Counseling the Tobacco Dependent Patient Gretchen Whitby, CNP The Lung Center
http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf
Tobacco Dependence Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist that can significantly increase rates of long-term abstinence
Smoking in Ohio 18,600 deaths/ year from smoking 378,000 Ohioans suffer from acute or chronic diseases related to tobacco use 4.37 billion/yr in medical care cost 1.4 billion / yr in Medicaid costs 4.6 billion / yr in lost productivity Source: 2010 Behavioral risk factor surveillance system. Chronic diseases and Behavioral Epidemiology, CPHSL, Ohio Department of health, 2011. US Median industries the 50 US states, Washington D.C. and the US territories.
Presentation Outline Assessing motivation to quit Assessing nicotine dependence Developing a tobacco control plan Pharmacotherapy Relapse Prevention
Case Study 68 year old male currently smoking 1-1 ½ ppd. Wife died 1 year ago from cancer. He becomes tearful during visit. Lives with daughter who smokes. Readiness to quit ladder 6 COPD; Shortness of breath; CAD; HTN
Assess Motivation to quit Assessment of Motivation: Readiness to Quit Ladder History
Readiness to Quit Ladder Circle the one number that shows what you think about quitting. Please read each sentence carefully before deciding. 10 I have quit smoking. 9 I have quit smoking, but I still worry about slipping back, so I need to keep working on living smoke free. 8 I still smoke, but I have begun to change, like cutting back on the number of cigarettes I smoke. I am ready to set a quit date. 7 I definitely plan to quit smoking in the next 30 days. 6 I definitely plan to quit smoking in the next 6 months. 5 I often think about quitting smoking, but I have no plans to quit. 4 I sometimes think about quitting smoking, but I have no plans to quit. 3 I rarely think about quitting smoking, and I have no plans to quit. 2 I never think about quitting smoking, and I have no plans to quit. 1 I have decided not to quit smoking for my lifetime. I have no interest in quitting.
Tobacco-Dependence Diagnosis History Longest time tobacco-free Most recent stop smoking attempt Nicotine withdrawal symptoms with prior stopsmoking attempts What behavioral techniques and medications were helpful with prior stop-smoking attempts What behavioral techniques and medications were not helpful with prior stop-smoking attempts
Motivating the patient Lung age/lung function Education Dispel myths
Lung Age and Smoking Cessation Informing smokers of their lung age (whether good or bad ) significantly enhanced smoking cessation! BMJ 2008;336:598
British Medical Journal 2008
Educational Handouts Process of Nicotine Addiction Benefits of Quitting Tobacco Tobacco and Your Lungs Smoking Damages Most Organs in Your Body
Educational Handouts How to Quit Smoking Getting Through the First Week without Tobacco Medicines to Help Stop Tobacco Use What is in Tobacco Smoke How Much Have You Spent on Tobacco
Only one-third of smokers correctly report that patches are less likely to cause a heart attack than cigarettes... Cummings KM, Hyland A, Giovino GA, Hastrup J, Bauer JE, Bansal MA. Are Smokers Adequately Informed About the Health Risks of Smoking and Medicinal Nicotine? Nicotine & Tobacco Research 2004;6(Supplement 3):S333-S340. ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition Slides Prepared by Gary A Giovino, PhD, MS
Triggers & action Plan Trigger Strength (0-4) When do I smoke 3 During Breakfast What is my routine Wake up, drink coffee, smoke 2 In car Drive & Smoke New strategies for dealing with each trigger 1. Switch to drinking tea. 2. Eat in different room. 3. Water flowers Use Nicotine Inhaler or lozenge. Chew sugar free gum.
