1. JENNIFER PERCIVAL NURSE, MIDWIFE, HEALTH VISITOR
HELPING PEOPLE TO STOP SMOKING
JENNIFER PERCIVAL NURSE, MIDWIFE, HEALTH VISITOR

2. TOBACCO IS A SERIOUS PROBLEM In the year 2000
1 in every 6 deaths worldwide
was caused by smoking
By the year 2030
1 in every 3 deaths worldwide
will be due to smoking
70% of these deaths will be in
developing countries.
Source: WHO

3. WHO Global statistics Five countries
China, India, Indonesia, Russia and Bangladesh
account for half of all the world’s smokers
Smoking is a risk factor for six of the eight leading causes of deaths in the world.
Smoking will kill at least a third of all current smokers
many more develop serious illness because of tobacco. 
People killed by tobacco lose on average years of life.
Almost half of the world's children breathe air polluted by tobacco smoke.

4. WHY IS TOBACCO USE INCREASING GLOBALLY?

5. Tobacco Industry constantly works to make cigarettes socially acceptable
The tobacco industry has been trying to develop more socially acceptable cigarettes for years. For example, this is a Capri direct mail promotion from 2001 for a cigarette claiming less secondhand smoke, aimed at smokers concerned about secondhand smoke.
Source:
“You’re clearly someone who considers others. That’s why Superslim Capri is the choice for you…great tobacco flavor, but less smoke for those around you.”

6. Tobacco advertisers have no boundaries

7. China has been a success story for the tobacco industry

8. Adverts have long been targeting women

9. Be your own woman (2)
‘Find your voice’ from your own cultural tradition/ethnic group (US ads 2000/2001)

11. The truth about Women and Tobacco
Lung cancer surpassed breast cancer as leading cause of cancer death in 1987
More women die from lung cancer than breast, ovarian, cervical & endometrial cancers combined

12. The WHO Framework Convention on Tobacco Control Main Measures
Ban on tobacco advertising
Increase Taxation
Take effective measures on passive smoking
Put Labelling and warnings on tobacco
Provide Education campaigns
Cessation guidelines and services
Take Action on illicit trade
Control sales to minors

13. will be killed by to tobacco in the first half of this century have
Sir Richard Peto
WHO Epidemologist
“Most of those who
will be killed by to tobacco in the first half of this century have
already begun to smoke.
These tobacco deaths can be substantially reduced only by current smokers giving up the habit.”

14. What is smoking? A chronic relapsing dependence syndrome
First and foremost, smoking is about the administration of the addictive drug, nicotine. Cigarettes without nicotine have been produced and failed commercially. Smokers rapidly form dependence on nicotine, and find it hard to quit.
Nicotine vaporises from smoke particles in the lungs and is rapidly absorbed into the blood and carried to the brain. The nicotine reaches the brain in a bolus with great speed – creating a ‘hit’ which underpins the addictiveness. The time from inhaling to a rush in the brain is a few seconds.
As well as physiological dependence, smoking is sustained by behavioural factors, such as movements of the hands and social pressures. The withdrawal syndrome is unpleasant and may start to affect the user within less than one hour of the last cigarette.
The harm caused is immense – 50 different diseases causing 1 in 5 deaths in the UK, around 120,000 deaths per year (RCP 2000). The vast majority of the harm associated with smoking is NOT caused by the drug nicotine itself, but by its ‘delivery system’; the smoke of burning tobacco. This contains many toxic products of combustion and most of these would arise whatever organic material is burned (as for example, cannabis or herb cigarettes). Where nicotine is taken without combustion (chewing or oral tobacco, pharmaceutical products) far less harm is caused.
Tobacco is the only consumer product that kills when used as intended by the manufacturer, causing addiction and harm on a scale without equal. However, some of the world’s strongest brands – like Marlboro – are tobacco brands, and advertising and promotion of these products run to billions of dollars world-wide (ASH 2002). Tobacco is widely sold and readily available.
Tobacco remains subject to limited regulation - for example on warning labels, and maximum ‘tar yields’, which scientists now regard as highly misleading to consumers.
_____________________________
Royal College of Physicians. Nicotine Addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians. London: Royal College of Physicians of London, 2000.
ASH Factsheet Tobacco advertising & promotion. ASH 2002
A chronic relapsing dependence syndrome
Use of the addictive drug nicotine delivered rapidly to the brain via the lungs and blood
A strong habit reinforced by sensory, behavioural and social conditioning
Entrenched by powerful withdrawal syndrome
Great harm is caused by toxins in the smoke

