Tobacco Basics and Brief Cessation Interventions. Prepared by: Margie Kvern, RN, MN Diane Mee, RN, BN October 2014

Transcription

1 Tobacco Basics and Brief Cessation Interventions Prepared by: Margie Kvern, RN, MN Diane Mee, RN, BN October 2014

2 Outline Tobacco Basics WRHA Clinical Practice Guideline for Management of Tobacco Use and Dependence Smoking Cessation 5A Brief Intervention Smokers Helpline (SHL) Fax Referral Program Pharmacotherapy Options

3 Why the concern about tobacco use? Each year in Canada, more than 37,000 people die prematurely due to tobacco use (Health Canada, 2007) Approximately 16% of the population 15 years of age and older smoke = about 4.8 million Canadians (CTUMS, 2012) 17.9% of Manitobans aged 15 yrs and older are current smokers (CTUMS 2012)

4 Tobacco Prevalence Canada 10 Manitoba Canadian Tobacco Use Monitoring Survey

5 FFHV Data Smoking during Pregnancy 25 Winnipeg Winnipeg

6 Environmental Tobacco Smoke Exposure years years Canadian Tobacco Use Monitoring Survey, 2012

7 What is tobacco? Tobacco is a plant that contains the drug nicotine Nicotine the addictive substance in tobacco; other substances in tobacco cause disease Cigarettes, cigars and smokeless tobacco products all contain tobacco

8 What is Nicotine? Substance that makes cigarettes addictive Inhaled tobacco smoke moves from the lungs into the bloodstream and up to the brain within 7-10 seconds Causes release of dopamine giving feeling of pleasure and well being Depletes the body within 4 hours and has a ½ life of 2 hours

9 Typical Withdrawal Symptoms Headaches Anxiety and irritability Difficulty concentrating and sleeping Increased appetite Decreased heart rate and blood pressure Craving for nicotine Fatigue and coughing (Health Canada, 2007)

10 Smoking Cessation Quitting smoking is the single most effective thing that a person who smokes can do to enhance the quality and length of their life. Canadian Pharmacists Association. (2001, January). Joint statement on smoking cessation. Retrieved from we_are/policy_position/pdf/smoking_cessation_joint_ stat.pdf

11 Benefits of Quitting Within 20 minutes blood pressure and heart rate drop to normal rate and body temperature normalizes Within 8 hours Carbon Monoxide levels drop and oxygen levels increase Within 24 hours heart attack risk decreases After 2 weeks coughing, congestion, tiredness and shortness of breath decreases After 1 year heart attack risk decreases by 50% After years risk of premature death approaches that of never smokers and risk of certain cancers decreases

12 People want to quit Health concerns and current health problems Cost of cigarettes Persistent advice to quit from family Advice to quit from health professionals 39% of Canadian smokers were thinking of quitting in next 6 months (CTUMS 2010) 16 % were thinking of quitting in the next 30 days ( CTUMS 2010)

13 You can make the difference 10% of smokers will quit without interventions 13.4% with brief intervention (<3minutes) 16 % with low intensity intervention (3-10 minutes) 22.1% with high intensity intervention (>10 minutes) All rates will double using pharmaceutical aids Fiore MC, Jaen CR, Baker TB, et al. (2008). Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service.

14 CPG - Management of Tobacco Use and Dependence Purpose: To consistently identify tobacco use and provide evidence-based, stage-based interventions WRHA CPG 5As Ask Advise Assess Assist Arrange

15 5A Protocol Ask about tobacco use with all clients Advise all clients of the importance of quitting in a clear, non-judgmental manner Assess readiness/willingness to quit Assist according to readiness to change Arrange for follow-up or referral to resources

16 ASK Tobacco use history should be determined and recorded at every appointment Have you used tobacco in the past 7 days? Have you used tobacco in the past 6 months?

