John Bell Counter says Connection Smoking cessation Pharmacy assistant s education Module 229 Smoking cessation By Lynn Greig This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed. Smoking is the largest single preventable cause of death and disease in Australia. It is responsible for more drug-related hospitalisations and deaths than alcohol and illicit drug use combined. Pharmacy assistants can help their customers quit smoking by identifying customers who smoke, informing them of the health dangers of smoking and the benefits of quitting, and advising them about options and strategies available to help them quit. General Health 0110 2011 Staying a Non-smoker Think of yourself as a non-smoker from the moment you quit. Learn new ways of doing things without cigarettes and over time the desire to smoke will fade. If an urge to smoke returns, you can remain a non-smoker by knowing ways to deal with it. General Health 0556 2011 Nicotine Replacement Therapy The smart way to quit When you quit smoking your body craves nicotine, giving you an urge to smoke. You may also suffer other (Help to stop smoking) nicotine withdrawal effects. You will have the best chance of quitting if you use an advice or support service and, if Nicotine replacement therapy (NRT) products provide nicotine to reduce the you smoke more than 10 cigarettes per cravings and withdrawal symptoms that many people experience when day, a quitting medicine. Medicines they try to stop smoking. Using NRT can increase the chances of successfully proven to help quitting are: quitting. A pharmacist can advise on safe and effective use of NRT. Non-prescription Nicotine Replacement Therapy (NRT) Non-nicotine quitting medicines, Quitting which must be prescribed by a doctor. The nicotine in tobacco is very addictive A doctor or pharmacist can explain how and makes people want to smoke. to use these medicines. Continual exposure to the many chemicals in tobacco smoke can then cause heart disease, emphysema, lung cancer, bronchitis and many other health problems. Self Care is a program of the Pharmaceutical Society When of Australia. you quit smoking, your body Self Care is committed to providing current and reliable can health still information. crave nicotine, which creates an urge to smoke. You may also suffer other nicotine withdrawal effects (e.g. irritability, anxiety, loss of concentration, hunger and sleepless nights). NRT replaces cigarettes as your source of nicotine in order to reduce nicotine withdrawal symptoms, while you focus on breaking smoking habits. If you are addicted to smoking, the correct use of NRT can double your Self Care is a program of the Pharmaceutical Society of Australia. Self Care is committed to providing current and reliable health information. Merely cutting down the number of cigarettes smoked each day does not result in any improvement in health. The health risks of smoking Tobacco smoke contains over 4,000 chemical compounds, including tar, carbon monoxide, nicotine, hydrogen cyanide and arsenic. Many of these chemical compounds are toxic, and more than 60 of them can cause cancer. Smoking harms almost every part of the body. Health problems caused by smoking include: Cancer smoking causes 80% of all lung cancers and 20% of all cancer deaths in Australia. Other cancers caused by smoking include cancer of the throat, mouth, tongue, oesophagus, bladder, kidney, liver, pancreas, stomach, bowel, cervix, breast and blood. Heart disease smoking increases the heart rate and blood pressure and narrows small blood vessels (making blood clots more likely). It can lead to heart attack and stroke. Smokers are four times more likely than non-smokers to die from heart disease. Respiratory problems chemicals in tobacco smoke damage the lungs and respiratory passages. Smokers are more likely to get respiratory infections such as bronchitis, influenza and pneumonia. Smoking is the main cause of chronic obstructive pulmonary disease (COPD), and smokers often have chronic cough and wheezing. Smokers with asthma have poorer asthma control. Diabetes complications smokers with type 1 diabetes have more difficulty controlling their blood sugar levels than non-smokers. They are more likely to suffer from diabetes-related complications such as circulation problems in the legs (possibly leading to amputation), kidney disease, eye damage and nerve damage. Infections smoking reduces the effectiveness of the immune system, making smokers more likely to develop infections. Infections in smokers can be more severe and can take longer to treat. Smoking also slows the process of wound healing. Other health problems caused by smoking include gum disease, osteoporosis, stomach ulcers, eye problems, premature wrinkling of the skin, and reduced ability to smell and taste. Men who smoke may suffer from impotence and reduced fertility. Women who 18 inpharmation August 2012 I Pharmaceutical Society of Australia Ltd.
