1. 1 Treating Nicotine Dependency Paul Zemann Public Health - Seattle & King County Tobacco Prevention Program 401 5 th Ave, Suite 900 Seattle, WA 98104 paul.zemann@kingcounty.gov

2. 2 Overview Importance of nicotine treatment for clients Importance of nicotine treatment for clients Three-link chain of addiction Three-link chain of addiction What nicotine dependency treatment look like “THE 5 A’s and 5 R’s What nicotine dependency treatment look like “THE 5 A’s and 5 R’s Preventing Relapse Preventing Relapse

3. 3 Be aware that: Tobacco dependence is chronic Tobacco dependence is chronic Tobacco users may have other addictions Tobacco users may have other addictions The physical and psychological environment is part of the message The physical and psychological environment is part of the message Community resources are available Community resources are available We have interventions that work We have interventions that work

4. 4 Systematic Approach Client-centered Client-centered Specific to your audience Specific to your audience Evidence-based Evidence-based Integrated into your practice Integrated into your practice

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6. 6 Patients Want to Quit Documented interest in quitting among clients across all treatment modalities Documented interest in quitting among clients across all treatment modalities Standard treatment approaches work (NRT plus behavioral counseling) Standard treatment approaches work (NRT plus behavioral counseling) Promise of emerging new drugs Promise of emerging new drugs Patients are already in a secure, supportive environment ideal for nicotine cessation Patients are already in a secure, supportive environment ideal for nicotine cessation

7. 7 An Unfair Share of Mortality Number of Deaths (thousands) Source: CDC AIDS Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced Est. 200,000 per year for mentally ill and SA

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9. 9 Why Don’t They Just Quit? + No Cessation Help

10. 10 Three-Link Chain 1. Biological addiction to nicotine Feeling of pleasure, decrease in anxiety Feeling of pleasure, decrease in anxiety Lasting chemical changes in brain Lasting chemical changes in brain Quitting produces withdrawal symptoms Quitting produces withdrawal symptoms 2. Psychological addiction to smoking Triggered by other behaviors Triggered by other behaviors Self-medication Self-medication

11. 11 How is nicotine the same/different from other addictive drugs? 85+% who use nicotine, use daily 85+% who use nicotine, use daily 10% of cocaine/alcohol users 10% of cocaine/alcohol users Withdrawal not life-threatening Withdrawal not life-threatening Can be for alcohol Can be for alcohol Most severe consequences delayed Most severe consequences delayed

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13. 13 T obacco D elivered N icotine – a C hemical C ocktail Acetaldehyde : synergistic addictive effects Acetaldehyde : synergistic addictive effects Ammonia: increase speed and efficiency of nicotine absorption Ammonia: increase speed and efficiency of nicotine absorption Leuvenalic acid, chocolate and menthol: may increase ease of inhalation and deep lung absorption Leuvenalic acid, chocolate and menthol: may increase ease of inhalation and deep lung absorption Menthol: may also provide a cue for Pavlovian conditioning 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 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 Glycerin: can form particles to enable deep lung exposure Ventilation holes may increase free nicotine fraction Ventilation holes may increase free nicotine fraction

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15. 15 Three-Link Chain (cont’d) 3. Cultural support for smoking addiction Friends who smoke Friends who smoke Activities that involve smoking Activities that involve smoking PLUS: Limited access to treatment

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20. 20 Access to Treatment

21. 21 Cessation Tools Counseling Counseling Doubles quit rates Doubles quit rates More counseling (time, modes, different people) increases quit success More counseling (time, modes, different people) increases quit success Brief – 3-10 minutes at a time Brief – 3-10 minutes at a time Nicotine Replacement Therapy (NRT) Nicotine Replacement Therapy (NRT) With counseling, can double quit rates With counseling, can double quit rates Available free from Public Health Available free from Public Health Reduces withdrawal symptoms Reduces withdrawal symptoms

22. 22 Cessation Counseling The 5 A’s ASK ADVISE ASSESS ASSIST ARRANGE

23. 23 ASK Ask clients at screening or when appropriate if they smoke Ask clients at screening or when appropriate if they smoke

24. 24 ADVISE Urge every tobacco user to quit Clear: “One of the best things you can do for your health is to quit smoking. I can help you.” Clear: “One of the best things you can do for your health is to quit smoking. I can help you.” Strong: “As your case manager, I need you to know that quitting smoking is one of the most important things you can do for your health.” Strong: “As your case manager, I need you to know that quitting smoking is one of the most important things you can do for your health.” Personalized: Tie tobacco use to current health issues, relationships, or economic stress Personalized: Tie tobacco use to current health issues, relationships, or economic stress

25. 25 ASSESS Ask every tobacco user about quitting Examples: Examples: “On a scale of 1 to 5, how ready do you feel to quit?” “On a scale of 1 to 5, how ready do you feel to quit?” “Have you thought about quitting in the next 30 days?” “Have you thought about quitting in the next 30 days?” If the patient is ready to quit in the next 30 days provide assistance If the patient is ready to quit in the next 30 days provide assistance If the patient is not ready to quit provide a motivational intervention (5R’s) If the patient is not ready to quit provide a motivational intervention (5R’s)

