Tobacco Cessation & Motivational Interviewing: Connecting Patients to Quit Annie Ottney, PharmD, BCPS, CTTS Learning Objectives- Pharmacists Describe the current burden of tobacco abuse in the United States Recognize trends in tobacco use Apply motivational interviewing techniques to help a patient quitting smoking Differentiate between current pharmacologic options for tobacco cessation Describe unique considerations for tobacco cessation in the following special populations: smokeless tobacco users, pregnant patients, patients with mental health disorders Learning Objectives- Pharmacy Technicians Describe the current burden of tobacco abuse in the United States Recognize trends in tobacco use Apply motivational interviewing techniques to help a patient quitting smoking Differentiate between current pharmacologic options for tobacco cessation 1
Tobacco Use in the U.S. 1 16.8 % of adults in the U.S. are current cigarette smokers Cigarette smoking is the leading cause of preventable death in the U.S., accounting for ~ 1 in 5 deaths annually 2014 Surgeon General Report 2 Health Consequences of Smoking Conditions in red represent new diseases that have been causally linked to smoking in this report. Source: USDHHS 2004,2006,2012. What Smokers Are Up Against Deadly in Pink Source: Campaign for Tobacco Free Kids. http://www.tobaccofreekids.org/ad_gallery 2
http://www.tobaccofreekids.org/content/what_we_do/industry_watch/warning_to_parents/slide_images/image_04.jpg What Smokers Are Up Against Addictive potential of nicotine Nicotine is considered to be more addictive than cocaine, heroin, or alcohol Nicotine inhaled via a cigarette reaches the brain in ~ 5 heartbeats Cigarettes as a nicotine delivery device High alkalinity of nicotine found in cigarettes (as controlled by the tobacco industry) greatly increases nicotine absorption and dependence Insurance company Insurance-Industry Investments in Big Tobacco 4 Reynolds American Imperial Tobacco British American Tobacco Lorillard Philip Morris USA Total (in millions of $) Prudential 513.2 871.4 1384.6 Prudential Financial 69.4 8.8 186.1 264.3 MassMutual 17.3 155.4 412.6 585.3 New York Life 13.0 13 Northwestern Mutual 22.8 10.8 202.2 235.8 Standard Life 307 641.2 948.2 Sun Life 125.7 889.9 1015.6 TOTAL (in millions of $) 122.5 820.2 1512.6 300.7 1690.8 4446.8 3
Reduced Harm Products?? Reduced Harm Products? Reduced Harm Products?? Risks of using smokeless tobacco Leukoplakia Dental caries Cancer Esophageal Pharynx Larynx Stomach Pancreatic 4
Electronic Cigarettes 5,6 Battery-powered device that emits a propylene glycol vapor when activated Supplied with flavored e-juice that may or may not contain nicotine Michigan is 1 of 4 states that still allows sale to minors (although many retailers have implemented age restrictions) Electronic Cigarettes For youth For current smokers For society & nonsmokers Potential Harms -Nicotine poisoning - initiation of conventional cigarette use -Future disease risk -Slows cessation -May not allow for complete cessation -Renormalization of nicotine and smoking -Secondhand aerosol exposure Potential Benefits -Reduced disease for those who switch to e- cigarettes and reduce or quit smoking altogether E-cigarette advertising The End Game: What Works Nearly 70% of people who smoke want to quit Counseling and medications are more effective than either alone Pharmacists are becoming increasingly involved in tobacco cessation programs Population-wide efforts Smoke-free workplaces and communities 28 states and D.C. have comprehensive smoke-free laws Increasing taxes on tobacco products 5
The End Game: What Works 7 Tobacco 21 Increases minimum sale age of tobacco products and electronic cigarettes to 21 Data indicates 80% of adult smokers began smoking before the age of 20 and 90% of people who purchase cigarettes for distribution to minors are under 21 Hawaii became first state to adopt new minimum age requirements January 1, 2016 2009 Family Smoking Prevention Act Cigarettes can no longer contain flavor (except menthol) Cigarette packaging can no longer contain the words light, low, or mild Coming Soon to a Store Near You?? Plain Cigarette Packaging Now in Australia Tips from Former Smokers 6
