Approach to Nicotine Dependent Patient

Assocc Prof Dr Hülya AKANDepartment of Family Medicine

Aims and objectives

At the end of this lesson every student should be able to:

- Explain the effects of nicotine dependence on health

- Explain the importnace of legislative measures- Explain the major steps of nicotine dependence

treatment- Tell the major drugs and their mechanisms used

in nicotine dependence treatment

Cigarette /pipe

Snus

Nargile

Bidi, Gunthar, Kreteks

Facts

• Smoking causes cancer, heart disease, stroke, and lung diseases (including emphysema, bronchitis, and chronic airway obstruction).

• On average, smokers die 13 to 14 years earlier than nonsmokers

• COPD will be third leading cause of death by 2030 • For every person who dies from a smoking-related

disease, 20 more people suffer with at least one serious illness from smoking.

FACTS

• Tobacco use, primarily cigarette smoking, is the leading cause of preventable morbidity and mortality in all over the world.

• Goals of the Healthy People 2013 initiative include increasing to 75 percent the proportion of family physicians who routinely

provide smoking cessation counseling

What is going on Turkey about tobacco use?

Küresel Yetişkin Tütün Araştırması; GATS; Global Adult Tobacco Survey

Küresel Gençlik Tütün Araştırması (GYTS; Global Youth Tobacco Survey)

Before 1983

• Tobacco enters Ottoman about 1600 • Major surgeon of palace İbrahim Efendi tried

to limit– unsuccessful• Sultan IV. Murat- heavy punishment to

smokers• 19. century- import was forbidden • 1872 : industry and sales rights were sold to

Rum bankers

• 1883: consesssion of tobacco industry was sold to Reji managed by English. So an important income of rural people sold to foreign industry.

• 1923: Turkish Republic • 1925: TC get back industry from Reji• Turkish State Liquor and Tobacco Monopoly

• Besim Ömer Paşa (Akalın): 1888 – academic manuscripts about tobacco risks for health

• 1990: first academic manuscripts abouth the health risks of tobacco use

1983 – 1996

• General Directorate of Monopoly• 19.10.1983 : İmport get free (forbidden on

1862)• 1987 : foreign firms allowed to import

• 1983 -1999 :80% increase in tobacco use

• 1995 : “Sigara ve Sağlık Ulusal Komitesi (SSUK)” (National Comittee of Tobacco and Health)

• 1996 : 4207 no. law “Law on Prevention of Hazards of Tobacco Products” accepted

After 1996

• 2003 : WHO general assembly: Framework Convention on Tobacco Control

• Turkey signed the contract in 2004• National Tobacco Control Programm and

2008–2012 National Act Plan• Legislative changes: 3 january 2008 “Law on

Prevention of Hazards of Tobacco Products”

Chronic Diseases and Risk factors survey of Turkey 2013

• 24% regular , 6% irregular smoker, • 9%past smoker• 37% of men regular smoker• 17% of females regular smoker

http://www.thsk.saglik.gov.tr/dosya/kronik_hastaliklar/chronic_english/chronic-diseases-risk-foctors-survey-in-turkey.html

Main approach strategy

Turkish acronymsASK ÖĞREN (SOR) DEĞERLENDİR Her görüşmede

sigara kullanımınısor

ADVICE ÖNER DOĞRU BİLGİ/KESİN TAVSİYE

Sigara kullananlarıntümüne bırakmayıöner

ASSESS ÖLÇ(DEĞERLENDİR)

DERECELENDİR Bırakma girişimikonusunda kiisteğini değerlendir

ASSIST ÖNDERLİK ET(YARDIMCI OL)

DESTEK OL Bırakma konusundayardımcı ol

ARRANGE ÖRGÜTLE(DÜZENLE)

DÜZENLİOLARAK İZLE

Hastanın bırakmaçabalarınıdestekleyecekdüzenli izlemi yap

STEP 1: ASK Screen every patient for tobacco use•Ask your patient if he/she currently or has ever smoked cigarettes or used other tobacco products. Document the response in the patient’s chart.“Do you smoke cigarettes or use other tobacco products?Have you in the past?”•If your patient is a former smoker remind them of the many health benefits of not smoking.“Quitting smoking is the most important thing you can do for your health.”

