Clinical Tobacco Intervention Program (CTIP) Generalist Module

Transcription

1 Clinical Tobacco Intervention Program (CTIP) Generalist Module

2 Clinical Tobacco Intervention Program (CTIP) Generalist Module All rights reserved. No part of this publication may be reproduced or transmitted without written permission from the BC Cancer Agency Prevention Programs. The BC Cancer Agency Prevention Programs would like to thank all those that have contributed to the creation of this module and their continuing support of the Clinical Tobacco Intervention Program. 2011, BC Cancer Agency Clinical materials, including stop smoking chart reminders, patient educational materials, and forms for use in clinical tobacco intervention are available from: BC Cancer Agency Prevention Programs Suite 600 (6 th Floor West), Box 614 Vancouver, BC Canada V5Z 1H5 Toll Free Telephone: ext Fax: [email protected] Website: TobaccoEd.org CTIP Generalist Module Oct2011 Version Page 2

3 TABLE OF CONTENTS CLINICAL TOBACCO INTERVENTION PROGRAM (CTIP) EMPOWERING OTHERS TO BECOME TOBACCO FREE... 5 LEARNING OBJECTIVES...5 RATIONALE FOR PROVIDING CTIP...6 TOBACCO USE IN BRITISH COLUMBIA... 7 IN CANADA...7 IN THE REST OF THE WORLD...8 TOBACCO DEPENDENCE AND ADDICTION... 9 Brain Chemistry and nicotine addiction...9 Behavioural Conditioning...10 Psychology...10 Cultural and Social Aspects...10 ASSESSING LEVEL OF ADDICTION...11 NICOTINE WITHDRAWAL SYMPTOMS...12 DEALING WITH STRESS...12 HEALTH CONSEQUENCES OF TOBACCO USE...13 BENEFITS OF STOPPING TOBACCO USE...15 TOBACCO USE AND ASSOCIATED HEALTH OUTCOMES...16 Stop Smoking Before Surgery...16 CTIP TREATMENT PROGRAM...17 PRINCIPLES OF CTI...17 INTERVENTION COMPONENTS OF CTI...19 The 5 A s Ask, Advise, Assess, Assist, Arrange...19 Stage matched interventions...21 Intensive Interventions...22 Behavioural Counselling Counselling tobaccos users...23 Developing a Quit Plan...25 THE 5 R S MOTIVATION FOR TOBACCO USERS NOT WILLING TO QUIT AT THIS TIME...26 STOP SMOKING MEDICATIONS...27 Nicotine Replacement Therapy (NRT) and Pharmacotherapy (Prescription Drugs)...27 COST FINANCIAL IMPLICATIONS...28 NICOTINE REPLACEMENT THERAPY (NRT)...29 Nicotine Patch...30 Nicotine Gum...31 Nicotine Lozenge...32 Nicotine Inhaler...33 Nicotine Nasal Spray (Not currently available in Canada)...33 LONG TERM USE OF NRT...34 PHARMACOTHERAPY...34 Bupropion (Zyban )...34 Varenicline (Champix )...35 COMBINATIONS OF NRT AND PHARMACOTHERAPY...36 REDUCING TOBACCO USE IN COMBINATION WITH USING NRT AND PHARMACOTHERAPY...37 SPECIAL TOPICS...38 CTIP Generalist Module Oct2011 Version Page 3

4 WEIGHT GAIN AFTER CESSATION OF SMOKING...38 SPECIAL POPULATIONS...38 Tobacco Users with Heart Disease...38 Pregnancy...39 Adolescents...39 Older tobacco users...39 Mental illness...40 SPIT TOBACCO...40 CTIP GENERALIST MODULE CLINICAL TOOL KIT...42 CONDITIONS CAUSED BY TOBACCO USE...43 BENEFITS OF QUITTING...44 EFFECTIVENESS OF INTERVENTIONS AND CESSATION RESOURCES...45 FAGERSTROM TEST FOR NICOTINE DEPENDENCE [7]...47 THE 5A'S FLOWCHART...48 ASK FLOWCHART: DETERMINING TOBACCO USE STATUS...49 THE 5 R S MOTIVATION FOR TOBACCO USERS NOT WILLING TO QUIT AT THIS TIME...50 CLINICAL TOBACCO INTERVENTION CHECKLIST FOR PRACTITIONERS...52 STOP SMOKING MEDICATIONS...53 TREATMENT...53 NICOTINE REPLACEMENT THERAPY (NRT) CLEAN NICOTINE PRESCRIPTION MEDICATIONS NICOTINE WITHDRAWAL...54 NICOTINE TOXICITY...54 NICOTINE REPLACEMENT THERAPY (NRT)...54 PRESCRIPTION MEDICATIONS...56 NRT MYTHS AND FACTS...57 DECISIONAL BALANCE: PROS AND CONS [19]...59 CHANGE PLAN WORKSHEET...60 DRUG INTERACTIONS...62 Pharmacokinetic Interactions...62 RESOURCES FOR CLIENTS & HEALTH CARE PROFESSIONALS...64 REFERENCES...65 CTIP Generalist Module Oct2011 Version Page 4

5 Clinical Tobacco Intervention Program (CTIP) Empowering others to become tobacco free Tobacco use is categorized as a chronic disease which will contribute to the death of 50% of those who use tobacco products. Each tobacco user has a personal experience with tobacco use and their stopping will be as unique as their history of using tobacco products. Clinical Tobacco Interventions (CTI) and brief clinical interventions, or simply brief interventions (BI), have the potential to help support behaviour change and to increase the odds of having a tobacco user stop. Clinical Tobacco Intervention (CTI) has been recommended by the Canadian Task Force on Preventive Health Care, in the Canadian Guide to Clinical Preventive Health Care, as having A level evidence and effectiveness as a preventive measure. Learning objectives Understand there is currently a higher incidence of tobacco use in specific populations: mental health, perinatal women, and aboriginal. Describe the major health risks of tobacco use and the benefits of quitting. Identify how brain chemistry, behavioural conditioning, psychological and social factors contribute to tobacco addiction. Recognize the principles of tobacco intervention. Identify the 5 "A's" of clinical tobacco intervention. Recognize the importance of identifying the tobacco use status of every client/patient and use a chart reminder system to support cessation support. Conduct a basic assessment of level of tobacco addiction and readiness to stop smoking. Assist tobacco users to stop with appropriate counselling and use of stop smoking medication where appropriate and recommended. Perform appropriate follow up with every client/patient, including referral back to all relevant health care providers which may include the following: physicians, nurses, pharmacists, dental hygienists, dentists, radiation therapists, psychiatrists, social workers, cancer navigators, smoking cessation specialists. Understand that the most common tobacco related diseases are cancers (lung, bladder and oropharyngeal), cardiovascular disease and chronic lung disease. Tobacco misuse is responsible for approx % of all cancer related deaths and 85% of lung cancer related deaths. [1] CTIP Generalist Module Oct2011 Version Page 5

6 Tobacco use causes oral cancer. Long term spit tobacco use is directly correlated with an increased risk of mouth, larynx, throat and esophagus cancers and users are 50 times more likely to develop cancer of the cheek than non users. Rationale for providing CTIP There is evidence that simply advising patients to discontinue tobacco use has been shown to increase the rate of abstinence by a third, and longer and more intensive interventions had even greater impact. Furthermore, interventions by clinicians were shown to be more effective than self help and several clinicians intervening (a team approach) increased the abstinence rate two to three fold. Whether the tobacco user is ready to quit or not, support for behaviour change can be provided in as little as 30 sec to 3 minutes. Best practices go well beyond simply advising tobacco users of the harmful effects of tobacco use and clinical guidelines recommend that tobacco cessation support should include: [2] The 5 A's (ask, advise, assess (affirm and acknowledge), assist, and arrange followup). Intensive intervention for the smokers who are ready to quit. Brief intervention for the remaining smokers. Supportive counselling, stop smoking medication where recommended, and systematic follow up for smokers who are quitting. A systems approach to supporting clinical tobacco intervention. CTIP Generalist Module Oct2011 Version Page 6

