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Tobacco Cessation: Academic Nursing Partnerships for Success

Janie Heath PhD, APRN-BC, ANP, ACNPAssociate Dean Academic Nursing PracticeMedical College of Georgia

Georgetown University

Washington, DC

Medical College of Georgia

Augusta, GA

VANDERBILT SCHOOL OF NURSING

Nashville, TN

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Objectives" Identify the importance of

integrating tobacco cessation inDAILY practice

" Identify key strategies /approaches for integrating tobaccocessation in DAILY practice

" Identify essential resources forintegrating tobacco cessation inDAILY practice

VISIT: www.tobaccofreenurses.org

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Why Make Tobacco Cessation a

Standard for Practice?" QUALITY OUTCOMES =

PAYMENT and HEALTH

" HEIDIS says to do it!

" JCAHO says to do it!

" The Surgeon Generalsays to do it!

" The wife says to do it!

http://www.surgeongeneral.gov/tobacco/

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TRENDS in ADULT SMOKING, by

SEXU.S., 19552004Trends in cigarette current smoking among persons aged 18 or older

Graph provided by the Centers for Disease Control and Prevention. 1955 Current PopulationSurvey; 19652001 NHIS. Estimates since 1992 include some-day smoking.

Percent

The GOOD News: 70% want to quit

0

15

30

45

60

1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999 2003

Male

Female 23.4%

18.5%

20.9% of adultsare current

smokers

Year

44.5 Million Adults are Addicted to Cigarettes

The BAD News: < 36% Receive Information on HOW to quit

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STATE-SPECIFIC PREVALENCE of

SMOKING among ADULTS, 2004

Centers for Disease Control and Prevention. (2005). MMWR 54:11241127.

California14.8%

Utah10.5%

Kentucky27.6%

Nevada23.2%

TN26.1%

GA20.1%

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STATE-Cigarette Excise Tax / Pk,

10/2006

California87 cents

Utah69.5 cents

Kentucky30 cents

Nevada80 cents

TN20 cents

GA37 cents

HIGHEST

NJ = $2.56

LOWEST

SC = 00.07cents

Campaign for Tobacco-Free Kids. (2006). State Cigarette Excise Tax Rates & Rankings. Retrieved

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PREVALENCE of ADULT SMOKING,

by RACE/ETHNICITYU.S., 2004

0% 50%

11.3% Asian

33.4% American Indian/Alaska Native

20.2% Black, non-Hispanic

22.2% White, non-Hispanic

15.0% Hispanic

Centers for Disease Control and Prevention. (2005). MMWR 54:11211124.

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Prevalence and Harm of SMOKING

during PREGNANCY" Miscarriage

" Stillbirth

" Preterm delivery

" Low birth weightBABY ALERT: 27% OF TobaccoDependent WOMEN Continue to

SMOKE THROUGHOUTPREGNANCY

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PREVALENCE of ADULT SMOKING,

by EDUCATIONU.S., 2004

0% 50%

11.7% Undergraduate degree

26.2% No high school diploma

39.6% GED diploma

24.0% High school graduate

22.2% Some college

8.0% Graduate degree

Centers for Disease Control and Prevention. (2005). MMWR 54:11211124.

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Sources: (AIDS) HIV/AIDS Surveillance Report, 1998; (Alcohol) McGinnis MJ, Foege WH. Review:Actual Causes of Death in the United States.JAMA1993;270:2207-12; (Motor vehicle) NationalHighway Transportation Safety Administration, 1998; (Homicide, Suicide) NCHS, vital statistics,1997; (Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995

Column 1

NumberofDeaths(thousands)

0

110

220

330

440

AIDS

Alcoho

l

Motor

Vehicle

Homicid

e

Drug

Indu

ced

Suicid

e

Smokin

g

Annual Causes of Death from Smoking

Compared to Other PREVENTABLE Causes

AMAZING

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ANNUAL U.S. DEATHSATTRIBUTABLE to SMOKING, 1997

2001

Centers for Disease Control and Prevention. (2005). MMWR 54:625628.

