Tobacco Addiction, Tobacco Addiction, Why is It so Powerful? Why is It so Powerful? Gaylene Mooney, M.Ed, RRT-NPS Gaylene Mooney, M.Ed, RRT-NPS
Jan 30, 2016
Tobacco Addiction, Tobacco Addiction, Why is It so Powerful?Why is It so Powerful?
Gaylene Mooney, M.Ed, RRT-NPSGaylene Mooney, M.Ed, RRT-NPS
Points to CoverPoints to Cover Tobacco Use StatisticsTobacco Use Statistics Two Forms of Nicotine Two Forms of Nicotine Monoamineoxidase (MAO)Monoamineoxidase (MAO) Definition of AddictionDefinition of Addiction Maslow’s Hierarchy of NeedsMaslow’s Hierarchy of Needs Triangle of AddictionTriangle of Addiction Neurobiology of AddictionNeurobiology of Addiction Stages of ChangeStages of Change The Association for the Treatment of Tobacco Use and The Association for the Treatment of Tobacco Use and
Dependence (ATTUD)Dependence (ATTUD) Brief discussion of the new Medicare reimbursementBrief discussion of the new Medicare reimbursement
Tobacco Use StatsTobacco Use Stats
46 Million Adults 46 Million Adults
15.6% 5.3%
23.9%
54.9%
One Approximately Every One Approximately Every Two Minutes Two Minutes
Http://phil.cdc.gov/Phil/default.asp >430,000 (1178/day)
It Isn’t Breast Cancer?It Isn’t Breast Cancer?
Sir Richard DollSir Richard Doll Died in June at age 92Died in June at age 92 1950 study linking 1950 study linking
smoking to lung cancersmoking to lung cancer 1954: Doll and Hill 1954: Doll and Hill
published “The Mortality published “The Mortality of Doctors and Their of Doctors and Their Smoking Habits” in BMJ Smoking Habits” in BMJ (lead to most M.D. giving (lead to most M.D. giving up smoking)up smoking)
Follow-up study in 2004Follow-up study in 2004 ½ - 2/3 of all individuals ½ - 2/3 of all individuals
who begin smoking in who begin smoking in youth will die because of ityouth will die because of it
Two Forms of Nicotine Two Forms of Nicotine
Bound to tobacco leaf Bound to tobacco leaf Free (altered by pH of the smoke)Free (altered by pH of the smoke)
Results when ammonia is added Results when ammonia is added Immediate impactImmediate impact More satisfactionMore satisfaction
http://tobaccodocuments.org/product_design/00044522-4523.htmlhttp://tobaccodocuments.org/product_design/00044522-4523.html
pHpH Cigarette: 5.5 – 6.0 (filter & carbon actually increases pH, Cigarette: 5.5 – 6.0 (filter & carbon actually increases pH,
verified by tobacco documents)verified by tobacco documents) Spit: up to 8.3 (Source: CDC)Spit: up to 8.3 (Source: CDC) Cigar: 6.2 – 8.2Cigar: 6.2 – 8.2
http://cancercontrol.cancer.gov/tcrb/monographs/9/m9_6.PDFhttp://cancercontrol.cancer.gov/tcrb/monographs/9/m9_6.PDF
Absorption of NicotineAbsorption of Nicotine
Rate of AbsorptionRate of Absorption Cigarette : fastest routeCigarette : fastest route Cigar : slower than cigarettesCigar : slower than cigarettes Spit : slowest rateSpit : slowest rate
http://cancercontrol.cancer.gov/tcrb/monographs/9/m9_6.PDFhttp://cancercontrol.cancer.gov/tcrb/monographs/9/m9_6.PDF
How much Nicotine?How much Nicotine?
10mg of nicotine/cigarette10mg of nicotine/cigarette 1 to 2 mg of nicotine/cigarette absorbed1 to 2 mg of nicotine/cigarette absorbed
10 puffs over 5 minutes10 puffs over 5 minutes 1 ½ pack/day = 300 hits1 ½ pack/day = 300 hits
Cigar = up to 1 ½ packs of cigarettesCigar = up to 1 ½ packs of cigarettes Spit = 1 can = 3 packs of cigarettesSpit = 1 can = 3 packs of cigarettes
http://www.nida.nih.gov/researchreports/nicotine/nicotine2.html
When is it Addiction?When is it Addiction?Three or more of the following:Three or more of the following: Preoccupation with getting tobaccoPreoccupation with getting tobacco Compulsive useCompulsive use Difficulty with controlling intakeDifficulty with controlling intake Persistent, even with health problemsPersistent, even with health problems RelapseRelapse Tolerance Tolerance WithdrawalWithdrawal
References: World Health OrganizationReferences: World Health Organization Diagnostic and Statistical Manual - IV (DSM-IV) Diagnostic and Statistical Manual - IV (DSM-IV)
How long does it take to become dependent?How long does it take to become dependent? Can be after the first cigarette!Can be after the first cigarette!http://cancercontrol.cancer.gov/tcrb/monographs/9/m9_6.PDFhttp://cancercontrol.cancer.gov/tcrb/monographs/9/m9_6.PDF
What Initiates Tobacco Use?What Initiates Tobacco Use?