7 Tobacco Use In British Columbia According to Statistics Canada, Canadian Community Health Survey (CCHS) 2010, Tobacco Use in Canada: Findings from the CCHS report, BC continues to have a low smoking prevalence rate of 17.4%. This is one of the lowest smoking rates in Canada. BC's youth (age 12 19) had a low smoking prevalence rate of 8.6 (+/ 2.5). The highest smoking rate in BC is among year olds at 23.9%. (+/ 4.0) The BC Stats report Tobacco Attitudes and Behaviours Survey Report sourced from 2008 Community, Health, Education and Social Services (CHESS) Omnibus Survey also states that: 48.5% of smokers were thinking of quitting in the next 12 months. BC has a high proportion of people who have never smoked at 57%. Approximately 5,972 British Columbians die each year from smoking related conditions. This is a higher death toll than that from alcohol, drug use, accidents and AIDS combined. Of these smoking related deaths: In Canada 2,521 were due to cancer. 1,996 were from circulatory disease. 1,455 were from respiratory disease. The British Columbia Healthy Living Alliance Tobacco Reduction Strategy reports that smoking costs the BC economy more than $2.7 billion annually in direct and indirect health care costs. The 2009 Canadian Tobacco use Monitoring Survey (CTUMs) found a smoking prevalence of 18% in Canada among those aged 15 years and older, which translates to be about 4.9 million smokers. The CTUMS 2009 results also found: Males still smoke slightly more than females (19% to 16%). 14% of Canadians smoked daily, with 4% smoking occasionally. 14% of youth aged smoked (equal prevalence among males and females). 23% of young adults aged smoked (26% for males and 20% for females). 11% of Canadian households had at least one person who smoked inside the home every day, or almost every day. 11% reported being exposed to second hand smoke every day. CTIP Generalist Module Oct2011 Version Page 7

8 In the rest of the World The prevalence of tobacco use is continuing to decline in Canada however it is increasing worldwide, and is a significant cause of disease and death, both in Canada and around the world. The World Health Organization's 2008 and 2010 Reports on the Global Tobacco Epidemic states that: Tobacco kills one person every six seconds. Tobacco kills 5 million people a year and by 2030, this number will be 8 million people per year. More than 80% of the world's tobacco related deaths will be in low and middleincome countries by There were 1.1 billion smokers in the world in 2010 and there will be 1.6 billion by CTIP Generalist Module Oct2011 Version Page 8

9 Tobacco Dependence and Addiction Approximately 24% of tobacco users are heavily addicted to nicotine and have more difficulty in their attempts to stop using tobacco products. [3] The intensity of addiction and the likelihood of stopping smoking are predicted by: The number of cigarettes smoked per day The smoking of the first cigarette immediately after awakening And the severity of withdrawal symptoms experienced by tobacco users during tobacco use Nicotine is a powerful, psycho active drug that affects mood, thinking, and focus. It affects the user in four ways: Brain Chemistry and nicotine addiction When nicotine is absorbed through the lungs (cigarette smoking), or through the mouth (spit tobacco), the brain receives a "hit" of nicotine within seconds for smokers and minutes for chewers. This "nicotine hit": [3] Improves attention. Elevates mood and pleasure. Suppresses hunger. Relieves stress. Often creates a craving for repeated applications to satisfy the neuro response/request. Relieves uncomfortable symptoms of nicotine withdrawal. The smoker is also able to adjust the nicotine dose on a puff by puff basis to meet his/her needs. By inhaling more deeply or at a faster rate, the smoker is able to increase the amount of nicotine that is obtained by the cigarette. In recent decades the cigarette has become a highly engineered and carefully designed nicotine delivery system. Essentially, the cigarette does for nicotine what crack does for cocaine: it makes a highly addictive form of the drug readily available and convenient to repeatedly selfadminister, resulting in high rates of morbidity and mortality. CTIP Generalist Module Oct2011 Version Page 9

10 Behavioural Conditioning A stimulus (a situation) causes a response (lighting a cigarette) which provokes a consequence (gratification). Since such a consequence is positive, the behaviour is reinforced, and more likely to occur again. [4] With smoking, the tobacco user reinforces his/her tobacco addiction with each puff. Assuming 10 puffs per cigarette, a package a day smoker will repeat the regular hand to mouth motion 200 times per day and over 70,000 times per year. Smoker s behaviours are strongly conditioned by the useful psychoactive effects noted under nicotine addiction and by the associated physical aspects (tactile, visual, and smell) of smoking. The cigarette smoke, its smell, the cigarette package, the handling of a cigarette all serves a reinforcing role in the addiction. The pattern of nicotinic receptors in the brain, which is genetically determined, plays a major role in smoking addiction. [4][21] Psychology The way a person thinks, acts and/or reacts to situational stimuli in their environment (advertising, invitation to using tobacco products) combined with their socio economic status and education level, affects their lifestyle choices. Once introduced to tobacco products, evidence has shown that nicotine dependence and addiction proceeds very quickly. People vary in how nicotine affects the brain which helps to explain why some tobacco users have a more difficult time quitting. Depression, schizophrenia, and attention deficit are also associated with higher than average levels of tobacco addiction. [2] Cultural and Social Aspects Cultural and social factors all contribute to the initiation and use of tobacco. Occupation, years of education, cultural background, and marital status are all major factors which contribute to tobacco use as a lifestyle choice. Some social activities, such as going to community venues, or spending time with friends who use tobacco, are strongly associated with tobacco use. In these situations, it feels natural for the person to use tobacco. BC s new Tobacco Legislation was recently changed to restrict tobacco use in most places. [6] It can be helpful for the tobacco user to go public and to seek support for their decision to stop from family, friends and co workers. CTIP Generalist Module Oct2011 Version Page 10

11 Assessing Level of Addiction It is helpful for a tobacco user to understand their level of addiction when thinking about stopping tobacco use. It will help determine what elements are included in their treatment plan including specific recommendations for stop smoking medications. Carl Fagerstrom s Test for Nicotine Dependence can be used to determine and discuss levels of addiction. Fagerstrom s test has found that people who are heavily addicted will: [7] Smoke within 5 min of waking. Find it very difficult to not have a cigarette first thing in the morning. Find it difficult to not smoke in areas where it is prohibited. Smoke more than cigarettes per day. Smoke more during the first hours after waking. Smoke when very ill. Tobacco users who are highly addicted often: Have a history of many quit attempts. Frequently require special care or referral to all appropriate health care providers. They may be: o Addicted to other drugs or alcohol. o Have a history of schizophrenia, clinical depression, panic disorder, and/or attention deficit disorder. o On medication that interacts with nicotine. o Have a medical condition which requires immediate cessation such as acute myocardial infarction or hypertensive crisis. This information will help determine: 1. Which stop smoking medications products to use where recommended 2. What level of dosing will be appropriate for the tobacco user 3. Duration of the treatment A personalized plan which addresses the level of addiction contributes to greater levels of success. CTIP Generalist Module Oct2011 Version Page 11

