Health Risks Posed by Smoking

Transcription

1 Tobacco Interventions for Urgent Care Patients Alan A. Ayers, MBA, MAcc Content Advisor, Urgent Care Association of America Associate Editor, Journal of Urgent Care Medicine Vice President, Concentra Urgent Care Many smokers think about quitting in the New Year and the seasonal upsurge in urgent care patients presenting with cold, flu, sinusitis and respiratory infections makes now the ideal time to promote the benefits of smoking cessation. There are practical and ethical reasons for offering tobacco interventions not only can they significantly improve the long- term health of patients but research suggests smokers are generally more satisfied with their care when they receive smoking cessation advice. Why Offer Tobacco Interventions? According to the Centers for Disease Control and Prevention (CDC), tobacco use is responsible for 443,000 deaths annually more than that of human immunodeficiency virus (HIV), illegal drug use, alcohol abuse, automobile accidents, suicide and murder combined. The CDC further reports that 68.8 percent of current smokers want to give up their habits completely, and there are now more former smokers than current smokers. However, millions of current smokers have tried unsuccessfully to quit and struggle to break the habit without support. For these individuals, evidence- based cessation treatments including brief clinical interventions, counseling, behavioral cessation therapies and cessation medications have life- saving potential. If just a small percentage of the estimated 45.3 million adult smokers in the United States were motivated to quit following clinical intervention, the positive impact upon public health would be huge. With smoking cessation greatly reducing the risk of numerous diseases and premature death, not just to smokers themselves but also to infants and children exposed to second- hand smoke, the moral case for offering tobacco interventions is clear. Why do people smoke? Diverse physical, psychological, genetic and social factors are involved in the development and maintenance of a smoking habit including: Nicotine Addiction: Although most of the toxic effects of smoking are due to other components of tobacco smoke, nicotine is thought to be predominantly responsible for tobacco addiction. Its effects are complex and not fully understood, but it is known to facilitate the release of various neurotransmitters associated with drug dependence, including dopamine, glutamate and gamma aminobutyric acid (GABA). Psychological Factors: The role of dopamine in stimulus- reward learning frequently leads to psychological dependence upon various elements of the smoking process the taste of cigarette smoke, the act of smoke inhalation or the sensation of handling cigarettes. The formation of strong associations between cues and triggers such as the sight of cigarettes or of particular situations including drinking coffee, finishing a meal or socializing with other smokers can also occur. Withdrawal: Nicotine withdrawal often entails a range of undesirable effects. Whilst symptoms for most individuals commence within a few hours of the last nicotine hit, peak within 12 to 24 hours and subside within a week, withdrawal symptoms can be intense and persistent, particularly in long- term or heavy smokers.

2 Genetics: Genetics are thought to play a significant role in the initiation and degree of tobacco dependence, as well as affecting susceptibility to various smoking- related diseases including lung cancer. The aim of much current research into the genetics of smoking is to enable the development of personalized cessation treatments. Social Factors: Many smokers cite peer pressure, family influence or the desire to fit in with a particular social group as being a primary reason for taking up smoking, with children whose parents smoke being twice as likely to develop the habit as those whose parents are non- smokers. Poor working conditions, unemployment, lack of educational opportunities and social stress are all associated with higher rates of smoking and living in a household with another smoker is strongly predictive of relapse. Mental Health: Individuals with mental illness and substance abuse disorders are at increased risk for tobacco addiction. It is thought that genetic susceptibility to tobacco addiction may share a common pathway with alcohol abuse and major depression, and there is also evidence to suggest that the effects of nicotine can relieve certain psychiatric symptoms and may additionally serve to ameliorate some of the unpleasant sedative side effects of psychiatric medications and alcohol. Health Risks Posed by Smoking According to the CDC, smoking harms nearly every organ in the body and exposure to secondhand smoke is also a serious disease risk: Cardiovascular Disease: Smoking is known to contribute to coronary heart disease, the leading cause of death in the US, and is also associated with other forms of cardiovascular disease including abdominal aortic aneurism and peripheral vascular disease. Cancer: Cigarette smoke contains more than 60 known carcinogens. The link between smoking and lung cancer is well established, with an estimated 90 percent of all lung cancer deaths in men and 80 percent of lung cancer deaths in women attributable to smoking. In addition, smoking can cause numerous other forms of cancer, including acute myeloid leukemia, cervical cancer, stomach cancer, pancreatic cancer and cancers of the oral cavity and pharynx. Female Health and Pregnancy: Women who smoke are at increased risk of infertility, hip fracture and lower postmenopausal bone density, and smoking during pregnancy increases the risk of various complications including premature birth, low birth weight and stillbirth. Infants born to women who smoke are at increased risk of sudden infant death syndrome (SIDS). Respiratory Conditions: Smoking is the most common cause of chronic obstructive pulmonary disease (COPD), and is also an established risk factor for community- acquired pneumonia (CAP) and respiratory tuberculosis (TB). An increased incidence of upper respiratory tract illnesses (URTIs) in smokers versus non- smokers has been observed and various studies have reported a dose- response relationship between smoking and invasive pneumococcal disease, and smoking and mortality from influenza respectively. Secondhand Smoke: The dangers of involuntary exposure to tobacco smoke, also known as secondhand or passive smoking are also substantial. Secondhand smoke is known to cause cancer, cardiovascular disease and acute respiratory effects and its impact upon pediatric health can be particularly devastating, with parental smoking a known risk factor for SIDS, acute respiratory infections including pneumonia, bronchitis and bronchiolitis, development or exacerbation of asthma, chronic ear infections and slow lung growth.

