Nico-hosp 1 Training hospital staff to deal with smoking From: Nicomède DGS Training programme designed for hospital staff to deal with smoking Version

Nico-hosp 1Training hospital staff to deal with smoking

From: Nicomède DGS

Training programme designed Training programme designed for hospital staff to deal with for hospital staff to deal with

smokingsmokingVersion 2001

Smoke-free HospitalEuropean Training Guide

Nico-hosp


From: Nicomède DGS

1. Engage decision-makers. Inform all personnel and patients. 2. Appoint an action group. Propose a strategy and an implementation plan. 3. Set up a training plan to instruct all staff on how best to approach smokers.4. Organise cessation support facilities for patients and staff in the hospital and provide

continuity outside the hospital. 5. Indicate smoking zones clearly, as long as they are considered necessary, keeping

them away from clinical and reception areas.6. Adopt appropriate signs, including posters, signposts, etc. 7. Remove all incentives to smoke (such as ashtrays, tobacco sales, etc.).8. Renew and broaden information to maintain commitment to the policy. 9. Ensure follow-up and quality assurance. 10. First convince, constrain considering legislation if needed. Have patience!

Smoke-free Hospital codeSmoke-free Hospital code


From: Nicomède DGS

Clinical staff role in smoking cessationClinical staff role in smoking cessationPastIn Northern Europe, tradition of nurses dealing with nicotinic weaning. In France, tradition of doctors dealing with nicotinic weaning,In the States, tradition of psychologists dealing with smoking cessation,

PresentNRT are available OTC (possible self medication ).Nicotine substitutes are available in hospitals.

FutureStaff have a central information role.Smoking : a nursing diagnosis as well as a medical oneSmoking amongst patients : nurses and other health professionals are often the closest.


From: Nicomède DGS

23 tobacco related illnesses23 tobacco related illnessesMOUTH & PHARYNX• cancer

BRAIN

• Stroke

LARYNX & TRACHEA

• cancer

• inflammationLUNGS

• cancer

• emphysema

• chronic bronchitis

PANCREAS

• cancer

URINARY

• kidney cancer

• bladder cancerBONES

• osteoporosis

PERIPHERIAL ARTERY

• arteritis

TESTICLES

• infertility

• impotence

HEART

• coronary disease

WOMB & OVARIES

• infertility

• abortion

• growth delay

• early menopause

• cervical cancer

SKIN

• dry, wrinkled complexion

OESOPHAGUS & STOMACH

• cancer

• ulcer


From: Nicomède DGS

How to identify smokers?

Identify smokers

Collect a smoking history

Include smoking status with vital signs

Amongst Patients:


From: Nicomède DGS

Collect a smoking historyCollect a smoking history

Paramedical evaluation of smoking history includes :

• Number of cigarettes smoked daily (work days and week-ends)• Smoking history (start age, regular start, number of years)• Use of smoking : frequency, factors leading to cigarette lighting• Addiction level (Fagerström)• Previous attempts to quit

• Illness and risk factors history• Family history• Use of medicines(This history builds day by day.)

Medical evaluation of smoking history includes also:


From: Nicomède DGS

• Smoking must be noted down next to weight and blood pressure in paramedical and medical files of all patients, smoker, non smoker, ex smoker (since when).

• Actual smoking habits, starting age, duration and quantity.

• Time between wake up and first cigarette.• Attempts to quit and reasons for failing.• The patient must be aware that medical staff

are interested in this sign as much in other vital signs.

• Marking the file is effective.

Include smoking with vital signsInclude smoking with vital signs


From: Nicomède DGS

Stages preparing smoking cessationStages preparing smoking cessation

Source : Prochaska and Di Clemente, Am Psychologist 1999,47:1102

Thinks about quitting

Decides to quit

Tries to quit

Relapses

preparation

Does not start again

Stays quitSatisfied smoker

Quits


From: Nicomède DGS

What to do in relation to the stage of preparation to quit What to do in relation to the stage of preparation to quit smoking?smoking?

STAGE

Not ready

Hesitating

Ready

Stay quit

Restart

WHAT TO DO ?

Short information on how to quit smoking.Offer to talk about it later.

Weigh up smoking pros and cons.Discussion concerning smoking, examples : health, quitting, weight gain, health effects; This stage can be longOffer to talk about it later.

Preparation: Use hospital stay to stop or chose a day to stop with the patient ,

Follow up to prevent relapse.Enquire frequently and reinforce quitting.

Re-state the benefits from quitting.(Many ex-smokers start again within one year).


From: Nicomède DGS

Brief advice towards smoking cessationBrief advice towards smoking cessationDo you smoke ? Why ? Would you like to stop ?

