Promoting Smoke Free Homes: Counseling Patients and Their Families about Second Hand Tobacco Smoke and Tobacco Use in the Primary Care Setting Your name,

Promoting Smoke Free Homes:

Counseling Patients and Their Families about Second Hand Tobacco Smoke and Tobacco Use

in the Primary Care Setting

Your name, institution, etc. here

YOUR LOGO HERE(paste to each slide)

…dedicated to eliminating children’s exposure to tobacco and 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

SIDsSIDsBronchiolitisBronchiolitisMeningitisMeningitis

InfancyInfancy

Low Birth WeightLow Birth WeightStillbirthStillbirthNeurologic ProblemsNeurologic Problems

In uteroIn utero

AsthmaAsthmaOtitis MediaOtitis MediaFire-related InjuriesFire-related Injuries

InfluencesInfluencesto Startto StartSmokingSmoking

Nicotine AddictionNicotine Addiction

CancerCardiovascular DiseaseCOPD

AdulthoodAdulthood

AdolescenceAdolescence

ChildhoodChildhood

The Social Cycle of Tobacco Use

InfancyInfancy

In uteroIn utero

InfluencesInfluencesto Startto StartSmoking: Smoking: Media,Media,Household Members,Household Members,PeersPeers

AdulthoodAdulthood

AdolescenceAdolescence

ChildhoodChildhood

Alienation from peersAlienation from peerswho don’t use tobaccowho don’t use tobacco

The Economic Cycle of Tobacco Use

InfancyInfancy

In uteroIn utero

Decreased Decreased lifetimelifetimeearningsearnings

AdulthoodAdulthood

AdolescenceAdolescence

ChildhoodChildhood

Increased likelihood ofIncreased likelihood ofLiving in povertyLiving in poverty

A pack-a-day smokerA pack-a-day smokerSpends over $2000/yearSpends over $2000/year

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 AreEspecially 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 CounselHow To Counsel

The 5 As

Assess readiness to quit

Ask about tobacco use and SHS exposure

Advise to quit

Assist in quit attempt

Arrange follow-up

The 5 As

AssessAssess

AskAsk

AdviseAdvise

AssistAssist

ArrangeArrange

AskAsk

AdviseAdvise

ReferRefer

“2As and an R”

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 BetterWays to Ask

• “…if someone comes at you with an accusatory tone [you’re] going to be defensive.”

• “…putting me down about it doesn't help. If they talk down to me, making me feel small, it makes it so I don't want to quit. It…makes me feel bad.”

When We Don’t Ask in theRight 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

Behavior changeBehavior change

occurs in stagesoccurs in stages

– – not all at once.not all at once.

The Stages of Change Model

Precontemplation

Contemplation

Ready for Action

Action

Maintenance

Relapse

Requirements for Change

XX ==

MotivationMotivation(Should I?)(Should I?)

Self-ConfidenceSelf-Confidence(Can I?)(Can I?)

CommitmentCommitment(Will I?)(Will I?)

Your Goal: Help the TobaccoUser Take the Next Step

Help 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 process

2. Confidence: a clinician has expectations about the power of his or her skills to promote health behavior change

10

Importance

Confidence0

10

Unaware or Cynical :“It’s not my role to counsel patients. Plus, it’s too difficult to do this kind of counseling.”

Low Importance - Low Confidence

10

High Importance - Low Confidence

Frustrated :“I believe it is important for me to help patients change, but I don’t know how to do it”

Importance

Confidence0

10

10

Importance

Confidence0

10

Low Importance - High Confidence

Skeptical :“I could work with patients on behavior change, but it’s just not proven to work.”

10

Importance

Confidence0

10

High Importance - High Confidence

Moving, Helping :“I believe it is important for me to work with patients on health behaviors no matter what the obstacles are.”

10

Importance

Confidence0

10

Importance - Confidence

Moving, Helping :“I believe it is important for me to work with patients on health behaviors no matter what the obstacles are.”

Frustrated :“I believe it is important for me to help patients change, but I don’t know how to do it”

Unaware or Cynical :“It’s not my role to counsel patients. Plus, it’s too difficult to do this kind of counseling.”

Skeptical :“I could work with patients on behavior change, but it’s just not proven to work.”

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 uses

You 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 communication

You 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 Importance

• “On a scale of 0 to 10, how is important is it to you to _________ (make this change)?

0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10Not at all important

Extremely important

• “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 Change

Pros Pros

“What are some of the good things about eating so much junk food?”

I like how it tastes

Going out with my friends-we like to hang out at McDonalds

“What are some of the good things about changing the way you eat?”