12 Nicotine Withdrawal Symptoms Withdrawal symptoms can range from being very uncomfortable to being unbearable. A tobacco user who understands his/her level of addiction (amount of nicotine in his/her system at peak periods) and prepares himself/herself for withdrawal symptoms will contribute to their increased success in stopping tobacco use. The method of nicotine delivery (cigarette/cigar/cigarillo, spit tobacco, snuff, water pipe) determines the time it takes to reach peak nicotine level and how high the level is. Inhaling tobacco smoke delivers the fastest and highest nicotine level, which maximizes the psychoactive effects on the brain. Nicotine from cigarettes reaches the brain in only seconds. [4] Nicotine has a half life of approximately 2 hours. This requires that the drug be repeated throughout the day to maintain the blood nicotine level within the user's comfort range. This comfort range varies with the time of day (diurnal variation). When tobacco users go to sleep, their nicotine levels fall, and upon awakening, smokers have their lowest nicotine levels of the day. Hence the first cigarette of the day is often very rewarding. The most common withdrawal symptoms are: [2] Anxiety Restlessness Inability to concentrate Irritability Severe urges to use tobacco Reduced pulse rate Headaches Problems with sleeping Dealing with stress Clients who have made the decision to stop using tobacco may experience different levels of stress. In fact they may have been using tobacco products to reduce stress for many years. Stress reduction tools can help the patient develop new coping skills. These techniques can help to alleviate the stress often experienced when stopping tobacco use and from stress of coping with the effects of chronic diseases. CTIP Generalist Module Oct2011 Version Page 12

13 Counselling (Group or Individual) Biofeedback/Relaxation Exercise Family and Friends Laughter Meditation/Yoga Increases support for cessation and survival rates for patients with chronic disease, i.e., cancer. [8] Relaxing muscles through biofeedback, relaxation tapes or guided imagery Improves overall health, reduces stress and releases endorphins which reduce pain Getting support from family and friends who will listen and who have a positive outlook Takes the patient's mind off his/her situation and off cravings for tobacco Can lower blood pressure and stress hormones as well as relieve tobacco cravings Nutrition/Drinking water Diets that are high in animal protein have been linked to anxiety and panic attacks. Drinking enough water helps flush tobacco toxins out of the body Positive thinking/visualization Sleep Visualizing a healthy immune system, a tobacco free lifestyle and a disease free body can help deal with the withdrawal symptoms from stopping tobacco as well as the serious effects of chronic disease, i.e., tumours. Getting enough sleep can strengthen the immune system and help patients deal with the disease and tobacco cravings. Health Consequences of Tobacco Use Tobacco use has effects on human beings from before birth until death and is linked to numerous health issues over the life span. A common misconception is that nicotine is the harmful substance in tobacco products. Nicotine alone has not been shown to cause cancer, heart disease, or chronic respiratory disease, but it is highly addictive. The carcinogens in tobacco products, the carbon monoxide in cigarette smoke and the particulate matter are what cause most of the tobacco related diseases. Of head and neck cancers, 85% are associated with tobacco use. The relative risk of morbidity from lung cancer is over 90% and between 60 70% for other tobacco related cancers (larynx, bladder, esophagus, kidney, oral cavity). CTIP Generalist Module Oct2011 Version Page 13

14 Engaging in tobacco use before age 30 has been identified as a strong risk for colorectal cancer. Tobacco use impairs the immune system and affects dental health as well. Below is a table of other ailments, increased risks, and diseases that tobacco use has been known to be associated with: Cancers Lung Larynx Oral: Lip, mouth, cheek, tongue Pharynx Esophagus Pancreas Kidney Bladder Cervix Impaired Immunity and wound healing Affecting white blood cells Decreased supply of blood and oxygen Clumping of platelets Slower tissue repair Breathing Decreased lung function Bronchitis Emphysema Sinusitis Increased pulmonary complications after surgery Occupational Diseases: increased risk Asbestos, nickel, chromate, silica, radium. Decreases workers compensation for these conditions. Reproduction Female/baby: Pelvic inflammatory disease Ectopic pregnancy Infertility Placenta abruption, previa, premature rupture of the membranes LBW Low birth weight Male: Impotence Decreased sperm count and motility Cardiovascular diseases Heart attack Sudden coronary death Stroke Children exposed to second hand smoke SID sudden infant death syndrome More hospitalizations for pulmonary diseases Increased risk of future nicotine addiction Higher future incidence of cancer & leukemia More bronchitis More ear infections Aggravation of asthma More missed days of school Associated risks: increased risk Fire, motor vehicle, industrial accidents Peptic ulcers Esophageal disease Crohn s disease of the small intestine CTIP Generalist Module Oct2011 Version Page 14

15 Benefits of Stopping Tobacco Use Many tobacco users feel that there is no point in quitting because the damage has already been done. Contrary to this belief, within hours of quitting and at any age, the body begins to repair itself. Discussing the health benefits of quitting can help to motivate and encourage the patient: [10] Within 8 hours, carbon monoxide levels in the blood drop significantly. Within 48 hours, the risk of heart attack begins to decrease and the senses of smell and taste improve. Within 72 hours, lung capacity starts to increase and breathing often becomes easier. Within several weeks, white blood cells, immunity, and circulation improve. Within 6 months, coughing, sinus congestion, fatigue and shortness of breath often improve. Within 1 year, the risk of having a heart attack as a result of tobacco use is cut in half. Within 5 10 years, the risk of dying from a heart attack or stroke is that of a person who has never used tobacco. Within 10 years, the risk of lung cancer is cut in half Other benefits of quitting tobacco: Feeling better physically. No longer controlled by cigarettes and the addiction they cause. Not exposing children, family, friends and coworkers to second hand smoke. Saving money. (cost of tobacco, cleaning costs of clothes, insurance) Reducing the chances of complications of pregnancy and harm to the baby. Feeling less socially isolated (when they no longer have to go outside to smoke). Cessation after treatment of small cell lung cancer is associated with fewer tobacco related second primary cancers. Cessation has been shown to reduce risk of renal cell carcinoma. CTIP Generalist Module Oct2011 Version Page 15

16 Tobacco Use and Associated Health Outcomes Tobacco use has been shown to: Delay healing post surgery. Worsen dental disease(s): oral cancers, worsen dental disease(s): oral cancers, leukoplakia, gingival and peridontal conditions, receding gums, dental staining and calculus, halitosis, black hairy tongue, recurrent cancer sores, melanosis (pigmentation of the gum tissues), and oral candidiasis. Can exacerbate the effects of many chronic diseases including: o Cancer: reduces effectiveness of treatments, increases the risk of contracting a second cancer, increases the side effects of cancer treatment and can cause complication during treatment requiring that it be stopped. o Diabetes: increased vision problems, raised risk of: gum disease and tooth loss, nerve damage, heart attack and stroke, rate of amputation of foot and legs. o Asthma: decreased lung function, breathing problems, coughing, shortness of breath, bronchoconstriction, airway inflammation, increased mucous production. obstructive pulmonary disease: contributes to the progression of the disease, increasing the difficulty to breath. o Cardiovascular disease: increase in blood pressure, damage to cerebrovascular system, decreases good cholesterol, contributes to blood clotting, increased risk for peripheral arterial disease and aortic aneurysm. While the effects of tobacco use can be very invasive, devastating and often debilitating, the benefits of stopping have shown to greatly improve health outcomes. Our bodies have the ability to repair, renew and regenerate. Stop Smoking Before Surgery It is beneficial for surgical patients to stop using tobacco 8 weeks prior to having surgery to help reduce the risk of complications. [24] wounds will heal more quickly surgical wounds are less likely to get infected decreased risk of lung and chest infection after surgery reduced length of hospitalization CTIP Generalist Module Oct2011 Version Page 16

