View
213
Download
0
Category
Tags:
Preview:
Citation preview
Fundamentals of Tobacco
Interventions
22
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.
Copyright
33
The recipient of the funding is in compliance with the CMA and the CPA guidelines /
recommendations for interaction with the pharmaceutical industry.
Disclaimer
44
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.
Disclaimer
55
Disclaimer: TEACH Curriculum Development
The TEACH Curriculum and slides were developed and compiled withfunding from the Government of Ontario, Ministry of Health Promotion.Content of slides are primarily based on evidence based guidelinesincluding:• 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.
66
Modules 1 • 2 • 3
123
Environment
Behaviour
Medication
77
Learning ObjectivesAt the end of this course, you will be able to:
• 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
1
2
3
88
Learning Assessment 1
• 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.
ENVIRONMENT
1
1010
Environment
Learning Objectives
At the end of Module 1 you will be able to:
1. Describe why clinicians should implement tobacco cessation interventions
2. Summarize smoking prevalence in Canada by gender and among some special populations
3. Integrate cessation interventions into your clinical practice
1
1111
Optional Exercise
1212
“Fast facts” on Tobacco Use in Canada
• 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)
1313
• 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)
Why should health professionals get involved?
1414
Understand tobacco dependence as a chronic, relapsing disease and the need for a
paradigm shift
1515
Gender-Specific Smoking Prevalence across the World
US26%21%
Australia28%22%
Belarus64%24%
Brazil20%13%
Canada19%17%
Chile42%31%
China59%4%
Egypt25%1%
France37%27%
Iceland25%27%
Mexico37%12%
Iran24% 2%
Kenya24%1%
Sweden19%25%
Philippines39%9%
Portugal41%31%
South Africa25%8%
India28%1%
Russian Fed70%27%
Italy33%19%
Spain36%31%
Germany37%26%
Shafey et al. The Tobacco Atlas, 2009.
MenWomen
1616
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 1st
cigarette within 30 minutes of waking up. 75% within the hour!
CTUMS, 2010
1717
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 Epidemichttp://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf
1818
Smoking Prevalence (Ages 15+)
Differences by Province
19%
17%
19%21%24% 16%
20%
21%20%12%
CTUMS 2010 Wave 1 data
36%
36%61%
Territory data obtained using 2009 Canadian Community Health Survey; Provincial data obtained using CTUMS 2010 Wave 1 data.
1919
0
5
10
15
20
25
30
35
BC AB SK MN ON QC NB NS NF PEI
1999
2009
Current Canadian Adult Smokers (15+) by Province, 1999 & 2009
Ontario, Alberta, Nova Scotia, and PEI reduced by 9% in 10 years
9%
CTUMS, 1999 and 2009 Annual data
2020
Tobacco Use in Ontario
2121
Gender Differences
Smoking rates 19% 16.0%
Cigarettes per day
15.8 12.9
Current teen smokers (15-19)
14.9% 10.9%
Men aged 23-24 have the highest smoking rate (28.9%)
Male Female
CTUMS, 2009 Annual data
2222
Levels of Interventions• Minimal / Brief Contact
– Delivered during the course of a regular health care encounter in less than 3 minutes. i.e.: 5A’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
2323
Brief Cessation Interventions: The “5As”
Fiore et al. 2008.
– Ask about tobacco use
– Advise to quit
– Assess willingness to make a quit attempt
– Assist in quit attempt
– Arrange follow-up
2424
Quitting Smoking at any Age Can Increase Life Expectancy
Increased Life Expectancy
Doll R et al. 2007
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
2525
Effective Amount of Contact Time
Fiore et al., 2000
Need to consider resources available
Total Contact Time Estimated Abstinence Rate
None 11.0 %
1 – 3 minutes 14.4 %
4 – 30 minutes 18.8 %
31 – 90 minutes 26.5 %
91 – 300 minutes 28.4 %
> 300 minutes 25.5 %
Optimal Intervention
Time
2626
Environment Summary
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.
