Smoking Cessation Counseling Strategies

Transcription

1 Smoking Cessation Counseling Strategies Click to edit Master subtitle style Renato Galindo RRT-CPFT, AE-C, CTTS

2 Objectives: Discuss factors associated with tobacco addiction Discuss tobacco cessation strategies based on evidencebased treatment guidelines Cost concerns in cessation strategies

3 Why is tobacco Cessation Critical?

4 What People Say about quitting: It s just a bad habit, I can quit when I like. It relaxes me. I have given up every other vice, if I quit I may relapse. You will not like me when I am not smoking!!!!

5 Why is quitting so hard?

6 American Society of Addiction Medicine Definition: Inability to consistently Abstain Impairment in Behavioral control Craving; or increased hunger for drugs or rewarding experiences Diminished recognition of significant problems with one s behaviors and interpersonal relationships A dysfunctional Emotional response. American Society of Addiction Medicine, Public Policy Statement: Definition of Addiction, August 15,2011. Retrieved from:

7 Click subtitle style Whattoisedit themaster first step in tobacco cessation counseling? Understanding how nicotine affects the patient!

8 Neurobiology of Nicotine Addiction

9 What is nicotine? Addictive drug that is a naturally occurring colorless liquid Absorbed through the skin, mucosal lining of the nose and mouth or by inhalation Average cigarette contains about 10mg of nicotine Of which 1-2 mg is actually absorbed by the smoker Stimulates the release of neurotransmitters

10 Effects of nicotine on the body Acts on the cholinergic receptors Appetite suppressant Causes skeletal muscle relaxation Constricts the peripheral blood vessels + Causing an increase in heart rate and blood pressure When we take vital signs, an increase in HR and BP are flags to us Why do patients who use tobacco say it relaxes them?

11 Why is nicotine so addictive? Nicotine activates the brain circuitry that regulates the feelings of pleasure Nicotine stimulates the release of dopamine and acetylcholine It is the release of dopamine that causes pleasure to the patient Dopamine affects the reward pathway

12 Deep Brain Reward pathway is found within the deep brain structures When organisms engage in behaviors that are rewarding, the pleasurable feelings provide positive reinforcement This causes the behavior to be repeated Reward pathway

13 What activates the reward pathway? The reward pathway is activated in response to: Food Water Sex Nurturing Exercise Feeling in love Laughing Our brains are supported to feel pleasure If it feels good, we do it time and time again

14 Chronic exposure to nicotine leads to: Development of tolerance Average smoker inhales 10 puffs on a cigarette It takes 10 seconds for the inhaled nicotine to reach the brain Nicotine is metabolized rapidly + Requiring the patient to increase doses Ex.: person smokes 1.5 packs a day (30 cigarettes) hits of nicotine a day That is why it is so addictive! What does the brain feel with each hit of nicotine?

15 Tobacco cessation strategies that

16 Click to edit Master subtitle style Dispel certain myths: It is a matter of willpower. Nicotine is an addiction. Smoking low-tar is healthier. People smoke low- tar differently than other cigarettes. They inhale deeper, bringing in more of the toxins If you fail to quit the first time, you will never be able to quit. On average it takes 8-10 efforts to break free. If I quit I know I will gain weight. Benefits of quitting far outweigh the risks of weight gain.

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18 Findings and Recommendations Tobacco dependence is a chronic condition that often requires repeated intervention Every patient who uses tobacco should be offered treatments All healthcare systems should institutionalize the consistent identification, documentation, and treatment of every tobacco user Tobacco dependence treatments are both clinically effective and cost effective relative to other medical and disease prevention interventions.

19 Provider interventions Public Health Service Guidelines 5 A s and 5 R s Ask Advise Assess Relevance Risks Rewards Roadblocks Repetition Assist Arrange

20 1. Ask : Identify smoker status Never too old, young, sick or healthy to quit

21 2. Advise: Message should be: Clear Strong Positive Personalized

22 3. Assess: Readiness to quit If yes- assist If no- motivate 5 R s

23 1. Relevance: Help patient identify personal reasons to quit

24 2.Invite Risks : the patient to discuss negative consequences Acute risks: shortness of breath, impotence, exacerbation of asthma, infertility, increased risk during pregnancy, etc. Long term risks: cardiovascular effects, cancer, COPD, etc. Effects of second hand smoke on loved ones

25 3. Rewards : Improved health outcomes Improve quality of life More money Improve sense of smell and taste Healthier children Etc.

26 4. Roadblocks : Ask patient to identify barriers to quitting and offer suggestions to overcome them Withdrawal Weight gain Depression Fear of failure Lack of support Feeling deprived

27 5. Repetition : Repeat the above motivational techniques every time an unmotivated patient visits.