What do you not like in smoking ?

Compare reasons to cease and continueWhat is your motivation

to quit now ?

At what point do you feel confident in your ability to quit ?

What can we do together in order for you to

gain in motivation and confidence ?

Generally: speak about tobacco at every meeting


From: Nicomède DGS

Weigh pros and cons of quitting Weigh pros and cons of quitting in 4 stagesin 4 stages

Stage 1: Ask :

Stage 2: Ask :

Stage 3:

Stage 4: Ask :

"What do you like about smoking ?"

"What do you not like about smoking? "

Sum up what you understood from the patient’s pros and cons

”When would you stop ? "


From: Nicomède DGS

What to ask patients on admission to hospital ?What to ask patients on admission to hospital ?

nono

Do you usually smoke ?Do you usually smoke ?

nono

Would you like take advantage of

your hospital stay to quit smoking ?

Would you like take advantage of

your hospital stay to quit smoking ?

yesyes

nonoyesyes

Propose NRTPropose NRTGo forward in the steps towards cessation

Go forward in the steps towards cessation

Help to quitHelp to quit

yesyes

Will you find it difficult not to smoke while in hospital ?

Will you find it difficult not to smoke while in hospital ?


From: Nicomède DGS

1. How soon after you wake up do you smoke your first cigarette ?Within 5 minutes 3 6-30 minutes 231-60 minutes 1After 60 minutes 0

2. How many cigarettes per day do you smoke?10 or less 011-20 1 21-30 231 or more 3

Interpretation

0-2 no or low dependence

3-4 dependence

5-6 high dependence

These 2 questions are the most important in the Fagerström test. They represent 60% of the final score. The questions could be learnt by heart by health workers, who could evaluate quickly the level of dependence.

Short TestShort Test


From: Nicomède DGS

Risk of contracting an illness due to smokingRisk of contracting an illness due to smoking

Sources : Fielding, 1985 ; US Dept of Health and Human Services, 1989; Wald, 1996; Slama, 1998.

illness

Arteritis 1 9 68 - 98 %

1 2 25 - 43%Coronary heart disease

1 5 75 - 80%Fatal heart attack before 45 years

1 6 80 - 90 %COPD

1 10 80 - 85%Lung cancer

1 2 30 %Death from carcinoma

“Risk” non-smoker

Risksmoker

% of deathssmoking related


From: Nicomède DGS

Tobacco’s attack on lungs

Chronic Bronchitis

Emphysema

Attack on the elastic fibres of the lung

Reduces lung efficiency to deliver oxygen to blood.

Main cause of obstructive respiratory insufficiency.

Lung cancer

Smoking is responsible for 9 out of 10 cases of lung cancer.

A 20 cigarettes-a-day smoker has 20 times higher risk of suffering from lung cancer than a non-smoker.

Less than 10% of patients with lung cancer survive more than 5 years.

A second-hand smoker living or working with a smoker has himself an increased risk of lung cancer.

Chronic Bronchitis

Emphysema

Attack on the elastic fibres of the lung

Reduces lung efficiency to deliver oxygen to blood.

Main cause of obstructive respiratory insufficiency.

Lung cancer

Smoking is responsible for 9 out of 10 cases of lung cancer.

A 20 cigarettes-a-day smoker has 20 times higher risk of suffering from lung cancer than a non-smoker.

Less than 10% of patients with lung cancer survive more than 5 years.

A second-hand smoker living or working with a smoker has himself an increased risk of lung cancer.


From: Nicomède DGS

Obstructive respiratory insufficiencyObstructive respiratory insufficiency

NF 10 20 30 40 50 60 70 80

1

9,7

2127

44

51

58

66

32

Tobacco consumption (packs/years)

relative death riskIf the death risk

of dying from chronic

bronchitis is as 1 for a non-

smoker, the risk can be

multiplied by 66 for a heavy

smoker.

Source: R Doll B med J 1976, 25, 1526-1536


From: Nicomède DGS

Cerebrovascular accident risk is increased in young women when smoking is combined with oestrogen intake.

Thrombophlebitis risk is also increased when smoking is associating with oestrogen intake.

Taking the pill and smoking must not be associated.