Physiological Needs
Security & Safety Needs
Social Needs
Esteem Needs
SelfActualization Being Need
Deficit Needs
A. H. Maslow. A Theory of Human Motivation. Psychological Review, 50, 370-396. (1943)
Maslow’s Hierarchy of Need
Triangle of AddictionTriangle of Addiction
Emotion (emotional need)
Environmental or social (relieves stress)
Physiologic (changes to
need of nicotine)
Spiritual (Best Friend)
Other Risk Factors for Initiation Other Risk Factors for Initiation
1.1. Children of Moms who smoke regularly Children of Moms who smoke regularly 2.2. Risk of nicotine addiction increased more if Risk of nicotine addiction increased more if
smoked during pregnancysmoked during pregnancy3.3. Co-Twin (within two years)Co-Twin (within two years)4.4. Same Sex Sibling who smokesSame Sex Sibling who smokes5.5. Older Sibling who smokesOlder Sibling who smokes6.6. Adolescents more vulnerable to addictionAdolescents more vulnerable to addictionEur Addict Res. 2003 Jul;9(3):120-30 Twin Res. 2003 June;6(3):209-17Eur Addict Res. 2003 Jul;9(3):120-30 Twin Res. 2003 June;6(3):209-17 J Adolesc Health. 2003 Jul;33 (1): 25-30 J Adolesc Health. 2003 Jul;33 (1): 25-30 J Neurosci. 2003 Jun 1;23(11):4712-6J Neurosci. 2003 Jun 1;23(11):4712-6
Can School Outcome Predict Can School Outcome Predict Smoking Behavior?Smoking Behavior?
Low gradesLow grades Poor teachers’ prognosesPoor teachers’ prognoses Early unemploymentEarly unemployment
Scand J Public Health.2003;31 (3):229-32Scand J Public Health.2003;31 (3):229-32
Risk Factors for Risk Factors for InitiationInitiation
Count Down from TenCount Down from Ten
•DopamineDopamine““I feel good”I feel good”
•AcetylcholineAcetylcholine•Serotonin Serotonin
Anti-depressantAnti-depressant•EpinephrineEpinephrine
Adrenal glandAdrenal glandVentral Tegmental Area
Medial Forebrain Bundle
http://www.nida.nih.gov/researchreports/nicotine/nicotine3.html#how
Is Nicotine the Only Chemical Is Nicotine the Only Chemical Causing the Addiction?Causing the Addiction?
Marked reduction of Monoamineoxidase Marked reduction of Monoamineoxidase (MAO)(MAO) Enzyme that breaks dopamine downEnzyme that breaks dopamine down Something other than nicotine causing the Something other than nicotine causing the
change in MAOchange in MAO
http://www.nida.nih.gov/researchreports/nicotine/nicotine2.html
Stages of Change ModelStages of Change Model
Prochaska, J. & DiClemente, C. (1983). Stages and processes of self-change in smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390-395.
