Tobacco Free:Tobacco Free:The NurseThe Nurse’’s Roles Role

Linda Sarna, RN, Linda Sarna, RN, DNScDNScProfessor, UCLA School of NursingProfessor, UCLA School of Nursing

April, 2008April, 2008University of WashingtonUniversity of Washington

Changing what agood nurse doesrequires knowledge& skills

Objectives

Describe the health impact of tobacco use and theDescribe the health impact of tobacco use and thehealth benefits of quittinghealth benefits of quitting

Discuss how to implement effective evidence-Discuss how to implement effective evidence-based cessation strategies for helping patients quitbased cessation strategies for helping patients quitusing tobaccousing tobacco

Address major barriers and facilitatorsAddress major barriers and facilitators

TRENDS in ADULTSMOKING,

by SEX — U.S., 1955–2006Trends in cigarette current smoking among persons aged 18 or older

Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey;1965–2005 NHIS. Estimates since 1992 include some-day smoking

Perc

ent

70% want to quit70% want to quit

0

10

20

30

40

50

60

1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999 2003

Male

Female 23.9%18.0%

20.8% of adultsare current

smokers

Year

Washington State Adult Cigarette Use: 1997-2006Washington State Adult Cigarette Use: 1997-2006 (BRFSS)(BRFSS)

0

5

10

15

20

25

30

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Overall

Male

Female

Male 18.9%, Female 15.3% Overall 17.1%Male 18.9%, Female 15.3% Overall 17.1%17.6% decrease: 235,000 fewer smokers17.6% decrease: 235,000 fewer smokers

Health Disparities: Smoking prevalenceby race/ethnicity in Washington 33% Native Americans33% Native Americans 17.8% African Americans17.8% African Americans 7.3% Asian7.3% Asian 25.8% Pacific Islanders25.8% Pacific Islanders 16.8% Hispanics16.8% Hispanics 30% low income (<$25,000/yr)30% low income (<$25,000/yr)

Annual Causes of Death, United States, % in 1990and 2000

1

1

1

2

3

4

5

14

19

0.7

1.8

0.8

1.2

2.3

3.1

3.5

16.6

18.1

0 2 4 6 8 10 12 14 16 18 20

Illicit drug use

Motor ve hicle s

Se xual be havior

Fire arms

Pollutants/toxins

Infe ctious age nts

Alcohol

Poor die t.lack of e xe rcise

Tobacco

1990 2000

Percentage (of all deaths)

•The percentages used in this figure are composite approximations derived from published scientific studiesThat attribute deaths to these causes.Source: McGinnis JM, Foege WH. Actual causes od death in the United States. JAMA 1993; 270: 2207-12;Mokdad et al., JAMA, 2004

2004 Report of the Surgeon GeneralHealth Consequences of Smoking

Smoking harms nearly every organ in the body,Smoking harms nearly every organ in the body,causing many diseases and reducing the health ofcausing many diseases and reducing the health ofsmokerssmokers

Quitting smoking has immediate as well as long-Quitting smoking has immediate as well as long-term health benefitsterm health benefits

Smoking cigarettes with lower tar and nicotineSmoking cigarettes with lower tar and nicotineprovide not health benefitsprovide not health benefits

List of diseases has expandedList of diseases has expanded

ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING,1997–2001

Centers for Disease Control and Prevention. (2005). MMWR 54:625–628.

32%28%23%

9%8%

<1%

437,902 deaths annually; 7,645 in WA state

1,8281,828OtherOther34,69334,693Cancers other than lungCancers other than lung38,11238,112Second-hand smoke*Second-hand smoke*

101,454101,454Respiratory diseasesRespiratory diseases123,836123,836Lung cancerLung cancer137,979137,979Cardiovascular diseasesCardiovascular diseases

Percentage of all smoking-attributable deaths*

* In 2005, it was estimated that nearly 50,000 persons died due to second-hand smoke exposure.

Cancer Death Rates*, for Men,US,1930-2004

*Age-adjusted to the 2000 US standard population.Source: US Mortality Public Use Data Tapes 1960-2004 US Mortality Volumes 1930-1959,National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.

Cancer Death Rates for Women,US 1930-2004

*Age-adjusted to the 2000 US standard population.Source: US Mortality Public Use Data Tapes 1960-2003, US Mortality Volumes 1930-1959,National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.