17 Advise In a clear, unambiguous, personalized way, advise about the importance of quitting I am concerned about your smoking because Stopping smoking is the most important thing you can do to protect your health (RNAO 2007)

18 Assess Readiness to quit: What are your thoughts about stopping smoking?

19 Assist Stage Matched Interventions Provide intervention (minimal or intensive) according to readiness/stage of change Build motivation and strengthen commitment to quit, reduce or stay quit Help the client set realistic, achievable goals (RNAO 2007)

20 Stages of Change

21 Precontemplation No, I do not intend to quit in the next 6 months I don t need to change Behavior not seen as a problem/in denial

22 For smokers who don t want to quit ASSIST, ARRANGE Build Confidence, Importance through 5Rs: Relevance tailor counseling to the patient s condition/health Risks discuss health risks associated with smoking Rewards have patient identify benefits of quitting Improved health, taste, money, breath, odor Roadblocks have the patient identify barriers to quitting withdrawal symptoms, fear of failure, depression, weight gain, lack of support, loss of friends Repetition use the 5R s and motivational interviewing techniques each time a tobacco user receives dental treatment keep the intervention short and focused Discuss their pros of smoking and cons of stopping smoking

23 Contemplation On the fence I might quit in the next 6 months Realize smoking is a problem More receptive to information BUT

24 For smokers who don t want to quit ASSIST, ARRANGE Evaluate pros of change and cons of staying the same What are the reasons you don t want to quit? What might be better if you quit? What concerns you about continuing to smoke? Build importance of change Why is quitting important to you? Reframe cons as barriers/obstacles that have solutions

25 Preparation Testing the waters I will change but just not yet, I intend to quit in the next 30 days 24 hour quit attempt made in last 12 months Make referral to SHL

26 Preparation ASSIST, ARRANGE I m thinking about quitting in the next 30 days Goal: Help the patient make a quit plan (STAR) Set a date Tell family/friends about plan to quit (social supports) Anticipate challenges (withdrawal, triggers) Remove tobacco products from your environment

27 Action Yes, I have quit but for less than 6 months I am changing Need to develop effective ways of coping with stress Relapse can happen

28 Action ASSIST, ARRANGE I have quit recently. (within the last 6 months) GOAL: Help patient stay quit Support recovery from relapse Review the quit plan pharmaceuticals, adequate social support, set-backs Provide support and suggestions how to deal with withdrawal symptoms, weight gain, irritability, anxiety and/or rejection by friends who smoke Remind patient of his/her stated reasons to quit and the great choices made have confidence to stay quit! Resources to support staying quit

29 Maintenance Yes, I have quit, and for more than 6 months Less vulnerable to relapse Have a plan for slips

30 Maintenance ASSIST, ARRANGE I quit. (6 months or more) GOAL: Help patient stay smoke-free for lifetime Provide support - constantly remind person of the benefit of quitting and the right choice they made The person might crave tobacco the rest of their life and need to find strategies to resist triggers

31 Arrange If the client is interested, ARRANGE for follow-up or referral to resources to help her quit/reduce Smokers Helpline Community resources Referral to other Health Care Provider

32 Smokers Helpline All clients in contemplation and preparation stages are to be offered SHL referral Fax referral forms anytime!

33 Ask, Advise, Assist, Arrange Model with the Stages of Change Stage Of Change ASK ADVISE ASSIST ARRANGE Pre-Contemplation Goal: Get client to think about quitting Ask about their feelings about quitting Offer quitting information Be available in the future if they decide they want to talk about quitting Contemplation Goal: Get client to move towards a decision to quit Goal: Improve client confidence Ask the PERSONAL pros and cons of quitting (decisional balance sheet) Acknowledge ambivalent feelings Offer quitting information Reinforce reasons to change Suggest cutting back or 24 hr stop period Offer future visit & SC information Preparation Goal: Help prepare for quitting Ask about concerns preparations made & lessons learned from quitting in the past Offer quitting information Identify Barriers & solutions Provide SC Booklet, Action Plan, NRT, Quit Date Setting (BAND) Contact PH/Unit for information on local SC services & refer 2 Community resource Action Goal: Help client prevent relapse Ask what are they doing re: NRT, avoiding triggers, successes etc Relapse, weight gain, triggers How to deal with withdrawal symptoms Focus on successes Offer increased support Encourage self-reward Congratulate them! Contact PH/Unit for information on local SC services & refer 2 Community resource Maintenance Goal: Help client be smoke free for life Ask what they are doing in risk situations that could cause relapse It is normal to go thru the stages 3 to 4 times before finally quitting Offer suggestions re, triggers, supports, encouragement Congratulate them! Contact PH/Unit for information on local SC services & refer 2 Community resource

