Tobacco Cessation Techniques Dana H. Breeding, BSN, RN, BS Certified Tobacco Treatment Specialist Certified Health and Wellness Coach

Tobacco, especially smoking, is socially unacceptable. True/False? Your thoughts? Tobacco, especially smoking, is socially unacceptable. True/False? Scenario

Two of the brain-signaling pathways targeted by drugs of abuse transmit dopamine and serotonin: Dopamine and serotonin are chemicals (also known as neurotransmitters) that are normally involved in communication between neurons in the brain. Abused substances can influence functions modulated by either or both of these chemicals. Dopamine is found in numerous brain areas (blue) related to pleasure, motivation, motor function, and saliency of stimuli or events. Serotonin, (red) plays a role in learning, memory, sleep, and mood.

Principles of Tobacco Dependence Treatment Tobacco dependence is a chronic, relapsing condition Nicotine is addictive Effective treatments exist Every person who uses tobacco should be offered treatment Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. April 2009. DSM-5, Tobacco use disorder 305.1 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th ed. Arlington, VA: American Psychiatric Association; 2013. 571-4. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. April 2009. Tobacco use disorder DSM-5, 305.1 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th ed. Arlington, VA: American Psychiatric Association; 2013. 571-4. 4

Tobacco Users Want to Quit Patients and families expect healthcare provider to discuss tobacco use 70% of tobacco users report wanting to quit 44% have made at least one quit attempt in the past year Users say expert advice is important to their decision to quit Basic Counseling Delivered in a non-judgmental manner, usually well-received Even small “doses” are effective. And cumulative! Centers for Disease Control and Prevention. (2008). Cigarette Smoking Among Adults and Trends in Smoking Cessation- United States, 2008. Morbidity and Mortality Weekly Report, 58(44), 127-32. CITATION: Centers for Disease Control and Prevention. (2002). Cigarette Smoking Among Adults- United States, 2000. Morbidity and Mortality Weekly Report, 51(29), 642-5. Centers for Disease Control and Prevention. (2008). Cigarette Smoking Among Adults and Trends in Smoking Cessation- United States, 2008. Morbidity and Mortality Weekly Report, 58(44), 127-32.

Why do family physicians not act Only 70% of family physicians ask their patients if they use tobacco. Only 40% take action. Too busy Lack of expertise No financial incentive Think smokers can’t or won’t quit Don’t want to appear judgmental Respect for patient’s privacy Negative message might scare patients away American Academy of Family Physicians www.aafp.org www.askandact.org

Readiness to Change Pre-contemplation: Not thinking about change, May be resigned, Feeling of no control, Denial: does not believe it applies to self , Believes consequences are not serious Contemplation: Weighing benefits and costs of behavior, proposed change Preparation Experimenting with small changes, gathering information Action Taking a definitive action to change Maintenance Maintaining new behavior over time Relapse Experiencing normal part of process of change Usually feels demoralized [5]

Three Easy Steps Ask Assist Refer If your patient/client uses any tobacco.. ask: If they are interested in quitting? Would they like assistance? Assist If Yes: Recommend/Prescribe medication (and/or NRT) to assist their quit Document services delivered to enhance complexity of visit to level 4 Set a quit date in the next 30 days If no, state without judgement: ‘Quitting tobacco is the single best thing you can do for your health. Let me know when you are ready.’ Refer Local Tobacco Cessation class/program Enroll in Quit-line, via FAX. Set up practice as referral agent. Ask/Assist/Refer strategy that uses a family-centered approach so that parental and teen smoking are all addressed using the tobacco dependence treatment guideline. Assistance includes novel motivational messaging and provision of pharmacotherapy. Referral includes quit line enrollment or referral to local class. Sometimes simple things are profound…In step one we ask what they want and in step 2 we give it to them. If they don’t want anything then make sure home and car are completely smokefree and agree to check in next time Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. April 2009.