Other Morbidity

OsteoporosisOsteoporosis CataractsCataracts Impotence/infertilityImpotence/infertility Early menopauseEarly menopause Periodontal disease (bad breath, discolored teeth, alteredPeriodontal disease (bad breath, discolored teeth, altered

taste and smell)taste and smell) WrinklesWrinkles Poor surgical outcomesPoor surgical outcomes

Women and lung cancer

Surgeon General ReportSurgeon General Reportin 1964 linking smokingin 1964 linking smokingand lung cancer basedand lung cancer basedprimarily on data fromprimarily on data frommenmen

Lung cancer & women:Lung cancer & women:more annual deathsmore annual deaths(69,800) than breast,(69,800) than breast,ovarian, cervical &ovarian, cervical &endometrial cancerendometrial cancercombinedcombined

Estimated costs of tobacco use

Smoking attributable costs for medical careSmoking attributable costs for medical care(1997-2001): $75 billion(1997-2001): $75 billion 1.95 billion/year for WA1.95 billion/year for WA

Productivity losses: $92 billion Productivity losses: $92 billion

Smoking attributable mortality, CDC, July 1, 2005

14.4% of pregnant women in WA smoke(12.6% national average)

Increased carbon monoxide,Increased carbon monoxide, Increased spontaneousIncreased spontaneous

abortion, premature delivery,abortion, premature delivery,still birthstill birth

Low birth weight, cleft palateLow birth weight, cleft palate Decreased oxygenDecreased oxygen Increase in nicotine receptorsIncrease in nicotine receptors 910 deaths, 910 deaths, estest, 1997-2001, 1997-2001

Smoking attributable mortality,CDC, July 1, 2005

WA state: 4.3% use Smokeless “spit” tobacco

Obesity and Smoking:shorter life spans

Overweight people who are non-smokers lose: 3Overweight people who are non-smokers lose: 3years of lifeyears of life

Obese people who are non-smokers lose: 7 yearsObese people who are non-smokers lose: 7 years

Obese people who are smokers lose: 13.5 yearsObese people who are smokers lose: 13.5 years

Source: USA Today, October 14, 2003, page 7DSource: USA Today, October 14, 2003, page 7D

USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of theSurgeon General.

There is no safelevel of second-

hand smoke.

Second-hand smoke causes prematureSecond-hand smoke causes prematuredeath and disease in nonsmokers (childrendeath and disease in nonsmokers (childrenand adults)and adults)

Children:Children:Increased risk for sudden infant deathIncreased risk for sudden infant death

syndrome, acute respiratory infections,syndrome, acute respiratory infections,ear problems, and more severe asthmaear problems, and more severe asthma

2006 REPORT of theSURGEON GENERAL:

INVOLUNTARY EXPOSURE to TOBACCO SMOKE

HELPING SMOKERS QUIT IS aCLINICIAN’S RESPONSIBILITYClinicians have a professional obligation to help theirClinicians have a professional obligation to help their

patients quit using tobacco.patients quit using tobacco.

THE DECISION TO QUIT LIES IN THEHANDS OF EACH PATIENT.

0

5

10

15

30 40 50 60

Yea

rs o

f life

gai

ned

Age at cessation (years)

Prospective study of 34,439 male British doctorsProspective study of 34,439 male British doctors Mortality was monitored for 50 years (1951Mortality was monitored for 50 years (1951––2001)2001)

On average, cigarette smokersdie approximately10 years younger than dononsmokers.

Among those who continuesmoking, at least half will diedue to a tobacco-relateddisease.

SMOKING CESSATION: REDUCED RISKof DEATH

Doll et al. (2004). BMJ 328(7455):1519–1527.

