Tobacco Cessation: Academic Nursing Partnerships for Success

Janie Heath PhD, APRN-BC, ANP, ACNP

Associate Dean Academic Nursing Practice
Medical College of Georgia
Georgetown University
Washington, DC
Medical College of Georgia
Augusta, GA
VANDERBILT SCHOOL OF NURSING
Nashville, TN
Objectives
"
Identify the importance of
integrating tobacco cessation in
DAILY practice
"
Identify key strategies /
approaches for integrating tobacco
cessation in DAILY practice
"
Identify essential resources for
integrating tobacco cessation in
DAILY practice
VISIT: www.tobaccofreenurses.org
Why Make Tobacco Cessation a
Standard for Practice?
"
QUALITY OUTCOMES =
PAYMENT and HEALTH
"
HEIDIS says to do it!
"
JCAHO says to do it!
"
The Surgeon General
says to do it!
"
The wife says to do it!
http://www.surgeongeneral.gov/tobacco/
TRENDS in ADULT SMOKING, by
SEXU.S., 19552004
Trends in cigarette current smoking among persons aged 18 or older
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population
Survey; 19652001 NHIS. Estimates since 1992 include some-day smoking.
P
e
r
c
e
n
t
The GOOD News: 70% want to quit
0
15
30
45
60
1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999 2003
Male
Female
23.4%
18.5%
20.9% of adults
are current
smokers
Year
44.5 Million Adults are Addicted to Cigarettes
The BAD News: < 36% Receive Information on HOW to quit
STATE-SPECIFIC PREVALENCE of
SMOKING among ADULTS, 2004
Centers for Disease Control and Prevention. (2005). MMWR 54:11241127.
California
14.8%
Utah
10.5%
Kentucky
27.6%
Nevada
23.2%
TN
26.1%
GA
20.1%
STATE-Cigarette Excise Tax / Pk,
10/2006
California
87 cents
Utah
69.5 cents
Kentucky
30 cents
Nevada
80 cents
TN
20 cents
GA
37 cents
HIGHEST
NJ = $2.56
LOWEST
SC = 00.07cents
Campaign for Tobacco-Free Kids. (2006). State Cigarette Excise Tax Rates & Rankings. Retrieved
October 19, 2006, from http://tobaccofreekids.org/research/factsheets/pdf/0097.pdf.
PREVALENCE of ADULT SMOKING,
by RACE/ETHNICITYU.S., 2004
0% 50%
11.3% Asian
33.4% American Indian/Alaska Native
20.2% Black, non-Hispanic
22.2% White, non-Hispanic
15.0% Hispanic
Centers for Disease Control and Prevention. (2005). MMWR 54:11211124.
Prevalence and Harm of SMOKING
during PREGNANCY
"
Miscarriage
"
Stillbirth
"
Preterm delivery
"
Low birth weight
BABY ALERT: 27% OF Tobacco
Dependent WOMEN Continue to
SMOKE THROUGHOUT
PREGNANCY
PREVALENCE of ADULT SMOKING,
by EDUCATIONU.S., 2004
0% 50%
11.7% Undergraduate degree
26.2% No high school diploma
39.6% GED diploma
24.0% High school graduate
22.2% Some college
8.0% Graduate degree
Centers for Disease Control and Prevention. (2005). MMWR 54:11211124.
Sources: (AIDS) HIV/AIDS Surveillance Report, 1998; (Alcohol) McGinnis MJ, Foege WH. Review:
Actual Causes of Death in the United States.JAMA 1993;270:2207-12; (Motor vehicle) National
Highway Transportation Safety Administration, 1998; (Homicide, Suicide) NCHS, vital statistics,
1997; (Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995
Column 1
N
u
m
b
e
r

