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Motivational Interviewing : A Workshop on Smoking Cessation Strategies
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Motivational Interviewing : A Workshop on Smoking Cessation Strategies

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Covered in this workshop presentation are the goals and techniques of motivational interviewing, with short practice exercises on slides 48 and 51, and strategies to help families become tobacco-free, ...

Covered in this workshop presentation are the goals and techniques of motivational interviewing, with short practice exercises on slides 48 and 51, and strategies to help families become tobacco-free, including pharmacotherapy options. An opportunity to practice the rest of the skills learned in this workshop is provided on slide 111.

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  • The Ask, Advise, Refer approach integrates the 5As into an abbreviated intervention that remains consistent with PHS-recommended guidelines. Ask ensures that parental and teen smoking are addressed using the tobacco dependence treatment guideline. Assistance includes motivational messaging and provision of pharmacotherapy. Refer includes quitline enrollment. Quitlines are telephone-based tobacco cessation services that provide callers with a myriad of services including educational materials, referral to formal cessation programs, and individualized telephone counseling. Referrals to the National quitline (1-800-QUITNOW) and local resources, in addition to discussing and prescribing pharmacotherapies, are effective strategies to help smokers quit.In our talk today, we will be focusing on the first two steps of the process- Ask, and Advise.The last step, refer, is what you can do with someone who is interested in quitting smoking altogether. Refer the person to the state’s Quitline (form can be obtained by contacting richmondcenter@aap.org), and BE SURE to follow up with the person at the next visit. Just asking how it’s going makes a big impression and reinforces that the person is not alone in their attempt.CITATION:Hall, N., Friebely, J., Ossip, D., Winickoff, J. (2009). Addressing Family Smoking in Child Health Care Settings. Journal of Clinical Outcomes Management, 16(8), 367–73.

Motivational Interviewing : A Workshop on Smoking Cessation Strategies Motivational Interviewing : A Workshop on Smoking Cessation Strategies Presentation Transcript

  • Promoting Smoke Free Homes: Counseling Patients and Their Families aboutSecond Hand Tobacco Smoke and Tobacco Use in the Primary Care SettingPARKS MEDICAL-LEGAL CONSULTING & RESEARCH “integrating medicine & law”
  • …dedicated to eliminating children’s exposure to tobaccoand secondhand smoke
  • Today’s Workshop• Motivational Interviewing 101: – Goals, techniques and PRACTICE! • We will break down MI and practice, taking a longer period of time to become comfortable with the language and techniques, breaking into groups of three • Effective MI can occur in just a few minutes! • Helpful techniques for all kinds of behavior change• Helping Patients and Families – Pharmacotherapy nuts and bolts
  • Learning Objectives• By the end of this session, participants will – Describe how to incorporate an assessment of SHS exposure into every provider visit – Apply Motivational Interviewing techniques to facilitate open conversations with parents or family members that smoke – Explain practical tips for smoking cessation and pharmacological agents available – Describe how to help families move towards a tobacco free home and car
  • The Health Effects of Tobacco Use Asthma Otitis Media Influences Fire-related Injuries to Start SmokingSIDsBronchiolitisMeningitis Childhood Infancy Adolescence Nicotine Addiction In utero Adulthood Low Birth Weight Stillbirth Neurologic Problems Cancer Cardiovascular Disease COPD
  • The Social Cycle of Tobacco Use Influences to Start Smoking: Media, Household Members, Peers Childhood Infancy Adolescence Alienation from peers In utero who don’t use tobacco Adulthood
  • The Economic Cycle of Tobacco Use Decreased lifetime earningsA pack-a-day smokerSpends over $2000/year Childhood Infancy Adolescence In utero Adulthood Increased likelihood of Living in poverty
  • 47 Years After the 1st Surgeon General’s Report – People Still Smoke!• 21% of US adults are smokers• More than 30% of U.S. children live with at least one smoker
  • Why Do People Use Tobacco?• Nicotine is physically addictive – Tolerance develops – Withdrawal symptoms occur• Nicotine is a potent drug, causing dopaminergic activation and CNS stimulation• Use is reinforced by social cues and habits
  • Youth Are Especially Susceptible• For many youth, symptoms of dependence develop before daily use begins, and can begin within a day after inhalation!• There is no minimum requirement of number smoked, frequency, or duration of use!