QUITTING: HEALTH BENEFITS

Lung cilia regain normal functionAbility to clear lungs of mucusincreasesCoughing, fatigue, shortness ofbreath decreaseExcess risk of CHD

decreases to half that of acontinuing smoker

Risk of stroke is reduced to that ofpeople who have never smokedLung cancer death rate drops

to half that of a continuingsmoker

Risk of cancer of mouth,throat, esophagus, bladder,kidney, pancreas decrease

Risk of CHD is similar to that ofpeople who have never smoked

2 weeks to3 months

1 to 9months

1year

5years

10years

after15 years

Time Since Quit Date Circulation improves,

walking becomes easier Lung function increases up

to 30%

Reduction in amount of smoking

TOTAL CESSATION NECESSARYTOTAL CESSATION NECESSARYFOR HEALTH BENEFITSFOR HEALTH BENEFITS

NO SUCH THING AS A SAFENO SUCH THING AS A SAFECIGARETTE OR SAFE AMOUNT OFCIGARETTE OR SAFE AMOUNT OFSMOKINGSMOKING

http://cancercontrol.cancer.gov/tcrb/smokersrisk/charts/index.jsp

Calculate smokers risk & benefits of quitting

Nicotinestimulates

dopamine release

Repeat administration

Tolerance develops

Discontinuation leads towithdrawal symptoms.Pleasurable feelings

Nicotine addictionis not just a bad habit.

ADDICTION to NICOTINE:Tobacco Dependence is a chronic relapsingcondition

“Cigarettes are not addictive”

“Cigarettes are nicotine delivery devices”(Fiore, 2000)

Henningfield et al., Drug Alcohol Depend 1993;33:23-29.

0

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40

50

60

70

80

0 1 2 3 4 5 6 7 8 9 10

Minutes after light-up of cigarette

Pla

sma

nic

oti

ne

(n

g/m

L) Arterial

Venous

Nicotine reaches the brain within 11 secondsNicotine reaches the brain within 11 seconds

Nicotine entersNicotine enters brain brain

Stimulation ofStimulation ofnicotine receptorsnicotine receptors

Dopamine releaseDopamine release

DOPAMINE REWARD PATHWAYPrefrontal

cortex

Nucleusaccumbens

Ventraltegmental

area

Addictive Characteristics: DSM IV criteria

Tolerance developsTolerance develops Addictive characteristicsAddictive characteristics

PsychoactivePsychoactive Compulsive use despite harmful effectsCompulsive use despite harmful effects Physical dependencePhysical dependence Withdrawal symptomsWithdrawal symptoms

Symptomspeak within 24-48 hrs, subside within 2-4 weeks

CravingCraving Irritability, anxiety, restlessnessIrritability, anxiety, restlessness Impaired concentration, reaction timeImpaired concentration, reaction time Insomnia, drowsinessInsomnia, drowsiness Depressed moodDepressed mood GI disturbancesGI disturbances

11stst edition, 1996 edition, 1996 22ndnd edition, 2000 edition, 2000 33rdrd edition, 2008 edition, 2008

AHRQ (Agency for HealthcareAHRQ (Agency for HealthcareResearch and Quality) of the USPHSResearch and Quality) of the USPHS(US Public Heath Service)(US Public Heath Service)

CLINICAL PRACTICE GUIDELINETREATING TOBACCO USE and DEPENDENCE

Effective treatments can significantlyincrease long-term abstinence Tobacco dependence is a chronic condition thatTobacco dependence is a chronic condition that

requires repeated interventionrequires repeated intervention Every patient who uses tobacco should be offeredEvery patient who uses tobacco should be offered

treatmenttreatment Tobacco interventions are cost effectiveTobacco interventions are cost effective

Cost Per Years

Of Life Saved

Years of Life

Saved/$1 million

Tobacco Advice $ 1,000 1,000 Tobacco Advice & Nicotine $ 8,000 125 Replacement

Trauma Care $ 20,000 50 Coronary Bypass $ 500,000 2 Heart Transplant $ 1,000,000 1 Low Risk MI in CCU $ 400,000 2.5

BP Rx with Propranolol $ 12,000 86 BP Rx with Captopril $ 83,000 12

Mammography (55 -65) $ 100,000 10 Mammography (40 -49) $ 167,000 6 PAP Smear Screening $ 71,000 14 Low-Risk every 5 -yrs. PAP Smear Screening $ 500,000 2 Low-Risk every year)

Cholestero l (Low-Risk, Male, <45) $ 1,000,000 1 Cholesterol (Low -Risk Female, <45) $10,000,000 0.1

(Only Immunization is a cheaper intervention than tobacco advice.)