Assess Dependence Fagerstrom Test for Nicotine Dependence (FTND) Quantitative Nicotine withdrawal Symptom Scale (NWS Scale)
FTND How soon after you wake up do you smoke your first cigarette? After 60 minutes (0), 31-60 minutes (1), 6-30 minutes (2), Within 5 minutes (3) Do you find it difficult to refrain from smoking in places where it is forbidden? No (0) Yes (1) Which cigarette would you hate most to give up? The first in the AM (1) Any other (0) How many cigarettes per day do you smoke? 10 or less (0), 11-20 (1), 21-30 (2), 31 or more (3) Do you smoke more frequently during the first hours after awakening than during the rest of the day? No (0) Yes (1) Do you smoke even if you are so ill that you are in bed most of the day? No (0) Yes (1)
Measures of Dependence General Amount: > 20 cigarettes/day; 3 tins/week Smokes/dips within 30 minutes of waking Strong withdrawal symptoms in first few days of previous quit attempts History of psychiatric disorder History of chemical dependency Length of longest previous abstinence
Nicotine Withdrawal Score None (0) Slight(1) Mild (2) Moderate (3) Severe (4) Angry, irritable, frustrated Anxious, nervous Depressed mood, sad Desire or craving to smoke Difficulty concentrating Increased appetite, hungry, weight gain Insomnia, sleep problems, awakening at night Restless Impatient Constipation Dizziness Coughing Dreaming or nightmares Nausea Sore throat
CLASSIFY TOBACCO-DEPENDENCE SEVERITY Clinical Features Before Treatment* Cigarette Use Nicotine Withdrawal Symptoms Quantitative STEP 4 Very Severe >40 CPD Daily use Time To 1 st Cig: 0-5 min Constant NWS >40 FTND 8-10 Se Cotinine >400 ng/ml STEP 3 Severe 20-40 CPD Daily use Time To 1 st Cig: 6-30 min Constant NWS 31-40 FTND 6-7 Se Cotinine 250-400 ng/ml STEP 2 Moderate 6-19 CPD Daily use Time To 1 st Cig: 31-60 min Frequent NWS 21-30 FTND 4-5 Se Cotinine 151-250 ng/ml STEP 1 Mild 1-5 CPD Occasionally Intermittent Use Time To 1 st Cig: >60 min Intermittent NWS 11-20 FTND 2-3 Se Cotinine 51-150 ng/ml STEP 0 Non-Daily/Social Non-daily cigarette use Social setting, only Time To 1 st Cig: >>60 min None NWS <10 FTND 0-1 Se Cotinine <50 ng/ml *The presence of one feature of severity is sufficient to place patient in that category. CPD=Cigarettes Per Day Time To 1 st Cig=Time To First Cigarette after Awakening in the Morning NWS=Nicotine Withdrawal Symptom Score FTND=Fagerström Test for Nicotine Dependence Score Se=Serum Cotinine=First-pass, hepatic metabolite of nicotine; physiologically inactive
Case Study J.B. 29 yo male with a 2 year history of a non productive cough. Hx of GERD. Readiness to quit ladder: 6 FTND: 6 NWS: 6 Lung age: Spiro not performed yet Additional Questions? Medications?
Pharmacotherapy for Tobacco Dependence Daily Controller medications Chantix Nicotine Patch Welbutrin Quick relief or as needed medications Nicotine nasal spray Nicotine inhaler Nicotine gum Nicotine lozenge
Stepwise Approach to Tobacco-Dependence Therapy Adults (Based on the Asthma Model) Outcome: Tobacco-Dependence Control No Nicotine Withdrawal Symptoms and No Smoking Controller: None Reliever: Not Known STEP 0: Non-Daily/Social Controller: Nicotine Patch or Bupropion-SR or Varenicline OR Reliever Meds: (NNS, NI, NG, NL)*, prn STEP 1: Mild Controller: Nicotine Patch or Bupropion-SR And/Or Reliever Meds: (NNS, NI, NG, NL)*, prn OR Controller: Varenicline, alone STEP 2: Moderate Controller(s): (1 or More) Nicotine Patch and/or Bupropion-SR And/Or Reliever Meds: (NNS, NI, NG, NL)*, prn OR Controller(s): Varenicline and/or Bupropion-SR STEP 3: Severe Multiple Controllers: Nicotine Patch and/or Bupropion-SR And/Or Multiple Reliever Meds: (NNS, NI, NG, NL)*, prn OR Varenicline and/or Bupropion-SR STEP 4: Very Severe When tobacco dependence is controlled (patient is not smoking AND not suffering from nicotine withdrawal symptoms): Gradually reduce medications, one at a time Monitor, to maintain NO nicotine withdrawal symptoms STEP Down & Maintenance *Reliever Medications (Rapid Acting Nicotine Agonists): NNS=Nicotine Nasal Spray NI=Nicotine [Oral] Inhaler NG=Nicotine Gum NL= Nicotine Lozenge. Some patients will need indefinite use of Controller or Reliever Medications to maintain zero nicotine withdrawal symptoms and no cigarette use.
Bioavailability Balfour, David J.K. & Fagerstrom, Karl O.; Pharmacology of Nicotine and Its Therapeutic Use in Smoking Cessation and Neurodegenerative Disorders. Pharmacol. Ther. Vol 72, No 1, pp. 51-81, 1996
Follow up Visits Relapse prevention NWS score Relapse or Slip Stress management Tapering pharmacologic therapy Reduce/ discontinue daily Reliever medication Supportive message
Resources 1-800-quit-now pregnant women; un insured Limited medicaid and private insurance ALA website online course Freedom from smoking www.ffsonline.org Pulmonary rehabilitation www.quitnet.com American Cancer Society s Kick the Habit Smokefree.gov OSU College of Dentistry Tobacco Cessation Clinic
Case Study 50 y.o. female who comes in to follow-up of COPD. She has been doing fairly well without exacerbation. Unfortunately, she continues to smoke about 1/2 PPD. She has a morning cough She has a current medication list which includes the following prescription(s), bupropion, nicotine, buspirone, and tenormin. She reports that she has been smoking Cigarettes. She has a 7.5 pack-year smoking history. She does not have any smokeless tobacco history on file. She reports that drinks alcohol. She reports that she does not use illicit drugs. Additional Questions? Medications?