3 Although most smokers are aware of the serious health consequences of smoking, the diverse and pervasive range of motivations for maintaining a tobacco habit makes quitting without support a seemingly insurmountable challenge. Conversely, there is strong evidence that even brief smoking cessation counseling, taking less than three minutes, is effective in improving quit rates amongst adult patients. Incorporating a tobacco cessation intervention into routine clinical practice can therefore have a significant positive impact upon patient health. The 5 A s Intervention Developed by the US Public Health Service, the 5 A s represent a core set of evidence- based peer- reviewed recommendations for screening and treating tobacco use and dependence, and have been designed for easy integration into office practice. 1. Ask: Ask about tobacco use. Identify and document the tobacco use status of every patient. Consider implementing a formal process within your center to ensure that this data is recorded at every visit. 2. Advise: Strongly and clearly advise all current smokers to quit. Highlight the dangers of smoking, emphasizing the fact that cutting down is not sufficient and that even light or occasional smoking can lead to serious negative health consequences. Make sure the individual is aware that they will receive support from clinic staff should they decide to make a cessation attempt. 3. Assess: Assess every tobacco user s current willingness to make a cessation attempt. For current smokers, how willing are they to attempt to quit at this time? For ex- smokers, when did they quit and are they facing any challenges to abstinence? For those who are willing to make a quit attempt, are they are willing to participate in an intensive treatment? If so, make arrangements for them to receive a suitable intervention. For those who are unwilling to quit at this time, let them know that support and effective treatments are available when they feel ready to quit, and follow up at subsequent visits. 4. Assist: Assist smokers with treatments and referrals. For current smokers willing to make a quit attempt, offer appropriate support in the form of medication, counseling and/or referral for additional treatment. A combination of counseling and pharmacologic support is more effective than either approach used alone. Directly provide or make an onward referral for practical counseling to teach problem- solving methods and cognitive behavioral coping strategies to deal with psychological cues and triggers. Offer a supportive clinical environment to encourage the patient throughout their cessation attempt. Suggest seeking social support from others outside the urgent care center including spouse/partner, friends, co- workers and other family members. For current smokers not willing to quit, offer motivational interventions designed to promote future cessation attempts. The risk of relapse tends to decrease over time, but can persist or in some individuals or be triggered by changes in circumstance. Relapse prevention should therefore be offered to recent ex- smokers and those who face ongoing challenges.

4 5. Arrange: All patients receiving the preceding A s should receive follow- up support. Relapse is most common within the first or second weeks of quitting so arrange for follow- up contact with the patient either in person or via telephone, ideally within one week and one month of the quit date respectively. Congratulate the patient for success he/she has had in quitting, and provide encouragement to maintain abstinence. Discuss any problems they have encountered or are concerned about, such as lack of support, low mood or weight gain. Review medications used and assess efficacy and adherence. Practical Suggestions for Implementing a Tobacco Intervention Consult Employing a process that requires routine screening for and documentation of smoking status for every patient at every visit greatly increases rates of intervention delivery by clinicians and of smoking abstinence amongst patients. Whilst patients are most receptive to smoking cessation advice delivered directly by clinicians, other aspects of the intervention, such as administering questionnaires, providing educational materials or making onward referrals, can be delegated to registration staff if time constraints are a consideration. A method that closely matches current office workflow is most likely to stick and is as simple as modifying existing check- in protocols or administering a brief intake questionnaire. An office action plan or flow sheet can help facilitate this approach. Patient Motivation Smoking cessation advice has greatest impact when tailored to the individual. For smokers presenting with colds and flu or receiving flu shots, emphasize the fact that their tobacco habit increases the risk of developing respiratory infections. The welfare of others can be a powerful motivator for quitting, so explaining the dangers associated with secondhand smoke, or highlighting the fact that smoking could be a contributing factor in their child s recent ear infection or asthma attack can prompt some individuals to make a cessation attempt. Urgent care visits are typically less costly than equivalent visits to the ER and many urgent care patients do not have regular access to a primary care. For patients for whom cost is a significant factor, discuss the financial implications of smoking- related illnesses, alongside the immediate savings to be made by giving up tobacco. Patient Support Partnering with other local healthcare service providers can enable provision of a comprehensive smoking cessation package. Providing informational literature, self- help materials and details of local and national support networks, websites and telephone quitlines can help patients to stay abstinent when immediate clinical support is not available. Adequate preparation can have a significant impact upon quitting success. Working with patients to construct a personalized cessation plan involves setting a quit date, telling friends, family and co- workers about their quit attempt and requesting support and understanding, anticipating particular challenges such as withdrawal symptoms or trigger situations, and removing tobacco products and smoking paraphernalia from their home, workplace, car and other locations where they spend a lot of time. Under circumstances where efficacy is proven and no contraindications exist, the use of FDA- approved medications such as varenicline, bupropion SR, and nicotine replacement lozenge, gum, patch, inhaler, or nasal spray can be recommended. Explain how these medications can reduce withdrawal symptoms and improve chances of quitting success.