1
BEHAVIOUR
2
2828
Behaviour
Learning Objectives
At the end of Module 2 you will be able to:
1. Enhance clients’ motivation to quit smoking2. Implement a structured, adaptable cognitive
behavioural approach to smoking cessation3. Integrate cessation interventions into your clinical
practice
2
Assessing Tobacco
Dependence
3030
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
3131
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
3232
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. Miller and Rollnick (2002). Motivational Interviewing (2nd ed), p. 25
2. Miller (2009). Ten Things that MI is Not
3333
The Spirit of Motivational Interviewing
• Ambivalence is a normal human condition
• Underlying spirit: collaborative, evocative, supporting autonomy
3434
Change as a Process
3535
The Stages of Change
Prochaska and DiClemente, 1984
?PrecontemplationPrecontemplation ContemplationContemplation
PreparationPreparation
ActionAction
MaintenanceMaintenance
3636
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)
3737
Change is not something you do toto people,
but withwith people.
3838
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. Tolerance2. 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.
3939
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.
4040
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
Withdrawal syndrome
Use of more of the drug or use for longer than intended
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
Most smokers are aware of health risks and want to stop because of them, but feel unable to do so
Experienced by majority of smokers
Fast Facts: Smoking Cessation, Robert West and Saul
Shiffman, 2nd edition 2007
4141
DSM-IV Criteria Dependence (2)
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
Important activities forgone because of the drug
Criterion related mainly to illicit drugs or those that impair function (intoxicating drugs)
Heavily dependent smokers may give up or interrupt activities in non-smoking areas
Fast Facts: Smoking Cessation, Robert West and Saul Shiffman, 2nd edition 2007
4242
Daily Diary - BaselineThink back to the last week starting today and make a note
when you engaged in the current behaviour(s).
4343
• 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
Assessing Our Clients
4444
AssessmentsSeven 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
4545
Assessment Components
1. Level of nicotine dependence/ withdrawal
• 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)
4646
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
4747
Symptoms Duration Prevalence
Irritability / Aggression < 4weeks 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%
Nicotine Withdrawal Symptoms:
Slide Source: TEACH, CAMH, 2009
4848
Assessment Components
2. Motivation • 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
4949
Assessment Components
3. Past quit attempts and smoking history
• 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
5050
Assessment Components
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?
4. Co-morbidities
5151
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?
5252
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. ________________________________
5353
Assessment Components
6. Social Supports and Barriers• What supports do they have in place?• What is smoking status of friends, family, colleagues?
• What in their environment perpetuates their smoking?• Is this a good time to quit or reduce?• How does stress affect their smoking? Their quitting?
5454
Assessment Components
7. Smoker’s Preference • 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?
5555
Tools / Scales to Consider
– 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
5757
4 steps to stopping destructive behaviours and leading a healthier life:
1.1. SSTRATEGIZE
2.2. TTAKE ACTION
3.3. OOPTIMIZE
4.4. PPREVENT RELAPSE (PPERSEVERE)
5858
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
Step 1: STRATEGIZE
6060
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
6161
• 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: Psychological
6262
Strategize – Cognitive/Affective
• 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
6363
Strategize – Behavioural
• 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
6464
Strategize - Environmental
• Smoke-free environments
– Make home and vehicle smoke-free
– Explore areas of home to restrict smoking behaviour if entire home cannot go smoke-free
– Work environment – avoiding smoking areas
– Other
6565
Strategize - Biological
• 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?
6666
Reasons for ChangeMaking 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 ____________________________________________________________
6767
Decision to Change Worksheet
Changing my current behaviour
Continuing to behave in the same way
Benefits
Costs
6868
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
6969
Goal Statement
The behaviour I want to/need to change is:
What is your goal now?
START DATE:
ACHIEVEMENT DATE:
7070
Readiness Ruler
How important is it to change this behaviour?
How confident are you that you could make this change?
How ready are you to make this change?
0 1 2 3 4 5 6 7 8 9 10
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.
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
7171
For Reflection: “Readiness Ruler”
What are 3 reasons you are at _____ and not zero?
1.
2.
3.
7272
Hands-On Practice!
• 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?
STRATEGIZEIdentifying
Barriersand Risky Situations
7474
Identifying Barriers and Solutions to Change
Possible Barriers: Proposed Solutions:
© CAMH/TEACH Project
Step 2: TAKE
ACTION
7676
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
7777
Take Action (2)
• 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
7878
Triggers and Consequences
• 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?