34 Pharmacotherapy Nicotine Replacement Therapy (NRT)» Long acting» Short acting Bupropion SR (Zyban, Wellbutrin) Varenicline (Champix)

35 NRT vs. Cigarettes Cigarettes Arterial return Absorbed quickly 4,000 harmful chemicals over 50 of which are cancer causing NRT Venous return Absorbed slowly No harmful chemicals

36 NRT Very safe sold over the counter (OTC) The long-acting nicotine patch continuously delivers small amounts of nicotine through the skin The client doesn't get the peaks and valleys in nicotine levels that occur with smoking and they may still have cravings to smoke or experience some withdrawal The short-acting forms of NRT help people to get an additional dose of nicotine when they have a craving

37 Forms of NRT Long-Acting Patch Short-Acting Gum Lozenge Inhaler Mist

38 Bupropion SR (Zyban) Not a nicotine replacement therapy Antidepressant that has been found to help people with nicotine withdrawal It is a pill - requires a prescription Started before quit date (usually 7-10 days before) as it takes time to build up in the bloodstream Increases dopamine and adrenaline levels Can be combined with NRT

39 Varenicline (Champix) It is a pill - requires a prescription Attaches to the nicotine receptors in your brain to block nicotine from attaching, which reduces cravings and decreases the pleasurable effects of cigarettes and tobacco Should not be combined with NRT as it blocks uptake of nicotine

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42 Other quit methods Acupuncture Hypnotherapy E cigarette discussion

43 Harm Reduction Strategies Smoke-free home (limit smoking to one part of the home) Smoke free car No smoking in front of children Reduce number of cigarettes smoked

44 WRHA Safe Sleep and Smoke-Free Resource Rollout Launched in December 2011 Resulted from the Joint Statement on Safe Sleep: Preventing SIDS in Canada (PHAC 2011) - provides updated information to provide infant deaths related to SIDS/SUDS - highlights new evidence for the link between smoking and SIDS New resources now available for HCP use

45 Safe Sleep and Smoke-Free Home Resources Information sheet for PHNs and Home Visitors about the rollout Two new safe sleep and smoke-free home resource Door hangtag and smoke-free home magnet Information on how to use these resources Posted on Insite>PPH>Tobacco Reduction

46 Documentation for PHNs Smoking listed under Family Assessment on page 1 of care map Tobacco Smoke-Free environment listed under Health Counselling Family page 7 care map V from page 1 and PN from page 7 of care map link to Progress Notes in DARP format

47 Documentation for Home Visitors Documentation will be done on the HV log Safe sleep/smoke-free environments documented under Status of Home Does home smell like tobacco smoke? Infant sleeping arrangements

48 Documentation for Home Visitors Distribution of hangtag & magnet along with discussion of Safe sleep/smoke-free home documented under How did you support the family to Depending on the conversation, SC may become a Work towards their goals Promote healthy childhood G&D would include benefits to the child for tobacco reduction

49 Smoking Cessation Resource Hub Kit Each office has a SC Resource Hub Kit Developed by a group of nursing students during their Community Health placement Resource Hub Kit contains the top 10 resources for PPH staff to use according to the stage of change the client is in

50 Summary Smoking is not a habit - it s an addiction Implement WRHA CPG Use 5As will all clients Identify Stage of Change Match appropriate intervention using the 5As Refer to Smokers Helpline WRHA Safe Sleep/Smoke-Free Home info Harm Reduction strategies Documentation