Transcript www.nicotinedependenceclinic.com

Fundamentals of
Tobacco
Interventions
Copyright
Copying or distribution of these materials is
permitted providing the following is noted on all
electronic and print versions:
© CAMH/TEACH
No modification of these materials can be made
without prior written permission of CAMH/TEACH.
2
Disclaimer
The recipient of the funding is in compliance
with the CMA and the CPA guidelines /
recommendations for interaction with the
pharmaceutical industry.
3
Disclaimer
These materials (and any other materials provided
in connection with this presentation) as well as the
verbal presentation and any discussions, set
out only general principles and approaches to
assessment and treatment pertaining to tobacco
cessation interventions. They do not constitute
clinical or other advice as to any particular situations
and do not replace the need for individualized
clinical assessment and treatment plans by health
care professionals with knowledge of the specific
circumstances.
4
Disclaimer: TEACH Curriculum
Development
The TEACH Curriculum and slides were developed and compiled with
funding from the Government of Ontario, Ministry of Health Promotion.
Content of slides are primarily based on evidence based guidelines
including:
•
US Guidelines Treating Tobacco Use and Dependence: Clinical Practice
Guideline 2008 Update. US Department of Health and Human Services, Public
Health Service
•
The Canadian Action Network for the Advancement, Dissemination and Adoption
of Practice-informed Tobacco Treatment (CAN-ADAPTT)
•
Rethinking Stop-Smoking Medications: Treatment Myths and Medical
Realities OMA Position Paper, January 2008.
•
The development or delivery of the TEACH curriculum was not influenced or
funded in any part by tobacco industry. TEACH has not received funding from
the tobacco industry. The development of the TEACH curriculum has not been
influenced by pharmaceutical industry. TEACH project did receive a $10 000
unrestricted grant from Pfizer, to develop video vignettes that are used in our
training. Information presented on pharmacotherapy refers to generic products
only, and recommendations are based on existing research, including the US
guidelines. An algorithm is provided to help practitioners determine if and which
pharmacotherapy is appropriate for a smoker.
5
Modules 1 • 2 • 3
1
2
3
6
Environment
Behaviour
Medication
Learning Objectives
At the end of this course, you will be able to:
1
2
3
7
•
•
•
•
•
•
•
•
Describe why clinicians should implement tobacco cessation
interventions
Summarize smoking prevalence in Canada by gender and
among some special populations
Enhance clients’ motivation to quit smoking
Implement a structured, adaptable cognitive behavioral
approach to smoking cessation
Understand the effects of tobacco and nicotine on the brain
List the pharmacotherapies that increase the odds of quitting
Discuss or recommend cessation medications with your clients
Integrate cessation interventions into your clinical practice
Learning Assessment 1
•
•
•
8
Please complete Learning Assessment 1
This is a self-reflection tool, designed to
gauge whether your responses change
throughout the workshop
Keep the assessment for your own
reflection.
1
ENVIRONMENT
Environment
1
Learning Objectives
At the end of Module 1 you will be able to:
1.
2.
3.
10
Describe why clinicians should implement tobacco
cessation interventions
Summarize smoking prevalence in Canada by
gender and among some special populations
Integrate cessation interventions into your clinical
practice
Optional Exercise
11
“Fast facts” on Tobacco Use in
Canada
•
•
•
•
•
•
12
Tobacco kills 1 in 5 Canadians, or 45,000 people every year
(more than deaths due to traffic accidents, suicides, homicides,
drug abuse and HIV-AIDS combined) (Physicians for a SmokeFree Canada, 2003)
Economic impact of smoking estimated at $17 billion every year
(Rehm et al., 2006)
90% of people who smoke became addicted before age 18
(Fiore et al., 2008)
Tobacco-related disease accounts for at least 500,000 hospital
days each year in Ontario alone (MHP, 2009)
17.5% of Canadians age 15 and over are current smokers
(CTUMS, 2010)
Rates of smoking are much higher among sub-populations:
e.g.,90% - people with schizophrenia, 90% - people with opioid
dependence (Kalman, Morisette and George, 2005; NIDA, 2008)
Why should health
professionals get involved?
•
•
•
•
13
Tobacco is the leading cause of preventable death in the
developed world
70% of smokers want to quit, and the remaining 30% would
likely choose to not start, or would not want their child to
smoke (Fiore et al., 2008)
Just 3-5% of unassisted quit attempts are successful,
compared with up to 20% success for those receiving
cessation counselling and medications (Fiore, Baker et al.,
2008)
Outcomes of evidence-based cessation interventions are
comparable with other chronic disease management
(hypertension, asthma, diabetes) (West and Shiffman, 2007)
Understand tobacco dependence as a
chronic, relapsing disease and the need for a
paradigm shift
14
Gender-Specific Smoking Prevalence
across the World
Canada
19%
17%
Mexico
37%
12%
Men
Women
Sweden
Russian Fed
Iceland
19%
70%
25%
25%
27%
27% France Germany
Portugal
37% Belarus
37%
41%
26%
27%
64%
US
Italy
31%
China
24%
26%
Spain
Iran
33%
59%
21%
36%
19% 24%
4%
31%
2%
Egypt
Kenya
India
25%
24%
28%
1%
1%
1%
Brazil
South Africa
20%
25%
13%
8%
Chile
42%
31%
Shafey et al. The Tobacco Atlas, 2009.
15
Philippines
39%
9%
Australia
28%
22%
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
16
Mortality Due to Tobacco
•
•
•
35,000-48,000 Canadians die from smoking per
year
– 100 infants/year
1 in 5 deaths are due to smoking
– Five times those due to car accidents,
suicides, other drug abuse, murder and HIV
combined!
1 in 2 smokers die from smoking related
diseases.
