Guideline by the U.S. Dept. of Health and Human Services, Public Health Service (USPHS), 2000 THE 5 Rs MOTIVATIONAL TECHNIQUES From the USPHS Tobacco Guideline, 2000
A HEALTHCARE Relevance Health of the smoker Health of others (second-hand smoke affects adults and children) Costs of smoking Social/environmental pressure Personal commitment and control Risks 2x greater risk of stroke 6x greater risk of oral cancer 10x greater risk of larynx cancer and COPD 12x greater risk of lung cancer and CAD Rewards IMMEDIATE = within minutes to several weeks, B/P decreases, CO level decreases, O2 level increases IMMEDIATE = within months to 1 year, respiratory congestion and infections decrease; after 1 year, excess risk of CAD reduced to half of a smoker LONG-TERM = after 5 years, lung cancer death rate decreases by almost half; after 5 years, risk of upper airway and esophageal cancer is half of a smoker; after 510 years, stroke risk is reduced to that of a nonsmoker; after 10 years, lung cancer death rate similar to a nonsmoker; after 15 years, risk of CAD is that of a nonsmoker Roadblocks Triggers to smoke Concern for nicotine withdrawal Concern for weight gain Relapse Repetition The 5 As and 5 Rs must be repeated at each healthcare setting visit Incident of relapse is high (only 2% are successful at 1 year quit date) It takes multiple attempts (711) to quit before becoming successful Counseling and pharmacological treatment increases success to 2025% at 1 year quit date PROVIDERS EVIDENCE- BASED GUIDE
TO SUCCESSFUL TOBACCO CESSATION INTERVENTIONS
Offered by the Nurses for Tobacco Control Coalition
FOR MORE INFORMATION, FAGERSTROM TEST FOR NICOTINE DEPENDENCE (ADULTS) Visit www.nurses4tobaccocontrol.org 1) How soon after you wake up do you smoke your first cigarette? Within 5 minutes = 3 630 minutes = 2 3160 minutes = 1 After 60 minutes = 0 2) Do you find it difficult to refrain from smoking in the places where it is forbidden (e.g., in church, at the library, in cinema)? Yes = 1 No = 0 3) Which cigarette would you hate most to give up? The first one in the morning = 1 Any other = 0 4) How many cigarettes/day do you smoke? < 10 = 0 2130 = 2 1120 = 1 > 31 = 3 5) Do you smoke more frequently during the first hours after waking than during the rest of the day? Yes = 1 No = 0 6) Do you smoke if you are so ill that you are in bed most of the day? Yes = 1 No = 0
TOTAL (higher scores indicate higher levels of dependence, e.g. > 5)
HELP YOUR PATIENTS TAKE CONTROL Refer to 1-800-QUIT NOW ITS FAST, ITS EASY, IT WORKS PHARMACOLOGIC PRODUCT GUIDE: FIRST-LINE RECOMMENDATIONS Avg. wholesale price from 2006 Drug Topics Redbook Modified from the Rx for Change: Clinician Assisted Tobacco Cessation Curriculum The University of Virginia, University of Arkansas for Medical Sciences and University of South Carolina Initiative For complete guide, visit www.rxforchange.ucsf.edu Nicotine Gum Nicotine Lozenge Nicotine Patch Nicotine Nicotine Buproprion SR Varenicline PRODUCTS: PRODUCT: PRODUCTS: Nasal Spray Oral Inhaler PRODUCT: PRODUCT: Nicorette 1
2 mg, 4 mg; regular, mint, orange, fruit chill Generic 2 mg, 4 mg PRECAUTIONS: pregnancy (Category D), recent (< 2 weeks) MI, unstable angina, serious underlying arrhythmias, TMJ disease, difficult to use with dentures DOSING: 25 cigarettes/day = 4 mg < 25 cigarettes/day = 2 mg MAXIMUM gum/day = 24 pieces Chew slowly 1 piece every 12 hours Park between cheek and gum when taste/tingling sensation appears (~15 chews) Resume chewing when taste/tingling fades Repeat steps until taste/tingling gone (~30 minutes) NO food/beverage 15 minutes prior or during GUM use Duration usually 12 weekstaper off as appropriate POSSIBLE ADVERSE EFFECTS: mouth/jaw soreness, hiccups, dyspepsia, if incorrect chewing = lightheadedness, n/v, throat and mouth irritation COST: 2 mg = $2.65$5.16 (9 pieces) 4 mg = $3.18$5.81 (9 pieces) Most packages = 2 week supply Commit 1
2 mg, 4 mg; regular, mint PRECAUTIONS: pregnancy (Category D), recent (< 2 weeks) MI, unstable angina, serious underlying arrhythmias DOSING: 1st cigarette = > 30 minutes after waking = 2 mg 1st cigarette = 30 minutes after waking = 4 mg MAXIMUM lozenge/day = 20 lozenges Dissolve slowly 1 piece every 12 hours Dissolves completely ~30 minutes Occasionally rotate lozenge to different areas of the mouth Do NOT chew or swallow the lozenge NO food/beverage 15 minutes prior or during lozenge use Duration usually 12 weekstaper off as appropriate POSSIBLE ADVERSE EFFECTS: hiccups, dyspepsia, if incorrect dissolving = lightheadedness, n/v, throat and mouth irritation COST: 2 mg = $4.92 (9 pieces) 4 mg = $5.26 (9 pieces) Most packages = 2 week supply a) Nicoderm CQ Patch 1