  • That First Puff…• The nicotine in 1-2 puffs occupies 50% of nicotinic receptors in the brain• A single dose increases – Noradrenaline synthesis in the hippocampus – Neuronal potentiation lasting > month (meaning that neurons discharge action potentials at lower threshold)
  • What Can We Do?
  • Principles of Tobacco Dependence Treatment • Nicotine is addictive • Tobacco dependence is a chronic condition • Effective treatments exist • Every person who uses tobacco should be offered treatment
  • Smokers Want to Quit• 70% of tobacco users report wanting to quit• Most have made at least one quit attempt• Cite health expert advice as important • Regardless of type! THIS MEANS YOU!
  • Pediatrician Intervention is Important• > 80% child exposure to tobacco in home is due to parental smoking• Pediatricians see 25% of the population of smokers through child visits – and smoking is highly heritable• Many parents see their child’s health care provider more often than their own (# QA increases with more episodes of advice)• Counseling interventions in the pediatric office setting have been successful: – Decreased number of cigarettes smoked and home cotinine levels – Increases in parent-reported smoke-free homes and parent-reported quit rates
  • Counseling 101• Patients and families expect you to discuss tobacco use• If counseling is delivered in a non-judgmental manner, it is usually well-received• Even small “doses” are effective - and cumulative! • Strength of Evidence = A
  • Counseling IS Effective• As little as 3 minutes of counseling doubles quit attempts and successes• Intensive counseling is more effective – Dose-response relationship• Most effective: – Problem-solving skills – Support from clinician – Active referral – Social support outside of treatment
  • How To Counsel
  • The 5 AsAsk about tobacco use and SHS exposure Advise to quit Assess readiness to quit Assist in quit attempt Arrange follow-up
  • The 5 As “2As and an R” Ask Ask Advise Assess Advise AssistArrange Refer
  • Ask: The Concept• Ask about tobacco use and SHS exposure at every visit – Include current tobacco use, SHS exposure – If appropriate, ask about tobacco use prior to and during pregnancy• Make asking routine, consistent, and systematic• Document as a “vital sign” – Use standardized documentation• Just asking can double quit attempts
  • We Can Learn Better Ways to Ask• “…if someone comes at you with an accusatory tone *you’re+ going to be defensive.”• “…putting me down about it doesnt help. If they talk down to me, making me feel small, it makes it so I dont want to quit. It…makes me feel bad.”
  • When We Don’t Ask in the Right Way…• We elicit social desirability bias• Parents may modify tobacco use reporting to avoid lectures – Not divulge “slips” – Underreport tobacco use – Modify where and when smoking occurs
  • Ask: How• Say: “Does your child live with anyone who uses tobacco?”• Avoid judgement – check your body language, tone of voice, the phrasing of the question• Avoid leading: “You don’t smoke, do you?”• Depersonalize the question
  • Ask: If No One Uses Tobacco• Explore: “You say no one smokes around your son. What does that mean?”• Congratulate and Document
  • Ask: If Someone Uses Tobacco• “Who is it?”• “How do they use tobacco?”• “Where do they smoke?”• “Is that inside the house?” – Many people perceive that smoking away from the children is sufficient to protect them… or that a fan is helpful…
  • If at First You Find No Smoking… ASK NEXT TIME!• Families who were initially identified as non-smoking on entry to a practice were not asked again about smoking status (in spite of a parent relapsing)• Child Care situations are often in flux, so repeat the full ASK step at all health care encounters…
  • Advise: The Concept• Ask for permission to make suggestions and offer help – “May I make a suggestion…?” – Offer help – not “rules”• Elicit ideas from the parent• Offer alternatives or preparatory steps, such as making the home and car tobacco free• Help the parent to set their own goals for behavior change
  • Is the Tobacco User Ready to Quit?• The Stages of Change model can help you figure out what to say and how to help• Regardless of what stage the parent or patient is in, provide information about cessation to all tobacco users
  • The Stages of Change Model Precontemplation Behavior change Contemplation occurs in stages – not all at once. RelapseReady for Action Maintenance Action
  • Requirements for Change X =Motivation Self-Confidence Commitment(Should I?) (Can I?) (Will I?)
