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Nori de la PeñaMichael Leon-GuerreroPublic Health - Seattle & King CountyTobacco Prevention Program(206) 296-7613

Brief Tobacco Intervention Skills (BTIS) training

Summer 2010 DESC training

Cessation.partnership@kingcounty.gov

Framing the issue, understanding the addiction

and implementing an effective intervention

program

HealthPoint

August 10th

, 2010

Brief Tobacco Intervention TrainingTraining Info Here

Overview

• Frame the issue• What’s new: mental

illness/alternative products• Three-link chain of addiction• 2A’s• 5A’s• Resources

Smoking Statistics

• Those with mental health issues smoke more – US: 22.5% v. 34.8% (MI in lifetime) v. 41.0% (MI

in last month)• The poor smoke more than the rich

– KC: 10% for > $50,000/yr v. 25% for <$15,000/yr

• 70% of homeless people smoke (three times national rate) MI purchase nearly 50% of all cigarettes

• Homeless, substance abusers and the mentally ill more vulnerable to health effects of smoking

Drug Abuse Alcohol Tobacco

US Annual Deaths (thousands)

McGinnis & Foege, 1999

Drug Abuse Alcohol Tobacco

Ginzel, 1985

Medical Textbook Coverageof Substance Abuse

Doctors advise adolescents about tobacco <2% of visits

Medical Bias in Considering Tobacco a "Drug of Abuse"

Tobacco smoke:

• No safe level of exposure• Class A carcinogen (causes

cancer)• Over 60 chemicals cause cancer• Over 2000 chemicals total• Effects every system in the body

A Toxic Waste Dump

• Arsenic • Ammonia• Benzene• Carbon Monoxide• Ethanol• Formaldehyde• Hydrogen

Cyanide• Lead

• Methane• Mercury• Silicon• Polonium 210• Vinyl Chloride• Urethane• Tar (resinous matter

from burning tobacco and includes most of the carcinogenic substances)

www.tobacco.org

4119 14

An Unfair Share of MortalityN

Source: CDC

AIDS Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced

Est. 200,000 per year for mentally ill and SA

The Double Whammy!

• As smoking rates fall in the general population, smoking is concentrating in the poor– Populations with less access to care

have fewer chances to quit or to get treatment for smoking related diseases

– Tobacco companies actively target folks living with mental illness and substance use

Brief Tobacco Intervention TrainingTraining Info Here Truth-dot-com_Project-SCUM-cigarettes.mov

SUCCESS =

• Everyone is asked tobacco status and advised then referred

• Tobacco status is documented• Follow-up happens at each visit

Mental Health and NicotineMental Health and Nicotine

44% of all

cigarettes bought &

consumed in the US

are by individuals

living with mental

illness.

MI and Nicotine

• 7.1 % of the US population has a psychiatric illness; however this populations buys/consumes 44.2% of all cigarettes

• Smoking rates are 3-5 times higher

• Successful in stopping their tobacco use

Unfair Share of the Burden

Without help, nearly 60% of mental health clients will die from tobacco related illness.

Be Aware That:

• Tobacco dependence is chronic

• Tobacco users may have other addictions

• The physical environment is part of the message

• Other community agencies promoting cessation

Alternative tobacco

Your Role

Your clients have many competing health/mental health/substance use issues:Helping them quit smoking will directly improve their overall health.

WHY don’t they just QUIT?

Why Don’t They Just Quit?

+ No Cessation Help

The intervention: 2A’s & R

Site Champ

• Ask clients at screening or when appropriate if they smoke

ADVISE

Urge every tobacco user to quit• Clear: “One of the best things you can do

for your health is to quit smoking. I can help you.”

• Strong: “As your case manager, I need you to know that quitting smoking is one of the most important things you can do for your health.”

• Personalized: Tie tobacco use to current health issues, relationships, or economic stress

1) SITE CHAMP

2) 1-800-QUIT NOW1-877-2NO FUME

www.quitline.com

Washington State Quitline – OVER 18

• Free telephone counseling for people ready to quit in the next 30 days

• Proven to increase success in quitting for many

• Includes different pharmacotherapy benefits for different populations

Medicaid eligible:

• Free services available for 18+ clients:

• Phone counseling and follow-up support calls through the quit line

• Nicotine patches or gum through the quit line, if appropriate

• Prescription medications recommended by quit line and prescribed by individual physicians, if appropriate

Is the Quitline a Good Fit?

