How You Can Help Smokers Quit

Taneisha Scheuermann, PhDUniversity of Kansas Medical Center

Department of Population Healthtscheuermann@kumc.edu

Promoting Quitting in Pregnant Smokers

• Pregnancy is a good time to intervene

• Brief counseling works better than simple advice to quit

• Counseling with self-help materials offered by a trained clinician can improve cessation rates by 30% to 70%

Advise Every Patient That Uses Tobacco to Quit

3

ONE statement that is clear, nonjudgmental, and

personalized

“Cindy, I know you’ve tried before to quit- which is great. You

should quit—it is the best thing you can do for your diabetes.”

http://doh.sd.gov/documents/AARposter.pdf

Why don’t smokers just stop?

• Cigarettes smoking is addictive• Cigarette constituents are readily absorbed through the lungs

• Smokers take 12-15 puffs per cigarette -> thousands of puffs per year• Each puff is reinforcing

Tobacco’s Addictive Properties• Smoking is rewarding

• Nicotine increases dopamine release

• Smokers experience withdrawal symptoms • Cold-like symptoms, sweating, headache, difficulty sleeping,

irritability, anxious feelings, feeling down

• Peaks and dips in blood levels create a “learning cycle”

• Chronic use creates long-term brain changes

ASSESS

ASSIST

Arrange Follow-up

Medications, counseling, quit plan

Readiness to quit Not ready? Motivate

Ready? Assist with quitting

Future visits, referral to quit line

PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

ADVISE To quit, discuss treatment options

The 5 A’s: Ask, Advise, Assess, Assist, Arrange

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ASK If he or she uses tobacco

Or 2 A’s and an R: Ask, Advise, Refer

Asking Pregnant Women about Tobacco Use

• Which statement best describes your smoking status:

A. I have NEVER smoked or have smoked LESS THAN 100 cigarettes in my lifetime.

B. I stopped smoking BEFORE I found out I was pregnant, and I am not smoking now.

C. I stopped smoking AFTER I found out I was pregnant, and I am not smoking now.

D. I smoke some now, but I have cut down on the number of cigarettes I smoke SINCE I found out I was pregnant.

E. I smoke regularly now, about the same as BEFORE I found out I was pregnant.

• Source: American Congress of Obstetricians and Gynecologists (ACOG)

Assess Tobacco UseSome ways we ask that are less effective:• You don’t use tobacco, do you?•Are you a smoker?

More effective:•Have you used any tobacco products in the past

month?•Have you ever smoked cigarettes?

Advise Every Patient That Uses Tobacco to Quit

9

ONE statement that is clear,

nonjudgmental, and personalized

“Cindy, I know you’ve tried before to quit- which is

great. You should quit—it is the best thing you

can do for your diabetes.”

http://doh.sd.gov/documents/AARposter.pdf

10PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

Advice to Quit Works

• Brief advice – 3 minutes or less!

• Significantly impacts quitting

• Even when patients are not willing to make a quit attempt, use brief advice

• Enhances motivation• Increases the likelihood of future quit attempts

• Has cumulative effect on quitting

Unwilling patients may:

• Lack information about harmful effects or benefits of quitting

• Think they can’t afford medication

• Have had terrible experiences from past quits

• Think or fear they can’t quit –feel like a failure

Discuss pros and cons:

Assess Interest in Quitting

• Build confidence!

– Tell them about medications/counseling resources

– Tell them you know how hard it is to quit, but you will stick with them

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What are your thoughts about quitting tobacco?

Not interested?

•Use motivational interviewing

• “In case you want to think about it in the future, here are some resources….”

• “This is so important, I will check in with you again.”

13PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

Assist: Developing a Quit Plan

• Evidence-based treatment:

• Support – Quitline, health care provider, other support from family and friends

• Medications – solo or combination

• Follow up – to adjust treatment

Planning a Quit Attempt• What are her top three reasons for quitting smoking?

• What are the benefits of quitting?• How much money would she save?• What would she like about being a non-smoker?

• When and where does she usually smoke?

• What might be the hardest cigarette to give-up? (e.g., the first cigarette in the morning, smoke break with friends)

• Willing to practice short quit attempt?• Go without ____________ cigarette? Stop smoking when you get in the

car.

Schlosberg. Quit Smoking for Life: A Simple, Proven 5 Step Plan.

Preparing to Quit

• Set a quit date

• Develop a plan for dealing with urges to smoke and craving

• Get support from family and friends• Who in her life will be helpful?

• Get rid of all tobacco products!!!! • Clean/wash clothes and linens that smell like smoke

Schlosberg. Quit Smoking for Life: A Simple, Proven 5 Step Plan

Preparing to Quit: Common Triggers

• Time of day• Mornings, work breaks, meals

• Location • Car, bar, bus stop

• Activity• Talking on the phone, tv, being around others who smoke

• Emotions• Stressed, lonely, bored, anxious

What are her biggest triggers?