  • Your Goal: Help the Tobacco User Take the Next StepHelp a precontemplator become a contemplator……a contemplator start to make plans……someone who relapsed become “ready for action”…And so on….
  • Motivational Interviewing 101
  • Clinician view of patient change• A clinician views patient health behavior change from two perspectives:1. Importance: a clinician has beliefs about health behavior change counseling and his or her role in the process2. Confidence: a clinician has expectations about the power of his or her skills to promote health behavior change
  • Low Importance - Low Confidence 10Importance Unaware or Cynical : “It’s not my role to counsel patients. Plus, it’s too difficult to do this kind of counseling.” 0 10 Confidence
  • High Importance - Low Confidence 10 Frustrated : “I believe it is important for me to help patients change, but I don’t knowImportance how to do it” 0 10 Confidence
  • Low Importance - High Confidence 10Importance Skeptical : “I could work with patients on behavior change, but it’s just not proven to work.” 0 10 Confidence
  • High Importance - High Confidence 10 Moving, Helping : “I believe it is important for me to work with patients on healthImportance behaviors no matter what the obstacles are.” 0 10 Confidence
  • Importance - Confidence 10 Frustrated : Moving, Helping : “I believe it is important “I believe it is important for me to help patients for me to work with change, but I don’t know patients on healthImportance how to do it” behaviors no matter what the obstacles are.” Unaware or Cynical : Skeptical : “It’s not my role to “I could work with counsel patients. Plus, patients on behavior it’s too difficult to do this change, but it’s just not kind of counseling.” proven to work.” 0 10 Confidence
  • The Challenge• People don’t follow physicians’ advice and recommendations – 50% don’t follow long term medication regimens – Many don’t follow advice to change health behavior• Patients often do not recall anticipatory advice given
  • Research has shown:• Clinician-patient interactions influence the behavior change process.• When given the tools to help motivate patients to change health behaviors, good doctors become even more effective.• When patients arrive at action plans that fit within their personal goals and values, change is more likely.
  • Motivational Interviewing (MI): Key Elements• Use key counseling skills (open ended questions, reflective listening, empathy)• “Roll with resistance” – The MI encounter resembles a dance rather than a wrestling match Assess importance and confidence• Develop discrepancy between the patient’s goals and current behaviors• Support patient’s change efforts
  • Overview of the MI Encounter• Set the agenda – Collaborative process• Use key counseling skills to understand the patient’s experience• Determine importance and confidence• Enhance importance and confidence• Elicit patient’s “change language”, reinforce it, and build on it• Help patient develop action steps
  • Agenda Setting• Elicit items patient wishes to discuss – “What were you hoping to talk about today?” – Always ask permission before discussing a topic• Raise items you wish to discuss and ask permission – “I’m concerned about your child’s frequent asthma attacks. Would it be okay if we talked about it today?”• Prioritize multiple concerns• Agree on what you’re going to talk about
  • Key Counseling Skills: Open-Ended Questions• Goal-understand meaning rather than collect facts• Use “How” and “What” questions – Caution: “Why” questions can sound judgmental• Examples: – Tell me about… – Could you help me understand more about… – What have you tried before? – How was that for you?
  • Key Counseling Skills: Reflective Listening• Listening is often considered the passive part of conversation• Reflective listening is an active process• Reflect the meaning of what your patient said• Every reflection opens a possibility – The patient may verify, correct, add to, or refine their message – The clinician can clarify, correct misinterpretations, and learn about their own assumptions and distortions
  • Key Counseling Skills: Reflective Listening (continued)• Stems: – It sounds like you… – So what I hear you saying is… – You’re wondering if… – You feel…and that makes you want to… – It seems like… – You are…
  • Practice Exercise 1: Open-Ended Inquiry & Reflective Listening Task: In groups of 3, practice using open-ended inquiry and reflective listening skills – Interviewer: Interview your colleague about something he/she has been motivated to do – Interviewee: Tell your story – Observer: Observe and jot down open-ended questions and reflections that the interviewer usesYou will have 3 minutes to conduct each interview, then get 2 minutes of feedback from observer, then rotate!