– 20% of smokers develop lung cancer
– 80% of lung cancer caused by smoking
WHO Report on the Global Tobacco Epidemic
17
http://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf
Differences by Province
Smoking Prevalence (Ages 15+)
CTUMS 2010 Wave 1 data
61%
36%
36%
20%
19%
17%
12%
18
20%
21% 24%
Territory data obtained using 2009 Canadian
Community Health Survey; Provincial data obtained
using CTUMS 2010 Wave 1 data.
16%
21% 19%
Current Canadian Adult Smokers
(15+) by Province, 1999 & 2009
35
30
25
20
1999
15
2009
10
9%
5
0
BC
AB
SK
MN
ON
QC
NB
NS
NF
PEI
Ontario, Alberta, Nova Scotia, and PEI reduced by 9% in 10 years
19
CTUMS, 1999 and 2009 Annual data
Tobacco Use in Ontario
20
Gender Differences
Male
Female
Smoking rates
19%
16.0%
Cigarettes per
15.8
12.9
day
Current teen
14.9%
10.9%
smokers (15-19)
Men aged 23-24 have the highest smoking
rate (28.9%)
21
CTUMS, 2009 Annual data
Levels of Interventions
•
•
•
22
Minimal / Brief Contact
– Delivered during the course of a regular
health care encounter in less than 3 minutes.
i.e.: 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
Brief Cessation Interventions:
The “5As”
– Ask about tobacco use
– Advise to quit
– Assess willingness to make a quit
attempt
– Assist in quit attempt
– Arrange follow-up
Fiore et al. 2008.
23
Quitting Smoking at any Age
Can Increase Life Expectancy
Increased Life Expectancy
Age stop smoking by
Life years gained
<30 years
10
<40 years
9
<50 years
6
<60 years
3
Quitting smoking before the age of 30, normal life expectancy
Doll R et al. 2007
24
Effective Amount of Contact Time
Total Contact Time
Estimated Abstinence Rate
None
11.0 %
1 – 3 minutes
14.4 %
4 – 30 minutes
18.8 %
31 – 90 minutes
Optimal
Intervention
Time
26.5 %
91 – 300 minutes
28.4 %
> 300 minutes
25.5 %
Need to consider resources available
Fiore et al., 2000
25
Environment Summary
1
You are now able to describe the prevalence
of tobacco use on a national and international
level by gender and among some special
populations, explaining why clinicians play a
critical role in implementing tobacco cessation
interventions.
26
2
BEHAVIOUR
Behaviour
2
Learning Objectives
At the end of Module 2 you will be able to:
1.
2.
3.
28
Enhance clients’ motivation to quit smoking
Implement a structured, adaptable cognitive
behavioural approach to smoking cessation
Integrate cessation interventions into your clinical
practice
Assessing
Tobacco
Dependence
Assessment
•
Components of Assessments
– History of smoking and quit attempts
– Level of nicotine dependence
– Withdrawal
– Reasons for smoking, reasons for wanting to quit
– Social environment
– Co morbidities – psychiatric, and/or other
substance use
– Intrinsic motivation and self-confidence
– Client’s goals, views of treatment, preference for
treatment
Abrams et al, 2007
30
All Smokers Benefit From
Proactive Assistance to Quit
 Motivation to quit does not predict response to
treatment
 Motivation can increase when effective
treatment is offered
 Smokers with low motivation can achieve high
continuous abstinence rates
 Irrespective of motivation, all smokers should
be actively offered assistance to quit
31
What is Motivational
Interviewing?
2002: “A directive, client-centred style of
counselling that helps clients to explore and
resolve their ambivalence about changing.”1
2009: “Is a collaborative, person-centered
form of guiding to elicit and strengthen
motivation for change.” 2
32
1.
Miller and Rollnick (2002). Motivational
Interviewing (2nd ed), p. 25
2.
Miller (2009). Ten Things that MI is Not
The Spirit of Motivational
Interviewing
33
•
Ambivalence is a normal human condition
•
Underlying spirit: collaborative, evocative,
supporting autonomy
Change as a Process
34
The Stages of Change
?
Precontemplation
Contemplation
Action
Maintenance
Prochaska and DiClemente, 1984
35
Preparation
Stages of Change
•
•
•
•
People do not move in a linear fashion
through the cessation process
Stages are arbitrary
May misguide clinicians to diagnose
clients at a certain level – too rigid
BUT: if you consider these points when
using the model it can be one of many
helpful tools to use
West (2005)
36
Change is not
something you do
to people, but
with people.
37
DSM-IV Diagnostic Criteria for
Nicotine Dependence
In the DSM-IV 3 or more of the following criteria are
required for a diagnosis of Nicotine Dependence:
1. Tolerance
2. Withdrawal. Requires daily use for at least several
weeks. A minimum of 4 withdrawal symptoms are
required. The withdrawal symptoms must “cause
clinically significant distress or impairment in social,
occupational, or other important areas of functioning.”
3. The substance is used in larger amounts or over a
longer period than was initially intended.
38
DSM-IV Diagnostic Criteria for
Nicotine Dependence (2)
4. Unsuccessful efforts to cut down, regulate, or
discontinue use.
5. A great deal of time spent obtaining the substance,
using the substance, or recovering from its effects.
6. Important social, occupational, or recreational
activities may be given up or reduced because of
substance use.
7. Substance use continues despite the individual's
realization that the substance is contributing to a
psychological or physical problem.
