1. © 2007 TCRC, All Rights Reserved. Provider Training 02/2008 Paul Zemann PHSKC paul.zemann@kingcounty.gov The Brief Tobacco Intervention

2. © 2007 TCRC, All Rights Reserved. Overview We will discuss: Secondhand smoke, smoking and asthma An effective approach you can use to counsel families about tobacco cessation How to use this approach Tobacco cessation resources

3. © 2007 TCRC, All Rights Reserved. Tobacco Use Tobacco Use is the single greatest cause of preventable disease and premature death in the United States

4. © 2007 TCRC, All Rights Reserved. You can make a difference Research shows that YOU can have a significant influence on your families’ decision to quit by recommending that they stop using tobacco

5. © 2007 TCRC, All Rights Reserved. How Does Tobacco Smoke Trigger Asthma? When a person inhales tobacco smoke, irritating substances settle in the moist lining of the airways. These substances can cause an attack in a person who has asthma. In addition, tobacco smoke damages tiny hair-like structures in the airways called cilia. Normally, cilia sweep dust and mucus out of the airways. Tobacco smoke damages cilia so they are unable to work, allowing dust and mucus to accumulate in the airways. Smoke also causes the lungs to make more mucus than normal. As a result, even more mucus can build up in the airways, triggering an attack.

6. © 2007 TCRC, All Rights Reserved. Is Second-Hand Smoke Harmful to a Person with Asthma? Second-hand smoke is the combination of smoke from a burning cigar or cigarette and smoke exhaled by a smoker. Inhaling second-hand smoke, also called "passive smoke" or "environmental tobacco smoke," may be even more harmful than actually smoking. That's because the smoke that burns off the end of a cigar or cigarette contains more harmful substances (tar, carbon monoxide, nicotine, and others) than the smoke inhaled by the smoker. Second-hand smoke is especially harmful to people who already have asthma. When a person with asthma is exposed to second-hand smoke, he or she is more likely to experience the wheezing, coughing and shortness of breath associated with asthma.

7. © 2007 TCRC, All Rights Reserved. Can Smoking Harm My Child? Second-hand smoke harms children with asthma even more than adults. When a child is exposed to tobacco smoke, his lungs become irritated and produce more mucus than normal. Since children's airways are smaller, the side effects of second-hand smoke affect them faster and can also affect lung function in later life. Children of parents who smoke are also more likely to develop lung and sinus infections. These infections can make asthma symptoms worse and more difficult to control.

8. © 2007 TCRC, All Rights Reserved. Can Smoking Harm My Unborn Child? Smoking harms an unborn child in many ways. Nicotine, the addictive substance in tobacco products, is carried through the mother's bloodstream directly into the baby. Children of mothers who smoked during pregnancy are more likely to have lung problems and are 10 times more likely to develop asthma. Smoking during pregnancy has also been linked with low-birth weight newborns, premature births, and sudden infant death syndrome (SIDS).

9. © 2007 TCRC, All Rights Reserved. How Can Tobacco Smoke Be Avoided? If you smoke, quit. Quitting isn't always easy, but there are many programs and methods to help. Ask your doctor to help you find the one that is best for you. If your spouse or other family members smoke, help them understand the dangers of smoking and encourage them to quit. Do not allow smoking in your home or your car. Do not let anyone smoke around you or your child

10. © 2007 TCRC, All Rights Reserved.

15. The Opportunity Most tobacco users want to quit Half make a serious attempt each year 80% see a healthcare provider each year 80,000 fewer adult smokers since 1997

16. © 2007 TCRC, All Rights Reserved. Provider Impact The National Cancer Institute projects that if providers assisted even 10% of their tobacco-using patients in quitting, the number of tobacco users in the U.S. would drop by 2 million people annually Fiore et al., 1990

17. © 2007 TCRC, All Rights Reserved. Best Practices The Public Health Service Guidelines – Treating Tobacco Dependence: A Systems Approach

18. © 2007 TCRC, All Rights Reserved. PHS Recommendations The Public Health Service Guidelines advise providers to: Counsel people on tobacco cessation using a tool called the Brief Tobacco Intervention

19. © 2007 TCRC, All Rights Reserved. Evidence for Brief Intervention Substantial evidence* shows that Brief Tobacco Interventions are effective The Surgeon general states that if every provider used the brief tobacco intervention every time they saw a tobacco user, we would reduce tobacco use by 20% * Selected Evidence: Schroeder – What to do with a patient who smokes (JAMA 2005) Public Health Service Guidelines – US Department of Health and Human Services (June 2000) U.S. Preventive Services Task Force, “Counseling to Prevent Tobacco Use” (November 2003)

