JUULING VAPING SMOKING. Help Your Clients Quit Tobacco with ASK.ADVISE.REFER.

Transcription

1 JUULING VAPING SMOKING Help Your Clients Quit Tobacco with ASK.ADVISE.REFER. Sponsored by Mom s Quit Connection for Families with support from the New Jersey Department of Health.

2 Housekeeping Muting With more than 100 attendees, all are muted. Questions Please type questions using the question panel on right. If time permits, we will answer at the conclusion of the webinar or will answers after the webinar ends. Evaluation Survey immediately following webinar 2 month follow-up Nursing contact hours Will receive separate evaluation via Webinar is being recorded

3 By the end of this session, participants should be able to: 1. Develop practice wide protocol to assess and address tobacco use by utilizing CDC s Ask, Advise, Refer: Brief Intervention Model. 2. Apply motivational messages about tobacco use into regular interactions with clients. 3. Summarize the health risks associated with smoking, exposure to second & third hand smoke and tobacco dependence. 4. Refer to available smoking cessation resources in New Jersey.

4 The Toll of Cigarette Smoking Smokers become addicted to nicotine, a drug that is found naturally in tobacco. More people in the United States are addicted to nicotine than to any other drug. Research suggests that nicotine may be as addictive as heroin, cocaine or alcohol. Quitting smoking is hard and may require several attempts. People who stop smoking often start again because of withdrawal symptoms, stress and weight gain.

5 Smoking in 2018

6 Smoking Rates National 14% NJ Residents 13.8% NJ Pregnant Women 3.8% NJ High School Students 5% *National Health Interview Survey (NHIS), CDC/NCHS *Healthy NJ 2020, NJDOH

7 County Atlantic 23% 19% 17% 19% Bergen 15% 12% 12% 13% Burlington 18% 14% 13% 14% Camden 20% 15% 17% 17% Cape May 22% 17% 14% 15% Cumberland 25% 19% 20% 17% Essex 17% 17% 15% 15% Gloucester 21% 15% 16% 16% Hudson 20% 15% 16% 16% Hunterdon 15% 12% 11% 13% Mercer 15% 16% 14% 13% Middlesex 15% 12% 11% 12% Monmouth 17% 14% 13% 14% Morris 14% 13% 11% 12% Ocean 20% 17% 15% 14% Passaic 17% 16% 14% 16% Salem 24% 19% 18% 17% Somerset 12% 11% 10% 11% Sussex 20% 15% 13% 14% Union 17% 15% 13% 13% Warren 22% 15% 16% 16% NEW JERSEY 17% 15% 14% 14% County Health Rankings

8 Clinical Practice Guidelines

9 Treating Tobacco Use and Dependence: 2008 Update Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long-term abstinence. Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective. Clinicians should encourage medications that are available for tobacco dependence to all patients attempting to quit smoking. Unless it is medically contraindicated or with specific populations with insufficient evidence of effectiveness. Telephone quitline counseling is effective with diverse populations and has broad reach. Fiore MC, Jaén CR, Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. clinicians should encourage Department of Health and Human Services. Public Health Service.

10 Estimated abstinence at 5+ months Impact of Clinician Intervention Compared to patients who receive no assistance from a physician, patients who receive assistance are between 1 ½ and 2 times more likely to quit successfully for 5 months or more. It only takes 3 minutes to use Ask, Advise, Refer: Brief Intervention Model No clinician Self-help material Nonphysician clinician Physician clinician

11 Ask Advise Refer

12 CDC Brief Counseling: Ask, Advise, Refer ASK About tobacco USE ADVISE Tobacco users to QUIT REFER To other resources Clinical Practice Guideline, 2008

13 ASK (1 Minute) Purpose: To ask about tobacco use Identify smokers and recent quitters Assess nicotine dependence Determine possible barriers to quitting Determine readiness to enroll in tobacco treatment program Use nonjudgmental and open-ended questions

14 Scripting Samples Ask about the type and amount of tobacco used: Explain your use of tobacco in any form. Tell Me about your tobacco use. Describe your tobacco use in the past. Continue the conversation: How many cigarettes per day do you smoke? How many cigars per day do you smoke? How often do you puff on your e-cigarette?

