SMOKING CESSATION. Learning Objectives Understand the hazards of smoking Recognize the health benefits of smoking cessation Describe the rationale for

SMOKING CESSATION

Learning Objectives

Understand the hazards of smoking Recognize the health benefits of smoking cessation Describe the rationale for treating tobacco dependence Explain why tobacco dependence is a chronic disease Initiate clinical interventions for tobacco users who are willing to

quit as well as users who are not willing to make a quit attempt Assist users attempting to quit with strategies designed to

prevent relapse

The smoking epidemic

1 billion smokers Smoking represents the most readily preventable risk factor for

morbidity and mortality. 5 million people die every year because of smoking related

illnesses. By 2030, if current trends continue, smoking will kill one in 6

people.

( world health organization. 2008.


75% of smokers want to quit <2% of smokers quit each

year


Effective government policy:

• Bans on tobacco advertising and sponsorship

• Regular price rises

• Stronger public health warning labels

• Smoking bans in all public places

Prevalence of Smoking in Saudi Arabia

2.4-52.3% (median = 17.5%) School students 12-29.8% (median = 16.5%), University students 2.4-37% (median = 13.5%), Adults 11.6-52.3% (median = 22.6%). Elderly people 25%. Males 13-38% (median = 26.5%) Females 1-16% (median = 9%).

Prevalence of Smoking in Saudi Arabia

17% of primary health care physicians in Riyadh city were current smokers, 20% ex-smoker.

Al- shahri M, Al Almaie S. promotion of non-smoking: The role of primary health care physicians. Ann Saudi Med 1997;17:515-17

Smoking Health Risks

Short-term Shortness of breath Worsening asthma or bronchitis Increased risk of respiratory infection Harm to pregnancy Impotence Infertility

Smoking Health Risks

Long-term Heart attack and stroke Lung and other cancers

Chronic obstructive pulmonary disease (COPD)

Osteoporosis Disability (chronic bronchitis

and emphysema) Need for extended care

larynx oral cavity pharynx

esophagus pancreas stomach

kidney bladder cervix

acute myelocytic leukemia

Tobacco-based products:

Cigarettes pipes cigars hookahs ((shisha/ narghile/ argileh/ hubble bubble and goza)) chewing tobacco etc.

Why do people continue to smoke?

Addiction to nicotine Perceived benefits (relaxation, stress relief, weight loss) Social context Mental health issues

Smoking Cessation Barriers

Withdrawal symptoms Fear of failure Weight gain Lack of support Depression Enjoyment of tobacco Being around other users Limited knowledge of effective treatment options

Physician Barriers to Helping Patients Stop Smoking

Time constraints of practice Lack of office systems Low expectation of success Lack of knowledge of what to do Reimbursement issues Frustration with smokers

Smoke vs. Quit

Common Reasons not to Quit Family and friends smoke Withdrawal symptoms Inability to cope with stress Connection with smoking Previous unsuccessful

attempts to quit

Common Reasons to Quit Encouragement from family

and friends Health improvements To save money Pregnancy Smoke-free environment

policies Desire to be a role model Medical treatment that

requires abstinence

Tobacco Dependence as a chronic disease

What is a cigarette?

Delivers nicotine to the lungs and brain within 7 sec each time a smoker inhales

Frequent, small-dose stimulation makes smoking highly addictive

Most cigarettes contain ≥ 10 mg of nicotine Average smoker absorbs 1-2 mg of nicotine per cigarette Cigarettes release carbon monoxide which adheres to red blood

cells faster than oxygen• Reduced oxygen in the body causes increased heart rate

What’s in a Cigarette?

4000 chemicals many of which are highly toxic. 40 known cancer-causing substances.

Tobacco Carbon monoxide Hydrogen cyanide Nitrogen oxide Ammonia (sub-micron sized particles) Nicotine, phenol, polyaromatic hydrocarbons, tobacco specific nitrosamines. Tar total particulate matter (nicotine and water) Filter with titanium oxide accelerant Flavours Liquid vapour Benzene Formaldehyde Acrolein N-nitrosamines Non-particulate matter

What is Nicotine Dependence?

