CLINICIANS POSITIONED TO ADDRESS TOBACCO USE

Clinicians

OBJECTIVES

Our detailed course is based on 2008 Updates for Treating Tobacco Use and Dependence.

Designed to boost clinician’s confidence to engage smokers in a conversation with a goal to help them quit.

EXPECTED CONTENT Why is this important? (Impact on families, healthcare, tax payers)

Types of Tobacco and Nicotine Use

Clinicians have an active role, it’s SAD Quiz after this.

Beyond the 40’s Significant Facts

Clinicians Practice Guidelines – Treating Tobacco Use

Smoking and Tobacco use

Today – (Changes, trends, improvements)

Lung and Disease Process as a discussion for clinicians

The 5 A’s

Ask Advise

Assess Assist

Arrange

Expand Vital Signs to ASK

Every Patient Every Visit

We can help you

It is important for

you to quit now

Continuing to smoke can make your

asthma worse

Occasional smoking is

still dangerous

Quitting can dramatically improve your

health

As your clinician, I want you to know that quitting tobacco is the most important thing you can do for your health.

Advise

Are you willing to quit tobacco use?

We can help you.

Yes or no, Either way show them the way.

If the patient is unwilling to quit, provide links, and resources to encourage intervention.

Assess

Florida Residents

http://smokefree.gov/health-effects

Please contact the Bureau of Tobacco Free Florida

850-245-4144

TobaccoFreeFlorida@flhealth.gov

Fax 850-414-7497

Mailing Address

Florida Department of Health Bureau of Tobacco Free Florida

4052 Bald Cypress Way, Mail Bin C-23

Tallahassee, Florida 32399

National – 1800 – Quit – Now

Info to share with your patients

Assist

S – Set an ideal quit date within two weeks.

T- Tell family friends, and coworkers and request support.

A- Anticipate challenges to the upcoming quit attempt, particularly during the critical first few weeks.

R – Remove tobacco products from you environment. Prior to quitting avoid smoking in places where you spend a lot of time. (work, home, car) Make your home smoke free.

Assist

Follow Up

Medication Cautions/Warnings Side Effects Dosage Use Availability

Bupropion/SR 150 Not for use if,▪ Using monoamine oxidase (MAO) inhibitor▪ Use bupropion in any other form▪ History of seizures▪ History of eating disorders▪ See FDA package insert warning regarding suicidality and

antidepressant drugs when used in children, adolescents and young adults

• Insomnia• Dry Mouth

• Day 1-3 150mg each morning

Start 1-2 weeks beforequit date, for 2-6 months

Prescription only• Generic• Zyban• Wellbutrin SR

Nicotine Gum • Caution with Dentures• Do not eat or drink 15 minutes before or during use

• Mouth soreness• Stomach ache

• 1 piece Q1-2 h• 6-15 pieces per day• If < 24 cigs: 2mg• If >25 cigs:/day or

chewing tobacco 4mg

Up to 12 weeks or as needed

OTC only:• Generic • Nicorette

Nicotine Inhaler May irritate mouth/throat at first(but improves with use) Local irritation of mouth & throat

• 6-16 cartridges/day• Inhale 80

times/cartridge• May save partially used

cartridge for next day

Use up to 6 months; taper at end

Prescription only; Nicotrolinhaler

Nicotine Lozenge (2 or 4mg) • Do not eat or drink 15 minutes before or during use• One Lozenge at a time• Limit 20 in 24hours

• Hiccups• Cough• Heartburn

• If smoke/chew> 30 min. after waking: 2mg

• If smoke/chew<30 min. after waking: 4mg

• Wk. 1-6: 1 Q 1-2 h• Wk. 7-9 1 Q 2-4 hrs.• Wk. 10-12: 1 every 4-8 h

3-6 months

NicotineNicotine Spray

• Not for patients with asthma• May irritate nose (improves over time)• May cause dependence

Nasal irritation • 1 dose=1 squirt per nostril

1 to 2 doses per hour• 8 to 40 doses per day• Do not inhale

3-6 months taper at end Prescription only• Nicotrol NS

Medication Cautions/Warnings Side Effects Dosage Use Availability(check Insurance)

Nicotine Patch Do not use if you have severe eczema or psoriasis

Local Skin reactionInsomnia

• One patch per day• If > 10 cigs/day: 21mg for 4

wks,14 mg 2-4wks7mg 2-4wks• If <10/day: 14 mg for 4 wks,

then 7 mg for 4 wks.

