DIMENSIONS: Tobacco Free Fundamentals Training Objectives 1/7/2015 DIMENSIONS: Tobacco Free Program. Introduction: Program Overview.

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1 DIMENSIONS: Tobacco Free Program Fundamentals v.4.0 DIMENSIONS: Tobacco Free Program Introduction: Program Overview Tobacco Free Fundamentals Training Objectives This specialized training is designed to: Build on your existing tobacco and tobacco cessation knowledge Provide information on the latest evidence-based tobacco cessation strategies Provide the resources and skills to assist individuals to live tobacco-free 1

2 Our Wellness Philosophy Leading a meaningful and fulfilling life through conscious and self-directed behaviors, focused upon living at one s fullest potential. Eight Dimensions of Wellness Emotional Environmental Financial Intellectual Occupational Physical Social Spiritual This is a Critical Issue What is killing the majority of us is not infectious disease, but our chronic and modifiable behaviors. 2

3 DIMENSIONS: Tobacco Free Program Module 1: Persons with Behavioral Health Conditions and Tobacco Use Prevalence and Patterns of Tobacco Use Burden of Tobacco 480,000 tobacco-related deaths in the U.S. each year 6 million tobacco-related deaths worldwide each year It is estimated that one person dies from a tobaccorelated illness every 6 seconds 16 million people living with tobaccorelated chronic illness 42,000 deaths each year in the U.S. due to second-hand smoke exposure 3

4 Number of deaths (thousands) 1/7/2015 Behavioral Causes of Death in U.S. 700 Annual Causes of Death in the United States, Heart Disease* Cancer* *Tobacco Related Illnesses 500 **Tobacco Use is a Risk Factor Chronic Respiratory Diseases* Cerebrovascular Disease* Accidents** Rates of Tobacco Use 21.3% of adults in the U.S. currently use tobacco products Cigarettes 17.8% Smokeless tobacco 2.6% Cigars, cigarillos or small cigars 2.0% Electronic cigarettes 1.9% Water pipes/hookah 0.5% Pipes 0.3% 4

5 Trends in U.S. Adult Smoking % of adults are current smokers Men Women Rates of Tobacco Use Smoking rates by state: Ranges from 11.8% in Utah to 29% in Kentucky Smoking rates by region: Highest in the Midwest (20.6%) and South (19.2%) Lowest in the Northeast (16.9%) and West (13.6%) Demographic Characteristics There are several demographic characteristics that may influence patterns of tobacco use among the U.S. population: Age Gender Race/Ethnicity Geography Income/Education Occupation Behavioral Health Sexual Orientation 5

6 Tobacco Industry Targeting In 2011, tobacco companies spent $8.8 billion on advertising and promotional materials Tobacco companies sought out individuals with limited resources to cessation services Promoted smoking in treatment settings Monitored or directly funded research supporting the idea that people with schizophrenia need to smoke to manage symptoms For every $1 the state spends to reduce tobacco use, $18 is spent by tobacco companies to promote their products. Tobacco and Youth (12-17) 23% of U.S. high school students report tobacco use in the last 30 days As with adults, rates of tobacco use are higher among youth with a behavioral health diagnosis 90% of youth try tobacco before age 18 88% of daily adult smokers started smoking by age 18 99% of adult smokers become daily users before the age of 26 Tobacco and Youth Youth are more likely to: Benefit long-term from preventative interventions Be a target of aggressive marketing by tobacco companies Become susceptible to social and environmental pressures to use tobacco 6

7 Tobacco and Young Adults (18-25) 24% of young adults report tobacco use Report the highest usage rates for hookah, cigar/cigarillo, regular pipe and e-cigarettes as compared to other age groups 72% of young adult who use tobacco, either socially or daily, become tobacco-dependent adults Tobacco and Young Adults Young adult interventions are most effective if they are: Technology-based (i.e., , websites, texting or social media) Individually tailored to the population they target (i.e., straight-to-work, college-bound, high school, etc.) Free and/or offer financial incentives Social and involve their family or friends Brief in terms of contact with cessation support Tobacco and Older Adults Older adults are more likely to: Have increased rate of mortality for a tobacco-related illness Be motivated by negative health consequences Not receive tobacco cessation resources due to provider beliefs about their desire to quit Older adults have been found to quit smoking at rates comparable to those of younger smokers. 7