17 CTIP Treatment Program Health professionals can offer tobacco users assistance in stopping smoking because the systematic delivery of clinical tobacco intervention can greatly benefit tobacco users and the efficiency of the healthcare system. Clinical tobacco intervention (CTI) will require varying amounts of time depending on whether the tobacco user is ready or not to quit. Over 70% of tobacco users would like to stop but are not ready or prepared. Tobacco users who are ready often benefit from more counselling, and more follow up. It is equally important to provide brief CTI for those who are not ready to quit. Brief CTI delivered consistently can contribute to behaviour change and tobacco cessation success. [2] Principles of CTI The following principles may be used to guide the application of clinical tobacco intervention: [2][10][12] To treat tobacco addiction as a chronic condition that will require on going clinical support and repeated intervention. Clinical tobacco intervention is an essential part of tobacco control, which also includes: o Monitoring tobacco use. o Eliminating exposure to second hand smoke. o Health education. o Regulation of cigarette packaging, marketing and sales. o Legislation towards elimination of tobacco use. Tobacco users should be treated with respect, dignity, and sensitivity when they are offered clinical tobacco intervention. Tobacco users have the right to decide whether, when, and how they will stop smoking. The following 5 A s describe the major steps of clinical tobacco intervention: Ask, Advise, Assess, Assist, and Arrange follow up. The 5 R s: Relevance, Risks, Rewards, Roadblocks, and Repetition are designed to motivate tobacco users who are unwilling to quit at this time. They are used in conjunction with the 5A s. Individual counselling is the most effective format, followed by group counselling, pro active telephone counselling, and self help (least impact). CTIP Generalist Module Oct2011 Version Page 17

18 Having a tobacco use screening/chart reminder system in place substantially increases the rate of clinician intervention, and in turn doubles the rate of abstinence achieved in the practice compared to those that did not use a screening/chart reminder system. The meta analysis of the types of counselling and behavioural therapy showed that the most effective types (two fold increases) were general problem solving, aversive tobacco use interventions and receiving intra and extra treatment social support. The US Department of Health and Human Services Clinical Practise Guideline Panel, Treating Tobacco Use and Dependence recommend that all patients be offered NRT (Nicotine Replacement Therapy) and/or pharmacotherapy for tobacco cessation except where contra indicated. Changing the duration or combining medications can also increase the odds ratio for success. The guideline also reviewed the abundant clinical research on the effectiveness of the various components of CTI with other cessation support options such as selfhelp. The interventions were then ranked according to their level of effectiveness in supporting cessation. INTERVENTION COMPONENT ODDS RATIO* Total counselling time (>300 minutes) 2.8 Two clinicians intervening (e.g. doctor and medical office assistant) 2.5 High intensity counselling (>10 minutes and >8 sessions) 2.3 Intensive intervention by physician st line stop smoking medications (NRT/bupropion/varenicline) Having a tobacco use identification system (sticker/computer based) 2.0 Intensive intervention by non physician clinician 1.7 Physician advise to quite 1.3 Group counselling 1.3 Pro active telephone counselling 1.6 Self help 1.1 Pamphlets/booklets/manuals (no effect alone) 1.0 *the higher the ratio, the more effective; 1.0 = same effect as control group CTIP Generalist Module Oct2011 Version Page 18

19 Intervention Components of CTI The 5 A s Ask, Advise, Assess, Assist, Arrange The following chart refers to the appropriate strategy for each category of intervention using the 5 A s: [2] Ask about tobacco use Ask permission Advise to quit Acknowledge & Affirm Identify every patient's tobacco use status. Those who never smoked and long term ex smokers don't have to be asked again. Begin with: We have a system where we ask everyone about their tobacco use is it ok if we talk about it today? "Have you ever smoked regularly?", then "Do you use tobacco on a regular basis?" then "Approximately how much do you use?", and finally "How do you feel about stopping?" Put the information gathered into their chart. Having a tobacco use screening/chart system in place substantially increases the rate of clinician intervention and doubles the rate of abstinence achieved in the practice that did not use such a system. Express encouragement and support. Ask about personal relevance. Identify family, social and/or financial reasons for wanting to stop. I know you ve told me you d like to quit that s great that you re thinking about it as you know it s one of the most important things you can do to be healthy. You ll know when you re ready to stop and I can help and/or let you know about some of the services and info available. What would be your most important reason for stopping? CTIP Generalist Module Oct2011 Version Page 19

20 Assess willingness to quit Assist in quit attempts Arrange follow up If the person has indicated that they may be ready to stop ask if they ve ever assessed their level of addiction. Good that you re ready to quit. It s often helpful to find out how addicted you are. I have some info about that I can give you If you have an appointment with the person you have an opportunity to complete a medical history and identify any complicating factors. Ask about medications. If the person is not ready to quit, let them know that you have information to help when they are ready and if they would like it. Ask if the person has tried to stop before and if they d like to think about creating a plan to stop. Have a sample plan/template available and help identify other supports: doctor, social supports, back up plans, past successes. Ask if they have info about stop smoking medications and offer to provide. Affirm that their doctor, pharmacist or other health care provider can help them assess which would work best for them. Emphasize personal autonomy in choosing a product(s) and in working with their doctor to get the best product(s) it may take several tries to do this. There are many products available now and it s often a very personal plan that is developed to support success. Encourage the person to have regular visits with their family doctor, pharmacist and/or cessation specialist preferably within two weeks of the quit date and then ideally (regularly) throughout the first year. Encourage them to access other supports. Have appropriate resources available to provide or for referrals. (i.e.: Confirm your continued support. Ask how they will reward themselves for making this important decision to be tobacco free. CTIP Generalist Module Oct2011 Version Page 20

21 Stage matched interventions Tobacco users should be offered specific interventions based on their Stage of change and readiness to stop, and using tobacco use chart reminders enable you to track progress and promote consistent follow up as well. [2] Not interested in stopping. (Pre Contemplation Stage) Ask if the person would like to talk about their tobacco use and confirm the importance to stop. Find out what the person knows about the health consequences and discuss other relevant issues such as financial implications Listen in an empathetic way to the patient's pros and cons about tobacco use. Let them know you are willing to help when they're ready. Thinking about stopping. (Contemplation Stage) Express confidence in the patient's ability to stop using tobacco Ask the patient if they have educational materials on stopping and on available medications. Find out what information they have and what they need. Help the patient to develop a plan for stopping. Ready to stop. (Preparation Stage) Restate your belief in their ability to quit. Evaluate the patient's plan for stopping and note quit date on chart. Review appropriate use of stop smoking medications. Encourage the patient to get support from friends, family, and community programs. Just stopped (within past two weeks). (Action Stage) Listen to the patient's positive and negative feelings about stopping. Review the symptoms of tobacco withdrawal. Make sure that medications are proceeding as planned. Check that the patient is getting adequate social support. Recent ex smoker (last puff was less than five years ago). (Maintenance Stage) Make sure the patient's medication is on track or completed. Review possible relapse situations: stress, alcohol, social situations. CTIP Generalist Module Oct2011 Version Page 21

22 Ask how the patient has rewarded him/herself for stopping. Long term ex smoker (last puff more than five years ago). (Maintenance Stage) Discuss if relevant. Recognize patient's feelings about stopping and being a nonsmoker Review possible relapse situations: stress, alcohol, social situations. Congratulate the patient on her or his success. Intensive Interventions Intensive interventions are appropriate for any tobacco user who is willing to use them. Evidence shows that intensive interventions are more effective than brief interventions and should be used whenever possible (e.g., available resources, patient is willing). The following table presents the results and guideline analyses that examine different components of intensive treatment programs. Assessment Program clinicians Program intensity Program format Type of counselling and behavioural therapies Components of an intensive intervention Assessments should ensure that tobacco users are willing to make an attempt to quit using an intensive treatment program. Assessments can provide useful information which can be incorporated into the counselling process (e.g., stress level, presence of co morbidity). Multiple types of clinicians are effective and should be used. One counselling strategy would be to have a medical/health care clinician provide information about health risks and benefits and pharmacotherapy, and non medical clinicians deliver additional psychosocial or behavioural interventions. Because of evidence of a strong dose response relationship, the intensity of the program should be: Session length longer than 10 minutes. Number of sessions 4 or more sessions. Total contact time longer than 30 minutes. Either individual or group counselling may be used. Proactive telephone counselling also is effective. Use of adjuvant self help material is optional. Follow up assessment intervention procedures should be used. Counselling and behavioural therapies should involve practical counselling (problem solving/skills training) and intra treatment and extra treatment social support. CTIP Generalist Module Oct2011 Version Page 22

