Download Brief Tobacco Interventions for Methadone Maintenance Providers

Los Angeles County Department of Public Health
Chronic Disease and Injury Prevention Division
Brief Tobacco
Interventions for Opioid
Maintenance Providers
Susan Bradshaw, MD, MPH
Tobacco Control and Prevention Program
September 18, 2013
Outline
• Burden of Tobacco Use
• Tobacco Products
• Tobacco Addiction
• Brief Intervention (Ask, Advise, Refer)
2
Introduction
• Native Americans used tobacco
prior to the arrival of Columbus
•Consumption was for medicinal
and ceremonial purposes
•Commonly smoked in peace pipes
3
Introduction
John Rolfe (1585–1622) ….
• Married Pocahontas
• First to cultivate tobacco as an
commercial export and cash crop
• Until 1883, taxes from tobacco
accounted for 1/3 of IRS revenue
4
Introduction
1881: Cigarette machine
1882: Ten million cigarettes sold
1887: One billion cigarettes sold
5
Introduction
Anti-Tobacco
1798: Benjamin Rush….
• First surgeon general
• Signer of the Declaration of
Independence
• “Tobacco use supports excess
alcohol consumption”
6
Introduction
Anti-Tobacco
1870: Tobacco ….
•
Harmful addictive substance
•
Contributing factor in relapse from
alcoholism and drug dependence
•
Treated along with alcoholism and
other addictions in asylums
7
Stop drinking to die from smoking?
Founding father of AA
movement, Bill W., died
from tobacco-related
disease.
1930s: Tobacco use is no longer viewed as an
addiction and becomes embedded in
recovery programs.
BURDEN of TOBACCO
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Burden of Tobacco Use
Morbidity and Mortality
•Leading cause of preventable and
unnecessary death, disability and disease
•Causes more deaths than homicide, suicide,
heroin, cocaine and alcohol combined each
year
•Everyday, approximately 1,200 people die
from tobacco-related diseases
10
Burden of Tobacco Use
Morbidity and Mortality
For every 8 smokers who die,
one non-smoker dies from
exposure to secondhand
smoke (SHS).
Secondhand Smoke (SHS)
•Causes 50,000 deaths annually
•Mainstream smoke is exhaled
by a smoker
•Side stream smoke comes from
the end of a burning tobacco
product
12
Question?
True or False. Secondhand smoke contains
more than 7,000 chemicals.
True. Secondhand smoke is a toxic mixture of
gases, chemicals and particles. It contains
about 70 carcinogens.
13
Secondhand Smoke
There is no safe level of exposure to secondhand smoke.
14
Burden of Tobacco Use
Thirdhand smoke?
• Residue left on a variety of surfaces by tobacco
smoke. It builds up on surfaces and resists normal
cleaning.
• Can't be eliminated by airing out rooms, opening
windows, using fans or air conditioners, or confining
smoking to only certain areas
• The only way to protect nonsmokers from thirdhand
smoke is to create a smoke-free environment
15
Burden of Tobacco Use
Economic
Which state charges the most for a
pack of cigarettes?
New York. It costs $11.90 for one
pack of cigarettes.
16
Burden of Tobacco Use
Environment
•Cigarette butts are the most littered item in US
• 153 million pounds of cigarette butts are
dumped each year
•26,400 smoking- related fires occur annually
17
Smoking Rates
Mental Illness (MI)