STEP 2 ADVICE your patient to quit smoking.A clinician’s advice to quit is an important motivator for patients attempting to quit smoking. The advice must be clear, strong, and personalized“As your doctor and someone who cares about you and your health, I’d like to help you quit smoking because it’s the best thing you can do for your health and anyonewho lives with you.”Discuss some of the health problems associated with smoking: Emphysema/COPD High blood pressure Heart disease and heart attack Stroke Cancer Gum disease Bad breath Tooth loss Decreased circulation to the hands and feetRemind patients:“Quitting at anytime is the best thing to do for your health.”

ActionIn a clear, strong, and personalizedmanner, urge every tobacco user to quit.

Strategies for ImplementationAdvice should be:• Clear—"I think it is important for you toquit smoking now and I can help you.""Cutting down while you are ill is notenough."• Strong—"As your clinician, I need you toknow that quitting smoking is the mostimportant thing you can do to protectyour health now and in the future. Theclinic staff and I will help you."• Personalized—Tie tobacco use to current health/ illness, and/or its social and economic costs, motivation level/readiness to quit, and/or the impact of tobacco use on children and others in the household.

STEP 3 ASSESS readiness to quit.•Ask your patient whether she/he would like to quit. Most smokers would like to stop smoking, but fear they will be unable to quit.“Would you like to quit smoking?”•A provider’s advice and support may be a strong motivator.Document the patient’s response in the medical chart.•If a patient is ready to quit, provide counseling•If a patient is not ready to quit, reassess his/her smoking status at the next visit and all subsequent visits. During each visit, the provider should assess for tobaccodependence, advise to quit, and assess readiness to quit.

Assess Readiness of Patient

• I don’t think to quit• It will be good to quit, but I am not sure if I

can• I have decided to quit• I do not smoke• I keep on not smoking• I have started again

Assess Contemplation

• Before contemplation • Contemplation • Aim (prepare): Decision level• Action• Maintanence• Relaps

Assess dependency level

STEP 3 ASSESS nicotine dependence for current smokers using the Heavy Smoking Index (HSI), consisting of 2 simple questions:“To better understand your smoking habits, I’d like to ask you a few questions.”

a. How many cigarettes, on average, do you smoke per day?1-10 (score 0) 11-20 (score 1)21-30 (score 2) 31+ (score 3)

b. How soon after waking do you smoke your first cigarette?Within 5 minutes (score 3) 6-30 minutes (score 2)31-60 minutes (score 1) 61+ minutes (score 0)

Document the HSI score in the patient’s chart. An HSI score ≥4 indicates a high level of nicotine dependence and the need for specific strategies to combat acute nicotine withdrawal symptoms.

Assess dependency level:Fagerstrom Test for Nicotine Dependence

0 1 2 3

How soon after you wake up do you smoke your first cigarette?

After 60Min.

31 – 60Min.

6-30 min.

Within 5 min.

Do you find it difficult to refrain from smoking in places where it is forbidden, e.g., in church, at the library, cinema, etc?

No Yes

Which cigarette would you hate most to give up?

All others First one in themorning

How many cigarettes/day do you smoke? 10 or less 11-20 21-30 31 ormore

Do you smoke more frequently during the first hours of waking than during the rest of the day?

No Yes

Do you smoke if you are so ill that you are in bed most of the day?

No Yes

Scoring the Fagerstrom Test for Nicotine Dependence (FTND)

• In scoring the Fagerstrom Test for Nicotine Dependence, the three yes/no items are scored 0 (no) and 1 (yes). The three multiple-choice items are scored from 0 to 3.

