Download smoking cessation 2014

SMOKING CESSATION
Learning Objectives
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Understand the hazards of smoking
Recognize the health benefits of smoking cessation
Describe the rationale for treating tobacco dependence
Explain why tobacco dependence is a chronic disease
Initiate clinical interventions for tobacco users who are willing to
quit as well as users who are not willing to make a quit attempt
Assist users attempting to quit with strategies designed to
prevent relapse
The smoking epidemic
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1 billion smokers
Smoking represents the most readily preventable risk factor for
morbidity and mortality.
5 million people die every year because of smoking related
illnesses.
By 2030, if current trends continue, smoking will kill one in 6
people.
( world health organization. 2008.
The smoking epidemic
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75% of smokers want to quit
<2% of smokers quit each
year
The smoking epidemic
Effective government policy:
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Bans on tobacco advertising and sponsorship
Regular price rises
Stronger public health warning labels
Smoking bans in all public places
Prevalence of Smoking in Saudi Arabia
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2.4-52.3% (median = 17.5%)
School students 12-29.8% (median = 16.5%),
University students 2.4-37% (median = 13.5%),
Adults 11.6-52.3% (median = 22.6%).
Elderly people 25%.
Males 13-38% (median = 26.5%)
Females 1-16% (median = 9%).
Prevalence of Smoking in Saudi Arabia
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17% of primary health care physicians in Riyadh city were
current smokers, 20% ex-smoker.
Al- shahri M, Al Almaie S. promotion of non-smoking: The role of primary health care
physicians. Ann Saudi Med 1997;17:515-17
Smoking Health Risks
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Short-term
Shortness of breath
Worsening asthma or bronchitis
Increased risk of respiratory infection
Harm to pregnancy
Impotence
Infertility
Smoking Health Risks
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Long-term
Heart attack and stroke
Lung and other cancers
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larynx
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oral cavity
pharynx
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Chronic obstructive
pulmonary disease (COPD)
Osteoporosis
Disability (chronic bronchitis
and emphysema)
Need for extended care
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esophagus
pancreas
stomach
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kidney
bladder
cervix
acute myelocytic leukemia
Tobacco-based products:
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Cigarettes
pipes
cigars
hookahs ((shisha/ narghile/ argileh/ hubble bubble and goza))
chewing tobacco etc.
Why do people continue to smoke?
Addiction to nicotine
 Perceived benefits (relaxation, stress relief, weight loss)
 Social context
 Mental health issues
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Smoking Cessation Barriers
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Withdrawal symptoms
Fear of failure
Weight gain
Lack of support
Depression
Enjoyment of tobacco
Being around other users
Limited knowledge of effective treatment options
Physician Barriers to Helping
Patients Stop Smoking
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Time constraints of practice
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Lack of office systems
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Low expectation of success
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Lack of knowledge of what to do
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Reimbursement issues
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Frustration with smokers
Smoke vs. Quit
Common Reasons not to Quit
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Family and friends smoke
Withdrawal symptoms
Inability to cope with stress
Connection with smoking
Previous unsuccessful
attempts to quit
Common Reasons to Quit
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Encouragement from family
and friends
Health improvements
To save money
Pregnancy
Smoke-free environment
policies
Desire to be a role model
Medical treatment that
requires abstinence
Tobacco Dependence as a chronic
disease
What is a cigarette?
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Delivers nicotine to the lungs and brain within 7 sec each time a
smoker inhales
Frequent, small-dose stimulation makes smoking highly addictive
Most cigarettes contain ≥ 10 mg of nicotine
Average smoker absorbs 1-2 mg of nicotine per cigarette
Cigarettes release carbon monoxide which adheres to red blood
cells faster than oxygen
• Reduced oxygen in the body causes increased heart rate
What’s in a Cigarette?
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4000 chemicals many of which are highly toxic.
40 known cancer-causing substances.
Tobacco
Carbon monoxide
Hydrogen cyanide
Nitrogen oxide
Ammonia (sub-micron sized particles)
Nicotine, phenol, polyaromatic hydrocarbons, tobacco specific nitrosamines.
Tar total particulate matter (nicotine and water)
Filter with titanium oxide accelerant
Flavours
Liquid vapour
Benzene
Formaldehyde
Acrolein
N-nitrosamines
Non-particulate matter
What is Nicotine Dependence?