The "5 A's" model for treating tobacco use and dependence Ask about tobacco use: Identify and document tobacco use status of every patient at every visit. Advise to quit In a clear, strong and personalized manner urge every tobacco user to quit. Assess For current tobacco user, is the tobacco user willing to make a quit attempt at this time? For the ex-tobacco user, how recent did you quit and are there any challenges to remaining abstinent? Assist For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional behavioral treatment to help the patient quit. For patients unwilling to quit at this time, provide motivational interventions designed to increase future quit attempts. For the recent quitter and any with remaining challenges, provide relapse prevention. Arrange All those receiving the previous A's should receive follow-up. [3]

Tobacco Users who do not want to quit now: Enhancing motivation to quit tobacco—the "5 R's" Relevance - Encourage the patient to indicate why quitting is personally relevant, being as specific as possible Risks - The clinician should ask the patient to identify potential negative consequences of tobacco use. Rewards - The clinician should ask the patient to identify potential benefits of stopping tobacco use. Roadblocks The clinician should ask the patient to identify barriers or impediments to quitting and provide treatment (problem-solving counseling, medication) that could address barriers. Repetition The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting. [3]

Evidenced Based Treatments 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 should also consider the use of certain combinations of medications identified as effective in the Guideline Combinations: Patch + bupropion Patch + gum Patch + lozenge + inhaler Only patch + bupropion is currently FDA approved Follow instructions for individual medications

Real Stories Reluctant Bupropion User Caving Chantix User All Guns blazing – Bupropion and 2 NRTs Persistent Quitter

Augusta Health: Past, Present, and Future Tobacco Free Campus: August 2009 2010’s Now and beyond…

Resources for Tobacco Cessation Treating Tobacco Use and Dependence, Quick Reference Guide for Clinicians: http://www.ahrq.gov/clinic/tobacco/tobaqrg.htm Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. April 2009. Ask and Act website: www.askandact.org, http://www.aafp.org/online/en/home/clinical/publichealth/tobacco/askandact.html Smoking Cessation Interventions for Hospitalized Patients With Cardio-Pulmonary Disorders: http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume82003/No2May2003/HirshArticle/SmokingCessationInterventionsforHospitalizedPatientsWithCardioPulmonaryDisorders.aspx Promotional materials for nurses to use for patients and peers: http://www.tobaccofreenurses.org/media.php and for specific populations: http://tobaccofreenurses.org/resources/treatment/treat_populations.php  http://www.surgeongeneral.gov/tobacco http://www.smokefreevirginia.org /

Key Resources Best Practices for Comprehensive Tobacco Control Programs 2014 Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—2014. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. April 2009.

References 1 –Centers for Disease Control and Prevention. Cigarette Smoking Among Adults and Trends in Smoking Cessation—United States, 2008. Morbidity and Mortality Weekly Report 2009;58(44):1227–1232 [accessed 2009 Nov 16]. 2- Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. November 14, 2008 / Vol. 57 / No. 45. 3- Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. April 2009. 4 - Di Chiara G, A Imperato : Drugs abused by humans preferentially increase synaptic dopamine concentrations in the mesolimbic system of freely moving rats , PNAS , 1988 5 - Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Am Psychol 1992;47:1102-4, and Miller WR, Rollnick S. Motivational interviewing: preparing people to change addictive behavior. New York: Guilford, 1991:191-202. 6 – McLellan AT,Lewis DC, O'Brien CP,Kleber HD, Drug dependence, a chronic medical illness, JAMA. 2000;284:1689-1695. 7 - Richter, K.P., & Arnsten, J.H. (2006). A rationale and model for addressing tobacco dependence in substance abuse treatment. Substance Abuse Treatment, Prevention, and Policy, 1, 23. Retrieved on April 26, 2010, from http://www.substanceabusepolicy.com/content/1/1/23#B10. 8 - The Adoption of Smoke-Free Hospital Campuses in the United States, Scott C Williams, Joanne M Hafner, David J Morton, Amanda L Holm, Sharon M Milberger, Richard G Koss, and Jerod M Loeb, Tobacco Control Published Online First: 20 August 2009. doi:10.1136/tc.2009.030494 http://tobaccocontrol.bmj.com/cgi/content/abstract/tc.2009.030494v1)

Questions and Comments My Contact information: Dana H. Breeding, RN, BSN, BS, CTTS RN, Health Educator, Community Wellness Augusta Health PO Box 1000 64 Sports Medicine Dr. Fishersville, VA 22939 540-332-4988 540-332-4215 dbreeding@augustahealth.com Last edit 9-12-17 18