Smoking cessation Pharmacy assistant s education Module 229 Counter Connection smoke may find it more difficult to become pregnant and are more likely to have missed periods and more painful periods. Smoking during pregnancy Smoking is harmful not only to the mother but to her unborn baby. Smoking during pregnancy: is a major cause of sudden infant death syndrome (SIDS) increases the risk of miscarriage, premature birth, stillbirth and complications during birth increases the likelihood of having a low birth-weight baby who has health problems increases the likelihood of having a baby with weak lungs and immune system increases the baby s risk of having a stroke, heart attack, diabetes and kidney disease later in life. Women who stop smoking before or during their pregnancy reduce the risk of all complications, miscarriage and having a baby with health problems. Passive smoking Passive smoking (inhalation of second-hand smoke by non-smokers) can also lead to health risks. Inhaling even a small amount of second-hand smoke can be harmful. Babies and children exposed to second hand smoke are more likely to have respiratory infections, middle-ear infections and asthma. Babies exposed to second hand smoke have a 2½ 3½ times greater risk of dying from SIDS. In adults, passive smoking can increase the likelihood of heart disease, lung cancer, COPD, asthma, stroke and respiratory infections. The risk of other cancers (including pancreatic, cervical, breast, kidney and bladder cancer) is also increased. People who are exposed to second-hand smoke are also more likely to develop diabetes and dementia. The benefits of quitting Stopping smoking has both immediate and long-term benefits. It reduces the risk of developing diseases caused by smoking and improves health in general. Merely cutting down the number of cigarettes smoked each day does not result in any improvement in health. The following timeline gives an indication of how a person s health improves after giving up smoking: After 12 hours almost all of the nicotine is out of the system. After 24 hours the level of carbon monoxide in the blood has dropped and the level of oxygen has increased. After 5 days most nicotine by products have gone and the senses of taste and smell are improving. Within 72 hours breathing becomes easier and energy levels increase. Within a month blood pressure has returned to normal and the immune system begins to recover. Skin appearance improves. After 2 months the lungs are no longer producing extra mucus. Blood circulation has improved. After 3 9 months coughs, wheezing and breathing problems have improved. After 1 year the risk of dying from heart disease is halved. After 5 years the risk of stroke, and of several types of cancer, is significantly reduced. After 10 years the risk of lung cancer is halved. After 15 years the risk of heart attack and stroke is the same as that of a person who has never smoked. Helping smokers quit About two-thirds of Australian smokers are thinking about quitting. Pharmacy assistants can play an important role in helping to identify smokers; educating them about the health risks of smoking and the benefits of quitting; assessing their readiness to quit; and providing help and support with quitting. The 5As is a guide which can be used to help customers quit smoking: Ask each customer Do you smoke? The subject of smoking could be raised as part of a conversation about the customer s health (e.g. How does your smoking affect your asthma? ). The answer will give an indication of the customer s willingness to talk about his/her smoking. Alternatively, customers could be asked if they would like to complete a questionnaire about their smoking. Advise smokers to quit in a way that is clear, supportive and encouraging (e.g. The best thing you can do for your health is to quit smoking ). Advice should be based on the negative health effects of smoking and the benefits of quitting. To reinforce this information, the customer can be given a Smoking Self Care fact card to read at home. Assess the person s readiness to quit using the stages of change guide (see following section). Assist all smokers to quit. The assistance required will depend on the customer s stage of change (see below). Assistance should include spoken and written information. The person can also be referred to Quitline for a free Quit pack and telephone counselling (Telephone13 78 48 or go to: www.quit.org.au). Arrange follow-up visits or phone calls in the first week of the quit attempt and about one month after the quit day. At their next visit, ask the customer again about their smoking and congratulate them on their progress or encourage them to set a quit date. Assessing readiness to quit A customer s readiness to quit smoking can be assessed using the stages of change guide. The type of assistance they require will depend on their stage of change. Stages of change Pre-contemplation (not ready) not worried about smoking and not seriously thinking about