Tobacco Cessation: Academic Nursing Partnerships for Success

Janie Heath PhD, APRN-BC, ANP, ACNP Associate Dean Academic Nursing Practice Medical College of Georgia

VANDERBILT SCHOOL OF NURSING Nashville, TN

Georgetown University
Washington, DC

Medical College of Georgia Augusta, GA

Objectives

Identify the importance of integrating tobacco cessation in DAILY practice Identify key strategies / approaches for integrating tobacco cessation in DAILY practice Identify essential resources for integrating tobacco cessation in DAILY practice
VISIT: www.tobaccofreenurses.org

TRENDS in ADULT SMOKING, by SEXU.S., 19552004

Trends in cigarette current smoking among persons aged 18 or older
60 50 40

Male

20.9% of adults are current smokers

23.4% 18.5%

Percent

30 20 10 0
1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999 2003

Female

44.5 Million Adults are Addicted to Cigarettes

Year

The BAD News: < 36% News: Receive70% Information The GOOD want on to HOW quit to quit
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 19652001 NHIS. Estimates since 1992 include some-day smoking.

STATE-SPECIFIC PREVALENCE of SMOKING among ADULTS, 2004

California 14.8% Kentucky 27.6%

Nevada 23.2% Utah 10.5%

GA TN 26.1% 20.1%
Centers for Disease Control and Prevention. (2005). MMWR 54:11241127.

STATE-Cigarette Excise Tax / Pk, 10/2006

California
87 cents

Kentucky
30 cents

HIGHEST

Nevada
80 cents

NJ = $2.56 LOWEST SC = 00.07cents

Utah
69.5 cents

TN
20 cents

GA
37 cents

Campaign for Tobacco-Free Kids. (2006). State Cigarette Excise Tax Rates & Rankings. Retrieved October 19, 2006, from http://tobaccofreekids.org/research/factsheets/pdf/0097.pdf.

PREVALENCE of ADULT SMOKING, by RACE/ETHNICITYU.S., 2004

33.4% American Indian/Alaska Native 22.2% White, non-Hispanic 20.2% Black, non-Hispanic 15.0% Hispanic

11.3% Asian
0% 10% 20% 30% 40% 50%

Centers for Disease Control and Prevention. (2005). MMWR 54:11211124.

Prevalence and Harm of SMOKING during PREGNANCY

Miscarriage Stillbirth

Preterm delivery
Low birth weight

BABY ALERT: 27% OF Tobacco Dependent WOMEN Continue to SMOKE THROUGHOUT PREGNANCY

PREVALENCE of ADULT SMOKING, by EDUCATIONU.S., 2004

26.2% No high school diploma 39.6% GED diploma 24.0% High school graduate 22.2% Some college 11.7% Undergraduate degree 8.0% Graduate degree
0% 10% 20% 30% 40% 50%

Centers for Disease Control and Prevention. (2005). MMWR 54:11211124.

Annual Causes of Death from Smoking Compared to Other PREVENTABLE Causes

440 400 360 320 280 240 200 160 120 80 40 0
Number of Deaths (thousands)

430

AMAZING

81 17
A ID S oh ol

41

19
e

14
ce d

30

ic l

ic id

ic id

eh

In du

A lc

Sources: (AIDS) HIV/AIDS Surveillance Report, 1998; (Alcohol) McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States.JAMA 1993;270:2207-12; (Motor vehicle) National Highway Transportation Safety Administration, 1998; (Homicide, Suicide) NCHS, vital statistics, 1997; (Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995

H om

Su

ot o

D ru g

Sm

rV

ok in

ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, 19972001

Percentage of all smokingattributable deaths*

Cardiovascular diseases Lung cancer Respiratory diseases Second-hand smoke Cancers other than lung Other

137,979 123,836 101,454 38,112 34,693 1,828

32% 28% 23% 9% 8% <1%

TOTAL: 437,902 deaths annually

Centers for Disease Control and Prevention. (2005). MMWR 54:625628.