15 Advise (1 Minute) Clear, strong, personalized advice to quit Clear: Simply state the need to cut down and quit Strong: State the necessity for action Personalized: Tie tobacco use to current symptoms and health concerns or exposure to children

16 Employ the Teachable Moment The provider should emphasize the importance of quitting: Before health problems arise or worsen The impact of current health/illness status of the patient Impact on children and others in the home Costs associated with smoking ($ and health) Facts to incorporate: 6 to 10 quit attempts in their lifetime to be quit for good 7,000 chemicals Triples risk of SIDS in infants Second and thirdhand smoke

17 Scripting Samples "As your (nurse, Doctor, etc.), I must advise you to stop smoking now." "Let me give you the phone number for the NJ Quitline/Mom's Quit Connection for Families. You can receive free counseling on how to quit and remain tobacco-free." "My best advice for you and your baby is for you to quit smoking." "By quitting smoking, you protect your children from illness caused by secondhand smoke."

18 Scripting Samples "Tobacco companies want you to think their products make you look healthy and exciting like the people in their ads. Actually, smoking tobacco can make you look sick and dull and it can cause you to have yellow teeth and fingers, bad breath and make your clothing and hair smell." "Quitting smoking is one of the most important things you can do to reduce your risk of a second heart attack."

19 Refer (1 Minute) Refer: Fax patient referral to Mom s Quit Connection for Families, the NJ Quitline or local quit centers. Provide toll free number Provide website Scripting Example: New Jersey has free services to help you quit smoking; Mom s Quit Connection for Families, the NJ Quitline and local quit centers. Using support services can more than double your chances of quitting.

20 Mom s Quit Connection for Families & New Jersey Quitline

21 Mom s Quit Connection for Families Pregnant or Mother with children 7 years old and younger Family members of child 7 years old and younger Does NOT need to be ready to quit Face-to-face counseling in the community in Southern NJ Telephone counseling for Northern and Central NJ Resident of New Jersey Must be ready to quit No age restriction 18 years or older for free nicotine patches for those that qualify Telephone based counseling

22 Mom s Quit Connection for Families Quit for Kids Family Health Initiatives Face-to-face and phone sessions, texting support and educational self-help materials Registration and counseling available: Monday Friday, 8:30am 5pm Fax referral: Self referral: Web referral: Facebook referral

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24 Fax to Quit Clients do not have to be ready to quit. MQC for Families accepts clients in any stage of readiness. * See bottom left corner.

25 Provider Follow-UP MQC for Families generates and sends to individual providers a report documenting the status of each patient they refer to the program.

26 NJ Quitline Roswell Park Cancer Institute Available for ANY resident of NJ Registration and counseling available: M-F, 9am 9pm and Sa-Su, 9am 5pm Voic and quit tips after hours. English and Spanish speaking staff; interpretive services for other languages. Fax referral: Self referral: Web referral:

27 Studies show only 3% to 5% of smokers are able to quit without any quitting assistance. The U.S. Public Health Service s clinical practice guideline found Quitline counseling can more than double a smoker s chances of quitting and Quitline counseling combined with medication can more than triple the chances of quitting. Gateway to other cessation resources (e.g. medications), can link tobacco users to broader health-related information and resources (diabetes, hypertension).

28 FAX Form New Jersey QuitLine The provider is asked to only fax refer patients to the NJ Quitline who are in a stage where they are at least thinking about making a quit attempt in the near future.

29 Feedback NJ Quitline

30 FAX-TO-QUIT Benefits to Clinician Increase likelihood of patient engagement Integrates tobacco cessation into treatment plan Receive patient progress reports Saves time Benefits to Participant Increase likelihood of quitting Personalized quit coaching Review of quit date and quit plan Evidence-based intervention

31 FAX-TO-QUIT SUMMARY MQC for Families will personalize NJ Quitline and MQC fax-to-quit referral forms for your office. Referral forms are available at Easy to use for both professional and client. Client MUST sign the fax form to be HIPPA compliant. Form encourages providers to utilize the Ask, Advise, Refer: Brief Intervention Model. If your office uses the fax-to-quit referral form, you will receive patient feedback form. NJ QL report dedicated to fax-to-quit referrals can be shared with your office.