quitting. Assistance: give brief, clear, supportive advice. Discuss the benefits of quitting and the risks of continued smoking. Discuss the dangers of exposing others to passive smoking. Reassure them that help is available when they re ready. Contemplation (unsure) aware of the need to quit and considering quitting in the next six months. Assistance: discuss the pros and cons of quitting (motivational interviewing see following section). Explore their doubts and barriers to quitting. Offer written information (e.g. Smoking and Staying a non-smoker Self Care fact cards) and referral to Quitline. Preparation (ready) planning to quit within the next 30 days. Assistance: provide support and encouragement. Discuss a quit plan. Provide advice about nicotine replacement therapy (NRT). Offer referral to Quitline. Action has stopped smoking within the last six months. This is when the risk of relapse is highest. Assistance: congratulate. Reinforce benefits of quitting. Discuss relapse prevention strategies. If they are using NRT, find out if they are using it correctly and if it is helping them. inpharmation August 2012 I Pharmaceutical Society of Australia Ltd. 19
John Bell Counter says Connection Smoking cessation Pharmacy assistant s education Module 229 Maintenance has quit smoking over six months ago. Assistance: encourage them in their efforts. Discuss strategies for relapse prevention. Relapse has started smoking again. Assistance: encourage and motivate the person to quit again. Explore reasons for relapse. Offer ongoing support. Motivational Interviewing Motivational interviewing is a technique for helping people explore and resolve their uncertainties about changing their behaviour. It tries to steer people towards choosing to change their own behaviour, and to encourage their self-belief. The principles of motivational interviewing are to: create an atmosphere of acceptance and trust allow the person to do most of the talking respond with empathy let them know that you can see the issue from their point of view avoid jumping in with solutions rather draw out the person s own thoughts and ideas develop discrepancy roll with resistance. Developing discrepancy means helping the person understand that there is a When to refer If you receive a request for Nicotine Replacement Therapy (NRT), use the WHAT STOP GO or CARER protocol to guide your response. A customer requesting NRT should be referred to the pharmacist if: The person has an existing medical condition (e.g. heart disease; diabetes; liver or kidney disease; gastrointestinal problems or ulcers; a skin rash; asthma). The person is taking other medicine/s. Chemicals in tobacco smoke affect certain medicines, and when a smoker quits, the doses of these medicines may need to be reduced. The woman is pregnant or breastfeeding. The person is under 18 years of age. NRT is causing side effects NRT is not suitable and the person wants to use bupropion or varenicline. The person is unable to stop smoking after using NRT as directed. The person is having a problem with weight gain (a common problem for people who quit smoking); referral to a dietitian may be helpful. discrepancy between their present behaviour and their personal goals (i.e. they don t match). For example, ask the person What do you like about smoking? and then ask: What are the things you don t like about smoking? Ask them about their personal goals for health and fitness and how they believe smoking may be affecting these goals. Encouraging them to think about the positives and negatives may help them realise that there is a discrepancy. Resistance may take the form of denying that they need to stop smoking; or making excuses for why they cannot quit smoking. Rolling with resistance means avoiding arguing with the person, or making the person feel that he or she is wrong. Rather, the person s thoughts and ideas should be discussed, and they should be encouraged to develop their own solutions to the problem. Exploring the reasons behind the resistance can lead the person to consider possibilities for change. Examples of questions to ask: How would you like things (e.g. your health) to be different in the future? What do you think you would have to do to make your health better in the future? Have you ever tried to quit smoking before? How did it turn out? Why do you think your quit attempt didn t succeed? Most smokers make several attempts at quitting before finally succeeding. Smokers who have not succeeded in a quit attempt should be reassured that this is normal and need not be a reason to give up the idea of quitting. Lessons learned from each attempt can be used to increase the chance of success in the next attempt. Assessing nicotine dependence Nicotine is the chemical in tobacco smoke that causes addiction. When a person quits smoking they can experience nicotine withdrawal symptoms, including difficulty concentrating, restlessness, nervousness, headaches, insomnia, irritability, anxiety, depression, and weight gain