State of Tobacco Control 8 Did Michigan Make the Grade? F B F F Tobacco Prevention Smokefree Air Tobacco Taxes Access to Cessation Services Nicotine Addiction as a Chronic Disease I would rather be an ex-smoker with an occasional desire to smoke than a smoker with a constant desire to quit. Nicotine addiction represents one of the most challenging addictions to break Average tobacco user will make 11 quit attempts before quitting for good (#loveyourquitter) Continue to assess tobacco use and offer treatment at every visit!!! Premature discontinuation of tobacco cessation medications often results in relapse The Truth About Motivation Motivated by information Not going to be motivated Motivated by how I interact with them over time 10% 10% 80% 7
Exploring and enhancing motivation for stopping smoking may be more important than helping your patients with a plan on how to stop smoking. The Spirit of MI Not That This On a scale from 0 to 10, how. Scaling 0 1 2 3 4 5 6 7 8 9 10 Not at all ready Readiness Extremely ready 0 1 2 3 4 5 6 7 8 9 10 Not at all important Importance Extremely important 0 1 2 3 4 5 6 7 8 9 10 Not at all confident Confidence Extremely confident 8
MI Skills O = Open-ended questions A = Affirmations R = Reflections S = Summary statements Closed Questions Do you want to stop smoking? Have you ever quit smoking before? Have you ever tried the nicotine gum? MI Skills Types of reflections Simple reflection Repeating, rephrasing, paraphrasing, feeling Acknowledges patient letting them know, This is what I hear you saying. Amplified reflection Reflects resistant issue in an exaggerated manner Double-sided reflection On one hand and on the other hand 9
Reflection Exercise Write one statement of resistance you have heard from a patient regarding quitting smoking. Medications for Tobacco Dependence Ask permission to share options with patient Elicit-Provide-Elicit Think of as a menu-patients can pick and choose what they feel will work best for them Limitations: Contraindications/precautions Insurance coverage/cost Using medication doubles likelihood of quitting compared to no method Nicotine gum Nicotrol inhaler Varenicline (Chantix ) Bupropion SR (Zyban ) Nicotine lozenge Nicotine patch Nicotrol NS nasal spray Source for NRT pictures: http://mayoclinic.com Source for Chantix picture: http://www.ehow.com 10
Smokeless Tobacco Cessation Medication Nicotine patch Nicotine gum Nicotine lozenge Nicotine inhaler Nicotine nasal spray Bupropion Varenicline Dosing > 3 cans or pouches/week = 42 mg/day 2-3 cans or pouches/week = 21 mg/day < 2 cans or pouches/week = 14 mg/day Adjust based on symptoms of withdrawal, cravings, and comfort. > 3 cans or pouches/week = 4 mg gum < 3 cans or pouches /week = 2 mg gum (May combine with nicotine patch as outlined above.) > 3 cans or pouches/week = 4 mg lozenge < 3 cans or pouches /week = 2 mg lozenge (May combine with nicotine patch as outlined above.) Not recommended in smokeless tobacco users Not recommended in smokeless tobacco users Evidence suggests efficacy-follow same guidelines for dosing as with cigarette users Evidence suggests efficacy-follow same guidelines for dosing as with cigarette users Using Meds: Patient Case MM is a 46 year-old female who comes into the pharmacy to pick up refills on her lisinopril and atorvastatin. She tells you she has been working on quitting smoking, but has been struggling to do it on her own. Smokes ½ pack per day (PPD). She smokes her first cigarette of the day about 5 minutes after waking. 1) Reflect a statement back to the patient that expresses empathy. 2) What medication options are available to the patient at this time? Weight Gain and Quitting Smoking 8 Average smoker will gain 7 to 19 pounds within 8 years of quitting vs. continued smoker who will gain 4 to 5 pounds Bupropion may be the most effective tobacco cessation medication for delaying weight gain NRT also shown to delay post-cessation weight gain Addressing and reducing concerns about weight gain increases likelihood of maintaining abstinence 11
Weight Gain: Patient Case TH is a 24 year-old female She quit smoking 2 years ago cold turkey, but started up again because she gained 20 pounds. She took up smoking again 3 months ago to try to get the weight off. Smokes 1 PPD Importance = 5 Confidence = 9 I know I can quit, but I am really afraid of gaining more weight. Weight Gain: Patient Case 1) Reflect a statement back to the patient that expresses empathy. 2) Which medication options might be considered to help this patient with quitting smoking? 3) How would you address the patient s concern about weight gain from quitting? Mental Health & Tobacco: A Hidden Epidemic 9-11 Smoking prevalence rates are between 60-80% in people diagnosed with depression, bipolar disorder, or schizophrenia Nearly half of all cigarettes smoked in the U.S. are consumed by people with mental illness All first line tobacco cessation medications are reasonable options in patients with mental health issues Certain psych meds may need to be adjusted when people quit smoking (e.g. clozapine, olanzapine, TCAs, caffeine) 12