5 Conclusion With numbers of primary care physicians steadily in decline, and limited office hours making it difficult to obtain convenient appointments, many Americans lack regular access to a stable healthcare provider who can provide the support necessary to successfully quit smoking and avoid relapse. Smokers in particular are less likely to have a primary care physician than non- smokers. A clear role therefore exists for urgent care centers to provide smoking cessation interventions and act as a gateway to additional sources of care and information for individuals who might otherwise have limited access to those resources. By providing walk- in appointments beyond standard office hours, urgent care centers are uniquely suited to offering immediate support to individuals who need help to give up their tobacco habit. Acknowledging the link between smoking and ill- health is an important first step in reaching the decision to quit for many smokers, so providing information on smoking cessation to patients presenting with a smoking- related condition can be powerfully motivating. Point- of- care dispensing means that patients can be provided with suitable medication before leaving the clinic and can begin their quit attempt without delay.

6 Nicotine Dependency Consult for Urgent Care Physicians Sample Outline for Urgent Care Patient Encounters Consider a nicotine dependency consult to: Help the patient develop a quit plan; Provide counseling; Provide intra- treatment social support; Help patient obtain extra- treatment support; and Recommend the use of pharmacotherapy. The 5 A s for Brief Intervention The 5 A's developed by the U.S. Public Health Service represent a set of clinical practice guidelines for treating tobacco use and dependence in patients: Ask about tobacco use: Identify and document tobacco use status for every patient at every visit. Advise to quit: In a clear, strong and personalized manner, urge every tobacco user to quit. Assess willingness to make a quit attempt: Is the tobacco user willing to make a quit attempt at this time? Assist in quit attempt: For the patient willing to make a quit attempt, use counseling and pharmacotherapy to help him or her quit. Arrange follow- up: Schedule follow- up contact, preferably within the first week after the quite date. Treating Tobacco Use and Dependence: Bupropion SR 150 Nicotine Gum Nicotine Inhaler Nicotine Lozenge Nicotine Nasal Spray Nicotine Patch Varenicline Begin tx 1-2 weeks before quitting smoking. Initial dose: 150 mg every morning for three days, then increase to 150 mg twice daily. Continue twice daily for 7-12 weeks following quit date. Can use for long- term therapy six months post quit date. Less than 25 cigarettes/day (2 mg/piece) More than 25 cigarettes/day (4 mg/piece) Use up to 12 weeks, no more than 24 pieces/day One dose = one cartridge (approximately 80 puffs/cartridge) Recommended dose: 6-16 cartridges/day Use up to six months. Taper off doses during final three months of treatment Allow one lozenge to dissolve in mouth (don t chew or swallow it) every 1-2 hours during first six weeks; minimum nine lozenges/day, then decrease to one lozenge every 2-4 hours during weeks 7-9 and then one lozenge every 4-8 hours for weeks Each dose of spray consists of one 0.5 mg dose to each nostril (1mg total). Initial dose: 1-2 doses per hour, increase as needed to relieve symptoms; minimum (eight doses/day) with maximum 40 doses/day or five doses/hour. Duration: 3-6 months. Four weeks: 21 mg/24 hours Then two weeks: 14mg/24 hours Then two weeks: 7mg/24 hours Start one week before quit date at 0.5 mg once daily (three days) followed by 0.5 mg twice daily (four days) followed by 1 mg twice daily for 3-6 months. Use at least three months. Patient should be instructed to quit on day 8 when dosage is increased to 1 mg twice daily. Additional Resources: QUIT- NOW: A free, phone- based service providing education materials and personal coaching that can help patients quit smoking or chewing tobacco. A government- sponsored web site dedicated to helping patients quit smoking.