Interaction tobacco / contraceptivesInteraction tobacco / contraceptives


From: Nicomède DGS

Tobacco and pregnancy : facts

1- Spontaneous abortion

2- Intra uterin growth retardation

3- GEU

4- Premature labour

risk X 1,5

less than 10-20g per cig- 450g for smoking> 20 cig/d

20cig = risk X 3> 30cig. : risk X 5

Risk X 2

1 = Kline NEJM 1977; 297 : 793-796 2 = Liberman Am J Public Health 1994; 84 : 1127-11313 = Coste Am J Epidemiol 1991, 133, 839-8494 = Williams Am K épidemiol 1992, 135 : 895-903

nicotine accumulates in the amniotic fluid


From: Nicomède DGS

Tobacco, alcohol and oesophageal cancerTobacco, alcohol and oesophageal cancer

Source : CRDP Nice

05

1015202530354045

30 cig/d 20 cig/d 10 cig/d

40g/d

80g/d

120g/d

Alcohol

Oesophageal

cancer risk


From: Nicomède DGS

Nicotine KineticNicotine KineticNicotine KineticNicotine KineticFrom Russell

0 30 60 minutes

Cigarette

Nasal Spray

Gum 2 mg

Patch 21 mg

Nicotine plasmaticng/ml

25

0

Gum 4 mgInhalor


From: Nicomède DGS

1- Check Zero (30 seconds at room atmosphere ). The figure must read between -5 and + 5 (some devices have an automatic Zero)If the figure is out of this interval, the device has to checked by maintenance (or it has to checked for pollution).For figures at room atmosphere between -5 and + 5, it is necessary to subtract from the figure obtained after smoker’s measurement. (For example, if the CO level in the room is 2 ppm and the value measured is 14, the level of expired CO will be 14-2 = 12 ppm.)

2- Use a single use mouth piece.3- Deep breath, then hold the breath for 15 seconds, then breath out in a normal way, for as

long as possible (”emptying lungs completely").The reading is made 30 seconds after the expiration.Measurement is made in particles per (ppm). (Some devises convert on request the equivalent in HbCO.)

4- After the measure, remove the mouth piece and shake the device slowly before taking a second measurement. (Even in this case, it is necessary to wait for Zero which takes around 2 minutes.)

Steps in CO analysisSteps in CO analysisSteps in CO analysisSteps in CO analysis


From: Nicomède DGS

The measure of the expired CO level is related to CO in haemoglobin (HbCO = carboxyl haemoglobin) and CO related to muscles.

The level of expired CO will reflect recent tobacco intoxication (other causes of CO intoxication: underground car parks, fires, extreme pollution....).

CO’s half life in the body is approximately 6 hours

Expired CO analyser Expired CO analyser Expired CO analyser Expired CO analyser


From: Nicomède DGS

NRT use to start smoking cessation NRT use to start smoking cessation for hospitalised patientsfor hospitalised patients

Examples of proposed initial dosage (Dosages are best adapted based on the Fagerström test)

Smokes 10-19 cig/day 20-30cig/day > 30 cig/day

not every daynothing or gum

not in the morning

gum high dose patch

< 60' after waking up

gum high dose patchHigh dose patch ±

gum

< 30' after waking up

high dose patchhigh dose patch ± gum

high dose patch +

gum < 5' after waking up

high dose patch ± gum

high dose patch + gum

high + medium patch ± gum

nothing or gum


From: Nicomède DGS

Advice on the use of Nicotine Gum Advice on the use of Nicotine Gum

Nicotine Gum should be available for patient use on request. The smoker needs to:Be encouraged to take the necessary quantity to reduce the

withdrawal symptoms.Place the gum in the mouth and chew it slowly, taking the same

length of time it would take to smoke a cigarette. Usually the gum lasts for at least 30 min.

Be taught to throw away used gum in a safe place in order to avoid a child using it (it contains residual nicotine).

Note the amount of gum used in order to monitor and adapt nicotine dosage.

Without over-dramatising, discourage smoking during this treatment.


From: Nicomède DGS

Advice on the use of Patches Advice on the use of Patches These transdermal devices must be applied on a clean and dry skin in the

morning, replacing immediately the one from the day before (patch 24 hours) or replacing the one taken off before sleeping (patch 16 hours).

Its patch size (30, 20 or 10 cm2) determines the nicotine dosage.Its position must be changed every day. Use scissors to take the patch out of its packaging. Avoid touching the adhesive part of the patch.Avoid moistening the patch too long even if it resists water. If the patch un-sticks it can be re-stuck. After use, the patch is folded and put in a safe place in order to avoid

children playing with it (significant dose of residual nicotine).Without over-dramatising, discourage smoking during this treatment.


From: Nicomède DGS

Characteristics of withdrawal syndromeCharacteristics of withdrawal syndrome(nicotine under dosage)(nicotine under dosage)

Characteristics of withdrawal syndromeCharacteristics of withdrawal syndrome(nicotine under dosage)(nicotine under dosage)

Craving to smoke, nervousness, irritability related to the absence of nicotine intake

Within the first few days, momentary difficulties in concentration,

A sufficient nicotine intake reduces withdrawal symptoms. +++

Analysis is essential within the first few days in order to adjust the dosage.