39
DSM-IV Criteria Dependence
Persistent desire or inability to stop
Most smokers want to stop, fewer than 5%
of unassisted attempts last a year or more
Continued use despite harmful
consequences
Most smokers are aware of health risks and
want to stop because of them, but feel
unable to do so
Withdrawal syndrome
Experienced by majority of smokers
Use of more of the drug or use for
longer than intended
40
Fast Facts: Smoking Cessation, Robert West and Saul
Shiffman, 2nd edition 2007
Many smokers try to cut down but cannot
maintain reduction; many learning to smoke
believe they will stop before the damage is
done but few manage to do so
DSM-IV Criteria Dependence (2)
41
Important activities forgone because
of the drug
Heavily dependent smokers may give up or
interrupt activities in non-smoking areas
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
Criterion related mainly to illicit drugs or
those that impair function (intoxicating
drugs)
Fast Facts: Smoking Cessation, Robert West and Saul
Shiffman, 2nd edition 2007
Daily Diary - Baseline
Think back to the last week starting today and make a note
when you engaged in the current behaviour(s).
Date
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
42
Behaviour
Describe the situation (e.g., were you
alone or with others, at home or in a social
setting, etc.)
Thoughts and Feelings (What
were you thinking and feeling in
this situation?)
Assessing Our Clients
•
43
Importance of Assessing
– Builds alliance / relationship – basic
ingredient of treatment
– Big picture of client
– Identifies co-occurring issues
– Opportunity to educate client –
“teachable moments”
– Ongoing process
– Collaborative approach
Assessments
Seven Key Components
1.Level of nicotine dependence/ severity of
withdrawal
2. Motivation
3. Past quit attempts and smoking history
4. Co- morbidities
5. Reasons for smoking, environment, triggers,
reasons for quitting
6. Social environment supports and barriers
7. Smokers’ preference
44
Assessment Components
1. Level of nicotine dependence/
withdrawal
•
•
•
45
Withdrawal symptoms, what happens when they
don’t smoke or are unable to smoke?
How much do they smoke presently?
Menu of tools (addressed in the next section)
Withdrawal Symptoms
•
Withdrawal symptoms can predict lapse and
relapse after cessation attempt
(Killen & Fortman, 1997; Shiffman et al, 1997)
•
Can help determine if client needs a
withdrawal management plan including
pharmacotherapy
The Tobacco Dependence Treatment Handbook, 2007
46
Nicotine Withdrawal Symptoms:
Symptoms
Duration
Prevalence
Irritability / Aggression
< 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%
Slide Source: TEACH, CAMH, 2009
47
Assessment Components
2. Motivation
•
•
•
•
48
What brought this person in?
Urgent issues (i.e. pregnant, COPD, transplant
lists)
May need to modify assessment depending on
client’s situation
Reasons for wanting to quit (why now?)
– External or internally motivated
Assessment Components
3. Past quit attempts and smoking history
•
49
When did they start smoking, using tobacco
products? Daily smoking?
– How long? How much? How many quit
attempts?
– Longest time quit?
– What have they tried? Review use of
medications and supports
Assessment Components
4. Co-morbidities
Other substance use / mental health issues
– Can have an impact on treatment planning
– Do they see a connection between their
other issues and smoking?
•
Medical issues / medications
– Will these have an impact on quit
attempts?
– Sometimes small adjustments in
medication can shift a client’s attitude
towards taking NRT
– Are they motivators or stressors?
50
Assessment Components
5. Environment, triggers,
reasons for smoking
– Identify high-risk
situations and triggers
to smoking
– What led to relapse?
– What does their
environment look like?
51
Helping to Define Triggers (5)
Asking the Client:
“ Can you identify 3 times in your daily
routine when you are 100% certain that you
will smoke?”
1.
2.
3.
52
________________________________
________________________________
________________________________
Assessment Components
6. Social Supports and Barriers
• What supports do they have in place?
• What is smoking status of friends, family, colleagues?
•
•
•
53
What in their environment perpetuates their smoking?
Is this a good time to quit or reduce?
How does stress affect their smoking? Their quitting?
Assessment Components
7. Smoker’s Preference
•
•
54
What are the client’s goals around smoking?
Resources / coping skills
– Client’s perception of self-efficacy
– Learnings from past quits,
– What are their preferences, expectations,
timelines around treatment?
– What other stress management techniques do
they utilize?
– What are the client’s strengths?
Tools / Scales to Consider
–
–
–
–
–
–
–
–
–
–
–
55
Fagerstrom Test for Nicotine Dependence
Heaviness of Smoking Index
Beck Inventory of Depression
Beck Anxiety Inventory
Why you Smoke Scale
Reasons for Quitting Questionnaire
Minnesota Withdrawal Scale
QSU – Questionnaire of Smoking Urges
Cigarette Withdrawal Scale
Coping with Temptations Inventory (CWTI)
Smoking Consequences Questionnaire
Behaviour
Change
Roadmap:
THE 4 POINT
PLAN
4 steps to stopping destructive
behaviours and leading a healthier life:
1.
2.
3.
4.