  • Key Counseling Skills: Expressing Empathy• Empathy: – Understand the experience of another at a deeper level – Acknowledge and value the other person’s perspective and feelings – Empathy communicates to your patient that what they say, think, and feel is important to you.• Empathy is NOT: – Sympathy - Shared suffering – Pity - A condescending relationship which separates physician and patient – Reassurance
  • Key Counseling Skills: Expressing Empathy• “You seem pretty frustrated”• “So you’re just not sure what to do next.”• “So you really want to change your eating habits, but its overwhelming because you’re not sure where to start.”• “Most people I know would feel anxious in that situation.”• “It sounds like deciding to take that first step is a little scary for you.”
  • Practice Exercise 2: Expressing Empathy Task: In groups of 3, develop an understanding of the interviewee’s perceptions about working with a challenging patient – Interviewer: Practice open-ended inquiry, reflective listening skills, and expressing empathy – Interviewee: Share your story – Observer: Observe and jot down examples of open-ended inquiry, reflective listening and empathic communicationYou will have 3 minutes to conduct each interview, then get 2 minutes of feedback from observer, then rotate!
  • Exchanging Information vs. Advice on Empty Ears• Exchanging information is different from advice, which is a one-way process• Always ask permission before giving information• Elicit-Provide-Elicit Process – ELICIT interest • “Would you like to know more about…?” – PROVIDE feedback neutrally • “What happens to some people is…Other people find…” – ELICIT the patient’s interpretation and follow it • “What do you make of this?” • “How do you see the connection between smoking and your health?”
  • Assessing Importance and Confidence• Goal: Understand how the patient feels and thinks about changing their current behavior• Strategy: Scaling questions• In order to move toward change, the patient may need to: – Further explore the importance of change – Build the confidence to undertake change – Enhance both importance and confidence
  • Assessing ImportanceNot at all 0 1 2 3 4 5 6 7 8 9 10 Extremelyimportant important• “On a scale of 0 to 10, how is important is it to you to _________ (make this change)?
  • • “What makes you say a 5?”• “What led you to say 5 and not zero?”• “What would it take to move it to a 6 or a 7?”• “What could I do to help you make it a 6 or 7?”
  • Strategies for Enhancing Importance: Examining Pros and Cons• Examining pros and cons gives a lot of information about how the patient views the issue (Ex.: all cons and no pros)• Patients often experience ambivalence about the value of change – There are costs and benefits to changing as well as staying the same – New behaviors can be hard to do• There are 2 ways of examining pros/cons: – Look at the current behavior – Look at change
  • Current Behavior ChangePros Pros“What are some of the good things about “What are some of the good things abouteating so much junk food?” changing the way you eat?”I like how it tastes If lose weight, will feel more attractiveGoing out with my friends-we like to hang out It would be easier to fit into the kinds of clothes Iat McDonalds want to wear I’d feel good about accomplishing itCons Cons“What are the not so good things about “What are some of the not so good things abouteating junk food?” changing the way you eat?”I don’t like how I look-I think its making me I’d have to think about what I can and can’t eatheavy and it also make my skin greasy all of the timeI can’t run as well as I used to, so I’m doing I’d have to give up my favorite junk foodbadly on my field hockey team It would be hard to go out with my friends How would you summarize both sides of what you hear?
  • Responding to Ambivalence• Return to a reflective statement• Double-sided reflection – “So, on the one hand…while on the other hand…”• Roll with resistance – Patient: “I know you expect me to quit eating all the things I like. I want to lose weight, but I don’t plan on sticking to some strict diet where you can only eat salad!” – Clinician: “A lot of people feel the same way you do when they start thinking about changing the way they eat. Tell me more about your concerns.”