CLINICIANS CAN MAKEa DIFFERENCE

Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

0

10

20

30

No clinician Self-help material Nonphysician

clinician

Physician clinician

Type of Clinician

Est

imat

ed a

bst

inen

ce a

t 5+

month

s

1.0 1.1(0.9,1.3)

1.7(1.3,2.1)

2.2(1.5,3.2)

n = 29 studies

Compared to smokers who receive no assistance from aclinician, smokers who receive such assistance are1.7–2.2 times as likely to quit successfully for 5 or moremonths.

NURSES CAN MAKE aDIFFERENCE

0

10

20

Usual Care Nurse Intervention

Type of Intervention

n = 31 studies; 15,205 participants Compared to smokers who receive usual care,smokers who receive assistance from a nurse have a28% greater probability of successfully quitting for 5 ormore months.

Rice & Stead. (2008). Cochrane Database Syst Rev. 1:CD001188.

Estim

ated

abs

tinen

ce a

t5+

mon

ths

Nursing intervention for smoking cessation vs. usual care

1.01.28

(1.2, 1.4)

Algorithm for Treating Tobacco Use

Provide appropriate

tobacco dependence

treatments

Promote motivation

to quit

Is patient now

willing to quit?

Prevent relapse No intervention

required-encourage

continued abstinence

DId patient once

use tobacco?

Does patient now

use tobacco?

IF YES IF NO

IF YES IF NO IF YES IF NO

Clinical Practice Guidelines, 2000

The “5 A’s” for Cessation Intervention

Schedule followup contact, preferably within the first week afterSchedule followup contact, preferably within the first week afterthe quit date.the quit date.

AArrangerrangefollowup.followup.

For the patient willing to make a quit attempt, use counseling andFor the patient willing to make a quit attempt, use counseling andpharmacotherapy to help him or her quit.pharmacotherapy to help him or her quit.

AAssist in quitssist in quitattempt.attempt.

Is the tobacco user willing to make a quit attempt at this time?Is the tobacco user willing to make a quit attempt at this time?AAssessssesswillingness towillingness tomake a quitmake a quitattempt.attempt.

In a clear, strong and personalized manner urge every tobacco userIn a clear, strong and personalized manner urge every tobacco userto quit.to quit.

AAdvise to quit.dvise to quit.

Identify and document tobacco use status for every patient at everyIdentify and document tobacco use status for every patient at everyvisit.visit.

AAsk aboutsk abouttobacco use.tobacco use.

Source: Clinical Practice Guideline, 2000

Resource for Nurses HelpingHelping SmokersSmokers QuitQuit: A: A

Guide for Nurses Guide for Nurses usingusingthe 5Athe 5A’’ss

Nurses have the power toNurses have the power tomake a BIG differencemake a BIG difference 2.4 mill nurses helped2.4 mill nurses helped

one person/monthone person/monthquit, we help 28quit, we help 28million smokers quitmillion smokers quit

www.tobaccofreenurse.org

Ask: Essential to assess smoking status

Institutional commitmentInstitutional commitment Systematically identify*all tobacco usersSystematically identify*all tobacco users

at every visit ( increase quit rate)at every visit ( increase quit rate)Vital signs approach, stickersVital signs approach, stickersComputerized recordsComputerized records

Assessment Facts

70% of smokers see a health care provider70% of smokers see a health care providerevery yearevery year

70% of smokers want to quit70% of smokers want to quit

90% are now asked about smoking90% are now asked about smoking

ADVISE

Health care provider’s advice to quit isa powerful motivator

Brief advice by a clinician(< 3 minutes) significantly increase long-term

abstinence rates

Delivering AdviceDelivering AdviceAdvice should beAdvice should be::

•• ClearClear: : ““I think it is important for you to quitI think it is important for you to quitsmoking now and I will help you.smoking now and I will help you.””

•• StrongStrong: : ““I need you to know that quittingI need you to know that quittingsmoking is the most important thing you cansmoking is the most important thing you cando to protect your health.do to protect your health.””

•• PersonalizedPersonalized: Tie smoking to current: Tie smoking to currenthealth/illness/symptom, and/or the impact ofhealth/illness/symptom, and/or the impact ofsmoking on others in household.smoking on others in household.

