1 Tobacco Cessation A Brief Intervention Makes a Difference! October 2007 MaryAnne Waters Tobacco Reduction Coordinator - Interior Health Authority

2 THANKS Mayo Clinic Nicotine Dependence Center (Rochester Minnesota) Calgary Health Region (Alberta) Northern Health Authority (BC) Ottawa Heart Institute (Ontario) Interior Health (BC)

3 Tobacco and You Your journey Values Check

4 Why TOBACCO? Tobacco use remains our number one preventable cause of illness and death in our society!

5 Most tobacco users want to stop!

6 “ How will historians describe a society that: watches the equivalent of 3 jumbo jets crash every day, and does so little to prevent it?” Richard Hurt MD Mayo Clinic 1999 Mayo Clinic slide

7 Challenges - Paradigm shifts –Tobacco use is a chronic disease not “just a bad habit” –Tobacco users are not bad people with a bad habit, they are good people with a difficult disease Tim Gauvin, Mayo Clinic –Tobacco is not the “least of the worries” –Secondhand smoke is not just a nuisance, it’s a health problem. There is NO safe limit of exposure. (Class A carcinogen) –Effective treatment exists

8Ex-smokers Risk of Heart Attack Mayo Clinic slide CM Smokers vs. Ex-Smokers Currentsmokers No. years since quitting smoking Noincreasedrisk Men Women Increasedrisk Relative risk estimate

9 A Very Powerful Intervention… InterventionReduction in Mortality Smoking Cessation36% Statin Therapy29% Beta-Blockers23% ACE Inhibitors23% Aspirin15% Critchley JA, Capewell S. JAMA;2003;290:86-97

10 Cost Effectiveness Smoking Cessation $ 2,000 – 6,000 R x of Hypertension$ 9,000 – 26,000 R x of Hyperlipidemia $ 50,000 – 196,000 Cost per life-year saved: Benowitz NL Prog Cardiovasc Dis 2003;46:91-111

11 “The safety of nicotine-replacement therapy in cardiovascular disease patients is supported by data from randomized trials, efficacy studies, observational data and physiologic studies.” Joseph AM, Fu, Progress in Cardiovascular Diseases 2003;45:

12 “Our finding that nicotine patch therapy did not increase mortality in inpatients admitted with acute coronary syndromes suggests the likelihood of safety in this population…” Meine TJ, Patel MR, et al Am J Cardiol 2005;95:

13 NRT and CV Risk “The use of NRT is not associated with any increase in the risk of myocardial infarction, stroke, or death.” N = 33,247 Hubbard R, Lewis S, et al. Tobacco Control 2005;14:

14 What can be done? Brief Interventions are effective ! ASK, ADVISE, ASSIST Dose Response If we don’t address it the silent message is that “it’s not a problem” If parents don’t smoke; kids much less likely to. “If the 2.2 million working nurses in the U.S. each helped one person per year quit smoking, nurses would triple the quit rate.” Tobacco Free Nurses Don’t forget about secondhand smoke……

15 But do BIT work? l BIT are way better than doing nothing l Simple advice adds 2% to baseline quit rates (to 7%) l 10 minutes of counseling brings it to 19% l Adding medication results in quit rates as high as 29% Most smokers do not need complex, long-term, intensive treatment

16 Brief Interventions - “Bare Bones” Tobacco data tracking on forms is essential Provide support options Sample Scripting: Do you currently use tobacco? __ Yes __ No –If yes, are you interested in stopping? __ Yes __ No –If yes, referral (to Quitline or other local resource) given? __ Yes __ No

17 Brief Interventions, Next Steps 3 A’s: ASK Advise Assist

18 Changes: We don’t all see the world the same! In any change the person changing is the “expert”! We “get by with a little help from our friends”! Help is only help if it is helpful! We have 2 ears and 1 mouth! Opportunityisnowhere!

19 Spirit of Motivational Interviewing A dance not a wrestling match!

20 Motivational Interviewing “… directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Rollnick and Miller, 1995 Used to enhance positive health-behavior change by placing the client in the center of the change process.

21 ASK Do you currently use tobacco? Tell me about where tobacco “fits” for you? One of the areas of health I always discuss is tobacco; where does tobacco fit for you? Are you ready to consider stopping smoking (or chewing)?

22 Advise / Assist My experience in cardiac care is that tobacco is closely linked with heart health; I urge you to consider stopping smoking. As a nurse I see the effects of tobacco on health, would it be helpful for me to share some possible benefits I see for you, if you were to stop smoking? As a …, I know most tobacco users want to quit and effective help exists, would you be interested in finding out what help is available?

23 Assist: Many smokers are very concerned about nicotine withdrawal. Would you be interested in NRT as a support to help you deal with your cravings? If it would be helpful, I could share with you some tips that have worked for others who wanted to stop smoking / chewing….. If it would be helpful, we could discuss some “good things” and some “not so good things” about your tobacco use….

24 Other “tools” Assess readiness for change Assess Nicotine Dependence Assess supports

25 Readiness Ruler On a scale of 0-10: –How ready are you to stop smoking (tobacco)? –How important is stopping to you? –How confident are you in your ability to stop?

26 Assessing Dependence “How soon after waking do you smoke your first cigarette?”  more than 1 hour = low  6-59 minutes = moderate  less than 6 minutes = high “How many cigarettes, on average, do you smoke each day?”  10or less = low  = moderate  20 or more = high

27 Medications Nicotine Replacement Therapy (NRT) 3 Control urges by preventing withdrawal symptoms 3 Patch gum or inhaler 3 Dependence, >10 cigarettes per day, and ready to quit; or, Zyban intolerant Check to see if on local formulary l Bupropion (Zyban) l Champix – available April 2007

28 Assessing Supports: Social support – family and friends Health Professionals Local cessation support – groups, “quit lines” (toll free), web sites Print resources – CCS, Lung Association, etc

29 Handouts “Changes” worksheet 3A’s sample scripts Tobacco Cessation Support – NEXT STEPS Algorithms Benefits of Stopping Scenarios Canadian Quitlines

30 Summary: YOU can MAKE a DIFFERENCE! l Brief Interventions are effective!! l Ask, Advise, Assist – basics can be done in less than a minute. l Start with small steps and build (PDSA cycles) l “You can do it, we can help” message for patients