Tobacco Basics and Brief Cessation Interventions

Prepared by:

Margie Kvern, RN, MN

Diane Mee, RN, BN

October 2014

Outline

• Tobacco Basics

• WRHA Clinical Practice Guideline for Management of Tobacco Use and Dependence

• Smoking Cessation – 5A Brief Intervention

• Smokers’ Helpline (SHL) Fax Referral Program

• Pharmacotherapy Options

Why the concern about tobacco use? • Each year in Canada, more than 37,000 people

die prematurely due to tobacco use (Health Canada,

2007)

• Approximately 16% of the population 15 years of age and older smoke = about 4.8 million Canadians (CTUMS, 2012)

• 17.9% of Manitobans aged 15 yrs and older are current smokers (CTUMS 2012)

Tobacco Prevalence

0

5

10

15

20

25

30

2000 2002 2004 2006 2008 2010 2012

Canada

Manitoba

Canadian Tobacco Use Monitoring Survey

FFHV Data – Smoking during Pregnancy

0

5

10

15

20

25

2007 2008 2009 2010 2011

Winnipeg

Winnipeg

Environmental Tobacco Smoke Exposure

0

5

10

15

20

25

30

2000 2002 2004 2006 2008 2010 2012

0-11 years

0-11 years

Canadian Tobacco Use Monitoring Survey, 2012

What is tobacco?

• Tobacco is a plant that contains the drug nicotine

• Nicotine the addictive substance in tobacco; other substances in tobacco cause disease

• Cigarettes, cigars and smokeless tobacco products – all contain tobacco

What is Nicotine?

• Substance that makes cigarettes addictive

• Inhaled tobacco smoke moves from the lungs into the bloodstream and up to the brain within 7-10 seconds

• Causes release of dopamine giving feeling of pleasure and well being

• Depletes the body within 4 hours and has a ½ life of 2 hours

Typical Withdrawal Symptoms

• Headaches

• Anxiety and irritability

• Difficulty concentrating and sleeping

• Increased appetite

• Decreased heart rate and blood pressure

• Craving for nicotine

• Fatigue and coughing • (Health Canada, 2007)

Smoking Cessation

Quitting smoking is the single most effective thing that a person who smokes can do to enhance the quality and length of their life.

Canadian Pharmacists Association. (2001, January).

Joint statement on smoking cessation. Retrieved from

http://www.pharmacists.ca/content/about_cpha/who_

we_are/policy_position/pdf/smoking_cessation_joint_

stat.pdf

Benefits of Quitting

• Within 20 minutes blood pressure and heart rate drop to normal rate and body temperature normalizes

• Within 8 hours Carbon Monoxide levels drop and oxygen levels increase

• Within 24 hours heart attack risk decreases • After 2 weeks coughing, congestion, tiredness and

shortness of breath decreases • After 1 year heart attack risk decreases by 50% • After 10-15 years risk of premature death

approaches that of never smokers and risk of certain cancers decreases

People want to quit

• Health concerns and current health problems

• Cost of cigarettes

• Persistent advice to quit from family

• Advice to quit from health professionals

• 39% of Canadian smokers were thinking of quitting in next 6 months (CTUMS 2010)

• 16 % were thinking of quitting in the next 30 days ( CTUMS 2010)

You can make the difference • 10% of smokers will quit without interventions

• 13.4% with brief intervention (<3minutes)

• 16 % with low intensity intervention (3-10 minutes)

• 22.1% with high intensity intervention (>10 minutes)

• All rates will double using pharmaceutical aids

Fiore MC, Jaen CR, Baker TB, et al. (2008). Treating tobacco use and

dependence: clinical practice guideline. Rockville, MD: US Department of

Health and Human Services, Public Health Service.

CPG - Management of Tobacco Use and

Dependence

WRHA CPG – 5As

• Ask

• Advise

• Assess

Purpose: To consistently identify tobacco use

and provide evidence-based, stage-based

interventions

• Assist • Arrange

5A Protocol

Ask about tobacco use with all clients

Advise all clients of the importance of quitting in a clear, non-judgmental manner

Assess readiness/willingness to quit

Assist according to readiness to change

Arrange for follow-up or referral to resources

ASK

Tobacco use history should be determined and recorded at every appointment

Have you used tobacco in the past 7 days?

Have you used tobacco in the past 6 months?

