Addressing Tobacco Use Elizabeth Fildes Ed D RN
Addressing Tobacco Use Elizabeth Fildes, Ed. D, RN, CNE, CARN-AP, APHN-BC, FIAAN, FANAI Kimber Nagy, BSN, RN
Getting to know you… 1. Name and background 2. Why did you choose to work with nicotine dependent patients? 3. Approximately, how many patients/clients have you worked with? 4. What do you know about your patients/ clients? 5. What is helpful/not helpful in quitting to them? 6. What challenges do you have? 7. If you have the luxury, what three things would you want to empower your patients to achieve their goal?
“CIGARETTE SMOKING… is the chief, single, avoidable cause of death in our society and the most important public health issue of our time. ” C. Everett Koop, M. D. , former U. S. Surgeon General All forms of tobacco are harmful.
Tobacco’s Impact in the Philippines (GATS, 2015) � 22. 7% were current smokers; representing 15. 9 million Filipinos � 18. 7% were daily smokers; representing 13. 1 million Filipinos � 37. 4% were exposed to secondhand smoke at home representing 24. 0 million adult Filipinos � 40. 3% of men smoke � 5. 1% of women smoke
Philippine Legislation �The Philippine laws and Executive Order that have something to do with tobacco control are the following: �Republic Act 8749 or the Philippine Clean Air Act of 1999 �Republic Act 9211 or the Tobacco Regulation Act of 2003 � Executive Order No. 26 : Providing for the Establishment of Smoke-free Environments in Public and Enclosed Places
� Quitline is funded by DOH but the money has been transferred to Lung Center of the Philippines since October 30, 2017. The mobile texting (m. Cessation using Textit system) is a collaboration between WHO and ITU (International Telecommunication Union). � � According to Dr. Glynna Ong-Cabrera, the idea of putting up a Quitline came from Dr. Balanag during the time of DOH Secretary Ona. WHO just wanted DOH to implement the mobile texting. However, the idea of Quitline was shelved when Dr. Ona was replaced by Dr. Garin. It was resurrected during the term of Dr. Ubial. DOH has allocated 27 M pesos but initial transfer was only 20. 2 M pesos. The 27 M is for salaries, operating expenses, training, promotions and procurement of call center system. We have spent 1. 8 M as of December 31, 2017. �
PUBLIC HEALTH versus “BIG TOBACCO” The biggest opponent to tobacco control efforts is the tobacco industry itself. Nationally, the tobacco industry is outspending our state tobacco control funding. The tobacco industry outspends tobacco prevention dollars in states by 20 to 1
MPOWER �Protect �Offer �Warn �Enforce �Monitor �Raise
PROTECT OUR YOUTH FROM TOBACCO USE 400 children begin to smoke daily and 5. 6 million will die early from complications of smoking. � 12. 0% of youth are current smokers in the Philippines � 8. 0% of high school students in the United States reported using tobacco
FORMS of TOBACCO �Pipes �Cigarettes �Cigars �Clove cigarettes �Bidis �Smokeless tobacco (chewing tobacco, dissolvables, oral snuff) �Hookah (water-pipe or bong smoking) �Electronic cigarettes (“e-cigarettes”)* *e-cigarettes are devices that deliver nicotine and are not a form of tobacco. Image courtesy of the Centers for Disease Control and Prevention / Rick Ward
ELECTRONIC CIGARETTES �Battery operated devices that deliver vaporized nicotine �Battery warms cartridge; user inhales nicotine vapor or ‘smoke’ �Available on-line and in stores �Youth are more likely to use n n n Contain detrimental and possibly harmful materials Conflicting data on effectiveness of using as a smoking deterrent Can cause hazardous injuries
Dopamine Reward Pathway Prefrontal cortex Dopamine release Nucleus accumbens Stimulation of nicotine receptors Ventral tegmental area Nicotine enters brain
The Tobacco Addiction Cycle 2010; 362: 2295 -2303
The Health Consequences of Smoking- 50 Years of Progress A Report of the Surgeon General 2014
Health Consequences Causally Linked to Smoking Cancers Oropharynx Larynx Trachea Esophagus Blood Liver Pancreas Stomach Kidney Cervix Bladder Colorectal
Health Consequences Causally linked to Smoking Chronic Diseases �Stroke �Blindness, cataracts, agerelated macular degeneration �Congenital defects- maternal smoking: orofacial clefts �Periodontitis �Aortic aneurysm �Coronary heart disease �Pneumonia �Atherosclerotic peripheral vascular disease � Chronic obstructive pulmonary disease, tuberculosis, asthma, other respiratory effects � Diabetes � Reproductive effects in women � infertility � Hip fractures � Ectopic pregnancy � Male sexual function-erectile dysfunction � Rheumatoid arthritis � Immune function � Overall diminished health
DIABETICS WHO SMOKE �Have a higher A 1 C �Have increased blood sugars � Have more complications of: � Heart and kidney disease � Amputations � Retinopathy � PVD � ESRD
Smoking and Renal Disease �Causes clogged blood vessels �Causes inflammation of the glomerulus, therefore glomerular nephritis �Have higher creatinine levels �Have higher albumin in their urine �Decrease blood flow decrease efficiency Increase BP ESRD(End Stage Renal Disease) smoking High Blood Pressure Diabetes Kidney Disease ESRD
Smoking and High Blood Pressure �Smoking increases heart rate and blood pressure � blood vessels constrict forcing the heart to work harder to deliver oxygen to all cells of the body �CO attaches to the hemoglobin, decreasing its ability to carry oxygen to all cells �Smoking decreases the effectiveness of antihypertensives; may actively metabolize these medications
