, Canada)2 → >70% want to quit → 30%– 50% try to quit each year – Some smokers succeed after making several attempts 3 → Past failure does not prevent future success 144 1. 2. 3. Fiore MC et al. 2008. Foulds J et al. 2004; 9: 39– 53. Grandes G et al. 2003; .
Cessation Objectives 1. 2. 145 Increase the number of quit attempts Increase long-term success of quit attempts
Sometimes the doorway has to be opened wider and held open longer… 146
Medication Summary 3 You are now more able to recommend the various pharmacotherapies available for smoking cessation and reduction, and engage your clients in discussion of if and how these medications can play a role in their tobacco interventions. 147
Workshop Summary 1 2 3 After this training you will find yourself more familiar with the various components that inform tobacco interventions, such as why they are important for clinicians, enhancing client motivation, the physical and behavioural properties of tobacco addiction, and various evidence-based treatments. 148
Learning Assessment 2 • • 149 Please complete Learning Assessment 2 This is a self-reflection tool designed to gauge whether your responses to the earlier assessment have changed, and can be used for you to track these changes It is also an opportunity for you to set practice objectives This will not be collected
Course Evaluation • • 150 Please complete the course evaluation which will help us improve future trainings We will be collecting this!
TEACH Community of Practice Listserv As a participant in this training, you are eligible to join the TEACH Community of Practice Listserv! Our TEACH COP Listserv is configured so that you need to self-register, which is quick and easy to do. To “subscribe” to the Listserv, please send an email to: teach-request@info 2. camh. net and write… “subscribe teach” in the subject line of your e-mail. You will then receive a message confirming your subscription to the List, as well as instructions on how to post or unsubscribe. 151
CAN-ADAPTT Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment CAN-ADAPTT is a practice-based research network designed to facilitate knowledge exchange in the area of smoking cessation between practitioners, healthcare providers and researchers. It includes • Access to a dynamic set of Tobacco Control Guidelines For further information or to register for free, please visit www. can-adaptt. net 152
Tobacco Informatics Monitoring System (TIMS) http: //tims. otru. org/ 153
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