8-12 weeks OTC or prescription: • Generic• Nicoderm CQ• Nicotrol

Varenicline Use with Caution in patients with • Significant renal impairment• Serious psychiatric illness• Dialysis• FDA warning: Depressed Mood,

agitation, changes in behavior, suicidal ideation, suicide,

• See www.fds.gov for safe use, and updates

• Nausea• Insomnia• Abnormal, vivid, or strange

dreams

• Days 1-3: 0.5mg every morning

• Days 4-7: 0.5mg twice daily• Day 8 – end: 1mg twice daily.

Start 1 week before quit date; use 3-6 months

Prescription only, Chantix

Combinations:1) Patch + bupropion2) Patch + gum3) Patch + lozenge + inhaler

• Only patch + bupropion is currently FDA approved

• Follow instructions for individual medications

See individual medications above See individual medications above See above See above

Based on 2008 Clinical Practice guideline: Treating Tobacco Use and Dependence

What are the Symptoms of Nicotine Withdrawal?

Withdrawal is different for every smoker‚ but here is a list of the most common symptoms:

Feeling down or sad

Having trouble sleeping

Feeling irritable‚ on edge‚ grouchy

Having trouble thinking clearly and concentrating

Feeling restless and jumpy

Slower heart rate

Feeling more hungry or gaining weight

Medications and behavior changes can help manage the symptoms. Remember that these symptoms‚ including cravings. This will fade with every day that you stay smoke free.

TRIGGERS

When you smoke, it becomes an important part of your life. Certain activities, feelings, and people are linked to your smoking. When you come across these things, they may "trigger" or turn on your urge to smoke. Try to anticipate these smoking triggers and develop ways to deal with them. Here are a few tips:

Go to places that don't allow smoking. Shops, movie theatres, and many restaurants are now smoke free.

Spend more time with non-smokers. You won't want to smoke as badly if you are around people who don't smoke.

Keep your hands busy. Play a game on your phone, eat a healthy snack, or squeeze a stress ball.

Take a deep breath. Remind yourself of the reasons why you want to stop smoking. Think of people in your life who will be happier and healthier because you decided to quit.

For a more detailed description of triggers and tips on handling them, visit our cravings page.

CHALLENGES AND MOOD CHANGES

Mood changes are common after you quit. You might be irritable, restless, or feel down or blue. If you’re experiencing these feelings after quitting smoking, there are many things you can do to help lift your mood.

Exercise. Stay active.The type of exercise depends on how fit you are, but any kind of activity can help—from taking a walk to going to the gym to joining a team sport. If you need to, start small and build over time. This can be hard to do when you are depressed because feeling down saps all your energy. But making the effort will pay off! It will help you feel better.

Structure your day.Create a plan to stay busy. It is especially important to get out of the house whenever you can.

Talk and do things with other people.Many people who are feeling depressed are cut off from others. Having daily contact with other people will help your mood.

Build rewards into your life.For many who are depressed, rewards and fun activities are missing from life. It is helpful to find ways to reward yourself. Even small things, like reading a magazine or listening to music, add up and can help your mood.

Do what used to be fun, even if it does not seem fun right now.One of the common signs of depression is not wanting to do activities that used to be fun. It may take a little time, but doing fun activities again will help improve your mood. Some people like to make a list of fun events and then do at least one a day.

Talk with friends and loved ones.Your support system is a key to you feeling better. Having a chance to tell them your concerns can help things seem less scary.

http://smokefree.gov/ways-to-boost-your-mood-after-quitting

SMOKING

Bidis (pronounced "bee-Dees") are small, thin hand-rolled cigarettes imported to the United States primarily from India and other Southeast Asian countries. They consist of tobacco wrapped in a tendu or temburni leaf (plants native to Asia), and may be secured with a colorful string at one or both ends. Bidis can be flavored (e.g., chocolate, cherry, mango) or unflavored.

BIDI

Bidi smoking is associated with an increased risk for oral, lung, stomach, and esophageal cancer and an increased risk for coronary heart disease and heart attacks, and risk for chronic bronchitis. Bidis are carcinogenic. There is no evidence to indicate that bidis are safer than conventional cigarettes. They have higher concentrations of nicotine, tar, and carbon monoxide than conventional cigarettes sold in the United States, so are even more addictive than cigarettes.

