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Nori de la PeñaMichael Leon-GuerreroPublic Health - Seattle & King CountyTobacco Prevention Program(206) 296-7613
Brief Tobacco Intervention Skills (BTIS) training
Summer 2010 DESC training
[email protected]
Framing the issue, understanding the addiction
and implementing an effective intervention
program
HealthPoint
August 10th
, 2010
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Overview
• Frame the issue• What’s new: mental
illness/alternative products• Three-link chain of addiction• 2A’s• 5A’s• Resources
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Smoking Statistics
• Those with mental health issues smoke more – US: 22.5% v. 34.8% (MI in lifetime) v. 41.0% (MI
in last month)• The poor smoke more than the rich
– KC: 10% for > $50,000/yr v. 25% for <$15,000/yr
• 70% of homeless people smoke (three times national rate) MI purchase nearly 50% of all cigarettes
• Homeless, substance abusers and the mentally ill more vulnerable to health effects of smoking
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0
100
200
300
400
500
Drug Abuse Alcohol Tobacco
US Annual Deaths (thousands)
McGinnis & Foege, 1999
0
20
40
60
80
100
per
cen
t o
f su
bst
ance
abu
se p
ages
Drug Abuse Alcohol Tobacco
Ginzel, 1985
Medical Textbook Coverageof Substance Abuse
Doctors advise adolescents about tobacco <2% of visits
Medical Bias in Considering Tobacco a "Drug of Abuse"
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Tobacco smoke:
• No safe level of exposure• Class A carcinogen (causes
cancer)• Over 60 chemicals cause cancer• Over 2000 chemicals total• Effects every system in the body
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A Toxic Waste Dump
• Arsenic • Ammonia• Benzene• Carbon Monoxide• Ethanol• Formaldehyde• Hydrogen
Cyanide• Lead
• Methane• Mercury• Silicon• Polonium 210• Vinyl Chloride• Urethane• Tar (resinous matter
from burning tobacco and includes most of the carcinogenic substances)
www.tobacco.org
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81
4119 14
30
440
0
50
100
150
200
250
300
350
400
450
An Unfair Share of MortalityN
um
ber
of
Dea
ths
(th
ou
san
ds)
Source: CDC
AIDS Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced
Est. 200,000 per year for mentally ill and SA
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The Double Whammy!
• As smoking rates fall in the general population, smoking is concentrating in the poor– Populations with less access to care
have fewer chances to quit or to get treatment for smoking related diseases
– Tobacco companies actively target folks living with mental illness and substance use
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Brief Tobacco Intervention TrainingTraining Info Here Truth-dot-com_Project-SCUM-cigarettes.mov
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SUCCESS =
• Everyone is asked tobacco status and advised then referred
• Tobacco status is documented• Follow-up happens at each visit
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Mental Health and NicotineMental Health and Nicotine
44% of all
cigarettes bought &
consumed in the US
are by individuals
living with mental
illness.
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MI and Nicotine
• 7.1 % of the US population has a psychiatric illness; however this populations buys/consumes 44.2% of all cigarettes
• Smoking rates are 3-5 times higher
• Successful in stopping their tobacco use
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Unfair Share of the Burden
Without help, nearly 60% of mental health clients will die from tobacco related illness.
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Be Aware That:
• Tobacco dependence is chronic
• Tobacco users may have other addictions
• The physical environment is part of the message
• Other community agencies promoting cessation
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Alternative tobacco
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Your Role
Your clients have many competing health/mental health/substance use issues:Helping them quit smoking will directly improve their overall health.
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WHY don’t they just QUIT?
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Why Don’t They Just Quit?
+ No Cessation Help
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The intervention: 2A’s & R
Site Champ
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ASK
• Ask clients at screening or when appropriate if they smoke
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ADVISE
Urge every tobacco user to quit• Clear: “One of the best things you can do
for your health is to quit smoking. I can help you.”
• Strong: “As your case manager, I need you to know that quitting smoking is one of the most important things you can do for your health.”
• Personalized: Tie tobacco use to current health issues, relationships, or economic stress
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1) SITE CHAMP
2) 1-800-QUIT NOW1-877-2NO FUME
www.quitline.com
REFER
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Washington State Quitline – OVER 18
• Free telephone counseling for people ready to quit in the next 30 days
• Proven to increase success in quitting for many
• Includes different pharmacotherapy benefits for different populations
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Medicaid eligible:
• Free services available for 18+ clients:
• Phone counseling and follow-up support calls through the quit line
• Nicotine patches or gum through the quit line, if appropriate
• Prescription medications recommended by quit line and prescribed by individual physicians, if appropriate
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Is the Quitline a Good Fit?
• Does your client have – A phone line?– An address for mailings?