7979
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? _____________%
8080
Triggers and Coping Skills – Sample Plan
Triggers
Smoke with colleague every day at breaks
Coping Skills
Tell colleague I am quitting
After mealsChew gum after meals, get up from table right away
Stress at work gets too much on some days
Plan to take walks when stress is high
8181
3 Options to Cope with Triggers
1. Avoid the triggers or situations
2. Change the trigger or situation
3. Find an alternative or substitute for the cigarette in response to the trigger or situation
8282
• 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
Example: Getting together with friends on Saturday night
8383
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...
Change Plan Worksheet
Step 3: OPTIMIZE
YOUR PLAN
8585
Doing a 360: Asking for Feedback
• SOCIAL SUPPORTS (FAMILY MEMBERS, FRIENDS, COLLEAGUES)
• PROFESSIONALS ( MD, RN, PHARMACIST, OTHERS)
• FEEDBACK ON MY PLAN?• THINGS MISSING?• WATCH FOR SABOTEURS AND
ENLIST SUPPORTERS
Step 4: PREVENT RELAPSE
(Persevere)
“ A Slip is Not a Fall ”
8787
Relapse Prevention
Song et al., (2009)
75% relapse within 4 – 52
weeks
• 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
8888
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
Quit attempt
8989
…it would most likely be in the following situation:
If I were to relapse...
What coping strategies could I use to avoid this relapse?
9090
• If the client has quit or reduced• Congratulate on changes made
• Review benefits
• Identify future challenges and plan to cope
• Pharmacotherapy
• Engagement
Prevent Relapse
9191
Prevent Relapse (2)
• If client had slips/relapsed:– Assess what happened
– What can be done differently?
– What worked?
9292
• 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
Example: Getting Together with Friends on Saturday Night
9393
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?
9494
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.
Revisiting the Decision to Change Worksheet
Changing my current behaviour
Continuing the behaviour in the same way
Benefits
Costs
9595
Readiness Ruler
How important is it to change this behaviour?
How confident are you that you could make this change?
How ready are you to make this change?
0 1 2 3 4 5 6 7 8 9 10
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.
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
9696
Concluding Thoughts on Relapse Prevention
• 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”
9797
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?
Current Motivation and Next Steps
9898
Additional resources that can support me…
9999
Even people who quit intermittently have
substantial health benefits over those who continue to
smoke.
101000
Behaviour Summary
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.
2
MEDICATION
3
101022
Medication
Learning Objectives
At the end of Module 3 you will be able to:
1. Understand the effects of tobacco and nicotine on the brain
2. List pharmacotherapies that increase the odds of quitting
3. Discuss or recommend cessation medications with your clients
4. Integrate cessation interventions into your clinical practice
3
Smoking as an Addiction
101044
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.
101055
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.
101066
Tobacco is a legal product.....
AmmoniaToilet Cleaner
Paint
MethanolRocket Fuel
MethaneSewar
GasAcetic Acid
Vinegar
ButaneLighter
Fluid
CadmiumBatteries
NicotineInsecticide
TolueneIndustrial
Solvent
Stearic AcidCandle Wax
CarbonMonoxide
ArsenicPoison
HexamineBarbeque
Lighter
101077
Anatomy of a Cigarette
Side stream smoke Side stream smoke – 800x toxic– 800x toxic
Filter: Hold back tar Filter: Hold back tar Mild: more holes in filterMild: more holes in filter
Paper: burn Paper: burn rings, titanium rings, titanium oxide oxide accelerantaccelerant
Tobacco: Tobacco: Leaf Leaf Reconstituted Reconstituted PuffedPuffed
101088
101099
‘‘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
Philip Morris. Internal presentation. 1984, 20th March; Kenny et al. Pharmacol Biochem Behav. 2001; 70: 531-549.
