Rx for CHANGE
Clinician-Assisted Tobacco Cessation
TRAINING OVERVIEW
Epidemiology of Tobacco Use module
Nicotine Pharmacology & Principles of Addiction module
Drug Interactions with Smoking module
Assisting Patients with Quitting module
Hands-on workshop
Aids for Cessation module
Tobacco trigger tapes
Case scenarios
EPIDEMIOLOGY
of TOBACCO USE
is the chief, single,
avoidable cause of death in our society and the most
important public health issue of our time.”
C. Everett Koop, M.D., former U.S. Surgeon General
“CIGARETTE
SMOKING…
Mackay & Erickson. (2002). The Tobacco Atlas. World Health Organization.
WORLDWIDE ADULT TOBACCO USE PREVALENCE (Men/Women)
Canada 25.0 (27.0/23.0)
USA 20.9 (23.9/18.1)
UK 26.5 (27.0/26.0)
Australia 19.5 (21.1/18.0)
China 35.6 (66.9/4.2) Russian Federation
36.5 (63.2/9.7)
Japan 33.1 (52.8/13.4)
India 16.0 (29.4/2.5) Brazil
33.8 (38.2/29.3)
Namibia 50.0 (65.0/35.0)
South Africa 26.5 (42.0/11.0)
Sweden 19.0 (19.0/19.0)
Yugoslavia 47.0 (52.0/42.0)
Iran 15.3 (27.2/3.4) Guinea
51.7 (59.5/43.8)
New Zealand 25.0 (25.0/25.0)
Philippines 32.4 (53.8/11.0) France
34.5 (38.6/30.3)
TRENDS in ADULT CIGARETTE
CONSUMPTION — U.S., 1900 – 2005
Annual adult per capita cigarette consumption and major smoking and health events
Centers for Disease Control and Prevention. (1999). MMWR 48:986–993.
Per-capita updates from U.S. Department of Agriculture, provided by the American Cancer Society.
1964 Surgeon General’s Report
Great Depression
End of WW II
First modern reports linking smoking and
cancer Federal cigarette
tax doubles
Master Settlement Agreement;
California first state to enact ban on smoking in bars
Broadcast ad ban
Cigarette price drop Nonsmokers’
rights movement begins
N u m b er o f ci g a re tt es
Year
U.S. entry intoWW I
20 states have > $1 pack tax Marketing
of filtered cigarettes
Adapted from NCI Smoking and Tobacco Control Monograph 8, 1997, p. 13. Data from U.S. Department of Agriculture.
Reprinted with permission. Thun et al. 2002. Oncogene 21:7307–7325.
ADULT PER-CAPITA CONSUMPTION of TOBACCO, 1880–2005
All forms of
tobacco harmful. are
Year
TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2005
Trends in cigarette current smoking among persons aged 18 or older
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2005 NHIS. Estimates since 1992 include some-day smoking.
P er ce n t
70% want to quit 70% want to quit
Male
Female 23.9%
18.1%
20.9% of adults are current
smokers
Year
STATE-SPECIFIC PREVALENCE of SMOKING among ADULTS, 2005
California 15.2%
New York 20.5%
Utah 11.5%
Texas 20.0%
Illinois
19.9% Kentucky
28.7%
Nevada 23.1%
Centers for Disease Control and Prevention. (2006). MMWR 55:1148–1151.
Florida 21.6%
Indiana
27.3%
PREVALENCE of ADULT SMOKING, by RACE/ETHNICITY—U.S., 2005
13.3% Asian*
32.0% American Indian/Alaska Native*
21.5% Black*
21.9% White*
16.2% Hispanic
Centers for Disease Control and Prevention. (2006). MMWR 55:1145–1148.
* non-Hispanic.
PREVALENCE of ADULT SMOKING, by EDUCATION—U.S., 2005
10.7% Undergraduate degree 25.5% No high school diploma 43.2% GED diploma
24.6% High school graduate 22.5% Some college
7.1% Graduate degree
Centers for Disease Control and Prevention. (2006). MMWR 55:1145–1148.
TRENDS in TEEN SMOKING, by ETHNICITY—U.S., 1977–2006
Trends in cigarette smoking among 12th graders: 30-day prevalence of use
Institute for Social Research, University of Michigan, Monitoring the Future Project www.monitoringthefuture.org
P er ce n t
White
Hispanic Black
PUBLIC HEALTH versus
“BIG TOBACCO”
The biggest opponent to tobacco control efforts is the tobacco
industry itself.
In the U.S., for every $1 spent on tobacco prevention,
the tobacco industry spends $28 to market its products.
The TOBACCO INDUSTRY
For decades, the tobacco industry has publicly denied the
addictive nature of nicotine and the negative health effects of tobacco.
April 14, 1994: Seven top executives of major tobacco
companies state, under oath, that they believe nicotine is not addictive.
Tobacco industry documents suggest otherwise
Documents available at http://legacy.library.ucsf.edu
The cigarette is a heavily engineered product.
Designed and marketed to maximize bioavailability of nicotine and addictive potential
Profits over people
An EFFECTIVE MARKETING
STRATEGY: “LIGHT” CIGARETTES
The difference between Marlboro and Marlboro Lights…
an extra row of ventilation holes an extra row of ventilation holes
Image courtesy of Mayo Clinic Nicotine Dependence Center - Research Program / Dr. Richard D. Hurt
The Marlboro and Marlboro Lights logos are registered trademarks of Philip Morris USA.
