Tobacco Use Disorder A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1 A Presentation for SOMC Medical Education Kendall L. Stewart, MD, MBA, DFAPA September 21, 2012 1 This presentation is designed as a problem-based learning module.
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Tobacco Use Disorder
A Patient-Centered, Evidence-Based Diagnostic and Treatment Process1
A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPASeptember 21, 2012
1 This presentation is designed as a problem-based learning module.
What current diagnoses are included in this category?
• Nicotine Dependence• Nicotine Withdrawal• Nicotine-Related Disorder NOS• In DSM-5, these will likely be replaced
with Tobacco Use Disorder and included in the Substance Use Disorders category.
What are the diagnostic criteria?1
• Problematic pattern of tobacco use causing significant impairment or distress– Tobacco used longer than intended– Unsuccessful efforts to cut down usage– A great deal of time consumed by tobacco-related activities
and complications– A tobacco-related failure to fulfill obligations at school, work
or home– Continued tobacco use in spite of the problems it causes– Tobacco use negatively impacts social, occupational or
recreational activities– Recurrent use when physically hazardous– Continued use in spite of tobacco-related complications– Tolerance– Withdrawal– Craving
1 These are the proposed DSM-5 criteria.
How many people does smoking kill each year?1
Lung Cancer 128,900
Heart Disease 126,000
COPD 92,900
Other Diseases 44,000
Stroke 15,900
Other Cancers 35,300
1 Adapted from Rakel and Rakel, Textbook of Family Medicine and the CDC, Average Annual Number of Deaths, 2000-2004.
What are some of the key demographics of tobacco use?1
• Few people start smoking after age 18.• About 4000 children smoke for the first time every
day; 2/3 will become addicted.• 70% of smokers would like to stop.• 50% try to stop.• Less than 5% will succeed.• College graduates are more likely to succeed.• Only about 6% of people with graduate degrees
smoke.• People with mental illness smoke 70% of the
cigarettes in the United States.• Smoking is a pestilence mostly embraced by the
poor, uneducated and mentally ill.11 Rakel and Rakel, Textbook of Family Medicine
What about filtered cigarettes?1
• These varieties, 97% of those sold here, are not safer.
• Those who smoke “low nicotine, low tar” cigarettes just smoke more of them to get the same nicotine hit.
• Likewise, “natural” and “organic” cigarettes are just marketing ploys.
1 Rakel and Rakel, Textbook of Family Medicine
What about cigars?1
• These carry the same risks as cigarettes.• The risk varies with the number
smoked and the degree on inhalation.• More than 9% of men and 2% of women
smoke cigars.• The higher pH of cigar smoke permits
nicotine absorption across the oral mucosa.
• Cigar smokers do tend to inhale less.• The use of alcohol multiplies the risks.
1 Rakel and Rakel, Textbook of Family Medicine
What about electronic cigarettes?1
• These were developed in China in 2003.• They contain a battery, atomizer and cartridge
with liquid nicotine, and propylene glycol (used in antifreeze and cosmetics)
• Flavors such as chocolate and bubblegum are included to entice children.
• The FDA regulates them, but testing has not yet been completed.
• Internet sales are growing.• The price is dropping.• These may become “harm reduction” tools
and play some helpful role.1 Rakel and Rakel, Textbook of Family Medicine
• There is no risk-free level of exposure.• Only eliminating smoking indoors completely
protects nonsmokers.• Cleaning rooms after smokers pollute them is
not entirely possible.1 Rakel and Rakel, Textbook of Family Medicine
What about third hand smoke?1
• Tobacco smoke reacts with nitrous acid to produce tobacco-specific nitrosamines—a carcinogen that becomes more potent over time.
• It is concentrated in dust and carpeting and is thus more harmful to children.
• Worse still, this stuff is essentially impossible to remove.
• This danger is regularly overlooked by parents who mistakenly think not smoking indoors when kids are present is safe.
1 Rakel and Rakel, Textbook of Family Medicine
What counseling techniques are helpful?1
• Assess the patient’s readiness for change and respond accordingly:– Pre-contemplation (not interested)– Contemplation (thinking about quitting)– Preparation (planning to quit in next 30 days)– Action (in process of quitting)– Maintenance (tobacco free for 3 months or more)
• Use motivational interviewing to build patient’s self motivation.
• Brief counseling (<3 minutes) = 13% quit rate.• Intensive counseling = 22% quit rate• Prenatal care, non fatal MIs and hospitalizations for
tobacco-use complications are the best teachable moments. Seize them!
• Study Treating Tobacco Use and Dependence: 2008 Update, a critical clinical practice guideline.
• Enforce tobacco advertising bans.• Raise the price of tobacco products.• Provide smokers who want to quit with the
help they need.• Prevent unwanted exposure to secondhand
smoke.• Publicize the health hazards of tobacco use.• Decrease the impact of the marketers of death.• Increase the influence of anti-smoking forces.• Use attention-getting warning labels.• Read more about this problem here.
• “My patients are not motivated.”• “My patients don’t have the necessary
insurance coverage.”• “I am not reimbursed enough for my time
when treating these people.”• “I don’t have enough time to do this.”• “There are not enough resources to refer my
patients to.”• “Nothing works anyway.”• “I’m not trained to do this; this is not my
specialty.”• “I don’t like this kind of work.”
1 Rakel and Rakel, Textbook of Family Medicine
What should you do?1
• You must be the change you want to see in the world. Mahatma Gandhi
• Become a wellness champion and continue that lifestyle as long as you live.
• If you smoke or use any tobacco product, stop now.
• Support prevention efforts for kids.• Ask every new patient about tobacco use.• If they use, ask them to please stop.• Inquire whether patients who are using
tobacco are ready to stop—at every visit.1 Rakel and Rakel, Textbook of Family Medicine
What else should you do?1
• Seize every teachable moment to urge quitting.
• Make sure your users know 1-800-QUITNOW (1-800-784-8669)
• Remember, the first two weeks are critical; arrange daily phone or text follow up contacts.
• View this as a chronic disease.• Focus on what you can do instead of fretting
about what you can’t do.• Never, never, ever give up.
1 Rakel and Rakel, Textbook of Family Medicine
The Psychiatric InterviewA Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking some
routine demographic questions.• Ask me to list all of problems and concerns.• Using my problem list as a guide, ask me
clarifying questions about my current illness(es).
• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.
• Ask about my past psychiatric history.• Ask about my family and social histories.• Clarify my pertinent medical history.• Perform an appropriate mental status
examination.
• Review my laboratory data and other available records.
• Tell me what diagnoses you have made.• Reassure me.• Outline your recommended treatment
plan while making sure that I understand.
• Repeatedly invite my clarifying questions.
• Be patient with me.• Provide me with the appropriate
educational resources.• Invite me to call you with any
additional questions I may have.• Make a follow up appointment.• Communicate with my other
physicians.1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.
Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093
• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January
2008• Medina, John,
Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008
• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000• Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.
Where can you find evidence-based information about mental disorders?
• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.
• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.
• Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.
• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.
• Download this presentation and related presentations and white papers at www.KendallLStewartMD.com.
• Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.
• Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.