Chronic Nicotine consumption with the following characteristics:
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Substance abuse
Continues self-administer substance despite perceived
negative effects
High tolerance towards the substance
Manifests withdrawal symptoms when trying to stop use
Effects of Nicotine
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Highly toxic drug
Increase HR, BP
Decrease body temp
Slows circulation
Affects appetite
Increase BMR
changes brain activity - improving reaction times, ability to pay
attention and brings on euphoria
Addiction
Increases dopamine levels
Creates a feeling of pleasure
The addiction pathways
‘Reward’ pathway
(mesolimbic dopamine system)
‘Withdrawal’ pathway
(locus coeruleus)
“Reward” Pathway
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Mesolimbic dopamine system has been characterized as a
“reward "pathway
Nicotine produces a dopamine surge in the nucleus accumbens
Smoking cessation is followed by pathophysiologic withdrawal
and craving
Withdrawal
Chronic drug use affects brainstem structures
(locus ceruleus)
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Noradrenergic cells become more excitable
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When a person abstains, the firing rates become abnormally
high – a possible basis of withdrawal symptoms
Nicotine withdrawal syndrome
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acute/uncontrollable need to smoke (craving)
irritability
restlessness, anger, anxiety feelings
tiredness
increased appetite, especially for sweets and resultant weight
gain
trouble to concentrate and focus memory
depression
headaches
insomnia
dizziness
Benefits of Quitting
20 mins:
8 hours:
24 hours:
48 hours:
72 hours:
blood pressure and pulse rate return
to normal
blood nicotine & CO halved, oxygen
back to normal
CO eliminated; lungs start to clear
mucus etc.
nicotine eliminated; senses of taste
& smell much improved.
breathing easier; bronchial tubes
begin to relax; energy levels
increase
Benefits of Quitting
2-12 weeks:
3-9 months:
5 years:
10 years:
circulation improves
lung function increased by <10%
coughs, wheezing decrease
risk of heart attack halved
risk of lung cancer halved compared
to continued smoking
risk of heart attack equal to neversmoker’s
Quitting- other benefits
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Improved health and physical performance
Improved taste of food and sense of smell
Better appearance, including reduced wrinkling/aging of skin
and whiter teeth
Healthier families, babies and children
A good example for children and others
More money in your pocket
Treatment of Nicotine Addiction
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Combination of counseling and pharmacotherapy is more
effective than either option alone
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The more intense the intervention, the better the outcome of
abstinence
Pharmacologic Options
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Clients/patients attempting to quit smoking should always be
encouraged to use effective medications unless they are
contraindicated in specific populations
eg. pregnant women, smokeless tobacco users, light
smokers, adolescents (Fiore, et al)
Two categories of pharmaceutical options:
 Nicotine replacement therapy (NRT)
 Non-nicotine replacement therapy
Nicotine Replacement Therapy (NRT)
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Nicotine Patch
Nicotine Lozenges
Nicotine Gum
Nicotine Inhalers
Provide nicotine to reduce withdrawal symptoms
Take between 1-4 hours to reach maximum blood levels (unlike
cigarettes, 7 seconds)
Do not cause sudden boost to nicotine blood levels (prevents
addiction to product)
Dose depends on habits of the smoker but is reduced over a 12
week period
Non-nicotine Therapy
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Bupropion Hydrochloride (Zyban)
• Also marketed as the anti-depressant medication Wellbutrin
• Presumed to alleviate cravings associated with nicotine
withdrawal affecting noradrenaline and dopamine
Varenicline Tartrate (Champix)
• Targets nicotinic acetylcholine receptors to decrease
cravings and withdrawal
Clonidine & Nortriptyline
• Second-line medications used in smoking cessation
All of these medications require a prescription
Counselling
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Intensive intervention that last a minimum of 10 minutes
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Commonly conducted by nurses in various health-care settings
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Motivational Interviewing
 Directive and client-centred standard counselling techniques
 Stages of Change theory
Other options of treatment
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Hypnosis
Herbal remedies
Acupuncture
Laser treatment
No clinical evidence to verify results from these
treatments
Some clients/patients report that they are beneficial (Fiore, et al., 2008)
Protection: Second-hand smoke
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Second-hand smoke:
Also known as environmental tobacco smoke
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Combination of:
◦ Side stream smoke (smoke from the end of a cigarette)
◦ Smoke exhaled by the smoker
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67% of smoke from a burning cigarette is not inhaled by the
smoker and ends up in the surrounding environment
Second-hand smoke (cont.)
‣ 4000 chemicals have been identified in second-hand smoke
50 of these are known carcinogens
(United States Environmental Protection Agency, 2000)
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‣ Examples:
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- Arsenic compounds
- Benzene
- Chromium compounds
- Ethylene oxide (chemical to sterilize medical devices)
- Vinyl Chloride (chemical used in plastics manufacture)
- Polonium – 210 (radioactive species)
Second-hand smoke (cont.)