due to increased appetite. Assessing a smoker s level of nicotine dependence can help to predict how likely they are to experience withdrawal symptoms when they stop smoking. A quick assessment of nicotine dependence can be made by asking the smoker: How soon after waking do you have your first cigarette? How many cigarettes do you smoke each day? Have you had cravings for a cigarette or withdrawal symptoms when you have tried to quit? Indicators of nicotine dependence include: Smoking within 30 minutes of waking. Smoking more than 10 cigarettes per day. Smoking when ill. Smoking more in the morning than in the afternoon. A history of withdrawal symptoms in previous attempts to quit. Finding the first cigarette of the day the most difficult to give up. A lot of smokers choose to quit cold turkey (i.e. without using a smoking cessation medicine), and many succeed. Smokers who want to try quitting cold turkey should be encouraged to do so, especially if they smoke less than 10 cigarettes a day. However, smokers who are nicotine dependent can increase their chances of successfully quitting by using a smoking cessation medicine. Available smoking cessation medicines are NRT and two prescription medicines (varenicline and bupropion). Nicotine replacement therapy NRT reduces withdrawal symptoms by providing nicotine without the other harmful substances found in tobacco smoke. NRT is available in the form of patches, chewing gum, lozenges, microtabs and inhaler. The different forms of NRT are all equally effective. Nicotine patches deliver the nicotine dose slowly and steadily, whereas the other types of NRT are faster-acting. The inhaler may be useful for smokers who miss the hand mouth action of smoking. The person should take shallow puffs approximately every two seconds, or four deep inhalations a minute, for up to 20 minutes. The cartridges in the inhaler should be changed regularly. For the gum, it is important to use the correct chewing technique. The gum should be chewed slowly until a bitter taste or tingling sensation is felt (10 15 chews), then it should be placed under the tongue or between the cheek and gums until the taste or sensation disappears. This cycle should be repeated for about 30 minutes. Microtabs must not be swallowed. One or two microtabs should be placed under the tongue and allowed to dissolve over about 30 minutes. 20 inpharmation August 2012 I Pharmaceutical Society of Australia Ltd.
Smoking cessation Pharmacy assistant s education Module 229 Counter Connection Smokers who are not ready to quit abruptly can use NRT to help them reduce the number of cigarettes they smoke before progressing to quitting (reduce to quit). If they have not made a quit attempt within six to nine months of starting NRT, they should be referred to the pharmacist for further advice. Smokers who are unable to quit or who have withdrawal symptoms using only one type of NRT can use a combination of patches plus low-strength gum or lozenges. The patches provide a steady nicotine level and the gum or lozenges can be used when the person has an urge to smoke. People who smoke 15 or more cigarettes a day can use Nicabate Pre-Quit patches while preparing to quit. The pre-quit patches should be used for two weeks, after which the person should stop smoking completely and use NRT or combination therapy as directed. For more information on NRT refer to Table 2 in the Facts Behind the Fact Card article on Page 11. Side effects of NRT Some of the side effects of NRT (e.g. insomnia, dizziness, weight gain, headache, mouth ulcers) may also be a result of stopping smoking. Side effects specific to the products used are usually minor and short-lived. The gum, inhaler, lozenges and microtabs can cause hiccups, nausea, and a sore throat and mouth. The inhaler, lozenges and microtabs can also cause coughing. The gum should be avoided by people with dentures, as it may stick to and damage them. The patches can cause skin irritation and vivid dreams. If vivid dreams are experienced with the 24-hour patch, the person can try removing the patch at bedtime or switching to a 16-hour patch. Making a quit attempt Once a smoker has decided on a quitting strategy (e.g. cold turkey, NRT), pharmacy assistants can provide practical advice about how to carry out the quit attempt. The smoker should be encouraged to: Pick a suitable quit date ideally within the next two weeks. Prepare to stop smoking by trying to reduce the number of cigarettes smoked each day. Practice quitting (e.g. quit for a day; try to not smoke at the usual times, such as at the pub or during work breaks). Keep a smoking diary for several days before quit day to identify smoking triggers and high-risk situations, and plan alternative activities for when these situations arise. Plan strategies for dealing with cravings. During the early stages of quitting, smokers should be encouraged to: Avoid known smoking triggers (e.g. alcohol, coffee, friends who smoke). Alter situations which may encourage