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/bidis_kreteks/index.htm

CIGARETTES

A cigarette is a combination of cured and finely cut tobacco, reconstituted tobacco and other additives rolled or stuffed into a paper wrapped cylinder. Many cigarettes have a filter on one end. More than 4,000 different chemicals have been found in tobacco and tobacco smoke. Among these are more than 60 chemicals that are known to cause cancer.

Studies have proven that smoking cigarettes causes cancers of the bladder, oral cavity, pharynx, larynx (voice box), esophagus, cervix, kidney, lung, pancreas, and stomach, and causes acute myeloid leukemia. It also causes heart disease and stroke

CIGARS

Most cigars are made up of a single type of air-cured or dried tobacco. Cigar tobacco leaves are first aged for about a year and then fermented in a multi-step process that can take from 3 to 5 months. Fermentation causes chemical and bacterial reactions that change the tobacco. This is what gives cigars a different taste and smell from cigarettes. Regular cigars are larger than cigarettes and do not have a filter.

CIGARS CONTINUED

Studies have shown that cigar smoking is linked to cancers of the mouth, lips, tongue, throat, larynx, lung, pancreas and bladder cancer. Cigar smoking, like cigarette smoking, is also linked to gum disease, where the gums shrink away from the teeth. It also raises your risk that teeth will actually fall out.

DISSOLVABLE TOBACCO

This type of tobacco is finely processed to dissolve on the tongue or in the mouth. Varieties include strips, sticks, orbs and compressed tobacco lozenges. They are smoke and spit free, are held together by food-grade binders and look similar to a breath mint or candy. Since this product is very new to the market, research has not been conducted on the health effects. This product does contain nicotine. Smokeless tobacco products are known to cause significant health risks and are not a safe substitute for smoking tobacco

E - CIGARETTES

The e-cigarette is a battery-powered device that contains a cartridge filled with nicotine, flavor and other chemicals. The e-cigarette is not a tobacco product but a nicotine delivery system. The e-cigarette turns the nicotine and other chemicals into a vapor that is then inhaled by the user.

E – CIGARETTES CONTINUED

Re-fillable and replaceable cartridges are available with different nicotine levels and flavors such as menthol, cherry, chocolate, mint, and orange. There are also cartridges available that state they contain no nicotine, although the US Food and Drug Administration (FDA) conducted studies showing that these cartridges do contain nicotine.

This product is often marketed as an alternative to smoking or an aid in quitting but the World Health Organization claims there are no studies showing that the electronic cigarette is a safe and effective nicotine replacement therapy and no scientific evidence to confirm the product's safety. Recent studies by the FDA show that the e-cigarette contains known carcinogens and toxic chemicals that are harmful to the user.

World Health Organization Marketers of electronic cigarettes should halt unproved therapy claims –http://www.who.int/mediacentre/news/releases/2008/pr34/en/index.html obtained July 22, 2009

HOOKAH

Hookah is a pipe used to smoke Shisha, a combination of tobacco and fruit or vegetable that is heated and the smoke is filtrated through water. The Hookah consists of a head, body water bowl and hose. The tobacco or Shisha is heated in the hookah usually using charcoal. According to a World Health Organization advisory, a typical one-hour session of hookah smoking exposes the user to 100 to 200 times the volume of smoke inhaled from a single cigarette. Even after passing through water, tobacco smoke still contains high levels of toxic compounds, including carbon monoxide, heavy metals and cancer-causing chemicals (carcinogens). Hookah smoking also delivers significant levels of nicotine — the addictive substance in tobacco. Hookah smoking has been associated with lung, mouth and other cancers, heart disease and respiratory infections.

KRETEKS

Kreteks (pronounced "Cree-techs") are sometimes referred to as clove cigarettes. Kreteks are imported from Indonesia, and typically contain a mixture consisting of tobacco, cloves, and other additives. As with bidis, standardized machine-smoking analyses indicate that kreteks deliver more nicotine, carbon monoxide, and tar than conventional cigarettes. Kretek smoking is associated with an increased risk for acute lung injury, especially among susceptible individuals with asthma or respiratory infections. Research shows that regular kretek smokers have 13−20 times the risk for abnormal lung function compared with nonsmokers. There is no evidence to indicate that kreteks are safe alternatives to conventional cigarettes.