32%

28%23%

9%

8%

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USDHHS. (2006).The Health Consequences of Involuntary Exposure to Tobacco Smoke:Report of the Surgeon General.

2006 REPORT of theSURGEON GENERAL:

INVOLUNTARY EXPOSURE to TOBACCO SMOKE

" Approximately 50,000adults & infants die / yearfrom secondhand smoke

" 126 million nonsmokers inthe U.S. are exposed tosecondhand smoke

" Secondhand smokecontains more than 50carcinogens

" TWENTY YEARS later weFINALLY haveevidencethe right of

smokers to smoke endswhere their behavior affectsthe health and well-being ofothers

" Surgeon General Koop,USDHHS Surgeon GeneralReport, 1986

There is nosafe level ofsecond-hand

smoke.

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FINANCIAL IMPACT of SMOKING

Packsperday

Buying cigarettes every day for 50 years @ $4.12 per packMoney banked monthly, earning 1.5% interest

0 100 200 300 400

Hundreds of thousands of dollars lost

$331,467

$220,978

$110,489

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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

Gases (~500 isolated) Particles (~3,500 isolated)

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Marketing Strategy: Light and Ultra-Light Cigarettes

The difference between Marlboro and Marlboro Lights

an extra row of ventilation holes

Image courtesy of Mayo Clinic Nicotine Dependence Center - Research Program / Dr. Richard D. HurtThe Marlboro and Marlboro Lights logos are registered trademarks of Philip Morris USA.

15mg tar, 1.1 mgnicotine

10mg tar, 0.8 mgnicotine

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The Safer Cigarette NOT!

Unveiling the SMOKING gun about Safe Cigarettes!

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Face the Facts: Tobacco VS Marijuana

" Prevalence of Marijuanause among adults = 4%

compared to 21% fortobacco use

" NIH, 2002 report, National Institute onDrug Abuse

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Face the Facts: Tobacco VS Marijuana" Marijuana smoke contains

50 70% more carcinogensthan tobacco smoke

" Marijuana smoke has 3-5 xthe amount of tar andcarbon monoxide

" One joint = 4 cigarettes

" NIH, 2002 report, National Institute on DrugAbuse

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Face the Facts: Tobacco VS Marijuana" Marijuana is an intoxicant

makes you high/drunk

" THC, tetrahydrocannabinol, isthe active psychoactiveingredient that alters sense ofreality & euphoria

" THC over stimulatescannabinoid receptors in thehippocampus

" Increase in THC content from0.2% in 1960 to 12% in 2000

" NIH, 2002 report, National Institute on Drug Abuse

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Face the Facts: Tobacco VS Marijuana

" Regardless of the form /delivery of Marijuana, it is

illegal" Exception = medicinal

purposes such as Marinolcapsule used for pain / loss ofappetite / nausea for pts with

AIDS or cancer

" NIH, 2002 report, National Institute on

Drug Abuse

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The Rest of the Story: Theres Other

Tobacco ProductsChewing tobacco

" Looseleaf" Plug" Twist

Snuff" Moist" Dry

The Copenhagen and Skoal logos are registered trademarks of U.S. Smokeless Tobacco Company,and Red Man is a registered trademark of Swedish Match.

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Other Tobacco Products

CIGARS KRETEKS / CLOVE CIGARETTES

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Other Tobacco Products

BIDIS HOOKAH PIPE,

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BENEFICIAL PULMONARY EFFECTS of

QUITTING

Reprinted with permission. Fletcher & Peto. (1977). BMJ 1(6077):16451648.

Disability

Death

Smokedregularly and

susceptible toeffects of smoke

Never smokedor not susceptibleto smoke

Stopped smokingat 45 (mild COPD)

Stopped smokingat 65 (severeCOPD)

25

FEV1

(%o

fvalueatage2

5)

25

50

75

100

0

50 75

Age (years) COPD = chronic obstructive pulmonary disease

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Breaking the NICOTINE DEPENDENCE Cycle at ANY age!

