1. The Quitting Process

2. Providing Intervention: Helping Someone Quit 4 Identify stage 4 Increase motivation 4 Break through barriers 4 Promote coping 4 Discuss pharmacotherapy 4 Provide materials 4 Get commitment 4 Plan followup

3. Stages of Quitting 4 Thinking About Quitting 4 Quitting 4 Maintenance 4 Slip 4 Relapse

4. Thinking About Quitting 4 Just considering quitting, has no definite plans, has not set a quit date 4 Patient Need: Motivation

5. Your Goal 4 Encourage a Commitment to Quit

6. The Process 4 Explore/reinforce specific motivations - personalize health risk -financial benefit -social/family 4 Debunk myths - create accurate expectations 4 Increase self-efficacy -focus on accomplishments -review past attempts

7. Quitting 4 Definitely ready to quit, has already made soma changes in smoking behavior, or has set a quit date 4 Patient Need: Coping Skills/Strategies

8. Your Goal 4 Help the patient quit successfully

9. The Process 4 Get a commitment - “two weeks” 4 Set the stage for success 4 Identify potential barriers 4 Teach appropriate coping skills 4 Select smoking cessation medication 4 Schedule follow up

10. Maintenance 4 Quit for three weeks or more; has not had any cigarettes during that time 4 Patient Need: Support/Encouragement

11. Your Goal 4 Help the patient stay quit permanently

12. The Process 4 Acknowledge accomplishment 4 Reinforce successful coping 4 Warn the patient not to become complacent -encourage continued coping -medication compliance 4 Instruct patient to: -anticipate problems -plan strategies -practice

13. Slip - Occasional Smoking -one or two isolated cigarettes -situational smoking -non-daily smoking - Patient Need: Fine tune coping strategies

14. Your Goal 4 Regain abstinence immediately

15. The Process 4 Reframe quit attempt as a success 4 Address negative emotions 4 Identify trigger 4 Plan targeted coping strategies 4 Review medication use

16. Relapse 4 Return to routine smoking: smoking one or more cigarettes on a regular daily basis 4 Patient Need: Reevaluation

17. Your Goal 4 Recommit to quit

18. The Process 4 Identify trigger of first violation 4 Suggest targeted coping 4 Examine sequence leading to relapse 4 View quitting as a learning process 4 Terminate medication use 4 Renegotiate a quit date

19. Motivations for quitting 4 HEALTH 4 MONEY 4 SOCIAL/FAMILY PRESSURE 4 OTHER

20. Barriers to quitting 4 Stress 4 Weight gain 4 Cravings 4 Automatic smoking 4 History of failure

21. Coping 4 Learning to deal with the urges, desires and triggers to smoke without having a cigarette

22. Coping Techniques TYPE TIME Cognitive Anticipatory Behavioral Immediate

23. Cognitive Techniques: Anticipatory 4 Challenge perceived benefits 4 Contemplate/visualize positive outcomes 4 Plan self rewards 4 Anticipate- Plan - Rehearse

24. Cognitive Techniques: Immediate - Distraction - Thought stopping - Substitute other thoughts - Evaluate need -Think of consequences -Review benefits of abstinence -Visualize pleasant experiences - Be objective -Remind yourself that urgers are brief -Accept the thought -Delay decision -

25. Behavioral Techniques: Anticipatory - Avoid situations/triggers - Change patterns -When/Order - What - Where - How - Who

26. Behavioral Techniques: Immediate 4 Deep breathing 4 Escape the situation 4 Alternative behaviors

27. Combining Techniques Stress management -Leave the scene -Take some deep breaths -See yourself on the beach -Think “I am calm” Morning Routine -Get up from “wrong” side of bed -Say to yourself “I can make it today” -Take a bath instead of a shower

28. Pharmacotherapy 4 Nicotine patches 4 Nicotine gum 4 Nasal inhaler 4 Oral inhaler 4 Buproprion

29. NRT Pharmacotherapy - Prevents withdrawal symptoms -maintains nicotine serum concentrations at or above patient’s comfort concentration - Gives patients time to break the habit and psychological dependency

30. Patch NRT Heavy Smokers (>10cigs/day) - Nicoderm (OTC) 24/16 hr -21mg x 6 wks, 14mg x 2 wks, 7 mg x 2 wks - Habitrol RX) 24 hr -21mg x 6 wks, 14mg x 2 wks, 7 mg x 2 wks - Nicotrol (OTC) 16 hrs -15 mg x 6 wks -Private labels (OTC) 24 hr (> 15 cigs/day) -22 mg x 6 wks