Smoking and High Cholesterol �Smoking causes clogged arteries by multiple effects of blood fats or blood lipids �Interferes with the normal metabolism of triglycerides �The remaining HDL’s anti artery clogging effects are decreased �Aspirin is less effective for controlling clot formation HDL LDL
Smoking and COPD � 90% of COPD are caused by smoking �Asthma, TB, influenza and common cold are worse in smokers �Increase in mucous due to inflammation from smoking �Smoking paralyzes the cilia and eventually destroys it. May cause clogging of mucous glands with harmful substances inside �Destroys alveoli -> decrease oxygen available to all cells �Airways clamps down due to poisons causing SOB �Decrease in forced expiratory volume
Compounds in Tobacco Smoke An estimated 4, 800 compounds in tobacco smoke Gases – – – Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde Particles – – – Nicotine Nitrosamines Lead Cadmium Polonium-210 11 proven human carcinogens
Complications Associated With Cigarette Smoking � placental abruption � spontaneous pregnancy loss � preterm premature rupture of membranes � placenta previa � preterm labor and delivery � low birth weight � ectopic pregnancy
Identifying Smoking in Pregnancy “Most important modifiable risk factor associated with adverse pregnancy outcomes” �Ask all pregnant women if they smoke �Social norms discourage pregnant women who smoke from disclosing the truth �Urine continine testing �Exhaled carbon monoxide �Exposure to second hand smoke
Smoking outcomes during pregnancy �Attributed to prenatal smoking in the United States � 5 -8% of preterm deliveries � 13 -19% of term infants with growth restrictions � 5 -7% of preterm-related deaths � 23 -34% of Sudden Infant Death Syndrome
USPSTF Grade A Recommendations �Clinicians should ask all adults about tobacco use �Advise them to quit smoking �Provide behavioral medications �Suggest FDA approved pharmacotherapy for smoking cessation
Smoking Cessation Interventions �Tobacco kills over 7 million individuals yearly �Cessation Counseling can help smokers quit �Only 1/3 of smokers used an evidenced based cessation treatment. �Counseling by healthcare providers is low
76. 7 % Of current smokers in Philippines want to quit
In the Philippines most people want to quit Almost 52. 2% made a quit attempt in the past year 95% of adults in the Philippines believe that smoking causes serious illness 96. 4% believe that smoking causes lung cancer 85. 7% believe that smoking causes heart attack 79. 6% believe that smoking causes stroke
Brief Interventions for Smoking Cessation �Improves tobacco abstinence �Helps patients develop coping skills �Assists with identifying barriers to quitting �Promotes a quit plan Unfortunately only 1/3 of smokers used proven cessation treatments to quit (Babb et al. , 2017))
The 5 -As Behavioral Counseling Framework Tobacco use assessment and cessation advise is one of the most efficient and effective preventative action that can be used in a health setting. �ASK �ADVISE �ASSESS �ASSIST �ARRANGE
Perceived Barriers to Using the 5 A’s �Lack of time �Patients do not want to quit �Preoccupation with other problems �Low confidence in provider’s ability to help �Lack of familiarity with treatment resources �Lack of engagement with smoking cessation with their health care providers �Lack of insurance coverage
3 A’s Model �Ask about tobacco use �Advice patients to quit based on what is important to them �Arrange by referring patients to resources
Transtheoretical Model Behavior Change �Assesses an individual’s readiness �Precontemplation �Contemplation �Preparation �Action �Maintenance
Precontemplation Stage �People have not intended to quit within the next 6 months (May be unaware of their problem) �Encourage patients to begin to think about the pros and cons of tobacco cessation �Cons may be overestimated in this stage �How can you initiate the conversation with patients in the precontemplation stage? �Capitalize on teachable moments � Respiratory infection � Illness of children
Contemplation Stage �Individuals intend to start a health behavior within the next 6 months �Shift towards equity in pros and cons �Equity may be delaying initiation �How can you add one more pro to a patients list? �Encourage them to talk to people who have successfully quit
Preparation Stage �Individuals are ready to start taking action within the next 30 days �Begin to take small steps leading towards change �Telling friends and family about plans �What are some other areas in preparation that you can talk to patients about? �Reducing triggers �Anticipating challenges �Speak to patient about stress reducing techniques
Action Stage �Individuals have made the change within the last 6 months �At this stage there is a need to strengthen commitments and overcome obstacles �How can you encourage a patient to strengthen their commitment? �Highlight positive health outcomes that have already occurred
Maintenance Stage �Individuals have changed the behavior for 6 months �Fortify patterns to avoid relapse in stressful situations �For the majority of people tobacco cessation will take multiple attempts. How can you help a patient during the maintenance Stage?