ThePHYSICAL

TheEMOTIONAL

TheBEHAVIOR

Physical addiction ofcravings & withdrawals

Role of cigarettes in lifepleasure, stress, social

Automatic learnedbehavior with cigarettes

A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

Adapted from Legacys GSD&M Presentation 12/5/03

O

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Nicotine entersbrain

Stimulation ofnicotine receptors

Dopamine release

DOPAMINE REWARD PATHWAY

Prefrontalcortex

Nucleusaccumbens

Ventraltegmental

area

Within 7 11 seconds

I feel good

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"An individual smokes 1pack per day x 20 yrs

" 20 cigarettes / pack

" 10 puffs / cigarette

" = ?? puffs / day

" THATs ____ HITS ofNICOTINE per DAY

NICOTINE BEHAVIORAL EFFECTS:

Do the Math!" Now Multiply that # by days /

year

" THEN multiply that numberby years smoking!

"

YIKES! No wonder it is SOdifficult to QUIT-

" Average attempts = 7-10per smokers lifetime

200

73,000

1.4 million

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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):S159S163.

! 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

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" 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 Psychiatry48:5259.Hughes & Hatsukami. (1998). Tob Control 7:9293.

Most symptoms

peak 2448 hrafter quitting and

subside within24 weeks.

* Not considered a withdrawal symptom by DSM-IV criteria.

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ASSESSING

NICOTINE DEPENDENCE" How soon after you wake up do

yousmoke your first cigarette

" Do you find it difficult torefrain from smoking in

restricted areas" Which cigarette do you hate

to give up most

" How many cigarettes do yousmoke per day

" Do you smoke morefrequently during the firsthours after waking

" Do you smoke if you are so illthat you are in bed most ofthe day

Fagerstrm Test for NicotineDependence (FTND)

Scores range from 0 to 10; a score ofgreater than 5 indicates substantial

dependence

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ASK

ADVISE

ASSESS

ASSIST

ARRANGE

The 5 As

Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.Rockville, MD: USDHHS, PHS.

IF timedoes notallow.do 3 AsandREFER

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" In the absence of time or expertise. ask, advise,assess, and refer to other resources, such as local

programs or the toll-free quitline1-800-QUIT-NOW

Modified Version of 5 As = The 3 As &

REFER

This brief

intervention canbe achieved in 30

seconds.

TO ORDER CARDS www.smokingcessationleadershipcenter.org

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METHODS for INCREASING

MOTIVATIONFIVE Rs" FOR INDIVIDUALS NOT READY TO

QUIT YET: Tailor messages withMotivational InterviewingTechniques

" RELEVANCE

" RISKS

"

REWARDS

" ROADBLOCKS

" REPETITION

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline.Rockville, MD: USDHHS, PHS, 2000.

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STRATEGIES for Successful Tobacco

Cessation" Walk the Talk of Evidence Based

Practice

" Acute and critical care admissions =

HIGHLY TEACHABLE MOMENTS

" Provide structures/systems (chartprompts, standing orders, dedicatedcounselors) to facilitate success in

breaking the nicotine cycles ofaddiction

" Emotional -Cognitive Tools

" Behavioral- Tools

" Physical - Biological ToolsINTERDISCIPLINARY APPROACHESSENTIALS: collaboration, effective decision

making AND compassionate caring practices

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Cognitive Evidence-Based

STRATEGIES" SET DATE

" Design individualized plan

" TRIGGERS"

MOTIVATION andCONFIDENCE to quit (0-10)" Routines/situations

associated with tobacco use Tobacco Log

" Social support

" ASSIST to change routine" Non-food / healthy items instead

of cigarettes" Tea instead of coffee / Exercise

instead of smoking

A modified US PHS GuidelineApproach: START

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" ASSIST (continued)" Coping strategies for life

stressors /emotionaltriggers

" Weight gain concerns

" Withdrawal concerns the 4 Ds

" Relapse concerns" Daily affirmation" Pharmacotherapy options

" REMOVE tobacco products forQUIT day" Home Car Office

" TREAT SELF" Facial, Dental, Manicure

ThePHYSICAL

Cognitive Evidence-Based

STRATEGIES Continued

A modified US PHS Guideline Approach:START

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Quitting is HARD to do!