Chronic Nicotine consumption with the following characteristics: Substance abuse Continues self-administer substance despite perceived

negative effects High tolerance towards the substance Manifests withdrawal symptoms when trying to stop use

Effects of Nicotine

Highly toxic drug Increase HR, BP Decrease body temp Slows circulation Affects appetite Increase BMR changes brain activity - improving reaction times, ability to pay

attention and brings on euphoria Addiction Increases dopamine levels Creates a feeling of pleasure

‘Reward’ pathway(mesolimbic dopamine system) ‘Withdrawal’ pathway

(locus coeruleus)

The addiction pathwaysThe addiction pathways

“Reward” Pathway

Mesolimbic dopamine system has been characterized as a “reward "pathway

Nicotine produces a dopamine surge in the nucleus accumbens Smoking cessation is followed by pathophysiologic withdrawal

and craving

Withdrawal

Chronic drug use affects brainstem structures

(locus ceruleus) Noradrenergic cells become more excitable When a person abstains, the firing rates become

abnormally high – a possible basis of withdrawal symptoms

Nicotine withdrawal syndrome

acute/uncontrollable need to smoke (craving) irritability restlessness, anger, anxiety feelings tiredness increased appetite, especially for sweets and resultant weight

gain trouble to concentrate and focus memory depression headaches insomnia dizziness

Benefits of Quitting

blood pressure and pulse rate return to normal

blood nicotine & CO halved, oxygen back to normal

CO eliminated; lungs start to clear mucus etc.

nicotine eliminated; senses of taste & smell much improved.

breathing easier; bronchial tubes begin to relax; energy levels increase

20 mins:

8 hours:

24 hours:

48 hours:

72 hours:

Benefits of Quitting

circulation improves

lung function increased by <10% coughs, wheezing decrease

risk of heart attack halved

risk of lung cancer halved compared to continued smoking

risk of heart attack equal to never-smoker’s

2-12 weeks: 3-9 months:

5 years:10 years:

Quitting- other benefits

Improved health and physical performance Improved taste of food and sense of smell Better appearance, including reduced wrinkling/aging of skin

and whiter teeth Healthier families, babies and children A good example for children and others More money in your pocket

Treatment of Nicotine Addiction

Combination of counseling and pharmacotherapy is more effective than either option alone

The more intense the intervention, the better the outcome of abstinence

Pharmacologic Options

Clients/patients attempting to quit smoking should always be encouraged to use effective medications unless they are contraindicated in specific populations

eg. pregnant women, smokeless tobacco users, light smokers, adolescents (Fiore, et al)

Two categories of pharmaceutical options: Nicotine replacement therapy (NRT) Non-nicotine replacement therapy

Nicotine Replacement Therapy (NRT)

Nicotine Patch Nicotine Lozenges Nicotine Gum Nicotine Inhalers

Provide nicotine to reduce withdrawal symptoms Take between 1-4 hours to reach maximum blood levels (unlike

cigarettes, 7 seconds) Do not cause sudden boost to nicotine blood levels (prevents

addiction to product) Dose depends on habits of the smoker but is reduced over a 12

week period

Non-nicotine Therapy

Bupropion Hydrochloride (Zyban)• Also marketed as the anti-depressant medication Wellbutrin• Presumed to alleviate cravings associated with nicotine

withdrawal affecting noradrenaline and dopamine Varenicline Tartrate (Champix)

• Targets nicotinic acetylcholine receptors to decrease cravings and withdrawal

Clonidine & Nortriptyline• Second-line medications used in smoking cessation

All of these medications require a prescription

Counselling

Intensive intervention that last a minimum of 10 minutes

Commonly conducted by nurses in various health-care settings

Motivational Interviewing Directive and client-centred standard counselling techniques Stages of Change theory

Other options of treatment

Hypnosis Herbal remedies Acupuncture Laser treatment No clinical evidence to verify results from these treatments

Some clients/patients report that they are beneficial (Fiore, et al., 2008)

Protection: Second-hand smoke

Second-hand smoke:

Also known as environmental tobacco smoke

Combination of:◦ Side stream smoke (smoke from the end of a cigarette)◦ Smoke exhaled by the smoker

67% of smoke from a burning cigarette is not inhaled by the smoker and ends up in the surrounding environment

Second-hand smoke (cont.)