20. © 2007 TCRC, All Rights Reserved. Traditional Tools ASK about tobacco use. ARRANGE follow-up. ASSIST in quit attempt. ASSESS willingness to make a quit attempt. ADVISE to quit.     The 5A Intervention

21. © 2007 TCRC, All Rights Reserved. New Tools ASK about tobacco use ASSESS ASSIST ARRANGE REFER to an internal or external entity that completes the rest of the 5As ADVISE to quit    Schroeder (2005), JAMA. The 2A and R Intervention

22. © 2007 TCRC, All Rights Reserved. Brief Intervention - 2As and R Ask or identify people who use tobacco: “Do you smoke, chew or use other forms of tobacco?”

23. © 2007 TCRC, All Rights Reserved. Brief Intervention - 2As and R Advise people to quit – this doubles the chances that they will try to quit “Quitting tobacco is the single most important thing you can do for your health and your families health, we can help you identify some community resources.”

24. © 2007 TCRC, All Rights Reserved. Brief Intervention - 2As and R Refer to community resources or to the Washington State Tobacco Quit Line for help in quitting tobacco King County Resources are identified in the list you will be receiving today

25. © 2007 TCRC, All Rights Reserved. Not Ready to Quit? Not everyone who uses tobacco is ready to quit “When you are ready to quit, I will be here to help you.”

26. © 2007 TCRC, All Rights Reserved. Who is Ready to Quit? 20% Not ready to quit (Motivational Interviewing) 40% Think about quitting 20% Ready

27. © 2007 TCRC, All Rights Reserved. Why Don’t They Just Quit? Chain of Addiction: Biologically Addictive Psychologically Addictive Culturally Addictive

28. © 2007 TCRC, All Rights Reserved. Be aware that: Tobacco dependence is chronic Tobacco users may have other addictions The physical and psychological environment is part of the message Community resources are available We have interventions that work

29. © 2007 TCRC, All Rights Reserved. Three-Link Chain 1. Biological addiction to nicotine –Feeling of pleasure, decrease in anxiety –Lasting chemical changes in brain –Quitting produces withdrawal symptoms

30. © 2007 TCRC, All Rights Reserved. The Brain

31. © 2007 TCRC, All Rights Reserved. What’s in a Smoke

32. © 2007 TCRC, All Rights Reserved. Cancer in a Can

33. © 2007 TCRC, All Rights Reserved. Tobacco Delivered Nicotine – a Chemical Cocktail Acetaldehyde: : synergistic addictive effects Ammonia: : increase speed and efficiency of nicotine absorption Leuvenalic acid, chocolate and menthol: : may increase ease of inhalation and deep lung absorption Menthol: may also provide a cue for Pavlovian conditioning Physical engineering by particle physicists results in more rapid and efficient absorption of nicotine and toxins Glycerin : can form particles to enable deep lung exposure

34. © 2007 TCRC, All Rights Reserved. Small Amounts of Exposure are Dangerous Scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke. Breathing even a little secondhand smoke can be harmful to your health.

35. © 2007 TCRC, All Rights Reserved. Secondhand smoke causes lung cancer Secondhand smoke is a known human carcinogen and contains more than 50 chemicals that can cause cancer. Concentrations of many cancer- causing and toxic chemicals are potentially higher in secondhand smoke than in the smoke inhaled by smokers.

36. © 2007 TCRC, All Rights Reserved. Secondhand smoke causes heart disease Breathing secondhand smoke for even a short time can have immediate adverse effects on the cardiovascular system, interfering with the normal functioning of the heart, blood, and vascular systems in ways that increase the risk of heart attack. Even a short time in a smoky room can cause your blood platelets to become stickier, damage the lining of blood vessels, decrease coronary flow velocity reserves, and reduce heart rate variability. Persons who already have heart disease are at especially high risk of suffering adverse affects from breathing secondhand smoke, and should take special precautions to avoid even brief exposure.

37. © 2007 TCRC, All Rights Reserved. Secondhand smoke causes acute respiratory effects Secondhand smoke contains many chemicals that can quickly irritate and damage the lining of the airways. Even brief exposure can trigger respiratory symptoms, including cough, phlegm, wheezing, and breathlessness. Brief exposure to secondhand smoke can trigger an asthma attack in children with asthma. Persons who already have asthma or other respiratory conditions are at especially high risk for being affected by secondhand smoke, and should take special precautions to avoid secondhand smoke exposure.