8 Tobacco and Women Research indicates there may be generational differences between women and men in cessation behaviors Women tend to smoke less for nicotine reinforcement and more for non-nicotine reinforcement, such as: Sensory effects of smoking Management of stress and negative affect Secondary social reinforcement Weight management Tobacco and Women Greater risk of developing a smoking-related disease than men Gender-specific health issues and pregnancy complications More difficulty quitting Tobacco Use and Race/ Ethnicity Rates of tobacco use: Multiple race 26.8% American Indian/Native American 26.1% White 19.4% Black 18.3% Hispanic 12.1% Asian 9.6% Tobacco industry targets specific racial/ ethnic groups through advertising, product development and sponsoring cultural events 8

9 Tobacco and Poverty Individuals who are working class, low income, and have low educational levels have the highest percentages of smoking behaviors Smoking rates for those: Below the poverty line is 29.2% Above the poverty line is 16.2% Tobacco and Poverty 70%-80% of adults who are homeless smoke 41% of homeless service organizations offer tobacco cessation services Tobacco needs to be addressed not only as a health issue, but as a social justice issue Tobacco and Occupation Job stress, exposure to occupational hazards, shift work and other factors impact tobacco use 35% 30% 25% 20% 15% 10% 5% 0% 9% Adult Tobacco Use in Selected Industries 30% 27% 13% 2% 2% 17% 9% 19% 8% 32% 21% Current Cigarette Smoking Current Smokeless Tobacco Use 9

10 Tobacco and Sexual Orientation Smoking prevalence is higher for lesbian, gay or bisexual adults (26.6%) than for heterosexual adults (17.6%) Lesbian women are more than twice as likely to engage in tobacco use regardless of age Gay men at age 18 are 80% more likely to be current smokers Gay men younger than 50 are 60% more likely to be current smokers Tobacco Use and Treatment: Behavioral Health Populations Tobacco and Behavioral Health Populations Persons with behavioral health conditions: Are nicotine dependent at rates 2-3 times higher Represent over 44% of the U.S. tobacco market Consume over 40% of all cigarettes smoked 10

11 Tobacco Use by Diagnosis Schizophrenia 62-90% Bipolar disorder 51-70% Major depression 36-80% Anxiety disorders 32-60% Post-traumatic stress disorder 45-60% Attention deficit/ hyperactivity disorder 38-42% Alcohol abuse 34-80% Other drug abuse 49-98% Tobacco Use Affects Mental Health Care and Treatment Persons with behavioral health conditions who use tobacco: Have more psychiatric symptoms; Have increased hospitalizations; Require higher dosages of medications; Are twice as likely to leave against the advice of their doctors, if withdrawal symptoms are not treated. ANTIPSYCHOTICS ANTIDEPRESSANTS MOOD STABLIZERS ANXIOLYTICS OTHERS Medications Known or Suspected To Have Their Levels Affected by Smoking and Smoking Cessation Chlorpromazine (Thorazine) Clozapine (Clozaril) Fluphenazine (Permitil) Haloperidol (Haldol) Mesoridazine (Serentil) Amitriptyline (Elavil) Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin (Sinequan) Duloxetine (Cymbalta) Carbamazepine (Tegretol) Alprazolam (Xanax) Diazepam (Valium) Acetaminophen Caffeine Heparin Insulin Rasagiline (Azilect) Olanzapine (Zyprexa) Thiothixene (Navane) Trifluoperazine (Stelazine) Ziprasidone (Geodon) Fluvoxamine (Luvox) Imipramine (Tofranil) Mirtazapine (Remeron) Nortriptyline (Pamelor) Trazodone (Desyrel) Lorazepam (Ativan) Oxazepam (Serax) Riluzole (Rilutek) Ropinirole (Requip) Tacrine Warfarin 11

12 Tobacco Use Affects Treatment & Recovery from Addiction People who are alcohol dependent are three times more likely to use tobacco Tobacco use is a strong predictor in use of illegal substances, such as methamphetamines, cocaine, and opiates Addressing tobacco dependence during treatment for other substances is associated with a 25% increase in long-term abstinence rates from alcohol and other substances Concurrent with Other Substance Abuse Treatment 75% of clients believe tobacco treatment should be offered while in treatment for other addictions At discharge, 50% of smokers thought the tobacco-free policy helped them address their tobacco use Does not cause people to experience worsening psychiatric symptoms Contributing Factors Bio-psycho-social model Systems factors Provider factors Personal factors 12

13 Bio-psycho-social Model Psychological Factors Biological Factors Social Factors Tobacco Use Systems Factors Tobacco as reward Disruption of treatment setting Fear of increased symptoms & relapse Financial gain Provider Factors Expectation of failure Competing demands Lack of training Minimization 13