Pharmacological Approaches to
Smoking Cessation Treatment
111111
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
Fast Facts: Smoking Cessation, Robert West and Saul Shiffman, 2nd ed, 2007
111122
0
20
40
60
80
100
0 50 100 150 200
Days Since Quit Date
Perc
enta
ge o
f R
ela
pse
d a
t
6 M
onth
s S
till A
bst
inent
Quitting Smoking Unaided: Analysis of 4 Studies
Long-term smoking abstinence in those who try to quit unaided = 3%–5%
Hughes JR et al. (2004)
3 - 5%
Per
cent
age
Stil
l Abs
tinen
t
111133
“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
Guideline #7 for Treating Tobacco Addiction
111144
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
Guidelines for Treating Tobacco Addiction
111155
Costs of Smoking vs. Pharmacotherapy
One Week Supply: Approx. Cost/Week
Name-brand patch $34.00
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 $40.00
111166
Nicotine Replacement Therapy
• 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
111177
Who Should Not Use NRT?
• 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
111188
Medications for Quitting SmokingMedication
Nicotine gum
Nicotine lozenge
Nicotine patch
Nicotine inhaler
Bupropion Varenicline
Treatment length
1-3 months
12 weeks 8-12 weeks12-24 weeks
7-12 weeks 12 -24weeks
Main side effects
• Upset stomach
• Hiccups
• Mouth irritation
• Irregular heartbeat
• Nausea
• Heartburn
• Hiccups
•Disturbed sleep (insomnia, abnormal/vivid dreams)
•Headache
• Site rash (pruritis erythema, burning)
• Irritation of throat
and nasal passages
• Sneezing
• Coughing
• Dyspepsia
• insomnia
• Nausea
•Dry mouth
• Nausea•Sleep disturbances •Constipation•Flatulence
Dosage2 mg, 4
mg2 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
Effectivenessat six monthsor longer† (OR [CI])
1.66 (1.52-1.81)
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)
* 4mg, effectiveness at 6-weeks
Algorithm for Tailoring Pharmacotherapy for Smoking Cessation1,2
Ask about tobacco use: How much do you smoke? 0 - ___ cigarettes per day (cpd)?(one large pack = 25 cpd, one small pack = 20 cpd)
Advise: As your physician, I am concerned about your tobacco use, and advise you to quit. Would you like my help?
Yes
Motivational InterviewingAssess the 5 R’s:
RelevanceRewardsRiskRoadblocksRepetition
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?
Low importance or confidence (≤ 5)
Assist in Quit Attempt: Would you like to quit abruptly?
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 cravingsStep 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 monthsStep 3: (within 9 months)- Smoker stops all cigarettes and continues to use gum to relieve cravingsStep 4: (within 12 months)- Smoker cuts down the amount of gum used, then stops gum use completely (within 3 months of stopping smoking)
Has bupropion/NRT failed? YIs weight gain a concern? N ...History of seizures? N…History of mental illness?
N…Eating disorder? N...Allergic to varenicline? N...Previous non-responder? NWant to quit within 7 days?
N = Varenicline
Has NRT failed? Y/NIs weight gain a concern? Y…History of seizures? N ...History of mental illness? N…Eating disorder? N...Allergic to bupropion? N...Previous non-responder? NWant to quit within 7 days? N = Bupropion SR
Has bupropion/NRT failed? NIs weight gain a concern? NWant to quit within 7 days? Y = NRT (Gum, Patch, Lozenge or Inhaler)
Choose the following combinations:1. Two or more forms of NRT a. patch (15mg) + gum (2mg) b. patch + inhaler c. patch + lozenge2. Bupropion + form of NRTa. Bupropion + patchb. Bupropion + gum
No Varenicline with NRT
Arrange Follow Up
1. Monitor carefully2. Consider contraindications3. Consider comorbidities and specific pharmacotherapy4. Consider dual purpose medications5. If after 4 weeks no response, consider alternative 1st line medications.*
Consider combination pharmacotherapy, based on:1. failed attempt with monotherapy2. breakthrough cravings3. level of dependence4. multiple failed attempts5.experiencing nicotine withdrawal
@ 4 weeksPartial response
High importance or confidence (>5)
NoHave you tried quitting cold turkey?
Yes: Pharmacotherapy options
Cold Turkey
No
*N.B. for 2nd line medications (clonidine and nortriptyline), see guidelines.
No response
YesNo
Yes
Developed by Peter Selby, MBBS, CCFP. This algorithm is based on: Bader, McDonald, Selby, Tobacco Control, 2009: 18: 34-42. Fiore MC et al., Clinical Practice Guideline: Treating Tobacco Use and Dependence, May 2008. Gray, Therapeutic Choices: 5th Ed., 2007, Chapter 10: 147-157.