Schizophrenia
Bipolar Disorder
Heavy drinkers
Depression or Anxiety
Post-traumatic Stress Disorder
Substance Use Disorder (SUD)
62-90%
51-70%
65-90%
40-50%
45-60%
49-98%
Burden of Tobacco Use
MI/SUD
Compared to general population …..
Begin smoking earlier
Smoke more cigarettes each day
Smoke cigarettes them down to the filter
Inhale deeper
Burden of Tobacco Use
MI/SUD
• Consume 44% of all cigarettes sold
• Spend 30% of their income
• Poorer tobacco cessation outcomes
• Want to quit
20
Smoking cessation does not
interfere with recovery
21
Burden of Tobacco Use
Key Points
Compared to general population, MI/SUD…..
• Smoke more
• Suffer more
• Spend more
22
Benefits of Quitting
 Health
 Recovery
 Wealth
 Environment
 Pets
23
TOBACCO PRODUCTS
Update
24
Question?
What is the name of the President
who started smoking a pipe after
he was diagnosed with throat
cancer?
President Grant
It is alleged he thought smoking a pipe was safer
than smoking cigars.
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Smoked Tobacco
Cigarettes
Expensive & Unhealthy
Natural & Deadly
Cheap & Toxic
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Photo source: FACT collection
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Smoked Tobacco
Cigarette , Little Cigar, Cigarillo and Cigar
Cigarette:
wrapped in paper not
containing tobacco
Cigar and cigarillo:
wrapped in substance
containing tobacco
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Smoked Tobacco
Little Cigars and Cigarillos
• Many flavors
• Package
• Tip or no tip
• Examples:
 Black & Mild
 Swisher Sweets
 White Owl
29
Smoked Tobacco
Other
Hookah
Blunts
Bidis
30
Photo source: FACT collection
New Smokeless Tobacco
• May be in pouch
• Marketed as energizing
• May contain:
 Caffeine
 Vitamin C
 Flavor
31
Smokeless Tobacco
Snus
•Variety of flavors
•Packaged in small pouches
•Addresses smoke-free policies
32
Smokeless Tobacco
Dissolvables
•Strips
•Sticks
•Mints (Orbs)
33
Electronic Nicotine Devices
Smoke and tobacco free
34
TOBACCO PRODUCTS
Key Points
• Cigarettes are the most common form of
tobacco used in the U.S.
• All tobacco products are harmful
• Screen patients for different tobacco products
35
TOBACCO
ADDICTION
Nicotine
• Cigarettes and other forms of
tobacco contain nicotine
• Research suggests that nicotine
may be as addictive as heroin,
cocaine, or alcohol
37
Nicotine and the Brain:
Prefrontal
cortex
Dopamine release
Stimulation of
acetylcholine receptors
Nucleus
accumbens
Ventral
tegmental
area
Nicotine enters
brain
38
Nicotine Hijacks the Brain

Smokers feel normal with nicotine

When nicotine levels decrease, smokers
may experience nicotine withdrawal
symptoms (NWS)

NWS include irritability, anxiety, difficulty
concentrating, and increased appetite
39
Nicotine Addiction
Easy to Start, Hard to Quit
In general:
• Ninety percent of smokers began using tobacco
before age 18
• Smokers often relapse because of stress, weight gain,
and withdrawal symptoms
• Numerous quit attempts are usually necessary to stop
successfully
40
Nicotine Addiction
Easy to Start, Hard to Quit
• Each day, approximately 3,500 U.S. kids
smoke their first cigarette
• Of every three young smokers:
o One will quit
o One will die from a tobacco-related
disease
41
Treatment Options
Examples
NonPharmacological
Behavioral issues
•
•
•
•
Self-help
Advice
Counseling
Other
Pharmacological
Withdrawal symptoms
• Nicotine Replacement
• Non-Nicotine
Combination is BEST.
42
Nicotine Replacement Therapy
(NRT)
• Reduces withdrawal symptoms
• Few contraindications and side effects
• Toxicity and abuse are rare
• Does not contain toxins
43
Nicotine Replacement Therapy
Update
• Instructions on label will change
• Recommendations by experts differ from label




Combination NRT
Higher dosage
Treat withdrawal symptoms
Taper based on patient’s preference
44
Nicotine Replacement Therapy (NRT)
Delivery time
NRT therapy
• Nicotine gum
• Lozenge
• Patch
• Nasal spray
• Inhaler
Onset of Action
20 to 60 minutes
Faster than gum
6-8 hours
5 to 10 minutes
10 minutes
45
NRT Patch
• Apply to skin that is clean, dry
and non-hairy. Press onto skin
for 10 seconds.
7,14,& 21 mg/24 hr
5,10 & 15 mg/16 hr
• Rotate placement on different
parts of the body each week
• Avoid cutting
46
NRT Gum (Chew and Park)
• Bite gum slowly
• Stop at first sign of mild tingling or
peppery taste
• “Park” between the cheek and gum
• Bite again when tingling or peppery
sensation fades (20 minutes)
47
NRT Lozenge
• Easier to use and delivers ~25% more
nicotine compared to NRT gum
• Allow to dissolve slowly. Rotate in mouth
until it dissolves ( 20 minutes).
• Should not be chewed or swallowed
Do not eat or drink 15 minutes before using NRT gum
or lozenge.
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NICOTINE ADDICTION
Key points