Mental Health: Patient Case JZ is a 30 year-old male who is coming in to see you today to follow-up for his depression. He has been taking Lexapro 10 mg/day for the last 7 months. Upon asking, the patient admits to smoking 1 pack of cigarettes/day. He is open to quitting, but prefers to take a tablet instead of using other products. 1) Which products would be available to this patient? 1) What are the risks and benefits of these medications? Pregnancy & Tobacco 12 Carbon monoxide is a potent reproductive toxin Behavioral interventions are considered 1 st line Short acting, low dose NRT or bupropion may be used Avoid varenicline Pregnancy: Patient Case NJ is a 23 year-old female who found out 3 weeks ago that she is pregnant. She has smoked 1 PPD of cigarettes since she was 13 years old. She was able to cut back to ½ PPD after she found out she was pregnant, but has not been able to stop entirely. 1) In addition to behavioral therapy, what other options are available to this patient? 2) What factors are associated with an increased risk of relapse in the post-partum period? 13
Relapse Prevention Talk about high risk situations with the patient and figure out an escape plan to manage Continued follow-up and interaction with patient Does not have to be face-to-face Discuss patient s support system Stress management Clinical Scenario Your patient relapses to smoking after 6 months of continuous abstinence. Which strategy listed below is most likely to be effective? A) Wait until the patient is ready to stop again and be cautious of providing advice that might be shaming B) Assess the patient s motivation for making another quit attempt, help build confidence by eliciting discussion, and consider restarting the treatment that led to 6 months of abstinence C) Prescribe varenicline D) Advise the patient to stop again as soon as possible so as not to jeopardize any health gains that were acquired by quitting Tobacco Treatment Specialist Programs Mayo Clinic Nicotine Dependence Center Rochester, Minnesota 5 day program; $1000/person University of Massachusetts Medical School Boston, Massachusetts 4 days program; $1000/person Additional offerings: ATTUD website (http://www.attud.org/findprog.php) 14
References 1) Centers for Disease Control and Prevention. Current cigarette smoking among adults- United States, 2005-2014. MMWR Morb Mortal Wkly Rep 2015;64(44):1233-40. 2) U.S. Department of Health and Human Services. The health consequences of smoking-50 years of progress: a report of the surgeon general. Available at: http://www.surgeon general.gov/library/reports/50-years-of-progress/front-matter.pdf. Accessed: January 28, 2016. 3) Centers for Disease Control and Prevention. Smoking & tobacco use: fast facts. Available at: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm#cost. Accessed: January 28, 2016. 4) Boyd JW, Himmelstein D, Woolhandler S. Insurance-industry investments in tobacco. N Engl J Med 2009;360:2483-2484. 5) Wollscheid KA, Kremzner ME. Electronic cigarettes: safety concerns and regulatory issues. AJHP 2009;66:1740-1742. 6) Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet 2013;382:1629-37. 7) Winickoff JP, Gottlieb M, Mello MM. Tobacco 21-an idea whose time has come. N Engl J Med 2014; 370:295-7. References 8) American Lung Association. State of Tobacco Control 2015. Available at: http://www.stateoftobaccocontrol.org/state-grades/michigan/. Accessed: January 28, 2016. 9) Audrain-McGovern J, Benowitz NL. Cigarette smoking, nicotine, and body weight. Clin Pharmacol Ther 2011;90: 164-168. 10) Prochaska J. Smoking and mental illness-breaking the link. N Engl J Med 2011;365:196-198. 11) Legacy Foundation. A hidden epidemic: tobacco use and mental illness, June 2011. Available at: http://www.legacyforhealth.org/pdf/a_hidden_epidemic.pdf. Accessed: January 26, 2013. 12) Benowitz N, Dempsey D. Pharmacotherapy for smoking cessation during pregnancy. Nicotine Tob Res 2004;suppl 2:S189-202. Additional Resources: Rollnick S, Miller WR, Butler CC. Motivational interviewing in healthcare: helping people change behavior. New York City,NY:Guilford Publications, Inc.;2007. Burke M, Ebbert J, Hays JT. Treatment of tobacco dependence. Mayo Clin Proc 2008;83:479-484. 15