14 Personal Factors Boredom Self-identity Lack of recovery Expectation of failure Fear of withdrawal symptoms Coping with tension and anxiety Fear of gaining weight Quitting: It Can Be Done Persons with behavioral health conditions: Are able to quit using 75% want to quit using 65% tried to quit in the last 12-months Cessation Rates Although tobacco cessation rates for persons with behavioral health conditions are lower than the general population, smoking cessation rates are still substantial. Major Depression up to 38% Schizophrenia between 10-30% Most studies combine medications & psychoeducation and/or Cognitive Behavioral Therapy (CBT) Cessation rates for people without a behavioral health diagnosis are 25-30% (with combination therapy ) 14

15 Why Help People Quit? Improve health and overall quality of life Increase healthy years of life Improve the effect of medications for mental health problems Decrease social isolation Save money by not buying cigarettes Quitting smoking is a right and is important for recovery DIMENSIONS: Tobacco Free Program Discussion DIMENSIONS: Tobacco Free Program Module 2: Tobacco Use and Addiction 15

16 Tobacco and Nicotine Products Tobacco Products that are Smoked Cigarettes: Most common form of tobacco in the U.S. Cigars: One cigar has as much tobacco as a pack of cigarettes Contain high levels of nicotine Clove Cigars/ Bidis: Cloves are a mixture of tobacco and cloves and have twice the nicotine compared to cigarettes Bidis look like marijuana joints, come in candy flavors, and have higher levels of tar, carbon monoxide, and nicotine than cigarettes Tobacco Products that are Smoked Waterpipe smoking (hookah): Tobacco flavored with fruit pulp, honey, and molasses Often used for longer amounts of time than cigarettes, so more tar and nicotine is inhaled Pipes: Puffed into the mouth, typically not inhaled One of the least commonly used forms of tobacco 16

17 Smokeless Tobacco Products In 2013, about 2.6% of Americans used smokeless tobacco Rates of use for smokeless tobacco have not changed over the last five decades Chewing Tobacco Dissolvable Tobacco Wet Snuff Snus Dry Snuff E-Cigarettes A battery-powered electronic device that provides doses of nicotine in a vapor form Ingredients: Propylene glycol and/or glycerin Nicotine, 0-20mg/ml Flavoring and other additives Not an FDA-approved cessation device Do not address addiction to nicotine or behavior patterns Unknown health risks E-cigarettes are not emission free Contain harmful chemicals No long term studies E-Cigarettes 17

18 Chemicals in Tobacco Products Arsenic Ammonia Butane Cadmium Marijuana Smoke Marijuana smoke contains several of the same carcinogens as the tar from tobacco Secondhand marijuana smoke contains 50 harmful chemicals (70% more than tobacco smoke) Marijuana smoke contains significant amounts of mercury, lead, ammonia, and hydrogen cyanide, among others Respiratory symptoms caused by marijuana smoke include: Chronic bronchitis Frequent phlegm Shortness of breath Frequent wheezing Chest sounds without a cold Tobacco Dependence 18

19 Tobacco Dependence Has Two Parts Tobacco dependence is a 2-part problem Physical The addiction to nicotine Treatment Behavior The habit of using tobacco Treatment Medications for cessation Behavior change program Treatment should address both the addiction and the habit. Courtesy of the University of California, San Francisco Nicotine Addiction Cycle Courtesy of Signal Behavioral Health Network Prefrontal cortex Dopamine Reward Pathway Dopamine release Stimulation of nicotine receptors Nucleus accumbens Ventral tegmental area Nicotine enters brain 19

20 Nicotine Withdrawal Effects Irritability/ Frustration/ Anger Anxiety Most symptoms: Difficulty Concentrating Appear within the first 1 2 days Restlessness/ Impatience Peak within the Depressed Mood first week Insomnia Decrease within Increased Appetite 2 4 weeks Health Consequences of Tobacco Use 2010 Report of the Surgeon General: How Tobacco Smoke Causes Disease MAJOR FINDINGS: Any level of exposure to tobacco smoke is harmful Number and severity of health problems are directly related to how long a person smokes or is exposed to smoke Smoking light, organic, or filtered cigarettes does not decrease your risk of disease 20

21 2014 Report of the Surgeon General: The Health Consequences of Smoking MAJOR FINDINGS: Smoking is linked to diseases of nearly all organs in the body Research continues to identify smoking-related diseases New evidence reveals that exposure to secondhand smoke is associated with increased risk for stroke Disease risks for women are now equal to those for men How Tobacco Harms You From The Tobacco Atlas Third Edition The Dangers of Second-Hand Smoke There is no safe level of second-hand smoke Being around tobacco smoke is directly linked to disease and premature death in nonsmokers Serious health effects on children and adults sudden infant death syndrome (SIDS), lung and ear problems, and asthma include 21