32 Nicotine Addiction

33 Components of a Cigarette Cigarette smoke is a deadly mix of more than 7,000 chemicals. Hundreds are toxic, over 70 cause cancer Each cigarette contains 2mg of nicotine Nicotine is what the body becomes addicted to after about 100 cigarettes

34 NICOTINE ADDICTION Cigarettes and other forms of tobacco are addicting. Nicotine is the drug in tobacco that causes addiction. The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine. U.S. Department of Health and Human Services. (1988). The Health Consequences of Smoking: Nicotine Addiction. A Report of the Surgeon General.

35 Smoking is an ADDICTION! ADDICTION IS POWERFUL Three components of addiction: 1. Physical A physical craving for tobacco and withdrawal symptoms may be present in the absence of the drug 2. Habitual The use is ritualistic and done without thought 3. Psychological The belief that the user cannot function without the habit

36 TOBACCO DEPENDENCE: A 2-PART PROBLEM Tobacco Dependence Physiological Behavioral The addiction to nicotine The habit of using tobacco Treatment Treatment Medications for cessation Behavior change program Treatment should address the physiological and the behavioral aspects of dependence.

37 Prefronta l cortex DOPAMINE REWARD PATHWAY Dopamine release Nucleus accumbens Ventral tegmental area Stimulation of nicotine receptors Nicotine enters brain

38 Withdrawal Symptoms Cravings for a cigarette Dizziness Headaches Coughing Trouble concentrating Irritability Fatigue Constipation

39 The Body Begins to Heal Within Minutes 20 mins 8 hrs 24 hrs 48 hrs 72 hrs 2-12 wks 3-9 mths 1 yr 10 yrs 15 yrs Blood pressure, heart rate return to normal. O 2 level returns to normal; nicotine and CO levels reduced by half. CO eliminated from body; lungs begin eliminate mucus / debris. Nicotine eliminated from body; taste and smell improve. Breathing is easier; bronchial tubes relax; energy levels increase. Circulation improves. Lung function increases up to 10%; coughing, wheezing, breathing problems reduced. Heart attack risk decreased by 50% Lung cancer risk decreased by 50% Heart attack risk same as for someone who never smoked.

40 Nicotine Replacement Therapy Available over-the-counter Nicotine gum Available by prescription Nicotine inhaler Nicotine lozenge Nicotine nasal spray Nicotine patch Bupropion (Wellbutrin, Zyban) NRT Chart Chantix

41 The Health Effects of Tobacco Use

42 The Facts Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general. More deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides and murders combined. Health impacts by Cancer, Pulmonary Disease, Cardiovascular Disease, Reproductive health problems/infertility As it appears that the benefits of breastfeeding outweigh the risks of nicotine exposure, nicotine is no longer listed as a drug that is contraindicated during breastfeeding. * Almost half (200,000) of annual deaths from smoking are among people with mental illness and/or substance use disorders. Tars in cigarette smoke affect the rate at which the liver metabolizes certain medications, causing blood levels of antidepressants and antipsychotics to decline. *Chart for Drug Interactions: medication-intera.pdf Mennella JA, Yourshaw LM, Morgan LK. Breastfeeding and smoking: short-term effects on infant feeding and sleep. Pediatrics Sep;120(3):

43 Secondhand Smoke There is no safe amount of secondhand smoke. The U.S. Surgeon General reports released in 2006 and 2010 stated that secondhand smoke is a Class A carcinogen, with no safe level of exposure. Secondhand smoke is the combination of smoke from the burning end of the cigarette and the smoke breathed out by smokers. Secondhand smoke contains about 7,000 chemicals and over 70 are cancer-causing chemicals. Causes an estimated 41,000 deaths each year among adults in the United States