38. © 2007 TCRC, All Rights Reserved. Secondhand smoke can cause sudden infant death syndrome Smoking by women during pregnancy has been known for some time to cause SIDS. Infants who are exposed to secondhand smoke after birth are also at greater risk of SIDS. Children exposed to secondhand smoke are also at an increased risk for acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children.

39. © 2007 TCRC, All Rights Reserved. Seperation and Ventilation Does not Work The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), the preeminent U.S. standard-setting body on ventilation issues, has concluded that ventilation technology cannot be relied on to completely control health risks from secondhand smoke exposure.

40. © 2007 TCRC, All Rights Reserved. continued …. Conventional air cleaning systems can remove large particles, but not the smaller particles or the gases found in secondhand smoke. Operation of a heating, ventilating, and air conditioning system can distribute secondhand smoke throughout a building.

41. © 2007 TCRC, All Rights Reserved. Nicotine/other addictive drugs 85+% who use nicotine, use daily –10% of cocaine/alcohol users Withdrawal not life-threatening –Can be for alcohol Most severe consequences delayed

42. © 2007 TCRC, All Rights Reserved. The Three-Link Chain 2. Psychological addiction to smoking –Triggered by other behaviors –Self-medication

43. © 2007 TCRC, All Rights Reserved.

44. Weight Control

45. © 2007 TCRC, All Rights Reserved. Three-Link Chain (cont’d) 3. Cultural/Environmental link to nicotine addiction –Friends who smoke –Activities that involve smoking –Advertising –Movies

46. © 2007 TCRC, All Rights Reserved. Come to Where the Flavor IS

47. © 2007 TCRC, All Rights Reserved. The Marlboro Man

48. © 2007 TCRC, All Rights Reserved. And Now for the Ladies

49. © 2007 TCRC, All Rights Reserved. VM – Find Your Voice

50. © 2007 TCRC, All Rights Reserved. Advertising

51. © 2007 TCRC, All Rights Reserved. Centers for Disease Control; Tobacco & Lung Cancer Lung Cancer Rates - Women

52. © 2007 TCRC, All Rights Reserved. Systematic Approach Client-centered Specific to your audience Evidence-based Integrated into existing structure

53. © 2007 TCRC, All Rights Reserved. Cessation Tools Counseling –Doubles quit rates –More counseling (time, modes, different people) increases quit success –Brief – 3-10 minutes at a time Nicotine Replacement Therapy (NRT) –With counseling, can double quit rates –Available free from Public Health –Reduces withdrawal symptoms

54. © 2007 TCRC, All Rights Reserved. Behavioral Change Stress - Deep Breathing, understanding of nicotine's role in generating stress, delay, call a friend Weight gain – Increase activity level, don’t substitute food for smokes, NRT Triggers – Anticipate and cope Increase Self Efficacy – positive “self talk”

55. © 2007 TCRC, All Rights Reserved. Motivational Interviewing Is Starting where client is Understanding client’s frame of reference Knowing choice to change is client’s Exploring options with client Finding and reinforcing the client’s motivation to change

56. © 2007 TCRC, All Rights Reserved. Nicotine Replacement Therapy NRT increases quit success (patch/counseling doubles rate) Safe, FDA approved, available OTC Reduces most withdrawal symptoms so quitter can comfortably break the habit Eliminates the reinforcing effect of nicotine as administered through smoking

57. © 2007 TCRC, All Rights Reserved. Withdrawal Symptoms Appear within hours, last up to weeks Depressed mood Insomnia Irritability Frustration Anger Anxiety Difficulty concentrating Restlessness Decreased heart rate Increased appetite or weight gain

58. © 2007 TCRC, All Rights Reserved. Currently available products Over-the-counter –Patch – available from Public Health –Gum –Lozenge Prescription –Oral Inhaler –Nasal Inhaler –Bupropion (Zyban ®, Wellburtrin ® ) – non-nicotine –Varenicline (Chantix ® ) – non-nicotine

59. © 2007 TCRC, All Rights Reserved. Nicotine Replacement Therapy NRT provides nicotine – in the form of gum, patches, sprays, inhalers or lozenges – without the other harmful chemicals in tobacco It can help relieve some of the symptoms so that the user can concentrate on the psychological aspects of quitting