What you can say �“It is important that you quit smoking now, and I can help you” �“Cutting down while you are ill is not enough. ” �“Occasional or light smoking is still dangerous. ” �“Are you willing to give quitting a try? ”
How you can help �Set a quit date. �Encourage patients to tell family, friends, and coworkers about quitting, and request understanding and support. �Anticipate challenges to the upcoming quit attempt. �Remove tobacco products from environment and make home smoke-free �Recommend medications to aid the quit attempt when appropriate
Follow-up Contact � Should be within the first week and a second follow-up within the first month �Further follow-up may be needed.
BRIEF COUNSELING: ASK, ADVISE, REFER (cont’d) �Brief interventions have been shown to be effective �In the absence of time or expertise: �Ask, advise, and refer to other resources, such as local group programs or the Philippine DOH This brief intervention can be achieved in less than 3 minutes.
WHAT ARE “TOBACCO QUITLINES”? �Evidenced based tobacco cessation counseling, provided at no cost via telephone to all Americans �Staffed by trained specialists �Up to 4– 6 personalized sessions (varies by state) �Some state quitlines offer pharmacotherapy at no cost (or reduced cost) �Up to 30% success rate for patients who complete session
Don’t give up �Many smokers have had multiple unsuccessful quit attempts �Counsel patients to identify what helped and what hindered previous attempts and build on past successes. �Identify triggers and also identify how to overcome triggers
5 R’s for Patient Not Ready to Quit �Risk �Rewards �Roadblocks �Repetition �Relevance
Reaching Tobacco Users Referral Quitlines Health care Tobacco user Referral Community Cessation Programs
NRT Warnings USE PRECAUTIONS WHEN PRESCRIBING TO PATIENTS WITH HISTORY OF ACUTE CORONARY SYNDROME OR SEVER ARRHYTHMIAS Experts believe the risks of NRT in heart patients are small in relation to the risks of continued tobacco use.
TRANSDERMAL NICOTINE PATCH ADVANTAGES v v v Provides consistent nicotine levels Is easy to use and conceal Has less compliance issues DISADVANTAGES v Dose cannot be titrated v Skin irritation to adhesive v Difficulty sleeping and/or abnormal dreams
Nicotine Patch �Apply patch to hairless area—new location daily �Can bathe or shower while wearing the patch �Do not cut patches to adjust dose �Keep new and used patches out of the reach of children and pets �Only wear one patch at a time �Wash hands after applying a patch.
Nicotine Gum Advantages �Can titrate to manage withdraw symptoms �Delays weight gain �Satisfies oral cravings �Can be used with other NTR agents Disadvantages �Gastrointestinal side effects �Socially unacceptable �Difficult to use with dentures �Must use proper chewing techniques
NICOTINE GUM CHEWING TECHNIQUE Chew slowly Stop chewing at first sign of peppery taste or tingling sensation Chew again when peppery taste or tingle fades Park between cheek & gum
NTR Lozenge Advantages Disadvantages �Can be used as a tobacco substitute �Can delay weight gain �Can be titrated �Can be used in combination with other agents �Need to use frequently which can decrease adherence �Has Gastrointestinal side effects �Can cause flatulence �Can cause insomnia
NICOTINE INHALER ADVANTAGES n n n Can easily titrate therapy Mimics hand-tomouth ritual of smoking Delivers consistent nicotine levels over 24 hours DISADVANTAGES �Frequent use can compromise compliance �Are less effective in cold conditions �Mouth and throat irritation initially can be problematic
NICOTINE NASAL SPRAY ADVANTAGES n n Most rapidly absorbed form of nicotine replacement Patients can easily titrate therapy to rapidly manage withdrawal symptoms DISADVANTAGES �Nasal/throat irritation �Dependence can result* �Patients must wait 5 min before driving or operating heavy machinery * The data on higher dependence are not definitive and are based on small trials.