Advise

• In a clear, unambiguous, personalized way, advise about the importance of quitting

“I am concerned about your smoking because…”

“Stopping smoking is the most important thing you can do to protect your health”

(RNAO 2007)

Assess

• Readiness to quit:

“What are your thoughts about stopping smoking?”

Assist – Stage Matched Interventions • Provide intervention (minimal or intensive)

according to readiness/stage of change

• Build motivation and strengthen commitment to quit, reduce or stay quit

• Help the client set realistic, achievable goals

(RNAO 2007)

Stages of Change

Precontemplation

• “No, I do not intend to quit in the next 6 months”

• “I don’t need to change”

• Behavior not seen as a problem/in denial

For smokers who don’t want to quit ASSIST, ARRANGE

Build Confidence, Importance through 5Rs: • Relevance – tailor counseling to the patient’s condition/health

• Risks – discuss health risks associated with smoking

• Rewards – have patient identify benefits of quitting – Improved health, taste, money, breath, odor

• Roadblocks – have the patient identify barriers to quitting – withdrawal symptoms, fear of failure, depression, weight gain, lack of

support, loss of friends

• Repetition – use the 5R’s and motivational interviewing techniques each time a tobacco user receives dental treatment – keep the intervention short and focused

Discuss their pros of smoking and cons of stopping smoking

Contemplation

• On the fence

• “I might quit in the next 6 months”

• Realize smoking is a problem

• More receptive to information… BUT

Evaluate pros of change and cons of staying

the same •What are the reasons you don’t want to quit?

•What might be better if you quit?

•What concerns you about continuing to smoke?

Build importance of change •Why is quitting important to you?

Reframe cons as barriers/obstacles that have

solutions

For smokers who don’t want to quit

ASSIST, ARRANGE

Preparation

• Testing the waters

• “I will change but just not yet, I intend to quit in the next 30 days”

• 24 hour quit attempt made in last 12 months

• Make referral to SHL

Preparation – ASSIST, ARRANGE

“I’m thinking about quitting in the next 30 days”

Goal: Help the patient make a quit plan (STAR)

• Set a date

• Tell family/friends about plan

to quit (social supports)

• Anticipate challenges (withdrawal,

triggers)

• Remove tobacco products

from your environment

Action

• Yes, I have quit but for less than 6 months

• I am changing

• Need to develop effective ways of coping with stress

• Relapse can happen

Action –

ASSIST, ARRANGE

“I have quit recently.” (within the last 6 months)

GOAL: Help patient stay quit

Support recovery from relapse

• Review the quit plan – pharmaceuticals, adequate social support, set-backs

• Provide support and suggestions how to deal with withdrawal symptoms, weight gain, irritability, anxiety and/or rejection by friends who smoke

• Remind patient of his/her stated reasons to quit and the great choices made – have confidence to stay quit!

• Resources to support staying quit

Maintenance

• “Yes, I have quit, and for more than 6 months”

• Less vulnerable to relapse

• Have a plan for slips

Maintenance – ASSIST, ARRANGE

“I quit.” (6 months or more)

GOAL: Help patient stay smoke-free for lifetime

• Provide support - constantly remind person of the benefit of quitting and the right choice they made

• The person might crave tobacco the rest of their life and need to find strategies to resist ‘triggers’

Arrange

If the client is interested, ARRANGE for follow-up or referral to resources to help her quit/reduce

• Smokers’ Helpline

• Community resources

• Referral to other Health

Care Provider

Smokers’ Helpline

• All clients in contemplation and preparation stages are to be offered SHL referral

• Fax referral forms

• 1-877-513-5333

• www.smokershelpline.ca anytime!

Ask, Advise, Assist, Arrange Model with the Stages of Change

Stage Of Change ASK ADVISE ASSIST ARRANGE

Pre-Contemplation

Goal: Get client to think about quitting

• Ask about their feelings about quitting

• Offer quitting information

• Be available in the future if they decide they want to talk about quitting

Contemplation

Goal: Get client to move towards a decision to quit

Goal: Improve client confidence

• Ask the PERSONAL pros and cons of quitting (decisional balance sheet)

• Acknowledge ambivalent feelings

• Offer quitting information

• Reinforce reasons to change

• Suggest cutting back or 24 hr stop period

• Offer future visit & SC information

Preparation

Goal: Help prepare for quitting

• Ask about concerns preparations made & lessons learned from quitting in the past

• Offer quitting information

• Identify Barriers & solutions

• Provide SC Booklet, Action Plan, NRT, Quit Date Setting (BAND)

• Contact PH/Unit for information on local SC services & refer 2 Community resource

Action

Goal: Help client prevent relapse

• Ask what are they doing re: NRT, avoiding triggers, successes etc

• Relapse, weight gain, triggers

• How to deal with withdrawal symptoms

• Focus on successes

• Offer increased support

• Encourage self-reward

• Congratulate them!