2006 REPORT of the SURGEON GENERAL:

INVOLUNTARY EXPOSURE to TOBACCO SMOKE

Approximately 50,000 adults & infants die / year from secondhand smoke TWENTY YEARS later we FINALLY have evidencethe right of smokers to smoke ends There is no where their behavior affects 126 million nonsmokers insafe level of the health and well-being of the U.S. are exposed to second-hand others smoke. secondhand smoke Secondhand smoke contains more than 50 carcinogens
Surgeon General Koop, USDHHS Surgeon General Report, 1986

USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.

FINANCIAL IMPACT of SMOKING

Buying cigarettes every day for 50 years @ $4.12 per pack Money banked monthly, earning 1.5% interest

$331,467

$220,978
Packs per day

$110,489
0 100 200 300 400

Hundreds of thousands of dollars lost

COMPOUNDS in TOBACCO SMOKE

An estimated 4,800 compounds in tobacco smoke
Gases (~500 isolated)

Particles (~3,500 isolated)

Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde

Nicotine Nitrosamines Lead Cadmium Polonium-210

Marketing Strategy: Light and Ultra-Light Cigarettes

The difference between Marlboro and Marlboro Lights

15mg tar, 1.1 mg nicotine

10mg tar, 0.8 mg nicotine

an extra row of ventilation holes

Image courtesy of Mayo Clinic Nicotine Dependence Center - Research Program / Dr. Richard D. Hurt
The Marlboro and Marlboro Lights logos are registered trademarks of Philip Morris USA.

The Safer Cigarette NOT!

Unveiling the SMOKING gun about Safe Cigarettes!

Face the Facts: Tobacco VS Marijuana

Prevalence of Marijuana use among adults = 4% compared to 21% for tobacco use

NIH, 2002 report, National Institute on Drug Abuse

Face the Facts: Tobacco VS Marijuana

Marijuana smoke contains 50 70% more carcinogens than tobacco smoke

Marijuana smoke has 3-5 x the amount of tar and carbon monoxide One joint = 4 cigarettes
NIH, 2002 report, National Institute on Drug Abuse

Face the Facts: Tobacco VS Marijuana

Marijuana is an intoxicant makes you high/drunk

THC, tetrahydrocannabinol, is the active psychoactive ingredient that alters sense of reality & euphoria THC over stimulates cannabinoid receptors in the hippocampus Increase in THC content from 0.2% in 1960 to 12% in 2000

NIH, 2002 report, National Institute on Drug Abuse

Face the Facts: Tobacco VS Marijuana

Regardless of the form /delivery of Marijuana, it is illegal

Exception = medicinal purposes such as Marinol capsule used for pain / loss of appetite / nausea for pts with AIDS or cancer

NIH, 2002 report, National Institute on Drug Abuse

The Rest of the Story: Theres Other Tobacco Products

Chewing tobacco

Looseleaf Plug Twist

Snuff

Moist Dry

The Copenhagen and Skoal logos are registered trademarks of U.S. Smokeless Tobacco Company, and Red Man is a registered trademark of Swedish Match.

Other Tobacco Products

CIGARS

KRETEKS / CLOVE CIGARETTES

Other Tobacco Products

BIDIS

HOOKAH PIPE,

BENEFICIAL PULMONARY EFFECTS of QUITTING

Never smoked or not susceptible to smoke

FEV1 (% of value at age 25)

100

75 Smoked regularly and susceptible to effects of smoke Disability 25 Death 0 25 50 75 Stopped smoking at 65 (severe COPD) Stopped smoking at 45 (mild COPD)

50

Age (years)

COPD = chronic obstructive pulmonary disease

Reprinted with permission. Fletcher & Peto. (1977). BMJ 1(6077):16451648.

Breaking the NICOTINE DEPENDENCE Cycle at ANY age!

