JENNIFER PERCIVALNURSE, MIDWIFE, HEALTH VISITORHELPING 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 statistics

Five countries China, India, Indonesia, Russia and Bangladesh account for half of all the worlds 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 acceptableYoure clearly someone who considers others. Thats why Superslim Capri is the choice for yougreat 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 TobaccoLung 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 MeasuresBan on tobacco advertisingIncrease TaxationTake effective measures on passive smokingPut Labelling and warnings on tobaccoProvide Education campaignsCessation guidelines and servicesTake Action on illicit tradeControl 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?

Whats in a cigarette?

4,000 chemicals

Tar

Carbon monoxide

Light-headednessSleep disturbancePoor concentrationCraving Irritability/aggressionDepressionRestlessnessIncreased appetite 10 wks 70%What happens when you try to stop? Withdrawal effects: duration and frequency

NZ Best PracticeAsk about smokingGive Brief advice to quitOffer Cessation support

Miller WR et al. J Consult Clin Psychol 1993;61:45561; Miller and Rollnick, 1991You may have already noticed that professional persuasion does not always make people decideto stop smoking

Charlotte Lewis - Jennifer - do you have the full citation for Miller and Rollnick, 1991?

GOOD ADVICE

Charlotte Lewis - Jennifer - you mentioned that you might be able to provide some alternative cartoons which are more relevant to the renal setting? I wondered whether you are still planning to do this?

Charlotte Lewis - Jennifer - you mentioned that you might be able to provide some alternative cartoons which are more relevant to the renal setting? I wondered if you were still planning to do this?

Its 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 changeMiller WR et al. J Consult Clin Psychol 1993;61:45561; Miller and Rollnick, 1991CREATING RESISTANCE TO CHANGE?

ADVICEReasons for Current Behaviour

ADVICEReasons for Current Behaviour

PREGNANCY CAN BE A DIFFICULT TIME

FEAR

CONCERN FOR BABY

PEOPLE NAGGING

GUILT

NICOTINE ADDICTION

STRESS RELIEF

HABIT

PARTNER SMOKES

NORMAL

Current Behaviour

ROBERT said I knew you could get cancer from smoking.My Dad got lung cancer in his 60s and Id planned to give up long before that could happen to me. My last cigarette was to have been on my 40th birthdayRobert was diagnosed with cancer of the tonsils at age 36

THE CHANGE PROCESSNo-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 Id 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 CHANGEDeciding

Preparing

Taking action

KEEPING UP THE CHANGE

Coping with setbacks

PEOPLE CHANGE WHEN THEY:Want to change Invest time and thought in the issueKnow what to expectHave enough information and/or developed new coping strategies to manage the changeHave plans for difficult or unexpected situationsHave encouragement Believe in the benefits of the changeCan see themselves acting/ behaving differently

HOW TO HELP - WHAT WORKS?First elicit what the client already knows and theirinterest in receiving information about stopping smoking.

Provide information on their personal health status and the benefits of stopping in a neutral manner

Elicit the clients 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 peoples past choices

Be realistic, rather than judgmental as demonstrating acceptance helps facilitate change

Reflective listening is essential to helping facilitatechange

MOTIVATIONAL INTERVIEWING (2)Resistance is a signal to do something different

Emphasize the clients 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 smokerExplore any concerns now and for the futureAsk What do you think could happen to you if you dont stop smoking?

Client making plans to change?Congratulate them and recommend they use a treatment product Help them to set a quit dateFind 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 elseLack of personal motivationAttaching insufficient importance to stoppingWithdrawal symptomsPoor timingA question of self-imageI thought `just one wouldnt 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 COMMUNICATIONSKILLS

Work out helpful responses to the following statements.Statement 1I was really upset when the specialist told me I had to stop smokingStatement 2Ive cut down on how much I smoke - isnt that enough?Statement 3I dont want to get addicted to the NRTStatement 4I know I should stop smoking now Im pregnant - but its not easyStatement 5Im so afraid I will put on weight if I stop smokingStatement 6I want to give up -but its hard as my partner smokes at home