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Labeled as a known human carcinogen
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Labeled as a class A cancer-causing substance (Class A = most
dangerous)
Model for treatment of tobacco use and dependence
General
Populatio
n
Patient
presents to
healthcare
setting
Relapse
ASK: Current users
screen all
ADVISE
patients for
to quit
tobacco
use
Non users
Primary
preventio
n
Prevent
relapse
Yes, willing
ASSESS
willingne
ss to quit
ASSIST
with
quitting
ARRANG
Ea
follow-up
No, unwilling
Promote
motivatio
n to quit
Patient now
willing to quit
Abstinent
Where to begin?
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ASK- about smoking – understand your patient
ASSESS - what is the next step?
ADVISE - why cessation is important
ASSIST - offer to help
ARRANGE- follow-up process
The 5 As apply to
Those who:
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are willing to quit,
aren’t willing to quit, and
recently quit.
Smoking Cessation Treatment
Smoking Cessation Treatment for Those
Willing to Quit
Smoking Cessation Treatment for Those
Willing to Quit
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ASK Identify and document tobacco use status of every patient
at every visit.
Example: When recording vital signs, include an area to note
tobacco use.
Smoking Cessation Treatment for Those
Willing to Quit
ADVISE In a clear, strong, and personalized manner advise every
tobacco smoker to quit.
Smoking Cessation Treatment for Those
Willing to Quit
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Advise examples:
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Clear
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Strong
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Personalized
“I think it’s important for you to quit
smoking now, and I can help you.”
“As your clinician, I need you to know
that quitting smoking now is the most important thing
you can do to protect your health.”
asthma worse.”
“Continuing to smoke makes your
Smoking Cessation Treatment for Those
Willing to Quit
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ASSESS
Is the user willing to make a quit attempt at
this time?
YES
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Provide assistance to dependence treatments.
NO
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Provide an intervention shown to increase
future quit attempts, such as nicotine gum,
quit lines and behavioral counseling.
Smoking Cessation Treatment for Those
Willing to Quit
ASSIST
Offer medication. Provide or refer for counseling or additional
behavioral treatment.
Medication examples:
 Nicotine lozenge
 Varenicline
Smoking Cessation Treatment for Those
Willing to Quit
ASSIST
Behavioral treatment examples:
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Recommend a quit plan, such as STAR.
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Set a quit date.
 Tell family, friends and coworkers.
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Anticipate challenges.
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Remove tobacco products.
Smoking Cessation Treatment for Those
Willing to Quit
ARRANGE
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Arrange for follow-up soon after quit date, a second follow-up
within the first month and others as needed.
Identify problems and anticipate challenges.
Remind patients of available sources, such as quit lines.
Provide encouragement.
Smoking Cessation Treatment
Smoking Cessation Treatment for Those
NOT Willing to Quit
Smoking Cessation Treatment for Those
NOT Willing to Quit
ASK, ADVISE & ASSESS
Use the same 5As for users unwilling to quit as those willing to
quit.
Smoking Cessation Treatment for Those
NOT Willing to Quit
ASSIST
Provide motivational interventions designed to increase future
quit attempts.
Smoking Cessation Treatment for Those
NOT Willing to Quit
ASSIST
Motivational examples:
The 5 Rs
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Relevance
Identify why it is personally relevant to get the patient to quit.
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Risks
Ask the patient to identify negative consequences of smoking.
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Rewards
Ask the patient to identify the benefits of stopping.
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Roadblocks
Identify the patient’s barriers to success and how to approach them.
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Repetition
Repeat motivational interventions.
Smoking Cessation Treatment for Those
NOT Willing to Quit
ASSIST
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Motivational examples: Express empathy
Use open-ended questions.
“How important do you
think it is for you to quit?”
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Use reflective listening.
“So you think smoking helps
you maintain your weight.”
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Normalize patient’s feelings.
“Many people worry
about managing without cigarettes.”
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Support their right to choose.
when you are ready.” t to choose.
“I’m here to help you
Smoking Cessation Treatment for Those
NOT Willing to Quit
ASSIST
Motivational examples: Develop discrepancy
Highlight the discrepancy between the patient’s smoking versus the
patient’s stated values.
“You’re devoted to your family. How do
you think your smoking affects them?”
Reinforce change talk.
“So, you realize how smoking is making it
hard to keep up with your kids.”
Deepen the commitment to change.
“We would like to help you
avoid a stroke like the one your father had.”
Smoking Cessation Treatment for Those
NOT Willing to Quit
ASSIST
Motivational examples: Roll with resistance
Back off and use reflection.