Patients WANT help

Numerous studies show that patients, even thoseNumerous studies show that patients, even thosewho plan to continue smoking, who plan to continue smoking, preferprefer that health that healthprofessionals advise them to quitprofessionals advise them to quit

Most smokers want to quit and want support andMost smokers want to quit and want support andencouragement to do so, especially from thoseencouragement to do so, especially from thosethey highly respect and trustthey highly respect and trust

ASSESSWillingness to make a quit

attempt

The “5 R’s” to Motivate Patients

Motivational intervention should be repeated every timeMotivational intervention should be repeated every timean unmotivated patient visits the clinic settingan unmotivated patient visits the clinic setting

RRepetitionepetition

Ask patient to identify barriers or impediments toAsk patient to identify barriers or impediments toquittingquitting

RRoadblocksoadblocks

Ask patient to identify potential benefits of stoppingAsk patient to identify potential benefits of stoppingtobacco usetobacco use

RRewardsewards

Ask patient to identify potential negative consequencesAsk patient to identify potential negative consequencesof tobacco useof tobacco use

RRisksisks

Encourage patient to indicate why smoking isEncourage patient to indicate why smoking ispersonally relevantpersonally relevant

RRelevanceelevance

Use brief motivational interviewingstrategies to increase quit attempts Reasons for lack of motivationReasons for lack of motivation

Lack information Lack information Fears, concerns about quitting Fears, concerns about quitting Demoralized because of past relapses Demoralized because of past relapses Lack financial resources Lack financial resources

Exploring feelings, beliefs to uncover ambivalence aboutExploring feelings, beliefs to uncover ambivalence aboutusing tobaccousing tobacco

Support interest and commitment in changingSupport interest and commitment in changing

Promoting motivation to quit

Express empathyExpress empathy How important do you think it is for you to quitHow important do you think it is for you to quit

smoking?smoking? Reasons for continuing to smokeReasons for continuing to smoke What might happen if you quit?What might happen if you quit? Reflective listeningReflective listening

What you have heardWhat you have heard Normalize feelings, concernsNormalize feelings, concerns

When patients express resistance ““Sounds like you are feeling pressured to quitSounds like you are feeling pressured to quit””

Express empathyExpress empathy ““YouYou’’re worried about how you would managere worried about how you would manage

withdrawal symptomswithdrawal symptoms””

Support self-efficacySupport self-efficacy Help to build upon past experiencesHelp to build upon past experiences ““Would you be willing to use a website to get moreWould you be willing to use a website to get more

information?information?”” Ask patient to share ideas about cessationAsk patient to share ideas about cessation

Assist: Effective treatments areavailable

One half of all smokers have quitOne half of all smokers have quit Even interventions <3 min increase quit rate Even interventions <3 min increase quit rate Brief counseling 3-10 minutes also worksBrief counseling 3-10 minutes also works Person-to-person treatment delivered forPerson-to-person treatment delivered for 4 or 4 or

more sessions is most effectivemore sessions is most effective Dose-response relationship: higher success rates withDose-response relationship: higher success rates with

increasing treatment intensityincreasing treatment intensity

CHANGING BEHAVIOR Many do not understand the need to change behaviorMany do not understand the need to change behavior

They can just They can just ““make themselves quitmake themselves quit””

Few adequately PREPARE and PLAN for their quitFew adequately PREPARE and PLAN for their quitattempt.attempt.

< 5% of people who quit without assistance are successful< 5% of people who quit without assistance are successfulin quitting for more than a year.in quitting for more than a year.

Behavioral counseling is a key component of treatment fortobacco use and dependence.

Providing Counseling & Social SupportProviding Counseling & Social Support

•• Individual or group counseling, proactiveIndividual or group counseling, proactivetelephone counselingtelephone counseling

•• Problem solving/skills trainingProblem solving/skills training

••Reasons for quittingReasons for quitting

••Reviewing past quit attempts, barriersReviewing past quit attempts, barriers

••Coping strategiesCoping strategies

Brief Behavioral Counseling(Also provided through telephone quitlines) Set Quit date:Set Quit date:

Set a stop date, preferably within 2 weeksSet a stop date, preferably within 2 weeks Starting on the quit date, total abstinence is essentialStarting on the quit date, total abstinence is essential

Review Past quit experience:Review Past quit experience: Identify what helped/what hurtIdentify what helped/what hurt