57
STRATEGIZE
TAKE ACTION
OPTIMIZE
PREVENT RELAPSE
(PERSEVERE)
Setting the Stage
•
Important aspects to consider
– Quitting is a process
– Automatic behavior: not always a conscious process
– A pack/day = 110,000 hand to mouth repetitions/year
– Linked with many behaviors: meals, alcohol, waking
up, coffee, environment – group homes, smoking
rooms in hospitals
– Linked with social relationships: breaks at work,
parties, friends houses
58
Step 1:
STRATEGIZE
1. Strategize
– Can take 1 session or can happen over several
– Involves developing a quit plan:
→ Tracking
→ Quit
smoking
date
→ Triggers, coping skills, plan for high-risk
events
→ Problem solving and coping skills
→ Support plan
→ Pharmacotherapy plan
60
Strategize: Psychological
•
•
61
Identify all positive supports
– Personal - partner, family, friends, colleagues
– Professional – physician, pharmacist, dentist,
nurse, etc
– Other support – Smokers’ Helpline, groups,
websites, self-help
Identify all negative influences
– Other smokers (partner, family)
– People who don’t want client to quit smoking
– Unhelpful “encouragement” to quit
Strategize – Cognitive/Affective
•
•
•
•
•
62
Personal relationship with cigarettes
Describe cigarettes as friend or lover
Can experience sense of loss when quitting
Help reframe this
thinking… abusive friend
or lover
Acknowledge these
emotions
Strategize – Behavioural
•
•
•
•
•
63
Relaxation strategies
Physical activity
Groups
Rewarding accomplishments
Tracking sheets / Self-monitoring
– Increase awareness of smoking behaviour
– Identify triggers, challenges
– Suggest which cigarettes will be easy and which will be
more difficult
– Begins to break the automatic smoking behaviour and
possibly reduces the number of cigarettes smoked
Strategize - Environmental
•
64
Smoke-free environments
– Make home and vehicle smoke-free
– Explore areas of home to restrict smoking
behaviour if entire home cannot go smokefree
– Work environment – avoiding smoking areas
– Other
Strategize - Biological
•
65
Pharmacotherapy
• If client is interested in medications, refer to
physician/pharmacist or provide information
• How much do they know about what is
available?
• What are the pros and cons of
pharmacotherapy?
• Who will help monitor this part of the quit plan?
Reasons for Change
Making a commitment to meeting your goal is important to
your success. Sometimes, it’s easy to forget why you’re
making the change, so write down your reasons and use this
as a reminder to yourself when things seem tough!
The most important reasons why I want to change are:
1
____________________________________________________________
2
____________________________________________________________
3
____________________________________________________________
66
Decision to Change Worksheet
Changing my current
behaviour
Benefits
Costs
67
Continuing to behave in the
same way
Strategize – Set a Goal
•
Setting a quit date:
• Provides specific date/goal to work toward
• Prevents delay in quitting
• Allows time to reduce, practice, refine quit
plan
• At a minimum, plan to meet with client 1 – 2
weeks before quit date and 1 – 2 weeks
after quit date
68
Goal Statement
The behaviour I want to/need to change is:
What is your goal now?
START DATE:
ACHIEVEMENT DATE:
69
Readiness Ruler
People usually have several things they would like to change in their lives –
this may be only one of those things. Answer the following three questions
with respect to the goal you have set.
How important is it to change this behaviour?
0
1
2
3
4
5
6
7
8
9
10
How confident are you that you could make this change?
0
1
2
3
4
5
6
7
8
9
10
9
10
How ready are you to make this change?
0
70
1
2
3
4
5
6
7
8
For Reflection: “Readiness Ruler”
What are 3 reasons you are at _____ and not zero?
1.
2.
3.
71
Hands-On Practice!
•
•
•
•
72
Think of a behaviour that you would like to change –
something you are comfortable sharing with a small
group
Examples could include: exercising more, healthy eating,
etc.
Take a few minutes to complete the Reasons for
Change, Decisional Balance, and Goal
Statement/Readiness Ruler
Then get together in groups of 3-4 people to discuss: (1)
What was this exercise like? (2) What impact did this
exercise have on your understanding of the issue you
are considering changing? (3) How might you use these
tools with your clients?
STRATEGIZE
Identifying
Barriers
and Risky
Situations
Identifying Barriers and
Solutions to Change
Possible Barriers:
74
Proposed Solutions:
© CAMH/TEACH Project
Step 2:
TAKE
ACTION
Take Action
• Discuss problems and potential strategies
• Changes in mood – what support is
needed?
• Withdrawal symptoms – re-assess
pharmacotherapy plan
• Low motivation – decisional balance, review
reasons to quit
• Weight gain – recommend physical activity,
healthy eating, additional support
• Lapses/slips – explore
76
Take Action (2)
•
•
•
•
•
•
77
Continue identifying triggers, stressful
situations
Continue self-monitoring
Maintain smoke-free environments
Can be one session or several sessions
Reset quit/reduce date if needed
Congratulate your client for coming back
Triggers and Consequences
•
•
•
•
•
78
Identify high-risk situations
Describe high-risk situation
Describe types of triggers usually
associated with the situation
Describe the types of consequences
associated with the situation
How often does this type of situation
occur?
Triggers and Consequences
Worksheet
High-risk situation: _______________________
1. Briefly describe one of your most serious high-risk situations.
2. Describe as specifically as possible the types of triggers usually
associated with this situation.
3. Describe as specifically as possible the types of consequences usually
associated with this situation (immediate and delayed consequences, and
positive and negative consequences).
4. How often did this type of situation occur in the past year? What
percentage of your total behaviour over the past year occurred in this type
of situation? _____________%
79
Triggers and Coping Skills – Sample Plan
Triggers
80
Coping Skills
Smoke with colleague
every day at breaks
Tell colleague I am
quitting
After meals
Chew 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
3 Options to Cope with Triggers
1.
2.
3.
Avoid the triggers or situations
Change the trigger or situation
Find an alternative or substitute
for the cigarette in response to the
trigger or situation
81
Example: Getting together with friends
on Saturday night
•
Avoid the triggers or situations
– Miss this event while I’m trying to quit smoking
•
Change the trigger or situation
– Ask friends to smoke outside b/c I am quitting
•
Find an alternative or substitute for the cigarette
– When someone lights up, get support from other friends
– Get up and get glass of water or move to another part of
–
82
the room
Might use nicotine gum or inhaler
Change Plan Worksheet
The changes I want to make are…
The most important reasons why I want to make these
changes are…..
The steps I plan to take in changing are…
The ways other people can help me are…
I will know that my plan is working if…
Some things that could interfere with my plan are...