TOBACCO INDUSTRY ADVERTISING
$15.15 billion spent in the U.S. in 2003
21.5% increase over 2002 figures
35.0% increase over 2001 figures
B il li o n s o f d o ll ar s sp en t
Year
Federal Trade Commission. (2005). Cigarette Report for 2003.
1932
1936
1990
ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, 1997–2001
Centers for Disease Control and Prevention. (2005). MMWR 54:625–628.
32%
28%
23%
9%
8%
<1%
TOTAL: 437,902 deaths annually
Cardiovascular diseases 137,979
Lung cancer 123,836
Respiratory diseases 101,454 Second-hand smoke* 38,112 Cancers other than lung 34,693
Other 1,828
Percentage of all smoking- attributable deaths*
* In 2005, it was estimated that nearly 50,000 persons died due to second-hand smoke exposure.
ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTS—U.S., 1995–1999
Annual lost productivity
costs (1995–1999)
Medical expenditures
(1998)
Billions of dollars
Men,
$55.4 billion Ambulatory care,
$27.2 billion
Prescription drugs,
$6.4 billion
Women,
$26.5 billion Nursing home,
$19.4 billion
Other care,
$5.4 billion
Centers for Disease Control and Prevention. (2002). MMWR 51:300–303.
Hospital care,
$17.1 billion
Societal costs:
$7.18 per pack
COMPOUNDS in TOBACCO SMOKE
Carbon monoxide
Hydrogen cyanide
Ammonia
Benzene
Formaldehyde
Nicotine
Nitrosamines
Lead
Cadmium
Polonium-210
An estimated 4,800 compounds in tobacco smoke, including 11 proven human carcinogens
Gases Particles
Nicotine does NOT cause the ill health effects of tobacco.
2004 REPORT of the SURGEON GENERAL:
HEALTH CONSEQUENCES OF SMOKING
Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general.
Quitting smoking has immediate as well as long-term benefits, reducing risks for diseases caused by smoking and improving health in general.
Smoking cigarettes with lower machine-measured yields of tar and nicotine provides no clear benefit to health.
The list of diseases caused by smoking has been expanded.
U.S. Department of Health and Human Services. (2004). The Health Consequences of Smoking: A Report of the Surgeon General .
FOUR MAJOR CONCLUSIONS:
HEALTH CONSEQUENCES of SMOKING
Cancers
Acute myeloid leukemia
Bladder and kidney
Cervical
Esophageal
Gastric
Laryngeal
Lung
Oral cavity and pharyngeal
Pancreatic
Pulmonary diseases
Acute (e.g., pneumonia)
Chronic (e.g., COPD)
Cardiovascular diseases
Abdominal aortic aneurysm
Coronary heart disease
Cerebrovascular disease
Peripheral arterial disease
Reproductive effects
Reduced fertility in women
Poor pregnancy outcomes (e.g., low birth weight, preterm
delivery)
Infant mortality
Other effects: cataract, osteoporosis, periodontitis, poor surgical outcomes
U.S. Department of Health and Human Services. (2004). The Health
Consequences of Smoking: A Report of the Surgeon General.
HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.
USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke:
Report of the Surgeon General.
There is no safe level of second-hand
smoke.
Second-hand smoke causes premature death and disease in nonsmokers (children and adults)
Children:
Increased risk for sudden infant death syndrome
(SIDS), acute respiratory infections, ear problems, and more severe asthma
2006 REPORT of the SURGEON GENERAL:
INVOLUNTARY EXPOSURE to TOBACCO SMOKE
Respiratory symptoms and slowed lung growth if parents smoke
Adults:
Immediate adverse effects on cardiovascular system
Increased risk for coronary heart disease and lung cancer
Millions of Americans are exposed to smoke in their homes/workplaces
Indoor spaces: eliminating smoking fully protects nonsmokers
Separating smoking areas, cleaning the air, and ventilation are ineffective
SMOKE-FREE
WORKPLACE LAWS
Smoke-free offices, restaurants, and bars: California, Colorado, Connecticut, Delaware, Hawaii, Maine, Massachusetts, New Jersey, New York, Rhode Island, Vermont, Washington
Smoke-free offices and restaurants: Arkansas, District of Columbia (bars in 2007), Florida, Georgia, Idaho, Louisiana, Montana (bars in 2009), Nevada, North Dakota, Utah (bars in 2009)
Smoke-free offices: Maryland, South Dakota
Data current as of November 9, 2006.
QUITTING: HEALTH BENEFITS
Lung cilia regain normal function
Ability to clear lungs of mucus increases
Coughing, fatigue, shortness of breath decrease
Excess risk of CHD decreases to half that of a continuing smoker
Risk of stroke is reduced to that of people who have never
smoked Lung cancer death rate
drops to half that of a continuing smoker Risk of cancer of mouth,
throat, esophagus, bladder, kidney, pancreas decrease
Risk of CHD is similar to that of people who have never smoked
2 weeks to 3 months
1 to 9 months
1 year
5 years
10 years
after 15 years
Time Since Quit Date Circulation improves,
walking becomes easier Lung function increases
up to 30%
BENEFICIAL EFFECTS of QUITTING:
PULMONARY EFFECTS
Reprinted with permission. Fletcher & Peto. (1977). BMJ 1(6077):1645–1648.