A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

The BEHAVIOR

The EMOTIONAL

The PHYSICAL

Automatic learned behavior with cigarettes

Role of cigarettes in life pleasure, stress, social

Physical addiction of cravings & withdrawals

Adapted from Legacys GSD&M Presentation 12/5/03

DOPAMINE REWARD PATHWAY

Prefrontal cortex
Within 7 11 seconds I feel good

Dopamine release

Nucleus accumbens Ventral tegmental area

Stimulation of nicotine receptors Nicotine enters brain

NICOTINE BEHAVIORAL EFFECTS: Do the Math!

An individual smokes 1 pack per day x 20 yrs 20 cigarettes / pack 10 puffs / cigarette = ?? puffs / day
200 HITS of THATs ____ NICOTINE per DAY

Now Multiply that # by days / year

73,000

THEN multiply that number by years smoking!

1.4 million

YIKES! No wonder it is SO difficult to QUITAverage attempts = 7-10 per smokers lifetime

NEUROCHEMICAL and RELATED EFFECTS of NICOTINE

N Dopamine I
Pleasure, reward Arousal, appetite suppression Arousal, cognitive enhancement Learning, memory enhancement Mood modulation, appetite suppression Reduction of anxiety and tension Reduction of anxiety and tension

Norepinephrine
Acetylcholine Glutamate Serotonin

C
O T I E

N -Endorphin
GABA

Benowitz. (1999). Nicotine Tob Res 1(Suppl):S159S163.

NICOTINE PHARMACODYNAMICS: WITHDRAWAL EFFECTS

Depression Insomnia Irritability/frustration/anger Anxiety Difficulty concentrating Restlessness Increased appetite/weight gain Decreased heart rate Cravings*
American Psychiatric Association. (1994). DSM-IV. Hughes et al. (1991). Arch Gen Psychiatry 48:5259. Hughes & Hatsukami. (1998). Tob Control 7:9293.

Most symptoms peak 2448 hr after quitting and subside within 24 weeks.

* Not considered a withdrawal symptom by DSM-IV criteria.

ASSESSING NICOTINE DEPENDENCE

How soon after you wake up do you smoke your first cigarette

Do you find it difficult to refrain from smoking in restricted areas Which cigarette do you hate to give up most How many cigarettes do you smoke per day Do you smoke more frequently during the first hours after waking Do you smoke if you are so ill that you are in bed most of the day

Fagerstrm Test for Nicotine Dependence (FTND)

Scores range from 0 to 10; a score of greater than 5 indicates substantial dependence

The 5 As
ASK ADVISE ASSESS
IF time does not allow. do 3 As and REFER

ASSIST ARRANGE
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

Modified Version of 5 As = The 3 As & REFER

In the absence of time or expertise. ask, advise, assess, and refer to other resources, such as local programs or the toll-free quitline 1-800-QUIT-NOW
This brief intervention can be achieved in 30 seconds.

TO ORDER CARDS www.smokingcessationleadershipcenter.org

METHODS for INCREASING MOTIVATIONFIVE Rs

FOR INDIVIDUALS NOT READY TO QUIT YET: Tailor messages

with Motivational Interviewing Techniques

RELEVANCE RISKS REWARDS

ROADBLOCKS
REPETITION

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, 2000.

STRATEGIES for Successful Tobacco Cessation

Walk the Talk of Evidence Based Practice Acute and critical care admissions = HIGHLY TEACHABLE MOMENTS Provide structures/systems (chart prompts, standing orders, dedicated counselors) to facilitate success in breaking the nicotine cycles of addiction

Emotional - Cognitive Tools Behavioral - Tools Physical - Biological Tools

INTERDISCIPLINARY APPROACH ESSENTIALS: collaboration, effective decision making AND compassionate caring practices

Cognitive Evidence-Based STRATEGIES

SET DATE Design individualized plan

TRIGGERS MOTIVATION and CONFIDENCE to quit (0-10) Routines/situations associated with tobacco use Tobacco Log Social support ASSIST to change routine Non-food / healthy items instead of cigarettes Tea instead of coffee / Exercise instead of smoking

A modified US PHS Guideline Approach: START

Cognitive Evidence-Based STRATEGIES Continued

ASSIST (continued) Coping strategies for life stressors /emotional triggers Weight gain concerns Withdrawal concerns the 4 Ds Relapse concerns Daily affirmation Pharmacotherapy options

The PHYSICAL

REMOVE tobacco products for QUIT day Home Car Office

TREAT SELF Facial, Dental, Manicure

A modified US PHS Guideline Approach: START

Quitting is HARD to do!

