“Smoking Cessation - What’s my Role?”

Daniel “Scotty” Silva, RRT, RCP

- Director of Pulmonary Services,

University of New Mexico Hospital

- Consultant,

New Mexico Medical Society -

Clinical Prevention Initiative

NMMRA – Hospital-initiated Tobacco Cessation Program

Educational Objectives• What can the attendee expect to learn in this meeting?

– Understand the tobacco problem in New Mexico

– Learn about the Tobacco Use Prevention & Control program’s funding of various programs to combat the tobacco problem

– Learn about the different types of nicotine replacement therapy available to tobacco users

– Learn how to conduct a tobacco cessation counseling session utilizing the motivational interviewing techniques

– Learn how to use motivational interviewing tools: Listening statements, Readiness Ladders, Accomplishment Story, Sidestepping

Tobacco in New Mexico

American Lung Association :• State of Tobacco Control: 2006

Report Card Grades:

• Youth Access F• Tobacco Prevention and Control Spending F• Cigarette Tax D• Smokefree Air F

Tobacco in New Mexico

American Lung Association :• State of Tobacco Control: 2009

Report Card Grades:

• Youth Access• Tobacco Prevention and Control Spending F• Cigarette Tax D• Smokefree Air A• Cessation Coverage C

Chemical Make-up of a Cigarette• > 4000 Chemicals found in tobacco;

1.) Fertilizers and Pesticides.

2.) Production of cigarettes.

3.) By-product or end-product.

- Primary

- Secondary

• 60 are known Group A Carcinogens (found to cause cancer in humans). Group A Carcinogens include;

- Acetylene - Copper - Hexamine - Nickel - Arsenic - DDT - Mercury - Phenol - Asbestos - Ethanol - Methane - Radon - Benzene - Formaldehyde - Methanol - Toluene- Butane - Vinyl Cloride - Naphthalene - Urethane

What Are the Facts?• An estimated, 20.8% of all adults (45.3 million people)

smoke cigarettes in the United States.

• Cigarette smoking estimates by age are as follows: 18–24 years (23.9%), 25–44 years (23.5%), 45–64 years (21.8%), and 65 years or older (10.2%).4

• Cigarette smoking is more common among men (23.9%) than women (18.0%).4

• Prevalence of cigarette smoking is highest among American Indians/Alaska Natives (32.4%), followed by (non-Hispanic) Blacks (23.0%), (non-Hispanic) Whites (21.9%), Hispanics (15.2%), and Asians [excluding Native Hawaiians and other Pacific Islanders] (10.4%).4

More Facts!

• Cigarette smoking estimates are highest for adults with a General Education Development (GED) diploma (46.0%) or 9–11 years of education (35.4%), and lowest for adults with an undergraduate college degree (9.6%) or a graduate college degree (6.6%).4

• Cigarette smoking is more common among adults who live below the poverty level (30.6%) than among those living at or above the poverty level (20.4%).4

Nicotine - What is it?

• Nicotiana tabacum

• First cultivated in the Americas as early as 6000 BC.

• Originally touted for its “medicinal properties”.

• C10H14N2 is a naturally occurring liquid alkaloid and makes up about 5% of the actual tobacco plant, by weight.

• Readily diffused into the body through skin, lungs, and mucous membranes.

• Half-life of Nicotine is 60 minutes.

Nicotine - The Perfect Drug!• Appetite Suppressant

• Anti-Depressant

• Stimulant

• Relaxant

• Improves Learning

• Increases Memory

• Painkiller

Is It Addiction?

Psychological: Continued and compulsive use of a product, without regard for it’s effects on health or life.

Physiological: Anything that turns on the reward pathway in the brain. Stimulation of this neural circuitry makes a person feel good and thus will do it again and again to “get that feeling”.

Tolerance: The development of tolerance to the product which results in needing more and more in order to illicit the same effect.

Why Smoking Cessation?• 438,000 smoking related deaths annually in the US.

• 2100 smoking related deaths annually in the New Mexico.

• 1 in 5 or 20% of all deaths in the US are attributable to cigarette smoking.

• Leading cause of cancer death in both men and women, it surpassed breast cancer in 1987 as the # 1 cancer killer of women!

• 66% ALL myocardial infarctions are related to cigarette smoking.

• 75 Billion dollars in Direct annual medical related costs.

• 92 Billion dollars in lost productivity.

Because They Want To Quit!

• Among current U.S. adult smokers, – 70% report that they want to quit completely.

– In 2006, an estimated 19.2 million (44.2%) adult smokers had stopped smoking for at least 1 day during the preceding 12 months because they were trying to quit.

– More than 54% of current high school cigarette smokers in the United States tried to quit smoking within the preceding year.

Nicotine and the Brain

Can We Make a Difference?

“If you treat an individual as he is, he will stay as he is, but if you treat him as if he were what he ought to be and could be, he will become what he ought to be and could be”

Johann Wolfgang von Goethe

Components of Change

• Importance of change

• Confidence in the ability to change

• Readiness to change

“Motivation is fundamental to change”

Contemplation Ladder

• 10 = Taking action to quit NOW.

• 8 = Starting to think about how to quit.

• 5 = Think that I should quit, unsure if I am ready too.

• 2 = Will consider quitting someday.

• 0 = Absolutely NO thoughts of quitting.

Motivation to Change?