• Is your client comfortable with telephone counseling?– Video and sample call on web can show them
what it’s like• Do they use interpreter services?
– Quitline has English and Spanish– Other languages available through telephone
interpreter• Has your client already used the benefit this year?
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“Ask”Identify Tobacco Use /exposure to smoke
Document chart
“Advise”To Quit
“Assess”willingness to quit
“Assist”with quitting
“Arrange”Follow-up
Quitline1-800-QUITNOW1-877-2NO FUME
Local ResourcesDESC champ(Provided by Sophie Balk, MD,
Albert Einstein College of Medicine)
Referrals
The 5 A’s
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ASSESS
Ask every tobacco user about quitting• Examples:
– “On a scale of 1 to 10, how ready do you feel to quit?”
– “Have you thought about quitting in the next 30 days?”
• If the client is ready to quit in the next 30 days provide assistance
• If the clients is not ready to quit provide a motivational intervention (5R’s)
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Header info here
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ASSIST
Help the ready client make a quit plan
• Set a quit date in 30 days• Plan to tell friends• Anticipate challenges • Plan to remove tobacco products • Recommend NRT use
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ARRANGE
Plan a time to follow-up after quit-date
• Congratulate success• Address challenges/relapse• Assess NRT use
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Benefits of Quitting
20 MinutesBP
Body Temp
8 Hours02 Levels
48 HoursTaste/Smell
Nerve Endings
2Weeks-3 MonthsCirculation
Lung Function
5 YearsLung Cancer Death Rate
Decreases by 50%
10 YearsRisk of HD/Stroke almost
the same as a non-smoker
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The 5R’s: Not Ready to Quit
The 5 R’s
RELEVANCE – Specific and personal reasons
RISKS – client identifies risks of smoking
REWARDS – client identifies benefits of quitting
ROADBLOCKS – client identifies barriers
REPITITION – Repeat motivational intervention
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Motivational Interviewing Is
• Starting where client is• Understanding client’s frame of
reference• Knowing choice to change is
client’s• Exploring options with client• Finding and reinforcing the
client’s motivation to change
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Motivation Enhancing SkillsMotivation Enhancing SkillsOARS - toolkit for SUCCESS!OARS - toolkit for SUCCESS!
• Open ended questions
• Affirmation• Reflections• Summarize
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Nicotine Replacement Therapy in biologically addicted adults
• NRT increases quit success (patch/counseling doubles rate)
• Safe, FDA approved, available OTC• Reduces most withdrawal symptoms
so quitter can comfortably break the habit
• Eliminates the reinforcing effect of nicotine as administered through smoking
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What NRT Does Not Do
• Without behavioral change/counseling, NRT does not increase quit rates
• NRT does not replace smoking– clients will still want to smoke– Does not provide bolus effect
(nicotine rush)
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Patch Counseling
• Apply promptly at quit date• Replace patch every day to dry,
clean, hairless place• Rotate sites over a seven day
period• Follow treatment plan for
decreasing dose over time
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Patch Side Effects
• Vivid dreams– Can remove before bed – New patch first thing in morning
• Localized skin reactions (rash)– Up to 50% of clientss have mild
form– Less than 5% discontinue therapy
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Smoking and NRT
• client should stop smoking on quit date
• “Slipping” will happen, and is not harmful
• If client continues to smoke after starting patch– Assess if they are really ready to quit – Address triggers for smoking
– Nausea, dizziness, vomiting
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Quitting the Three Link Chain
NRT??
BehavioralCounseling
Posters
Groups
Activities
+ Cessation Help @ DESC
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The best way to quit smoking is to combine a smoking cessation
message with a behavior modification program.
Some clients may benefit from NRT
Or medication.
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Relapse Is Common
• Tobacco dependence is chronic
• Cycle through relapse and remission
• 5 to 7 times not uncommon
• 7% long-term success quit on own
• Relapse not a failure—for clients or you
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Policies
• Tobacco policy• Tobacco free campus• I-901 compliance
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Public Health Contact
Community Tobacco Cessation Partnership
206-296-7613 [email protected]
For questions, and staff cessation referrals.
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Selected References
• Slide 4: – National Co morbidity Survey
– Washington State BRFSS 200-2004 Data:
– Connor et al, Smoking Cessation in a Homeless Population: There is a Will, but is There a Way? J Gen Int Med 2002;17:396-372.
• Slide 19: – Connor et al, Smoking Cessation in a Homeless Population: There
is a Will, but is There a Way? J Gen Int Med 2002;17:396-372.
• Slide 40: – Joseph Am. NEJM 1996 335:1792-8.
• JACC 29:1422-31
• Slide 47:
– Merck Manual, 2000