  • Assessing ConfidenceNot at all 0 1 2 3 4 5 6 7 8 9 10 Totallyconfident confident • “On a scale of 0 to 10, how confident are you that you can _______ (make this change)?
  • • “What makes you say a 6?”• “What led you to rate your confidence 6 and not 2?”• “What would help you move your confidence from a 6 to a 7 or 8?”
  • Strategies for Enhancing Confidence• Recall times in the past when the patient has been successful making changes – Explore role of family and peers in supporting change – Affirm persistence-often many attempts• Break it down – Define small, realistic, and achievable steps• Identify specific barriers and problem-solve – “What might get in the way?” – “What might help you get past that?” – “Here’s what others have done.”
  • The Ingredients of Readiness to Change Importance (Why should I change?)Readiness Confidence (Can I do it?)
  • Change Talk• Change talk includes desire, ability, reasons, need – “I really want to start eating healthier” – “I’m sure that I can turn the TV off after school” – “I need to cut back on junk food because I am starting to gain weight” – “It’s important for me to take my asthma medicine”• Listen carefully for change talk throughout the interview• Acknowledge, appreciate, affirm, and express support for change talk
  • How Do We Help the Patient Turn Interest Into Action?• Most people need help picking one do-able step that’s not too big• More likely to be successful if they come up with the options rather than you – You can prime the pump if they are stuck – Limit the number of changes to be attempted• Convey optimism and belief in their strengths• Write it down for the patient
  • The Paradox of ChangeWhen a person feels accepted for who they are andwhat they do-no matter how unhealthy-it allowsthem the freedom to consider change rather thanneeding to defend against it.
  • Assess Readiness for Change• Ask permission: – “Would it be okay if we spent a few minutes talking about _____?”• Understand their view of the problem. (“Tell me…”) :• Ask about readiness: – “On a scale of 0-10, how ready are you to consider ____?”• Ask scaling questions: – Backward: “What makes it a 5 and not a 2?” – Forward: “What would help you move it from a 5 to a 7?”
  • Assess Readiness (continued)• Pay attention to change talk – Change talk includes desire, ability, reasons, need – Change talk give clues about readiness to change – People are more persuaded by what they hear themselves say than by what someone tells them Summarize change talk• Confirm: – “Did I get it all?”• Ask about the next steps: – “Where does _______ fit into your future?”• Show appreciation: – “Thank you for your willingness to talk about ___ with me.”• Voice confidence: – “I’m confident that if and when you make a firm decision and commitment to ___ you will find a way to do it.”
  • Ready for Action?• Not ready to attempt change – Goal: Raise awareness – Tasks: Inform & encourage• Unsure about change – Goal: Build importance and/or confidence – Tasks: Explore ambivalence• Ready for Action – Goal: Agree on action steps and strategies
  • Not Ready - Inform & Encourage• Always ask permission before giving information• Elicit-Provide-Elicit Process – ELICIT interest • “Would you like to know more about…?” – PROVIDE feedback neutrally • “What happens to some people is…Other people find…” – ELICIT the patient’s interpretation and follow it • “What do you make of this?” • “How do you see the connection between smoking and your health?”
  • Unsure - Explore Ambivalence• Ask permission – “It seems that you have a lot of thoughts about this, Can we talk a little more about it?”• Ask “disarming” open-ended question: – “What are some of the advantages for keeping things just the way they are?”• Ask “reverse” open-ended question: – “On the other hand, what are some of the reasons for making a change?”• Summarize both sides of ambivalence – Start with the reasons for not changing, followed by reasons for changing
  • Unsure - Explore Ambivalence (cont.)• Ask about the next step: – “What’s the next step, if any?”• Show appreciation: – “Thank you for your willingness to talk with me about _____.”• Voice confidence: – “I’m confident that if and when you make a firm decision and commit to making a change, you’ll find a way to do it.”
  • Ready - Agree on Action Steps• Many people need help picking one do-able step that’s not too big• People are more likely to be successful if they come up with the options rather than you – You can prime the pump if they are stuck – Involve both mother and child• Show appreciation• Convey optimism and belief in their strengths• Write down one simple next step
  • What if the Patient Can’t Come up With Any Ideas?• Ask permission: – “If you’re interested, I have an idea for you to consider. Would you like to hear it?”• Offer advice: – “Based on my experience, I would encourage you to consider _________.”• Emphasize choice: – “Of course, it is totally up to you.”• Elicit response: – “What do you think about this idea?”
  • Recap of the MI Encounter• Set the agenda – Collaborative process• Use key counseling skills to understand the patient’s experience• Determine importance and confidence• Enhance importance and confidence• Elicit patient’s “change language”, reinforce it, and build on it• Help patient develop action steps
  • Back to Tobacco: YOUR Agenda• Use clear, strong messages• Anticipate challenges – Ask about cues to use tobacco – There are fewer cues in Smoke Free homes and cars• Practice problem-solving• Prescribe or provide information about pharmacotherapy• Help the parent set a quit date• Document your advice
  • What Do You Say?• Clear: “I strongly advise you to quit smoking.” (ok, it’s a one-way statement…but important to say!)• Strong: “Eliminating smoke exposure of your son is one of the most important things you can do to protect his health.”• Personalized: Emphasize the impact on health, finances, the child, family, or patient. “Smoking is harmful for you (and your child/family). I can help you quit.”
  • An Intermediate Goal• “Secondhand smoke is harmful for you and your family. Is it possible for you to make your home and car tobacco free now?”• Smokers who live in tobacco free homes smoke fewer cigarettes, which can help the next quit attempt succeed
  • What you may hear: Rationalization• No one wants to believe that they’re hurting their child – “…if she is there and we are smoking outside at least its very open.” – “Our daughter never goes in that room. We have a fan and a window and we leave the fan on when we’re smoking.” – “There is no smoking allowed anywhere near my house, my husband and I take turns going downstairs.”
  • Be Specific…• Remember MI: Ask Permission to give this advice, or it may fall on deaf ears… – “There are some things that may be helpful to know about what it means to have a Smoke Free Home. Can I go through them with you?”• Having a Smoke Free Home means no smoking ANYWHERE inside the home or car!• It DOES NOT mean smoking: – Near a window or exhaust fan – In the car with the windows open – In the basement – Inside only when the weather’s bad – Cigars, pipes, or hookahs – On the other side of the room
  • Help With Challenges• Tobacco Use can be a source of family discord – Smoking by a household member can be a source of tension – Not always identified by the parent as a barrier• Moms are more often the “gatekeepers” for maintaining a smoke free home – BUT, they may not be willing to risk a relationship – Want to maintain peace, may rationalize the risk
  • Help With Challenges• Strategize with the parent about ways to deliver the “you can quit” and “our home and car should be tobacco free” messages• Some parents would like to have a Smoke Free Home and car, but do not feel like they have the POWER to set this rule. – ASK if they can set a firm, 100% Smoke Free Rule – If they don’t have the power, ASK if a note from you will help!
  • Assist Through Pharmacotherapy*• Everyone who uses tobacco should be offered pharmacotherapies – Recommend and discuss use • Many are OTC – Prescribe if possible • Even if OTC • Some Medicaid plans require prescription for reimbursement or coverage *More on pharmacotherapies in 5 minutes…
  • Assist by Following Up• Plan to follow up on any behavioral commitments made – they are beginning a process of change! – Just asking at the next visit makes a big impression – Need to monitor and reinforce behavior change• If they set a quit date – Schedule follow-up in person or by telephone soon after the quit date• Look for “teachable moments” in the future
  • Refer: ____ Quitline Referral• List services, phone number, website, logo, etc. for that state’s quitline
  • What Do You Say?• “I recommend that you call this number. It’s a free service – and the person on the other end of the telephone can help you get ready to quit.”• “One thing that helps a lot is to learn as much as you can about quitting – the more you know, the more successful you’ll be. The quit line staff can help.”• “We’ve got a great state quit line. If you go on line and click a button, they call YOU back right away!”