If lose weight, will feel more attractive

It would be easier to fit into the kinds of clothes I want to wear

I’d feel good about accomplishing it

Cons Cons“What are the not so good things about eating junk food?”

I don’t like how I look-I think its making me heavy and it also make my skin greasy

I can’t run as well as I used to, so I’m doing badly on my field hockey team

“What are some of the not so good things about changing the way you eat?”

I’d have to think about what I can and can’t eat all of the time

I’d have to give up my favorite junk food

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 Confidence

• “On a scale of 0 to 10, how confident are you that you can _______ (make this change)?

0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10Not at all confident

Totallyconfident

• “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?)

Confidence

Readiness

(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 Change

When a person feels accepted for who they are and what they do-no matter how unhealthy-it allows them the freedom to consider change rather than needing 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 it's 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

• 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

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…*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

• List services, phone number, website, logo, etc. for that state’s quitline

Refer: ____ Quitline Referral

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 101

Everyone 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

• Anxiety

• Irritability

• Headache

• Insomnia

• Drowsiness

• Constipation

• Increased appetite

• Poor attention

• Impaired cognitive performance

• Decreased heart rate

Symptoms 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 level

Disadvantages– 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 day

Side effects: redness, itching, sleep disturbance Advantages

– Good compliance– Sustained blood levels

Disadvantages– Skin irritation

Nicotine Nasal Spray (Rx)

Dosage– 1 dose yields 1 mg of nicotine (2 sprays, one/nostril)

Side effects: cough, nasal /throat irritation

Advantages– 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 irritation

Advantages– 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 irritation

Advantages– Flexible dosing– Rapid blood level (4mg lozenge give 25% higher blood level than 4 mg

gum)– No chewing (discrete)

Disadvantages– Under-dosing– Oral pH

Minutes

Incr

ease

in

nic

oti

ne

con

cen

trat

ion

(n

g/m

l

CigaretteGum 4 mg

Gum 2 mg

InhalerNasal sprayPatch

5 10 15 20 25 30 0

2

4

6

8

10

12

14

Plasma nicotine concentrations for smoking and NRT

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®Zyban®)Dosage

150 mg QAM for 3 days, then increase to 150 mg BIDDoses should be at least 8 hours apartUse for 7-12 weeks after quit date; longer use possible

Side effectsDry mouth, headache, sleep disturbance, dizziness

AdvantagesMay be combined with NRT

DisadvantagesNeed to pre-load: Start 2 weeks BEFORE quit date

Varenicline (Chantix®)

Dosage Start 1 week BEFORE quit date0.5 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 waterUse for 12 weeks after quit date; longer use possible

Side effectsNausea, sleep problems

AdvantagesMay be more effective than Bupropion

DisadvantagesCan 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 ComparisonCharacteristics

Therapy Onset of action

Frequency of doses/24hrs

Effort required

Patch 2-12 hr 1 Low

Gum/Lozenge 10 min 9-20 High

Spray 5-10 min 13-20 Mod

Inhaler 15 min 6-16 High

Bupropion 1 week 2 Low

Varenicline 1 week 2 Low

Pharmacotherapy ComparisonCharacteristics

Therapy Availability Flexible dosing

Breaks habit

Patch OTC No Yes

Gum/Lozenge OTC Yes No

Spray Rx Yes No

Inhaler Rx Yes No

Bupropion Rx No Yes

Varenicline Rx No Yes

Adverse Effects and Contraindications

Product Adverse Effects Possible Contraindications

Patch Skin irritation, insomnia *Immediate post MI or unstable angina

Gum/lozenge Mouth soreness, dyspepsia Same

Nasal spray Nasal irritation, sneezing Same

Inhaler Coughing, throat irritation Same

Bupropion Insomnia, dry mouth, headaches

Eating disorder, seizure disorder, MAO inhibitor use

Varenicline Nausea, nightmares, agitation, depression? suicidal ideation?

*Schizophrenia, bipolar disorder, and major depressive disorder

Estimated Cost Per DayPharmacotherapy Smoking

Patch $3.00 1 pack $5.50

Bupropion $3.23 to $7.00 1 ½ packs $8.25

Varenicline $4.36 2 packs $11.00

Gum/Lozenge $3 to $6.50 2 ½ packs $13.75

Spray $5.00 3 packs $16.50

Inhaler $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

www.aap.org/richmondcenter

Need more information?The AAP Richmond Center

Audience-Specific Resources State-Specific ResourcesCessation InformationFunding Opportunities

Reimbursement InformationTobacco Control E-mail List

Pediatric Tobacco Control Guide

Skull of a Skeleton with Burning Cigarette Antwerp 1885-1886Van Gogh MuseumAmsterdam

QUESTIONS??QUESTIONS??