Nicotine Replacement Therapy, Zyban & Champix

NRTReduces severity of withdrawal symptomsReduces urges to smokeDelays weight gainReduces relapseDoubles 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, 2000Nicotine delivery

Nicotine chewing gum2mg and 4mgRecommend 10-15 pieces a day, hourlyRecommend use for up to 3 monthsStart chewing slowly (chew-park-chew technique), takes a few days to get used toEach piece lasts 30 minutes (can be chewed longer)Acid drinks slow down absorption

Gum things to tell your patientsChew it in the right way (its not like regular chewing gum)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-chewIt tastes disgusting to start with, but people do become tolerant of the taste and even grow to like itUse enough of it once an hour

LozengeCome in low and high strength1mg vs. 2mg (Novartis)Higher dose for more dependent smokers Recommend 10-15 lozenges a day, hourlyRecommend use for up to 3 monthsRoll around in the mouth until dissolved, takes a few days to get used to

Lozenge things to tell your patientsIt tastes disgusting to start with, but people do become tolerant of the taste and even grow to like itUse enough of it once an hourIf 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 patch24hr patch currently subsidisedSmaller patches for weaning-off period (these are not essential)Recommend use for some 3 months24 hr patches can cause nightmares (remove over night if problematic)In case of allergic skin reaction change product

Patches things to tell your patientsNew patch each morningOn upper arm, side of torso, hairless part of bodyDo not put on the same place, especially if still redSome redness of skin normal

How do you decide on the dose?Cigarette consumption is not always a good guideMost people can start on full strength patchesDose of oral product can be determined by time to first cigaretteSmokes within 30 minutes of waking use 4 mg gum or 2 mg lozengeSmokers after 30 minutes of waking use 2 mg gum or 1 mg lozenge

Simple guideSmokes 10 or more cigs per dayFull strength patch ANDoral product (dose based on time to first cigarette)

Smokers less than 10 cigs per dayOral product (dose based on time to first cigarette) ORMedium strength patch if cannot tolerate oral products

Assess level of withdrawal discomfort and adjust dose

ContraindicationsNone 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 nicotine1Significant over-replacement of nicotine is rare2Dose-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 failureUnrealistic expectationsIncorrect useNot used for long enoughNicotine is often seen as the dangerous element in cigarette smokeSafety concerns can be a barrier to use

Bupropion (Zyban)

Clinical EfficacyHughes JR et al. Cochrane Database Syst Rev. 2007;Jan 24(1):CD000031.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 pathway1,2CHAMPIX: 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 (

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 messagesYou have an important influence in prompting people to quitYou can help people stop smokingMedicines work but are not magic curesMedicines work even better with wrap around behavioural supportDont give up helping your patients to give up

Cessation Treatment

Can be provided by nursesIf too busy then nurses should refer for smoking cessation treatmentEasy referral pathwaysKnow 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 dont quit

Behavioural Treatment GoalsMotivateCreate accurate and positive expectationsPrepare for Quit DateOrient on withdrawal Encourage compliance with medicationAdvise on coping and relapseAffirm decision to quit

Youll 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 dont last long

Beware of tempting situations

D.E.A.D.

If you slip its not the end of the world!

The end

jennifer.percival@usa.net

Email address

**The tobacco industry has been trying to develop more socially acceptable cigarettes for years. For example, this is a Capri direct mail promotion from 2001 for a cigarette claiming less secondhand smoke, aimed at smokers concerned about secondhand smoke.

Source: http://www.trinketsandtrash.org/trendytrash/otcapricoup1a.htm

*Be your own woman (2)