Pre-Contemplation StagePre-Contemplation Stage
Not ready to quitNot ready to quit Not interested in Not interested in
changingchanging Are defensiveAre defensive ““I can’t quit”I can’t quit” ““It will not happen to me”It will not happen to me” ““I enjoy it to much”I enjoy it to much”
Stages of Change
Contemplation & Contemplation & Determination StagesDetermination Stages
Seriously thinking about Seriously thinking about changingchanging
Aware of the Aware of the needneed to quit to quit Taking small steps to quitTaking small steps to quit ““I know I need to quit”I know I need to quit” ““You know, I should quit”You know, I should quit” ““I I wantwant to quit within the to quit within the
next 30 days”next 30 days”
Stages of Change
Action StageAction Stage Ready for changeReady for change Prepared mentally to Prepared mentally to
changechange ““I am going to quit I am going to quit
smoking”smoking” ““I want to live to see my I want to live to see my
grandchildren”grandchildren”
Attends class or calls a Attends class or calls a quitlinequitline
Quits smokingQuits smoking Last approximately 6 Last approximately 6
monthsmonths
Stages of Change
DSM-IV Criteria for Nicotine DSM-IV Criteria for Nicotine Withdrawal (APA, 2994)Withdrawal (APA, 2994)
Maintenance StageMaintenance Stage
Has quit smokingHas quit smoking Prepares for stress Prepares for stress Handles temptationHandles temptation Reminds themselves Reminds themselves
of what they have of what they have accomplishedaccomplished
Continues to be Continues to be smoke-freesmoke-free
Stages of Change
Relapse StageRelapse Stage
Most experienceMost experience Sees oneself as a Sees oneself as a
failurefailure A normal eventA normal event A person may go A person may go
through the stages of through the stages of change several times change several times before complete before complete cessation.cessation.
Stages of Change
Symptoms of Nicotine Symptoms of Nicotine OverdoseOverdose
upset stomachupset stomach stomach pain stomach pain salivation salivation vomiting vomiting diarrhea diarrhea cold sweat cold sweat
bad headachesbad headaches dizzinessdizziness blurred visionblurred vision hearing difficultieshearing difficulties weakness weakness faintingfainting mental confusionmental confusion
Source: TobaccoFreeKids.org
We MustBreakThe Cycle
Not a
NoAsk: Do you use tobacco?
Have you ever used tobacco?
No No intervention
Encourage continued cessation & re-evaluate next visit
Access Readiness to
quit
Yes Yes
Do you want to quit?
Yes
Advise to quit
Assist and Arrange
Call _____ at ______to make appt.
No
Followup next visit
5 “R’s”RelevanceRisksRewardsRoadblocksRepetition
Do you want to quit within the next 30 days?
Yes
No
Re-evaluate next visit
Tobacco Use Assessment Protocol
The Association for the The Association for the Treatment of Tobacco Use and Treatment of Tobacco Use and
Dependence (ATTUD)Dependence (ATTUD) GoalsGoals
Build and maintain an organization representing providers dedicated to Build and maintain an organization representing providers dedicated to the treatment of tobacco use and dependence. the treatment of tobacco use and dependence.
Establish standards for core competencies, for training, and for credentEstablish standards for core competencies, for training, and for credentialing of tobacco treatment providersialing of tobacco treatment providers. .
Establish multiple forums (e.g., annual meeting, listserv, and journal) Establish multiple forums (e.g., annual meeting, listserv, and journal) for information exchange on best practices, innovations in treatment, for information exchange on best practices, innovations in treatment, and gaps in the empirical base of tobacco treatment. and gaps in the empirical base of tobacco treatment.
Serve as an advocate and voice for tobacco users to promote the Serve as an advocate and voice for tobacco users to promote the awareness and availability of awareness and availability of effectiveeffective tobacco treatments. tobacco treatments.
Serve as a Serve as a reliable and respected resource of evidence-based tobacco reliable and respected resource of evidence-based tobacco use and dependence treatmentuse and dependence treatment for the health care community, for the health care community, regulatory agencies, private foundations, and especially tobacco users. regulatory agencies, private foundations, and especially tobacco users.
Promote the implementation of and increased access to Promote the implementation of and increased access to evidence-evidence-based practicebased practice across the spectrum of treatment modalities via policy, across the spectrum of treatment modalities via policy, funding, and system changes. funding, and system changes.
www.attud.org
The New Medicare PolicyThe New Medicare Policy
AARC reviewAARC review Who is covered?Who is covered? What is covered?What is covered? What is not covered?What is not covered? Who can charge for services?Who can charge for services? Billing CodesBilling Codes
SummarySummary
Be more empatheticBe more empathetic Understand, it Understand, it ISIS all in the head all in the head It is part of your jobIt is part of your job Advise, Assess, & AssistAdvise, Assess, & Assist Every patient, every timeEvery patient, every time Remember, with open hands and not Remember, with open hands and not
pointing fingerspointing fingers RT as Tobacco Treatment Specialist’RT as Tobacco Treatment Specialist’
Do you want to have fun, while reducing stress Do you want to have fun, while reducing stress
and improving your cardiovascular health? and improving your cardiovascular health? Go Ballroom Dancing! 300 – 400 calories/hourGo Ballroom Dancing! 300 – 400 calories/hour