83
Step 3:
OPTIMIZE
YOUR PLAN
Doing a 360:
•
•
SOCIAL SUPPORTS (FAMILY MEMBERS,
FRIENDS, COLLEAGUES)
PROFESSIONALS ( MD, RN, PHARMACIST,
OTHERS)
•
•
•
85
Asking for Feedback
FEEDBACK ON MY PLAN?
THINGS MISSING?
WATCH FOR SABOTEURS AND
ENLIST SUPPORTERS
Step 4:
PREVENT
RELAPSE
(Persevere)
“ A Slip is Not a Fall ”
Relapse Prevention
•
75% relapse
within 4 – 52
weeks
87
Song et al., (2009)
A meta-analysis of 49 trials involving
cognitive-behavioural coping strategies
for smoking relapse prevention
interventions indicates motivated
quitters benefit from coping skills
training after the first week of quitting
A Perspective for Clients
A Lifetime of smoking
AGE 13
AGE 53
25 cig/day x 40 years = 365,000 cigarettes
4,380,000 hand to mouth repetitions
40 years of smoking
88
Quit
attempt
If I were to relapse...
…it would most likely be in the following situation:
What coping strategies could I use to avoid this
relapse?
89
Prevent Relapse
•
If the client has quit or reduced
•
•
•
•
•
90
Congratulate on changes made
Review benefits
Identify future challenges and plan to cope
Pharmacotherapy
Engagement
Prevent Relapse (2)
•
91
If client had slips/relapsed:
– Assess what happened
– What can be done differently?
– What worked?
Example: Getting Together with
Friends on Saturday Night
•
Avoid the triggers or situations
– Miss this event while I’m trying to quit smoking
•
Change the trigger or situation
– Ask friends to smoke outside b/c I am quitting
•
Find an alternative or substitute for the cigarette
– When someone lights up, get support from other friends
– Get up and get glass of water or move to another part of
the room
– Might use nicotine gum or inhaler
92
Prevent Relapse (3)
•
•
•
•
Pharmacotherapy – long term use for those
that would benefit
Staying engaged in treatment / counselling /
groups when possible
What other supports will remain available
beyond treatment?
Planning for relapse
– What situations/triggers might lead to a slip or
relapse?
– Is there a plan on how to deal with those
situations?
93
Revisiting the Decision to
Change Worksheet
When you started the change process, you completed a “Decisional
Balance” of anticipated costs and benefits of changing and of continuing
the behaviour in the same way. Now that you have made some changes,
complete the decisional balance again noting the actual costs and
benefits that you have experienced, as well as things that you didn’t
anticipate as costs or as benefits. Then go back and compare your
responses with your previous Decisional Balance.
Changing my current
behaviour
Benefits
Costs
94
Continuing the behaviour
in the same way
Readiness Ruler
Now that you have successfully made some changes, where would you rate the
importance of sustaining these changes? How confident do you feel now in
maintaining change? How ready are you to continue the journey of change? After
you have completed this sheet, go back and compare your responses with the one
you completed previously.
How important is it to change this behaviour?
0
1
2
3
4
5
6
7
8
9
10
How confident are you that you could make this change?
0
1
2
3
4
5
6
7
8
9
10
9
10
How ready are you to make this change?
0
95
1
2
3
4
5
6
7
8
Concluding Thoughts on
Relapse Prevention
•
•
•
96
Follow-up calls
– Evaluation and counselling calls
How can the client re-engage quickly in treatment if he/she
relapses?
What are the red flags/warning signs that a client might
relapse?
– “One won’t hurt”
– “I’m sure I can smoke socially now that I’ve quit”
– “I’m stressed. Just this once to help me get through this”
– “I’ve been quit for long enough that I have control over
this”
Current Motivation and Next Steps
Where were you when you started this process,
and where are you now?
What do you need to do to continue to make
positive changes?
What is your next step?
97
Additional resources that can
support me…
98
Even people who quit
intermittently have substantial
health benefits over those who
continue to smoke.
99
Behaviour Summary
2
In your practice you are now equipped to
enhance clients’ motivation to quit smoking
and implement a structured, adaptable
cognitive behavioural approach to smoking
cessation, while better understanding the
physiological responses to the addictive
properties of tobacco.
100
3
MEDICATION
Medication
3
Learning Objectives
At the end of Module 3 you will be able to:
1.
2.
3.
4.
102
Understand the effects of tobacco and nicotine on
the brain
List pharmacotherapies that increase the odds of
quitting
Discuss or recommend cessation medications with
your clients
Integrate cessation interventions into your clinical
practice
Smoking as an
Addiction
What are Tobacco and Nicotine?
•
Tobacco - plant that
contains nicotine
– Two kinds: Traditional
and Commercial
•
Nicotine - one of the
major addictive
components in
tobacco
Nicotine is not known to lead to any diseases such as
COPD or cancer. It is the 4,000 other chemicals in cigarette
smoke that contributes to these diseases.
104
Tobacco and Carcinogens
•
More than 60
carcinogens are in
cigarette smoke
•
A minimum of 16
carcinogens are in
unburned tobacco
Hecht (2003); Freiman et al. (2004); US Surgeon General’s Report 1989.
105
Tobacco is a legal product.....