60. © 2007 TCRC, All Rights Reserved. Medications Zyban Wellbutrin Chantix

61. © 2007 TCRC, All Rights Reserved. Relapse Is Common Tobacco dependence is chronic Cycle through relapse and remission 5 to 7 times not uncommon 7% long-term success quit on own Relapse not a failure—for patient or you

62. © 2007 TCRC, All Rights Reserved. Common Causes of Relapse Nicotine withdrawal discomfort Negative emotions Use of drugs & alcohol Stressful situations Traumatic events Lack of social support Social pressure Level of addiction or dependence Interpersonal conflict Loneliness Depression Weight gain

63. © 2007 TCRC, All Rights Reserved. Preventing Relapse Congratulate success Address challenges Review benefits of quitting Offer encouragement Refer to services, Washington Tobacco Quit Line

64. © 2007 TCRC, All Rights Reserved. Remember “Quitting smoking is the easiest thing in the world to do, I’ve done it a thousand times!” Mark Twain

65. © 2007 TCRC, All Rights Reserved. WA State Tobacco Quit Line Free, confidential, professional telephone counseling support for Washington residents. A Quit Kit of materials. A personalized Quit Plan. Tools to cope with withdrawal symptoms. Medication decision support. Provider Fax Referral Program

66. © 2007 TCRC, All Rights Reserved. Who is covered? 1-800-QUIT-NOW or 1-877-2NO-FUME (Spanish Line) Coverage update from July 1, 2007 – June 30, 2008 (subject to change) Additional details: Quit Line callers may be eligible for different services through local resources, their employer or their health plan. Options are assessed at the time of the first call. Dedicated onsite Spanish-speaking Quit Coaches. Services offered in over 100 languages: http://www.languageline.com/main/files/Language_List.pdfhttp://www.languageline.com/main/files/Language_List.pdf Fax-referral program available for proactive outreach. For the latest coverage updates, see: http://www.tobaccoprc.org/TCRC/QuitLine.cfmhttp://www.tobaccoprc.org/TCRC/QuitLine.cfm Age GroupEligible PopulationQuit Line ProgramLimitations Adults Priority Populations - Medicaid - Uninsured - Indian Health Services - Referred by Veteran’s Administration - Pregnant women (regardless of insurance) Multiple-Call Program Details: 1 Proactive call, 4 Reactive calls  Stage appropriate materials  NRT – 4 weeks  Enrollment once per year  Age 18 and over  Prepared to quit within 30 days OR already quit Adults Any Washington State resident regardless of insurance coverage can receive one call per year. Some callers can receive more services if they qualify through another plan. 1-Call Program Details: 1 Proactive call If prepared to quit in 30 days OR already quit, can receive:  Stage appropriate materials  2-week starter kit  One call per year  Age 18 and over Age 17 & under Youth (age 17 and under) 1-Call Program Details: 1 Proactive call  Multiple calls per year, but must be initiated by participant.  Age 17 and under

67. © 2007 TCRC, All Rights Reserved. Brief Intervention - 2As and R Review: Ask or identify tobacco use or exposure Advise them to quit Refer them to a resource to complete the remaining A’s

68. © 2007 TCRC, All Rights Reserved. ADVISE REFER ASSESS ASSIST ARRANGE ASK ADVISE Resources: Washington State Quitline Local County Resources Resources within your facility Referral resource completes remaining 3As. When to use 5As vs. 2As & R When you might use the 5As: Want to spend more time with the patient. Patient has other conditions/comorbidities. Patient has routine visits. Your office has a system set up to internally address all As. When you might use the 2As and R: You have good referral resources. You have shorter appointments. Patient is motivated to make a quit attempt. Your office does not have a system set up to handle all 5As.

69. © 2007 TCRC, All Rights Reserved. A Successful Brief Intervention Asking and advising is more effective than telling Non-confrontational interventions keep the family from being resistant to advice Tailoring advice to the visit or health issues can help the patient be more receptive to advice

70. © 2007 TCRC, All Rights Reserved. A Successful Brief Intervention Providing appropriate written materials can help inform the client about health issues and resources Let the client know that you have heard and understood there concerns Meet the tobacco users where he/she is in his/her willingness to discuss cessation

71. © 2007 TCRC, All Rights Reserved. 1)Institutionalize tobacco use assesment 2)Have materials readily accessible to refer patients to the resources they determine to be the most appropriate for their community and patient population A Successful Brief Intervention Agencies generally have the greatest success with Brief Tobacco Interventions when they: