Fundamentals of Tobacco

Interventions

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Copying or distribution of these materials is permitted providing the following is noted on all electronic and print versions:

© CAMH/TEACH

No modification of these materials can be made without prior written permission of CAMH/TEACH.

Copyright

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The recipient of the funding is in compliance with the CMA and the CPA guidelines /

recommendations for interaction with the pharmaceutical industry.

Disclaimer

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These materials (and any other materials provided in connection with this presentation) as well as the verbal presentation and any discussions, set out only general principles and approaches to assessment and treatment pertaining to tobacco cessation interventions. They do not constitute clinical or other advice as to any particular situations and do not replace the need for individualized clinical assessment and treatment plans by health care professionals with knowledge of the specific circumstances.

Disclaimer

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Disclaimer: TEACH Curriculum Development

The TEACH Curriculum and slides were developed and compiled withfunding from the Government of Ontario, Ministry of Health Promotion.Content of slides are primarily based on evidence based guidelinesincluding:• US Guidelines Treating Tobacco Use and Dependence: Clinical Practice Guideline

2008 Update. US Department of Health and Human Services, Public Health Service• The Canadian Action Network for the Advancement, Dissemination and Adoption of

Practice-informed Tobacco Treatment (CAN-ADAPTT) • Rethinking Stop-Smoking Medications: Treatment Myths and Medical Realities 

OMA Position Paper, January 2008.• The development or delivery of the TEACH curriculum was not influenced or funded

in any part by tobacco industry. TEACH has not received funding from the tobacco industry. The development of the TEACH curriculum has not been influenced by pharmaceutical industry. TEACH project did receive a $10 000 unrestricted grant from Pfizer, to develop video vignettes that are used in our training.  Information presented on pharmacotherapy refers to generic products only, and recommendations are based on existing research, including the US guidelines.  An algorithm is provided to help practitioners determine if and which pharmacotherapy is appropriate for a smoker.

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Modules 1 • 2 • 3

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Environment

Behaviour

Medication

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Learning ObjectivesAt the end of this course, you will be able to:

• Describe why clinicians should implement tobacco cessation

interventions• Summarize smoking prevalence in Canada by gender and

among some special populations

• Enhance clients’ motivation to quit smoking• Implement a structured, adaptable cognitive behavioral

approach to smoking cessation

• Understand the effects of tobacco and nicotine on the brain• List the pharmacotherapies that increase the odds of quitting• Discuss or recommend cessation medications with your clients• Integrate cessation interventions into your clinical practice

1

2

3

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Learning Assessment 1

• Please complete Learning Assessment 1• This is a self-reflection tool, designed to

gauge whether your responses change throughout the workshop

• Keep the assessment for your own reflection.

ENVIRONMENT

1

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Environment

Learning Objectives

At the end of Module 1 you will be able to:

1. Describe why clinicians should implement tobacco cessation interventions

2. Summarize smoking prevalence in Canada by gender and among some special populations

3. Integrate cessation interventions into your clinical practice

1

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Optional Exercise

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“Fast facts” on Tobacco Use in Canada

• Tobacco kills 1 in 5 Canadians, or 45,000 people every year (more than deaths due to traffic accidents, suicides, homicides, drug abuse and HIV-AIDS combined) (Physicians for a Smoke-Free Canada, 2003)

• Economic impact of smoking estimated at $17 billion every year (Rehm et al., 2006)

• 90% of people who smoke became addicted before age 18 (Fiore et al., 2008)

• Tobacco-related disease accounts for at least 500,000 hospital days each year in Ontario alone (MHP, 2009)

• 17.5% of Canadians age 15 and over are current smokers (CTUMS, 2010)

• Rates of smoking are much higher among sub-populations: e.g.,90% - people with schizophrenia, 90% - people with opioid dependence (Kalman, Morisette and George, 2005; NIDA, 2008)

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• Tobacco is the leading cause of preventable death in the developed world

• 70% of smokers want to quit, and the remaining 30% would likely choose to not start, or would not want their child to smoke (Fiore et al., 2008)

• Just 3-5% of unassisted quit attempts are successful, compared with up to 20% success for those receiving cessation counselling and medications (Fiore, Baker et al., 2008)

• Outcomes of evidence-based cessation interventions are comparable with other chronic disease management (hypertension, asthma, diabetes) (West and Shiffman, 2007)

Why should health professionals get involved?

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Understand tobacco dependence as a chronic, relapsing disease and the need for a

paradigm shift

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Gender-Specific Smoking Prevalence across the World

US26%21%

Australia28%22%

Belarus64%24%

Brazil20%13%

Canada19%17%

Chile42%31%

China59%4%

Egypt25%1%

France37%27%

Iceland25%27%

Mexico37%12%

Iran24% 2%

Kenya24%1%

Sweden19%25%

Philippines39%9%

Portugal41%31%

South Africa25%8%

India28%1%

Russian Fed70%27%

Italy33%19%

Spain36%31%

Germany37%26%

Shafey et al. The Tobacco Atlas, 2009.

MenWomen

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The Smoking Environment in Canada

• 17.5% of Canadians (~5 million) 15 years or older are current smokers

• 26 % are former smokers• 54% never smoked• 55.1% of daily smokers have their 1st

cigarette within 30 minutes of waking up. 75% within the hour!

CTUMS, 2010

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Mortality Due to Tobacco• 35,000-48,000 Canadians die from smoking per year

– 100 infants/year• 1 in 5 deaths are due to smoking

– Five times those due to car accidents, suicides, other drug abuse, murder and HIV combined!

