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JENNIFER PERCIVAL NURSE, MIDWIFE, HEALTH VISITOR HELPING PEOPLE TO STOP SMOKING
JENNIFER PERCIVALNURSE, MIDWIFE, HEALTH VISITOR
HELPING PEOPLE TO
STOP SMOKING
TOBACCO IS A SERIOUS PROBLEM
In the year 20001 in every 6 deaths worldwidewas caused by smoking
By the year 20301 in every 3 deaths worldwidewill be due to smoking
70% of these deaths will be indeveloping countries.
Source: WHO
WHO Global statisticsFive countries China, India, Indonesia, Russia and Bangladesh account for half of all the world’s smokers
Smoking is a risk factor for six of the eight leading causes of deaths in the world.
Smoking will kill at least a third of all current smokers many more develop serious illness because of tobacco.
People killed by tobacco lose on average 10 - 15 years of life.
Almost half of the world's children breathe air polluted by tobacco smoke.
WHY IS TOBACCO
USEINCREASINGGLOBALLY?
Tobacco Industry constantly works to make cigarettes
socially acceptable
“You’re clearly someone who considers others. That’s why Superslim Capri is the choice for you…great tobacco flavor, but less smoke for those around you.”
Tobacco advertisers have no boundaries
China has been a success story for the tobacco industry
Adverts have long been targeting women
The truth aboutWomen and Tobacco
• Lung cancer surpassed breast cancer as leading cause of cancer death in 1987
• More women die from lung cancer than breast, ovarian, cervical & endometrial cancers combined
The WHO Framework Conventionon Tobacco Control
Main Measures
• Ban on tobacco advertising• Increase Taxation• Take effective measures on passive smoking• Put Labelling and warnings on tobacco• Provide Education campaigns• Cessation guidelines and services• Take Action on illicit trade• Control sales to minors
Sir Richard PetoWHO Epidemologist
“Most of those who will be killed by totobacco in the first half of this century have
already begun to smoke.
These tobacco deaths can be substantially reduced only by current smokers giving up the habit.”
• A chronic relapsing dependence syndrome
• Use of the addictive drug nicotine delivered rapidly to the brain via the lungs and blood
• A strong habit reinforced by sensory, behavioural and social conditioning
• Entrenched by powerful withdrawal syndrome • Great harm is caused by toxins in the smoke
What is smoking?
What’s in a cigarette?
4,000 chemicals
Tar
Carbon monoxide
• Light-headedness• Sleep disturbance• Poor concentration• Craving • Irritability/aggression• Depression• Restlessness• Increased appetite
<48 hrs 10%< 1 wk 25%<2 wks 60%> 2 wks 70%< 4 wks 50%< 4 wks 60%< 4 wks 60%> 10 wks 70%
What happens when you try to stop? Withdrawal effects: duration and frequency
NZ Best Practice
•Ask about smoking
• Give Brief advice to quit
• Offer Cessation support
Miller WR et al. J Consult Clin Psychol 1993;61:455–61;Miller and Rollnick, 1991
You may have already noticed that
‘professional persuasion’ does not always
make people decideto stop smoking
GOOD ADVICE
• It’s tempting to be ‘helpful’ by informing clients of the urgency of their medical problems and the advantages of stopping smoking
• But these tactics can often increase client resistance and may even lessen the probability of change
Miller WR et al. J Consult Clin Psychol 1993;61:455–61;Miller and Rollnick, 1991
CREATING RESISTANCE TO CHANGE?
ADVICE
Reasons for Current
Behaviour
ADVICE
Reasons for Current
Behaviour
FEAR
CONCERN FOR BABY
PEOPLE “NAGGING”
GUILT NICOTINE ADDICTION
STRESS RELIEF
HABIT
PARTNER SMOKES
NORMAL
PREGNANCY CAN BE A DIFFICULT TIME
Current Behaviour
ROBERT said “I knew you could get cancer from smoking.My Dad got lung cancer in his 60’s and I’d planned to give up long before that could happen to me. My last cigarette was to have been on my 40th birthday”
Robert was diagnosed with cancer of the tonsils at age 36
THE CHANGE PROCESS
• No-one changes their behaviour without first changing their attitudes and beliefs.