If symptoms persists and if the smoker is very dependant (Fagerström > 6): increase dosage after 48 hours.


From: Nicomède DGS

Nicotine overdose symptomsNicotine overdose symptoms(less frequent than under dose)(less frequent than under dose)

No withdrawal symptoms, no desire to smoke.From the first day : - Nausea - Palpitations, headaches - Dry mouth (as if I had smoked too much) - Severe insomnia - Diarrhoea• Reduction of the doses disappearing

of the symptoms


From: Nicomède DGS

Comparative study: Bupropion vs NRTComparative study: Bupropion vs NRT

Source : Jorenby NEJM 1999, 340, 685

NB : In this study the dose of NRT is not optimal

0%

20%

40%

60%

80%

100%

0 3 6 12 26 52 weeks

Placebo

patch

Bupropion+ patch

AbstinenceSide effects

Buproprion 11,9%

NRT 6,6%


From: Nicomède DGS

Risk reductionRisk reduction for a smoking related illnessfor a smoking related illness

NRT is prescribed for hospital patients affected by a smoking related illness even without a voluntary request. It enables a consumption decrease (not compensated by a change in smoking habits) : for cardiac patients for respiratory patients for pregnant womenbefore surgical operation


From: Nicomède DGS

Indications for nicotine substitution in cardiovascular disease

Indications for nicotine substitution in cardiovascular disease

Quitting smoking is vitally important Coronary Heart Disease smoker: repeated vasoconstriction High HbCO --> risk ++ Myoglobine-COImmediate benefits from quitting: - suppression of vasoconstrictor effect - diminution of thromboses risk - augmentation of blood fluidity - better oxygenationNicotine replacement therapy is always less dangerous than smoking. Nicotine replacement therapy - necessary when smoking persists - safer than smoking +++


From: Nicomède DGS

Risk reduction for pregnant womenRisk reduction for pregnant women

Cessation without NRT is best.

Nicotine alone is better than smoking cigarettes : hundreds of toxic products are contained in tobacco smoke especially CO which can asphyxiate the baby.

Nicotine in amniotic fluid : use preferably a treatment which lasts less than 24 hours : gum or 16 hour patch.


From: Nicomède DGS

NRT indicators for smokers in hospital NRT indicators for smokers in hospital

Being a hospital patient is an indication for NRT

• whatever preparation stage the dependant patient is at and

• whatever illness justifies his presence in the hospital

Substitution avoids the patient to suffer from severe withdrawal syndrome

Being a hospital patient is an indication for NRT whatever stage of change (cessation) the dependant patient is at and whatever illness justifies his presence in the hospital.

Substitution spares the patient suffering from severe withdrawal symptoms.


From: Nicomède DGS

What can hospital staff do if they see a patient What can hospital staff do if they see a patient smoking inside the hospital ?smoking inside the hospital ?

Do you know that smoking is prohibited

within the hospital ?

Do you know that smoking is prohibited

within the hospital ?

Would you like to take advantage of your hospital stay to stop smoking ?

Would you like to take advantage of your hospital stay to stop smoking ?

yesyes

Propose NRTPropose NRT

nono

Help cessationHelp cessation

nono yesyes

Explain

policy

Explain

policy


From: Nicomède DGS

Cardiovascular effects

• Interaction tobacco Interaction tobacco /contraceptives/contraceptives

• Fall in cardiac related Fall in cardiac related deathsdeaths


From: Nicomède DGS

• The risk of dying from a cardiac related illness diminishes rapidly.

• Gradually the risk will reduce to become that of a non smoker.

Source Health Ministry USA

After smoking cessation:After smoking cessation:fall in cardiac related deathsfall in cardiac related deaths

Good News !


From: Nicomède DGS

Decrease in coronary related deaths Decrease in coronary related deaths after smoking cessationafter smoking cessation

10

8

6

4

2

00 5 10 15 20 25

Years after cessation

source : Health Minister USADeath for1000

smokers

ex-smokersNon smoker risk


From: Nicomède DGS

Lung cancer risk drop after smoking cessationLung cancer risk drop after smoking cessation

1.4

1.2

1.0

0.8

0.6

0.4

0.2

Years after cessationsource : Doll R et Peto R. British Medical Journal

deaths for

1 000

smokers

ex-smokers

Non smoker risk

0 252015105


From: Nicomède DGS

After smoking cessation, the drop After smoking cessation, the drop in respiratory related deathsin respiratory related deaths

Smoking cessation leads to :

• A progressive drop in the risk of dying from lung cancer. After 10 years, the risk remains higher than that of a non-smoker.

