Brief Tobacco Interventions for

Opioid Maintenance ProvidersSusan Bradshaw, MD, MPH

Tobacco Control and Prevention ProgramSeptember 18, 2013

Los Angeles County Department of Public HealthChronic Disease and Injury Prevention Division

Outline

• Burden of Tobacco Use

• Tobacco Products

• Tobacco Addiction

• Brief Intervention (Ask, Advise, Refer)

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• Native Americans used tobacco prior to the arrival of Columbus

• Consumption was for medicinal and ceremonial purposes

• Commonly smoked in peace pipes

Introduction

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John Rolfe (1585–1622) ….

• Married Pocahontas

• First to cultivate tobacco as an commercial export and cash crop

• Until 1883, taxes from tobacco accounted for 1/3 of IRS revenue

Introduction

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1881: Cigarette machine

1882: Ten million cigarettes sold

1887: One billion cigarettes sold

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Introduction

IntroductionAnti-Tobacco

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1798: Benjamin Rush….

• First surgeon general

• Signer of the Declaration of Independence

• “Tobacco use supports excess alcohol consumption”

IntroductionAnti-Tobacco

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1870: Tobacco ….• Harmful addictive substance

• Contributing factor in relapse from alcoholism and drug dependence

• Treated along with alcoholism and other addictions in asylums

Founding father of AA movement, Bill W., died

from tobacco-related disease.

Stop drinking to die from smoking?

1930s: Tobacco use is no longer viewed as an addiction and becomes embedded in

recovery programs.

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BURDEN of TOBACCO

• Leading cause of preventable and unnecessary death, disability and disease

• Causes more deaths than homicide, suicide, heroin, cocaine and alcohol combined each year

•Everyday, approximately 1,200 people die from tobacco-related diseases

Burden of Tobacco UseMorbidity and Mortality

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Burden of Tobacco UseMorbidity and Mortality

For every 8 smokers who die, one non-smoker dies from exposure to secondhand smoke (SHS).

Secondhand Smoke (SHS)

• Causes 50,000 deaths annually

• Mainstream smoke is exhaled by a smoker

• Side stream smoke comes from the end of a burning tobacco product

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Question?

True or False. Secondhand smoke contains more than 7,000 chemicals.

True. Secondhand smoke is a toxic mixture of gases, chemicals and particles. It contains about 70 carcinogens.

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Secondhand Smoke

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There is no safe level of exposure to secondhand smoke.

Burden of Tobacco UseThirdhand smoke?

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• Residue left on a variety of surfaces by tobacco smoke. It builds up on surfaces and resists normal cleaning.

• Can't be eliminated by airing out rooms, opening windows, using fans or air conditioners, or confining smoking to only certain areas

• The only way to protect nonsmokers from thirdhand smoke is to create a smoke-free environment

Burden of Tobacco UseEconomic

Which state charges the most for a pack of cigarettes?

New York. It costs $11.90 for one pack of cigarettes.

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• Cigarette butts are the most littered item in US

• 153 million pounds of cigarette butts are dumped each year

• 26,400 smoking- related fires occur annually

Burden of Tobacco UseEnvironment

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Smoking RatesMental Illness (MI)

Schizophrenia 62-90%

Bipolar Disorder 51-70%

Heavy drinkers 65-90%

Depression or Anxiety 40-50%

Post-traumatic Stress Disorder 45-60%

Substance Use Disorder (SUD) 49-98%

Burden of Tobacco UseMI/SUD

Compared to general population …..

Begin smoking earlier

Smoke more cigarettes each day

Smoke cigarettes them down to the filter

Inhale deeper

Burden of Tobacco UseMI/SUD

• Consume 44% of all cigarettes sold

• Spend 30% of their income

• Poorer tobacco cessation outcomes

• Want to quit

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Smoking cessation does not interfere with

recovery

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Burden of Tobacco UseKey Points

Compared to general population, MI/SUD…..

• Smoke more

• Suffer more

• Spend more22

Benefits of Quitting Health

Recovery

Wealth

Environment

Pets23

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TOBACCO PRODUCTS

Update

Question?

What is the name of the President who started

smoking a pipe after he was diagnosed with throat

cancer?

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President GrantIt is alleged he thought smoking a pipe was

safer than smoking cigars.

Smoked TobaccoCigarettes

Photo source: FACT collection

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Natural & Deadly Cheap & Toxic

Expensive & Unhealthy

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Smoked TobaccoCigarette , Little Cigar, Cigarillo and Cigar

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Cigarette: wrapped in paper not containing tobacco

Cigar and cigarillo: wrapped in substance containing tobacco

Smoked TobaccoLittle Cigars and Cigarillos

• Many flavors

• Package

• Tip or no tip

• Examples: Black & Mild Swisher Sweets White Owl

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Smoked TobaccoOther

Photo source: FACT collection

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Blunts

Bidis

Hookah

New Smokeless Tobacco

• May be in pouch

• Marketed as energizing

• May contain: Caffeine Vitamin C Flavor

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Smokeless TobaccoSnus

• Variety of flavors

• Packaged in small pouches

• Addresses smoke-free policies

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Smokeless Tobacco

Dissolvables

•Strips•Sticks•Mints (Orbs)

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Electronic Nicotine DevicesSmoke and tobacco free

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TOBACCO PRODUCTSKey Points

• Cigarettes are the most common form of tobacco used in the U.S.

• All tobacco products are harmful

• Screen patients for different tobacco products

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TOBACCO ADDICTION

Nicotine

• Cigarettes and other forms of tobacco contain nicotine

• Research suggests that nicotine may be as addictive as heroin, cocaine, or alcohol

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Nicotine enters brain

Stimulation of acetylcholine receptors

Dopamine release

Prefrontal cortex

Nucleus accumbens

Ventral tegmental

area

Nicotine and the Brain:

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Nicotine Hijacks the Brain

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Smokers feel normal with nicotine

When nicotine levels decrease, smokers may experience nicotine withdrawal symptoms (NWS)

NWS include irritability, anxiety, difficulty concentrating, and increased appetite

Nicotine AddictionEasy to Start, Hard to Quit

In general:

• Ninety percent of smokers began using tobacco before age 18

• Smokers often relapse because of stress, weight gain, and withdrawal symptoms

• Numerous quit attempts are usually necessary to stop successfully

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Nicotine AddictionEasy to Start, Hard to Quit

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• Each day, approximately 3,500 U.S. kids smoke their first cigarette

• Of every three young smokers: o One will quit o One will die from a tobacco-related

disease

Treatment OptionsExamples

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Non-Pharmacological Pharmacological

Behavioral issues Withdrawal symptoms

• Self-help • Nicotine Replacement• Advice • Non-Nicotine • Counseling• Other

Combination is BEST.

Nicotine Replacement Therapy (NRT)

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• Reduces withdrawal symptoms

• Few contraindications and side effects

• Toxicity and abuse are rare

• Does not contain toxins

Nicotine Replacement Therapy Update

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• Instructions on label will change

• Recommendations by experts differ from label

Combination NRT Higher dosage Treat withdrawal symptoms Taper based on patient’s preference

Nicotine Replacement Therapy (NRT)

Delivery time

NRT therapy • Nicotine gum• Lozenge• Patch• Nasal spray• Inhaler

Onset of Action20 to 60 minutesFaster than gum6-8 hours 5 to 10 minutes10 minutes

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NRT Patch• Apply to skin that is clean,

dry and non-hairy. Press onto skin for 10 seconds.

• Rotate placement on different parts of the body each week

• Avoid cutting

7,14,& 21 mg/24 hr5,10 & 15 mg/16 hr

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• Bite gum slowly

• Stop at first sign of mild tingling or peppery taste

• “Park” between the cheek and gum

• Bite again when tingling or peppery sensation fades (20 minutes)

NRT Gum (Chew and Park)

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NRT Lozenge• Easier to use and delivers ~25% more

nicotine compared to NRT gum

• Allow to dissolve slowly. Rotate in mouth until it dissolves ( 20 minutes).