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27. 27 ASSIST Help the ready client make a quit plan Set a quit date in 30 days Set a quit date in 30 days Plan to tell friends Plan to tell friends Anticipate challenges Anticipate challenges Plan to remove tobacco products Plan to remove tobacco products Recommend NRT use Recommend NRT use

28. 28 Behavioral Change Stress - Deep Breathing, understanding of nicotine's role in generating stress, delay, call a friend 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 Weight gain – Increase activity level, don’t substitute food for smokes, NRT Triggers – Anticipate and cope Triggers – Anticipate and cope Increase Self Efficacy – positive “self talk” Increase Self Efficacy – positive “self talk”

29. 29 ARRANGE Plan a time to follow-up after quit-date Congratulate success Congratulate success Address challenges Address challenges Assess NRT use Assess NRT use

30. 30 The 5R’s: Not Ready to Quit The 5 R’s RELEVANCE – Specific and personal reasons RISKS – Client identifies risks of smoking REWARDS – Client identifies benefits of quitting ROADBLOCKS – Client identifies barriers REPITITION – Repeat motivational intervention

31. 31 Motivational Interviewing Is Starting where client is Starting where client is Understanding client’s frame of reference Understanding client’s frame of reference Knowing choice to change is client’s Knowing choice to change is client’s Exploring options with client Exploring options with client Finding and reinforcing the client’s motivation to change Finding and reinforcing the client’s motivation to change

32. 32 Nicotine Replacement Therapy NRT increases quit success (patch/counseling doubles rate) NRT increases quit success (patch/counseling doubles rate) Safe, FDA approved, available OTC Safe, FDA approved, available OTC Reduces most withdrawal symptoms so quitter can comfortably break the habit Reduces most withdrawal symptoms so quitter can comfortably break the habit Eliminates the reinforcing effect of nicotine as administered through smoking Eliminates the reinforcing effect of nicotine as administered through smoking

33. 33 Withdrawal Symptoms Appear within hours, last up to weeks Appear within hours, last up to weeks Depressed mood Depressed mood Insomnia Insomnia Irritability Irritability Frustration Frustration Anger Anger Anxiety Anxiety Difficulty concentrating Difficulty concentrating Restlessness Restlessness Decreased heart rate Decreased heart rate Increased appetite or weight gain Increased appetite or weight gain

34. 34 What NRT Does Not Do Without behavioral change/counseling, does not increase quit rates Without behavioral change/counseling, does not increase quit rates NRT does not replace smoking NRT does not replace smoking Clients will still want to smoke Clients will still want to smoke Does not provide bolus effect (nicotine rush) Does not provide bolus effect (nicotine rush)

35. 35 Currently available products Over-the-counter Over-the-counter Patch – available from Public Health Patch – available from Public Health Gum Gum Lozenge Lozenge Prescription Prescription Oral Inhaler Oral Inhaler Nasal Inhaler Nasal Inhaler Bupropion (Zyban ®, Wellburtrin ® ) – non-nicotine Bupropion (Zyban ®, Wellburtrin ® ) – non-nicotine Varenicline (Chantix ® ) – non-nicotine Varenicline (Chantix ® ) – non-nicotine

36. 36 Smoking and NRT Client should stop smoking on quit date Client should stop smoking on quit date “Slipping” will happen, and is not harmful “Slipping” will happen, and is not harmful If client continues to smoke after starting patch If client continues to smoke after starting patch Assess if they are really ready to quit Assess if they are really ready to quit Address triggers for smoking Address triggers for smoking Nausea, dizziness, vomiting Nausea, dizziness, vomiting

37. 37 Quitting the Three Link Chain NRT Behavioral Counseling Posters Groups Activities + Cessation Help

38. 38 Relapse Is Common Tobacco dependence is chronic Tobacco dependence is chronic Cycle through relapse and remission Cycle through relapse and remission 5 to 7 times not uncommon 5 to 7 times not uncommon 7% long-term success quit on own 7% long-term success quit on own Relapse not a failure—for patient or you Relapse not a failure—for patient or you

39. 39 Common Causes of Relapse Nicotine withdrawal discomfort Nicotine withdrawal discomfort Negative emotions Negative emotions Use of drugs & alcohol Use of drugs & alcohol Stressful situations Stressful situations Traumatic events Traumatic events Lack of social support Lack of social support Social pressure Social pressure Level of addiction or dependence Level of addiction or dependence Interpersonal conflict Interpersonal conflict Loneliness Loneliness Depression Depression Weight gain Weight gain

40. 40 Preventing Relapse Congratulate success Congratulate success Address challenges Address challenges Review benefits of quitting Review benefits of quitting Offer encouragement Offer encouragement Refer to services, Washington Tobacco Quit Line Refer to services, Washington Tobacco Quit Line

41. 41 Remember “Quitting smoking is the easiest thing in the world to do, I’ve done it a thousand times!” Mark Twain