4/2/2015. Inpatient Smoking Cessation. Smoking Cessation Documentation Patient's Stage of Behavior Change

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1 Implementing Updates Barbara Darsow COTA/BA, CES TEAM Project: Promoting in Hospital Patients 1996 Smoke Free 2000 Coalition Completed Training Smoking cessation counselor at Mayo Clinic Tobacco research Division of Epidemology Inpatient Identify smokers All active smokers or smokers who quit in the last 6 months receive smoking cessation order. Standard order set for physicians Inpatient Treatment provide cessation Documentation Assessment Charging for smoking Cessation In Patient Documentation Patient's Stage of Behavior Change 1

2 Inpatient Treatment Affect of Nicotine Recommendations Education Inhaling nicotine gives the most immediate effects; lungs are lined with millions of alveoli which provide an enormous surface area - more than 40 times the surface area of your skin -most efficient way to get nicotine into the bloodstream Nicotine only stays in the human body for a few hours; it has a half-life of about an hour or two, meaning that six hours after smoking a cigarette, only about milligram of the 1 milligram of nicotine you inhaled remains. Nicotine can also be absorbed through your gastrointestinal tract and your skin -- this is how smokeless tobacco products such as chewing tobacco, skin patches and gum deliver their nicotine fix Effects of Nicotine Is nicotine harmful in itself? Inhaled Nicotine into lungs: quickly goes to brain and produces dopamine, a natural neurotransmitter that produces feeling of pleasure The evolutionary purpose of dopamine is to reward behavior that is good for the survival of a species. Sex is associate with pleasure because of a lot of dopamine is released during sex. Dopamine levels are often soring in people who are intensely infatuated with some. Dopamine is involved in all types of behaviors that are rewarding. Ex: Parents nurturing their infants, drinking when thirsty, eating. Increases HR, BP and constricts blood vessels Vaporized nicotine is better than smoked tobacco Concern regarding introducing adolescents to nicotine products crossing over to cigarettes Nicotine overdose 1 bottle of nicotine contains 1000 mg nicotine. Intentional overdose as high as 1500 mg. Nicotine overdose causes nausea and vomiting in adults. 2 year old died from ingested nicotine liquid by accident 2

3 Nicotine Withdrawal Symptoms Cigars 5% Men ~ 1% Women Physical strong cravings for the substance increased appetite insomnia and sleep disturbance gastrointestinal problems Intestinal movement decreases, hunger craving is confused for hunger pain Head ace Dry throat Emotional anxiety, anger and frustration, depression, irritability Restlessness Increase anxiety Restlessness Lack of concentration Health risk - Increased risk CAD, COPD, periodontist and oral an esophageal laryngeal, lung & other cancers. Cigarettes have decreased Cigars have increased 15.3 in 2005 Little Cigars all time high in 2001 Pipes Hookah and Increased risk CAD, COPD, periodontist and oral an esophageal laryngeal, lung & other cancers Smokeless Tobacco E- Cigarettes Pros/Cons Average-sized dip resting between your cheek and lip for about 30 minutes will give you the same nicotine fix as if you smoked three cigarettes. It is not a safe alternative to smoking; no evidence to suggest that it is effective in helping smokers quit. Insufficient evidence to suggest that the use of tobacco cessation medication increase long-term abstinence. To date study's have not shown decrease in usages Counseling treatments are effective Health risk: abrasion of teeth, gingival recession, periodontal bone loss, leukoplakia, oral and pancreatic CA. ENDS -Electronic Battery-powered personal vaporizer, that deliver nicotine with out any combustion or smoke, but produces an aerosol that resembles smoke. First devices out were delivering a minimal dose of nicotine. Now is similar to that delivered from conventional cigarette. Not FDA approved Concern with poor manufacturing practices Presence of known carcinogens in the limited products that they tested. A few studies have evaluated the effects of electronic cigarettes on plasma nicotine levels and heart rate but found negligible effects. Not sure of what is in the aerosol particles and what effects on body 3

