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

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

3. 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.

4. 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 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th ed. Arlington, VA: American Psychiatric Association;
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; 4

5. 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, Morbidity and Mortality Weekly Report, 58(44),
CITATION:
Centers for Disease Control and Prevention. (2002). Cigarette Smoking Among Adults- United States, Morbidity and Mortality Weekly Report, 51(29),
Centers for Disease Control and Prevention. (2008). Cigarette Smoking Among Adults and Trends in Smoking Cessation- United States, Morbidity and Mortality Weekly Report, 58(44),

6. 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

7. 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]

8. 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.

9. 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]

10. 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]

11. 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

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

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

15. Resources for Tobacco Cessation
Treating Tobacco Use and Dependence, Quick Reference Guide for Clinicians:
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:
Smoking Cessation Interventions for Hospitalized Patients With Cardio-Pulmonary Disorders:
Promotional materials for nurses to use for patients and peers: for specific populations: /

16. 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.

17. References
1 –Centers for Disease Control and Prevention. Cigarette Smoking Among Adults and Trends in Smoking Cessation—United States, 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 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 Di Chiara G, A Imperato : Drugs abused by humans preferentially increase synaptic dopamine concentrations in the mesolimbic system of freely moving rats , PNAS , 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: – McLellan AT,Lewis DC, O'Brien CP,Kleber HD, Drug dependence, a chronic medical illness, JAMA. 2000;284: 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 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 doi: /tc

18. Questions and Comments
My Contact information:
Dana H. Breeding, RN, BSN, BS, CTTS
RN, Health Educator, Community Wellness Augusta Health PO Box Sports Medicine Dr. Fishersville, VA
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