  • Close on Good Terms• Offer praise and encouragement – Earnestly praise for work done• Summarize your patient’s view on importance and confidence• Emphasize any agreement that was reached
  • 7th Inning Stretch…Cessation Pharmacology 101Everyone Stand Up and STRETCH….
  • Medications Work!
  • Rationale for Pharmacological Treatment• Nicotine addiction• Mood and affect modulation• Cognitive decrements during withdrawal• Tobacco-free lifestyle coping skills take time to acquire
  • Tobacco Withdrawal • Cigarette craving • Constipation • Anxiety • Increased appetite • Irritability • Poor attention • Headache • Impaired cognitive performance • Insomnia • Decreased heart rate • DrowsinessSymptoms occur within hours of stopping smoking,and may persist for weeks
  • Tobacco Dependence• Adolescents experience symptoms of nicotine dependence and withdrawal even prior to becoming daily smokers, and after exposure to only low doses of nicotine!• Effects associated with dependence: – Increased numbers of brain nicotine receptors – Changes in regional blood glucose metabolism – EEG changes – Release of catecholamines – Tolerance – Physiological dependence
  • Knowledge is a Good Thing…• Even if you never prescribe NRT or cessation medications, familiarity with the medications typically used can be helpful – Comfort with talking to patients and their parents about what is “out there”• But I encourage you to remove the barrier to pharmacotherapy and prescribe them!
  • Pharmacotherapy Types• Nicotine replacement therapy (NRT) (many brands, some generics) – Many OTC – Some states reimburse, even for OTC (prescription may be required)• Bupropion SR (Zyban, Wellbutrin)• Varenicline (Chantix)
  • NRT• Non-nicotine components of tobacco cause most of the adverse health effects – Tars, carbon monoxide, etc.• The benefits of NRT outweigh the risks, even in smokers with cardiovascular disease (remember they already smoke!)
  • Using NRT: Treatment Goals• Overall reduction of nicotine withdrawal symptoms – not to replace tobacco!• Help with momentary urges• Modify habitual behavior – Breaking the cigarette habit with use of NRT has been shown to increase likelihood of quitting• Postponement of smoking – May be used to defer smoking when in environment in which smoking is not allowed
  • Nicotine Polacrilex Gum (OTC)Dosage – CPD < 25 use 2 mg, CPD  25 use 4 mg, Use enough (guidelines), Use long enough (for full 12 weeks)Side Effects: taste, jaw pain, nausea, dyspepsia, constipation, headache,…Advantages – Flexible dosing – Rapid blood levelDisadvantages – Poor compliance and Under-dosing – Dietary influence
  • Nicotine Transdermal Patch (OTC)Dosage – 21mg, 14 mg, 7 mg, place the patch always at the beginning of the daySide effects: redness, itching, sleep disturbanceAdvantages – Good compliance – Sustained blood levelsDisadvantages – Skin irritation
  • Nicotine Nasal Spray (Rx)Dosage – 1 dose yields 1 mg of nicotine (2 sprays, one/nostril)Side effects: cough, nasal /throat irritationAdvantages – Flexible dosing – Rapid blood level (5-10 minutes)Disadvantages – Tolerance – Expensive
  • Nicotine Vapor Inhaler (Rx)Dosage – 10 mg/cartridge, 6-16 cartridges/day, MAX: 16/day, each puff yields about 13 μg, compared to 100μg per cigarette puffSide effects: throat irritationAdvantages – Flexible dosing, “habit replacement” – Sensory cues (menthol, throat irritant)Disadvantages – ineffective if used alone
  • Nicotine Lozenge (OTC)Dosage – 2 mg, 4 mg; Side effects: oral irritationAdvantages – Flexible dosing – Rapid blood level (4mg lozenge give 25% higher blood level than 4 mg gum) – No chewing (discrete)Disadvantages – Under-dosing – Oral pH