4 E- Cigarettes Pros/Cons Establish rapport & set agenda Safety data are mainly limited to surveys in which patients report only minor side effects, such as mouth and throat irritation, headache, vertigo, and nausea. Pub Med literature search 5/14 Cochrane Library 1 trial after 6 month abstinence rates show similar results between cigarettes and nicotine patches. Another trial reported 12.5% of participants achieving abstinence at 24 months 3 studies significate >50% reduction in cig per/day from baseline Understand how he feels about it. Asses importance and confidence is design to achieve this Some may need time to explore the importance of change Others are convinced that they want to change.. But need help to build confidence Goal is to continue dialogue of the issue for future sessions If he goes away with a hastily constructed and unrealistic action plan, fails to keep to it and embarrassed to come back and admit it. It s unhelpful if he feels nagged & judged, and next time he needs help, they feel reluctant to come and see us. We will not do our best b them if we diagnose reluctant patients as being in Precontemplation and write them off, not bothering to raise the topic with them again. Respect their decision - What would need to happen for you to reconsider change? Brief Interventions Where do you feel you are at in your process of reaching your goal? What would be helpful to you to do between now and when we meet again? What is your next step? Is there any information you d like me to give you that would help you make your mind up about this? What have you learned from previous attempts to change? What does your experience tell you is the best way to go about this? 4

5 Reluctance, defensiveness, resistance Ending consultation Change track, - pace Need patient center goals Skillful Where does this leave you now? What would help you between now and when we meet again? What is your next step? Is there more information you would like that I could give you or you would like me to know about this? What have you leaned from pervious attempts to change? Nicotine replacement, (NRT) can be affective in both sexes, however evidence is mixed Medications: Bupropion SR (Wellbutrin) Zyban can be combined with long term patch( >14 wk) majority of people use gum, nasal spray, inhaler long term Up to 6 months does not present known health risk, dependence on meds uncommon Nicotine inhaler 4 mg of nicotine over 80 inhalation, recommend 6-16 dosages per day for up to 6 months Nicotine lozenges Nicotine patch 5

6 Nicotine gum: is not independent risk factor for acute MI, use caution after acute MI (2 weeks) post MI, and serious arrhythmias, unstable angina. Avoid acidic beverages coffee, juices, soft drinks interfere with absorption 15 min prior and after chewing. Patients often do not use enough PRN NRT medications to obtain optimal effects. - 1 piece every 1-2 hours for up to 1-3 months, decrease dosage last month. Cost 2 mg, pieces $48. 4 mg pieces $63 Bupropion SR Zyban does not cause weight gain. Used for treating depression, smoking cessation, sexual dysfunction, obesity Side affects insomnia (don t take at bed time), dry mouth, possible increase in seizures Motivational Interviewing 1.Use open-ended questions to explore Use opened-ended questions how important do you think it is for you to quit smoking? What might happen if you quit 9 (bring up concerns) Use reflective listening techniques so you think smoking helps you maintain your weight? Summarize what they said Normalize many people worry about managing without cigarettes Support the patient s autonomy and right to choose or reject change. I hear you re not read to quit at this time. Minnesota Quit Line quit-now Provides individual free phone coaching, education on addiction, strategies, medications, benefits, support. 3 or more calls increased the chances of quitting Proactive counseling Reactive counseling Free nicotine replacement therapy - patch, gum or lozenges for those who have no health insurance or work place does not cover NRT for up to 4 weeks if agree with phone follow up NRT for up to 2 weeks if not wishing phone follow up 6

7 What s new in Technology? Resources to Help Increase Skills Mobile Phone Interventions Behavioral interventions through motivational phone text messaging. Messages suggest behavioral change, provide positive feedback, allow patients to request additional assistance as needed. Cell Phone apps behavior interventions including short video clips, cognitive behavioral tips, ( high quality data to support mobile phones apps are lacking.) More studies are needed. Computer based Interventions a meta-analysis of 22 randomized trials in 29,549 smoker found that use of such programs increased abstinence rates by 45%. After 12 months abstinence was 9.9 compared to 5.7 Changing for Good - James Prochska PH.D Health Behavior Changed - A Guide For Practitioners Pip Manson Christopher Bulter Motivational Interviewing Internet benefits of quitting smoking cessation techniques education about tobacco, motivation, support, on medications, handouts 7