Find your voice from your own cultural tradition/ethnic group (US ads 2000/2001)*First and foremost, smoking is about the administration of the addictive drug, nicotine. Cigarettes without nicotine have been produced and failed commercially. Smokers rapidly form dependence on nicotine, and find it hard to quit.Nicotine vaporises from smoke particles in the lungs and is rapidly absorbed into the blood and carried to the brain. The nicotine reaches the brain in a bolus with great speed creating a hit which underpins the addictiveness. The time from inhaling to a rush in the brain is a few seconds. As well as physiological dependence, smoking is sustained by behavioural factors, such as movements of the hands and social pressures. The withdrawal syndrome is unpleasant and may start to affect the user within less than one hour of the last cigarette. The harm caused is immense 50 different diseases causing 1 in 5 deaths in the UK, around 120,000 deaths per year (RCP 2000). The vast majority of the harm associated with smoking is NOT caused by the drug nicotine itself, but by its delivery system; the smoke of burning tobacco. This contains many toxic products of combustion and most of these would arise whatever organic material is burned (as for example, cannabis or herb cigarettes). Where nicotine is taken without combustion (chewing or oral tobacco, pharmaceutical products) far less harm is caused.Tobacco is the only consumer product that kills when used as intended by the manufacturer, causing addiction and harm on a scale without equal. However, some of the worlds strongest brands like Marlboro are tobacco brands, and advertising and promotion of these products run to billions of dollars world-wide (ASH 2002). Tobacco is widely sold and readily available. Tobacco remains subject to limited regulation - for example on warning labels, and maximum tar yields, which scientists now regard as highly misleading to consumers.

_____________________________Royal College of Physicians. Nicotine Addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians. London: Royal College of Physicians of London, 2000.

ASH Factsheet Tobacco advertising & promotion. ASH 2002Explain the action of carbon monoxide reducing the oxygen in circulation**Withdrawal is an important factor in sustaining addiction and maintaining smoking.This table shows the key symptoms, how long they are likely to last, and what proportion of quitters are affected by them (RCP 2000).

The short term withdrawal symptoms irritability, edginess, frustration, distraction, craving can begin to develop within one hour of the last cigarette, and become more distracting until relieved by smoking again. This process of relieving withdrawal symptoms accounts for why smokers say that smoking helps them to relax and concentrate. Studies comparing smokers and non-smokers do not show that smoking aids relaxation or concentration.

_____________________________

Royal College of Physicians, Nicotine Addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians. London, RCP, 2000

***********************Should have samples to hand round during this session.NRT is a way of delivering a reduced amount of clean nicotine into a smokers body to help take the edge off withdrawal symptoms. NRT does not contain any of the 4000 chemicals which do the damage to the body when smoking tobaccoNRT delivers nicotine in a slow & controlled fashion, unlike smoking which gives a hit within 7 seconds. NRT enters the system slowly & so there is a low risk of people becoming dependent on these products. Even if someone was to use NRT for a long period of time, it will not be detrimental to their health. Longer term use tends to be a confidence issue as opposed to an issue of addiction.NRT will deliver about half the amount of nicotine of cigarettes. It is not a complete replacement so people must be motivated in order for NRT to be helpful.NRT is designed in a step down programme usually full dose for 8 weeks, middle level for 2 weeks & lowest dose for 2 weeks.All are available for a prescription cost (if pay for prescriptions) paid for 4 weeks supply or no charge (if dont pay for prescriptions) through the services in Glasgow. All the NRT should be treated like a medicine, should use at least the minimum daily recommeded amount for the best chance of succeedingMore than one product can be used at the same time but mainly in a top up fashion, not both at the full dose. E.g. someone on a patch may find having some gum at danger times can help. Patches:A transdermal delivery system which releases nicotine slowly and steadily. Available in 16 hour or 24 hour strengths (24 hour patch may cause sleep disturbance). A new patch is applied each day on a hairless part of the body usually upper arm or thigh. Used for 8-12 weeks depending on the make.Why might patches suit?Work for up to 24 hours a day, Simple to use, Convenient, DiscreetGum:Not used like normal chewing gum, nicotine gum is chewed until the taste becomes strong & then 'parked' between the cheek & gum to allow the nicotine to be absorbed through the lining of the mouth.Available in different strengths, so suitable for a range of smokers. It is used for 12 weeks & the number of pieces chewed per day is gradually reduced. Why might gum suit?Puts patient in control, Chewed as required, Provides a small level of behavioural substitution for smoking, Chewing may take the mind of smoking.Lozenges:Nicotine is absorbed when the lozenge is restedbetween the cheek & gum. Available in different strengths so suitable for a range of smokers. It is used for 12 weeks & the number of Lozenges taken per day is gradually reducedWhy might lozenges suit?Puts patient in control, Taken as required, Discreet, If patient doesnt like chewing gum, Provides a small level of behavioural substitution for smokingInhalator:A cigarette shaped plastic tube which holds a replaceable nicotineimpregnated cartridge. Nicotine is absorbed through the lining of the mouth and throat (n.b. not the lungs). Each cartridge contains 20 minutes puffing time. Used for 12 weeks, the number of cartridges used is gradually reduced. Suitable for those who smoke less than 20 cigarettes each day.Why might Inhalator suit?Puts patient in control, Taken as required, Provides a behavioural substitute for smokingSublingual Tablets:Small tablet placed under tongue where it dissolves and slowly releases nicotine. It is used for 12 weeks & the number of tablets taken per day is gradually reduced.Why might sublingual tablets suit?Puts patient in control, Taken as required, Flexible, Discreet Provides a small level of behavioural substitution for smokingNasal Spray:Suitable mainly for heavy smokers (30-40 per day) Nicotine absorbed through lining of the nose. Very rapid absorption rate. Used for 12 weeks & the number of sprays used per day is gradually reduced. There are localised side effects (e.g. running nose, coughing, sneezing etc) but these should pass within 48 hours. Why might the Nasal Spray suit?Rapid absorption good for heavy smokers, Puts patient in control, Taken as required