• The items are summed to yield a total score of 0-10.• Classification of dependence:0-2 Very low3-4 Low5 Moderate6-7 High8-10 Very high

Assess: Previous attempts

• How many times?• How long?• The longest quitting time?• Used methods? Porfessional help?• Triggers to relapse?

STEP 4 ASSIST Counsel patients to quit.•Just 3 to 5 minutes of firm, specific counseling by a clinician can double quit rates.Clinician counseling should include: Practical suggestions for quitting. Managing withdrawal symptoms. Getting support.During counseling, use motivational interviewing techniques, including:* Open-ended questions: “What are some of the reasons you would like to quit smoking?”* Affirming statements: “It’s great that you are motivated to quit smoking.”* Reflective listening: “It sounds like trying to quit smoking has been frustrating for you.”

Strategies for patient ready to quitActionHelp the patient with a quit plan.

Strategies for ImplementationA patient's preparations for quitting:• Set a quit date—ideally, the quit date should be within 2 weeks.• Tell family, friends, and coworkers about quitting and requestunderstanding and support.• Anticipate challenges to planned quit attempt, particularlyduring the critical first few weeks. These include nicotinewithdrawal symptoms.• Remove tobacco products from your environment. Prior toquitting, avoid smoking in places where you spend a lot of time(e.g., work, home, car).

Strategies for patient ready to quitProvide practicalcounseling(problemsolving/training).

• Abstinence—Total abstinence is essential. "Not even a single puff after the quit date."• Past quit experience—Review past quit attempts includingidentification of what helped during the quit attempt and whatfactors contributed to relapse.• Anticipate triggers or challenges in upcoming attempt—Discuss challenges/triggers and how patient will successfully overcome them.• Alcohol—Because alcohol can cause relapse, the patient should consider limiting/abstaining from alcohol while quitting.• Other smokers in the household—Quitting is more difficult when there is another smoker in the household. Patients should encourage housemates to quit with them or not smoke in their presence.

Strategies for patient ready to quitProvide intratreatmentsocialsupport.

Provide a supportive clinical environment while encouraging the patient in his or her quit attempt. "My office staff and I are available to assist you."

Help patient obtainextra-treatmentsocial support.

Help patient develop social support for his or her quit attempt in his or her environments outside of treatment. "Ask your spouse/partner, friends, and coworkers to support you in your quit attempt."

Recommend the use of approved pharmacotherapy,except in special circumstances.

Recommend the use of pharmacotherapies found to be effective.Explain how these medications increase smoking cessation success and reduce withdrawal symptoms. The first-line pharmacotherapy medications include: bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and nicotine patch.

Provide supplementarymaterials.

Sources—Federal agencies, nonprofit agencies, or local/state health departments.Type—Culturally/racially/educationally/age appropriate for the patient. Location—Readily available at every clinician's workstation.

Common elements of practical counselling

Recognize danger situations—Identify events, internal states,or activities that increase therisk of smoking or relapse.

• Negative affect.• Being around other smokers.• Drinking alcohol.• Experiencing urges.• Being under time pressure.

Develop coping skills—Identify and practice coping orproblem solving skills.Typically, these skills areintended to cope with dangersituations.

Learning to anticipate and avoid temptation.• Learning cognitive strategies that will reducenegative moods.• Accomplishing lifestyle changes that reduce stress,improve quality of life, or produce pleasure.• Learning cognitive and behavioral activities to copewith smoking urges (e.g., distracting attention).

Provide basic information—Provide basic informationabout smoking and successfulquitting.

• Any smoking (even a single puff) increases thelikelihood of full relapse.• Withdrawal typically peaks within 1-3 weeks afterquitting• Withdrawal symptoms include negative mood,urges to smoke, and difficulty concentrating.• The addictive nature of smoking.

Nicotine withdrawal symptoms

• Anxiety: 87%• Irritability: 87%• Decreased heart rate: 80%• Difficulty in concentration: 73%• Increased apetite and weight gain: 73%• Urges to smoking: 62%

STEP 5 ARRANGE Follow up with patients who are trying to quit.If possible, follow up with your patient either in person or by telephone within a week of her quit date. A second follow-up is recommended within the first month.“How is it going?”“How are you feeling?”If the patient has not smoked, offer congratulations and encouragement.“You’re doing a great job. This is such an important step to take.”If the patient has smoked, consider revisiting previous steps above.“Quitting can be very difficult. It can often take someone several tries to successfully quit. Would you like to try again?”

Assess for relapse with patients who have quit

The first weeks after the quit attempt are most important because relapse rates are high. The patient’s visits 3 months to a year after the quit attempt are ideal times to screen for relapse.“The first few weeks after quitting can be very stressful, and many former smokers are tempted to smoke again during this time. Have you felt the urge to smoke?”If your patient has felt the urge to smoke, but resisted, congratulate her/him. Reiterate the benefits of remaining abstinent for their health.“You’re doing a great job. This is such an important step to take for your health.”If your patient has smoked, encourage him/her to make another quit attempt.“Quitting can be very difficult. It can often take someone several tries to successfully quit. Would you like to try again?”You can also emphasize the harmful effects of secondhand smoke on infants, children, household members, and pets. This message can motivate patients who have remained abstinent, as well as those who may have begun to smoke again.“It’s important that no one smokes in your home. Babies who breathe secondhand smoke are more likely to have asthma, ear infections, or upper respiratory infections.They are also more likely to die from SIDS—Sudden Infant Death Syndrome. To protect your baby’s health, keep him/her away from smoke.”

Nicotine replacement therapy

• Nicotine patch :30 cm2’/21 mg, 20 cm2/14 mg, 10 cm2/ 7 mg nicotine

• Nicotine gum: It's available in a 2-milligram (mg) dose for regular smokers and a 4-mg dose for heavy smokers. It can be used up to 20 pieces a day as needed.

• Nicotine lozenge :This is a tablet that dissolves in mouth and, like nicotine gum, delivers nicotine through the lining of mouth. The lozenges are available in 2- and 4-mg doses, for regular or heavier smokers.

Nicotine replacement therapy

• Nicotine nasal spray (Nicotrol NS). The nicotine in this product, sprayed directly into each nostril, is absorbed through nasal membranes. The nasal spray delivers nicotine a bit quicker than gum, lozenges or the patch, but not as rapidly as smoking a cigarette. Side effects may include nasal irritation.

• Nicotine inhaler (Nicotrol). This device is shaped something like a cigarette holder. Common side effects are mouth or throat irritation and occasional coughing.

Bupropion

• Antidepressant that inhibits neuronal reuptake of dopamine and noradrenaline, and is a noncompetitive nicotine antagonist at nicotinic cholinergic receptors

• The drug is commenced while the person is still smoking, and a quitting date should be set in the second week of therapy (eg day 8)

• 300 mg /day- 12 wks• Side effects: nausea, rashes, facial swelling, insomnia and dry mouth.

Serum sickness–like reactions can occur, and bupropion can precipitate mania in patients with bipolar disorder

• Seizure: The risk of seizure is increased in patients with known risk factors for seizures (such as head injury) and in patients taking other drugs known to reduce the seizure threshold (eg other antidepressants, including the selective serotonin reuptake inhibitors, and antipsychotics).

Varenicline

• Nicotinic acetylcholine–receptor partial agonist/ In the absence of nicotine it has agonist activity (activates nicotinic acetylcholine receptors), whereas in the presence of nicotine it has antagonist activity (blocks nicotine's ability to bind with these receptors)

• A quit date should be set, and varenicline started one to two weeks before the quit date

• Dose: day 1 to 3: 0.5 mg daily day 4 to 7: 0.5 mg twice daily day 8 and ongoing: 1 mg twice daily until the end of the 12 week courseSide effects: nausea, drawsiness, dizziness, exacerbations of underlying psychiatric illness (eg schizophrenia, bipolar disorder)Don’t use with nicotine replacement therapyDon’t use with bupropion