ThePHYSICAL

TheEMOTIONAL

TheBEHAVIOR

Physical addiction ofcravings & withdrawals

Role of cigarettes in lifepleasure, stress, social

Automatic learnedbehavior with cigarettes

A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

Adapted from Legacys GSD&M Presentation 12/5/03

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Nicotine Replacement Therapy

(NRT): RATIONALE for USE" Reduces physical

withdrawal from nicotine

" Allows patient to focuson behavioral andpsychological aspects oftobacco cessation

" It is NOT substitutingONE negative healthbehavior for another

IMPROVES SUCCESS RATES!

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LONG-TERM ("6 month) QUIT RATES for

AVAILABLE CESSATION MEDICATIONS

0

6

12

18

24

Nicotine gum Nicotine lozenge Nicotine inhaler

Active drugPlacebo

Data adapted from Silagy et al. (2004). Cochrane Database Syst Revand Hughes et al., (2004). Cochrane Database Syst Rev.

Percentquit

19.5

14.6

11.5

8.6

16.4

8.8

23.9

11.8

17.1

9.1

20.0

10.2

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FDA APPROVALS: SMOKING

CESSATION

1984

Rx

nicotine

gum 1991

Rx transdermalnicotine patch

1996

OTC nicotine gum & patch;

Rx nicotine nasal spray

1997

Rx nicotine

inhaler;

Rx bupropion SR

2002

OTC nicotine

lozenge

2006

Rx

varenicline

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NICOTINE ABSORPTIONAbsorption is pH dependent

" In acidic media

"

Ionized #

poorly absorbed across membranes" In alkaline media

" Nonionized #well absorbed across membranes

At physiologic pH (7.37.5),nicotine is readily absorbed.

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PLASMA NICOTINE CONCENTRATIONS for

NICOTINE-CONTAINING PRODUCTS

Plasmanicotine(mc

g/l)

0

7.5

15

22.5

30

0 3 5 10 15 30 45 60

CigaretteMoist snuffNasal sprayInhalerLozenge (2mg)Gum (2mg)Patch

0 10 20 30 40 50 60

Time (minutes)

Cigarette

Moist snuff

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Overall PRECAUTIONS, if ANY,

for NRT

"

All NRT products =Category D pregnancy

" Recent MI (< 2 wks),

unstable angina, seriousarrhythmias

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OTC NICOTINE GUM: Nicorette;

generic (GlaxoSmithKline; Watson Labs)

" Dose = 1 every 1-2 hrs;

" No food/beverage 15 min

prior - during or 15 min post

" Max = 24 / day

"

Available: 2 mg, 4 mg; regular, mint, orange" NOT recommended if use dentures or TMJ dz

" Possible jaw soreness/hiccups/dyspepsia

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OTC NICOTINE GUM:

CHEWING TECHNIQUE SUMMARY

Park

Stop chewing at first signof peppery, minty, orcitrus taste or tingle

Chew

slowly

Chew againwhen the tasteor tingle fades

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OTC TRANSDERMAL NICOTINE PATCH

" Dose = 1 patch every day(16 hrs or 24 hrs) mostdosage = 7mg/ 14mg/21mg

" 24 hr patch NOTrecommended for sleepdisorders

" Best if ROTATE patchdifferent areas

" Preferred sites abovethe waist

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OTC TRANSDERMAL NICOTINE PATCH" If problems sticking

apply TEGADERM dressingover patch

" May bathe/swim withpatch

" Do NOT cut patch

" Not recommended ifacute/chronic skin dz

" Possible local skin reaction

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OTC NICOTINE LOZENGE

Commit (GlaxoSmithKline)" Dose = 1every 1-2 hrs MAX = 20 / d

" No food/beverage 15 min prior

- during or 15 min post

" Delivers ~25% more nicotine thanequivalent gum dose

" Available: 2 mg, 4 mg

" Let dissolve 20-30 minutes; NOchewing/biting of product

" Possible hiccups/dyspepsia/

lightheadedness if chewing or biting

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Rx NICOTINE NASAL SPRAY

Nicotrol NS

(Pharmacia)

