“Smoking Cessation - What’s my Role?”Daniel “Scotty” Silva, RRT, RCP- Director of Pulmonary Services, University of New Mexico Hospital- Consultant, New Mexico Medical Society - Clinical Prevention Initiative NMMRA – Hospital-initiated Tobacco Cessation Program
Course Objectives• To become familiar with the addictive properties on nicotine and to identify the barriers to effective smoking cessation.• To define the role of the respiratory therapist in a smoking cessation program.• To identify the process of incorporating smoking cessation into your everyday clinical practice.
Educational Objectives• What can the attendee expect to learn in this meeting?W – Understand the tobacco problem in New Mexico – Learn about the Tobacco Use Prevention & Control program’s funding of various programs to combat the tobacco problem – Learn about the different types of nicotine replacement therapy available to tobacco users – Learn how to conduct a tobacco cessation counseling session utilizing the motivational interviewing techniques – Learn how to use motivational interviewing tools: Listening statements, Readiness Ladders, Accomplishment Story, Sidestepping
Tobacco in New MexicoAmerican Lung Association : • State of Tobacco Control: 2006Report Card Grades: • Youth Access F • Tobacco Prevention and Control Spending F • Cigarette Tax D • Smokefree Air F
Tobacco in New MexicoAmerican Lung Association : • State of Tobacco Control: 2009Report Card Grades: • Youth Access • Tobacco Prevention and Control Spending F • Cigarette Tax D • Smokefree Air A • Cessation Coverage C
Chemical Make-up of a Cigarette• > 4000 Chemicals found in tobacco; 1.) Fertilizers and Pesticides. 2.) Production of cigarettes. 3.) By-product or end-product. - Primary - Secondary• 60 are known Group A Carcinogens (found to cause cancer in humans). Group A Carcinogens include; - Acetylene - Copper - Hexamine - Nickel - Arsenic - DDT - Mercury - Phenol - Asbestos - Ethanol - Methane - Radon - Benzene - Formaldehyde - Methanol - Toluene - Butane - Vinyl Cloride - Naphthalene - Urethane
What Do They Say About It?“The cigarette should be conceived not as a product, but as a package. The product is nicotine…Think of the cigarette pack as a storage container for a day’s supply of nicotine… Think of a puff of smoke as the vehicle of nicotine and the cigarette the most optimized dispenser of smoke.” William Dunn, Tobacco Researcher , Philip Morris, 1972
What Are the Facts?• An estimated, 20.8% of all adults (45.3 million people) smoke cigarettes in the United States.• Cigarette smoking estimates by age are as follows: 18–24 years (23.9%), 25–44 years (23.5%), 45–64 years (21.8%), and 65 years or older (10.2%).4• Cigarette smoking is more common among men (23.9%) than women (18.0%).4• Prevalence of cigarette smoking is highest among American Indians/Alaska Natives (32.4%), followed by (non-Hispanic) Blacks (23.0%), (non-Hispanic) Whites (21.9%), Hispanics (15.2%), and Asians [excluding Native Hawaiians and other Pacific Islanders] (10.4%).4
More Facts!• Cigarette smoking estimates are highest for adults with a General Education Development (GED) diploma (46.0%) or 9–11 years of education (35.4%), and lowest for adults with an undergraduate college degree (9.6%) or a graduate college degree (6.6%).4• Cigarette smoking is more common among adults who live below the poverty level (30.6%) than among those living at or above the poverty level (20.4%).4
Nicotine - What is it?• Nicotiana tabacum• First cultivated in the Americas as early as 6000 BC.• Originally touted for its “medicinal properties”.• C10H14N2 is a naturally occurring liquid alkaloid and makes up about 5% of the actual tobacco plant, by weight.• Readily diffused into the body through skin, lungs, and mucous membranes.• Half-life of Nicotine is 60 minutes.
Is It Addiction?Psychological: Continued and compulsive use ofa product, without regard for it’s effects on healthor life.Physiological: Anything that turns on the rewardpathway in the brain. Stimulation of this neuralcircuitry makes a person feel good and thus will doit again and again to “get that feeling”.Tolerance: The development of tolerance to theproduct which results in needing more and more inorder to illicit the same effect.
Why Smoking Cessation?• 438,000 smoking related deaths annually in the US.• 2100 smoking related deaths annually in the New Mexico.• 1 in 5 or 20% of all deaths in the US are attributable to cigarette smoking.• Leading cause of cancer death in both men and women, it surpassed breast cancer in 1987 as the # 1 cancer killer of women!• 66% ALL myocardial infarctions are related to cigarette smoking.• 75 Billion dollars in Direct annual medical related costs.• 92 Billion dollars in lost productivity.
Because They Want To Quit!• Among current U.S. adult smokers, – 70% report that they want to quit completely. – In 2006, an estimated 19.2 million (44.2%) adult smokers had stopped smoking for at least 1 day during the preceding 12 months because they were trying to quit. – More than 54% of current high school cigarette smokers in the United States tried to quit smoking within the preceding year.
Can We Make a Difference?“If you treat an individual as he is, he will stay as he is, but if you treat him as if he were what he ought to be and could be, he will become what he ought to be and could be” Johann Wolfgang von Goethe
Components of Change• Importance of change• Confidence in the ability to change• Readiness to change“Motivation is fundamental to change”
Motivational Interviewing• Collaboration (Not Confrontation): – Working in partnership and consultation with the patient• Evocation (Not Education): – Listening more than talking• Autonomy (Not Authority): – Being respectful and honoring the patients autonomy, resourcefulness, and ability to choose
Contemplation Ladder• 10 = Taking action to quit NOW.• 8 = Starting to think about how to quit.• 5 = Think that I should quit, unsure if I am ready too.• 2 = Will consider quitting someday.• 0 = Absolutely NO thoughts of quitting.
Motivation to Change?• DARN D = DESIRE to Change A = ABILITY to Change R = REASON to Change N = NEED to Change
Explore Their Ambivalence!• What is AMBIVALENCE? Webster’s defines ambivalence as; “Simultaneous conflicting feelings” – “I want to quit smoking and I don’t want to quit smoking” – “I know that my smoking effects my asthma, but I really love to smoke”! – DEVELOP DISCREPANCY – Differentiate between the patient’s present state and their desired goals. – Without discrepancy there is no ambivalence and if there is no ambivalence, there is no potential for change! – You can’t have Motivational Interviewing without ambivalence.
The 5 A’s Ask Tobacco use as Smoking status a vital sign Advise To quit Brief, informative, clear, personalized Assess Weigh pros and cons Willingness to quit Assess importance, readiness, and confidence Assess st age of readiness to quit Assist Aid in quitting Offer help: e.g. - refer to counseling, quitline - analyze past attempt s - develop quit plan, - provide pharmacotherapy Arrange Follow-up 37
The 5 A’s• ASK - Does EVERY patient get asked about their smoking history?• ADVISE – Do we actively advise our smoking patient’s to quit?• ASSESS – Do we incorporate smoking cessation into our assessment and provide opportunities for our patient to pursue quitting options.• ASSIST – Do we incorporate smoking cessation into the treatment / care plan?• ARRANGE – Do we provide the patient with the necessary resources to be successful after discharge? (community resources, relapse plan, support)
Nicotine Replacement Therapy• CHANTIX™ (varenicline)• Indication: Smoking Cessation / Nicotine Inhibitor• Dose: (Day 1-3) White Tablet / 0.5mg / Qday – (Day 4-7) White Tablet / 0.5 mg / Bid – ( Daily) Blue Tablet / 1 mg / Bid• Mode of Action: CHANTIX contains no nicotine, but it targets the same receptors that nicotine does. CHANTIX is believed to block nicotine from these receptors.• Quit Rate: 44%
Nicotine Replacement Therapy• Bupropion (Wellbutrin XL / Wellbutrin SR / Zyban)• Indication: Depression / Smoking Cessation• Dose: 150 mg once daily for three days, and then the dose is increased if the patient tolerates the starting dose to 300 mg daily. Smoking is discontinued one -two weeks after starting bupropion therapy.• Mode of Action: Bupropion is an antidepressant medication that affects chemicals within the brain that nerves use to send messages to each other, therefore, reducing the cravings or urges to smoke.• Quit Rate: 32%
Nicotine Replacement Therapy• Nicotine Patch• Indication: Smoking Cessation• Dose: 21mg, 14mg, 7mg (all available over-the-counter)• Mode of Action: Delivers a steady dose of nicotine through the skin over a 24-hour period to lessen / taper the symptoms of nicotine withdrawal. Requires a gradual taper in dose over a 6 - 8 week period. May be used concurrently with other NRT under supervision.• General Rule: “1 Mg per Cig.”• Quit Rate: 23%
Nicotine Replacement Therapy• Nicotine Gum• Indication: Smoking Cessation• Dose: 2mg and 4mg (mint, orange, & wild berry flavor)• Mode of Action: Delivers nicotine to the bloodstream through the lining of the mouth (buccal mucosa) to lessen nicotine withdrawal symptoms.• General Rule: Chew It & Park It! This will help to eliminate the headache and nausea associated with this NRT.• Quit Rate 21%
Nicotine Replacement Therapy• Nicotine Lozenge• Indication: Smoking Cessation• Dose: 2mg and 4 mg• Mode of Action: Delivers nicotine to the bloodstream through the lining of the mouth (buccal mucosa) to lessen nicotine withdrawal symptoms.• General Rule: Suck It & Park it! This will help to eliminate the headache and nausea associated with this NRT. (TTFC) Time To First Cigarette.• Quit Rate: 22%
Nicotine Replacement Therapy• Nicotine Inhaler• Indication: Smoking Cessation in particular those with a multi-pack habit with associated oral fixation.• Dose: 4mg puncture pack per inhaler providing 15-20 minutes of nicotine with active puffing.• Mode of Action: Delivers nicotine to the bloodstream through the lining of the mouth (buccal mucosa) to lessen nicotine withdrawal symptoms.• General Rule: Inhaler is a VAPOR, not aerosol, and will dissipate relatively quickly.• Quit Rate: 23%
Nicotine Replacement Therapy• Nicotine Nasal Spray• Indication: Rapid relief of nicotine withdrawal symptoms.• Dose: 1 puff per nare (0.5mg) at the onset of symptoms.• Mode of Action: The spray delivers nicotine directly to the bloodstream through the lining of the nose (nasal mucosa) and is extremely fast -acting.• General Rule: Highly addictive and should be used only with supervision and for NO longer than 3 months. High association with nasal irritation, sinusitis, and burning eyes. Only use this NRT with careful consideration.• Quit Rate: 21%
It’s Up To You!"In any moment of decision the best thing you can do is the right thing, the next best thing is the wrong thing, and the worst thing you can do is nothing." Theodore Roosevelt