Anticipate triggers/challenges in upcoming attempt:Anticipate triggers/challenges in upcoming attempt: Discuss challenges/triggers and how patient willDiscuss challenges/triggers and how patient will

successfully overcome themsuccessfully overcome them Provide encouragement and supportProvide encouragement and support

Referral to resources

On site smoking cessation teams, clinicsOn site smoking cessation teams, clinics Referral to counseling: group, individualReferral to counseling: group, individual

Special programs: ALA, ACS, othersSpecial programs: ALA, ACS, others 1-800-Quitnow1-800-Quitnow Refer to internet supportRefer to internet support

www.quitnetwww.quitnet www.smokefree.govwww.smokefree.gov

Washington StateWashington StateTobacco Control ResourcesTobacco Control Resources

Washington State Tobacco Quit LineWashington State Tobacco Quit Line http://www.quitline.com/http://www.quitline.com/

Washington State Department of HealthWashington State Department of HealthTobacco Prevention and Control ProgramTobacco Prevention and Control Program

http://http://www.doh.wa.gov/Tobacco/default.htmwww.doh.wa.gov/Tobacco/default.htm

Pharmacotherapy:

Chief obstacle to quitting is theaddictive nature of nicotine:physical dependence, tolerance,

withdrawal symptoms

There are numerous effectivemedications

Cessation Pharmacotherapy Proven safe and effective for most patientsProven safe and effective for most patients Nicotine replacement therapies (NRT) medications approvedNicotine replacement therapies (NRT) medications approved

by the FDA for smoking cessationby the FDA for smoking cessationNicotine gum-OTC (2mg approved as Rx 1984; 4mg approvedNicotine gum-OTC (2mg approved as Rx 1984; 4mg approved

as Rx 1992; OTC 1996)as Rx 1992; OTC 1996) Nicotine patch Nicotine patch –– Rx and OTC (approved as Rx 1991; OTC Rx and OTC (approved as Rx 1991; OTC

1996)1996) Nicotine nasal spray- Rx (1996)Nicotine nasal spray- Rx (1996) Nicotine inhaler- Rx (1997)Nicotine inhaler- Rx (1997) Nicotine lozenge-OTC (2002)Nicotine lozenge-OTC (2002)

BuproprionBuproprion SR (Zyban)- Rx (1997) SR (Zyban)- Rx (1997) VareniclineVarenicline ( (ChantixChantix)-Rx (2006))-Rx (2006)

0

5

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15

20

25

1/0/1900 1/10/1900 1/20/1900 1/30/1900 2/9/1900 2/19/1900 2/29/1900

Pla

sm

a n

ico

tin

e (

mcg

/l)

Cigarette

Moist snuff

Nasal spray

Inhaler

Lozenge (2mg)

Gum (2mg)

Patch

0 10 20 30 40 50 60

Time (minutes)

Cigarette

Moist snuff

Nicotine Delivery SystemsPlasma nicotine concentrations

Nicotine levels for various nicotine-containing products

NICOTINE GUM: Nicorette; generic(GlaxoSmithKline; Watson Labs)

Approved for Rx use in 1984; OTC in 1996Approved for Rx use in 1984; OTC in 1996

Resin complexResin complex NicotineNicotine PolacrilinPolacrilin

Sugar-free chewing gum baseSugar-free chewing gum base

Buffering agents to enhance buccal absorption of nicotineBuffering agents to enhance buccal absorption of nicotine

Available: 2 mg, 4 mg; regular, mint, orangeAvailable: 2 mg, 4 mg; regular, mint, orange

TRANSDERMAL NICOTINE PATCHNicoderm CQ (GlaxoSmithKline); generic

Nicotine well absorbed across the skinNicotine well absorbed across the skin

Plasma nicotine levels lower and fluctuate less thanPlasma nicotine levels lower and fluctuate less thanwith smokingwith smoking

3-step Rx allows for gradual reduction of nicotine dose3-step Rx allows for gradual reduction of nicotine dose

NICOTINE INHALERNicotrol Inhaler (Pharmacia) (3-6 months)

Approved for Rx use in 1997Approved for Rx use in 1997Nicotine inhalation systemNicotine inhalation system

MouthpieceMouthpiece Cartridge with porous plug containingCartridge with porous plug containing