‣ 4000 chemicals have been identified in second-hand smoke 50 of these are known carcinogens

(United States Environmental Protection Agency, 2000)

‣ Examples: - Arsenic compounds - Benzene - Chromium compounds - Ethylene oxide (chemical to sterilize medical devices) - Vinyl Chloride (chemical used in plastics manufacture) - Polonium – 210 (radioactive species)

Second-hand smoke (cont.)

Labeled as a known human carcinogen

Labeled as a class A cancer-causing substance (Class A = most dangerous)

Model for treatment of tobacco use and dependence

General Populati

on

General Populati

on

Patient presents to healthcare

setting

Patient presents to healthcare

setting

ASK: screen all patients

for tobacco

use

ASK: screen all patients

for tobacco

use

Primary preventi

on

Primary preventi

on

ADVISE to quitADVISE to quit

ASSESS willingness to quit

ASSESS willingness to quit

ASSIST with

quitting

ASSIST with

quitting

ARRANGE a

follow-up

ARRANGE a

follow-up

Prevent relapsePrevent relapse

Relapse

AbstinentPromote motivati

on to quit

Promote motivati

on to quit

Yes, willing

No, unwilling

Patient now willing to quit

Current users

Non users

Where to begin?

ASK- about smoking – understand your patient ASSESS - what is the next step? ADVISE - why cessation is important ASSIST - offer to help ARRANGE- follow-up process

The 5 As apply to

Those who:

are willing to quit, aren’t willing to quit, and recently quit.

Smoking Cessation Treatment

Smoking Cessation Treatment for Those Willing to Quit


ASK Identify and document tobacco use status of every patient at every visit.

Example: When recording vital signs, include an area to note tobacco use.


ADVISE In a clear, strong, and personalized manner advise every tobacco smoker to quit.


Advise examples: Clear “I think it’s important for you to quit

smoking now, and I can help you.”

Strong “As your clinician, I need you to know that quitting smoking now is the most important thing you can do to protect your health.”

Personalized “Continuing to smoke makes your asthma worse.”


ASSESS Is the user willing to make a quit attempt at

this time?

Provide assistance to dependence treatments.

Provide an intervention shown to increase future quit attempts, such as nicotine gum, quit lines and behavioral counseling.

YES

NO


ASSIST

Offer medication. Provide or refer for counseling or additional behavioral treatment.

Medication examples: Nicotine lozenge Varenicline


ASSIST

Behavioral treatment examples: Recommend a quit plan, such as STAR. Set a quit date. Tell family, friends and coworkers. Anticipate challenges. Remove tobacco products.


ARRANGE

Arrange for follow-up soon after quit date, a second follow-up within the first month and others as needed.

Identify problems and anticipate challenges. Remind patients of available sources, such as quit lines. Provide encouragement.


Smoking Cessation Treatment for Those NOT Willing to Quit


ASK, ADVISE & ASSESS

Use the same 5As for users unwilling to quit as those willing to quit.


ASSIST

Provide motivational interventions designed to increase future quit attempts.

Smoking Cessation Treatment for Those NOT Willing to Quit ASSIST Motivational examples:

The 5 Rs Relevance Identify why it is personally relevant to get the patient to quit. Risks

Ask the patient to identify negative consequences of smoking. Rewards

Ask the patient to identify the benefits of stopping. Roadblocks Identify the patient’s barriers to success and how to approach

them. Repetition Repeat motivational interventions.


ASSIST Motivational examples: Express empathy Use open-ended questions. “How important

do you think it is for you to quit?” Use reflective listening. “So you think smoking

helps you maintain your weight.” Normalize patient’s feelings. “Many people

worry about managing without cigarettes.” Support their right to choose. “I’m here to help

you when you are ready.” t to choose.


ASSIST Motivational examples: Develop discrepancy Highlight the discrepancy between the patient’s smoking versus

the patient’s stated values. “You’re devoted to your family. How do you think your smoking affects them?”

Reinforce change talk. “So, you realize how smoking is making it hard to keep up with your kids.”

Deepen the commitment to change. “We would like to help you avoid a stroke like the one your father had.”


ASSISTMotivational examples: Roll with resistance

Back off and use reflection. “Sounds like you’re feeling pressured about your tobacco use.”