23 Pharmacotherapy Population Every tobacco user should be encouraged to use pharmacotherapies endorsed in the guideline, except in the presence of special circumstances. Special consideration should be given before using pharmacotherapy with selected populations (e.g., pregnancy, adolescents, mental health). The clinician should explain how these medications increase smoking cessation success and reduce withdrawal symptoms. The first line pharmacotherapy agents include: bupropion SR, varenicline, nicotine gum, nicotine lozenge, nicotine inhaler, nicotine nasal spray, and the nicotine patch. Intensive intervention programs may be used with all tobacco users willing to participate in such efforts. Behavioural Counselling Counselling tobaccos users Evidence shows that supportive, empathetic communication with tobacco users increases their motivation to quit. Ideal communication to support tobacco cessation includes the following: Listening to the tobacco user Eliciting info from them Asking open ended questions Reflecting Explaining tobacco addiction Providing info where needed Each person has a unique experience with tobacco. Through exploration and discussion he/she is able to reflect and make wise decisions to help himself/herself quit when they're ready. "Tell me more about that" or "How do you manage that" Open ended questions show your interest in the person's concerns and feelings. Let him/her know that you understand by reflecting his/her concerns back to them "It sounds like you've thought about this a lot..." Many tobacco users believe that quitting is a matter of will power alone, and feel less confident when they are not able to quit the first time. Find out what they know about tobacco addiction and provide info they may not know (e.g. brain chemistry) to help them better understand the process of quitting. CTIP Generalist Module Oct2011 Version Page 23

24 Expressing faith in their ability to quit Holding hope Let the person know that he/she is the expert relative to their ability and desire to quit. Emphasize the person's cumulative learning experience as a result of repeated quit attempts it's normal and natural to try a few times. You ve learned a lot about yourself through this process. Respecting and affirming their decisions Acknowledge their autonomy Being positive and patient Helping to develop a plan to quit Follow up Sometimes people are not ready to quit, or relapse after quitting. Affirm their decisions and offer your support when it may be needed. You ll know when you re ready to quit. I m available for you to call me when you want to talk about it. Most tobacco users want to quit. It is most often a matter of Importance, Readiness, and Confidence. They need to determine how important it is for them to quit, how ready they are and how confident they are that they can do it. Encourage them to explore these aspects of the quitting process or explore it with them. Scaling for Change: ask the person on a scale of 1 10 how important is it for you to make this change? If low ask what would it take to get to an 8 and if high say this may be an important issue in your life. Continue to explore roadblocks to stopping and/or what the person is willing to do to stop. A plan to stop can emerge. Use your combined knowledge and develop a unique plan for each patient. If the patient is quitting congratulate him/her and express empathy throughout the process. If the patient is not ready to quit let him/her know that you are available to help when they are ready. CTIP Generalist Module Oct2011 Version Page 24

25 Developing a Quit Plan Help the patient to develop a quit plan that seems practical and feasible to the patient. Each person will develop their own unique approach to quitting. [2] Some proven approaches include: Behavioural strategies Medication Relapse situations General health Support What will they do instead of using tobacco...? At home and in the car? On their break at work? When they go out with friends who smoke or chew? In stressful situations? Counsel them on the appropriate use of nicotine replacement therapy, bupropion SR (Zyban), and varenicline (Champix). Note the symptoms of nicotine withdrawal and nicotine toxicity. If the patient has quit in the past, review the reasons which contributed to their successful attempt and those situations that may have caused the relapse. What will they do differently this time? If this is the first attempt, common relapse situations include using alcohol, being under stress, and being in social situations where others use tobacco. Many tobacco users gain weight when they quit tobacco. Increasing physical activity, especially walking, is the best single supportive strategy. Healthy foods and lots of water also help good nutrition will help the body to repair itself. Discuss where they will get support when necessary: Friends, family, co workers and telephone help lines. Special care and/or referral to an addiction specialist may be required if the person: Is heavily addicted and has had many previous quit attempts. CTIP Generalist Module Oct2011 Version Page 25

26 Is addicted to other drugs or alcohol. Has a personal or family history of clinical depression or schizophrenia. Is on medication that interacts with nicotine. Is under severe psychological stress. Where immediate cessation is medically urgent, such as having acute and severe hypertension or a myocardial infarction with an abnormal cardiac rhythm. Note: A List of references and referrals can be found in the Clinical Tools section at the end of the module. The 5 R s Motivation for Tobacco Users Not Willing to Quit at This Time The "5 R's," Relevance, Risks, Rewards, Roadblocks, and Repetition, are designed to motivate tobacco users who are unwilling to quit at this time. Tobacco users may be unwilling to quit due to misinformation, concern about the effects of quitting, or demoralization because of previous unsuccessful quit attempts. Therefore, after asking about tobacco use, advising the tobacco user to quit, and assessing the willingness of the tobacco user to quit, it is important to provide the"5 R's" motivational intervention. [20] Relevance Encourage the patient to indicate why quitting is personally relevant. Be as specific as possible. Motivational information has the greatest impact if it is relevant to a patient's disease status or risk, family or social situation (e.g., having children in the home), health concerns, age, gender, and other important patient characteristics (e.g., prior quitting experience, personal barriers to cessation). Risks The clinician should ask the patient which negative consequences of tobacco use are most relevant to them. The clinician can affirm and acknowledge these. The clinician should emphasize that smoking low tar/low nicotine cigarettes or use of other forms of tobacco (e.g., smokeless tobacco, cigars, and pipes) will not eliminate these risks. Rewards The clinician should ask the patient to identify potential benefits of stopping tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. Some examples of rewards follow: Improved health CTIP Generalist Module Oct2011 Version Page 26

27 Save money Set a good example for children Not worry about exposing others to second hand smoke Feel better physically Perform better in physical activities Reduced wrinkling/aging of skin Roadblocks The clinician should ask the patient to identify barriers or impediments to quitting and note elements of treatment (problem solving, pharmacotherapy) that could address barriers. Typical barriers might include: Withdrawal symptoms Weight gain Lack of support Depression Enjoyment of tobacco Repetition The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting. Asking the patient if they would like to talk about their tobacco use reinforces the importance of the issue. It is a good idea to emphasize that stopping tobacco use is a personal experience and that the process will be very unique and may require several quit attempts. Stop Smoking Medications Nicotine Replacement Therapy (NRT) and Pharmacotherapy (Prescription Drugs) There are currently many NRT over the counter products available on the market, as well as, two prescription drugs which have been proven to help achieve tobacco cessation. Trained healthcare providers (those trained in Tobacco Dependence and stop smoking medications) should discuss stop smoking medications with patients. General CTIP Generalist Module Oct2011 Version Page 27

