Addressing Tobacco Use in Iowa A BRIEF TOBACCO INTERVENTION FOR HEALTHCARE PROVIDERS Lorene Mein Beth Turner Alyssa Reichelt DNP, ARNP, FNP-BC MA, CHES MA Mercy Clinics American Lung Association American Lung Association
Why is this important? Tobacco is the leading preventable cause of illness & death for Iowans 5,100 Iowa adults die each year due to their own smoking The estimated annual health care costs in Iowa directly related to tobacco use now total $1.28 billion
Disease and Tobacco Use ONE HIT OF NICOTINE: Adrenaline is released Increases HR, BP, RR Suppresses insulin output Sudden release of Glucose Leading to heart disease, lung disease, and diabetes Takes 7 11 seconds to reach the nicotinic receptors in the brain Dopamine and Norephinephrine Acetylcholine and Glutamate Serotonin, Beta Endorphin, and GABA Brain Pleasure, Appetite Suppression, Arousal, Cognitive Enhancement, Learning, Memory, Mood Modulation, and Reduction in Anxiety and Tension (Benowitz: Pharmacology of Nicotine and the Medications to Treat Tobacco Dependence, 2011; Connolly, 2010; Hurt: Neurobiology of Tobacco Dependence, 2013; Hurt: Question and Answer, 2013; National Institute on Drug Addiction: Are there other chemicals that may contribute to tobacco addiction?; National Institute on Drug Addiction: What is the extent and impact on tobacco use?; Potts & Garwood, 2007; U. S. Department of Health and Human Services: Surgeon General s Report 2010)
Tobacco Addiction Habit Chemosensory Response Brain Learned Behavior Practiced Mouth, Throat, Nose: Smell releases dopamine Recycled smoke leads to satisfaction and pleasure Tolerance Withdrawal Continued use ADDICTION (Anthenelli, 2005; Connolly, 2010)
2013
Treatment: Cigarettes Patch 21 mg = 17 mg absorbed nicotine 24 hrs to steady state Apply to clean, clear skin Leave on either 16 24hrs Dosing <10 cigs/d 7 14mg 10 20 cigs/d 14 21mg 21 40 cigs/d 21 42mg >40 cigs/d 42+mg (Ebbert, 2013; Ebbert, Hurt, & Pipe, 2011; Hays, 2005)
Treatment: Cigarettes Duration of Treatment Best results found when the patch was used for six months or longer. Target dose x 1m, then decrease dose by 7 14mg every 2 4 wks (pt can reduce at a rate that is comfortable for them). Risk: Site reaction Dependence with long term use Vivid dreams Nausea (Ebbert, 2013; Hays, 2005)
Treatment: Cigarettes Gum and Lozenge Gum and Lozenge: OTC Start with 2 mg if using > 30 minutes after waking. Start with 4 mg if using < 30 minutes after waking. Gum: Chew and Park Lozenge: Leave on tongue do not suck, chew or crush Peak absorption 15 20 mins after taking Affected by ph: avoid eating or drinking SE: Mouth sores Nausea Stomach upset (Bars et al., 2006; Hays, 2005)
Treatment: Cigarettes Nasal Spray 0.5mg/spray: Rx Peaks absorption at 5 10 minutes 1 2 doses/hr 2 sprays=1 dose Do not sniff, swallow, or inhale the spray. Side Effect Nasal irritation Stomach upset Headache Dizziness (Hays, 2005)
Treatment: Cigarettes Inhaler 10mg/cartridge: Rx Peak absorption 15 20 minutes 20 minutes of puffing = 4 mg of nicotine Side Effects Irritation Stomach upset Headache Dizziness (Hays, 2005)
Treatment: Cigarettes Bupropion Mechanism of action: increased dopamine in the reward center mimics nicotine, and may act as a nicotinic receptor blocker. Directions: 1 2 weeks before quitting begin taking Wellbutrin SR 150mg daily. Increase to 150mg twice a day on day 4, and continue taking until it is no longer needed. Stop smoking 1 2 weeks after starting the Wellbutrin. Not recommended to go over 300 mg/day.