smoking (e.g. remove the ashtray from the car or the coffee table). Seek support from family and friends and contact Quitline for support. The 4Ds some suggested strategies for coping with cravings to smoke and reducing the risk of relapse: Delay acting on the urge to smoke after five minutes the urge weakens and the resolve to quit will return. Deep-breathe take a long, slow breath in and then slowly release it; repeat three times. Drink water slowly and savour the taste. Do something else (e.g. exercise) to provide a distraction. New qualifications for staff in community pharmacies have been endorsed and will be available shortly. Pharmacy assistants and pharmacy dispensary technicians will be able to update their qualifications by undertaking recognition of prior learning and a bridging course. Take the opportunity to remain up to date and to gain the new skills and knowledge contained in these new qualifications. Update your Community Pharmacy qualifications For further information contact your local branch or visit www.psa.org.au PSA3645 PSA Enabling your future. inpharmation August 2012 I Pharmaceutical Society of Australia Ltd. 21
John Bell Counter says Connection Smoking cessation Pharmacy assistant s education Module 229 Assessment questions for the pharmacy assistant Select one correct answer from each of the following questions. Answers due 30 September 2012. Before undertaking this assessment, you need to have read the Counter Connection article, and the associated Fact Cards. Photocopy and/or use the answer sheet provided. Make sure to include your ID number. The pass mark for each module is five correct answers. Participants receive one credit for each successfully completed module. On completion of 10 correct modules participants receive an Achievement Certificate. Submit answers online To submit your response to these questions online, go to the PSA website: www.psa.org.au/selfcare 1. Which of the following statements about second-hand smoke (passive smoking) is CORRECT? a. There are no health risks in inhaling small quantities of second-hand smoke. b. Children who inhale second hand smoke are more likely to get respiratory and middle-ear infections. c. Inhaling second-hand smoke almost doubles a baby s risk of dying from SIDS. d. Adults who inhale second-hand smoke are less likely to develop dementia. 2. When a smoker stops smoking: a. Within 24 hours breathing becomes easier and energy levels increase. b. Within 72 hours the blood pressure has returned to normal. c. After three months the risk of dying from heart disease is halved. d. After 15 years the risk of having a heart attack is the same as that of a person who has never smoked. 3. A customer tells you that she has decided to quit smoking within the next few weeks. In which stage of change is she? a. Pre-contemplation. b. Contemplation. c. Preparation. d. Action. 4. Which of the following is a sign of nicotine dependence? a. Smoking more than 10 cigarettes per day. b. Smoking within two hours of waking in the morning. c. Smoking more in the afternoon than in the morning. d. Being unable to bear the thought of smoking when ill. 5. A young woman comes into the pharmacy and tells you she wants to stop smoking. She has already tried using nicotine patches but they didn t stop her craving for cigarettes. She has no medical conditions and takes no other medicines. Which of the following would be the MOST APPROPRIATE option for her? a. As NRT has been unsuccessful for her, she will have to try quitting cold turkey. b. She should keep smoking, but reduce the number of cigarettes she smokes each day. c. She could try using a combination of 15 mg/16 hour patches and 2mg gum. d. She should try using nicotine lozenges, as they are more effective than the patches. 6. A middle-aged woman comes into the pharmacy and asks you for something to help her stop smoking. On questioning, you find out that she smokes 20 cigarettes a day and starts smoking as soon as she wakes up in the morning. She takes blood pressure tablets but has no other medical conditions. Which would be the MOST APPROPRIATE response? a. You recommend that she use 4 mg nicotine gum. b. You recommend that she try quitting cold turkey. c. You suggest that she use a nicotine inhaler. d. You refer her to the pharmacist. Self Care helping meet your QCPP requirements 22 CPD CREDITS UP TO GROUP 2 Up to 5 hours of QCPP approved refresher training for pharmacy assistants Up to 22 Group 2 CPD credits each year for pharmacists Empower your staff to connect with more customers by increasing their knowledge of OTC medicines Better product knowledge drives sales growth and customer retention Unlimited Fact Cards a popular resource utilised by customers and staff Weekly Health Column promoting your pharmacy to the community Join Self Care now. Phone 1800 303 270 or email pscnat@psa.org.au PSA Your voice. PSA3575 Training and support for the whole team 22 inpharmation August 2012 I Pharmaceutical Society of Australia Ltd.