Disability
Death
Smoked regularly and susceptible to effects of smoke
Never smoked or not susceptible to smoke
Stopped smoking at 45 (mild COPD)
Stopped smoking at 65 (severe COPD) 25
F E V
1( % o f va lu e at a g e 25 )
25 50 75 100
0
50 75
Age (years)
COPD = chronic obstructive pulmonary disease
AT ANY AGE, there are benefits of quitting.
AT ANY AGE, there are benefits of quitting.
Reduction in cumulative risk of
death from lung cancer in men
Reprinted with permission. Peto et al. (2000). BMJ 321(7257):323–329.
C u m u la ti ve r is k (% )
Age in years
Y ea rs o f lif e ga in ed
Age at cessation (years)
Prospective study of 34,439 male British doctors
Mortality was monitored for 50 years (1951–2001)
On average, cigarette smokers die approximately
10 years younger than do nonsmokers.
Among those who continue smoking, at least half will
die due to a tobacco-related disease.
SMOKING CESSATION:
REDUCED RISK of DEATH
Doll et al. (2004). BMJ 328(7455):1519–1527.
FINANCIAL IMPACT of SMOKING
Packs per day
Buying cigarettes every day for 50 years @ $4.26 per pack Money banked monthly, earning 1.5% interest
0 100 200 300 400
Hundreds of thousands of dollars lost
$342,729
$228,486
$114,243
EPIDEMIOLOGY of TOBACCO USE: SUMMARY
About one in five adults are current smokers; smoking prevalence varies by sociodemographic characteristics.
Nearly half a million U.S. deaths are attributable to smoking annually.
Smoking costs the U.S. $157.7 billion per year. Lifetime financial costs of smoking can exceed $300,000 for a heavy smoker.
At any age, there are benefits to quitting smoking.
The biggest opponent to tobacco control efforts is the
tobacco industry itself.
NICOTINE PHARMACOLOGY and
PRINCIPLES of ADDICTION
NICOTINE ADDICTION
U.S. Surgeon General’s Report (1988)
Cigarettes and other forms of tobacco are addicting.
Nicotine is the drug in tobacco that causes addiction.
The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine.
U.S. Department of Health and Human Services. (1988). The Health Consequences
of Smoking: Nicotine Addiction. A Report of the Surgeon General.
Nicotiana tabacum Natural liquid alkaloid
Colorless, volatile base pK a = 8.0
N CH
3N
H
Pyridine ring
Pyrrolidine ring
CHEMISTRY of NICOTINE
PHARMACOLOGY
Effects of the body on the drug
Absorption
Distribution
Metabolism
Excretion
Effects of the drug on the body Pharmacokinetics
Pharmacodynamics
NICOTINE ABSORPTION
Absorption is pH dependent
In acidic media
Ionized poorly absorbed across membranes
In alkaline media
Nonionized well absorbed across membranes
At physiologic pH (7.3–7.5), ~31% of nicotine is unionized
At physiologic pH,
nicotine is readily absorbed.
NICOTINE ABSORPTION:
BUCCAL (ORAL) MUCOSA
The pH inside the mouth is 7.0.
Acidic media (limited absorption)
Cigarettes
Alkaline media
(significant absorption) Pipes, cigars,
spit tobacco,
oral nicotine products
Beverages can alter pH, affect absorption.
NICOTINE ABSORPTION: SKIN and GASTROINTESTINAL TRACT
Nicotine is readily absorbed through intact skin.
Nicotine is well absorbed in the small intestine
but has low bioavailability (30%) due to first-
pass hepatic metabolism.
NICOTINE ABSORPTION: LUNG
Nicotine is “distilled” from burning tobacco and carried in tar droplets.
Nicotine is rapidly absorbed across respiratory epithelium.
Lung pH = 7.4
Large alveolar surface area
Extensive capillary system in lung
NICOTINE DISTRIBUTION
Henningfield et al. (1993). Drug Alcohol Depend 33:23–29.
Arterial
Venous
Nicotine reaches the brain within 11 seconds.
Nicotine reaches the brain within 11 seconds.
Metabolized and excreted
in urine
NICOTINE METABOLISM
CH
3N
H 10–20%
excreted unchanged
in urine
Adapted and reprinted with permission. Benowitz et al. (1994). J Pharmacol Exp Ther 268:296–303 .
70–80%
cotinine ~ 10% other metabolites
N
NICOTINE EXCRETION
Half-life
Nicotine t ½ = 2 hr
Cotinine t ½ = 19 hr
Excretion
Occurs through kidneys (pH dependent;
with acidic pH)
Through breast milk
NICOTINE
PHARMACODYNAMICS
Nicotine binds to receptors in the brain and other
sites in the body.
Other:
Neuromuscular junction Sensory receptors
Other organs
Central nervous system
Exocrine glands Adrenal medulla
Peripheral nervous system Gastrointestinal system
Cardiovascular system
Nicotine has predominantly stimulant effects.