15. What’s in a cigarette? 4,000 chemicals Tar Carbon monoxide
Explain the action of carbon monoxide reducing the oxygen in circulation

16. What happens when you try to stop
What happens when you try to stop? Withdrawal effects: duration and frequency
Withdrawal is an important factor in sustaining addiction and maintaining smoking.
This table shows the key symptoms, how long they are likely to last, and what proportion of quitters are affected by them (RCP 2000).
The short term withdrawal symptoms – irritability, edginess, frustration, distraction, craving – can begin to develop within one hour of the last cigarette, and become more distracting until relieved by smoking again. This process of relieving withdrawal symptoms accounts for why smokers say that smoking helps them to relax and concentrate. Studies comparing smokers and non-smokers do not show that smoking aids relaxation or concentration.
_____________________________
Royal College of Physicians, Nicotine Addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians. London, RCP, 2000
Light-headedness
Sleep disturbance
Poor concentration
Craving
Irritability/aggression
Depression
Restlessness
Increased appetite
<48 hrs 10%
< 1 wk %
<2 wks %
> 2 wks 70%
< 4 wks 50%
< 4 wks 60%
> 10 wks 70% 16

17. Ask about smoking NZ Best Practice Give Brief advice to quit
Offer Cessation support

18. You may have already noticed that ‘professional persuasion’
does not always
make people decide
to stop smoking
Miller WR et al. J Consult Clin Psychol 1993;61:455–61; Miller and Rollnick, 1991

19. GOOD ADVICE

21. CREATING RESISTANCE TO CHANGE?
It’s tempting to be ‘helpful’ by informing clients of the urgency of their medical problems and the advantages of stopping smoking
But these tactics can often increase client resistance and may even lessen the probability of change
Miller WR et al. J Consult Clin Psychol 1993;61:455–61; Miller and Rollnick, 1991

22. Reasons for Current Behaviour
ADVICE

23. Reasons for Current Behaviour
ADVICE

24. PREGNANCY CAN BE A DIFFICULT TIME

26. Current Behaviour

27. Robert was diagnosed with cancer of the tonsils at age 36
ROBERT said “I knew you could get cancer from smoking. My Dad got lung cancer in his 60’s and I’d planned to give up long before that could happen to me. My last cigarette was to have been on my 40th birthday”

28. It takes a long time to make a behaviour change.
THE CHANGE PROCESS
No-one changes their behaviour without first changing their attitudes and beliefs.
When a client argues with you it means you have made a wrong assumption.
It takes a long time to make a behaviour change.

30. STEPS TO CHANGE Deciding Preparing Taking action KEEPING UP THE CHANGE
Coping with setbacks

31. PEOPLE CHANGE WHEN THEY:
Want to change
Invest time and thought in the issue
Know what to expect
Have enough information and/or developed new coping strategies to manage the change
Have plans for difficult or unexpected situations
Have encouragement
Believe in the benefits of the change
Can see themselves acting/ behaving differently

32. HOW TO HELP - WHAT WORKS?
First elicit what the client already knows and their interest in receiving information about stopping smoking.
Provide information on their personal health status and the benefits of stopping in a neutral manner
Elicit the client’s interpretation of the discussion
Ask: Do you think there would be any benefit
in your stopping smoking?

33. MOTIVATIONAL INTERVIEWING (1)
Ambivalence is a normal state of mind
Express empathy and understanding of people’s past choices
Be realistic, rather than judgmental as demonstrating acceptance helps facilitate change
Reflective listening is essential to helping facilitate change

34. MOTIVATIONAL INTERVIEWING (2)
Resistance is a signal to do something different
Emphasize the client’s choice and dilemma about making a change
Summarize the pros and cons of their decision to change
Help client to reflect on the whole situation by providing a summary

35. CLIENT - NOT READY! Respect this decision
If they show resistance: do not argue, instead, respectfully clarify their expressed views
Ask: What would need to be different for you to
consider changing?
Explain your own concerns about their smoking
Leave the door open for future discussions

36. CLIENT - UNSURE ABOUT CHANGE?
Discuss their ambivalence.
Ask them about the pros and cons of them being a smoker
Explore any concerns now and for the future
Ask “What do you think could happen to you if you don’t stop smoking?

37. Client making plans to change?
Congratulate them and recommend they use a treatment product
Help them to set a quit date
Find out their expectations of stopping smoking and if they have tried before
Ask “What could get in your way?”
“What could you do to avoid this?”
“Who could help/ support you?”
“When would you like to see me again?”

38. RELAPSE Why do smokers return to tobacco?
Stopping under pressure from someone else
Lack of personal motivation
Attaching insufficient importance to stopping
Withdrawal symptoms
Poor timing
A question of self-image
“I thought `just one’ wouldn’t hurt”

39. Empowering people to change
Support the persons decision and self-confidence to quit by asking:
“What are you actually planning to do next”?
“Who are you going to ask to support you?”
“What quit date have you set?
“Will you commit to not having a single puff of a cigarette from then onwards?”
“What medication are you going to use?”
“When would you like to see me again”?

40. INTERACTIVE WORKSHOP IN PAIRS
ONE TO ONE
COMMUNICATION
SKILLS

41. Work out helpful responses to the following statements.
Statement 1
“I was really upset when the specialist told me I had to stop smoking”   
Statement 2
“I’ve cut down on how much I smoke - isn’t that enough?”
Statement 3
“I don’t want to get addicted to the NRT”
   
Statement 4
“I know I should stop smoking now I’m pregnant - but its not easy”
Statement 5
“I’m so afraid I will put on weight if I stop smoking”
Statement 6
I want to give up -but it’s hard as my partner smokes at home