Express empathy. “I understand it’s hard to quit.”

Ask permission to provide information. “Would you like to hear about some strategies that can help you quit?”


ASSIST Motivational examples: Support self-efficacy

Help patients build on past successes. “You were fairly successful last time you tried to quit.”

Offer options for small, achievable steps toward change. “Can you try smoking one less cigarette a day? A quit line can help you.”


ARRANGE More than one motivational intervention may be needed. Provide follow-up at the next visit. Offer additional interventions to motivate and support.


Treatment for Those Who Recently Quit


ASK Determine if the smoker is still smoke-free. then,

ASSESS

relapse potential.


ASSESS Most relapses occur within the first two weeks, but the

risk can persist for a long time; therefore, Identify and address challenges, including lack of support for cessation, negative mood or depression, strong or prolonged withdrawal symptoms, weight gain and smoking lapses.


ASSIST

Provide encouragement and relapse prevention to address the challenges of staying smoke-free.

Challenge example Lack of support Depression Prevention response Schedule follow-ups, urge use of quit lines, identify source of

support Counsel or refer to counseling/support groups

Social

Smoking is a Complex Phenomenon

Spiritual

Bio-physiological

Psychological

Physical and Psychological

When “down”, smoking energizes When “anxious”, smoking calms Smoking focuses attention and conveys a sense of well-being,

every time

Psychological/Behavioural

Conditioning occurs over many years after exposure to things in the environment which stimulate the smoker to want a cigarette

People learn to manage their emotions with tobacco Patterns of behaviour are very difficult to change

Physical and Emotional

Pleasure, arousal, relaxation and the relief of tension and anxiety are therapeutic effects of nicotine

Smoking also treats effects of withdrawal All of these effects are biological and molecular

Emotional, Social & Spiritual

A comforting completion of pleasurable rituals: friends, drinks, sex, meals and breaks

A close, comforting friend that has always been there A way to cement certain social relationships and repel

unwanted ones Part of identity and sense of self

Bio-physiologic

Nicotine is an addictive substance. The chemical effects of nicotine are strongly related to the conditioning that occurs in many smokers. It is this link between stimulation/triggers in the environment and the immediate chemical, pleasurable effect on the body that often makes stopping smoking so difficult

Stages of Change

PRECOMTEMPLATIONo Unaware or unwilling to change

CONTEMPLATIONo Ambivalent, but thinking about changing

PREPARATIONo Decided to change and taking steps

ACTIONo Started to do things differently

MAINTENANCEo Changed for sometime and integrating the change into their

routine

Prochaska and DiClementeProchaska and DiClemente

ContemplationThinking of quitting in the next six months

MaintenanceQuit for morethan six months

PreparationPlanning to quit in the next month

ActionQuit in the lastsix months

Relapse

PrecontemplationNot thinking of quitting in the next six months

2

Myths you may encounter as you work with your patients to help them stop smoking: Myth 1: Smoking is just a bad habit. Fact: Tobacco use is an addiction. According to the U.S. Public Health Service

Clinical Practice Guideline, Treating Tobacco Use and Dependence, nicotine is a very addictive drug. For some people, it can be as addictive as heroin or cocaine.

Myth 2: Quitting is just a matter of willpower. Fact: Because smoking is an addiction, quitting is often very difficult. A number

of treatments are available that can help.

Myth 3: If you can’t quit the first time you try, you will never be able to quit. Fact: Quitting is hard. Usually people make two or three tries, or more, before

being able to quit for good.

Myths you may encounter as you work with your patients to help them stop smoking:

Myth 4: The best way to quit is “cold turkey.” Fact: The most effective way to quit smoking is by using a combination of

counseling and nicotine replacement therapy (such as the nicotine patch, inhaler, gum, or nasal spray) or non-nicotine medicines (such as bupropion SR).

Myth 5: Quitting is expensive. Fact: Treatments cost from $3 to $10 a day. A pack-a-day smoker spends

almost $1,000 per year. Check with your health insurance plan to find out if smoking. cessation medications and/or counseling are covered.

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

Documents

SMOKING CESSATION. Learning Objectives Understand the hazards of smoking Recognize the health benefits of smoking cessation Describe the rationale for