o
f

D
e
a
t
h
s

(
t
h
o
u
s
a
n
d
s
)
0
110
220
330
440
A
I
D
S
A
l
c
o
h
o
l
M
o
t
o
r

V
e
h
i
c
l
e
H
o
m
i
c
i
d
e
D
r
u
g

I
n
d
u
c
e
d
S
u
i
c
i
d
e
S
m
o
k
i
n
g
430
30
14
19
41
81
17
Annual Causes of Death from Smoking
Compared to Other PREVENTABLE Causes
AMAZING
ANNUAL U.S. DEATHS
ATTRIBUTABLE to SMOKING, 1997
2001
Centers for Disease Control and Prevention. (2005). MMWR 54:625628.
32%
28%
23%
9%
8%
<1%
TOTAL: 437,902 deaths annually
Cardiovascular diseases 137,979
Lung cancer 123,836
Respiratory diseases 101,454
Second-hand smoke 38,112
Cancers other than lung 34,693
Other 1,828
Percentage of all smoking-
attributable deaths*
USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke:
Report of the Surgeon General.
2006 REPORT of the
SURGEON GENERAL:
INVOLUNTARY EXPOSURE to TOBACCO SMOKE
"
Approximately 50,000
adults & infants die / year
from secondhand smoke
"
126 million nonsmokers in
the U.S. are exposed to
secondhand smoke
"
Secondhand smoke
contains more than 50
carcinogens
" TWENTY YEARS later we
FINALLY have
evidencethe right of
smokers to smoke ends
where their behavior affects
the health and well-being of
others
" Surgeon General Koop,
USDHHS Surgeon General
Report, 1986
There is no
safe level of
second-hand
smoke.
FINANCIAL IMPACT of SMOKING
Packs
per
day
Buying cigarettes every day for 50 years @ $4.12 per pack
Money banked monthly, earning 1.5% interest
0 100 200 300 400
Hundreds of thousands of dollars lost
$331,467
$220,978
$110,489
COMPOUNDS in TOBACCO SMOKE
"
Carbon monoxide
"
Hydrogen cyanide
"
Ammonia
"
Benzene
"
Formaldehyde
"
Nicotine
"
Nitrosamines
"
Lead
"
Cadmium
"
Polonium-210
An estimated 4,800 compounds in tobacco smoke
Gases (~500 isolated)
Particles (~3,500 isolated)
Marketing Strategy: Light and Ultra-
Light Cigarettes
The difference between Marlboro and Marlboro Lights
an extra row of ventilation holes
Image courtesy of Mayo Clinic Nicotine Dependence Center - Research Program / Dr. Richard D. Hurt
The Marlboro and Marlboro Lights logos are registered trademarks of Philip Morris USA.
15mg tar, 1.1 mg
nicotine
10mg tar, 0.8 mg
nicotine
The Safer Cigarette NOT!
Unveiling the SMOKING gun about Safe Cigarettes!
Face the Facts: Tobacco VS Marijuana
"
Prevalence of Marijuana
use among adults = 4%
compared to 21% for
tobacco use
"
NIH, 2002 report, National Institute on
Drug Abuse
Face the Facts: Tobacco VS Marijuana
"
Marijuana smoke contains
50 70% more carcinogens
than tobacco smoke
"
Marijuana smoke has 3-5 x
the amount of tar and
carbon monoxide
"
One joint = 4 cigarettes
"
NIH, 2002 report, National Institute on Drug
Abuse
Face the Facts: Tobacco VS Marijuana
"
Marijuana is an intoxicant
makes you high/drunk
"
THC, tetrahydrocannabinol, is
the active psychoactive
ingredient that alters sense of
reality & euphoria
"
THC over stimulates
cannabinoid receptors in the
hippocampus
"
Increase in THC content from
0.2% in 1960 to 12% in 2000
"
NIH, 2002 report, National Institute on Drug Abuse
Face the Facts: Tobacco VS Marijuana
"
Regardless of the form /
delivery of Marijuana, it is
illegal
"
Exception = medicinal
purposes such as Marinol
capsule used for pain / loss of
appetite / nausea for pts with
AIDS or cancer
"
NIH, 2002 report, National Institute on
Drug Abuse
The Rest of the Story: Theres Other
Tobacco Products
Chewing tobacco
"
Looseleaf
"
Plug
"
Twist
Snuff
"
Moist
"
Dry
The Copenhagen and Skoal logos are registered trademarks of U.S. Smokeless Tobacco Company,
and Red Man is a registered trademark of Swedish Match.
Other Tobacco Products
CIGARS KRETEKS / CLOVE CIGARETTES
Other Tobacco Products
BIDIS
HOOKAH PIPE,
BENEFICIAL PULMONARY EFFECTS of
QUITTING
Reprinted with permission. Fletcher & Peto. (1977). BMJ 1(6077):16451648.
Disability
Death
Smoked
regularly and
susceptible to
effects of smoke
Never smoked
or not susceptible
to smoke
Stopped smoking
at 45 (mild COPD)
Stopped smoking
at 65 (severe
COPD)
25
F
E
V
1

