1. TOBACCO CESSATION Angela F. Testa, CHES, TTS Health Services Consultant Aetna, Inc.

2. Tobacco Statistics Cigarette smoke contains over 4,800 chemicals, 69 of which are known to cause cancer. Smoking is directly responsible for approximately 90 percent of lung cancer deaths and approximately 80-90 percent of COPD (emphysema and chronic bronchitis) deaths. In 2009, an estimated 46.6 million, or 20.6% of adults (aged 18+) were current smokers. The annual prevalence of smoking declined more than 50 percent between 1965 and 2009. http://www.lung.org/stop-smoking/about-smoking/facts-figures/general-smoking-facts.html

3. Tobacco Statistics Percentage of U.S. adults who were current smokers in 2011: 10 19.0% of all adults: 21.6% of males, 16.5% of females (43.8 million people) Cigarette smoking costs more than $193 billion (i.e., $97 billion in lost productivity plus $96 billion in health care expenditures). http://www.lung.org/stop-smoking/about-smoking/facts-figures/general-smoking-facts.htmlhttp://www.lung.org/stop-smoking/about-smoking/facts-figures/general-smoking-facts.html & http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/

4. Types of Tobacco Cigarettes, Cigars, Cigarillos, Smokeless, Snuff, Snus, Pipe, Dip, Spit, Chew, Bidis, Dissolvable, Hookah, Kreteks There is no safe level of tobacco use. There is no safe form of tobacco use. All forms contain nicotine and can cause addiction and health problems.

5. Cigars, Cigarettes, Cigarillos Regular cigars are larger than cigarettes and do not have a filter. Little cigars or cigarillos are very similar in size and shape of cigarettes, have filters and are filled with pipe tobacco. They often have a flavor. They are sold in packs of 20 just like cigarettes.

6. SMOKELESS TOBACCO Two main types of smokeless tobacco Chewing Tobacco Comes in the form of Loose Leaf, Plug or Twist Snuff Finely ground tobacco that can be dry, moist, or in sachets

7. Smokeless Tobacco Holding an average-size dip in your mouth for 30 minutes gives you as much nicotine as smoking three cigarettes. A 2-can-a-week snuff dipper gets as much nicotine as a 1-1/2 pack-a-day smoker does. A can of dip costs an average of nearly $3. A two-can-a- week habit costs about $300 per year. A can-a-day habit costs nearly $1,100 per year. Likewise, chewing tobacco costs about $2. A pouch-a-day habit costs over $700 a year.

8. About Nicotine… Nicotine is harmful to the developing brain. Less than one tablespoon is enough to kill an adult and as little as 1 teaspoon could kill a child. Liquid nicotine can be lethal when inhaled. Also harmful when ingested or absorbed through skin.

9. Side Effects of Nicotine

10. How Long Does Nicotine Stay in the Body Nicotine patches and gums contain a specific dose of nicotine that is designed to clear from the body after a short period of time. Nicotine absorbed by the body through smoking, chewing and other tobacco use can linger for a longer period of time. Each person's unique metabolism also plays a role in how quickly the body gets rid of nicotine. Nicotine withdrawal symptoms usually peak between 12 and 24 hours after the last cigarette. As the nicotine slowly leaves your system, these symptoms will decrease. http://answers.webmd.com/answers/1200374/how-long-does-nicotine-stay-in-the-body

12. Types of NRT  GUM  White Ice Mint, Fresh Mint, Cinnamon Surge, Fruit Chill How to Use: Chew the gum slowly until you feel a tingle in your mouth (peppery taste) Park the gum between your cheek and gum When the tingle is gone, chew a few more times to get it back, then park again Repeat this procedure for about 30 mins to release most of the nicotine Food or drink can affect how well the nicotine is absorbed. Do not eat or drink 15 before and during gum use

13. Types of NRT  Gum Dosage: More than 25 cigarettes a day or smoke within 30 mins. of waking – 4 mg, up to 24 pieces per day Less that 25 cigarettes a day – 2 mg, up to 24 p

14. Types of NRT  GUM Possible Side Effects Hiccups Nausea Jaw Discomfort Racing Heartbeat Throat irritation The gum can also stick to and damage dentures and dental work.