Contact PH/Unit for information on local SC services & refer 2 Community resource

Maintenance

Goal: Help client be smoke free for life

• Ask what they are doing in risk situations that could cause relapse

• It is normal to go thru the stages 3 to 4 times before finally quitting

• Offer suggestions re, triggers, supports, encouragement

• Congratulate them!

Contact PH/Unit for information on local SC services & refer 2 Community resource

Pharmacotherapy

• Nicotine Replacement Therapy (NRT) » Long acting

» Short acting

• Bupropion SR (Zyban, Wellbutrin)

• Varenicline (Champix)

NRT vs. Cigarettes

Cigarettes

• Arterial return

• Absorbed quickly

• 4,000 harmful chemicals over 50 of which are cancer causing

NRT

• Venous return

• Absorbed slowly

• No harmful chemicals

NRT • Very safe – sold over the counter (OTC)

• The long-acting nicotine patch continuously delivers small amounts of nicotine through the skin

• The client doesn't get the peaks and valleys in nicotine levels that occur with smoking and they may still have cravings to smoke or experience some withdrawal

• The short-acting forms of NRT help people to get an additional dose of nicotine when they have a craving

Forms of NRT

Long-Acting

Patch

Short-Acting

Gum

Lozenge

Inhaler

Mist

Bupropion SR (Zyban)

• Not a nicotine replacement therapy

• Antidepressant that has been found to help people with nicotine withdrawal

• It is a pill - requires a prescription

• Started before quit date (usually 7-10 days before) as it takes time to build up in the bloodstream

• Increases dopamine and adrenaline levels

• Can be combined with NRT

Varenicline (Champix)

• It is a pill - requires a prescription

• Attaches to the nicotine receptors in your brain to block nicotine from attaching, which reduces cravings and decreases the pleasurable effects of cigarettes and tobacco

• Should not be combined with NRT as it blocks uptake of nicotine

Other quit methods

• Acupuncture

• Hypnotherapy

• E cigarette discussion

Harm Reduction Strategies

• Smoke-free home (limit smoking to one part of the home)

• Smoke free car

• No smoking in front of children

• Reduce number of cigarettes smoked

WRHA Safe Sleep and Smoke-Free Resource Rollout

• Launched in December 2011

• Resulted from the Joint Statement on Safe Sleep: Preventing SIDS in Canada (PHAC 2011)

- provides updated information to provide infant deaths related to SIDS/SUDS

- highlights new evidence for the link between smoking and SIDS

• New resources now available for HCP use

Safe Sleep and Smoke-Free Home Resources

• Information sheet for PHNs and Home Visitors about the rollout

• Two new safe sleep and smoke-free home resource

– Door hangtag and smoke-free home magnet

• Information on how to use these resources

• Posted on Insite>PPH>Tobacco Reduction

Documentation for PHNs

• Smoking listed under Family Assessment on page 1 of care map

• Tobacco Smoke-Free environment listed under Health Counselling – Family page 7 care map

• “V” from page 1 and PN from page 7 of care map link to Progress Notes in DARP format

Documentation for Home Visitors

• Documentation will be done on the HV log

• Safe sleep/Smoke-Free environments documented under “Status of Home”

–Does home smell like tobacco smoke?

– Infant sleeping arrangements

Documentation for Home Visitors

• Distribution of hangtag & magnet along with discussion of Safe sleep/Smoke-free home documented under “How did you support the family to…”

• Depending on the conversation, SC may become a “Work towards their goals”

• “Promote healthy childhood G&D” would include benefits to the child for tobacco reduction

Smoking Cessation Resource Hub Kit

• Each office has a SC Resource Hub Kit

• Developed by a group of nursing students during their Community Health placement

• Resource Hub Kit contains the top 10 resources for PPH staff to use according to the stage of change the client is in

Summary • Smoking is not a habit - it’s an addiction

• Implement WRHA CPG – Use 5As will all clients

• Identify Stage of Change

• Match appropriate intervention using the 5As

• Refer to Smokers Helpline

• WRHA Safe Sleep/Smoke-Free Home info

• Harm Reduction strategies

• Documentation