22 The Dangers of Third-Hand Smoke Particles and gases left behind after a cigarette is extinguished Third-hand smoke Collects on fabrics and surfaces and present in air Can remain for months Early research links exposure to multiple adverse health outcomes Infants and children at particular risk due to increased exposure Smokeless Tobacco Health Effects There is no safe form of tobacco Contains 28 known cancer-causing chemicals, including tobacco-specific nitrosamines, chemicals directly related to the risk of cancer Smokeless tobacco has been linked to these diseases: Oral cancer Heart disease Esophageal cancer Pancreatic cancer Stomach cancer Gum disease Oral lesions (such as leukoplakia) Within 20 minutes blood pressure returns to baseline 48 hours sense of smell and taste begin to return to normal 12 hours oxygen levels return to normal; carbon monoxide drops significantly 72 hours breathing is easier and lung function increases Quitting Smoking has Many Health Benefits 1-9 months chronic cough decreases; breathing improves, overall energy levels increase 1 year risk of heart disease, stroke, and heart attack less than half that of a smoker 10 years lowered risk of some cancers 15 years risk of heart disease is equal to someone who has never smoked 22

23 Years of extended life 1/7/2015 Benefits of Quitting Quitting smoking at ANY age leads to a longer and healthier life Age at cessation (years) DIMENSIONS: Tobacco Free Program Discussion DIMENSIONS: Tobacco Free Program Module 3: Tobacco Cessation Strategies 23

24 Tobacco Cessation Interventions 5A s and 2A s and R Tobacco Cessation Interventions: The 5 A s and 2A s & R Models The 5 A s: Ask Advise Assess Assist Arrange The 2 A s & R: Ask Advise Refer Tobacco Cessation Interventions: The 5 A s 24

25 Tobacco Cessation Interventions: 5 A s ASK all individuals about tobacco use Do you, or does anyone in your household, use any type of tobacco? How many times have you tried to quit? Explore tobacco use history Tobacco Cessation Interventions: 5 A s ADVISE people who use tobacco to quit Provide a clear, personalized and non-judgmental message about the health benefits of quitting tobacco What would motivate the person to quit? Tobacco Cessation Interventions: 5 A s ASSESS readiness to quit How do you feel about your smoking? Have you considered quitting? Explore barriers to quitting Assess nicotine dependence How many cigarettes do you smoke a day? How soon after you wake do you have your first cigarette? 25

26 Tobacco Cessation Interventions: 5 A s ASSIST individuals interested in quitting Set a quit date or gradually cut down Discuss their concerns Encourage social support Tobacco Cessation Interventions: 5 A s ARRANGE follow-up visits to track progress Encourage individuals to join the Tobacco Free group Discuss ways to remove barriers Congratulate successes Encourage individuals to talk with their providers Tobacco Cessation Interventions: 2 A s and R Model ASK if s/he uses tobacco ADVISE Provide a clear, personalized and nonjudgmental message about the health benefits of quitting tobacco REFER To Tobacco Free group To a provider/counselor To a quitline or helpline 26

27 Tobacco Cessation Interventions Pharmacotherapy Tobacco Dependence Has Two Parts Tobacco dependence is a 2-part problem Physical The addiction to nicotine Treatment Behavior The habit of using tobacco Treatment Medications for cessation Behavior change program Treatment should address both the addiction and the habit. Courtesy of the University of California, San Francisco Why Use a Medication for Quitting? Medications: Make people more comfortable while quitting by reducing withdrawal symptoms Allows people to focus on changing their behavior Improve chances of a successful quit attempt 27

28 Percent quit 1/7/2015 Tobacco Cessation Medications The only medications approved by the Food and Drug Administration (FDA) for tobacco cessation are: Nicotine gum Nicotine lozenge Nicotine patch Nicotine nasal spray Nicotine inhaler Bupropion SR tablets Varenicline tablets Long-Term (36-month) Quit Rates for Cessation Medications Active drug Placebo Nicotine gum Nicotine patch Nicotine lozenge Nicotine nasal spray Nicotine inhaler Bupropion Varenicline Sugar-free chewing gum Nicotine Gum Available in different flavors Absorbed through the lining of the mouth Available in two strengths Sold without a prescription May not be a good choice for people with jaw problems, braces, retainers, or significant dental work 28

29 Nicotine Lozenge Sugar-free lozenge Available in different flavors Absorbed through the lining of the mouth Available in two strengths Sold without a prescription Nicotine is absorbed through the skin Sold without a prescription Do not cut in half Apply a new patch every 24 hours Nicotine Patch Nicotine Nasal Spray About 100 doses per bottle Quickly absorbed through the lining of the nose Sold with a prescription as Nicotrol NS 29