28 information can be provided for information purposes but detailed information should be discussed with specific health care professionals such as pharmacists and physicians to determine which products will meet the needs of the patient and particularly for those who may have co morbidities and contra indications. There are a variety of situations which require very detailed care for individuals who have different biological susceptibilities and for those who may react differently to stop smoking medications. It is equally important to monitor the use of these medications to ensure proper use and to contribute to long term cessation success Efficacy Stop smoking medications are safe, effective treatments for tobacco dependence and cessation. The US Clinical Practice Guidelines recommend discussing use of NRT, varenicline (Champix), or bupropion SR (Zyban), whenever a tobacco using patient is first seen. Compared to placebo, the following table shows the odds ratio (factor of increase in abstinence) for each of the stop smoking medications. For example, bupropion doubles the rate of abstinence. Medication Odds Ratio Nicotine patch (6 14 weeks) 1.9 Nicotine gum (6 14 weeks) 1.5 Nicotine inhaler 2.1 Nicotine lozenge (2mg) 2.0 Varenicline (1mg) 2.1 Bupropion 2.0 Cost Financial Implications Many tobacco users who are preparing to stop need to prepare themselves for the initial increased costs of stop smoking medication and counselling. It is recommended that effective pharmacological treatment be followed for 8 12 weeks minimum. Many tobacco users prematurely discontinue their stop smoking medication due to cost, improper dosing and duration of treatment. There is a considerable cost to using tobacco products and a minimal cost to purchasing stop smoking medications over the long term. CTIP Generalist Module Oct2011 Version Page 28

29 PRODUCT Cost for 12 Weeks Annual Cost Patch $280 $420 Gum $150 $400 Lozenge $270 $400 Inhaler $400 $700 Champix $330 Zyban/Bupropion SR $123 CIGARETTES. A pack per day: Player s Filter $775 $3100 Accord $570 $2280 Based on 12 weeks supply. Includes taxes GST only on NRT and Cigarettes. No taxes on pharmacotherapy. Best prices available Based on largest quantity packaging. Including reduction planning over the 12 weeks for products based on reducing amount of nicotine. Based on lowest amount of medication and dosing to highest (i.e.. 2 mg. Gum at lowest dosing formula. 4 mg. gum at highest dosing) Nicotine Replacement Therapy (NRT) Non prescription medications include: nicotine gum nicotine patch nicotine lozenge nicotine inhaler nicotine nasal spray NRT provides a clean form of nicotine to the body no carbon monoxide, no tar, no poisonous particles to inhale. Thus, these medications are much safer than continuing to use tobacco products. [12] The key to proper use of stop smoking medications, whichever form, is to adjust the dosage to prevent the bothersome symptoms of tobacco withdrawal and to avoid the symptoms of nicotine toxicity (nausea, excess salivation, cold sweat, paleness, and an increased pulse rate). Nicotine in NRT does not cause cancer, heart disease or chronic respiratory disease nor does it contribute to nicotine addiction and is often called "clean nicotine". CTIP Generalist Module Oct2011 Version Page 29

30 Nicotine levels reached through nicotine replacement medication tend to be much less than the levels obtained by smoking or chewing (spit or chew) and generally taking longer to reach peak levels. Except for the 4mg gum which results in a comparable level of nicotine. Nicotine delivery method Time to peak blood level Route of delivery to brain Cigarette 5 10 minutes lungs to heart to arterial system Spit tobacco 30 minutes oral mucosa to venous system Nicotine gum 30 minutes oral mucosa to venous system Nicotine patch 2 5 hours epidermis to venous system Nicotine inhaler minutes nasal mucosa to venous system Nicotine nasal spray 4 15 minutes nasal mucosa to venous system Nicotine replacement users should be warned to stop using the patch, gum, nasal spray or inhaler if any of the following occur: a heart attack, sudden irregularity in heartbeat, severe or worsening angina (chest pain), severe high blood pressure, a sudden onset of stroke, allergic skin reactions, increase in ulcer symptoms, or any other worrisome symptom. The patient should immediately consult a physician in such circumstances. All stop smoking medications should be kept out of reach of children and pets. Nicotine Patch The patch is the simplest and easiest and therefore most reliable nicotine medication. It supplies nicotine continuously and does a good job of protecting against withdrawal The nicotine patch comes in 3 strengths. (21mg, 14mg, and 7mg) Nicotine from the patch is absorbed through the skin directly into the bloodstream, much more slowly than from the gum. Dosing: Determine which strength of the patch to use based on tobacco use. I.e.: if smoking a pack a day begin using the 21 mg patch. A person smoking between 10 and 20 cigarettes should begin with the 14 mg patch, Reduce the nicotine level from the patch after 3 6 weeks use the 14 mg. A person beginning with the 14 mg should reduce to 7 mg. Reduce to the 7 mg patch when ready and use until the 12 week treatment plan is complete this may vary for each person. CTIP Generalist Module Oct2011 Version Page 30

31 Toxicity or withdrawal: reduce or increase strength of patch if symptoms of nicotine toxicity or nicotine withdrawal appear. [2] Heavily addicted tobacco users: may be appropriate to use more than one patch, or supplement the patch with another form of nicotine replacement. This should be done under the care of a clinician familiar with clinical tobacco intervention. Usage: Wear the patch for a period of hours and remove. Apply a fresh patch at the same time every day. Applied to a hairless, clean, dry portion of the body in a different area each day. Do not apply to irritated skin. Apply sticky side down. Press down firmly for 20 seconds. Wash hands immediately after applying to remove any traces of nicotine. If experience itching or tingling should disappear in about an hour. Remove the patch if a rash or skin irritation persists beyond 1 2 hours and immediately seek medical advice (may have an allergic reaction). When a patch is removed, some redness may occur but should go away in less than 2 days. The patch can be worn while swimming, bathing or exercising. Remove patch two hours prior to any prolonged strenuous exercise to avoid possible nicotine overdosing. When disposing of used patches it is important to keep them out of the reach of children and pets. * Different brands of patches generate somewhat different nicotine blood levels. Nicotine Gum With nicotine gum, the tobacco user controls and adjusts the dosage of nicotine. Regular intake of the stronger gum, 4 mg instead of 2mg, produces a venous blood nicotine curve that resembles that of smoking. There are two strengths of nicotine gum, 2mg and 4mg. Product information recommends that the dose of nicotine gum be determined by the amount smoked as follows: 25+ cigarettes per day = use 4 mg gum Fewer than 25 cigarettes per day = use 2 mg gum CTIP Generalist Module Oct2011 Version Page 31

32 Procedure for using the gum is: It is important to counsel clients that the nicotine gum should not be used like regular chewing gum. Steps Description 1. Bite the gum slowly After 15 seconds there will be a peppery taste and a slight tingling which indicates the nicotine is being released 2. Park the gum between the cheek and gum The peppery taste and tingling will fade in about a minute 3. Bite the gum again The tingling effect and peppery taste will begin again 4. Park the gum in a different part of the mouth Continue this process for minutes or until the taste and tingle don't appear 5. Dispose of the gum Throw the gum away where children and pets cannot get at it The gum works best when it is used on a set schedule (for example, one piece an hour). This allows the user to maintain a comfortable blood level of nicotine and experience fewer withdrawal symptoms. Additional, unscheduled pieces of the gum should also be used to control cravings. CAUTION: The user should not exceed 24 pieces per day. The number of pieces used per day should be adjusted to any symptoms of nicotine withdrawal or toxicity. CAUTION: Nicotine gum should not be used by patients with tempero mandibular joint disease or dentures and, of course, by patients with symptoms of nicotine toxicity. The gum should be used for at least 12 weeks and reduced gradually over time. Users of the 4 mg gum can switch to the 2 mg to wean themselves from gum use. Tobacco users should be advised to keep a supply of the gum at home, at work, and wherever they travel. Regardless of which form of stop smoking medication is used, it is essential for the client to always keep the medication within reach 24 hours a day. Nicotine Lozenge The nicotine lozenge is a smoking cessation aid in the form of a hard candy. It comes in 1 mg, 2mg or 4mg strength (may also be available in other amounts), with the higher strength recommended for those who are more highly addicted to nicotine. The lozenge is slowly dissolved in the mouth over minutes, releasing nicotine slowly to be absorbed in the mouth. Do not chew or swallow lozenges as this will affect the absorption. Move the lozenge from one side of the mouth to the other periodically. CTIP Generalist Module Oct2011 Version Page 32