NICOTINE
PHARMACODYNAMICS (cont’d)
Central nervous system
Pleasure
Arousal, enhanced vigilance
Improved task performance
Anxiety relief
Other
Appetite suppression
Increased metabolic rate
Skeletal muscle relaxation
Cardiovascular system
Heart rate
Cardiac output
Blood pressure
Coronary vasoconstriction
Cutaneous vasoconstriction
NEUROCHEMICAL and RELATED EFFECTS of NICOTINE
Dopamine
Norepinephrine
Acetylcholine
Glutamate
Serotonin
-Endorphin
GABA
N I C O T I N
E
Benowitz. (1999). Nicotine Tob Res 1(Suppl):S159–S163.
Pleasure, reward
Arousal, appetite suppression
Arousal, cognitive enhancement
Learning, memory enhancement
Mood modulation, appetite suppression
Reduction of anxiety and tension
Reduction of anxiety and tension
WHAT IS ADDICTION?
”Compulsive drug use, without medical purpose, in the face of
negative consequences”
Alan I. Leshner, Ph.D.
Former Director, National Institute on Drug Abuse
National Institutes of Health
BIOLOGY of NICOTINE ADDICTION:
ROLE of DOPAMINE
Nicotine stimulates dopamine release
Repeat administration
Tolerance develops
Discontinuation leads to withdrawal symptoms.
Pleasurable feelings
Nicotine addiction
is not just a bad habit.
Nicotine enters Nicotine enters
brain brain
Stimulation of Stimulation of
nicotine receptors nicotine receptors Dopamine release
Dopamine release
DOPAMINE REWARD PATHWAY
Prefrontal cortex
Nucleus accumbens
Ventral tegmental
area
CHRONIC ADMINISTRATION of
NICOTINE: EFFECTS on the BRAIN
Perry et al. (1999). J Pharmacol Exp Ther 289:1545–1552.
Nonsmoker Smoker
Human smokers have increased nicotine receptors in the prefrontal cortex.
High
Low
Image courtesy of George Washington University / Dr. David C. Perry
Depression
Insomnia
Irritability/frustration/anger
Anxiety
Difficulty concentrating
Restlessness
Increased appetite/weight gain
Decreased heart rate
Cravings*
NICOTINE PHARMACODYNAMICS:
WITHDRAWAL EFFECTS
American Psychiatric Association. (1994). DSM-IV.
Hughes et al. (1991). Arch Gen Psychiatry 48:52–59.
Hughes & Hatsukami. (1998). Tob Control 7:92–93.
Most symptoms peak 24–48 hr after quitting and
subside within 2–4 weeks.
* Not considered a withdrawal symptom by DSM-IV criteria.
HANDOUT
NICOTINE ADDICTION CYCLE
Reprinted with permission. Benowitz. (1992). Med Clin N Am 2:415–437.
NICOTINE ADDICTION
Tobacco users maintain a minimum serum nicotine concentration in order to
Prevent withdrawal symptoms
Maintain pleasure/arousal
Modulate mood
Users self-titrate nicotine intake by
Smoking/dipping more frequently
Smoking more intensely
Obstructing vents on low-nicotine brand cigarettes
ASSESSING
NICOTINE DEPENDENCE
Fagerström Test for Nicotine Dependence (FTND)
Developed in 1978 (8 items); revised in 1991 (6 items)
Most common research measure of nicotine dependence;
sometimes used in clinical practice
Responses coded such that higher scores indicate higher levels of dependence
Scores range from 0 to 10; score of greater than 5 indicates substantial dependence
Heatherton et al. (1991). British Journal of Addiction 86:1119–1127.
HANDOUT
CLOSE TO HOME © 2000 John McPherson.
Reprinted with permission of UNIVERSAL PRESS SYNDICATE.
All rights reserved.
FACTORS CONTRIBUTING to TOBACCO USE
Physiology
Genetic predisposition
Coexisting medical conditions
Environment
Tobacco advertising
Conditioned stimuli
Social interactions
Pharmacology
Alleviation of
withdrawal symptoms
Weight control
Pleasure
Tobacco
Use
TOBACCO DEPENDENCE:
A 2-PART PROBLEM
Tobacco Dependence Tobacco Dependence
Treatment should address the physiological and the behavioral aspects of dependence.
Physiological
Physiological Behavioral Behavioral
Treatment Treatment
The addiction to nicotine
Medications for cessation
The habit of using tobacco
Behavior change program
NICOTINE PHARMACOLOGY and ADDICTION: SUMMARY
Tobacco products are effective delivery systems for the drug nicotine.
Nicotine is a highly addictive drug that induces a constellation of pharmacologic effects.
Nicotine activates the dopamine reward pathway in the brain, which reinforces continued tobacco use.
Tobacco users who are dependent on nicotine self-
regulate tobacco intake to maintain pleasurable
effects and prevent withdrawal.
NICOTINE PHARMACOLOGY and ADDICTION: SUMMARY (cont’d)
Nicotine dependence is a form of chronic brain disease.
Tobacco use is a complex disorder involving the interplay of the following:
Pharmacology of nicotine (pharmacokinetics and pharmacodynamics)
Environmental factors
Physiologic factors
Treatment of tobacco use and dependence
requires a multifaceted treatment approach.