" Dose = 1 dose (2 sprays per nostril)every hr

" MAX = 5 doses/hr OR 40 doses /day"

Each dose delivers -50 !L spray = 0.5 mgnicotine per spray" Rapidly absorbed across nasal mucosa --

faster onset of action (1113 minutes)compared to the gum, patch, or inhaler

" Not recommended if nasal/reactiveairway conditions

" Possible nasal/throat irritation

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Rx NICOTINE INHALER

Nicotrol Inhaler(Pharmacia)

" Dose = 6- 16 cartridges / d

" MAX = 16 cartridges / d

" Puff as lighting a cigar/pipebestif puff for ~ 20 minutes

" Delivers 4 mg nicotine vapor, which isabsorbed across buccal mucosa - ~ 20minutes of puffing = 1 cartridge

" Not recommended if reactive airwaycondition

" Possible nasal/throat irritation

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Rx BUPROPION SR (ZYBAN)(GlaxoSmithKline)

" Non-nicotine agent

" Sustained release antidepressant

" Dose = 150mg every a.m. x 3 daysthen 150mg twice a day

"

IMPORTANT to start 2 wks prior toQUIT date

" Contraindications = seizuredisorders, anorexia /bulimia,recent MAO inhibitor use,concomitant use of Bupropion

(Wellbutrin), abruptdiscontinuation of ETOH /sedatives

" Precaution pregnancy (Category B) anddrugs known to lower seizure threshold

" Leading side effect = dry mouth andinsomnia

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Rx VARENICLINE

Chantix (Pfizer): NEW & PROMISING" Non-nicotine

cessation aid

" Partial nicotinic

receptor agonist forthe $4!2nicotinic

acetylcholine receptor" Lessens sx of

withdrawal andcravings

" Inhibits surgesof dopaminerelease

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VARENICLINE

Chantix (Pfizer)

" Oral formulation- ~24 hr

half life- steady statewithin 4 days

" Leading side effect =nausea

" Category C pregnancy

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VARENICLINE: DOSINGPatients should begin therapy 1 week PRIOR to theirquit date. The dose is gradually increased to minimize

treatment-related nausea and insomnia.

Initial

dosetitration

*Patients should be treated for 12 weeks.

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Breaking the NICOTINE DEPENDENCE Cycle

ThePHYSICAL

TheEMOTIONAL

TheBEHAVIOR

Physical addiction ofcravings & withdrawals

Role of cigarettes in lifepleasure, stress, social

Automatic learnedbehavior with cigarettes

A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

Adapted from Legacys GSD&M Presentation 12/5/03

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Follow Up for SUCCESS

META ANALYSIS (n = 45 studies) Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating TobaccoUse and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health andHuman Services, Public Health Service.

FU PRIORITYFOCUS = cravings,

withdrawals, medtolerance, coping

with triggers &CONGRATS

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WHAT IF

a patient asksyou aboutyour use oftobacco?

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DR. GRO HARLEM BRUNTLAND,FORMER DIRECTOR-GENERAL of the WHO

If we do not act decisively, a hundredyears from now our grandchildren and

their children will look back andseriously question how people claimingto be committed to public health andsocial justice allowed the tobacco

epidemic to unfold unchecked.

USDHHS. (2001). Women and Smoking: A Report of the Surgeon General.Washington, DC: PHS.

The RESPONSIBILITY ofHEALTH PROFESSIONALS

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Slide resources/references available at

http://rxforchange.ucsf.edu

http://nurses4tobaccocontrol.org

htt //t b f

THANK YOU