• 1 in 2 smokers die from smoking related diseases.– 20% of smokers develop lung cancer– 80% of lung cancer caused by smoking

WHO Report on the Global Tobacco Epidemichttp://www.who.int/tobacco/mpower/mpower_report_full_2008.pdf

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Smoking Prevalence (Ages 15+)

Differences by Province

19%

17%

19%21%24% 16%

20%

21%20%12%

CTUMS 2010 Wave 1 data

36%

36%61%

Territory data obtained using 2009 Canadian Community Health Survey; Provincial data obtained using CTUMS 2010 Wave 1 data.

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0

5

10

15

20

25

30

35

BC AB SK MN ON QC NB NS NF PEI

1999

2009

Current Canadian Adult Smokers (15+) by Province, 1999 & 2009

Ontario, Alberta, Nova Scotia, and PEI reduced by 9% in 10 years

9%

CTUMS, 1999 and 2009 Annual data

2020

Tobacco Use in Ontario

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Gender Differences

Smoking rates 19% 16.0%

Cigarettes per day

15.8 12.9

Current teen smokers (15-19)

14.9% 10.9%

Men aged 23-24 have the highest smoking rate (28.9%)

Male Female

CTUMS, 2009 Annual data

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Levels of Interventions• Minimal / Brief Contact

– Delivered during the course of a regular health care encounter in less than 3 minutes. i.e.: 5A’s

• Intensive Interventions– Multi-session counselling programs involving

extensive contact with a health care provider/counsellor

– Inpatient programs (Mayo Clinic)• Self Help

Fiore MC et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence. 2008; Pbert et al., 2008; USDHHS, 2008

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Brief Cessation Interventions: The “5As”

Fiore et al. 2008.

– Ask about tobacco use

– Advise to quit

– Assess willingness to make a quit attempt

– Assist in quit attempt

– Arrange follow-up

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Quitting Smoking at any Age Can Increase Life Expectancy

Increased Life Expectancy

Doll R et al. 2007

Age stop smoking by Life years gained

<30 years 10

<40 years 9

<50 years 6

<60 years 3

Quitting smoking before the age of 30, normal life expectancy

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Effective Amount of Contact Time

Fiore et al., 2000

Need to consider resources available

Total Contact Time Estimated Abstinence Rate

None 11.0 %

1 – 3 minutes 14.4 %

4 – 30 minutes 18.8 %

31 – 90 minutes 26.5 %

91 – 300 minutes 28.4 %

> 300 minutes 25.5 %

Optimal Intervention

Time

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Environment Summary

You are now able to describe the prevalence of tobacco use on a national and international level by gender and among some special populations, explaining why clinicians play a critical role in implementing tobacco cessation interventions.

1

BEHAVIOUR

2

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Behaviour

Learning Objectives

At the end of Module 2 you will be able to:

1. Enhance clients’ motivation to quit smoking2. Implement a structured, adaptable cognitive

behavioural approach to smoking cessation3. Integrate cessation interventions into your clinical

practice

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Assessing Tobacco

Dependence

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Assessment• Components of Assessments

– History of smoking and quit attempts– Level of nicotine dependence– Withdrawal– Reasons for smoking, reasons for wanting to quit – Social environment– Co morbidities – psychiatric, and/or other

substance use – Intrinsic motivation and self-confidence– Client’s goals, views of treatment, preference for

treatment

Abrams et al, 2007

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All Smokers Benefit From Proactive Assistance to Quit

Motivation to quit does not predict response to treatment

Motivation can increase when effective treatment is offered

Smokers with low motivation can achieve high continuous abstinence rates

Irrespective of motivation, all smokers should be actively offered assistance to quit

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What is Motivational Interviewing?

2002: “A directive, client-centred style of counselling that helps clients to explore and resolve their ambivalence about changing.”1

2009: “Is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.” 2

1. Miller and Rollnick (2002). Motivational Interviewing (2nd ed), p. 25

2. Miller (2009). Ten Things that MI is Not

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The Spirit of Motivational Interviewing

• Ambivalence is a normal human condition

• Underlying spirit: collaborative, evocative, supporting autonomy

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Change as a Process

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The Stages of Change

Prochaska and DiClemente, 1984

?PrecontemplationPrecontemplation ContemplationContemplation

PreparationPreparation

ActionAction

MaintenanceMaintenance

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Stages of Change

• People do not move in a linear fashion through the cessation process

• Stages are arbitrary• May misguide clinicians to diagnose

clients at a certain level – too rigid• BUT: if you consider these points when

using the model it can be one of many helpful tools to use

West (2005)

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Change is not something you do toto people,

but withwith people.

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DSM-IV Diagnostic Criteria for Nicotine Dependence

In the DSM-IV 3 or more of the following criteria are required for a diagnosis of Nicotine Dependence:

1. Tolerance2. Withdrawal. Requires daily use for at least several

weeks. A minimum of 4 withdrawal symptoms are required. The withdrawal symptoms must “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

3. The substance is used in larger amounts or over a longer period than was initially intended.

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DSM-IV Diagnostic Criteria for Nicotine Dependence (2)

4. Unsuccessful efforts to cut down, regulate, or discontinue use.

5. A great deal of time spent obtaining the substance, using the substance, or recovering from its effects.

6. Important social, occupational, or recreational activities may be given up or reduced because of substance use.

7. Substance use continues despite the individual's realization that the substance is contributing to a psychological or physical problem.

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DSM-IV Criteria Dependence

Persistent desire or inability to stop Most smokers want to stop, fewer than 5% of unassisted attempts last a year or more

Continued use despite harmful consequences

Withdrawal syndrome

Use of more of the drug or use for longer than intended

Many smokers try to cut down but cannot maintain reduction; many learning to smoke believe they will stop before the damage is done but few manage to do so

Most smokers are aware of health risks and want to stop because of them, but feel unable to do so

Experienced by majority of smokers

Fast Facts: Smoking Cessation, Robert West and Saul

Shiffman, 2nd edition 2007

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DSM-IV Criteria Dependence (2)

Tolerance; diminished effect with continued use

In the case of nicotine, tolerance is mainly to the aversive effects

A lot of time spent obtaining the drug, using it or recovering from its effects

Important activities forgone because of the drug

Criterion related mainly to illicit drugs or those that impair function (intoxicating drugs)

Heavily dependent smokers may give up or interrupt activities in non-smoking areas

Fast Facts: Smoking Cessation, Robert West and Saul Shiffman, 2nd edition 2007

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Daily Diary - BaselineThink back to the last week starting today and make a note

when you engaged in the current behaviour(s).

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• Importance of Assessing

– Builds alliance / relationship – basic ingredient of treatment

– Big picture of client

– Identifies co-occurring issues

– Opportunity to educate client – “teachable moments”

– Ongoing process

– Collaborative approach

Assessing Our Clients

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AssessmentsSeven Key Components

1.Level of nicotine dependence/ severity of withdrawal

2. Motivation

3. Past quit attempts and smoking history

4. Co- morbidities

5. Reasons for smoking, environment, triggers, reasons for quitting

6. Social environment supports and barriers

7. Smokers’ preference

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Assessment Components

1. Level of nicotine dependence/ withdrawal

• Withdrawal symptoms, what happens when they don’t smoke or are unable to smoke?

• How much do they smoke presently?• Menu of tools (addressed in the next section)

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Withdrawal Symptoms

• Withdrawal symptoms can predict lapse and relapse after cessation attempt (Killen & Fortman, 1997; Shiffman et al, 1997)

• Can help determine if client needs a withdrawal management plan including pharmacotherapy

The Tobacco Dependence Treatment Handbook, 2007

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Symptoms Duration Prevalence

Irritability / Aggression < 4weeks 50%

Depression < 4 weeks 60%

Restlessness <4 weeks 60%

Poor concentration < 2 weeks 60%

Increase appetite > 10 weeks 70%

Light-headedness < 48 hours 10%

Night-time awakenings < 1 week 25%

Constipation > 4 weeks 17%

Mouth ulcers > 4 weeks 40%

Urges to smoke > 2 weeks 70%

Nicotine Withdrawal Symptoms:

Slide Source: TEACH, CAMH, 2009

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Assessment Components

2. Motivation • What brought this person in? • Urgent issues (i.e. pregnant, COPD, transplant

lists)• May need to modify assessment depending on

client’s situation• Reasons for wanting to quit (why now?)

– External or internally motivated

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Assessment Components

3. Past quit attempts and smoking history

• When did they start smoking, using tobacco products? Daily smoking?– How long? How much? How many quit

attempts?– Longest time quit?– What have they tried? Review use of

medications and supports

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Assessment Components

Other substance use / mental health issues– Can have an impact on treatment planning– Do they see a connection between their

other issues and smoking?

• Medical issues / medications– Will these have an impact on quit attempts?– Sometimes small adjustments in medication

can shift a client’s attitude towards taking NRT

– Are they motivators or stressors?

4. Co-morbidities

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Assessment Components

5. Environment, triggers, reasons for smoking

– Identify high-risk situations and triggers to smoking

– What led to relapse?

– What does their environment look like?

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Helping to Define Triggers (5)

Asking the Client:

“ Can you identify 3 times in your daily routine when you are 100% certain that you will smoke?”

1. ________________________________

2. ________________________________

3. ________________________________

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Assessment Components

6. Social Supports and Barriers• What supports do they have in place?• What is smoking status of friends, family, colleagues?

• What in their environment perpetuates their smoking?• Is this a good time to quit or reduce?• How does stress affect their smoking? Their quitting?

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Assessment Components

7. Smoker’s Preference • What are the client’s goals around smoking?• Resources / coping skills

– Client’s perception of self-efficacy

– Learnings from past quits,

– What are their preferences, expectations, timelines around treatment?

– What other stress management techniques do they utilize?

– What are the client’s strengths?

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Tools / Scales to Consider

– Fagerstrom Test for Nicotine Dependence

– Heaviness of Smoking Index

– Beck Inventory of Depression

– Beck Anxiety Inventory

– Why you Smoke Scale

– Reasons for Quitting Questionnaire

– Minnesota Withdrawal Scale

– QSU – Questionnaire of Smoking Urges

– Cigarette Withdrawal Scale

– Coping with Temptations Inventory (CWTI)

– Smoking Consequences Questionnaire

Behaviour Change

Roadmap:THE 4 POINT

PLAN

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4 steps to stopping destructive behaviours and leading a healthier life:

1.1. SSTRATEGIZE

2.2. TTAKE ACTION

3.3. OOPTIMIZE

4.4. PPREVENT RELAPSE (PPERSEVERE)

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Setting the Stage

• Important aspects to consider– Quitting is a process– Automatic behavior: not always a conscious process– A pack/day = 110,000 hand to mouth repetitions/year– Linked with many behaviors: meals, alcohol, waking

up, coffee, environment – group homes, smoking rooms in hospitals

– Linked with social relationships: breaks at work, parties, friends houses

Step 1: STRATEGIZE

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1. Strategize

– Can take 1 session or can happen over several

– Involves developing a quit plan:→Tracking smoking→Quit date→Triggers, coping skills, plan for high-risk events →Problem solving and coping skills→Support plan→Pharmacotherapy plan

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• Identify all positive supports– Personal - partner, family, friends, colleagues– Professional – physician, pharmacist, dentist,

nurse, etc– Other support – Smokers’ Helpline, groups,

websites, self-help• Identify all negative influences

– Other smokers (partner, family)– People who don’t want client to quit smoking– Unhelpful “encouragement” to quit

Strategize: Psychological

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Strategize – Cognitive/Affective

• Personal relationship with cigarettes• Describe cigarettes as friend or lover • Can experience sense of loss when quitting

• Help reframe this

thinking… abusive friend or lover

• Acknowledge these emotions

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Strategize – Behavioural

• Relaxation strategies• Physical activity• Groups• Rewarding accomplishments• Tracking sheets / Self-monitoring

– Increase awareness of smoking behaviour– Identify triggers, challenges– Suggest which cigarettes will be easy and which will be

more difficult– Begins to break the automatic smoking behaviour and

possibly reduces the number of cigarettes smoked

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Strategize - Environmental

• Smoke-free environments

– Make home and vehicle smoke-free

– Explore areas of home to restrict smoking behaviour if entire home cannot go smoke-free

– Work environment – avoiding smoking areas

– Other

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Strategize - Biological

• Pharmacotherapy

• If client is interested in medications, refer to physician/pharmacist or provide information

• How much do they know about what is available?

• What are the pros and cons of pharmacotherapy?

• Who will help monitor this part of the quit plan?

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Reasons for ChangeMaking a commitment to meeting your goal is important to your success. Sometimes, it’s easy to forget why you’re making the change, so write down your reasons and use this as a reminder to yourself when things seem tough!

The most important reasons why I want to change are:

1 ____________________________________________________________

2 ____________________________________________________________

3 ____________________________________________________________

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Decision to Change Worksheet

Changing my current behaviour

Continuing to behave in the same way

Benefits

Costs

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Strategize – Set a Goal• Setting a quit date:

• Provides specific date/goal to work toward

• Prevents delay in quitting

• Allows time to reduce, practice, refine quit plan

• At a minimum, plan to meet with client 1 – 2 weeks before quit date and 1 – 2 weeks after quit date

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Goal Statement 

The behaviour I want to/need to change is:

 What is your goal now?

START DATE:

ACHIEVEMENT DATE:

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Readiness Ruler

How important is it to change this behaviour?

How confident are you that you could make this change?

How ready are you to make this change?

0 1 2 3 4 5 6 7 8 9 10

People usually have several things they would like to change in their lives – this may be only one of those things. Answer the following three questions with respect to the goal you have set.

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

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For Reflection: “Readiness Ruler”

What are 3 reasons you are at _____ and not zero?

1.

2.

3.

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Hands-On Practice!

• Think of a behaviour that you would like to change – something you are comfortable sharing with a small group

• Examples could include: exercising more, healthy eating, etc.

• Take a few minutes to complete the Reasons for Change, Decisional Balance, and Goal Statement/Readiness Ruler

• Then get together in groups of 3-4 people to discuss: (1) What was this exercise like? (2) What impact did this exercise have on your understanding of the issue you are considering changing? (3) How might you use these tools with your clients?

STRATEGIZEIdentifying

Barriersand Risky Situations

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Identifying Barriers and Solutions to Change

Possible Barriers: Proposed Solutions:

© CAMH/TEACH Project

Step 2: TAKE

ACTION

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Take Action• Discuss problems and potential strategies

• Changes in mood – what support is needed?

• Withdrawal symptoms – re-assess pharmacotherapy plan

• Low motivation – decisional balance, review reasons to quit

• Weight gain – recommend physical activity, healthy eating, additional support

• Lapses/slips – explore

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Take Action (2)

• Continue identifying triggers, stressful situations

• Continue self-monitoring

• Maintain smoke-free environments

• Can be one session or several sessions

• Reset quit/reduce date if needed

• Congratulate your client for coming back

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Triggers and Consequences

• Identify high-risk situations• Describe high-risk situation• Describe types of triggers usually

associated with the situation• Describe the types of consequences

associated with the situation• How often does this type of situation

occur?

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Triggers and Consequences Worksheet

High-risk situation: _______________________

1. Briefly describe one of your most serious high-risk situations.

2. Describe as specifically as possible the types of triggers usually associated with this situation.

3. Describe as specifically as possible the types of consequences usually associated with this situation (immediate and delayed consequences, and positive and negative consequences). 

4. How often did this type of situation occur in the past year? What percentage of your total behaviour over the past year occurred in this type of situation? _____________%

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Triggers and Coping Skills – Sample Plan

Triggers

Smoke with colleague every day at breaks

Coping Skills

Tell colleague I am quitting

After mealsChew gum after meals, get up from table right away

Stress at work gets too much on some days

Plan to take walks when stress is high

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3 Options to Cope with Triggers

1. Avoid the triggers or situations

2. Change the trigger or situation

3. Find an alternative or substitute for the cigarette in response to the trigger or situation

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• Avoid the triggers or situations– Miss this event while I’m trying to quit smoking

• Change the trigger or situation– Ask friends to smoke outside b/c I am quitting

• Find an alternative or substitute for the cigarette – When someone lights up, get support from other friends

– Get up and get glass of water or move to another part of the room

– Might use nicotine gum or inhaler

Example: Getting together with friends on Saturday night

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The changes I want to make are…

The most important reasons why I want to make these

changes are…..

The steps I plan to take in changing are…

The ways other people can help me are…

I will know that my plan is working if…

Some things that could interfere with my plan are...

Change Plan Worksheet

Step 3: OPTIMIZE

YOUR PLAN

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Doing a 360: Asking for Feedback

• SOCIAL SUPPORTS (FAMILY MEMBERS, FRIENDS, COLLEAGUES)

• PROFESSIONALS ( MD, RN, PHARMACIST, OTHERS)

• FEEDBACK ON MY PLAN?• THINGS MISSING?• WATCH FOR SABOTEURS AND

ENLIST SUPPORTERS

Step 4: PREVENT RELAPSE

(Persevere)

“ A Slip is Not a Fall ”

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Relapse Prevention

Song et al., (2009)

75% relapse within 4 – 52

weeks

• A meta-analysis of 49 trials involving cognitive-behavioural coping strategies for smoking relapse prevention interventions indicates motivated quitters benefit from coping skills training after the first week of quitting

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A Perspective for Clients

A Lifetime of smoking

AGE 13 AGE 53

25 cig/day x 40 years = 365,000 cigarettes

4,380,000 hand to mouth repetitions

40 years of smoking

Quit attempt

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…it would most likely be in the following situation:

If I were to relapse...

What coping strategies could I use to avoid this relapse?

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• If the client has quit or reduced• Congratulate on changes made

• Review benefits

• Identify future challenges and plan to cope

• Pharmacotherapy

• Engagement

Prevent Relapse

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Prevent Relapse (2)

• If client had slips/relapsed:– Assess what happened

– What can be done differently?

– What worked?

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• Avoid the triggers or situations– Miss this event while I’m trying to quit smoking

• Change the trigger or situation– Ask friends to smoke outside b/c I am quitting

• Find an alternative or substitute for the cigarette – When someone lights up, get support from other friends

– Get up and get glass of water or move to another part of the room

– Might use nicotine gum or inhaler

Example: Getting Together with Friends on Saturday Night

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Prevent Relapse (3)

• Pharmacotherapy – long term use for those that would benefit

• Staying engaged in treatment / counselling / groups when possible

• What other supports will remain available beyond treatment?

• Planning for relapse– What situations/triggers might lead to a slip or

relapse?– Is there a plan on how to deal with those

situations?

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When you started the change process, you completed a “Decisional Balance” of anticipated costs and benefits of changing and of continuing the behaviour in the same way. Now that you have made some changes, complete the decisional balance again noting the actual costs and benefits that you have experienced, as well as things that you didn’t anticipate as costs or as benefits. Then go back and compare your responses with your previous Decisional Balance.

Revisiting the Decision to Change Worksheet

Changing my current behaviour

Continuing the behaviour in the same way

Benefits

Costs

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Readiness Ruler

How important is it to change this behaviour?

How confident are you that you could make this change?

How ready are you to make this change?

0 1 2 3 4 5 6 7 8 9 10

Now that you have successfully made some changes, where would you rate the importance of sustaining these changes? How confident do you feel now in maintaining change? How ready are you to continue the journey of change? After you have completed this sheet, go back and compare your responses with the one you completed previously.

0 1 2 3 4 5 6 7 8 9 10

0 1 2 3 4 5 6 7 8 9 10

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Concluding Thoughts on Relapse Prevention

• Follow-up calls

– Evaluation and counselling calls• How can the client re-engage quickly in treatment if he/she

relapses?• What are the red flags/warning signs that a client might

relapse?

– “One won’t hurt”

– “I’m sure I can smoke socially now that I’ve quit”

– “I’m stressed. Just this once to help me get through this”

– “I’ve been quit for long enough that I have control over this”

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Where were you when you started this process, and where are you now?

What do you need to do to continue to make positive changes?

What is your next step?

Current Motivation and Next Steps

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Additional resources that can support me…

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Even people who quit intermittently have

substantial health benefits over those who continue to

smoke.

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Behaviour Summary

In your practice you are now equipped to enhance clients’ motivation to quit smoking and implement a structured, adaptable cognitive behavioural approach to smoking cessation, while better understanding the physiological responses to the addictive properties of tobacco.

2

MEDICATION

3

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Medication

Learning Objectives

At the end of Module 3 you will be able to:

1. Understand the effects of tobacco and nicotine on the brain

2. List pharmacotherapies that increase the odds of quitting

3. Discuss or recommend cessation medications with your clients

4. Integrate cessation interventions into your clinical practice

3

Smoking as an Addiction

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What are Tobacco and Nicotine?

• Tobacco - plant that contains nicotine– Two kinds: Traditional and

Commercial

• Nicotine - one of the major addictive components in tobacco

Nicotine is not known to lead to any diseases such as COPD or cancer. It is the 4,000 other chemicals in cigarette smoke that contributes to these diseases.

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Tobacco and Carcinogens

• More than 60 carcinogens are in cigarette smoke

• A minimum of 16 carcinogens are in unburned tobacco

Hecht (2003); Freiman et al. (2004); US Surgeon General’s Report 1989.

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Tobacco is a legal product.....

AmmoniaToilet Cleaner

Paint

MethanolRocket Fuel

MethaneSewar

GasAcetic Acid

Vinegar

ButaneLighter

Fluid

CadmiumBatteries

NicotineInsecticide

TolueneIndustrial

Solvent

Stearic AcidCandle Wax

CarbonMonoxide

ArsenicPoison

HexamineBarbeque

Lighter

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Anatomy of a Cigarette

Side stream smoke Side stream smoke – 800x toxic– 800x toxic

Filter: Hold back tar Filter: Hold back tar Mild: more holes in filterMild: more holes in filter

Paper: burn Paper: burn rings, titanium rings, titanium oxide oxide accelerantaccelerant

Tobacco: Tobacco: Leaf Leaf Reconstituted Reconstituted PuffedPuffed

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‘‘Why do people smoke . . . to relax; for the taste; to fill the time; something to

do with my hands. . . . But, for the most part, people continue to smoke because

they find it too uncomfortable to quit’’

Philip Morris, 1984

Philip Morris. Internal presentation. 1984, 20th March; Kenny et al. Pharmacol Biochem Behav. 2001; 70: 531-549.

Pharmacological Approaches to

Smoking Cessation Treatment

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Biological Aspects of Addiction

– A biological need for a drug that arises because of physiological adaptation to the presence of a drug in the body and brain

– Body becomes dependent on the drug to be able to function normally

– Stopping the drug leads to a withdrawal syndrome which is unpleasant and motivates person to continue using

– Not the complete picture

Fast Facts: Smoking Cessation, Robert West and Saul Shiffman, 2nd ed, 2007

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0

20

40

60

80

100

0 50 100 150 200

Days Since Quit Date

Perc

enta

ge o

f R

ela

pse

d a

t

6 M

onth

s S

till A

bst

inent

Quitting Smoking Unaided: Analysis of 4 Studies

Long-term smoking abstinence in those who try to quit unaided = 3%–5%

Hughes JR et al. (2004)

3 - 5%

Per

cent

age

Stil

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tinen

t

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“Counseling and medication are effective when used by themselves for treating tobacco

dependence.

The combination of counseling and medication, however, is more effective than either alone.

Thus, clinicians should encourage all individuals making a quit attempt to use both counseling

and medication”.

Fiore et al. 2008

Guideline #7 for Treating Tobacco Addiction

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Clinicians should encourage the use of medication by all patients attempting to quit smoking except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents).

Six (in Canada) first-line medications that reliably increase quit rates: – Bupropion SR – Nicotine gum – Nicotine inhaler – Nicotine lozenge – Nicotine patch – Varenicline

Consider the use of certain combinations of medications.

USDHHS, 2008; Fiore MC & Jaén CR.,2008

Guidelines for Treating Tobacco Addiction

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Costs of Smoking vs. Pharmacotherapy

One Week Supply: Approx. Cost/Week

Name-brand patch $34.00

No-name patch $22.00

Nicorette gum (10 pieces/day) $99.00 (3 boxes at $33.00)

Nicorette inhaler (5 cartridges/day) $150 (3.5 boxes at $42.00)

Cheap brand of cigarettes (7 packs) $40.00

Name-brand cigarettes (7 packs) $66.00

Contraband Cigarettes $7.00 - $15.00

Varenicline $60 starter kit; $70 for continuation pack

Buproprion $40.00

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Nicotine Replacement Therapy

• Provides the body with nicotine to help minimize withdrawal symptoms and cravings

• Eliminates toxic substances one gets from cigarettes

• Shown to almost double quit rates• Most effective when combined with counselling• Can be used to help “reduce” smoking

– Can start before quit date

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Who Should Not Use NRT?

• Not everyone needs NRT• Not everyone can afford NRT• Studies show that NRT is not effective for

those that smoke 10 cigarettes or less or are non-daily smokers

• Need to assess case by case

– Discuss with client

– Use tools to assess dependence

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Medications for Quitting SmokingMedication

Nicotine gum

Nicotine lozenge

Nicotine patch

Nicotine inhaler

Bupropion Varenicline

Treatment length

1-3 months

12 weeks 8-12 weeks12-24 weeks

7-12 weeks 12 -24weeks

Main side effects

• Upset stomach

• Hiccups

• Mouth irritation

• Irregular heartbeat

• Nausea

• Heartburn

• Hiccups

•Disturbed sleep (insomnia, abnormal/vivid dreams)

•Headache

• Site rash (pruritis erythema, burning)

• Irritation of throat

and nasal passages

• Sneezing

• Coughing

• Dyspepsia

• insomnia

• Nausea

•Dry mouth

• Nausea•Sleep disturbances •Constipation•Flatulence

Dosage2 mg, 4

mg2 mg, 4 mg

7, 14, 21 mg

5, 10, 15 mg

6-12 cartridges per day

150-300 mg/day

0.5 mg qd to 1 mg bid

Effectivenessat six monthsor longer† (OR [CI])

1.66 (1.52-1.81)

3.69 *

(2.74-4.96)1.81

(1.63-2.02)2.14

(1.44-3.18)2.06

(1.77-2.40)2.83*

(1.91-4.19)

Adapted from Le Foll & George (2007),

Shiffman et al (2002)

* 4mg, effectiveness at 6-weeks

Algorithm for Tailoring Pharmacotherapy for Smoking Cessation1,2

Ask about tobacco use: How much do you smoke? 0 - ___ cigarettes per day (cpd)?(one large pack = 25 cpd, one small pack = 20 cpd)

Advise: As your physician, I am concerned about your tobacco use, and advise you to quit. Would you like my help?

Yes

Motivational InterviewingAssess the 5 R’s:

RelevanceRewardsRiskRoadblocksRepetition

Assess Readiness: Given everything going on in your life, on a scale of 0-10, where 0 is lowest…How important is it for you to quit smoking? How confident are you that you can quit smoking?

Low importance or confidence (≤ 5)

Assist in Quit Attempt: Would you like to quit abruptly?

Reduce to Quit (RTQ)Step 1: (0-6 weeks) - Smoker sets a target for no. of cigarettes per day to cut down and a date to achieve it by (at least 50% recommended)- Smoker uses gum to manage cravingsStep 2: (6 weeks up to 6 months)- Smoker continues to cut down cigarettes using gum- Goal should be complete stop by 6 months- Smoker should seek advice from HCP if smoking has not stopped within 9 monthsStep 3: (within 9 months)- Smoker stops all cigarettes and continues to use gum to relieve cravingsStep 4: (within 12 months)- Smoker cuts down the amount of gum used, then stops gum use completely (within 3 months of stopping smoking)

Has bupropion/NRT failed? YIs weight gain a concern? N ...History of seizures? N…History of mental illness?

N…Eating disorder? N...Allergic to varenicline? N...Previous non-responder? NWant to quit within 7 days?

N = Varenicline

Has NRT failed? Y/NIs weight gain a concern? Y…History of seizures? N ...History of mental illness? N…Eating disorder? N...Allergic to bupropion? N...Previous non-responder? NWant to quit within 7 days? N = Bupropion SR

Has bupropion/NRT failed? NIs weight gain a concern? NWant to quit within 7 days? Y = NRT (Gum, Patch, Lozenge or Inhaler)

Choose the following combinations:1. Two or more forms of NRT a. patch (15mg) + gum (2mg) b. patch + inhaler c. patch + lozenge2. Bupropion + form of NRTa. Bupropion + patchb. Bupropion + gum

No Varenicline with NRT

Arrange Follow Up

1. Monitor carefully2. Consider contraindications3. Consider comorbidities and specific pharmacotherapy4. Consider dual purpose medications5. If after 4 weeks no response, consider alternative 1st line medications.*

Consider combination pharmacotherapy, based on:1. failed attempt with monotherapy2. breakthrough cravings3. level of dependence4. multiple failed attempts5.experiencing nicotine withdrawal

@ 4 weeksPartial response

High importance or confidence (>5)

NoHave you tried quitting cold turkey?

Yes: Pharmacotherapy options

Cold Turkey

No

*N.B. for 2nd line medications (clonidine and nortriptyline), see guidelines.

No response

YesNo

Yes

Developed by Peter Selby, MBBS, CCFP. This algorithm is based on: Bader, McDonald, Selby, Tobacco Control, 2009: 18: 34-42. Fiore MC et al., Clinical Practice Guideline: Treating Tobacco Use and Dependence, May 2008. Gray, Therapeutic Choices: 5th Ed., 2007, Chapter 10: 147-157.

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Nicotine Patch• 24 hour continuous dose of nicotine

– 21, 14 and 7mg patches (applied every 24h)• 16 hour continuous dose of nicotine

– 15, 10, and 5 mg (applied every 16h) • Off-label use – higher than 21mg dose for highly

dependent smokers • Potential side effects

– May cause sleep disturbance or nightmares→ Remove before bed

– Skin irritation– Clear patch

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How to Use the Patch

• Apply to clean dry area above the waist, rotating site daily

• Remove old patch before applying new one• Do not use lotion, moisturizing soap• Touch only small corner of adhesive• Ensure complete adherence of patch• Wash hands in water after application• Discard old patch out of reach of children,

animals – can be harmful

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Nicotine Gum• Provides body with nicotine for 20-30 minutes• 2 & 4 mg doses• Responds to the immediate urge to smoke• Oral gratification• Must be able to chew gum (i.e. no dentures,

TMJ)• Potential side effects

– Upset stomach, hiccups→Chewing too fast: review

proper use of gum

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How to Use Nicotine Gum

Chew one piece at a time, no more than 1 per hour Use every hour – if not in combination with patch Up to 20 pieces per day as needed

2 mg 4 mg

Use in combination with patch as a breakthrough medication; typically if smoke <pack/day

Use in combination with patch or alone; typically if smoke > pack/day

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How to Use Gum (2)• Chew and park in between teeth and

cheeks • Absorbed via buccal mucosa• Repeat chew every minute or so• Each piece lasts approximately 30 minutes• Do not chew within 30 minutes of

caffeine/acidic products

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“Reduce to Quit” (RTQ) -Approaches

Smokers not ready or unable to quit abruptly

50% reduction in daily cigarette consumption between 6 weeks and 4 months of treatment

Self-titrate to the level of nicotine to reduce withdrawal symptoms. A reduction of cigarette consumption should be continued until complete cessation can be attempted

Craving to smoke in order to prolong smoke-free intervals for as long as possibleWhen?

How?

Goal?

Who?

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RTQ: Using NRT Gum

• If such a reduction has not been achieved by 4 months, the patient should be further counselled and/or re-evaluated.

• A quit attempt should be made as soon as the patient feels ready – but not later than 6 months after the start of treatment.

• Regular use of the gum beyond 12 months in the Quitting Gradually program is generally not recommended.

Shiffman, Ferguson, & Strahs, 2009

Maximum of 20 pieces gum / day

How long?

How much?

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Nicotine Inhaler• Small, cigarette-shaped inhaler• Satisfies sensory and ritualistic

aspect of smoking• One cartridge contains 10mg of

nicotine and 1mg menthol• Absorbed in oral cavity, throat and

upper respiratory tract by “puffing”• Potential side effects

– throat & mouth irritation, headache, nausea, indigestion(<20%)

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How to use the Nicotine Inhaler• Single cartridge equivalent to 4-5 cigarettes

- or 20 minutes of continuous use• Puff like cigar, not deeply into the lungs• May notice a burning, warm or cool sensation

when inhaling – OK unless it becomes bothersome

• Clean inhaler on a regular basis with soap and water

• Can use up to 6 cartridges/day – use as needed

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Nicotine Lozenge• 1 mg and 2 mg dosages• Max of 15 mg / day should be used• Slowly suck until strong taste is noticed• Rest lozenge between cheek and gum• Wait 1 minute or until taste fades• Repeat sucking• Each lozenge takes about 30 minutes to consume• Use only 1 at a time

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Dependence Potential of Nicotine Delivery Devices

• Dependence potential tends to correlate with time to peak concentration

• Because the nicotine is delivered differently, more slowly and at lower doses in NRT, it is significantly less addictive then smoking

Le Houezec, 2003

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Dependence Potential of Nicotine Delivery Devices

Reaches brain within 15-20 secs for non-daily and less dependent and 30 secs for daily, dependent smokers

Gum, lozenge, inhaler peaks in 20 – 30 minutes

1 hr

Patch peaks in 2 – 6 hrs

2 hrs0

Rose et al., 2010

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Effectiveness and Safety of NRT• Recent study of 2767 predominantly middle-aged

smokers not ready to quit: half were given NRT (gum, inhaler or choice of therapy) and half were given placebo for up to 18 months

• Primary Outcome was six months of sustained abstinence from smoking

• Results overwhelmingly positive• NRT was well tolerated• Those using the NRT achieved six months of

sustained abstinence & most lasted beyond 12- 26 months

Moore et al 2009;