121200
Nicotine Patch• 24 hour continuous dose of nicotine
– 21, 14 and 7mg patches (applied every 24h)• 16 hour continuous dose of nicotine
– 15, 10, and 5 mg (applied every 16h) • Off-label use – higher than 21mg dose for highly
dependent smokers • Potential side effects
– May cause sleep disturbance or nightmares→ Remove before bed
– Skin irritation– Clear patch
121211
How to Use the Patch
• 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
121222
Nicotine Gum• 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
121233
How to Use Nicotine Gum
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
2 mg 4 mg
Use in combination with patch as a breakthrough medication; typically if smoke <pack/day
Use in combination with patch or alone; typically if smoke > pack/day
121244
How to Use Gum (2)• 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
121255
“Reduce to Quit” (RTQ) -Approaches
Smokers not ready or unable to quit abruptly
50% reduction in daily cigarette consumption between 6 weeks and 4 months of treatment
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
Craving to smoke in order to prolong smoke-free intervals for as long as possibleWhen?
How?
Goal?
Who?
121266
RTQ: Using NRT Gum
• 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.
Shiffman, Ferguson, & Strahs, 2009
Maximum of 20 pieces gum / day
How long?
How much?
121277
Nicotine Inhaler• Small, cigarette-shaped inhaler• Satisfies sensory and ritualistic
aspect of smoking• One cartridge contains 10mg of
nicotine and 1mg menthol• Absorbed in oral cavity, throat and
upper respiratory tract by “puffing”• Potential side effects
– throat & mouth irritation, headache, nausea, indigestion(<20%)
121288
How to use the Nicotine Inhaler• Single cartridge equivalent to 4-5 cigarettes
- or 20 minutes of continuous use• 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
121299
Nicotine Lozenge• 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
131300
Dependence Potential of Nicotine Delivery Devices
• 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
131311
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
Gum, lozenge, inhaler peaks in 20 – 30 minutes
1 hr
Patch peaks in 2 – 6 hrs
2 hrs0
Rose et al., 2010
131322
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;
131333
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
131344
Long-Term Use of NRT• 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)
131355
Assessing Readiness to discontinue NRT
• 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?
131366
Pregnancy and Youth - NRT
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
131377
Bupropion• 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
131388
How To Use Bupropion
• Prescribed by Physician, Nurse Practitioner or Dentist
• Dose 150mg once daily for 3 days, increase to 150mg 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
131399
Varenicline• Oral medication to quit smoking• Reduces withdrawal and craving• Prevents pleasurable effects of smoking• Varenicline is a partial agonist (α42
nicotinic acetylcholine receptor), which partially mimics the effect of nicotine
141400
Varenicline: Drug Interactions / Precautions
• Concomitant use of nicotine replacement therapy– not expected to increase cessation– will increase adverse drug reactions
• Does not affect and is not affected by CYP450 enzyme system
• Reduce dose in severe renal impairment
141411
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:• 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
141422
2nd Line Medications
• 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
141433
The Future?
• Selegiline – Parkinson treatment• Vaccines – prevent nicotine from
reaching the brain• Transcranial Magnetic Stimulation
141444
Multiple Quit Attempts May Be Necessary
– >70% of US smokers have attempted to quit1
→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 attempts3
→Past failure does not prevent future success
1. Fiore MC et al. 2008.2. Foulds J et al. 2004;9:39–53. 3. Grandes G et al. 2003;.
141455
Cessation Objectives
1. Increase the number of quit attempts
2. Increase long-term success of quit attempts
141466
Sometimes the doorway has to be opened wider and held
open longer…
141477
Medication Summary
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.
3
141488
Workshop Summary
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.
2 31
141499
Learning Assessment 2
• 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
151500
Course Evaluation
• Please complete the course evaluation which will help us improve future trainings
• We will be collecting this!
151511
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@info2.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.
151522
CAN-ADAPTT
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
Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment
• Access to a dynamic set of Tobacco Control Guidelines
For further information or to register for free, please visit www.can-adaptt.net
151533
Tobacco Informatics Monitoring System (TIMS)http://tims.otru.org/
Recommended