Treatment: Cigarettes Side Effects Headache Insomnia: don t take at bedtime Dry mouth Agitation Seizure (1:1000) Emergent HBP Safe to Use CVD pts COPD pts On other anti depressents May need to decrease the dose of SSRIs and Effexor (Burke et al, 2013; Hancock, 2005; Hays, 2005; McFadden & Milbrandt, 2013)
Treatment: Cigarettes Don t Use Seizure Hx Brain Tumor Stroke Brain Surgery Use of drugs that lower the seizure threshold (ex: Alcohol) Anorexia/Bulimia Hx of abuse Contraindicated LOC for >30 mins in the last 5 yrs Skull Fx Inter cranial Bleed Hancock, 2005; Hays, 2005)
Treatment: Cigarettes (Hurt et al., 2010; McFadden & Milbrandt, 2013) Varenicline Chantix binds to the receptor: to a certain extent activating it and also blocking nicotine from binding. Dosage: Days 1 3: 0.5 mg daily Days 4 7: 0.5 mg twice a day Days 8 end of treatment: 1 mg twice a day Comes in starter kit and f/u month kits. Should be started one week before stopping nicotine. Off Label Use w/ NRT and/or Bupropion Use 1mg 3xd (Spanish Study looking at 4 5mg/d)
Treatment: Cigarettes SE Nausea (Take w/ water and a banana) Insomnia Constipation Flatulence Vomiting Dreams Contraindicated Pilots Heavy Equipment Users Seizure hx? (Burke et al., 2013; Package Insert 2015)
Treatment: Cigarettes Dosing restrictions: Hepatic: monitor if known impaired liver function or elderly pt Renal impairment: Creat Clearance <30mL/min 0.5mg dly bid Dialysis: Dose 0.5mg dly and only if pt tolerates Concerns Heart Effects Mental Changes Treatment w/ varenicline did not show significant difference in comparison w/ placebo or NRT regarding Fatal self harm Depression Suicidal thoughts (Hays, 2011; Package Insert 2015)
Treatment: Spit All treatments are off label NRT: Gum, Patch, Lozenge No Nasal Spray or Oral Inhaler Lozenge Park the lozenge like the gum between the gum and the cheek in the same area the ST is usually parked. Use as much as 20 pieces a day Lozenges are like Free Basing ST. (Ebbert: Nicotine Lozenge for Smokeless Tobacco Use, 2006; Ebbert, 2011; Ebbert 2013)
Treatment: Spit Spit Tobacco Treatment: Dosing the same for Varenicline and Bupropion Patches: Titrate up to 3 patches as needed Higher dose = > relief <2 cans/wk 14mg patch 2 3 cans/wk 21mg patch >3 cans/wk 2 21mg patches (Ebbert, 2013)
Effectiveness Too Much: Nausea Too Little: Cravings
What is the Brief Tobacco Intervention? An approach to address tobacco use with your patients and to dramatically increase the likelihood that they will quit tobacco It is effective in all types of health care organizations Considered by the U.S. Dept. of Health & Human Services Best Practice Guideline to be the benchmark standard of care for tobacco cessation
A Brief Overview: 2A s and R Brief Tobacco Intervention: 1. ASK if the patient uses tobacco 2. ADVISE all tobacco users to quit 3. REFER those ready to quit to QUITLINE Iowa Takes less than 3 minutes!
The Facts Smokers are more likely to quit when advised to do so by a healthcare professional Patients are twice as likely to call QUITLINE if referred by their provider 27% of callers to QUITLINE IOWA successfully quit!
QUITLINE IOWA QUITLINE IOWA is the primary resource in Iowa to help tobacco users quit QUITLINE IOWA is confidential & private QUITLINE IOWA offers FREE, specialized services such as: 1 on 1 counseling with a Quit Coach Support and advice on cessation medications Tools on how to overcome urges Tailored quit plans Cessation materials
ASK Ask Advise Refer Ask every patient about tobacco use at every visit Do you use tobacco? A nurse, dental assistant, or other staff can complete the ASK during intake or while taking vital signs
ASK Ask Advise Refer Ask every patient about tobacco use at every visit Ask if uses tobacco rather than asking if he/she is a smoker Ask what kind of tobacco and how often Document use status
ADVISE Ask Advise Refer Advise all tobacco users to quit The primary healthcare provider should be the one to advise quitting Quitting tobacco is one of the best things you can do for your health. I strongly encourage you to quit.
ADVISE Ask Advise Refer Advise all tobacco users to quit Give strong, respectful, & personalized message to get help quitting Help make connection between tobacco use & the patient s health Explain how quitting will benefit his/her specific health concern Advise those who have tried quitting and failed to try again!
REFER Refer those ready to quit to QUITLINE IOWA The primary healthcare provider or any assisting staff can complete the referral. Ask Advise Refer Congratulations on your decision to quit tobacco. May I refer you to QUITLINE IOWA? They will provide you with support, help you create a quit plan, & help you overcome urges.
REFER Ask Advise Refer Refer those ready to quit to QUITLINE IOWA Explain how the referral resource will help Fax a referral directly to QUITLINE IOWA They will place a proactive call to your patient Helpful for those who may not reach out to make the call on their own
Making the Referral A Fax Referral should be made for patients ages 13-up willing to quit in the next 30 days 2 ways to refer patients to QUITLINE IOWA: 1) Use the Fax Referral Program 2) Give them the toll-free QUITLINE phone number (1-800-QUIT NOW) so they can call on their own
The QUITLINE IOWA Fax Referral Provider Information can be filled out once and make copies Patient Information Patient Initial & Signature
Oral Medication Fax Referral For Medicaid patients For ages 18-up
NRT Fax Referral For Medicaid patients For ages 18-up
Lung Helpline Provides immediate, clear, accurate lung health & disease information Staffed with Registered Nurses, Respiratory Therapists, and Tobacco Addiction Specialists 1-800-LUNGUSA
Freedom From Smoking Gold standard cessation program Based on proven addiction and behavior change models. The program offers a structured, systematic approach to quitting. Available in person and online
Questions? Contact us: Beth Turner beth.turner@lung.org 515 309 9507 Alyssa Reichelt alyssa.reichelt@lung.org Original presentation developed by Shay Davis Produced with funding from the Iowa Department of Public Health Division of Tobacco Use Prevention and Control