• DARND = DESIRE to Change

A = ABILITY to Change

R = REASON to Change

N = NEED to Change

Explore Their Ambivalence!

• What is AMBIVALENCE? Webster’s defines ambivalence as;

“Simultaneous conflicting feelings”– “I want to quit smoking and I don’t want to quit

smoking”– “I know that my smoking effects my asthma, but I

really love to smoke”!– DEVELOP DISCREPANCY – Differentiate between

the patient’s present state and their desired goals.– Without discrepancy there is no ambivalence and if

there is no ambivalence, there is no potential for change!

– You can’t have Motivational Interviewing without ambivalence.

37

AskSmoking status

AdviseTo quit

AssessWillingness to quit

AssistAid in quitt ing

ArrangeFollow-up

Tobacco use asa vi tal sign

Brief, informative,clear, personalized

Weigh pros and cons

Assess importance, readiness,and confidence

Assess stage of readiness to quit

Offer help: e.g.

- refer to counseling, quitl ine

- analyze past attempts

- develop quit plan,

- provide pharmacotherapy

The 5 A’s

The 5 A’s• ASK - Does EVERY patient get asked about their

smoking history?• ADVISE – Do we actively advise our smoking

patient’s to quit?• ASSESS – Do we incorporate smoking cessation

into our assessment and provide opportunities for our patient to pursue quitting options.

• ASSIST – Do we incorporate smoking cessation into the treatment / care plan?

• ARRANGE – Do we provide the patient with the necessary resources to be successful after discharge? (community resources, relapse plan, support)

One Size Fits All?

Nicotine Replacement Therapy

• CHANTIX™ (varenicline)

• Indication: Smoking Cessation / Nicotine Inhibitor

• Dose: (Day 1-3) White Tablet / 0.5mg / Qday

– (Day 4-7) White Tablet / 0.5 mg / Bid

– ( Daily) Blue Tablet / 1 mg / Bid• Mode of Action: CHANTIX contains no nicotine, but it

targets the same receptors that nicotine does. CHANTIX is believed to block nicotine from these receptors.

• Quit Rate: 44%

Nicotine Replacement Therapy• Bupropion (Wellbutrin XL / Wellbutrin SR / Zyban)

• Indication: Depression / Smoking Cessation• Dose: 150 mg once daily for three days, and then the dose

is increased if the patient tolerates the starting dose to 300 mg daily. Smoking is discontinued one -two weeks after starting bupropion therapy.

• Mode of Action: Bupropion is an antidepressant medication that affects chemicals within the brain that nerves use to send messages to each other, therefore, reducing the cravings or urges to smoke.

• Quit Rate: 32%

Nicotine Replacement Therapy

• Nicotine Patch

• Indication: Smoking Cessation

• Dose: 21mg, 14mg, 7mg (all available over-the-counter)

• Mode of Action: Delivers a steady dose of nicotine through the skin over a 24-hour period to lessen / taper the symptoms of nicotine withdrawal. Requires a gradual taper in dose over a 6 - 8 week period. May be used concurrently with other NRT under supervision.

• General Rule: “1 Mg per Cig.”

• Quit Rate: 23%

Nicotine Replacement Therapy

• Nicotine Gum

• Indication: Smoking Cessation

• Dose: 2mg and 4mg (mint, orange, & wild berry flavor)

• Mode of Action: Delivers nicotine to the bloodstream through the lining of the mouth (buccal mucosa) to lessen nicotine withdrawal symptoms.

• General Rule: Chew It & Park It! This will help to eliminate the headache and nausea associated with this NRT.

• Quit Rate 21%

Nicotine Replacement Therapy

• Nicotine Lozenge

• Indication: Smoking Cessation

• Dose: 2mg and 4 mg

• Mode of Action: Delivers nicotine to the bloodstream through the lining of the mouth (buccal mucosa) to lessen nicotine withdrawal symptoms.

• General Rule: Suck It & Park it! This will help to eliminate the headache and nausea associated with this NRT. (TTFC) Time To First Cigarette.

• Quit Rate: 22%

Nicotine Replacement Therapy• Nicotine Inhaler• Indication: Smoking Cessation in particular those with a

multi-pack habit with associated oral fixation.• Dose: 4mg puncture pack per inhaler providing 15-20

minutes of nicotine with active puffing.• Mode of Action: Delivers nicotine to the bloodstream

through the lining of the mouth (buccal mucosa) to lessen nicotine withdrawal symptoms.

• General Rule: Inhaler is a VAPOR, not aerosol, and will dissipate relatively quickly.

• Quit Rate: 23%

Nicotine Replacement Therapy• Nicotine Nasal Spray

• Indication: Rapid relief of nicotine withdrawal symptoms.

• Dose: 1 puff per nare (0.5mg) at the onset of symptoms.

• Mode of Action: The spray delivers nicotine directly to the bloodstream through the lining of the nose (nasal mucosa) and is extremely fast -acting.

• General Rule: Highly addictive and should be used only with supervision and for NO longer than 3 months. High association with nasal irritation, sinusitis, and burning eyes. Only use this NRT with careful consideration.

• Quit Rate: 21%

It’s Up To You!

"In any moment of decision the best thing you can do is the right thing, the next best thing is the wrong thing, and the worst thing you can do is nothing."

Theodore Roosevelt

Thank You!

QUESTIONS?