Nicotine
Insecticide
Stearic Acid
Candle Wax
Toluene
Industrial
Solvent
Ammonia
Toilet Cleaner
Cadmium
Batteries
Hexamine
Barbeque
Lighter
Butane
Lighter Fluid
Paint
Methanol
Rocket Fuel
106
Carbon
Monoxide
Arsenic
Poison
Methane
Sewar Gas
Acetic Acid
Vinegar
Anatomy of a Cigarette
Side stream smoke
– 800x toxic
Tobacco: Leaf
Reconstituted
Puffed
107
Filter: Hold back tar
Mild: more holes in filter
Paper: burn
rings, titanium
oxide
accelerant
108
‘‘Why do people smoke . . . to relax; for
the taste; to fill the time; something to
do with my hands. . . . But, for the most
part, people continue to smoke because
they find it too uncomfortable to quit’’
Philip Morris, 1984
109
Philip Morris. Internal presentation. 1984, 20th March; Kenny
et al. Pharmacol Biochem Behav. 2001; 70: 531-549.
Pharmacological
Approaches to
Smoking
Cessation
Treatment
Biological Aspects of
Addiction
– A biological need for a drug that arises because
of physiological adaptation to the presence of a
drug in the body and brain
– Body becomes dependent on the drug to be able
to function normally
– Stopping the drug leads to a withdrawal
syndrome which is unpleasant and motivates
person to continue using
– Not the complete picture
111
Fast Facts: Smoking Cessation, Robert West and Saul
Shiffman, 2nd ed, 2007
Percentage of
Relapsed
at
Abstinent
Still
Percentage
6 Months Still Abstinent
Quitting Smoking Unaided:
Analysis of 4 Studies
100
80
60
40
3 - 5%
20
0
0
50
100
150
200
Days Since Quit Date
Long-term smoking abstinence in those who try to
quit unaided = 3%–5%
112
Hughes JR et al. (2004)
Guideline #7 for Treating
Tobacco Addiction
“Counseling and medication are effective when
used by themselves for treating tobacco
dependence.
The combination of counseling and medication,
however, is more effective than either alone.
Thus, clinicians should encourage all individuals
making a quit attempt to use both counseling
and medication”.
Fiore et al. 2008
113
Guidelines for Treating Tobacco
Addiction
Clinicians should encourage the use of medication by all patients
attempting to quit smoking except when medically contraindicated or with
specific populations for which there is insufficient evidence of effectiveness
(i.e., pregnant women, smokeless tobacco users, light smokers, and
adolescents).
Six (in Canada) first-line medications that reliably increase quit rates:
– Bupropion SR
– Nicotine gum
– Nicotine inhaler
– Nicotine lozenge
– Nicotine patch
– Varenicline
Consider the use of certain combinations of medications.
USDHHS, 2008; Fiore MC & Jaén CR.,2008
114
Costs of Smoking vs.
Pharmacotherapy
One Week Supply:
115
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
Nicotine Replacement Therapy
•
•
•
•
•
116
Provides the body with nicotine to help minimize
withdrawal symptoms and cravings
Eliminates toxic substances one gets from
cigarettes
Shown to almost double quit rates
Most effective when combined with counselling
Can be used to help “reduce” smoking
– Can start before quit date
Who Should Not Use NRT?
•
•
•
•
117
Not everyone needs NRT
Not everyone can afford NRT
Studies show that NRT is not effective for
those that smoke 10 cigarettes or less or are
non-daily smokers
Need to assess case by case
– Discuss with client
– Use tools to assess dependence
Medications for Quitting Smoking
Medication
Nicotine
gum
Nicotine
lozenge
Nicotine
patch
Nicotine
inhaler
Bupropion
Varenicline
Treatment
length
1-3
months
12 weeks
8-12 weeks
12-24
weeks
7-12 weeks
12 -24weeks
•
•
Main side
effects
Dosage
Effectiveness
at six months
or longer†
(OR [CI])
118
•
Upset
stomac
h
Hiccup
s
•
Mouth
irritation
Irregular
heartbeat
•Disturbed
sleep
(insomnia,
abnormal/viv
id dreams)
Irritation
of throat
and nasal
passages
•
Heartburn
•
Hiccups
Site rash
(pruritis
erythema,
burning)
2 mg, 4
mg
2 mg, 4 mg
7, 14, 21 mg
5, 10, 15 mg
6-12
cartridges
per day
150-300
mg/day
0.5 mg qd to
1 mg bid
1.66
(1.521.81)
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)
Shiffman et al (2002)
Coughing
•
Dyspepsia
Nausea
•
Adapted from Le Foll & George
(2007),
•
•
Nausea
•Sleep
disturbances
•Constipation
•Flatulence
•
Nausea
•
Sneezing
insomnia
•
•Headache
•
•
* 4mg, effectiveness
at 6-weeks
•Dry
mouth
Ask about tobacco use: How much do you smoke? 0 - ___ cigarettes per day (cpd)?
(one large pack = 25 cpd, one small pack = 20 cpd)
Yes
Algorithm for Tailoring Pharmacotherapy for Smoking Cessation1,2
Advise: As your physician, I am concerned about your tobacco use,
and advise you to quit. Would you like my help?
Motivational
Interviewing
Assess the 5 R’s:
Relevance
Rewards
Risk
Roadblocks
Repetition
No
Cold
Turkey
No response
Has bupropion/NRT failed? N
Is weight gain a concern? N
Want to quit within 7 days? Y
= NRT
(Gum, Patch, Lozenge or Inhaler)
No
Yes
Low importance or confidence (≤ 5)
High importance or confidence (>5)
Assist in Quit Attempt: Would you like to quit abruptly?
Have you tried quitting cold turkey?
Yes
No
Yes: Pharmacotherapy
options
Has NRT failed?
Y/N
Is weight gain a concern? Y
…History of seizures? N
...History of mental illness? N
…Eating disorder?
N
...Allergic to bupropion?
N
...Previous non-responder? N
Want to quit within 7 days? N
= Bupropion SR
Has bupropion/NRT failed? Y
Is weight gain a concern? N
...History of seizures?
N
…History of mental illness?