15. Types of NRT  GUM Advantage for Use: Fast Acting Allows you to control nicotine doses Can be used as needed or on a fixed schedule (1-2 pieces per hour) Good choice if you have sensitive skin and cannot use the patch

16. Types of NRT  LOZENGES: (mini or regular) 2 or 4 mg Regular Mint or Regular Cherry Mini Lozenges only come in mint Size of a Tic Tac Faster acting

17. Types of NRT  LOZENGES: DOSAGE : Smoke first cigarette more than 30 mins after waking – 2 mg Smoke first cigarette within 30 mins of waking - 4 mg How to Use: Place lozenge in mouth and allow to dissolve slowly (20-30 mins) Do not bite or chew and do not swallow. Do not use more than 5 lozenges in 6 hours or 20 lozenges/day. Do not use while drinking hot or cold beverages

18. Types of NRT  LOZENGES Possible Side Effects: Nausea Hiccups Coughing Trouble Sleeping Heart Burn Headache

19. Types of NRT  PATCHES Give a measured dose of nicotine through the skin Dosage: 16 or 24 hour patch More than 10 cigs/day: 21 mg x 6 weeks; 14 mg x2 weeks ;7 mg 2 weeks Fewer than 10 cigs/day: 14 mg. x6 weeks; 7 mg x2 weeks

20. Types of NRT  Patches: Possible Side Effects: Skin Irritation Racing Heartbeat Sleep problems or unusual dreams Head Ache Nausea

21. Types of NRT  PATCHES: What to do about side effects: Sleep problems may go away after 3-4 days. If not try switching to 16 mg patch or remove patch before bedtime. Try using a lower dose patch Stop using and try a different form of NRT. Use a hydrocortisone cream for minor skin reactions

22. Contraindications for NRT 1. Under 18 years of age 2. Pregnant or breast feeding 3. Plan on continuing to smoke, chew tobacco, use snuff, or other nicotine containing product 4. Heart disease, recent heart attack, or irregular heartbeat 5. High blood pressure, not controlled with medication 6. Using a non-nicotine stop smoking drug 7. Taking a Rx medicine for depression or asthma. Dose may need to be adjusted 8. Stomach ulcer or diabetes (Gum & Lozenge only—recommend Patch) 9. Sodium restricted diet (Gum & Lozenge only—recommend Patch) 10. Allergy to adhesive tape (Patch only—recommend Gum or Lozenge) https://aetsps.aetna.com/sites/WellnessResourceTool/HealthyLifestyleCoaching/Nicotine%20Replacement%20Therapy/NRT%20De cision%20Tree_Rev%203-1-12_Aetna%20(2).pdf

23.  ZYBAN (Wellbutrin, Bupropion) Dosage: MD prescription 150 mg in the am for first 3 days. On the 4 th day begin taking one 150 mg. tablet in am and on 150 mg. tablet in the evening. Take at least 8 hours apart. Begin taking 8-15 days before quit date. Continue use for at least 7-12 weeks. Pharmacologic Products

24.  ZYBAN Contraindications: Seizure Disorder Current or prior diagnosis of bulimia or anorexia Are abruptly discontinuing use of alcohol or sedatives < 18 years old Pregnancy and Breast Feeding

25. Pharmacologic Products  CHANTIX Dosage: Days 1-3: take white.5 mg. tablet once per day Days 4-7: take white. 5 mg. tablet twice per day Day 8: Take 1 blue tablet once per day Start taking one week before quit date

26. Pharmacologic Products  CHANTIX: Most Common Sid Effects: Nausea Vivid Dreams Constipation Gas

27. When to Use or Not to Use NRT When Not to Recommend the Patches Smokes 5 or less a day (offer 2 mg lozenges or gum as an alternative) When Not to Recommend any NRT Smokes a few cigs every other day or smokes sporadically (examples include: situational smoker, social smoker, etc.)

28. Electronic Cigarettes Developed in China and introduced to the US market in 2007. E-cigs, Vapors, Personal Vaporizers Many brands, flavors, and nicotine strengths Consists of a cartridge filled with liquid, vaporization chamber and an indicator light. Runs on lithium battery. E-cigs heat up liquid. The liquid turns into a vapor which is then inhaled of “vaped”.

31. Electronic Cigarettes Currently not regulated by the FDA Proposed FDA Regulations: Banning sales to minors Makers to register with the FDA FDA approval to market products Approval to make direct and implied claims of of reduced risk Include Health Warnings

32. Electronic Cigarettes What the new rules don’t cover: Do not ban online sales, TV ads, or flavored e-cigs