33 A person should avoid eating or drinking anything in the 15 minutes before taking a lozenge and not eat while the lozenge is in the mouth. Nicotine Inhaler The nicotine inhaler consists of a mouthpiece and a plastic cartridge which contains 4 mg of nicotine that yields nicotine vapour over 20 minutes of active puffing. The nicotine is absorbed through the mouth and throat, not through the lungs, and produces a blood nicotine curve that resembles that of the 2 mg gum, not the sharp peak of inhaling a cigarette. Compared to other means of nicotine replacement (patch, gum) the inhaler involves the hand and mouth, as cigarette smoking does, which may give it an advantage for some smokers. It is recommended that a person stop using tobacco products when using the inhaler. For best results, use at least 6 cartridges per day for the first 3 12 weeks. Do not use more than 12 cartridges in one day. After 3 12 weeks of therapy, stop using the Inhaler or slowly reduce the number of cartridges used each day over the next 6 to 12 weeks. The Inhaler should not be used for more than 6 months. Ask your prescriber for information and advice before purchasing any non prescription nicotine products if you are currently using Zyban. Using the two medications together requires special observation by your prescriber. Nicotine Nasal Spray (Not currently available in Canada) Nicotine nasal spray is available in pkgs. of four 10 ml bottles with a ratio of 10mg/mL. Each unit consists of a glass container with a metered spray pump. Persons should stop using tobacco products prior to using the spray. The spray should be administered with the head tilted back slightly. Do not sniff, swallow or inhale through the nose while administering. The dose of the nasal spray should be individualized to the person s nicotine dependence level. Recommended duration of treatment is 3 months. Each actuation of the spray delivers a metered 50 micro litre spray containing 0.5 mg of nicotine. One dose is 1 mg of nicotine. (one spray in each nostril) Persons should start with 1 or 2 doses per hour (max of 5 per hour) which may be increased to a maximum recommended dose of 40 mg per day. (80 sprays somewhat less than ½ bottle per day). Recommended strategies for discontinuation of use include: Use ½ dose at a time. CTIP Generalist Module Oct2011 Version Page 33

34 Use spray less frequently. Keep a tally of daily usage. Try to steadily reduce use. Skip a dose by not medicating every hour. Set a planned quit date for stopping use of the spray. Long Term Use of NRT Long term use of NRT has not been shown to cause adverse effects. Although Health Canada does not formally endorse long term use of stop smoking medications, their use is preferable to continuing tobacco use. [2] In addition, the slow delivery of the patch and gum does not reinforce nicotine addiction as does the faster and more powerful delivery of nicotine from cigarettes and spit tobacco. Since nicotine replacement is a relatively innocuous medication, experienced clinicians tend to prescribe it for a longer, rather than a shorter duration. Evidence from a Lung Health Study shows that the, use of long term NRT while the person is still using tobacco products is not more harmful than smoking alone. [22] Using NRT while using tobacco may be suitable for highly nicotine dependent individuals who are not ready, or able to quit completely. [23] Individuals would ideally replace more and more of the tobacco with NRT. Pharmacotherapy Bupropion (Zyban) and Verenicline (Champix) are the two most commonly used prescription drugs to assist in tobacco cessation. Bupropion (Zyban ) Bupropion is a prescription anti depressant also marketed as Wellbutrin. Bupropion acts continuously at dopaminergic and adrenergic receptor sites to block cravings and the withdrawal symptoms of anxiety, moodiness, and lack of concentration. Bupropion has a long half life (21 hours) and is usually taken twice daily. It is available in 150 mg tablets. Treatment: Start two weeks before the quit date Take once a day for three days Increase to twice a day with at least 8 hours between doses to avoid peak blood levels that might produce seizures. CTIP Generalist Module Oct2011 Version Page 34

35 Treatment should last at least three months and may be continued for a year if the patient reports major relief from nicotine withdrawal symptoms and no adverse effects from the drug. Bupropion's side effects include insomnia, dry mouth, shakiness, anxiety, and rash. Hypertension and allergic reactions (hives, difficulty breathing) have also been reported Contraindications and adverse effects with stop smoking medications: CAUTION: Before prescribing Bupropion review the possible contraindications listed below. History of seizure disorder Already taking Wellbutrin. A history of bulimia or anorexia nervosa. Discontinuing alcohol or sedative use. Have taken a monoamine oxidase inhibitor within the past 14 days. Are taking thioridazine. Have had an allergic reaction to bupropion. Tapering the dosage is not required when terminating bupropion treatment. Varenicline (Champix ) Varenicline tartrate blocks the specific nicotinic receptor that is thought to drive tobacco addiction. Several randomized clinical trials found the drug to achieve favourable one year continuous abstinence (22 23%) compared to bupropion (15 16%) and placebo (8 10%). (The corresponding early abstinence rates at 12 weeks were 44%, 30% and 18%). A randomized trial among only those who had maintained abstinence after 12 weeks of varenicline treatment (about two fifths of the smokers who started varenicline) was done to evaluate a further 12 weeks of varenicline treatment. The results showed that longer treatment with varenicline was useful. Compared to another 12 weeks of placebo, a second 12 weeks of varenicline treatment offered an increased likelihood of abstinence at 24 weeks (odds ratio 1.35). Treatment Varenicline tablets come in two sizes: 0.5mg and 1.0 mg. Dosing should begin 1 to 2 weeks before the patient s quit date. CTIP Generalist Module Oct2011 Version Page 35

36 Days 1 3: Days 4 7: Day 8 end treatment (12 weeks) 0.5 mg once daily 0.5 mg twice daily 1.0 mg twice daily Continuing for a second 12 week treatment is optional for those who have succeeded in staying tobacco free. This often strengthens the resolve of the person s intention to stay quit as well as supporting, lengthening and normalizing the nicotine free period. Dosage adjustment (to a maximum dosage of 1.0 mg per day) should be offered to those with severe renal impairment or those with moderate renal impairment who have adverse effects (next paragraph). The drug is 90% cleared in the urine and 10% metabolized in the liver. Tapering the dosage after the end of treatment may be considered for those with a history of severe tobacco withdrawal symptoms. Contraindications to varenicline use: hypersensitivity to the drug and end stage renal disease. CAUTION: Drug interaction: cimetidine slows its clearance by 29%. CAUTION: There is no adequate data on use of varenicline in pregnancy. The main adverse effects: observed in trials were nausea (usually mild or moderate), headache, and abnormal dreams/insomnia. Patients should be advised that a third of those receiving varenicline experience nausea that is mild or moderate. The overall treatment discontinuation rate was 11.4% in the varenicline group and 9.7% in the placebo group. Reducing the drug for those who experience troublesome side effects to 1.0 mg per day may be worthwhile. Since the drug causes dizziness and somnolence in some, patients should be advised not to drive, use hazardous machinery, nor engage in hazardous activities until its safety is better known. Combinations of NRT and Pharmacotherapy Using a combination of stop smoking medications may be appropriate for the heavilyaddicted tobacco user where the risks of relapse outweigh the risks of taking several medications. One approach to gaining higher levels of nicotine is to combine the gum and patch while both patient and clinician maintain vigilance for evidence of nicotine toxicity and overdose. CTIP Generalist Module Oct2011 Version Page 36