44 Secondhand Smoke Risks among Nonsmoking Adults Nonsmokers who are exposed to secondhand smoke at home or at the workplace are at an increased risk of developing: Lung cancer % Coronary heart disease % Acute respiratory problems

45 Secondhand Smoke and Children Nearly 400,000 children in New Jersey are exposed to secondhand smoke, most in their homes. Infants who are exposed to secondhand smoke after birth are at a greater risk for SIDS. Possible problems with cognitive functioning and behavioral development Decrease in lung development & function For teens, faster addiction caused by brains still in development Surgeon General s Report 2006, Campaign for Tobacco Free Kids 2010

46 Secondhand Smoke and Children Are more likely to suffer from: Ear infections Bronchitis Pneumonia Possible problems with cognitive functioning and behavioral development More likely to become smokers

47 Smoking Exposure Impact on Children with Asthma More flare-ups more often ED visits with more severe asthma flare-ups Missed school due to asthma Take more medication Harder to control, even with medicine KidsHealth from Nemours January 2014

48 Thirdhand Smoke Thirdhand smoke refers to the toxins from cigarette smoke that stick to soft surfaces. Through thirdhand smoke, people can be exposed to the same toxins found in tobacco smoke. Low levels of toxins can build up to dangerous levels in the body. This can cause learning problems for children. Thirdhand smoke can stay on unwashed surfaces for days, weeks, even months.

49 Encourage a Smoke Free Environment A smoke free environment decreases the health risks associated with secondhand smoke exposure. Children and adolescents who live in smoke-free homes are 74% less likely to be smokers. Scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke.

50 The New Generation of Tobacco Addiction

51 Electronic Nicotine Delivery Systems (ENDS) AKA: e-cigarettes, vape pens, hookah pens, tanks, mods, JUUL, etc. Battery-powered heating devices Originally designed to deliver liquid nicotine to users in the form of a vapor (instead of smoke) The vapor comes from heating liquid nicotine and flavoring. SOURCE: A Report of the Surgeon General: E-cigarette Use Among Youth and Youth Adults, CDC, 2018.

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53 SOURCE: CDC,2018. Truth Initiative, ENDS aerosol is NOT harmless "water vapor" Labeling is NOT always a reliable indicator of nicotine content. About 99% of ALL e-cigs sold at convenience stores, supermarkets and similar outlets contain nicotine.

54 E-liquid Facts ENDS contain propylene glycol or glycerin and flavorings. Some ENDS manufacturers claim these ingredients are safe because they meet the FDA definition of Generally Recognized as Safe (GRAS) for food additives, NOT inhalation. Although e-cigarette vapor does not contain 7,000 chemicals found in cigarette smoke, the vapor can contain toxins, metals and ultrafine particles. E-liquid poses a poisoning risk for young children. Less than a teaspoon can be lethal to a small child. Effects of many of these inhaled ingredients are largely unknown. Lung inflammation and disease (i.e. popcorn lung) 75% of e-cigarette flavors tested contained diacetyl SOURCE: CDC, 2018.

55 Kid-Friendly Misleading Labels SOURCE: FDA.gov, 2018.

56 JUUL WARNING: This product contains nicotine. Nicotine is an addictive chemical. 1 Juul pod contains 0.7 ml with 5% nicotine by weight // approximately equivalent to about 1 pack of cigarettes CALIFORNIA PROPOSITION 65 WARNING: This product contains chemicals known to the State of California to cause cancer and birth defects or other reproductive harm. SOURCE: JUUL Labs, Inc., 2017.

57 Nicotine Salts Nicotine for e- liquid begins as free base nicotine. An e-liquid maker adds an acid to lower the ph usually benzoic acid to change it to a salt. Initial patent for JUUL nicotine salt technology obtained in 2015 JUUL claims that their nicotine salt formulation increases the rate and amount of nicotine delivered into the blood, compared with other formulations. Delivery 2.7 times faster than other e-cigs SOURCE: Truth Initiative, CDC, 2018.