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Cardiac Disease and NRT

• NRT is safer than smoking• Cigarette smoke causes

– Increase in heart rate– Blood pressure– Decreased clotting time– Polycythemia

• NRT has not been associated with any increase in cardiac events (heart attack, stroke)

•Hubbard, R, et al. 2005

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Long-Term Use of NRT• Most of the time people who use NRT to stop smoking

gradually reduce or stop NRT medicine without difficulty

• May use NRT long-term if needed– Appropriate way of reducing the harm caused by

smoking– Using NRT is always preferable to using tobacco

products• Long-term use of NRT products can help in reducing

morbidity and mortality• Preliminary evidence suggests that long-term use of

oral NRT may be associated with certain kinds of cancer (Gemenetzidis et al., 2009)

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Assessing Readiness to discontinue NRT

• Have you been in a situation in which you would normally smoke but have been able to refrain from smoking with ease?

• Have you ever forgotten to put on your patch or use your inhaler/gum/lozenge?

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Pregnancy and Youth - NRT

NRT should be considered in pregnancy and for youth if the likelihood of smoking cessation justifies the potential risk of using it by the pregnant patient or youth who might continue to smoke.

Benowitz et al, 2000

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Bupropion• Originally designed to treat depression• Shown to double one’s chances of quitting• Shown to minimize weight gain associated with

quitting smoking• Contraindications

– Seizure history

– Active eating disorder

– MAOI Medications

– Using Bupropion, sensitivity to Bupropion

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How To Use Bupropion

• Prescribed by Physician, Nurse Practitioner or Dentist

• Dose 150mg once daily for 3 days, increase to 150mg twice daily on day 4

• 8 hours between doses• Take as early in evening as possible• Monitor closely for changes in mood, suicidal

ideations• Can be used alone or in combination with NRT

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Varenicline• Oral medication to quit smoking• Reduces withdrawal and craving• Prevents pleasurable effects of smoking• Varenicline is a partial agonist (α42

nicotinic acetylcholine receptor), which partially mimics the effect of nicotine

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Varenicline: Drug Interactions / Precautions

• Concomitant use of nicotine replacement therapy– not expected to increase cessation– will increase adverse drug reactions

• Does not affect and is not affected by CYP450 enzyme system

• Reduce dose in severe renal impairment

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Important Safety Information Regarding Varenicline

Boxed Warning:• Highlights important recommendations for healthcare professionals

regarding information related to neuropsychiatric adverse events.• A warning regarding rare reports of hypersensitivity reactions, such as

angioedema and serious skin reactions, including Stevens-Johnson syndrome and erythema multiforme.

Unintentional Varenicline Exposure:• Recent retroactive study assessed cases where varenicline was

unintentionally ingested, most common side effects were gastrointenstinal and neuropsychiatric

• Vast majority did not require admission to hospital

Varenicline and Psychiatric Side-Effects:• No clear evidence associated with depression or suicidal thoughts,

however twofold increase of self harm cannot be ruled out.• Varenicline may be associated with increased aggression and acts of

violence towards others

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2nd Line Medications

• Use at physicians discretion (first- line medications unsuccessful)

• Not approved as smoking cessation aids• Clonidine

– Anti-hypertensive– Helps to reduce withdrawal

• Nortriptyline– Antidepressant– Two studies demonstrated increased abstinence

rates

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The Future?

• Selegiline – Parkinson treatment• Vaccines – prevent nicotine from

reaching the brain• Transcranial Magnetic Stimulation

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Multiple Quit Attempts May Be Necessary

– >70% of US smokers have attempted to quit1

→Approximately 46% try to quit each year→Only 7% who try to quit are abstinent 1 year later

– Similar percentages in countries with established tobacco control programs (UK, Australia, Canada)2

→>70% want to quit→30%–50% try to quit each year

– Some smokers succeed after making several attempts3

→Past failure does not prevent future success

1. Fiore MC et al. 2008.2. Foulds J et al. 2004;9:39–53. 3. Grandes G et al. 2003;.

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Cessation Objectives

1. Increase the number of quit attempts

2. Increase long-term success of quit attempts

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Sometimes the doorway has to be opened wider and held

open longer…

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Medication Summary

You are now more able to recommend the various pharmacotherapies available for smoking cessation and reduction, and engage your clients in discussion of if and how these medications can play a role in their tobacco interventions.

3

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Workshop Summary

After this training you will find yourself more familiar with the various components that inform tobacco interventions, such as why they are important for clinicians, enhancing client motivation, the physical and behavioural properties of tobacco addiction, and various evidence-based treatments.

2 31

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Learning Assessment 2

• Please complete Learning Assessment 2• This is a self-reflection tool designed to

gauge whether your responses to the earlier assessment have changed, and can be used for you to track these changes

• It is also an opportunity for you to set practice objectives

• This will not be collected

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Course Evaluation

• Please complete the course evaluation which will help us improve future trainings

• We will be collecting this!

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TEACH Community of Practice Listserv

As a participant in this training, you are eligible to join the TEACH Community of Practice Listserv! Our TEACH COP Listserv is configured so that you need to self-register, which is quick and easy to do.

To “subscribe” to the Listserv, please send an email to:

teach-request@info2.camh.net and write…

“subscribe teach” in the subject line of your e-mail.

You will then receive a message confirming your subscription to the List, as well as instructions on how to post or unsubscribe.

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CAN-ADAPTT

CAN-ADAPTT is a practice-based research network designed to facilitate knowledge exchange in the area of smoking cessation between practitioners, healthcare providers and researchers. It includes

Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment

• Access to a dynamic set of Tobacco Control Guidelines

For further information or to register for free, please visit www.can-adaptt.net

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Tobacco Informatics Monitoring System (TIMS)http://tims.otru.org/