• When a client argues with you it means you have made a wrong assumption.
• It takes a long time to make a behaviour change.
Making Changes
A change I’d like to make:
The Advantages of
The Disadvantages of
Current behaviour
Making
the Change
Take into consideration: Consequences to self Consequences to others
How I feel about myself How others feel about me
My Conclusion / Decision / Goal:
STEPS TO CHANGE
1. Deciding
2. Preparing
3. Taking action
4. KEEPING UP THE CHANGE
5. Coping with setbacks
PEOPLE CHANGE WHEN THEY:
• Want to change • Invest time and thought in the issue• Know what to expect• Have enough information and/or developed new
coping strategies to manage the change• Have plans for difficult or unexpected situations• Have encouragement • Believe in the benefits of the change• Can see themselves acting/ behaving differently
HOW TO HELP - WHAT WORKS?• First elicit what the client already knows and
their interest in receiving information about stopping smoking.
• Provide information on their personal health status and the benefits of stopping in a neutral manner
• Elicit the client’s interpretation of the discussionAsk: Do you think there would be any benefit
in your stopping smoking?
MOTIVATIONAL INTERVIEWING (1)
• Ambivalence is a normal state of mind
• Express empathy and understanding of people’s past choices
• Be realistic, rather than judgmental as demonstrating acceptance helps facilitate change
• Reflective listening is essential to helping facilitate change
MOTIVATIONAL INTERVIEWING (2)
• Resistance is a signal to do something different
• Emphasize the client’s choice and dilemma about making a change
• Summarize the pros and cons of their decision to change
• Help client to reflect on the whole situation by providing a summary
CLIENT - NOT READY!
Respect this decisionIf they show resistance: do not argue, instead,
respectfully clarify their expressed views
Ask: What would need to be different for you to consider changing?
• Explain your own concerns about their smoking
• Leave the door open for future discussions
CLIENT - UNSURE ABOUT CHANGE?
• Discuss their ambivalence. • Ask them about the pros and cons
of them being a smoker• Explore any concerns now and for
the future• Ask “What do you think could
happen to you if you don’t stop smoking?
Client making plans to change?• Congratulate them and recommend they use
a treatment product • Help them to set a quit date• Find out their expectations of stopping
smoking and if they have tried beforeAsk “What could get in your way?” “What could you do to avoid this?”
“Who could help/ support you?” “When would you like to see me again?”
RELAPSEWhy do smokers return to tobacco?
• Stopping under pressure from someone else• Lack of personal motivation• Attaching insufficient importance to stopping• Withdrawal symptoms• Poor timing• A question of self-image• “I thought `just one’ wouldn’t hurt”
Empowering people to changeSupport the persons decision and self-
confidence to quit by asking:
• “What are you actually planning to do next”?• “Who are you going to ask to support you?”• “What quit date have you set? • “Will you commit to not having a single puff
of a cigarette from then onwards?” • “What medication are you going to use?”• “When would you like to see me again”?
INTERACTIVE WORKSHOP
IN PAIRS
ONE TO ONE COMMUNICATION
SKILLS
• Work out helpful responses to the following statements.• • Statement 1• “I was really upset when the specialist told me I had to stop smoking”• • Statement 2• “I’ve cut down on how much I smoke - isn’t that enough?”• • Statement 3• “I don’t want to get addicted to the NRT”• • Statement 4• “I know I should stop smoking now I’m pregnant - but its not easy”• • Statement 5• “I’m so afraid I will put on weight if I stop smoking”• • Statement 6• I want to give up -but it’s hard as my partner smokes at home
Nicotine Replacement Therapy, Zyban &
Champix
NRT• Reduces severity of withdrawal symptoms• Reduces urges to smoke• Delays weight gain• Reduces relapse• Doubles success rates of long-term
abstinence (regardless of type of support used)
Stead, L. F., Perera, R., Bullen, C., Mant, D. & Lancaster, T. (2008) Nicotine replacement therapy for smoking cessation, Cochrane Database Syst Rev, CD000146.