A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

The BEHAVIOR

The EMOTIONAL

The PHYSICAL

Automatic learned behavior with cigarettes

Role of cigarettes in life pleasure, stress, social

Physical addiction of cravings & withdrawals

Adapted from Legacys GSD&M Presentation 12/5/03

Nicotine Replacement Therapy (NRT): RATIONALE for USE

Reduces physical withdrawal from nicotine Allows patient to focus on behavioral and psychological aspects of tobacco cessation It is NOT substituting ONE negative health behavior for another IMPROVES SUCCESS RATES!

LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS

30 25

Active drug Placebo

19.5 16.4

23.9 20.0 17.1

Percent quit

20 15

14.6 11.5 11.8 8.6 8.8 9.1 10.2

10 5 0 Nicotine gum

Nicotine patch

Nicotine lozenge

Nicotine nasal spray

Nicotine inhaler

Bupropion

Data adapted from Silagy et al. (2004). Cochrane Database Syst Rev and Hughes et al., (2004). Cochrane Database Syst Rev.

FDA APPROVALS: SMOKING CESSATION

Rx nicotine inhaler; Rx bupropion SR

2006 2002

Rx transdermal nicotine patch Rx nicotine gum

1997 1996

Rx varenicline
OTC nicotine lozenge

1991
OTC nicotine gum & patch; Rx nicotine nasal spray

1984

NICOTINE ABSORPTION
Absorption is pH dependent

In acidic media

Ionized poorly absorbed across membranes Nonionized well absorbed across membranes

In alkaline media

At physiologic pH (7.37.5), nicotine is readily absorbed.

PLASMA NICOTINE CONCENTRATIONS for NICOTINECONTAINING PRODUCTS

25

Cigarette

Cigarette
20

Moist snuff

Plasma nicotine (mcg/l)

Moist snuff
Nasal spray
15

Inhaler
10

Lozenge (2mg)

Gum (2mg)
5

Patch
0 1/0/1900 0 1/10/1900 10 1/20/1900 20 1/30/1900 30 2/9/1900 40 2/19/1900 50 2/29/1900 60

Time (minutes)

Overall PRECAUTIONS, if ANY, for NRT

All NRT products = Category D pregnancy

Recent MI (< 2 wks), unstable angina, serious arrhythmias

OTC NICOTINE GUM: Nicorette;

generic

(GlaxoSmithKline; Watson Labs)

Dose = 1 every 1-2 hrs;

No food/beverage 15 min Max = 24 / day

prior - during or 15 min post

Available: 2 mg, 4 mg; regular, mint, orange

NOT recommended if use dentures or TMJ dz

Possible jaw soreness/hiccups/dyspepsia

OTC NICOTINE GUM: CHEWING TECHNIQUE SUMMARY

Chew slowly Chew again when the taste or tingle fades
Stop chewing at first sign of peppery, minty, or citrus taste or tingle

Park

OTC TRANSDERMAL NICOTINE PATCH

Dose = 1 patch every day (16 hrs or 24 hrs) most dosage = 7mg/ 14mg/ 21mg

24 hr patch NOT recommended for sleep disorders

Best if ROTATE patch different areas Preferred sites above the waist

OTC TRANSDERMAL NICOTINE PATCH

If problems sticking apply TEGADERM dressing over patch May bathe/swim with patch Do NOT cut patch Not recommended if acute/chronic skin dz

Possible local skin reaction

OTC NICOTINE LOZENGE Commit (GlaxoSmithKline)

Dose = 1every 1-2 hrs MAX = 20 / d No food/beverage 15 min prior - during or 15 min post
Delivers ~25% more nicotine than equivalent gum dose