DRUG INTERACTIONS with
SMOKING
Drugs that may have a decreased effect due to induction of CYP1A2:
Caffeine
Fluvoxamine
Olanzapine
Tacrine
Theophylline
Absorption of inhaled insulin is 2- to 5-fold higher in smokers than in nonsmokers
Use is contraindicated in current smokers and patients who quit less < 6 months prior to treatment
PHARMACOKINETIC DRUG
INTERACTIONS with SMOKING
HANDOUT
Smoking cessation will reverse these effects.
PHARMACODYNAMIC DRUG
INTERACTIONS with SMOKING
Smokers who use combined hormonal
contraceptives have an increased risk of serious cardiovascular adverse effects:
Stroke
Myocardial infarction
Thromboembolism
This interaction does not decrease the efficacy of hormonal contraceptives.
Women who are 35 years of age or older AND smoke at least 15 cigarettes
per day are at significantly elevated risk.
DRUG INTERACTIONS with SMOKING: SUMMARY
Clinicians should be aware of their patients’
smoking status:
Clinically significant interactions result not from nicotine but from the combustion products of tobacco smoke.
These tobacco smoke constituents (e.g., polycyclic aromatic hydrocarbons; PAHs) may enhance the metabolism of other drugs, resulting in a reduced pharmacologic response.
Smoking might adversely affect the clinical response to the
treatment of a wide variety of conditions.
ASSISTING PATIENTS
with QUITTING
Released June 2000
Sponsored by the Agency for Healthcare Research and Quality of the U.S. Public Heath Service with
Centers for Disease Control and Prevention
National Cancer Institute
National Institute for Drug Addiction
National Heart, Lung, & Blood Institute
Robert Wood Johnson Foundation
www.surgeongeneral.gov/tobacco/
CLINICAL PRACTICE GUIDELINE for
TREATING TOBACCO USE and DEPENDENCE
EFFECTS of CLINICIAN INTERVENTIONS
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS.
1.0 1.1
(0.9,1.3)
1.7
(1.3,2.1)
2.2
(1.5,3.2) n = 29 studies
Compared to smokers who receive no assistance from a clinician, smokers who receive such
assistance are 1.7–2.2 times as likely to quit
successfully for 5 or more months.
Tobacco users expect to be encouraged to quit by health professionals.
Screening for tobacco use and providing tobacco cessation counseling are positively
associated with patient satisfaction (Barzilai et al., 2001).
Barzilai et al. (2001). Prev Med 33:595–599.
Failure to address tobacco use tacitly implies that quitting is not important.
The CLINICIAN’s ROLE in
PROMOTING CESSATION
ASK ADVISE ASSESS ASSIST ARRANGE
The 5 A’s
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS.
HANDOUT
The 5 A’s (cont’d)
Ask about tobacco use
“Do you ever smoke or use any type of tobacco?”
“I take time to ask all of my patients about tobacco use—because it’s important.”
“Medication X often is used for conditions linked with or caused by smoking. Do you, or does someone in your household smoke?”
“Condition X often is caused or worsened by smoking.
Do you, or does someone in your household smoke?”
ASK
The 5 A’s (cont’d)
tobacco users to quit (clear, strong, personalized, sensitive)
“It’s important that you quit as soon as possible, and I can help you.”
“I realize that quitting is difficult. It is the most
important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan.”
ADVISE
The 5 A’s (cont’d)
Assess readiness to make a quit attempt ASSESS
Assist with the quit attempt
Not ready to quit: provide motivation (the 5 R’s)
Ready to quit: design a treatment plan
Recently quit: relapse prevention
ASSIST
Arrange follow-up care ARRANGE
The 5 A’s (cont’d)
Number of sessions Estimated quit rate*
0 to 1 12.4%
2 to 3 16.3%
4 to 8 20.9%
More than 8 24.7%
* 5 months (or more) postcessation
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS.
PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT
PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT
The 5 A’s: REVIEW
ASK about tobacco USE
ADVISE tobacco users to QUIT
ASSESS READINESS to make a quit attempt
ASSIST with the QUIT ATTEMPT
ARRANGE FOLLOW-UP care
Faced with change, most people are not ready to act.
Change is a process, not a single step.
Typically, it takes multiple attempts.
HOW CAN I LIVE
WITHOUT TOBACCO?
The (DIFFICULT) DECISION
to QUIT
HELPING SMOKERS QUIT IS a CLINICIAN’S RESPONSIBILITY
THE DECISION TO QUIT LIES IN THE HANDS OF EACH PATIENT.
TOBACCO USERS DON’T PLAN TO FAIL.
MOST FAIL TO PLAN.
Clinicians have a professional obligation to address tobacco use and can have
an important role in helping patients
plan for their quit attempts.
STAGE 1: Not ready to quit in the next month STAGE 2: Ready to quit in the next month
STAGE 3: Recent quitter, quit within past 6 months STAGE 4: Former tobacco user, quit > 6 months ago
ASSESSING
READINESS to QUIT
Patients differ in their readiness to quit.
Assessing a patient’s readiness to quit enables clinicians
to deliver relevant, appropriate counseling messages.