(
%

o
f

v
a
l
u
e

a
t

a
g
e

2
5
)
25
50
75
100
0
50 75
Age (years) COPD = chronic obstructive pulmonary disease
Breaking the NICOTINE DEPENDENCE Cycle at ANY age!
The
PHYSICAL
The
EMOTIONAL
The
BEHAVIOR
Physical addiction of
cravings & withdrawals
Role of cigarettes in life
pleasure, stress, social
Automatic learned
behavior with cigarettes
A COMPREHENSIVE APPROACH = A Successful Framework for Quitting
Adapted from Legacys GSD&M Presentation 12/5/03
Nicotine enters
brain
Stimulation of
nicotine receptors
Dopamine release
DOPAMINE REWARD PATHWAY
Prefrontal
cortex
Nucleus
accumbens
Ventral
tegmental
area
Within 7 11 seconds
I feel good
"
An individual smokes 1
pack per day x 20 yrs
"
20 cigarettes / pack
"
10 puffs / cigarette
"
= ?? puffs / day
"
THATs ____ HITS of
NICOTINE per DAY
NICOTINE BEHAVIORAL EFFECTS:
Do the Math!
"
Now Multiply that # by days /
year
"
THEN multiply that number
by years smoking!
"
YIKES! No wonder it is SO
difficult to QUIT-
"
Average attempts = 7-10
per smokers lifetime
200
73,000
1.4 million
NEUROCHEMICAL and RELATED
EFFECTS of NICOTINE
! Dopamine
! Norepinephrine
! Acetylcholine
! Glutamate
! Serotonin
! !-Endorphin
! GABA
N
I
C
O
T
I
N
E
Benowitz. (1999). Nicotine Tob Res 1(Suppl):S159S163.
! Pleasure, reward
! Arousal, appetite suppression
! Arousal, cognitive enhancement
! Learning, memory enhancement
! Mood modulation, appetite suppression
! Reduction of anxiety and tension
! Reduction of anxiety and tension
"
Depression
"
Insomnia
"
Irritability/frustration/anger
"
Anxiety
"
Difficulty concentrating
"
Restlessness
"
Increased appetite/weight gain
"
Decreased heart rate
"
Cravings*
NICOTINE PHARMACODYNAMICS:
WITHDRAWAL EFFECTS
American Psychiatric Association. (1994). DSM-IV.
Hughes et al. (1991). Arch Gen Psychiatry 48:5259.
Hughes & Hatsukami. (1998). Tob Control 7:9293.
Most symptoms
peak 2448 hr
after quitting and
subside within
24 weeks.
* Not considered a withdrawal symptom by DSM-IV criteria.
ASSESSING
NICOTINE DEPENDENCE
"
How soon after you wake up do
you smoke your first cigarette
"
Do you find it difficult to
refrain from smoking in
restricted areas
"
Which cigarette do you hate
to give up most
"
How many cigarettes do you
smoke per day
"
Do you smoke more
frequently during the first
hours after waking
"
Do you smoke if you are so ill
that you are in bed most of
the day
Fagerstrm Test for Nicotine
Dependence (FTND)
Scores range from 0 to 10; a score of
greater than 5 indicates substantial
dependence
ASK
ADVISE
ASSESS
ASSIST
ARRANGE
The 5 As
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS.