Source: CDC Fact Sheets- Bidis and Kreteks

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/bidis_kreteks/index.htm obtained July 15, 2009

PIPES

Pipes are often reusable and consist of a chamber or bowl, stem and mouthpiece. Tobacco is placed into the bowl and lit. The smoke is than drawn through the stem and mouthpiece and inhaled. Pipe smoking has been shown to cause gum disease and tooth loss, cancer of the mouth, lip, tongue, throat, larynx, lung, pancreas, kidney, bladder, colon, and cervix as well as leukemia and diseases such as chronic obstructive lung disease, stroke, and coronary heart disease. Pipe smoking can also cause "hairy tongue," furry-looking bumps on the tongue that can become stained by tobacco, making the tongue look discolored or black.

CHEWING TOBACCO AND SNUFF

The two main types of smokeless tobacco in the United States are chewing tobacco and snuff. Chewing tobacco comes in the form of loose leaf, plug, or twist. Snuff is finely ground tobacco that can be dry, moist, or in sachets (tea bag-like pouches). Although some forms of snuff can be used by sniffing or inhaling into the nose, most smokeless tobacco users place the product in their cheek or between their gum and cheek. Users then suck on the tobacco and spit out the tobacco juices, which is why smokeless tobacco is often referred to as spit or spitting tobacco. The nicotine in this tobacco is absorbed primarily through the skin in the mouth. Smokeless tobacco is a significant health risk and is not a safe substitute for smoking cigarettes. Smokeless tobacco contains 28 cancer-causing agents (carcinogens). It increases the risk of developing cancer of the oral cavity, is strongly associated with leukoplakia (a lesion of the soft tissue in the mouth that consists of a white patch or plaque that cannot be scraped off) and recession of the gums.

TREATING TOBACCO USE AND DEPENDENCE

The recommendations were made as a result of a systematic review and meta-analysis of 11 specific topics identified by the Panel (proactive quitlines; combining counseling and medication relative to either counseling or medication alone; varenicline; various medication combinations; long-term medications; cessation interventions for individuals with low socioeconomic status/limited formal education; cessation interventions for adolescent smokers; cessation interventions for pregnant smokers; cessation interventions for individuals with psychiatric disorders, including substance use disorders; providing cessation interventions as a health benefit; and systems interventions, including provider training and the combination of training and systems interventions).

CLINICAL GUIDELINES

1) Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long-term abstinence.

2) It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting.

CLINICAL GUIDELINES

3) Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use the counseling treatments and medications recommended in this Guideline.

4) Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective in this Guideline.

CLINICAL GUIDELINES

5) Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. Two components of counseling are especially effective, and clinicians should use these when counseling patients making a quit attempt:

Practical counseling (problem-solving/skills training)

Social support delivered as part of treatment

CLINICAL GUIDELINES CONTINUED

6) Numerous effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempting to quit smoking—except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents).

Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates: Bupropion SR

Nicotine gum

Nicotine inhaler

Nicotine lozenge

Nicotine nasal spray

Nicotine patch

Varenicline

Clinicians also should consider the use of certain combinations of medications identified as effective in this Guideline.

CLINICAL PRACTICE GUIDELINES

7) Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication.

8) Telephone quitline counseling is effective with diverse populations and has broad reach. Therefore, both clinicians and health care delivery systems should ensure patient access to quitlines and promote quitline use.

CLINICAL PRACTICE GUIDELINES CLINICAL PRACTICE GUIDELINES

9) If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments shown in this Guideline to be effective in increasing future quit attempts.

10) Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in this Guideline as covered benefits.

CONCLUSION

Finally, there is increasing evidence that the success of any tobacco dependence treatment strategy cannot be divorced from the health care system in which it is embedded. The updated Guideline contains new evidence that health care policies significantly affect the likelihood that smokers will receive effective tobacco dependence treatment and successfully stop tobacco use. For instance, making tobacco dependence treatment a covered benefit of insurance plans increases the likelihood that a tobacco user will receive treatment and quit successfully. Data strongly indicate that effective tobacco interventions require coordinated interventions. Just as the clinician must intervene with his or her patient, so must the health care administrator, insurer, and purchaser foster and support tobacco intervention as an integral element of health care delivery. Health care administrators and insurers should ensure that clinicians have the training and support to deliver consistent, effective intervention to tobacco users.