Former tobacco
user
Recent quitter
Ready to quit
Not ready to quit Relapse
Not thinking about it
Thinking about it, not ready
For most patients, quitting is a cyclical process, and their readiness to quit (or stay quit) will change over time.
Assess
readiness to quit (or to stay quit)
at each patient contact.
ASSESSING
READINESS to QUIT (cont’d)
IS a PATIENT READY to QUIT?
Does the patient now use tobacco?
Is the patient now ready to quit?
Provide treatment
The 5 A’s Promote
motivation
Yes
Yes No
Did the patient once use tobacco?
Prevent
relapse* Encourage
continued abstinence
Yes No
No
*Relapse prevention interventions not necessary if patient has not used tobacco for many years and is not at risk for re-initiation.
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS.
STAGE 1: Not ready to quit
Not thinking about quitting in the next month
Some patients are aware of the need to quit.
Patients struggle with ambivalence about change.
Patients are not ready to change, yet.
Pros of continued tobacco use outweigh the cons.
GOAL: Start thinking about quitting.
ASSESSING
READINESS to QUIT (cont’d)
STAGE 1: NOT READY to QUIT Counseling Strategies
DON’Ts
Persuade
“Cheerlead”
Tell patient how bad tobacco is, in a judgmental
manner
Provide a
treatment plan DOs
Strongly advise to quit
Provide information
Ask noninvasive questions;
identify reasons for tobacco use
“Envelope”
Raise awareness of health consequences/concerns
Demonstrate empathy, foster communication
Leave decision up to patient
The 5 R’s—Methods for increasing motivation:
Relevance
Risks
Rewards
Roadblocks
Repetition
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS.
Tailored, motivational
messages
STAGE 1: NOT READY to QUIT
Counseling Strategies (cont’d)
STAGE 1: NOT READY to QUIT A Demonstration
CASE SCENARIO:
MS. STEWART
You are a clinician providing care to Ms. Stewart, a 55-year-old patient with emphysema.
She uses two different inhalers to treat her emphysema.
VIDEO #1
Ask about tobacco use
Link inquiry to knowledge of disease
Assess readiness to quit
Aware of need to quit; not ready yet
Advise to quit
Discuss implications for disease progression
“I will help you, when you are ready”
STAGE 1: NOT READY to QUIT
Case Scenario Synopsis
The clinician has
Established a relationship
Established herself as a resource
Planted a seed to move patient forward
Opened a door to facilitate further counseling
STAGE 1: NOT READY to QUIT
Case Scenario Synopsis (cont’d)
Ready to quit in the next month
Patients are aware of the need to, and the benefits of, making the behavioral change.
Patients are getting ready to take action.
STAGE 2: Ready to quit
GOAL: Achieve cessation.
ASSESSING
READINESS to QUIT (cont’d)
Assess tobacco use history
Discuss key issues
Facilitate quitting process
STAGE 2: READY to QUIT
Three Key Elements of Counseling
STAGE 2: READY to QUIT Assess Tobacco Use History
Praise the patient’s readiness
Assess tobacco use history
Current use: type(s) of tobacco, brand, amount
Past use: duration, recent changes
Past quit attempts:
Number, date, length
Methods used, compliance, duration
Reasons for relapse
Reasons/motivation to quit (or avoid relapse)
Confidence in ability to quit (or avoid relapse)
Triggers for tobacco use
What situations lead to temptations to use tobacco?
What led to relapse in the past?
Routines/situations associated with tobacco use
STAGE 2: READY to QUIT Discuss Key Issues
When drinking coffee
While driving in the car
When bored or stressed
While watching television
While at a bar with friends
After meals
During breaks at work
While on the telephone
While with specific friends or family
members who use tobacco
“Smoking gets rid of all my stress.”
“I can’t relax without a cigarette.”
There will always be stress in one’s life.
There are many ways to relax without a cigarette.
THE MYTHS
STRESS MANAGEMENT SUGGESTIONS:
Deep breathing, shifting focus, taking a break.
Smokers confuse the relief of withdrawal with the feeling of relaxation.
STAGE 2: READY to QUIT Discuss Key Issues (cont’d)
THE FACTS
Stress-Related Tobacco Use
Patients who receive social support and
encouragement are more successful in quitting.
ADVISE PATIENTS TO DO THE FOLLOWING:
Ask family, friends, and coworkers for support, for example, not to smoke around them and not to leave cigarettes out
Talk with their health care provider
Get individual, group, or telephone counseling
STAGE 2: READY to QUIT Discuss Key Issues (cont’d)
Social Support for Quitting
HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.
Most smokers gain fewer than 10 pounds,
but there is a wide range.
Discourage strict dieting while quitting
Recommend physical activity
Encourage healthful diet, planning of meals, and inclusion of fruits
Suggest increasing water intake or chewing sugarless gum
Recommend selection of nonfood rewards
Maintain patient on pharmacotherapy shown to delay weight gain
Refer patient to specialist or program
STAGE 2: READY to QUIT Discuss Key Issues (cont’d)
Concerns about Weight Gain
Most pass within 2–4 weeks after quitting
Cravings can last longer, up to several months or years
Often can be ameliorated with cognitive or behavioral coping strategies
Refer to Withdrawal Symptoms Information Sheet
Symptom, cause, duration, relief
Most symptoms peak 24–48 hours
after quitting and subside within
2–4 weeks.
HANDOUT
STAGE 2: READY to QUIT Discuss Key Issues (cont’d)
Concerns about Withdrawal Symptoms
Discuss methods for quitting
Discuss pros and cons of available methods
Pharmacotherapy: a treatment, not a crutch!
Importance of behavioral counseling
Set a quit date
Recommend Tobacco Use Log
Helps patients to understand when and why they use tobacco
Identifies activities or situations that trigger tobacco use
Can be used to develop coping strategies to overcome the temptation to use tobacco
STAGE 2: READY to QUIT Facilitate Quitting Process
HANDOUT
Continue regular tobacco use for 3 or more days
Each time any form of tobacco is used, log the following information:
Time of day
Activity or situation during use
“Importance” rating (scale of 1–3)
Review log to identify situational triggers for tobacco use; develop patient-specific coping strategies
STAGE 2: READY to QUIT
Facilitate Quitting Process (cont’d)
Tobacco Use Log: Instructions for use
Discuss coping strategies
Cognitive coping strategies
Focus on retraining the way a patient thinks
Behavioral coping strategies
Involve specific actions to reduce risk for relapse
STAGE 2: READY to QUIT
Facilitate Quitting Process (cont’d)
HANDOUT
Review commitment to quit
Distractive thinking
Positive self-talk
Relaxation through imagery
Mental rehearsal and visualization
Cognitive Coping Strategies
STAGE 2: READY to QUIT
Facilitate Quitting Process (cont’d)
Thinking about cigarettes doesn’t mean you have to smoke one:
“Just because you think about something doesn’t mean you have to do it!”
Tell yourself, “It’s just a thought,” or “I am in control.”
Say the word “STOP!” out loud, or visualize a stop sign.
When you have a craving, remind yourself:
“The urge for tobacco will only go away if I don’t use it.”
As soon as you get up in the morning, look in the mirror and say to yourself:
“I am proud that I made it through another day without tobacco.”
Cognitive Coping Strategies: Examples
STAGE 2: READY to QUIT
Facilitate Quitting Process (cont’d)
Control your environment
Tobacco-free home and workplace
Remove cues to tobacco use; actively avoid trigger situations
Modify behaviors that you associate with tobacco: when, what, where, how, with whom
Substitutes for smoking
Water, sugar-free chewing gum or hard candies (oral substitutes)
Take a walk, diaphragmatic breathing, self-massage
Actively work to reduce stress, obtain social support, and alleviate withdrawal symptoms
Behavioral Coping Strategies
STAGE 2: READY to QUIT
Facilitate Quitting Process (cont’d)
Provide medication counseling
Promote compliance
Discuss proper use, with demonstration
Discuss concept of “slip” versus relapse
“Let a slip slide.”
Offer to assist throughout quit attempt
Follow-up contact #1: first week after quitting
Follow-up contact #2: in the first month
Additional follow-up contacts as needed
Congratulate the patient!
STAGE 2: READY to QUIT
Facilitate Quitting Process (cont’d)
Actively trying to quit for good
Patients have quit using tobacco sometime in the past 6 months and are taking steps to increase their success.
Withdrawal symptoms occur.
Patients are at risk for relapse.
STAGE 3: Recent quitter
GOAL: Remain tobacco-free for at least 6 months.
ASSESSING
READINESS to QUIT (cont’d)
HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.
STAGE 3: RECENT QUITTERS Evaluate the Quit Attempt
Status of attempt
Ask about social support
Identify ongoing temptations and triggers for relapse
(negative affect, smokers, eating, alcohol, cravings, stress)
Encourage healthy behaviors to replace tobacco use
Slips and relapse
Has the patient used tobacco at all—even a puff?
Medication compliance, plans for termination
Is the regimen being followed?
Are withdrawal symptoms being alleviated?
How and when should pharmacotherapy be terminated?
Congratulate success!
Encourage continued abstinence
Discuss benefits of quitting, problems encountered, successes achieved, and potential barriers to continued abstinence
Ask about strong or prolonged withdrawal symptoms (c hange dose, combine or extend use of medications)
Promote smoke-free environments
Social support
Discuss ongoing sources of support
Schedule additional follow-up as needed; refer to support groups
STAGE 3: RECENT QUITTERS Facilitate Quitting Process
Relapse Prevention
Tobacco-free for 6 months
Patients remain vulnerable to relapse.
Ongoing relapse prevention is needed.
STAGE 4: Former tobacco user
GOAL: Remain tobacco-free for life.
ASSESSING
READINESS to QUIT (cont’d)
HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.
STAGE 4:
FORMER TOBACCO USERS
Assess status of quit attempt
Slips and relapse
Medication compliance, plans for termination
Has pharmacotherapy been terminated?
Continue to offer tips for relapse prevention
Encourage healthy behaviors
Congratulate continued success
Continue to assist throughout the quit attempt.