IF time
does not
allow.d
o 3 As
and
REFER
"
In the absence of time or expertise. ask, advise,
assess, and refer to other resources, such as local
programs or the toll-free quitline
1-800-QUIT-NOW
Modified Version of 5 As = The 3 As &
REFER
This brief
intervention can
be achieved in 30
seconds.
TO ORDER CARDS www.smokingcessationleadershipcenter.org
METHODS for INCREASING
MOTIVATIONFIVE Rs
"
FOR INDIVIDUALS NOT READY TO
QUIT YET: Tailor messages with
Motivational Interviewing
Techniques
"
RELEVANCE
"
RISKS
"
REWARDS
"
ROADBLOCKS
"
REPETITION
Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, 2000.
STRATEGIES for Successful Tobacco
Cessation
"
Walk the Talk of Evidence Based
Practice
"
Acute and critical care admissions =
HIGHLY TEACHABLE MOMENTS
"
Provide structures/systems (chart
prompts, standing orders, dedicated
counselors) to facilitate success in
breaking the nicotine cycles of
addiction
"
Emotional - Cognitive Tools
"
Behavioral - Tools
"
Physical - Biological Tools
INTERDISCIPLINARY APPROACH
ESSENTIALS: collaboration, effective decision
making AND compassionate caring practices
Cognitive Evidence-Based
STRATEGIES
"
SET DATE
" Design individualized plan
" TRIGGERS
" MOTIVATION and
CONFIDENCE to quit (0-10)
" Routines/situations
associated with tobacco use
Tobacco Log
" Social support
" ASSIST to change routine
" Non-food / healthy items instead
of cigarettes
" Tea instead of coffee / Exercise
instead of smoking
A modified US PHS Guideline Approach: START
"
ASSIST (continued)
" Coping strategies for life
stressors /emotional
triggers
" Weight gain concerns
" Withdrawal concerns
the 4 Ds
" Relapse concerns
" Daily affirmation
" Pharmacotherapy options
" REMOVE tobacco products for
QUIT day
" Home Car Office
" TREAT SELF
" Facial, Dental, Manicure
The
PHYSICAL
Cognitive Evidence-Based
STRATEGIES Continued
A modified US PHS Guideline Approach: START
Quitting is HARD to do!
The
PHYSICAL
The
EMOTIONAL
The
BEHAVIOR
Physical addiction of
cravings & withdrawals
Role of cigarettes in life
pleasure, stress, social
Automatic learned
behavior with cigarettes
A COMPREHENSIVE APPROACH = A Successful Framework for Quitting
Adapted from Legacys GSD&M Presentation 12/5/03
Nicotine Replacement Therapy
(NRT): RATIONALE for USE
"
Reduces physical
withdrawal from nicotine
"
Allows patient to focus
on behavioral and
psychological aspects of
tobacco cessation
"
It is NOT substituting
ONE negative health
behavior for another
IMPROVES SUCCESS RATES!
LONG-TERM ("6 month) QUIT RATES for
AVAILABLE CESSATION MEDICATIONS
0
6
12
18
24
Nicotine gum Nicotine lozenge Nicotine inhaler
Active drug
Placebo
Data adapted from Silagy et al. (2004). Cochrane Database Syst Rev
and Hughes et al., (2004). Cochrane Database Syst Rev.
P
e
r
c
e
n
t