28 4. Assist : Help set up a quit plan

29 4. Assist : Medication Focus on Over the Counter Nicotine Replacement therapy (OTC NRT)

30 Over the Counter Nicotine Replacement Reasons for using NRT Doubles success rate It helps the patient feel more comfortable while they abstain (treats withdrawal) It is safe, patient is not getting a new drug- it is the same one being delivered via a different route that can weaned down Reasons for not using Certain medical conditions require more caution/physician input: e.g. recent (2weeks) MI, arrhythmia, pregnancy Under 18 should have parental consent Some patient may have specific problems with certain products (allergy to patch) Patient refusal

31 OTC nicotine replacement dosing:

32 OTC NRT dosing cont.: Initial Dose Estimate nicotine intake (2mg/cigarette) + Ex.: 1.5 pack a day smoker (30 cig.) X 2mg = 60 mg nicotine/day + Patch (21 mg/24 hr. period) + Gum Lozenge( 4mg piece = 1-2 mg delivered) Adjustments as necessary Increase dose Add an agent

33 Important points on Nicotine gum and lozenges: Gum Lozenge Decreases the absorption Do not swallow the saliva Allow the lozenge to dissolve in between the gums and cheek Do not eat or drink around use Chew and park the gum between the cheek and gums + The nicotine is absorbed through the oral mucosa May cause nausea Store brand vs. Name brand Both are just as effective + Difference is taste

34 Important points on Nicotine patch: Apply to clean skin (upper trunk or arms) Try for 24 hours (reduces morning cravings) There is not adverse events reported from placing the patch over the chest If patient states that it makes them restless at night, pull the patch off over night and place a new one in the morning Rotate sites If irritation develops use a topical steroid cream

35 Why are some reluctant to use nicotine replacement? Fear of CRAVINGS!!!!

36 Use of combination nicotine replacement: Use of combination nicotine replacement agents increases chances of success Ex. Patient smokes 1.5 pack/day = 60 mg nicotine + Patch only delivers 21 mg over a 24 hour period + Adding gum or lozenge will curb the cravings. Ex. 4 mg gum =2 mg delivered Patient may have up to 15 pieces a day (30 mg) The gum will make it easier to wean off the nicotine Steinberg, Michael. et al. Pharmacotherapy and smoking cessation at a tobacco dependence clinic. Preventative Medicine (2005) doi: /j.ypmed

37 Common patient Concerns: Am I not replacing one addiction for another? No, as a smoker you are already addicted to nicotine. NRT allows the nicotine to be weaned. How long can NRT be used? Depending on the product label, it can very 8-12 weeks. But it has been found that there are no long term effects if the Kozlowski, L.T. et al. Advice onrequires using over the countermonths nicotine replacement patient several or yearstherapy of Patch, gum, or lozenge to quit smoking. Addictive Behaviors (2007), NRT to stay off tobacco. It is better for doi: /j.addbeh

38 5. Arrange : Continue follow up Relapse prevention and management Help them anticipate obstacles Lack of support Triggers Cravings

39 What about the electronic cigarette?

40 What about the electronic cigarette?

41 Click to edit Master subtitle style E-Cigarette Some patients have successfully quit cigarettes, but cannot wean off e-cigarette. Not FDA regulated There are no quality assurance standards. Some devices stating to be nicotine free have tested positive for nicotine. Some devices state a certain dose, 2 mg per cartridge for example, but may actually have much less or much more No proven research showing long-term success Encourages dual use One slogan: When you cant, you can. Propylene glycol (ingredient in antifreeze) is used in the suspension that holds the nicotine Has been found to cause hypersensitive pneumonitis Patients should be encouraged to use proven techniques to quit smoking. Wollcheid, K and Kremsner, Electronic cigarettes: Safety concerns and regulatory issues, American Journal of Health, Vol. 66 Oct 1, DOI /ajhp Foulds, J., Veldheer, S.et.al, Electronic cigarettes: views of aficionados and clinical/ public health perspectives, International Journal of Clinical Practice, October 2011, 65

42 What about psychiatric patients or those with a history of chemical dependence? Does it jeopardize recovery from other substances? No, it may actually help with long-term abstinence from alcohol and other drugs + (Bobo, et al. 1996,1998, Hurt et al.,1994;cornelius et al. 1997,1999;Prochaska et al.2004;lemon et al, 2003) What about psychiatric patients? 44.3% of all tobacco consumed in the U.S. is by people who have a current mental health disorder (Lasser et al. 2000) Smoking causes more death in people with mental illness than suicide or symptoms related to their illness People with serious mental illness die, on average 25 years earlier than the general population (Brown et al 2000, Miller et al 2006) Every effort must be made to help both populations quit tobacco use.

43 Counseling is reimbursable

44 Benefits of Quitting Symptoms Lung Function 2-4 weeks: risk of respiratory infections decrease 4-12 weeks: improved lung function Cardiovascular Disease Lower BP, Lower carbon monoxide, better stamina, lower heart attack risk 2-3 months: improved circulation 1 year: 50% reduction for risk of heart attack 5-15 years: risk of heart attach and stroke equals non-smoker Cancer 10years: risk of lung cancer reduced by half.

45 Tobacco Cessation is key to improve outcomes for our COPD and Asthma patients!