10 mg nicotine10 mg nicotine

Delivers 4 mg nicotine vapor,Delivers 4 mg nicotine vapor,absorbed across absorbed across buccalbuccal mucosa mucosa

May satisfy hand-to-mouth ritual ofMay satisfy hand-to-mouth ritual ofsmokingsmoking

NICOTINE NASAL SPRAYNicotrol NS (Pharmacia)

Approved for Rx use in 1996Approved for Rx use in 1996Aqueous solution of nicotine,Aqueous solution of nicotine,

10 ml spray bottle10 ml spray bottleEach metered dose actuationEach metered dose actuation

deliversdelivers 50 50 µµL sprayL spray 0.5 mg nicotine0.5 mg nicotine

Rapidly absorbed across nasalRapidly absorbed across nasalmucosamucosa

Nicotine Lozenge: Commit(GlaxoSmithKline)

Approved for OTC use inApproved for OTC use in20032003

2 & 4 mg2 & 4 mg 9-20 per day9-20 per day Reduce over 12-weekReduce over 12-week

programprogram Mouth tinglesMouth tingles

BUPROPION SR (ZYBAN)(GlaxoSmithKline)

Non-nicotineNon-nicotinecessation aidcessation aid

Sustained releaseSustained releaseantidepressantantidepressant

Oral formulationOral formulation

VARENICLINEChantix (Pfizer)

Non-nicotine cessation aidNon-nicotine cessation aid Partial nicotinic receptor agonistPartial nicotinic receptor agonist Clinical effectsClinical effects

↓↓ symptoms of nicotine symptoms of nicotinewithdrawalwithdrawal

Blocks stimulationBlocks stimulationresponsible forresponsible forreinforcement & rewardreinforcement & rewardassociated with smokingassociated with smoking

VARENICLINE: DOSINGBegin therapy 1 week PRIOR to their

quit date. Dose is gradually increased to minimizetreatment-related nausea and insomnia.

1 mg bid1 mg bidWeeks 2Weeks 2––1212

0.5 mg bid0.5 mg bidDays 4Days 4––77

0.5 mg qd0.5 mg qdDays 1Days 1––33

DoseDoseTreatment DayTreatment Day

Initialdosetitration

VARENICLINE:ADVERSE EFFECTS

Common side effects include:Common side effects include:

Nausea/vomiting (temporary, take after eating)Nausea/vomiting (temporary, take after eating)

Sleep disturbances (insomnia, abnormal dreams, usuallySleep disturbances (insomnia, abnormal dreams, usuallytemporary)temporary)

Constipation, flatulenceConstipation, flatulence

FDA communicationFDA communication

Suicidal thoughts, new onset depressionSuicidal thoughts, new onset depression

Aggressive and erratic behaviorAggressive and erratic behavior

DrowsinessDrowsiness

Combine counseling & meds

Some medications can be combinedSome medications can be combinedCombination of counseling andCombination of counseling and

medication is more efficacious thanmedication is more efficacious thaneither medication or counseling aloneeither medication or counseling alone

Extended Use of CessationPharmacotherapy

For smokers with persistent withdrawal symptoms orFor smokers with persistent withdrawal symptoms orwho desire long-term therapy for maintainingwho desire long-term therapy for maintainingabstinenceabstinence

Minority of smokers who successfully quit use Minority of smokers who successfully quit use adadlibitumlibitum NRT agents long-term NRT agents long-term

Use does not present known health risks Use does not present known health risks NRT not FDA-approved for long-term maintenanceNRT not FDA-approved for long-term maintenance

Arrange for Follow-Up

Among the 19 million who tried to quit in 2005,Among the 19 million who tried to quit in 2005,only 4-6% were smoke-free one year later only 4-6% were smoke-free one year later (CDC, 2006)(CDC, 2006)

Have a plan for follow-up: phone callsHave a plan for follow-up: phone callsEncouragement and reinforcementEncouragement and reinforcement

Relapse common in the first weekRelapse common in the first week Review medication use and side effectsReview medication use and side effects Review benefits & problems with quittingReview benefits & problems with quitting Relapse is not a failure of the smoker or the healthRelapse is not a failure of the smoker or the health

care providercare provider

Variables Associated with HigherQuit Rates High motivation to quitHigh motivation to quit Ready to changeReady to change Confident in ability to quitConfident in ability to quit Supportive social networkSupportive social network

few smokers among family/friendsfew smokers among family/friends workplace bansworkplace bans