q
u
i
t
19.5
14.6
11.5
8.6
16.4
8.8
23.9
11.8
17.1
9.1
20.0
10.2
FDA APPROVALS: SMOKING
CESSATION
1984
Rx
nicotine
gum
1991
Rx transdermal
nicotine patch
1996
OTC nicotine gum & patch;
Rx nicotine nasal spray
1997
Rx nicotine
inhaler;
Rx bupropion SR
2002
OTC nicotine
lozenge
2006
Rx
varenicline
NICOTINE ABSORPTION
Absorption is pH dependent
"
In acidic media
"
Ionized # poorly absorbed across membranes
"
In alkaline media
"
Nonionized # well absorbed across membranes
At physiologic pH (7.37.5),
nicotine is readily absorbed.
PLASMA NICOTINE CONCENTRATIONS for
NICOTINE-CONTAINING PRODUCTS
P
l
a
s
m
a

n
i
c
o
t
i
n
e

(
m
c
g
/
l
)
0
7.5
15
22.5
30
0 3 5 10 15 30 45 60
Cigarette
Moist snuff
Nasal spray
Inhaler
Lozenge (2mg)
Gum (2mg)
Patch
0 10 20 30 40 50 60
Time (minutes)
Cigarette
Moist snuff
Overall PRECAUTIONS, if ANY,
for NRT
"
All NRT products =
Category D pregnancy
"
Recent MI (< 2 wks),
unstable angina, serious
arrhythmias
OTC NICOTINE GUM: Nicorette;
generic (GlaxoSmithKline; Watson Labs)
"
Dose = 1 every 1-2 hrs;
"
No food/beverage 15 min
prior - during or 15 min post
"
Max = 24 / day
"
Available: 2 mg, 4 mg; regular, mint, orange
"
NOT recommended if use dentures or TMJ dz
"
Possible jaw soreness/hiccups/dyspepsia
OTC NICOTINE GUM:

CHEWING TECHNIQUE SUMMARY
Park
Stop chewing at first sign
of peppery, minty, or
citrus taste or tingle
Chew
slowly
Chew again
when the taste
or tingle fades
OTC TRANSDERMAL NICOTINE PATCH
"
Dose = 1 patch every day
(16 hrs or 24 hrs) most
dosage = 7mg/ 14mg/
21mg
"
24 hr patch NOT
recommended for sleep
disorders
"
Best if ROTATE patch
different areas
"
Preferred sites above
the waist
OTC TRANSDERMAL NICOTINE PATCH
"
If problems sticking
apply TEGADERM dressing
over patch
"
May bathe/swim with
patch
"
Do NOT cut patch
"
Not recommended if
acute/chronic skin dz
"
Possible local skin reaction
OTC NICOTINE LOZENGE
Commit (GlaxoSmithKline)
" Dose = 1every 1-2 hrs MAX = 20 / d
" No food/beverage 15 min prior
- during or 15 min post
" Delivers ~25% more nicotine than
equivalent gum dose
" Available: 2 mg, 4 mg
" Let dissolve 20-30 minutes; NO
chewing/biting of product
" Possible hiccups/dyspepsia/
lightheadedness if chewing or biting
Rx NICOTINE NASAL SPRAY
Nicotrol NS

(Pharmacia)
"
Dose = 1 dose (2 sprays per nostril)
every hr
"
MAX = 5 doses/hr OR 40 doses /day
"
Each dose delivers -50 !L spray = 0.5 mg
nicotine per spray
"
Rapidly absorbed across nasal mucosa --
faster onset of action (1113 minutes)
compared to the gum, patch, or inhaler
"
Not recommended if nasal/reactive
airway conditions
"
Possible nasal/throat irritation
Rx NICOTINE INHALER
Nicotrol Inhaler (Pharmacia)
"
Dose = 6- 16 cartridges / d
"
MAX = 16 cartridges / d
"
Puff as lighting a cigar/pipe best
if puff for ~ 20 minutes
"
Delivers 4 mg nicotine vapor, which is
absorbed across buccal mucosa - ~ 20
minutes of puffing = 1 cartridge
"
Not recommended if reactive airway
condition
"
Possible nasal/throat irritation
Rx BUPROPION SR (ZYBAN)
(GlaxoSmithKline)
"
Non-nicotine agent
"
Sustained release antidepressant
"
Dose = 150mg every a.m. x 3 days
then 150mg twice a day
"
IMPORTANT to start 2 wks prior to
QUIT date
"
Contraindications = seizure
disorders, anorexia /bulimia,
recent MAO inhibitor use,
concomitant use of Bupropion
(Wellbutrin), abrupt
discontinuation of ETOH /
sedatives
"
Precaution pregnancy (Category B) and
drugs known to lower seizure threshold
"
Leading side effect = dry mouth and
insomnia

Rx VARENICLINE
Chantix (Pfizer): NEW & PROMISING
"
Non-nicotine
cessation aid
"
Partial nicotinic
receptor agonist for
the $
4
!
2
nicotinic
acetylcholine receptor
"
Lessens sx of
withdrawal and
cravings
"
Inhibits surges
of dopamine
release
VARENICLINE
Chantix (Pfizer)
"
Oral formulation- ~24 hr
half life- steady state
within 4 days
"
Leading side effect =
nausea
"
Category C pregnancy

VARENICLINE: DOSING
Patients should begin therapy 1 week PRIOR to their
quit date. The dose is gradually increased to minimize
treatment-related nausea and insomnia.
Treatment Day Dose
Days 13 0.5 mg qd
Days 47 0.5 mg bid
Day 8 through end of treatment* 1 mg bid
Initial
dose
titration
*Patients should be treated for 12 weeks.
COMPARATIVE DAILY COSTS
of PHARMACOTHERAPY
Cost per day, in U.S. dollars
Chantix
Inhaler
Gum
Lozenge
Bupropion SR
Cigarettes (1 pack/day)
Patch
Nasal spray
0 2 4 5 7
$6.07
$5.81
$5.31
$5.24
$3.93
$2.66
$4.12
$4.15
Breaking the NICOTINE DEPENDENCE Cycle
The
PHYSICAL
The
EMOTIONAL
The
BEHAVIOR
Physical addiction of
cravings & withdrawals
Role of cigarettes in life
pleasure, stress, social
Automatic learned
behavior with cigarettes
A COMPREHENSIVE APPROACH = A Successful Framework for Quitting
Adapted from Legacys GSD&M Presentation 12/5/03
Follow Up for SUCCESS
# of
sessions
# of arms Estimated odds
ratio (95% C.I.)
Estimated
abstinence rate
(95% C.I.)
0-1
2-3
4-8
> 8
43
17
23
51
1.0
1.4 (1.1,1.7)
1.9 (1.6,2.2)
2.3 (2.1,3.0)
12.4
16.3 (13.7,19.0)
20.9 (18.1,23.6)
24.7 (21.0,28.4)
META ANALYSIS (n = 45 studies) Fiore MC, Bailey WC, Cohen SJ, et al. (2000). Treating Tobacco
Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and
Human Services, Public Health Service.
FU PRIORITY
FOCUS = cravings,
withdrawals, med
tolerance, coping
with triggers &
CONGRATS
WHAT IF
a patient asks
you about
your use of
tobacco?
DR. GRO HARLEM BRUNTLAND,
FORMER DIRECTOR-GENERAL of the WHO
If we do not act decisively, a hundred
years from now our grandchildren and
their children will look back and
seriously question how people claiming
to be committed to public health and
social justice allowed the tobacco
epidemic to unfold unchecked.
USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS.
The RESPONSIBILITY of
HEALTH PROFESSIONALS
Slide resources/references available at
http://rxforchange.ucsf.edu
http://nurses4tobaccocontrol.org
http://tobaccofreenurses.org
THANK YOU