7 mg, 14 mg, 21 mg (24 hour) b) Generic Patch formerly Habitrol 7 mg, 14 mg, 21 mg (16 hour) PRECAUTIONS: pregnancy (Category D), recent (< 2 weeks) MI, unstable angina, serious underlying arrhythmias, acute and/chronic skin disorders DOSING: > 10 cigarettes/day = highest mg/day x 6 weeks; taper to medium mg/day x 2 weeks; taper to lowest mg/day x 2 weeks 10 cigarettes/day = not recommended for Nicotine Patch; all other patches start with medium mg/day x 6 weeks; taper to lowest mg/day x 2 weeks Apply patch to upper body over non-hairy area Remove patch at bedtime If experience sleep disturbance may remove 24 hour patch at bedtime May shower with patch Do not cut patch in half POSSIBLE ADVERSE EFFECTS: local skin reactions (erythema, pruritus, burning), headache COST: Nicoderm = $3.35$3.91 (1 patch) Generic = $2.10$2.94 (1 patch) PRODUCT: Nicotrol Nasal Spray 2 metered spray (0.5 mg nicotine in 50 ul aqueous nicotine solution); each bottle contains ~100 doses or 1 week supply PRECAUTIONS: pregnancy (Category D), recent (< 2 weeks) MI, unstable angina, serious underlying arrhythmias, underlying chronic nasal disorders (rhinitis, nasal polyps, sinusitis), severe reactive airway disease DOSING: 12 doses/hour ONE dose = 2 sprays (one in each nostril); each spray = 0.5 mg of nicotine MAXIMUM spray = 5 doses/ hour or 40 doses/day Do NOT sniff, swallow, or inhale through the nostril Tilt head back and spray Initially use at least 8 doses/day Duration usually 36 months taper off as appropriate POSSIBLE ADVERSE EFFECTS: nasal and/or throat irritation, PRODUCT: Nicotrol Inhaler 2
10 mg cartridge delivers 4 mg inhaled nicotine vapor PRECAUTIONS: pregnancy (Category D), recent (< 2 weeks) MI, unstable angina, serious underlying arrhythmias, underlying reactive airway disease DOSING: 616 cartridges/day MAXIMUM dose = 16 cartridges/day Initially use 6 cartridges/day Do NOT inhale into lungs Puff as if lighting a cigar/pipe Best effects with continuous puffing x 20 minutes Cartridge is depleted after ~20 minutes of active puffing Each cartridge retains potency x 24 hours Duration usually 6 months POSSIBLE ADVERSE EFFECTS: nasal and/or throat irritation, unpleasant taste, hiccups, Zyban 1
150 mg sustained released tablet PRECAUTIONS: pregnancy (Category B), concomitant therapy with meds known to lower the seizure threshold (e.g., antipsychotic/depressants, theophylline, lithium, etc.) CONTRAINDICATIONS: Hx of seizure Hx of bulimia or anorexia nervosa MAO inhibitor inprevious 14 days Concomitant use of bupropion Abrupt discontinuation of alcohol or sedatives DOSING: 150 mg Set QUIT date; start med 12 weeks prior Initially 150 mg every AM for 3 days; then 150 mg BID MAXIMUM dose = 300 mg/day Allow at least 8 hours between doses Avoid HS dosing Can be used safely with NRT products Duration usually 6 months for maintenance; tapering NOT necessary POSSIBLE ADVERSE EFFECTS: insomnia, dry mouth, nervousness/difficulty concentrating, rash, constipation, seizure risk (1/1000 or 0.1%) COST: $3.62$5.73 for 2 tablets Chantix 2
0.5 mg, 1 mg tablet PRECAUTIONS: Pregnancy (Category C), severe renal impairment (dosage adjustment is necessary) DOSING: Days 13: 0.5 mg po q AM Days 47: 0.5 mg po bid Weeks 212: 1 mg po bid Patients should begin therapy 1 week prior to quit date Take dose after eating with a full glass of water Dose tapering is not necessary Nausea and insomnia are side effects that are usually temporary Duration 12 weeks; an additional 12 week course may be used in selected patients POSSIBLE ADVERSE EFFECTS: nausea, sleep disturbances (insomnia, abnormal dreams), constipation, flatulence, vomiting COST: $4.00$4.22 for 2 tablets Most packages = 2 week supply rhinitis, tearing, sneezing, rhinitis, tearing, sneezing,
THE CDC REPORTS THAT, IN THE U.S. 46 million adults smoke . . . ~430,000 adult deaths occur per year related to smoking . . . 50,000 deaths occur per year related to second-hand smoke . . . smoking costs the U.S. ~$157.7 billion/year www.cdc.gov/tobacco/sgr cough, headache COST: $3.67 for 8 doses Most packages = 2 week supply cough, headache COST: $5.25$6.07 for 6 cartridges Most packages = 2 week supply
1 GlaxoSmithKline 2 Pfizer
NOTE: The Treating Tobacco Use and Dependence Practice Guidelines by the U.S. Department of Health and Human Services, Public Health Service (2000) recommend combination therapy (counseling, nicotine replacement therapy, and buproprion SR) to increase the rate of success with tobacco cessation.Varenicline is recommended as monotherapy with counseling.