2. Tobacco usage

4. Smoking prevalence 1 in 5 Americans smoke  21% of adults > 18 years  (23.9%men, 18% women)  AND  22% high school students  (The prevalence decreases as education levels  Increase) More than 400,000 people in the United States die annually as a result of smoking and exposure to second hand smoke.  For each person who dies from a smoking related disease, it is estimated 20 more people are living with a smoking related illness

6. Cancers caused by smoking Lung Esophageal Pancreatic Bladder Mouth Pharyngeal Stomach Kidney Cervical Acute myeloid leukemia

7. Lung Cancer Leading cause of cancer deaths  Smoking results in:  90% of lung cancer deaths in men  And  80% in women

8. Cessation readiness In the United States:  70% of smokers want to quit  45% attempt to quit  5% are successful without assistance

9. VARIABLESEXAMPLES High motivationTobacco user reports a strong motivation to quit. Ready to changeTobacco user is ready to quit within a 1- month period. Moderate to high self-efficacyTobacco user is confident in his or her ability to quit. Supportive social networkA smoke-free workplace and home; friends who do not smoke in the quitter's presence

10. Variables associated with lower abstinence rates VARIABLEEXAMPLES High nicotine dependenceTobacco user smokes heavily ( ≥ 20 cigarettes/day), and/or has first cigarette of the day within 30 minutes after waking in the morning. Psychiatric comorbidity and substance use Tobacco user currently has elevated depressive symptoms, active alcohol abuse, or schizophrenia. High stress levelStressful life circumstances and/or recent or anticipated major life changes (e.g., divorce, job change). Exposure to other smokersOther smokers in the household.

11. How to assist with successful nicotine cessation

12. PUBLIC POLICY Become aware of your community anti-tobacco activism Become a vocal member within your community Growing body of evidence for 3 approaches: 1)increased taxation on tobacco 2)restrictive smoking policies 3)anti-tobacco advertising

13. Framework for health promotion strategies Hopkins et al 2001

14. PRIMARY PREVENTION Begin with preadolescents Teach skills to resist pressure and ads Instructions and rehearsals with peers Community health leaders support 1)bans on tobacco use in public 2)enforce prohibitions on sales to minors 3)increase price of tobacco 4) restrict advertising that glamourizes smoking to youth

15. Primary prevention should also be implemented for all adolescents and abstinence reinforced for all non- tobacco users

16. HEALTH CARE OFFICE APPROACH Brief directed smoking interventions delivered during routine care are cost effective and have potential for impact Smoking cessation assessments and interventions included in each assessment like checking BP Essential that each provider adopt assessment as standard of practice

17. Ask about tobacco use. Identify and document tobacco use status for every patient at every visit. Expand the vital signs to include tobacco use, or use an alternative universal identification system VITAL SIGNS Weight: ___ Blood Pressure: ____ Pulse: ____ Temperature:______ Respiratory Rate: ______ Tobacco Use (circle one): Current Former Never

18. 1. Ask: Systematically identify all tobacco users at every visit 2. Advise: Strongly urge all tobacco users to quit 3. Assess: Determine willingness to make a quit attempt 4. Assist: Aid the patient in quitting (provide counseling and medication) 5. Arrange: Ensure follow-up contact Management of the patient addicted to nicotine The 5 A’s

19. Suggested Interview questions  "Do You smoke?"  Label Chart "SMOKER" (or sticker)  Make Smoking a Vital Sign  How Much do you smoke?  Greater nicotine dependence if >1 pack per day  How soon after waking do you have first cigarette?  Greater nicotine dependence if under 30 minutes  Have you tried to quit before?  Successful cessation requires 3-6 attempts (average)  (http://www.fpnotebook.com/Psych/CD/TbcCstn.htm)

20. Scripting Do you smoke or use any tobacco products? I probably don’t have to tell you how bad tobacco is for your health. I strongly encourage all of my patients to quit smoking/chewing/dipping. Do you ever think about quitting? What kind of help or support can I provide for you to help your efforts?

21. Screening for current or past tobacco use will result in four possible responses: 1. The patient uses tobacco but is not willing to make a quit attempt at this time 2. The patient uses tobacco and is willing to make a quit attempt at this time 3. The patient once used tobacco but has since quit 4. The patient never regularly used tobacco.