31. Patch NRT Light Smokers - 10 cigs/day or less - Nicoderm 14mg x 6 wks, then 7mg x 2 wks, 7 mg x 2 wks - Nicotrol not recommended - 5 cigs/day or less - NRT generally not necessary - Private label (<15 cigs/day) - 11 mg x 6 wks

32. Patch NRT Patient Counseling 4 Apply promptly after removal from pouch 4 Each day apply a new patch to a different place on skin that is dry, clean, and hairless. (Nicotrol - remove at bedtime, apply upon rising.) 4 Do not reuse same skin site for 7 days. 4 Wash hands after applying or removing.

33. Path NRT Patient Counseling (cont.) 4 Do not use if continuing to smoke, chew tobacco, use snuff, or use other nicotine products. 4 Do not leave the patch on for more than 24 hours.

34. Patch NRT Patient Counseling (cont.) Side Effects - Vivid dreams - Local skin reaction (rash, pruritus, burning) -up to 50% of patients have this reaction - incidence higher with 24 hour products - < 5% discontinue therapy

35. Dosing of Gum NRT Nicorette 2 mg (if smoke 25 cigs/day) Use above taper schedule.

36. Gum NRT Patient Counseling - Use of an inadequate number of pieces per day and/or use for an insufficient number of weeks can lead to a relapse. - Use gum on fixed schedule - Use at least one piece every 1-2 hrs (>9 a day). - Use for full 3 months and taper off. - Do not exceed 24 pieces a day

37. Gum NRT Patient Counseling (cont.) - Must use gum correctly - Activate slowly until “peppery” taste emerges - Then “park” between cheek and gum - Slowly and intermittently “activate and park” over 30 minutes - Avoid eating and drinking anything 15 minutes before and during use

38. Nicorette Precautions 4 Incorrect use may lead to mouth soreness, hiccups, dyspepsia and jaw ache 4 May stick to dentures, dental work and braces

39. Oral Nicotine Inhaler - Two-part mouthpiece enclosing a nicotine cartridge - Cartridge = 10 mg nicotine - One puff = 1/10 - 1/8 mg nicotine in one cigarette puff - 6-16 cartridges/day - within 12 weeks begin to taper - maximum 6 months usage - Side effects: Coughing, mouth/throat irritation

40. Nasal NRT Delivery System - Nasal Inhaler ( Nicotrol NS 10 mg/ml) - Dose - one metered spray contains 0.5 mg - One or two sprays in each nostril per hour initially; increase as needed - Not to exceed 5 doses/hr or 40 doses/day - Duration of therapy - 8 wks then gradually decrease over 4-6 weeks

41. Buproprion (Zyban) 4 Mechanism of action: May increase neurotransmitters 4 Begin one week prior to quitting 4 150 mg Qday x 3 days, then 150 mg BID 4 7-10 weeks of therapy, then DC (no taper) 4 Side effects: Dry mouth, insomnia, agitation 4 Absolute contraindication: Seizure disorder 4 Relative contraindication: Anxiety, PTSD, Bulimia, Anorexia

42. Buproprion (Zyban) - Drug Interactions -tricyclic antidepressants (lower seizure threshold) -MAOI (hypertensive crisis) - Effectiveness - 6 month abstinence rates -buproprion SR 150 mg BID 26.9% -buproprion SR 150 mg QD 27.5% -placebo 15.7%

43. Case Study #1 Jon is twenty-three years old and will be married in nine months. His fiancee hates his smoking and wants him to quit. He smokes only about three or four times a week, when he is out for dinner or having a few drinks, since many of his friends smoke. He never has more than eight cigs in an entire week.

44. Case Study #3 Sonny is a truck driver who takes long trips frequently. He smokes a lot in his truck and usually has two or three packs in there all the time. He has thought about quitting but can’t think of what else he could do in his truck for all those hours. He has caught his eleven-year-old son sneaking his cigs and really doesn’t want him to start smoking.

45. Case Study #5 Don is a stock broker on his first cruise to the Mediterranean since his heart attack. He quit smoking a few months ago, but in Naples he attended a party at a local bar. He had a few too many glasses of wine and began smoking at the party since it seemed as if everyone there was smoking. He woke up the next morning and figured that he might as well start again since he “blew it”. He is now back on the ship and has been smoking about five to seven cigs a day. He thinks he can “control” his smoking.