TREATMENT EXTENDERS

Online Resources – find sources that are easy to understand.

Local Quit Lines –

Self Help Materials

WHY QUIT

Toxic – Cigarettes are known to have many chemicals that are harmful There are over 600 chemicals in one cigarette and when burned this creates over 7,000 chemicals

Smoking is a deadly disease that kills nearly 500,000 people annually in the US and approximately 6 million death globally. (cdc)

It is the deadliest preventable disease.

Numerous Diseases caused from Smoking – Decrease quality of life, negatively affect families.

Smoking costs the United States billions of dollars each year.

Total economic cost of smoking is more than $300 billion a year, including Nearly $170 billion in direct medical care for adults5

More than $156 billion in lost productivity due to premature death and exposure to secondhand smoke (cdc.gov fact sheet)

NOT ALL PATIENTS ARE WILLING TO QUIT

3 Main Groups of Tobacco Users:

1) Those who are willing to quit

2) Those who are unwilling to quit now

3) Those who recently quit

Expand Each

1940’S

World War II: Smoking reaches a watershed mark. Rates of smoking increase among both men and women as army rations include cigarettes—often provided free by cigarette companies—and many women, now entering the workforce for the first time, begin smoking on the job. http://www.rwjf.org/maketobaccohistory

World War II: As part of the war effort, US President Roosevelt makes tobacco a protected crop. Cigarettes are include in soldiers’ rations. Tobacco companies send millions of free cigarettes to troops

1950’S Smoking continues to climb, as the evidence for

tobacco’s negative health effects builds. Rigorous studies link tobacco use to death and disease.

Dr.’s Wynder and Graham, of Washington University, USA, published a study showing that of 650 men with lung cancer, 95% had been smoking for 25 years of more.

Read the Article

1960’S Major health organizations join forces to

bring attention to the mounting evidence of the harms of smoking. Cigarette consumption reaches its peak before the landmark Surgeon General's report in 1964 definitively links smoking and lung cancer.

The government asked the tobacco industry to withdraw cigarette coupon schemes. It refused.

1970’S The first major actions are taken to curb death and disease

from tobacco use: TV and radio ads are banned, cigarettes get a strong warning label, and a handful of states and communities restrict smoking in some public places.

The Independent Broadcasting Authority publishes a Code of Advertising Standards which regulates all commercial TV and radio broadcasting. Cigarettes and cigarette tobacco are "unacceptable products" not to be advertised on commercial radio.

1980’S Tobacco control advocacy picks up momentum, and popular culture begins to

acknowledge the dangers of smoking.

A major review article in the American Journal of Epidemiology confirms the link between smoking and cervical cancer.

1990’S

Policy and systems changes, such as higher tobacco excise taxes, smoke-free indoor air laws, and access to cessation treatments, become more widespread as national and advocacy partners join forces in a nationwide initiative to significantly reduce death and disease from tobacco.

This is the first time that health warnings are legally required to be on packaging.

2000’S

Reductions in smoking saved millions of lives, but tobacco use remains the number one cause of preventable death in the United States.

Hospitals, Government facilities, many corporation turn their campuses into smoke free sites.

Employers screening for Tobacco use and will not hire smokers.

Many insurance plans pay for over the counter nicotine medications to end tobacco use.

HEALTH BENEFITS OF QUITTING

Smoking cessation is associated with the following health benefits:

Lowered risk for lung cancer and many other types of cancer.

Reduced risk for heart disease, stroke, and peripheral vascular disease (narrowing of the blood vessels outside your heart).

Reduced heart disease risk within 1 to 2 years of quitting.

Reduced respiratory symptoms, such as coughing, wheezing, and shortness of breath. While these symptoms may not disappear, they do not continue to progress at the same rate among people who quit compared with those who continue to smoke.

Reduced risk of developing some lung diseases (such as chronic obstructive pulmonary disease, also known as COPD, one of the leading causes of death in the United States).

Reduced risk for infertility in women of childbearing age. Women who stop smoking during pregnancy also reduce their risk of having a low birth weight baby.

SMOKE FREE RESOURCES

http://smokefree.gov/ready-to-quit

http://www.ash.org.uk/files/documents/ASH_741.pdf

http://www.ncbi.nlm.nih.gov/books/NBK63952/

http://betobaccofree.hhs.gov/health-effects/smoking-health/index.html

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