22. The Clinical Practice Guideline from Agency for Healthcare Research and Quality (AHRQ) provides the clinician with simple but effective interventions for all of these patient groups

23. Pharmaceutical Management 1. Nicotine Replacement 2. Smoking cessation aids 3. Off label medications

24. How the pharmaceuticals work Nicotine Replacement Therapy Mechanism of Action 1.Smoking stimulates the ventral tegmental area of the brain which results in the release of dopamine into the nucleus accumbens. 2.NRT activates the dopamine reward pathway with a lower dose of nicotine. 3.This slower steady state of plasma nicotine allows for reduction of withdrawal symptoms and promotion of better behavior control.

25. Fagerstrom Test for Nicotine Dependence Assessment of tobacco addiction for nicotine replacement dosing (short version)  How soon after waking do you smoke first cigarette?  Time less than 5 minutes: 3 points  Time 5 to 30 minutes: 2 points  Time 31 to 60 minutes: 1 point  How many cigarettes do you smoke per day?  more than 30 per day: 3 points  21 to 30 per day: 2 points  11 to 20 per day: 1 point

26. Suggested dosing for Nicotine Patch  Heavy nicotine dependence: 5-6 points  Consider 21 mg Nicotine patch  Moderate nicotine dependence: 3-4 points  Consider 14 mg Nicotine Patch  Light nicotine dependence: 0-2 points  Consider 7 mg Nicotine patch or no patch Heatherton (1991) Br J Addict 86:1119

27. Smoking Cessation Drugs Mechanism of Action 1. Bupropion-decreases withdrawal and cravings for nicotine by blocking dopamine and norepinephrine uptake in the CNS. 2. Varenicline- targets the neurobiology of nicotine addiction by blocking nicotine from binding to nicotinic receptors in the brain.

28. Off Label Medications 1. Clonidine 2. Naltrexone 3. Mecamylamine 4. Nortriptyline 5. Wellbutrin 6. Selegiline

29. Non-Pharmaceutical Management 1. Behavioral Therapy 2. Self help materials 3. Alternative methods 4. Quit lines 5. Internet resources

30. Additional Management 1. Symptoms of Withdrawal 2. Medication side effects 3. Avoiding weight gain

31. Remember: Tobacco use affects everyone

32. References AHCPR Supported Clinical Practice Guidelines/Treating Tobacco Use and Dependence: 2008 Update. (2008). Retrieved April 10, 2009, from HSTAT/ Health Services Technology Assessment Text: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.28163 http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.28163 American Lung Association. (2008). Trends in tobacco use 2008. Retrieved April 22, 2009, from American Lung Association Web Site: http://lungusa.org/site/pp.asp?c=dvLUK9O0E&b=33347 Barker, L., Burton, J. & Zieve, P. (2007). Principles of ambulatory medicine (7 th ed.). Baltimore: Williams and Wilkins Barone, C. P. Heath, J. (2007 ). Evidence-based strategies for tobacco cessation. American Association of Critical Care Nurses News, 4(1), 16-19. Centers For Disease Control And Prevention Smoking and tobacco use)Centers For Disease Control And Prevention. (n.d.). Smoking and tobacco use. Retrieved April 22, 2009, from http://www.cdc.gov/tobacco/ Heath, J., Barone, C. P., & Andrews, J. O. (2007). Pharmacotherapy advances for evidence-based tobacco cessation strategies. American Association of Critical Care Nurses News, 11(1), 12-14. Loughlin, K., & Generali, J. (2006). The guide to off label prescription drugs. : simon and schuster. Mundey, K. (2009). An appraisal of smoking cessation aids. Current Opinion in Pulmonary Medicine, 15, 105-112. Potts, L. A., & Garwood, C. L. (2007). American Journal of Health System Pharmacy, 64(13), 1381- 1384. Ranney, L., et al. (2006). Tobacco Use: Prevention, Cessation, & Control. No. 06-E015. Research Triangle Park: RTI International. Steele-Moses, S. K. (2008). Smoking cessation: what is the evidence? Clinical Journal of Oncology Nursing, 12(5), 813-815.