N
…Eating disorder?
N
...Allergic to varenicline? N
...Previous non-responder? N
Want to quit within 7 days? N
= Varenicline
Choose the following combinations:
1. Two or more forms of NRT
a. patch (15mg) + gum (2mg)
b. patch + inhaler
c. patch + lozenge
2. Bupropion + form of NRT
a. Bupropion + patch
b. Bupropion + gum
No Varenicline with NRT
Arrange Follow Up
1. Monitor carefully
2. Consider contraindications
3. Consider comorbidities and specific
pharmacotherapy
4. Consider dual purpose medications
5. If after 4 weeks no response,
consider alternative 1st line
medications.*
@ 4 weeks
Partial response
Consider combination
pharmacotherapy, based on:
1. failed attempt with
monotherapy
2. breakthrough cravings
3. level of dependence
4. multiple failed attempts
5.experiencing nicotine withdrawal
Assess Readiness: Given everything going on in your life, on
a scale of 0-10, where 0 is lowest…
How important is it for you to quit smoking?
How confident are you that you can quit smoking?
Developed by Peter Selby, MBBS, CCFP. This algorithm is based on: Bader, 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.
Reduce to Quit (RTQ)
Step 1: (0-6 weeks)
- Smoker sets a target for no. of cigarettes per day to cut down
and a date to achieve it by (at least 50% recommended)
- Smoker uses gum to manage cravings
Step 2: (6 weeks up to 6 months)
- Smoker continues to cut down cigarettes using gum
- Goal should be complete stop by 6 months
- Smoker should seek advice from HCP if smoking has not
stopped within 9 months
Step 3: (within 9 months)
- Smoker stops all cigarettes and continues to use gum to relieve
cravings
Step 4: (within 12 months)
- Smoker cuts down the amount of gum used, then stops gum use
completely (within 3 months of stopping smoking)
*N.B. for 2nd line medications (clonidine and nortriptyline), see
guidelines.
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
120
How to Use the Patch
•
•
•
•
•
•
•
121
Apply to clean dry area above the waist,
rotating site daily
Remove old patch before applying new one
Do not use lotion, moisturizing soap
Touch only small corner of adhesive
Ensure complete adherence of patch
Wash hands in water after application
Discard old patch out of reach of children,
animals – can be harmful
Nicotine Gum
•
•
•
•
•
•
122
Provides body with nicotine for 20-30 minutes
2 & 4 mg doses
Responds to the immediate urge to smoke
Oral gratification
Must be able to chew gum (i.e. no dentures,
TMJ)
Potential side effects
– Upset stomach, hiccups
→ Chewing too fast: review
proper use of gum
How to Use Nicotine Gum
2 mg
Use in combination with
patch as a breakthrough
medication; typically if smoke
<pack/day
4 mg
Use in combination with
patch or alone; typically if
smoke > pack/day
 Chew one piece at a time, no more
than 1 per hour
 Use every hour – if not in
combination with patch
 Up to 20 pieces per day as needed
123
How to Use Gum (2)
•
•
•
•
•
124
Chew and park in between teeth and
cheeks
Absorbed via buccal mucosa
Repeat chew every minute or so
Each piece lasts approximately 30 minutes
Do not chew within 30 minutes of
caffeine/acidic products
“Reduce to Quit” (RTQ) Approaches
Who?
Smokers not ready or unable to quit abruptly
Goal?
50% reduction in daily cigarette consumption
between 6 weeks and 4 months of treatment
How?
Self-titrate to the level of nicotine to reduce
withdrawal symptoms. A reduction of
cigarette consumption should be continued
until complete cessation can be attempted
When?
125
Craving to smoke in order to prolong smokefree intervals for as long as possible
RTQ: Using NRT Gum
How long? • If such a reduction has not been achieved by
4 months, the patient should be further
counselled and/or re-evaluated.
• A quit attempt should be made as soon as
the patient feels ready – but not later than 6
months after the start of treatment.
• Regular use of the gum beyond 12 months in
the Quitting Gradually program is generally
not recommended.
How much?
126
Maximum of 20 pieces gum / day
Shiffman, Ferguson, & Strahs, 2009
Nicotine Inhaler
•
•
•
•
•
Small, cigarette-shaped inhaler
Satisfies sensory and ritualistic
aspect of smoking
One cartridge contains 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%)
127
How to use the Nicotine Inhaler
•
Single cartridge equivalent to 4-5 cigarettes
- or 20 minutes of continuous use
•
•
•
•
128
Puff like cigar, not deeply into the lungs
May notice a burning, warm or cool sensation
when inhaling – OK unless it becomes
bothersome
Clean inhaler on a regular basis with soap and
water
Can use up to 6 cartridges/day – use as needed
Nicotine Lozenge
•
•
•
•
•
•
•
•
129
1 mg and 2 mg dosages
Max of 15 mg / day should be used
Slowly suck until strong taste is noticed
Rest lozenge between cheek and gum
Wait 1 minute or until taste fades
Repeat sucking
Each lozenge takes about 30 minutes to consume
Use only 1 at a time
Dependence Potential of
Nicotine Delivery Devices
•
•
130
Dependence potential tends to correlate
with time to peak concentration
Because the nicotine is delivered
differently, more slowly and at lower
doses in NRT, it is significantly less
addictive then smoking
Le Houezec, 2003
Dependence Potential of
Nicotine Delivery Devices
Reaches brain within 15-20 secs for
non-daily and less dependent and 30
secs for daily, dependent smokers
0
1 hr
Gum, lozenge,
inhaler peaks in 20
– 30 minutes
131
Rose et al., 2010
2 hrs
Patch peaks
in 2 – 6 hrs
Effectiveness and Safety of NRT
•
•
•
•
•
Recent study of 2767 predominantly middle-aged
smokers not ready to quit: half were given NRT
(gum, inhaler or choice of therapy) and half were
given placebo for up to 18 months
Primary Outcome was six months of sustained
abstinence from smoking
Results overwhelmingly positive
NRT was well tolerated
Those using the NRT achieved six months of
sustained abstinence & most lasted beyond 1226 months
Moore et al 2009;
132
Cardiac Disease and NRT
•
•
•
NRT is safer than smoking
Cigarette smoke causes
– Increase in heart rate
– Blood pressure
– Decreased clotting time
– Polycythemia
NRT has not been associated with any increase in
cardiac events (heart attack, stroke)
•Hubbard,
133
R, et al. 2005
Long-Term Use of NRT
•
•
•
•
134
Most of the time people who use NRT to stop smoking
gradually reduce or stop NRT medicine without
difficulty
May use NRT long-term if needed
– Appropriate way of reducing the harm caused by
smoking
– Using NRT is always preferable to using tobacco
products
Long-term use of NRT products can help in reducing
morbidity and mortality
Preliminary evidence suggests that long-term use of
oral NRT may be associated with certain kinds of
cancer (Gemenetzidis et al., 2009)
Assessing Readiness to
discontinue NRT
135
•
Have you been in a situation in which you
would normally smoke but have been able
to refrain from smoking with ease?