• Does your client have – A phone line?– An address for mailings?

• Is your client comfortable with telephone counseling?– Video and sample call on web can show them

what it’s like• Do they use interpreter services?

– Quitline has English and Spanish– Other languages available through telephone

interpreter• Has your client already used the benefit this year?

“Ask”Identify Tobacco Use /exposure to smoke

Document chart

“Advise”To Quit

“Assess”willingness to quit

“Assist”with quitting

“Arrange”Follow-up

Quitline1-800-QUITNOW1-877-2NO FUME

Local ResourcesDESC champ(Provided by Sophie Balk, MD,

Albert Einstein College of Medicine)

Referrals

The 5 A’s

ASSESS

Ask every tobacco user about quitting• Examples:

– “On a scale of 1 to 10, how ready do you feel to quit?”

– “Have you thought about quitting in the next 30 days?”

• If the client is ready to quit in the next 30 days provide assistance

• If the clients is not ready to quit provide a motivational intervention (5R’s)

Header info here

ASSIST

Help the ready client make a quit plan

• Set a quit date in 30 days• Plan to tell friends• Anticipate challenges • Plan to remove tobacco products • Recommend NRT use

ARRANGE

Plan a time to follow-up after quit-date

• Congratulate success• Address challenges/relapse• Assess NRT use

Benefits of Quitting

20 MinutesBP

Body Temp

8 Hours02 Levels

48 HoursTaste/Smell

Nerve Endings

2Weeks-3 MonthsCirculation

Lung Function

5 YearsLung Cancer Death Rate

Decreases by 50%

10 YearsRisk of HD/Stroke almost

the same as a non-smoker

The 5R’s: Not Ready to Quit

The 5 R’s

RELEVANCE – Specific and personal reasons

RISKS – client identifies risks of smoking

REWARDS – client identifies benefits of quitting

ROADBLOCKS – client identifies barriers

REPITITION – Repeat motivational intervention

Motivational Interviewing Is

• Starting where client is• Understanding client’s frame of

reference• Knowing choice to change is

client’s• Exploring options with client• Finding and reinforcing the

client’s motivation to change

Motivation Enhancing SkillsMotivation Enhancing SkillsOARS - toolkit for SUCCESS!OARS - toolkit for SUCCESS!

• Open ended questions

• Affirmation• Reflections• Summarize

Nicotine Replacement Therapy in biologically addicted adults

• NRT increases quit success (patch/counseling doubles rate)

• Safe, FDA approved, available OTC• Reduces most withdrawal symptoms

so quitter can comfortably break the habit

• Eliminates the reinforcing effect of nicotine as administered through smoking

What NRT Does Not Do

• Without behavioral change/counseling, NRT does not increase quit rates

• NRT does not replace smoking– clients will still want to smoke– Does not provide bolus effect

(nicotine rush)

Patch Counseling

• Apply promptly at quit date• Replace patch every day to dry,

clean, hairless place• Rotate sites over a seven day

period• Follow treatment plan for

decreasing dose over time

Patch Side Effects

• Vivid dreams– Can remove before bed – New patch first thing in morning

• Localized skin reactions (rash)– Up to 50% of clientss have mild

form– Less than 5% discontinue therapy

Smoking and NRT

• client should stop smoking on quit date

• “Slipping” will happen, and is not harmful

• If client continues to smoke after starting patch– Assess if they are really ready to quit – Address triggers for smoking

– Nausea, dizziness, vomiting

Quitting the Three Link Chain

BehavioralCounseling

Posters

Groups

Activities

+ Cessation Help @ DESC

The best way to quit smoking is to combine a smoking cessation

message with a behavior modification program.

Some clients may benefit from NRT

Or medication.

Relapse Is Common

• Tobacco dependence is chronic

• Cycle through relapse and remission

• 5 to 7 times not uncommon

• 7% long-term success quit on own

• Relapse not a failure—for clients or you

Policies

• Tobacco policy• Tobacco free campus• I-901 compliance

Public Health Contact

Community Tobacco Cessation Partnership

206-296-7613 cessation.partnership@kingcounty.gov

For questions, and staff cessation referrals.

Selected References

• Slide 4: – National Co morbidity Survey

– Washington State BRFSS 200-2004 Data:

– Connor et al, Smoking Cessation in a Homeless Population: There is a Will, but is There a Way? J Gen Int Med 2002;17:396-372.

• Slide 19: – Connor et al, Smoking Cessation in a Homeless Population: There

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