58 Dual Use The vast majority of current e-cigarette users are also current smokers. 65% of youth who had used an e-cig in the last 30 days also reported using another tobacco product in the same time frame. This raises additional concerns beyond the potential health effects of e-cigarettes alone. Research suggests that using e-cigarettes may lead youth to start smoking traditional cigarettes. SOURCE: Truth Initiative, The National Academies of Sciences, Engineering, and Medicine, 2018.

59 New Toys Old Tactics E-cigs traditionally have been an unregulated industry Nicotine concentration, other contents Online sale to minors Products made overseas Advertising E-cig marketing tactics similar to tobacco Misleading claims of being healthy & safe Cessation device Promote that e-cigarette can be used anywhere (indoors) Proven to have increased use by youth candy flavored products themes of rebellion, glamour sexy celebrity endorsements sports and music sponsorships discounts

60 Youth & ENDS Over 2.1 million youth are current e-cig users. Youth e-cig users cited flavors as the reason for use. 43% of youth who ever used e-cigs tried them because of the appealing flavors. SOURCE: CDC,2018. Truth Initiative, 2018.

61 Epidemic Levels SOURCE: FDA, National Youth Tobacco Survey,

62 Increase Use & Trends SOURCE: FDA, National Youth Tobacco Survey,

63 Adult Use SOURCE: Truth Initiative, 2018.

64 Young Adults & ENDS Among current e-cig users aged 18-24: 40% were never smokers 43% were current smokers 17% were former smokers Highest age group of adult nonsmokers to use e-cigs Young adults who use e-cigs are more than 4X as likely to begin smoking traditional cigarettes within 18 months as their peers who do not vape. SOURCE: Campaign for Tobacco Free Kids, CDC/NCHS, National Health Interview Survey, Truth Initiative, American Journal of Medicine, 2017.

65 FDA & ENDS Regulations 2009 Deemed all tobacco products including ENDS Min. age 18 Ban free samples & vending machines Warning Label (2018) Jul FDA & FTC took joint action against several e- liquid companies that marketed their products to look like candy, juice, cookies, etc. to remove from the market Sep Congress enacted TCA to grant the FDA rights to regulate all tobacco products including ENDS Aug FDA extended e- cig premarket approval from Aug to Aug May 2018 FDA gave JUUL and other e-cig manufactures 60 days to report how they re product does not appeal to youth use SOURCE: Food and Drug Administration, 2018.

66 JUUL Update JUUL will temporary remove flavored pods from retail stores with exception of mint and tobacco flavors. However, flavored pods will continue to sell online. Beware of competing products that resemble JUUL devices and pods that are on the rise Ex: Myle, KandyPens Rubi, etc.

67 State & Local Action In 2010, NJ s Smokefree Air Act was revised to include a ban on electronic smoking devices in indoor public places and workplaces. Many NJ municipalities have banned the use of e-cigs in city owned parks, playgrounds and outdoor recreation areas. Age of sale in NJ to purchase e-cigs increased from 19 to 21. SOURCE: NJ:26-3D-55; NJSA 2A:

68 Statewide Campaign Website for youth with factual information

69 In Summary

70 Conclusion Clinicians have an impact. Tobacco addiction is a chronic disease and deserves ongoing clinical treatment. Effective smoking cessation can reduce illness and improve patient quality of life. Every time, ASK your patients if they use tobacco. ADVISE them to quit. REFER to the resources available.

71 Free Online Resources Cigarette_FactSheet_FINAL.pdf

72 Courtesy of Mell Lazarus and Creators Syndicate. Copyright 2000, Mell Lazarus.

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74 How to Reach Us CATHY BUTLER-WITT, MA, BSW, NCTTP, CTTS Assistant Director, Public Health Programs Family Health Initiatives & Southern New Jersey Perinatal Cooperative BARBARA HEINZ, LSW, MSW, CPS, ICPS, NCTTP, CTTS Program Coordinator, MQC for Families Family Health Initiatives

75 At the conclusion of the webinar, please take a few more minutes to complete our survey.