BUPROPION SR ADVANTAGES n n n Fewer adherence problems May delay cessationrelated weight gain May be beneficial in patients with coexisting depression DISADVANTAGES �Seizure risk is increased �Side effects: Common: dry mouth, anxiety, insomnia (avoid bedtime dosing) � Less common: tremor, skin rash �
BUPROPION: CONTRAINDICATIONS and PRECAUTIONS �History of seizure �Current or prior eating disorder �History of cranial trauma, stroke, or neurosurgical intervention �Treatment with medications that lower the seizure threshold (e. g. , antipsychotics, antidepressants, theophylline) �Treatment with MAOIs in the past 2 weeks �Abrupt discontinuation of alcohol or sedatives (including benzodiazepines) �Severe hepatic cirrhosis
BUPROPION SR: DOSING for SMOKING CESSATION Initial treatment n 150 mg po q AM x 3 days Then, if tolerated… n 150 mg po bid x 7– 12 weeks Maximum Dose 200 mg twice daily Patients should begin therapy one to two weeks before quitting to assure therapeutic plasma levels of the drug are achieved when the patient is no longer smoking
Bupropion Patient Education �Dose tapering is not necessary when discontinuing �Do not drink alcohol, drive or operate heavy machinery when beginning the medication. �Do not chew bupropion �FDA boxed warning was removed in 2016(U. S. Department of Health & Human Services, 2016)
VARENICLINE (Chantix) ADVANTAGES n n n Oral formulation with twice -a-day dosing Offers a new mechanism of action for persons who previously failed using other medications Early industry-sponsored trials suggest this agent is superior to bupropion SR DISADVANTAGES �Common side effects: � � Nausea (in up to 33% of patients) Sleep disturbances (insomnia, abnormal dreams) � Constipation � Flatulence � Vomiting
VARENICLINE: DOSING Patients should begin therapy 1 week PRIOR to their quit date. The dose is increased gradually to minimize treatment-related nausea and insomnia. Initial dose titration Treatment Day Dose Days 1– 3 0. 5 mg qd Days 4– 7 0. 5 mg bid Day 8 – week 12 1 mg bid
Varenicline Patient Education �Do not combine with NRT—increase in side effects, including nausea, headache, vomiting, fatigue �Doses should be taken after eating, with a full glass of water �Nausea and insomnia are side effects that are usually temporary �Dose tapering is not necessary when discontinuing treatment �Use caution when driving or operating machinery
Abstinence Rates for Smoking Cessation Drugs
Quote from Dr. Tedros WHO Director-General “ WORKING TOGETHER, COUNTRIES CAN PREVENT MILLIONS OF PEOPLE FROM DYING EACH YEAR FROM PREVENTABLE TOBACCO-RELATED ILLNESS, AND SAVE BILLIONS OF DOLLARS A YEAR IN AVOIDABLE HEALTH CARE EXPENDITURES AND PRODUCTIVITY LOSSES. ”
Health Defined… �Holistic health is the overall state of wellness on all levels of being: physical, emotional, mental and spiritual. It encompasses the health of one’s entire being and extends to everyone and everything that affects a person in any way. That includes one’s resources, environment, and relationships. � http: //www. holistic-mindbody-healing. com/definition-ofholistic-health. html
Health defined… �Holistic Health is actually an approach to life. Rather than focusing on illness or specific parts of the body, this ancient approach to health considers the whole person and how he or she interacts with his or her environment. It emphasizes the connection of mind, body, and spirit. The goal is to achieve maximum well-being, where everything is functioning the very best that is possible. With Holistic Health people accept responsibility for their own level of well-being, and everyday choices are used to take charge of one’s own health. �https: //ahha. org/selfhelp-articles/holistic-health/
Dr. Engel http: //www. holistic-mindbody-healing. com/definition-of-holistic-health. html
Assessments �Strength assessments �Nicotine dependence cigarette smokers quiz �Why I smoke quiz �Smokeless Dependence Quiz �Readiness Ladder
Helping Tobacco Users Quit �The Holistic Way �Physical �Mental �Emotional �Spiritual
Physical Well-being �Managing withdrawal symptoms �Medication �Nicotine reduction �Triggers �Nutrition �Exercise
Emotional Well-being �Stress �Fear �Anger �Journaling �Humor and joy �Support system �Dos and don'ts for your support system
Mental-Wellbeing �Programming/Reprogramming �Assertiveness �Communication �Slip, lapse and relapse
Spiritual Well-being �Spirituality and Religion �Meditation �Prayer �Spending time in nature �Muscles of the soul
In Conclusion… �What did you learn? �What will be most useful for immediate use? �What other topics you want us to cover? �Will a distance narrated presentation be helpful?
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