42. Nicotine Replacement Therapy, Zyban & Champix
Should have samples to hand round during this session.
NRT is a way of delivering a reduced amount of clean nicotine into a smoker’s body to help take the edge off withdrawal symptoms.
NRT does not contain any of the 4000 chemicals which do the damage to the body when smoking tobacco
NRT delivers nicotine in a slow & controlled fashion, unlike smoking which gives a hit within 7 seconds. NRT enters the system slowly & so there is a low risk of people becoming dependent on these products. Even if someone was to use NRT for a long period of time, it will not be detrimental to their health. Longer term use tends to be a confidence issue as opposed to an issue of addiction.
NRT will deliver about half the amount of nicotine of cigarettes. It is not a complete replacement so people must be motivated in order for NRT to be helpful.
NRT is designed in a ‘step down’ programme – usually full dose for 8 weeks, middle level for 2 weeks & lowest dose for 2 weeks.
All are available for a prescription cost (if pay for prescriptions) paid for 4 weeks supply or no charge (if don’t pay for prescriptions) through the services in Glasgow.
All the NRT should be treated like a medicine, should use at least the minimum daily recommeded amount for the best chance of succeeding
More than one product can be used at the same time but mainly in a ‘top up’ fashion, not both at the full dose. E.g. someone on a patch may find having some gum at ‘danger times’ can help.
Patches:
A transdermal delivery system which releases nicotine slowly and steadily. Available in 16 hour or 24 hour strengths (24 hour patch may cause sleep disturbance). A new patch is applied each day on a hairless part of the body – usually upper arm or thigh. Used for 8-12 weeks depending on the make.
Why might patches suit?
Work for up to 24 hours a day, Simple to use, Convenient, Discreet
Gum:
Not used like normal chewing gum, nicotine gum is chewed until the taste becomes strong & then 'parked' between the cheek & gum to allow the nicotine to be absorbed through the lining of the mouth. Available in different strengths, so suitable for a range of smokers. It is used for 12 weeks & the number of pieces chewed per day is gradually reduced.
Why might gum suit?
Puts patient in control, Chewed as required, Provides a small level of behavioural substitution for smoking, Chewing may take the mind of smoking.
Lozenges:
Nicotine is absorbed when the lozenge is rested between the cheek & gum. Available in different strengths so suitable for a range of smokers. It is used for 12 weeks & the number of Lozenges taken per day is gradually reduced
Why might lozenges suit?
Puts patient in control, Taken as required, Discreet, If patient doesn’t like chewing gum, Provides a small level of behavioural substitution for smoking
Inhalator:
A cigarette shaped plastic tube which holds a replaceable nicotine–impregnated cartridge. Nicotine is absorbed through the lining of the mouth and throat (n.b. not the lungs). Each cartridge contains 20 minutes puffing time. Used for 12 weeks, the number of cartridges used is gradually reduced. Suitable for those who smoke less than 20 cigarettes each day.
Why might Inhalator suit?
Puts patient in control, Taken as required, Provides a behavioural substitute for smoking
Sublingual Tablets:
Small tablet placed under tongue where it dissolves and slowly releases nicotine. It is used for 12 weeks & the number of tablets taken per day is gradually reduced.
Why might sublingual tablets suit?
Puts patient in control, Taken as required, Flexible, Discreet Provides a small level of behavioural substitution for smoking
Nasal Spray:
Suitable mainly for heavy smokers (30-40 per day) Nicotine absorbed through lining of the nose. Very rapid absorption rate. Used for 12 weeks & the number of sprays used per day is gradually reduced. There are localised side effects (e.g. running nose, coughing, sneezing etc) but these should pass within 48 hours.
Why might the Nasal Spray suit?
Rapid absorption good for heavy smokers, Puts patient in control, Taken as required
Zyban®:
Zyban is different from Nicotine Replacement Therapy, the patient starts using it when they are still smoking in order to build up the levels of the drug within the body. The drug is taken for 8 weeks in total.
Zyban® is available to patients by prescription only. Zyban® is a non-nicotine based drug which is licensed for use with smokers. It is a low dose anti-depressant which treats the neuro-chemical changes in the brain associated with nicotine addiction. Thus the feelings of pleasure and reward usually associated with smoking a cigarette are reduced.
Zyban® has a good safety profile but, as with all anti-depressants, has a list of contraindications. E.g. should not be used with people who have a history of seizures, head injuries, stroke, eating disorders, drink a lot of alcohol, already on antidepressants etc. It is not available over the counter: only on prescription from a GP.
Champix®:
Champix® was put on the GG&C formulary in Feb 2007 and is a prescription only stop smoking aid I.e. it must be prescribed by a GP. It is similar to Zyban in that it must be taken before the quit date so it can build up in the quitter’s system to have an effect. The drug is taken for 12 weeks with an optional extra 12 weeks if the client & GP feel with would help.
Its mode of action is 2-fold – it partially binds to the receptors which smokers have in their brains where nicotine usually binds. This causes partial stimulation so a small amount of dopamine is released in the smoker’s brain, giving some (although reduced) pleasurable feeling. The other effect due to this partial binding is that if the quitter has a cigarette, the nicotine has nowhere to bind to so there will be no positive effect from having the cigarette, this in theory, should reduce relapse.
Main side effect reported is nausea but this can be reduced if the tablet is taken with food & water. There have recently been reports in the press of ‘increased suicidal thoughts’ – this is now mentioned on the packaging although it has only been reported in a small number of cases. It is important to bear in mind that anxiety, irritability & depression are all reported withdrawal symptoms of quitting smoking and smoking may mask some underlying mental health issues.