Zyban:Zyban is different from Nicotine Replacement Therapy, the patient starts using it when they are still smoking in order to build up the levels of the drug within the body. The drug is taken for 8 weeks in total.Zyban is available to patients by prescription only. Zyban is a non-nicotine based drug which is licensed for use with smokers. It is a low dose anti-depressant which treats the neuro-chemical changes in the brain associated with nicotine addiction. Thus the feelings of pleasure and reward usually associated with smoking a cigarette are reduced.Zyban has a good safety profile but, as with all anti-depressants, has a list of contraindications. E.g. should not be used with people who have a history of seizures, head injuries, stroke, eating disorders, drink a lot of alcohol, already on antidepressants etc. It is not available over the counter: only on prescription from a GP.

Champix:Champix was put on the GG&C formulary in Feb 2007 and is a prescription only stop smoking aid I.e. it must be prescribed by a GP. It is similar to Zyban in that it must be taken before the quit date so it can build up in the quitters system to have an effect. The drug is taken for 12 weeks with an optional extra 12 weeks if the client & GP feel with would help. Its mode of action is 2-fold it partially binds to the receptors which smokers have in their brains where nicotine usually binds. This causes partial stimulation so a small amount of dopamine is released in the smokers brain, giving some (although reduced) pleasurable feeling. The other effect due to this partial binding is that if the quitter has a cigarette, the nicotine has nowhere to bind to so there will be no positive effect from having the cigarette, this in theory, should reduce relapse.Main side effect reported is nausea but this can be reduced if the tablet is taken with food & water. There have recently been reports in the press of increased suicidal thoughts this is now mentioned on the packaging although it has only been reported in a small number of cases. It is important to bear in mind that anxiety, irritability & depression are all reported withdrawal symptoms of quitting smoking and smoking may mask some underlying mental health issues.*The chart shows the rapid bolus of nicotine delivered by cigarettes, compared with the pharmaceutical nicotine replacement therapy (NRT) devices. It is the speed of delivery that causes the sensation of a hit, and it is this experience that forms the basis of the dependence.

This also explains why patients are less likely to become addicted to the NRT products, and that the NRT products have different characteristics. The nasal spray delivers the sharpest bolus, and it is also the most effective cessation aid (it is, however, more uncomfortable to use).

__________________Royal College of Physicians, Nicotine Addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians. London, RCP, 2000*****The more traditional approach to tobacco control has been to focus primarily on preventionWhile this is important the biggest health gains will be made by helping people who smoke, and especially those with existing smoking related disease, to stopTobacco dependence has been described as a chronic relapsing diseaseDespite the majority of smokers wanting to quit, and many trying each year, many dont manage more than a few days to weeks