• Should not be chewed or swallowed

Do not eat or drink 15 minutes before using NRT gum or lozenge.

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NICOTINE ADDICTION Key points

Nicotine addiction can be a chronic and relapsing condition that usually begins in adolescence

Successful treatment often requires multiple quit attempts and interventions as well as long-term monitoring

Pharmacotherapy and behavioral interventions should be offer to all tobacco users who want to quit

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ASK, ADVISE, REFER (AAR)

Brief, Effective and Low Cost

Ask, Advise, Refer

Ask all patients about tobacco use

Advise all tobacco users to quit

Refer all tobacco users to 1-800-NO-BUTTS

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Step One

Ask…..

all patients about tobacco use

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Strategies to Identify and Document

• Vital sign• Stamp• Chart stickers• Medical record flow sheets• Checklists• Electronic medical records• Computer prompts

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Example of Vital Sign

Blood Pressure: ______Pulse: _______ Weight: _____Temperature: ________ Respiratory Rate: ________Tobacco Use: Current ____ Former ____ Never____SHS exposure: Home____ Work_____ Car_____

[ ] Advice given [ ] Referral provided

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Step Two

Advise…

all tobacco users to quit

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Advise….

• Studies have shown that healthcare providers can be effective in advising tobacco users to quit

• Your advice approximately doubles the chance that patients will make a quit attempt

• The way a healthcare provider talks to patients can substantially influence motivation to quit

Thereafter, assess willingness to quit

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Step Three

Refer…

all tobacco users to….

1-800-NO-BUTTS California Smokers’ Helpline

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ReferLet all tobacco users know:

• “You can double your chances of quitting successfully by calling 1-800-NO-BUTTS”

• “They will help you through the quitting process and the services are FREE”

• “FREE samples of NRT are available to Los Angeles County residents “

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Free and confidential services include:

Up to 6 counseling sessions

Personalized quit plan

Self-help materials and referral to local services

Services for former smokers, teens, pregnant women, tobacco chewers and people unwilling to quit

California Smokers’ Helpline1-800-NO-BUTTS or www.nobutts.org

California Smokers’ Helpline1-800-NO-BUTTS or www.nobutts.org

Coaching by trained counselors is available in six different languages and for hearing impaired

Financial information: o FREE NRT to Los Angeles County residents o $20 gift card for Medi-Cal memberso Health insuranceo Cost is similar to buying cigarettes

Monday-Friday: 7am to 9pmSaturday: 9am to 1pm

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Examples of Brief Clinical Interventions

Willing to Quit

Refer to 1-800-NO-BUTTS

If time permits: • Discuss medications• Set Target Quite Date

(TQD)• Develop quit plan• Contact 3 days after TQD

and follow-up monthly

Unwilling to Quit

Refer to 1-800-NO-BUTTS

If time permits:

• Provide motivational interventions (5 R’s)

• Encourage smoking journal

• Promote healthier lifestyle

• Defer, if patient requests 61

ResourcesPatient

Internet• Smokefree.gov• Becomeanex.org

Mobile app/Text • QuitSTART and QuitPal• SmokefreeTXT• QuitNowTXT

Nicotine Anonymous• Quitnowla

Provider

Training/Outreach materials• Nobutts.org

• Smokingcessationleadership.ucsf.edu

• Askadviserefer.org

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Ask Advise ReferKey Points

A brief intervention should be implemented at each visit:

•ASK all patients about tobacco use

•ADVISE all tobacco users to quit

•REFER all tobacco users to 1-800-NO-BUTTS and recommend pharmacotherapy to those who want to quit

AAR + Quitline + Meds63

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AAR Demonstratio

n

Questions?

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Thank you!

Susan Bradshaw, MD, MPH(213) 351-7319

Los Angeles County Department of Public HealthChronic Disease and Injury Prevention Division

Tobacco Control & Prevention Program

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