30 Nicotine Inhaler Absorbed through the lining of the mouth Allows for similar hand-tomouth ritual of smoking Sold with a prescription Bupropion SR Tablets Does not contain nicotine The tablet is swallowed whole, and the medication is released over time Sold with a prescription as Zyban or generic Varenicline Does not contain nicotine The tablet is swallowed whole Sold with a prescription only as Chantix People who take Chantix should be in regular contact with their doctor NOTE: Some people who used varenicline have reported experiencing changes in behavior, agitation, depressed mood, suicidal thoughts or actions. People should talk to their doctor before taking this medication. 30

31 Combination Therapy Use of two or more forms of tobacco cessation medications can improve cessation rates: PLUS OR OR OR PLUS PLUS OR Pre-Cessation Nicotine Replacement Studies show individuals who used NRT before their quit date: Did not experience any significant side effects Experienced an increase in their quit rates Were twice as likely to maintain their abstinence at 6 months Talking About Tobacco Cessation Medications Encourage people to talk with their primary care provider before starting any tobacco cessation medications Inform people about their different options for tobacco cessation medications Encourage people to read all the directions before they start using a tobacco cessation medication 31

32 Tobacco Cessation Interventions Counseling Tobacco Dependence Has Two Parts Tobacco dependence is a 2-part problem Physical The addiction to nicotine Treatment Behavior The habit of using tobacco Treatment Medications for cessation Behavior change program Treatment should address both the addiction and the habit. Courtesy of the University of California, San Francisco Counseling and Support People are more likely to be successful in stopping their tobacco use, if: They get help through counseling and social support They PREPARE and PLAN for their quit attempt They change their behaviors related to tobacco use 32

33 Relapse Prevention Relapse - (tobacco use after tobacco cessation) can be another challenge For many people, quitting takes more than one try People may need to practice quitting first Discussion: What can be learned from past quit attempts? Tobacco Cessation Interventions Motivational Intervention Motivational Intervention Conduct 30-minute semi-structured interview Work with individuals to increase their readiness for tobacco cessation Provide brief, personalized feedback about their carbon monoxide levels and the cost of smoking Encourage individuals to set concrete and manageable goals Discuss and list the supports they need to set a quit date and sustain their quit attempt 33

34 Stages of Change Stage Definition Intervention Pre-contemplation Not considering changing Educate/Inform Contemplation Preparation Action Maintenance Thinking about making a change Actively considering changing in the immediate future or within the next month Making overt attempts to change Made changes for longer than six months Encourage/Motivate Assist with goal setting Provide support, assist as needed to overcome barriers Continued support, set new goals when ready Motivational Intervention Motivational Intervention 34

35 Motivational Intervention Motivational Intervention Motivational Intervention 35

36 Motivational Intervention Other Tobacco Cessation Interventions DIMENSIONS: Tobacco Free Program An evidence-based tobacco cessation program that promotes positive health behavior change Initially developed in 2006 Implemented in 17 states (and counting!) The program supports tobacco cessation through motivational engagement strategies, group process, community referrals, and educational activities 36

37 Tobacco Free Group Overview Weekly, 60- to 90-minute, open group Participants may join at any time Some information does build on previous sessions Participants may attend as many sessions as needed Session topics cycle over a 6-week period Quitlines Telephone counseling Referrals for additional support May provide NRT or other medications May be available in multiple languages Tobacco-Free Policies Benefits for clients in healthcare settings: Increased quality of life Decreased disease, disability and death Decreased hospital admissions Benefits for employees: Increased productivity Increased job satisfaction Decreased hospital admissions Decreased absenteeism Decreased presenteeism 37

38 Tobacco Cessation Interventions Resources DIMENSIONS: Tobacco Free Toolkits for Healthcare Providers *supplements for other priority populations and Spanishtranslations are also available DIMENSIONS: Tobacco Free Program Module 4: Next Steps 38

39 Plan-Do-Study-Act Process Three key questions: Act Study Plan Do What are we trying to accomplish? How will we know a change is an improvement? What change can we make that will result in improvement? Steps for PDSA Process Plan: Decide what change will be made, who will do it, and when it will be done Do: Carry out the change Study: Ensure that you leave time to reflect and use experience of change to discuss results Act: Based on what you learned, what will your next plan be? What will be different? Act Study Plan Do Change Exercise 39

40 SMART Goals DIMENSIONS Action Plan Behavioral Health & Wellness Program Behavioral Health and Wellness Program BHWP_UCD 40