• Halts the progression of emphysema.

• A relief in coughing, often in breathlessness and even in the results of respiratory function tests.


From: Nicomède DGS

Smoking cessation is a major treatment for cardiac and Smoking cessation is a major treatment for cardiac and respiratory diseasesrespiratory diseases

After myocardial infarction :

Beta blockers and aspirin increase survival chances by at least 50%. Smoking cessation is the only treatment which doubles survival chances and divides in two the risk of coronary thrombosis recurrence.

After an operation for lung cancer, smoking cessation has more benefits than radiotherapy or chemotherapy.

Source :US department of health and human Service N°PHS 84-50204

Dally L BMJ 1983, 287, 324-326


From: Nicomède DGS

Others effect

Health related motivations

• 23 tobacco related illnesses • Other cancersOther cancers• Tobacco, alcohol and oesophageal Tobacco, alcohol and oesophageal

cancercancer• Smoking effects on skin and voiceSmoking effects on skin and voice• Risk of contracting an illness due to Risk of contracting an illness due to

smokingsmoking• Smoking cessation benefitsSmoking cessation benefits


From: Nicomède DGS

(% attributed amongst men)

• Mouth cancer (74%)

• Oesophageal cancer (53%)

• Cancer of the Larynx (87%)

• Cancer of the Bladder (50%)

• Cancer of the Kidneys (39%)

• Cancer of the Pancreas (38%)

• Cancer of the Cervix (6% femme)

Other cancers attributed & associated with Other cancers attributed & associated with tobaccotobacco

Source : Hill Conf Consensus, 1998


From: Nicomède DGS

• Smoking damages skin elastic fibres.• Elastic fibres are thicker, shorter and less

numerous in smokers’ skin.• Skin gets wrinkled earlier.• When quitting smoking skin tone improves

rapidly and skin is less grey.

• Smoking makes voice become hoarse especially for women.

Smoking effects on skin and voiceSmoking effects on skin and voice


From: Nicomède DGS

After give up smoking the former smoker rediscovers

- pleasure of a normal breath

- taste and good smell of food

- freedom from nicotine ( the end of nicotine slavery)

- disappearance of tobacco smell

- pleasure in not generating a smoky atmosphere for friends, family…

- pleasure in better health

Quality of life


From: Nicomède DGS

Smoking cessation benefitsSmoking cessation benefits

Sources : Engleland,1996; Fielding, 1985; Samet,1991; Slama, 1998.

Risk reduction from cessationRisks of disease

Coronary thrombosis

Cerebro -vascular incidents

Short term Long term

Drop by 50% of the risk at 1 year

same risk as a non smoker at 1 year

same risk as a non smoker after 5-20 years

Lung cancer Drop in risk after 5 years

50-90 %risk drop after 15- 20 years

COPD Low risk reduction 50 %drop in 20 years

same risk as a non smoker after 10 years

Lips, mouth and pharynx cancer

Pancreascarcinoma

Unknownsame risk as a non smoker after 28 years

Fast risk reduction


From: Nicomède DGS

European adaptation will be developed with many contributor : :BelgiumBelgiumMichael Petiaux. Fares - Brussel

SpainSpainGalice

Begoña Alonso. Direction Générale de la santé publique. Gouvernement de Galice. Santiago de CompostelaJorge Suanzes. Direction de la santé publique. Gouvernement de Galice. Santiago de Compostela

CatalognePilar Roig. Hopital Sant Joan de Reus. TarragonaEsteve Salto. Direction Générale de la santé publique. Catalan Government. BarcelonaElvira Mendez. Institut Catalan d’Oncologie. Barcelona Tarsila Ferro. Institut Catalan d’Oncologie. Barcelona

FranceFranceAnne-Laure Douspis. AP-HP – European Network for Smoke-free Hospital. ParisLoïc Josseran. AP-HP - European Network for Smoke-free Hospital ParisAnne Marie Schoelcher AP-HP - Network for Smoke-free Hospital ParisBertrand Dautzenberg. AP-HP - European Network for Smoke-free Hospital Paris

IrelandIrelandAnn O`Riordan, National Health Promoting Hospitals Network, Ireland

This training guide is base on the French Nicomède training module This training guide is base on the French Nicomède training module developed with the help of French Ministry of Healthdeveloped with the help of French Ministry of Health

Documents

Nico-hosp 1 Training hospital staff to deal with smoking From: Nicomède DGS Training programme designed for hospital staff to deal with smoking Version