43. NRT Reduces severity of withdrawal symptoms Reduces urges to smoke
Delays weight gain
Reduces relapse
Doubles success rates of long-term abstinence (regardless of type of support used)
Stead, L. F., Perera, R., Bullen, C., Mant, D. & Lancaster, T. (2008) Nicotine replacement therapy for smoking cessation, Cochrane Database Syst Rev, CD

44. Nicotine delivery
The chart shows the rapid bolus of nicotine delivered by cigarettes, compared with the pharmaceutical nicotine replacement therapy (NRT) devices. It is the speed of delivery that causes the sensation of a ‘hit’, and it is this experience that forms the basis of the dependence.
This also explains why patients are less likely to become addicted to the NRT products, and that the NRT products have different characteristics. The nasal spray delivers the sharpest bolus, and it is also the most effective cessation aid (it is, however, more uncomfortable to use).
__________________
Royal College of Physicians, Nicotine Addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians. London, RCP, 2000
Royal College of Physicians, Nicotine Addiction in Britain, 2000

45. Nicotine chewing gum 2mg and 4mg Recommend 10-15 pieces a day, hourly
Recommend use for up to 3 months
Start chewing slowly (chew-park-chew technique), takes a few days to get used to
Each piece lasts 30 minutes (can be chewed longer)
Acid drinks slow down absorption

46. Gum– things to tell your patients
Chew it in the right way (its not like regular chewing gum)
Chew until you get a hot peppery taste, then park it in the side of your mouth. After a few minutes chew it some more and repeat chew-park-chew
It tastes disgusting to start with, but people do become tolerant of the taste and even grow to like it
Use enough of it – once an hour

47. Lozenge Come in low and high strength
1mg vs. 2mg (Novartis)
Higher dose for more dependent smokers
Recommend lozenges a day, hourly
Recommend use for up to 3 months
Roll around in the mouth until dissolved, takes a few days to get used to

48. Lozenge– things to tell your patients
It tastes disgusting to start with, but people do become tolerant of the taste and even grow to like it
Use enough of it – once an hour
If it is taking a long time to dissolve – it can be discarded after minutes as most of the nicotine will have been absorbed

49. Transdermal patch 24hr patch currently subsidised
Smaller patches for weaning-off period (these are not essential)
Recommend use for some 3 months
24 hr patches can cause nightmares (remove over night if problematic)
In case of allergic skin reaction change product

50. Patches – things to tell your patients
New patch each morning
On upper arm, side of torso, hairless part of body
Do not put on the same place, especially if still red
Some redness of skin normal

51. How do you decide on the dose?
Cigarette consumption is not always a good guide
Most people can start on full strength patches
Dose of oral product can be determined by time to first cigarette
Smokes within 30 minutes of waking use 4 mg gum or 2 mg lozenge
Smokers after 30 minutes of waking use 2 mg gum or 1 mg lozenge

52. Simple guide Smokes 10 or more cigs per day
Full strength patch AND
oral product (dose based on time to first cigarette)
Smokers less than 10 cigs per day
Oral product (dose based on time to first cigarette) OR
Medium strength patch if cannot tolerate oral products
Assess level of withdrawal discomfort and adjust dose

53. Contraindications
None genuine, users take more nicotine from their cigarettes in addition to other dangerous chemicals
Can be used in all smokers over the age of 12

54. Can you give too much NRT?
Smokers know their own nicotine limits
You can trust them to work out the right amount for themselves
Concerns about ‘over substitution’ are not borne out by data that suggests NRT users typically under-replace their nicotine1
Significant over-replacement of nicotine is rare2
Dose-related adverse events are mild, predictable and self-limiting2,3
1. Kornitzer M, et al. Prev Med 1995; 24:41-47.
2. Kruse E, et al. 4th SRNT 2002.
3. Zevin S, et al. Clin Pharmacol Ther 1998; 64:87-95.

55. Reasons for NRT failure
Unrealistic expectations
Incorrect use
Not used for long enough
Nicotine is often seen as the dangerous element in cigarette smoke
Safety concerns can be a barrier to use

56. Bupropion (Zyban)

57. Zyban doubles chance of successful quitting
Clinical Efficacy
Average percentage
(actual range)
10%
(0-22%)
19%
(4-43%)
Zyban doubles chance of successful quitting
Hughes JR et al. Cochrane Database Syst Rev. 2007;Jan 24(1):CD

58. CHAMPIX: a new class of therapy in smoking cessation
CHAMPIX (varenicline) is the first drug specifically developed for smoking cessation1
Launched December 2006
Oral prescription-only medicine
Unique dual mode of action - targets the nicotine receptors which is key in the addiction pathway1,2
1. Coe JW. J Med Chem 2005; 48: Dani JA, Harris RA. Nature Neuroscience 2005; 8:

59. Who can use CHAMPIX? Varenicline is indicated for:
Smoking cessation in adults1 (18 years and over)
Varenicline is contraindicated in:
Patients known to be already hypersensitive to the active substance or any of the excipients1
Varenicline is not recommended for:
Children or adolescents (<18 years)
Pregnant women
Patients with end-stage renal disease1
Normal caution is advised for patients with epilepsy and psychiatric illness
prescriber’s should always advise their patients with a history of psychiatric illness that stopping smoking may exacerbate their condition
No known drug-drug interactions1*
*Stopping smoking can result in physiological changes that may affect some medications (e.g. warfarin) for which dosage adjustment may be necessary
1. CHAMPIX Summary of Product Characteristics.

60. Unique dual mode of action
‘The Blocker’ (antagonist)
What it does:
Champix blocks stimulation of nicotine receptor
Effect on the smoker:
Reduces pleasurable effects of smoking - smoker gets no satisfaction from inhaling nicotine
Also potentially reduces the risk of full relapse after a temporary lapse1-4
‘The Binder’ (partial agonist)
What it does:
Champix binds with nicotine receptor, stimulating a small amount of dopamine release1
Mimics effect of nicotine on brain1
Effect on the smoker:
Provides relief from craving and withdrawal symptoms1-3
1. Coe JW. J Med Chem 2005; 48: Gonzales D et al. JAMA 2006; 296: Jorenby DE et al. JAMA 2006; 296: Foulds J. Int J Clin Pract 2006; 60:

61. Dosing of CHAMPIX
Recommended dose of varenicline is 1 mg twice daily following 1 week titration1
Patients who cannot tolerate adverse effects (e.g. mild / transient nausea) may have the dose lowered to 0.5mg twice daily1
The patient should stop smoking in their second week of treatment with varenicline1
1. CHAMPIX Summary of Product Characteristics.

62. Nicotine withdrawal symptoms and smoking cessation
- What to look out for and patients to treat with caution
Smoking cessation, with or without treatment, is associated with nicotine withdrawal symptoms e.g. depression and the exacerbation of underlying
psychiatric illness
Care should be taken with patients with a history of psychiatric illness and patients should be advised accordingly
1. CHAMPIX Summary of Product Characteristics.

63. Take home messages
You have an important influence in prompting people to quit You can help people stop smoking Medicines work but are not magic cures Medicines work even better with ‘wrap around’ behavioural support Don’t give up helping your patients to give up

64. Cessation Treatment Can be provided by nurses
If too busy then nurses should refer for smoking cessation treatment
Easy referral pathways
Know what options are

65. Smoking is too big to ignore

66. Smoking is a serious addiction, over half of all people who smoke cannot quit without help
Even if we could prevent people from starting, the death toll will continue well beyond our lifetime if existing smokers don’t quit
The more traditional approach to tobacco control has been to focus primarily on prevention
While this is important the biggest health gains will be made by helping people who smoke, and especially those with existing smoking related disease, to stop
Tobacco dependence has been described as a chronic relapsing disease
Despite the majority of smokers wanting to quit, and many trying each year, many don’t manage more than a few days to weeks

68. Behavioural Treatment Goals
Motivate
Create accurate and positive expectations
Prepare for Quit Date
Orient on withdrawal
Encourage compliance with medication
Advise on coping and relapse
Affirm decision to quit
You’ll be helping them through
This is the BEST thing that they can do to for their health
You have some ways that will increase their chances of quitting for good
You can make quitting easier
BUT you have no magic cures
Use enough for long enough
Explain side effects and what to do about these
Nicotine replacement therapy does not cause cancer or heart disease!
Withdrawal symptoms are typically worst in the first few weeks
They will disappear over time
Smoking cessation medicines will help
Decide on a date
Get rid of remaining cigarettes
Tell friends and family
Explain the rationale for not a single puff.
Withdrawal symptoms don’t last long
Beware of tempting situations
D.E.A.D.
If you slip its not the end of the world!

69. The end
address