Royal College of Physicians, Nicotine Addiction in Britain, 2000
Nicotine delivery
Nicotine chewing gum• 2mg and 4mg
• Recommend 10-15 pieces a day, hourly
• Recommend use for up to 3 months
• Start chewing slowly (chew-park-chew technique), takes a few days to get used to
• Each piece lasts 30 minutes (can be chewed longer)
• Acid drinks slow down absorption
Gum– things to tell your patients
• Chew it in the right way (its not like regular chewing gum)
o Chew until you get a hot peppery taste, then park it in the side of your mouth. After a few minutes chew it some more and repeat chew-park-chew
• It tastes disgusting to start with, but people do become tolerant of the taste and even grow to like it
• Use enough of it – once an hour
Lozenge
• Come in low and high strength• 1mg vs. 2mg (Novartis)• Higher dose for more
dependent smokers• Recommend 10-15 lozenges a
day, hourly
• Recommend use for up to 3 months
• Roll around in the mouth until dissolved, takes a few days to get used to
Lozenge– things to tell your patients
•It tastes disgusting to start with, but people do become tolerant of the taste and even grow to like it
•Use enough of it – once an hour•If it is taking a long time to dissolve – it
can be discarded after 30-40 minutes as most of the nicotine will have been absorbed
Transdermal patch• 24hr patch currently subsidised• Smaller patches for weaning-off
period (these are not essential)• Recommend use for some 3
months• 24 hr patches can cause
nightmares (remove over night if problematic)
• In case of allergic skin reaction change product
Patches – things to tell your patients
•New patch each morning•On upper arm, side of torso, hairless
part of body•Do not put on the same place,
especially if still redoSome redness of skin normal
How do you decide on the dose?
•Cigarette consumption is not always a good guide•Most people can start on full strength patches•Dose of oral product can be determined by time to first cigarette
• Smokes within 30 minutes of waking use 4 mg gum or 2 mg lozenge
• Smokers after 30 minutes of waking use 2 mg gum or 1 mg lozenge
Simple guide
• Smokes 10 or more cigs per dayo Full strength patch ANDo oral product (dose based on time to first cigarette)
• Smokers less than 10 cigs per dayo Oral product (dose based on time to first cigarette) ORo Medium strength patch if cannot tolerate oral products
• Assess level of withdrawal discomfort and adjust dose
Contraindications
• None genuine, users take more nicotine from their cigarettes in addition to other dangerous chemicals
• Can be used in all smokers over the age of 12
Can you give too much NRT?
Smokers know their own nicotine limits You can trust them to work out the right amount for themselvesConcerns about ‘over substitution’ are not borne out by data that suggests NRT users typically under-replace their nicotine1
Significant over-replacement of nicotine is rare2
• Dose-related adverse events are mild, predictable and self-limiting2,3
1. Kornitzer M, et al. Prev Med 1995; 24:41-47.2. Kruse E, et al. 4th SRNT 2002.3. Zevin S, et al. Clin Pharmacol Ther 1998; 64:87-95.
Reasons for NRT failure
• Unrealistic expectations• Incorrect use• Not used for long enough• Nicotine is often seen as the dangerous
element in cigarette smoke• Safety concerns can be a barrier to use
Bupropion (Zyban)
Clinical Efficacy
Hughes JR et al. Cochrane Database Syst Rev. 2007;Jan 24(1):CD000031.