Nicotine addiction can be a chronic and relapsing
condition that usually begins in adolescence

Successful treatment often requires multiple quit
attempts and interventions as well as long-term
monitoring

Pharmacotherapy and behavioral interventions
should be offer to all tobacco users who want to quit
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ASK, ADVISE, REFER
(AAR)
Brief, Effective and Low Cost
Ask, Advise, Refer
Ask all patients about tobacco use
Advise all tobacco users to quit
Refer all tobacco users to 1-800-NO-BUTTS
51
Step One
Ask…..
all patients about tobacco use
52
Strategies to Identify and Document
•
•
•
•
•
•
•
Vital sign
Stamp
Chart stickers
Medical record flow sheets
Checklists
Electronic medical records
Computer prompts
53
Example of Vital Sign
Blood Pressure: ______Pulse: _______ Weight: _____
Temperature: ________ Respiratory Rate: ________
Tobacco Use: Current ____ Former ____ Never____
SHS exposure: Home____
Work_____ Car_____
[ ] Advice given
[ ] Referral provided
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Step Two
Advise…
all tobacco users to quit
55
Advise….
• Studies have shown that healthcare providers can be
effective in advising tobacco users to quit
• Your advice approximately doubles the chance that
patients will make a quit attempt
• The way a healthcare provider talks to patients can
substantially influence motivation to quit
Thereafter, assess willingness to quit
56
Step Three
Refer…
all tobacco users to….
1-800-NO-BUTTS
California Smokers’ Helpline
57
Refer
Let all tobacco users know:
•
“You can double your chances of quitting
successfully by calling 1-800-NO-BUTTS”
•
“They will help you through the quitting process
and the services are FREE”
•
“FREE samples of NRT are available to Los
Angeles County residents “
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California Smokers’ Helpline
1-800-NO-BUTTS or www.nobutts.org
Free and confidential services include:

Up to 6 counseling sessions

Personalized quit plan

Self-help materials and referral to local services

Services for former smokers, teens, pregnant
women, tobacco chewers and people unwilling
to quit
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California Smokers’ Helpline
1-800-NO-BUTTS or www.nobutts.org
 Coaching by trained counselors is available in six
different languages and for hearing impaired
 Financial information:
o FREE NRT to Los Angeles County residents
o $20 gift card for Medi-Cal members
o Health insurance
o Cost is similar to buying cigarettes
Monday-Friday: 7am to 9pm
Saturday: 9am to 1pm
60
Examples of Brief Clinical Interventions
Willing to Quit
Unwilling to Quit
 Refer to 1-800-NO-BUTTS
 Refer to 1-800-NO-BUTTS
If time permits:
If time permits:
• Discuss medications
• Set Target Quite Date
(TQD)
• Develop quit plan
• Contact 3 days after TQD
and follow-up monthly
• Provide motivational
interventions (5 R’s)
• Encourage smoking journal
• Promote healthier lifestyle
• Defer, if patient requests
61
Resources
Patient
Internet
• Smokefree.gov
• Becomeanex.org
Mobile app/Text
• QuitSTART and QuitPal
• SmokefreeTXT
• QuitNowTXT
Provider
Training/Outreach materials
• Nobutts.org
• Smokingcessationleaders
hip.ucsf.edu
• Askadviserefer.org
Nicotine Anonymous
• Quitnowla
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Ask Advise Refer
Key Points
A brief intervention should be implemented at each visit:
•ASK all patients about tobacco use
•ADVISE all tobacco users to quit
•REFER all tobacco users to 1-800-NO-BUTTS and
recommend pharmacotherapy to those who want to quit
AAR + Quitline + Meds
63
AAR
Demonstration
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Questions?
65
Thank you!
Susan Bradshaw, MD, MPH
(213) 351-7319
Los Angeles County Department of Public Health
Chronic Disease and Injury Prevention Division
Tobacco Control & Prevention Program
66