Variables Associated with LowerRates High nicotine dependenceHigh nicotine dependence

first cigarette with 30 minutes of awakeningfirst cigarette with 30 minutes of awakening High stress level/recent major life changeHigh stress level/recent major life change History of psychiatric problemsHistory of psychiatric problems

depression,schizophreniadepression,schizophrenia alcoholism/chemical dependencyalcoholism/chemical dependency

Weight Gain

Average person gains <10 lbsAverage person gains <10 lbs Women tend to gain more weight than menWomen tend to gain more weight than men Nicotine gum will delay weight gainNicotine gum will delay weight gain Minor health risk compared to risk of smokingMinor health risk compared to risk of smoking Keep focus on cessationKeep focus on cessation

Smoke-Free laws:Smoke-Free laws: Smoking banned in inSmoking banned in ingovernment & private worksites,government & private worksites,commercial day care centers, restaurantscommercial day care centers, restaurantsand barsand bars

Cigarette taxes:Cigarette taxes: $2.03/pack$2.03/pack

Big Tobacco spendingBig Tobacco spending: : $164.6 million/ year$164.6 million/ year

Policy Matters: Normalize QuittingPolicy Matters: Normalize QuittingWA State EffortsWA State Efforts

Changing standards of practice

The Joint Commission: cessation The Joint Commission: cessation isis an an indicatorindicatorfor for qualityquality of care: smoking cessation for of care: smoking cessation for patientspatientswith diagnoses of acute myocardial infarction,with diagnoses of acute myocardial infarction,heart failure and pneumonia.heart failure and pneumonia.

Changes in accreditation requirements: nursesChanges in accreditation requirements: nurses’’role and changes in practicerole and changes in practice

Barriers to Nursing InterventionsIn Clinical Practice

Smoking in the professionSmoking in the professionLack of professional leadershipLack of professional leadership

Lack of education and skillsLack of education and skills

1932

Health Professionals who smoke are less likely to offer interventions

Smoking prevalence for RNs & LPNs:Current Population Survey Tobacco-Use Supplement Data

0

5

10

15

20

25

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35

1992-93 1995-96 2001-02

RNs

LPNs

Nurses have contributed to our knowledge of thedevastation of tobacco use on women: Nurses’ Health Study

Figure 1. 1976-2000 Mortality rates by never, former, and current smokers: NHS

198315

446

734

1199

1873

262

433

716

1140

1919

2631

406

669

1135

1922

3153

4676

0

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1000

1500

2000

2500

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3500

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4500

5000

50-54 yrs 55-59 yrs 60-64 yrs 65-69 yrs 70-74 yrs 75+ yrs

Age groups

Mo

rta

lity

ra

tes

(d

ea

ths

pe

r 1

00

,00

0 p

ers

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Never smokers

Former smokers

Current smokers

Tobacco Free Nurses

Resources for allnurses to help patientsquit

www. tobaccofreenurses.org

National Nursing Tobacco Control Leadership SummitGaithersburg, MD, March, 2004

Myths about cessation

Smokers donSmokers don’’t want to quitt want to quitMore former than current smokersMore former than current smokers

Health professionals canHealth professionals can’’t helpt helpTreatments donTreatments don’’t workt work

Why Bother?

Single most effective step to lengthen andSingle most effective step to lengthen andimprove patientsimprove patients’’ lives lives

Interventions can take as little as 30 secondsInterventions can take as little as 30 seconds(advice and referral to (advice and referral to quitlinequitline))

No other No other healthhealth result could be achieved with such result could be achieved with sucha small investment of timea small investment of time

Power of Intervention

1/3 to ½ of smokers will die from smoking. Of the1/3 to ½ of smokers will die from smoking. Of the32 million smokers who want to quit, 10-1632 million smokers who want to quit, 10-16million will die from smoking.million will die from smoking.

If the 2.5% cessation rate were increased to 10%,If the 2.5% cessation rate were increased to 10%,2.4 million additional lives would be saved.2.4 million additional lives would be saved.

If the cessation rate rose to 15%, 4 millionIf the cessation rate rose to 15%, 4 millionadditional lives would be saved.additional lives would be saved.