Strategies for Dealing with Triggers• Substitutes

• Hard candy, chewing gum, toothpicks, carrots (or other crunchy vegetable)

• Hand movement: a stress ball, play with a pen, game on your phone

• Distractions• Take a walk at break time, change your routine (e.g., brush your

teeth first thing instead of smoking), get a healthy beverage as a break

• Reminders• Post a note to yourself, put a reminder of why you are quitting, get

a jar for the money you are saving by not buying tobacco

If Patient is Willing to Make a

Quit Attempt

✓Fax refer them to the Kansas Quitline• Free phone counseling

• Programs for youth and pregnant women

✓Use opt-out language

✓Check-in with them at future visits (indicate in your progress notes)

If Patient is Not Yet Ready to

Make a Quit Attempt

Arrange Follow-up

✓Offer encouragement to think about quitting

✓Let the patient know that you are happy to quitting with them at another time

✓Offer Kansas Quitlinecard

18KanQuit Materials are available at http://www.kdheks.gov/tobacco/cessation.html

Use Office Systems to Prompt You

1. Just having a system that ensures you ask about smoking

• Helps you remember to advise patients to quit

Which helps your patients quit

2. Document tobacco assessment and treatment in your progress note

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Enhancing Tobacco Treatment Delivery

• At your clinic, who asks about tobacco use?• Is this recorded and not addressed?

• Who completes the quit line referral process?• Fax-referral will engage more smokers in quitline than

giving a phone number

• How is this information communicated among providers and clinic staff to ensure all the steps are completed?• In busy practices, gaps in treatment occur because there

aren’t systems to communicate and provide reminders to follow-up

How Do Meds Help?

Helps smokers learn to live without tobacco:

• Stops withdrawal – irritability, anxiety, lack of concentration—that can drive smokers to relapse

• Can see others smoking/ads for smoking, without having strong craving

• Reduces chance that a slip becomes a relapse—when/if a slip occurs

21Improves Success Rates!

Smoking Cessation Medications and Pregnancy

•Medications are NOT a first-line treatment during pregnancy

•Varenicline (Chantix) is NOT appropriate for use during pregnancy/breast-feeding

•We will discuss medication generally

• E-cigarettes are NOT FDA approved for smoking cessation• Do not recommend!

• Long-acting: Patch

• Short-acting• Gum• Lozenge/Mini lozenge• Nasal spray• Inhaler

Nicotine Replacement Therapy

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PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update; Bolt et al, 2012

Nicotine Replacement Therapy (NRT)

Acts similar to nicotine from tobacco

• Withdrawal

– NRT reduces withdrawal symptoms such as anxiety, irritability, depressed mood

• Craving

– Nicotine patch reduces abstinence-induced craving

– Ad lib nicotine may help reduce cued craving

• Several different types of NRT

• Patients are not exposed to the carcinogens and other toxins in tobacco

• Provides lower, slower, and less variable nicotine concentrations than cigarettes

How NRT Works

25PHS Clinical Practice Guideline:Treating Tobacco Use and Dependence: 2008 Update; Bolt et al, 2012

Combinations of long-acting and short-acting products are even better than solo NRT

Pharmacotherapy during Pregnancy

• ACOG Committee Opinion and Health and Human Services Tobacco Treatment Guidelines recommend a cost-benefit analysis approach to prescribing Nicotine Replacement Therapies• Use if behavioral treatment fails and discuss risks• Prescribe with close supervision• May be necessary for heavier smokers who are

motivated to quitFiore, M. C., Jaén, C. R., Baker, T. B., & et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.

American Congress of Obstetricians and Gynecologists (ACOG). (2017). Committee opinion no. 721: Smoking cessation during pregnancy. Obstetrics and Gynecology, 130(4).

Risk/Benefits NRT for Pregnant Women

Nicotine Replacement

• Contains nicotine • Can limit duration of use (e.g., 6-14

weeks of treatment)• Treat as early in pregnancy as

possible, most benefit if quit 1st or 2cd trimester

• Dose to what the mother would smoke

• Nicotine alone can have negative effects during pregnancy and breastfeeding

Cigarette Smoking• Contain nicotine and over

7000 other chemicals• 70 of which are known

carcinogens• Carbon Monoxide

• Risks to both mother and fetus

• Likely to continue throughout pregnancy and beyond

Smoking Cessation Pharmacotherapy for Pregnant Women

•NRT• Don’t use 24 hour patches• Shorter acting NRT preferred

•Bupropion• Can be prescribed for pregnant women (used for depression)• Avoid in women with a history of seizure

•Varenicline• Not labelled for use with pregnant women• No safety data

Use the lowest effective dose : will need to follow-up to see how NRT

is working for the patient!

Pharmacotherapy during BreastfeedingNicotine Replacement Therapy

• Use shorter acting agents

• Ensure less nicotine than the mother would smoke (approx. 1 mg = 1 cigarette)

• Nicotine Patch

• 21 mg transdermal patch- equivalent of 17 cigarettes in breast milk

• 7 and 14 mg patch -proportionately lower amounts in breastmilk

• Nicotine Gum

• Maternal nicotine plasma concentrations similar to cigarettes

• Nicotine Spray

• Maternal plasma nicotine concentrations are one-third those of smokers Drugs and Lactation Database (LactMed) [Internet] 2018. ; Sachs, H. C., Frattarelli, D. A., Galinkin, J. L., Green, T. P., Johnson, T., Neville, K., ... & Van den Anker, J. (2013). The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics, 132(3), e796-e809.

Pharmacotherapy during Breastfeeding

• Bupropion• 2%-12% of the mother’s dose in breast milk• Concern with mothers and infants susceptible to seizure•Need to monitor for effect on infants

•Varenicline•NOT recommended during breast feeding

Drugs and Lactation Database (LactMed) [Internet] 2018. ; Sachs, H. C., Frattarelli, D. A., Galinkin, J. L., Green, T. P., Johnson, T., Neville, K., ... & Van den Anker, J. (2013). The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics, 132(3), e796-e809.