Available: 2 mg, 4 mg Let dissolve 20-30 minutes; NO chewing/biting of product

Possible hiccups/dyspepsia/

lightheadedness if chewing or biting

Rx NICOTINE NASAL SPRAY

Nicotrol NS (Pharmacia)

Dose = 1 dose (2 sprays per nostril) every hr MAX = 5 doses/hr OR 40 doses /day Each dose delivers -50 L spray = 0.5 mg nicotine per spray Rapidly absorbed across nasal mucosa -faster onset of action (1113 minutes) compared to the gum, patch, or inhaler

Not recommended if nasal/reactive airway conditions

Possible nasal/throat irritation

Rx NICOTINE INHALER
Nicotrol Inhaler (Pharmacia)

Dose = 6- 16 cartridges / d MAX = 16 cartridges / d Puff as lighting a cigar/pipe best if puff for ~ 20 minutes
Delivers 4 mg nicotine vapor, which is absorbed across buccal mucosa - ~ 20 minutes of puffing = 1 cartridge Not recommended if reactive airway condition

Possible nasal/throat irritation

Rx BUPROPION SR (ZYBAN)
(GlaxoSmithKline)

Non-nicotine agent Sustained release antidepressant Dose = 150mg every a.m. x 3 days then 150mg twice a day

IMPORTANT to start 2 wks prior to QUIT date

Contraindications = seizure disorders, anorexia /bulimia, recent MAO inhibitor use, concomitant use of Bupropion (Wellbutrin), abrupt discontinuation of ETOH / sedatives Precaution pregnancy (Category B) and drugs known to lower seizure threshold

Leading side effect = dry mouth and insomnia

Rx VARENICLINE Chantix (Pfizer): NEW & PROMISING

Non-nicotine cessation aid

Partial nicotinic receptor agonist for the 42 nicotinic acetylcholine receptor Lessens sx of withdrawal and cravings Inhibits surges of dopamine release

VARENICLINE Chantix (Pfizer)

Oral formulation- ~24 hr half life- steady state within 4 days

Leading side effect = nausea Category C pregnancy

VARENICLINE: DOSING
Patients should begin therapy 1 week PRIOR to their quit date. The dose is gradually increased to minimize treatment-related nausea and insomnia. Treatment Day
Initial dose titration

Dose 0.5 mg qd 0.5 mg bid

Days 13 Days 47

Day 8 through end of treatment*

1 mg bid

*Patients should be treated for 12 weeks.

COMPARATIVE DAILY COSTS of PHARMACOTHERAPY

Chantix Inhaler Gum Lozenge Bupropion SR Cigarettes (1 pack/day) Patch Nasal spray

$4.15 $6.07 $5.81 $5.31 $5.24 $4.12 $3.93 $2.66

Cost per day, in U.S. dollars

Breaking the NICOTINE DEPENDENCE Cycle

A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

The BEHAVIOR

The EMOTIONAL

The PHYSICAL

Automatic learned behavior with cigarettes

Role of cigarettes in life pleasure, stress, social

Physical addiction of cravings & withdrawals

Adapted from Legacys GSD&M Presentation 12/5/03

Follow Up for SUCCESS

# of sessions # of arms Estimated odds ratio (95% C.I.) Estimated abstinence rate (95% C.I.)

0-1
2-3 4-8 >8

43
17 23 51

1.0
1.4 (1.1,1.7) 1.9 (1.6,2.2) 2.3 (2.1,3.0)

12.4
16.3 (13.7,19.0) 20.9 (18.1,23.6) 24.7 (21.0,28.4)

FU PRIORITY FOCUS = cravings, withdrawals, med tolerance, coping with triggers & CONGRATS

META ANALYSIS (n = 45 studies) Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

WHAT IF
a patient asks you about your use of tobacco?

The RESPONSIBILITY of HEALTH PROFESSIONALS

If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.
DR. GRO HARLEM BRUNTLAND, FORMER DIRECTOR-GENERAL of the WHO
USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS.

THANK YOU

Slide resources/references available at http://rxforchange.ucsf.edu

http://nurses4tobaccocontrol.org http://tobaccofreenurses.org