•
Have you ever forgotten to put on your
patch or use your inhaler/gum/lozenge?
Pregnancy and Youth - NRT
NRT should be considered in pregnancy
and for youth if the likelihood of smoking
cessation justifies the potential risk of
using it by the pregnant patient or youth
who might continue to smoke.
Benowitz et al, 2000
136
Bupropion
•
•
•
•
137
Originally designed to treat depression
Shown to double one’s chances of quitting
Shown to minimize weight gain associated with
quitting smoking
Contraindications
– Seizure history
– Active eating disorder
– MAOI Medications
– Using Bupropion, sensitivity to Bupropion
How To Use Bupropion
•
•
•
•
•
•
138
Prescribed by Physician, Nurse Practitioner or
Dentist
Dose 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
Varenicline
•
•
•
•
139
Oral medication to quit smoking
Reduces withdrawal and craving
Prevents pleasurable effects of
smoking
Varenicline is a partial agonist (α42
nicotinic acetylcholine receptor),
which partially mimics the effect of
nicotine
Varenicline:
Drug Interactions / Precautions
•
•
•
140
Concomitant use of nicotine replacement
therapy
– not expected to increase cessation
– will increase adverse drug reactions
Does not affect and is not affected by CYP450
enzyme system
Reduce dose in severe renal impairment
Important Safety Information
Regarding Varenicline
Boxed Warning:
•
Highlights important recommendations for healthcare professionals
regarding information related to neuropsychiatric adverse events.
•
A warning regarding rare reports of hypersensitivity reactions, such as
angioedema and serious skin reactions, including Stevens-Johnson
syndrome and erythema multiforme.
Unintentional Varenicline Exposure:
•
Recent retroactive study assessed cases where varenicline was
unintentionally ingested, most common side effects were gastrointenstinal
and neuropsychiatric
•
Vast majority did not require admission to hospital
Varenicline and Psychiatric Side-Effects:
•
•
141
No clear evidence associated with depression or suicidal thoughts,
however twofold increase of self harm cannot be ruled out.
Varenicline may be associated with increased aggression and acts of
violence towards others
2nd Line Medications
•
•
•
•
142
Use at physicians discretion (first- line medications
unsuccessful)
Not approved as smoking cessation aids
Clonidine
– Anti-hypertensive
– Helps to reduce withdrawal
Nortriptyline
– Antidepressant
– Two studies demonstrated increased
abstinence rates
The Future?
•
•
•
143
Selegiline – Parkinson treatment
Vaccines – prevent nicotine from
reaching the brain
Transcranial Magnetic Stimulation
Multiple Quit Attempts
May Be Necessary
– >70% of US smokers have attempted to 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
144
1.
2.
3.
Fiore MC et al. 2008.
Foulds J et al. 2004;9:39–53.
Grandes G et al. 2003;.
Cessation Objectives
1.
2.
145
Increase the number of quit
attempts
Increase long-term success of quit
attempts
Sometimes the doorway has to
be opened wider and held
open longer…
146
Medication Summary
3
You are now more able to recommend the
various pharmacotherapies available for
smoking cessation and reduction, and engage
your clients in discussion of if and how these
medications can play a role in their tobacco
interventions.
147
Workshop Summary 1 2 3
After this training you will find yourself more
familiar with the various components that
inform tobacco interventions, such as why
they are important for clinicians, enhancing
client motivation, the physical and
behavioural properties of tobacco addiction,
and various evidence-based treatments.
148
Learning Assessment 2
•
•
•
•
149
Please complete Learning Assessment 2
This is a self-reflection tool designed to
gauge whether your responses to the earlier
assessment have changed, and can be
used for you to track these changes
It is also an opportunity for you to set
practice objectives
This will not be collected
Course Evaluation
•
•
150
Please complete the course evaluation
which will help us improve future trainings
We will be collecting this!
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151
CAN-ADAPTT
Canadian Action Network for the Advancement, Dissemination and
Adoption of Practice-informed Tobacco Treatment
CAN-ADAPTT is a practice-based research network designed
to facilitate knowledge exchange in the area of smoking
cessation between practitioners, healthcare providers and
researchers. It includes
• Access to a dynamic set of
Tobacco Control Guidelines
For further information or to
register for free, please visit
www.can-adaptt.net
152
Tobacco Informatics Monitoring
System (TIMS)
http://tims.otru.org/
153