“Sounds like you’re feeling
pressured about your tobacco use.”
Express empathy.
“I understand it’s hard to quit.”
Ask permission to provide information.
“Would you like to
hear about some strategies that can help you quit?”
Smoking Cessation Treatment for Those
NOT Willing to Quit
ASSIST
Motivational examples: Support self-efficacy
Help patients build on past successes.
“You were fairly
successful last time you tried to quit.”
Offer options for small, achievable steps toward change.
“Can you try smoking one less cigarette a day? A quit line can
help you.”
Smoking Cessation Treatment for Those
NOT Willing to Quit
ARRANGE
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More than one motivational intervention may be needed.
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Provide follow-up at the next visit.
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Offer additional interventions to motivate and support.
Smoking Cessation Treatment
Treatment for Those Who Recently Quit
Treatment for Those Who Recently Quit
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ASK
Determine if the smoker is still smoke-free. then,
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ASSESS
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relapse potential.
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Treatment for Those Who Recently Quit
ASSESS
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Most relapses occur within the first two weeks, but the risk can
persist for a long time; therefore,
Identify and address challenges, including
lack of support for cessation,
negative mood or depression,
strong or prolonged withdrawal symptoms,
weight gain and
smoking lapses.
Treatment for Those Who Recently Quit
ASSIST
Provide encouragement and relapse prevention to address the
challenges of staying smoke-free.
 Challenge example
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Lack of support
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Depression
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Prevention response
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Schedule follow-ups, urge use of quit lines, identify source of
support
 Counsel or refer to counseling/support groups
Smoking is a Complex Phenomenon
Social
Psychological
Spiritual
Biophysiological
Physical and Psychological
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When “down”, smoking energizes
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When “anxious”, smoking calms
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Smoking focuses attention and conveys a sense of well-being,
every time
Psychological/Behavioural
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Conditioning occurs over many years after exposure to things in
the environment which stimulate the smoker to want a cigarette
People learn to manage their emotions with tobacco
Patterns of behaviour are very difficult to change
Physical and Emotional
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Pleasure, arousal, relaxation and the relief of tension and
anxiety are therapeutic effects of nicotine
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Smoking also treats effects of withdrawal
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All of these effects are biological and molecular
Emotional, Social & Spiritual
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A comforting completion of pleasurable rituals: friends, drinks,
sex, meals and breaks
A close, comforting friend that has always been there
A way to cement certain social relationships and repel unwanted
ones
Part of identity and sense of self
Bio-physiologic
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Nicotine is an addictive substance. The chemical effects of
nicotine are strongly related to the conditioning that occurs in
many smokers. It is this link between stimulation/triggers in the
environment and the immediate chemical, pleasurable effect on
the body that often makes stopping smoking so difficult
Stages of Change
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PRECOMTEMPLATION
o
Unaware or unwilling to change
CONTEMPLATION
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Ambivalent, but thinking about changing
PREPARATION
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Decided to change and taking steps
ACTION
o
Started to do things differently
MAINTENANCE
o
Changed for sometime and integrating the change into their
routine
Prochaska and DiClemente
Precontemplation
Not thinking of
quitting in the next
six months
Contemplation
Thinking of
quitting in the
next six months
Relapse
Maintenance
Quit for more
than six
months
Preparation
Planning to
quit in the
next month
Action
Quit in the last
six months
2
Myths you may encounter as you work with your
patients to help them stop smoking:
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Myth 1: Smoking is just a bad habit.
Fact: Tobacco use is an addiction. According to the U.S. Public Health Service
Clinical Practice Guideline, Treating Tobacco Use and Dependence, nicotine is a
very addictive drug. For some people, it can be as addictive as heroin or
cocaine.
Myth 2: Quitting is just a matter of willpower.
Fact: Because smoking is an addiction, quitting is often very difficult. A number
of treatments are available that can help.
Myth 3: If you can’t quit the first time you try, you will never be able to quit.
Fact: Quitting is hard. Usually people make two or three tries, or more, before
being able to quit for good.
Myths you may encounter as you work with your
patients to help them stop smoking:
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Myth 4: The best way to quit is “cold turkey.”
Fact: The most effective way to quit smoking is by using a combination of
counseling and nicotine replacement therapy (such as the nicotine patch,
inhaler, gum, or nasal spray) or non-nicotine medicines (such as bupropion SR).
Myth 5: Quitting is expensive.
Fact: Treatments cost from $3 to $10 a day. A pack-a-day smoker spends
almost $1,000 per year. Check with your health insurance plan to find out if
smoking. cessation medications and/or counseling are covered.
*Source: http://www.surgeongeneral.gov/tobacco