SMOKING CESSATION FOR PHARMACY STAFF BRIEF INTERVENTION. February 2016

Transcription

1 SMOKING CESSATION FOR PHARMACY STAFF BRIEF INTERVENTION February 2016

2 SLIDE TITLE THE WELLBEING TEAM Established for 16 years Providers & facilitators of specialist SC interventions Clinically proven to be the most effective way to quit Pregnancy Under 18s Secondary Care Mental Health Areas of high deprivation Clients with high dependence Clinically proven to be the most effective way to quit Core team of specialists in this field Clinical registered Nurse prescribers Behaviour change Medication

3 How we work Structure Specialist Practitioner > LEVEL mins Community Practitioner > GP/Doctor > LEVEL 1 Brief intervention Opportunistic advice 30secs/3mins 40% response to make quit attempt QOF LEVEL 2 10 to 30min 1 to 1 support Able to recommend appropriate medications May be working in a range of community settings Monitoring form. Pregnancy Mental health Secondary care Monitoring form

4 What we will cover by the end of the workshop delegates will: Understand the structure of the Stop Smoking Service (Wellbeing Team) Understand how the community adviser service operates Your role within a pharmacy team Be aware of the disease and ill health caused by smoking tobacco Gain some understanding of why people smoke Be aware of the smoking cessation medications used. Have increased knowledge of the e-cigarette Be confident in raising the issue and engaging with people who smoke Understand the cycle of change and appropriate interventions

5 Quiz

6 1. What percentage of the population of England smoke? 18.4 %

7 2. What percentage of people in Plymouth smoke? 24%

8 3. What percentage of smokers in England would like to stop? 72%

9 4. How many chemicals are there in tobacco smoke? A How many of these are carcinogenic? A

10 Some of the effects that nicotine has on the body Highly addictive Stimulant Slightly increased heart rate/ blood pressure Vaso-constrictor Appetite suppressant Increase tremor

11 7. What percentage of tar is retained in the lungs? A 70% 8. What percentage of lung cancers are caused by smoking? A 90%

12 9.List some of the dangers of smoking in pregnancy

13 These are some of the risks that you run if you smoke in pregnancy Cot death Still Birth Miscarriage Headaches Dizziness Nausea Increased Morning Sickness Premature Birth Foetal Malformation Slower Foetal Growth Placenta Separation Low Lying Placenta Reduced Blood Supply to Foetus Bleeding Also Low birth weight Behaviour problems Reduced milk supply Reduced milk quality

14 10. List some of the diseases caused by smoking

15 Cancers Respiratory: Chronic obstructive pulmonary disease Pneumonia Circulatory Digestive

16 Has an impact on/causes: Age related hearing loss Back and neck pain Cataract, macular degeneration Crohn s disease Gum disease Rheumatoid arthritis Psoriasis, wrinkling skin Type 2 diabetes

17 11. What is the gas inhaled from tobacco smoke called? A. Carbon Monoxide 12. What is the average life lost from a smoke related disease A years

18 Smoking & Disease Smoking causes: almost 90% deaths from lung cancer 80% deaths from bronchitis and emphysema 17% deaths from heart disease one third of all cancer deaths can be attributed to smoking people who smoke between 1 to 14 cigarettes per day are eight times more likely to die from lung cancer smokers under the age of 40 have five times greater risk of a heart attack than non smokers

19 What we inhale from cigarette smoke TAR the primary cause for smoking related disease it is a brown/yellow substance which causes tissue damage to the lungs contains at least 60 carcinogens CARBON MONOXIDE CO is a gas which reduces a smokers 02 carrying capacity by attaching itself to the haemoglobin in red blood cells CO can be eliminated from the body within 24 hours NICOTINE the addictive part of the cigarette. is the reason that people continue to smoke addictive but not carcinogenic limited cardiovascular risk The cigarette is purely a delivery system for nicotine