  • Plasma nicotine concentrations for smoking and NRT 14Increase in nicotine concentration 12 10 (ng/ml 8 Cigarette Gum 4 mg 6 Gum 2 mg 4 Inhaler 2 Nasal spray Patch 0 5 10 15 20 25 30 Minutes
  • Nicotine Replacement Therapy• All forms of NRT appear to be equally effective (increase quit rates by ~1.5-2 fold) – Heavier smokers should start with higher dosing• Effectiveness of NRT increased with amount of behavioural support• Choice of medication is based mainly on susceptibility to side effects, patient preference and availability
  • Bupropion SR (Zyban®)Dosage 150 mg QAM for 3 days, then increase to 150 mg BID Doses should be at least 8 hours apart Use for 7-12 weeks after quit date; longer use possibleSide effects Dry mouth, headache, sleep disturbance, dizzinessAdvantages May be combined with NRTDisadvantages Need to pre-load: Start 2 weeks BEFORE quit date
  • Varenicline (Chantix®)Dosage Start 1 week BEFORE quit date 0.5 mg QD for 3 days, then 0.5 mg BID for 4 days, then 1 mg BID for 12 weeks or longer After a meal with a full glass of water Use for 12 weeks after quit date; longer use possibleSide effects Nausea, sleep problemsAdvantages May be more effective than BupropionDisadvantages Can not combine with NRT
  • Combining Nicotine Replacement• OTC: Gum, Patch, Lozenge• RX: Inhaler, Nasal spray• May use together – E.g., patch for maintenance, gum or lozenge for strong urges• May be used with Zyban; nausea may be severe if used with Chantix• READ AND FOLLOW INSTRUCTIONS!
  • Pharmacotherapy Comparison CharacteristicsTherapy Onset of Frequency of Effort required action doses/24hrsPatch 2-12 hr 1 LowGum/Lozenge 10 min 9-20 HighSpray 5-10 min 13-20 ModInhaler 15 min 6-16 HighBupropion 1 week 2 LowVarenicline 1 week 2 Low
  • Pharmacotherapy Comparison CharacteristicsTherapy Availability Flexible Breaks habit dosingPatch OTC No YesGum/Lozenge OTC Yes NoSpray Rx Yes NoInhaler Rx Yes NoBupropion Rx No YesVarenicline Rx No Yes
  • Adverse Effects and ContraindicationsProduct Adverse Effects Possible ContraindicationsPatch Skin irritation, insomnia *Immediate post MI or unstable anginaGum/lozenge Mouth soreness, dyspepsia SameNasal spray Nasal irritation, sneezing SameInhaler Coughing, throat irritation SameBupropion Insomnia, dry mouth, Eating disorder, seizure headaches disorder, MAO inhibitor useVarenicline Nausea, nightmares, *Schizophrenia, bipolar agitation, depression? disorder, and major suicidal ideation? depressive disorder
  • Estimated Cost Per Day Pharmacotherapy SmokingPatch $3.00 1 pack $5.50Bupropion $3.23 to $7.00 1 ½ packs $8.25Varenicline $4.36 2 packs $11.00Gum/Lozenge $3 to $6.50 2 ½ packs $13.75Spray $5.00 3 packs $16.50Inhaler $10.00
  • More Role Playing Exercises
  • The Rules• Role playing exercises can help you become “comfortable” with new language• Role playing exercises DON’T work if you DON’T say the words out loud• Be silly. Have fun!
  • Break into Groups of 3• Using the guidelines listed on your handout and what you’ve learned today, take turns as the “clinician” and “patient” or “parent”, and observer• Create your own scenarios, but be sure to stay within the guidelines of motivational interviewing to elicit information from the patient
  • Motivational Interviewing• http://www.motivatehealthyhabits.com/ – Rick Botelho is a family doc who does a fabulous job• http://www.motivationalinterview.org/ – The website for motivational interviewing trainers; many good resources from the psychology literature
  • Need more information?The AAP Richmond Centerwww.aap.org/richmondcenter Audience-Specific Resources State-Specific Resources Cessation Information Funding Opportunities Reimbursement Information Tobacco Control E-mail List Pediatric Tobacco Control Guide
  • QUESTIONS??Skull of a Skeleton withBurning CigaretteAntwerp 1885-1886Van Gogh MuseumAmsterdam