READINESS to QUIT: A REVIEW
Recent quitter
Not ready to quit Former tobacco user
Quit date
Ready to quit
- 30 days + 6 months
Promote motivation The 5 R’s
Behavioral counseling Pharmacotherapy
The 5 A’s
Behavioral counseling
Relapse prevention Behavioral
counseling Pharmacotherapy
Relapse
prevention
Routinely identify tobacco users (ASK)
Strongly ADVISE patients to quit
ASSESS readiness to quit at each contact
Tailor intervention messages (ASSIST)
Be a good listener
Minimal intervention in absence of time for more intensive intervention
ARRANGE follow-up
Use the referral process, if needed
COMPREHENSIVE
COUNSELING: SUMMARY
Brief interventions have been shown to be effective
In the absence of time or expertise:
Ask, advise, and refer to other resources, such as local programs or the toll-free quitline
1-800-QUIT-NOW
BRIEF COUNSELING:
ASK, ADVISE, REFER
This brief
intervention can be achieved in
30 seconds.
WHAT IF…
a patient asks you
about your use of
tobacco?
Courtesy of Mell Lazarus and Creators Syndicate. Copyright 2000, Mell Lazarus.
The RESPONSIBILITY of HEALTH PROFESSIONALS
It is inconsistent
to provide health care and
—at the same time—
remain silent (or inactive) about a major health risk.
TOBACCO CESSATION
is an important component of
THERAPY.
DR. GRO HARLEM BRUNTLAND,
FORMER DIRECTOR-GENERAL of the WHO:
“If we do not act decisively, a hundred years from now our grandchildren and their children will look back and
seriously question how people claiming to be committed to public health and social justice allowed the tobacco
epidemic to unfold unchecked.”
USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS.
AIDS for CESSATION &
CASE SCENARIO OVERVIEW
METHODS for QUITTING
Nonpharmacologic
Pharmacologic
Combination therapy is preferred.
NONPHARMACOLOGIC METHODS
Cold turkey: Just do it!
Unassisted tapering (fading)
Reduced frequency of use
Lower nicotine cigarettes
Special filters or holders
Assisted tapering
QuitKey
NONPHARMACOLOGIC METHODS (cont’d)
Formal cessation programs
Self-help programs
Individual counseling
Group programs
Telephone counseling
1-800-QUITNOW
1-800-786-8669
Web-based counseling
www.smokefree.gov
www.quitnet.com
Aversion therapy
Acupuncture therapy
Hypnotherapy
Massage therapy
SCHEDULED GRADUAL REDUCTION of SMOKING
Gradual reduction of the total number of cigarettes smoked per day
Computerized unit facilitates reduction:
QuitKey
Tapering curve developed based on patient’s smoking level
19–24% abstinent at 1 year
Includes telephone counseling support
QuitKey
SMOKING CESSATION PROGRAM
QuitKey
SMOKING CESSATION PROGRAM
Stage 1 (7 days)
Push the SMOKE button every time you smoke, to record smoking habits
Turn unit on every morning and off every night
Stage 2 (14–34 days)
Smoke only when you hear the tone or see the SMOKE SIGNAL; tapers smoking over time
Press the SMOKE button every time you smoke
Turn unit on every morning and off every night
SCHEDULED GRADUAL REDUCTION (cont’d)
Who is a candidate for scheduled gradual reduction?
Anyone who wants to quit smoking
Particularly useful in persons for whom medications might not be a first-line choice, such as pregnant women or teens
Spit tobacco users (18.4% abstinent after 1 year) Ordering information
www.quitkey.com or 1-800-543-3744 ($59.95)
PHARMACOTHERAPY
“All patients attempting to quit should be encouraged to use
effective pharmacotherapies for smoking cessation except
in the presence of special circumstances.”
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS.
PHARMACOLOGIC METHODS:
FIRST-LINE THERAPIES
Three general classes of FDA-approved drugs for smoking cessation:
Nicotine replacement therapy (NRT)
Nicotine gum, patch, lozenge, nasal spray, inhaler
Psychotropics
Sustained-release bupropion
Partial nicotinic receptor agonist
Varenicline
Currently, no medications have an FDA indication
for use in spit tobacco cessation.
FDA APPROVALS:
SMOKING CESSATION
1984
Rx nicotine
gum 1991
Rx transdermal nicotine patch
1996
OTC nicotine gum & patch;
Rx nicotine nasal spray
1997
Rx nicotine inhaler;
Rx bupropion SR
2002
OTC nicotine lozenge
2006
varenicline Rx
NRT: RATIONALE for USE
Reduces physical withdrawal from nicotine
Allows patient to focus on behavioral and psychological aspects of tobacco cessation
NRT APPROXIMATELY DOUBLES QUIT RATES.
NRT APPROXIMATELY DOUBLES QUIT RATES.
Polacrilex gum
Nicorette ( OTC)
Generic nicotine gum (OTC)
Lozenge
Commit (OTC)
Generic nicotine lozenge (OTC)
Transdermal patch
Nicoderm CQ (OTC)
Generic nicotine patches (OTC, Rx)
Nasal spray
Nicotrol NS (Rx)
Inhaler
Nicotrol (Rx)
NRT: PRODUCTS
PLASMA NICOTINE CONCENTRATIONS for NICOTINE-CONTAINING PRODUCTS
0 10 20 30 40 50 60 Time (minutes)
Cigarette
Moist snuff
NRT: PRECAUTIONS
Patients with underlying cardiovascular disease
Recent myocardial infarction (within past 2 weeks)
Serious arrhythmias