20 The benefits of quitting NHS Smokefree Booklet

21 Exercise Why do people: Smoke Stop smoking Relapse

22 Understanding Smoking & Nicotine Addiction

23 A model for nicotine dependence Dependence Drug Nicotine + ve -ve Cigarette +ve reinforcement -ve reinforcement Behaviour Cup of Tea Cup of Coffee Drinking Alcohol On the Phone Driving After Meals Social Situations

24 The Central Reward Pathway Puff on a cigarette: rapid nicotine hit Dopamine release in nucleus accumbens Teaching Signal Behaviour Reinforced Subsequent repeat behaviour becomes more likely Nicotine acts on the part of the brain that trains us to behave in particular ways. Positive Reinforcement: Helps with survival and reproduction. E.g. Dogs can learn to beg or sit. Involves seeking out rewarding stimuli (such as eating or drinking). Negative Reinforcement: Involves avoiding or escaping unpleasant stimuli (such as withdrawal symptoms/pain). E.g. A child quickly learns not to touch a hot surface. This type of learning is very powerful & can become deeply entrenched Fast Facts: Smoking Cessation. Robert West & Saul Shiffman 2004

25 The Power of Learning A pack a day smoker: 20 cigarettes per day 12 puffs per cigarette therefore this learning process is reinforced 240 times a day 1680 times per week 87, 600 times per year 2,190,000 times over a 25 year smoking career

26 Engaging with the Smoker When to engage in order to be most effective: Ask: Do you smoke? How do you feel about your smoking? Advise: the single most important thing you can do for your future and current health is to stop smoking

27 Emily's Story

28 NCSCT National Centre for Smoking Cessation Training Very Brief Advice training module (30 mins) Variety of free NCSCT Certified training modules available i.e. stop smoking practitioner training programme Pregnancy mental health second hand smoke

29 PLANNING TO QUIT Getting ready to quit. Setting a quit day ACTION (QUIT DAY) Actually stopping smoking CONCERNED SMOKER Worried about effects of smoking or thinking about quitting MAINTAIN QUIT ATTEMPT Staying stopped CONTENTED SMOKER Not interested in quitting at all. Happy to continue with smoking CONTENTED NON SMOKER Not interested in smoking. Very little danger of relapse

30 medications

31 . Nicotine Replacement Therapy Simply another delivery system for nicotine Delivers therapeutic measures of nicotine into the body This nicotine binds with nicotine receptors Speed of delivery much slower and lower amount delivered

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34 Types of Nicotine Replacement Therapy Gum Inhalator Lozenge Cools Lozenge Patch Mouth Spray

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36 Recommending NRT to a client Advise your customers to see a stop smoking adviser This might be in house or with the specialist service or GP surgery Combination therapy is usually used. All products are available on prescription (exemptions for some) It is much cheaper to get products through a prescription Success is 4 times more likely by seeing a stop smoking adviser and using medication

37 Increase in successful quitting % increase of success for six months over unaided attempts for each type of quitting West & Shiffman based on Cochrane review data. West R, Shiffman S (2007). Fast facts: smoking cessation (2nd ed.

38 Possible changes to levels of medications on stopping smoking or using NRT. Plasma levels of some drugs may rise on smoking cessation This interaction is caused by polycarbons in the tobacco smoke and changes in metabolism. It may be necessary to adjust the dosages of some medications.

39 Medications which may need dose adjustment Olanzapine: be alert for increased dizziness, sedation, hypotension. Reduce dose as necessary Theophylline: monitor plasma concentrations as dose may need reducing by 1/4 to 1/3 one week after quitting. Chlorpromazine: be alert for increased dizziness, sedation, extra pyramidial effects. Warfarin: INR might increase so monitor more closely. Test 5 days after commencing smoking cessation and 7 days later. Insulin: Insulin dose may need to be reduced. Test blood glucose more frequently Ropinirole: dose may need adjustment on cessation