0
5
10
15
20
Quit Rates
placebobupropion
Aver
age
perc
enta
ge(a
ctua
l ran
ge)
10%(0-22%)
19%(4-43%)
Zyban doubles chance of successful quitting
1. Coe JW. J Med Chem 2005; 48:3474-3477. 2. Dani JA, Harris RA. Nature Neuroscience 2005; 8:1465-1470.
• CHAMPIX (varenicline) is the first drug specifically developed for smoking cessation1
• Launched December 2006
• Oral prescription-only medicine
• Unique dual mode of action - targets the nicotine receptors which is key in the addiction pathway1,2
CHAMPIX: a new class of therapy in smoking cessation
1. CHAMPIX Summary of Product Characteristics.
• Varenicline is indicated for:– Smoking cessation in adults1 (18 years and over)
• Varenicline is contraindicated in:– Patients known to be already hypersensitive to the active substance or any of the excipients1
• Varenicline is not recommended for:– Children or adolescents (<18 years)– Pregnant women– Patients with end-stage renal disease1
• Normal caution is advised for patients with epilepsy and psychiatric illness
– prescriber’s should always advise their patients with a history of psychiatric illness that stopping smoking may exacerbate their condition
• No known drug-drug interactions1*
*Stopping smoking can result in physiological changes that may affect some medications (e.g. warfarin) for which dosage adjustment may be necessary
Who can use CHAMPIX?
‘The Binder’ (partial agonist) What it does:• Champix binds with nicotine receptor,
stimulating a small amount of dopamine release1
• Mimics effect of nicotine on brain1
Effect on the smoker:• Provides relief from craving and
withdrawal symptoms1-3
1. Coe JW. J Med Chem 2005; 48:3474-3477. 2. Gonzales D et al. JAMA 2006; 296:47-55. 3. Jorenby DE et al. JAMA 2006; 296:56-63. 4. Foulds J. Int J Clin Pract 2006; 60:571-576.
‘The Blocker’ (antagonist)
What it does: • Champix blocks stimulation of nicotine
receptor
Effect on the smoker:• Reduces pleasurable effects of smoking
- smoker gets no satisfaction from inhaling nicotine
• Also potentially reduces the risk of full relapse after a temporary lapse1-4
Unique dual mode of action
Recommended dose of varenicline is 1 mg twice daily following 1 week titration1
• Patients who cannot tolerate adverse effects (e.g. mild / transient nausea) may have the dose lowered to 0.5mg twice daily1
• The patient should stop smoking in their second week of treatment with varenicline1
1. CHAMPIX Summary of Product Characteristics.
Dosing of CHAMPIX
1. CHAMPIX Summary of Product Characteristics.
•Smoking cessation, with or without treatment, is associated with nicotine withdrawal symptoms e.g. depression and the exacerbation of underlying psychiatric illness
Care should be taken with patients with a history of psychiatric illness and patients should be advised accordingly
Nicotine withdrawal symptoms and smoking cessation
- What to look out for and patients to treat with caution
Take home messages
You have an important influence in prompting people to quit
You can help people stop smoking
Medicines work but are not magic cures
Medicines work even better with ‘wrap around’ behavioural support
Don’t give up helping your patients to give up
Cessation Treatment
1.Can be provided by nurses2.If too busy then nurses should refer for smoking cessation treatment
• Easy referral pathways• Know what options are
Smoking is too big to ignore
Smoking is a serious addiction, over half of all people who smoke cannot quit without help
Even if we could prevent people from starting, the death toll will continue well beyond our lifetime if existing smokers don’t quit
Behavioural Treatment Goals
MotivateCreate accurate and positive expectationsPrepare for Quit DateOrient on withdrawal Encourage compliance with medicationAdvise on coping and relapse
Affirm decision to quit
You’ll be helping them through
This is the BEST thing that they can do to for their health
You have some ways that will increase their chances of quitting for good
You can make quitting easier
BUT you have no magic cures
Decide on a date
Get rid of remaining cigarettes
Tell friends and family
Explain the rationale for not a single puff.
Withdrawal symptoms are typically worst in the first few weeks
They will disappear over time
Smoking cessation medicines will help
Use enough for long enough
Explain side effects and what to do about these
Nicotine replacement therapy does not cause cancer or heart disease!
Withdrawal symptoms don’t last long
Beware of tempting situations
D.E.A.D.
If you slip its not the end of the world!