40 Clozapine: one to watch out for Smokers taking Clozapine often require higher doses of the drug Upon smoking cessation metabolism returns to normal (reduces) and plasma levels of Clozapine may increase. As a rough guide it is estimated that the plasma Clozapine level would increase by a factor of 1.5, 2 to 4 weeks later. Current advice from CPMS is that patients should have a trough level taken prior to stopping smoking, or converting to NRT, and two weeks afterwards

41 Flowchart for Patients taking Clozapine and Quitting Smoking Patient taking clozapine attends smoking cessation appointment Patient sets quit date Patient does not set quit date Smoking cessation adviser to: 1. Speak to patient s CPN and advise to take bloods * 2. Confirm results with CPN 3. Inform GP 4. If patient relapses inform CPN and GP No action required Signs of toxicity include: Nausea, vomiting, headaches Any queries please contact: Livewell Stop Smoking Service on or PCH Pharmacy Team on * Bloods to be taken one day prior to quitting and 2 weeks after quitting

42 Medications Varenicline: (Champix )

43 Varenicline: treatment schedule Quit Day Quit day Days 1 to 3 0.5mg/Day Days 4 to 7 2 x 0.5mg/Day 2 x 1mg tablets / Day for remainder of course (11 weeks) Week Smoking Smoke free Titration Occurs in First Week Note: Tablets should be taken at least eight hours apart

44 Varenicline: treatment schedule PRESCRIPTION 1 PRESCRIPTION 2 PRESCRIPTION 3 PRESCRIPTION 4 2 Weeks (Initiation Pack) 25 tabs 2 Weeks (Maintenance Pack) 28 tabs 4 Weeks (Maintenance Pack) 56 tabs 4 Weeks (Maintenance Pack) 56 tabs DAYS 1 3: 0.5mg ONCE DAILY DAYS 4 7: 0.5mg TWICE DAILY DAY 8 SHOULD BE THE QUIT DAY DAYS 8 14: 1mg TWICE DAILY 1mg TWICE DAILY 1mg TWICE DAILY 1mg TWICE DAILY Initiation pack

45 Contra indicated: Hypersensitive to Varenicline Patient under 18 Pregnant or breast feeding End stage renal disease Cautioned: Does the patient have epilepsy? Does the patient have a history of psychiatric illness? Does the patient have a history of cardio vascular disease? If the patient does have a history of epilepsy, psychiatric illness or cardiovascular disease a risk benefit assessment should be made by the GP. NRT should also be reconsidered

46 Electronic cigarettes E-cigarettes are electronic devices designed to vaporise a nicotine containing liquid. This is inhaled and produces vapour on exhalation They are NOT a tobacco containing product. Their use is often referred to as vaping. It is not smoking 2.6m adults use them in GB

47 Basic components consist of: Cartridge or tank containing liquid The battery and the atomiser which heats and vaporises the liquid The e-cigarette liquid may contain: nicotine in various concentrations, propylene glycol and /or glycerol water, citric acid and a wide variety of flavourings.

48 Electronic cigarettes under the EU TPD (May 2016 onwards) Products which contain less than 20mg/ml of nicotine come under the TPD These products will be regulated under consumer products Products containing more than 20mg/ml nicotine will be prohibited unless licensed as medications. These products will require authorisation by the MHRA in the UK. Ash September 2015

49 ASH recognises that the priority is to support people to stop smoking. For people unwilling/unable to stop, nicotine containing products including the E-cig which have been properly regulated to ensure product safety should be available as an alternative to tobacco ASH briefing November 2014

50 NCSCT National Centre for Smoking Cessation Training Very Brief Advice training module (30 mins) Variety of free NCSCT Certified training modules available i.e. stop smoking practitioner training programme Pregnancy mental health second hand smoke

51 SIGNPOSTING: WELLBEING TEAM (STOP SMOKING SERVICE) PHARMACIES ACROSS PLYMOUTH GP SURGERIES

52 ANY QUESTIONS? Sub title Day Month Year