37 Using the patch and gum together is effective because it provides the user with a steady intake of nicotine from the patch, supplemented by the occasional and additional "hit" from the nicotine gum. Using Bupropion, the nicotine patch, and the 4 mg gum together is recommended by some experts in clinical tobacco intervention to treat very heavily addicted tobacco users. It may even be appropriate to use more than one patch at a time. Nicotine overdose is naturally more likely among those who take more than one form of nicotine. Reducing tobacco use in combination with using NRT and Pharmacotherapy Nicotine replacement can also help tobacco users who are not ready to stop but may be ready to cut down the amount of tobacco used per day, which reduces health risks and the intensity of addiction. Tobacco users who receive significant amounts of nicotine from any form of replacement (patch, gum, nasal spray or inhaler) should reduce their tobacco use to keep their total daily nicotine intake at the same level. CTIP Generalist Module Oct2011 Version Page 37

38 Special Topics Weight Gain after Cessation of Smoking Many tobacco users are very concerned about weight gain when they consider discontinuing tobacco use. Foods are likely to taste better and some substitute their hunger for cigarettes or spit tobacco with food. Weight gain and a change in metabolism Even if a person does not increase their caloric intake, they may still gain weight. A slower metabolism may result from stopping tobacco use. This metabolic change appears to reverse after a year or so. Clinical practice guidelines recommend that neither emphasizing the likelihood of weight gain nor downplaying its significance be stated to the patient. Weight gain should be discussed in a realistic manner. Some clients may gain 10 lbs +/. If a client shows concern for weight gain it is helpful to plan for this in advance and discuss strategies to control this aspect of cessation. Affirm the client s decision to reduce and eliminate the health risks of tobacco. The focus should be quitting and maintaining abstinence from tobacco. [2] In some studies, nicotine gum and bupropion have been shown to delay post cessation weight gain. However, once the medication is discontinued, the evidence suggests that the person will gain an amount of weight that is about the same as if they had not used the medication. Special Populations Tobacco Users with Heart Disease Tobacco use puts people at high risk for cardiovascular events, such as: [4] Acute myocardial infarction (heart attack) Sudden death Stroke Atherosclerosis Nicotine increases heart rate and heart contractility. It may cause worsening of high blood pressure. Smoking activates clotting mechanisms and promotes thrombosis. Carbon monoxide from smoking reduces the delivery of oxygen to the heart. Thus, it is even more dangerous for those with heart disease to use tobacco than for ordinary smokers. If unable to quit through other means, those with heart disease may CTIP Generalist Module Oct2011 Version Page 38

39 be considered for NRT and their use of NRT should be closely monitored by the physician. Use of bupropion SR (Zyban ) is not contraindicated for patients with heart disease. As with any prescribed drug, its use should be based on an assessment of potential risks and benefits of treatment by the physician during consultation with the patient. Pregnancy Even though pregnancy is likely one of the top motivators to discontinue tobacco use, most pregnant women do not stop using tobacco products during pregnancy. Nevertheless, intensive clinical intervention increases the odds that she will quit. [4] Smoking cessation offers health benefits to the fetus and postpartum benefits to the mother. Quitting early in the pregnancy is preferable, but health benefits accrue from the time the women stops. There is no safe level of tobacco use for pregnant women, particularly in the third trimester when the fetus is most vulnerable to effects of nicotine. If the woman does not quit by other means, nicotine replacement therapy provides a healthier alternative to using tobacco. Pregnant women should avoid second hand smoke. Health Canada has not approved the use of nicotine replacement therapy or bupropion SR (Zyban ) during pregnancy. [12] As with any other drug, nicotine replacement therapy in pregnancy should be monitored closely by the clinician. [3] Adolescents Most tobacco users start smoking or chewing before the age of 18. Those who continue are likely to develop addiction before reaching adulthood. No evidence has shown that nicotine replacement is harmful to adolescents. However, Health Canada has not yet recommended the use of NRT or bupropion for adolescents as safer than cigarettes or spit tobacco. [13] Older tobacco users Evidence shows that tobacco users over the age of 65 who stopped using tobacco benefit from doing so. Quitting reduces risks of stroke, chronic lung disease, heart attack, coronary heart disease and lung cancer and promotes more rapid recovery from illnesses that are exacerbated by tobacco use. [3] Specific interventions which have been shown effective with older populations include: Clinician advice to quit, Counselling interventions, Buddy support programs, CTIP Generalist Module Oct2011 Version Page 39

40 Age tailored educational materials, Telephone counselling (especially for those with mobility issues) Stop smoking medication Mental illness The rate of tobacco use is often very high in those with mental illnesses, (approximately 60%) particularly those with schizophrenia and depression. Persons with mental illnesses may be "self medicating" with tobacco products. Quitting tobacco may exacerbate their mental illness, particularly depression. Doses of some psycho active medications may have to be adjusted. [3] Because of these factors, it is more difficult for patients with mental illness to quit and maintain abstinence. They are sometimes referred to as "hard core" tobacco users. Nevertheless, persons with mental illness can be helped by clinical tobacco intervention and may be highly motivated to quit. [3] Spit tobacco Spit tobacco is often referred to as "smokeless" tobacco. It is also called chew, snus, dip and rub. It contains more nicotine than cigarettes. The use of spit or chew results in similar health consequences and specifically increases the risk for oral cancers and specific dental conditions. [17] The health risks include: Abrasion of teeth Gingival recession Periodontal bone loss Leukoplakia Oral cancers Cardiovascular disease. Cancers of the esophagus, larynx, stomach, and pancreas (increased risk). The most common type of oral cancer is squamous cell carcinoma which makes up about 90% of all oral malignancies. These cancers form on the tongue, floor of the mouth, lips or gums. Spit tobacco can also stain teeth and cause bad breath or 'black hairy tongue'. Studies of rats have found adverse effects on fetal viability and development. CTIP Generalist Module Oct2011 Version Page 40

41 Nicotine from chewing tobacco and snuff is absorbed more slowly than from cigarettes. Blood levels peak at 30 minutes. However, the total body dose of nicotine from chewing tobacco and snuff is greater than from cigarettes and can reach very high blood levels. Nicotine is released slowly from the mucous membranes for up to one hour after the tobacco is removed from the mouth. Withdrawal symptoms from spit tobacco are similar to those from smoking. Indicators of addiction to spit tobacco are similar to those from smoking cigarettes. Smokeless tobacco is sometimes used in the workplace where there are few breaks, or if the employee is constantly using both hands during work. Smokeless tobacco is popular in many industrial areas where there is a safety risk in having an open flame such as oil rigs or refineries. The use of smokeless tobacco is often promoted as a substitute for cigarettes or cigars where regulations prohibit their use. CTIP Generalist Module Oct2011 Version Page 41

42 CTIP Generalist Module Clinical Tool Kit Conditions caused by tobacco use Benefits of stopping Effectiveness of tobacco cessation interventions & resources Clinical Tobacco Intervention Client Assessment Form The 5A s Flowchart. Ask Flow Chart The 5R s Relevance, Risks, Rewards, Roadblocks, and Repetition Clinical Tobacco Intervention Checklist for Practitioners Stop Smoking Medications Summary. NRT & Pharmacology. (Prescription drugs) Myths about NRT Good & Not so Good Things about tobacco use and/or stopping Client Quit Plan Drug Interactions Resources for Clients CTIP Generalist Module Oct2011 Version Page 42

43 Conditions Caused by Tobacco Use Tobacco addiction (strong cravings and severe withdrawal). Heart attack and sudden coronary death, stroke, other vascular diseases. Cancer of the lung, larynx, throat, tongue, mouth, esophagus, pancreas, kidney, bladder, and cervix. Diseases of air passages: sinusitis, bronchitis, pneumonia, decreased lung function, asthmatic attacks. Obstructive lung disease, more frequent chest complications after general anesthesia. Aggravation of peptic ulcers, diseases of the esophagus, and Crohn's disease. Reproductive conditions: increased pelvic inflammatory disease, ectopic pregnancy, and infertility (effect of nicotine on Fallopian tubes); male impotence, decreased sperm count and motility. Increase of occupational risks (asbestos, nickel, chromate, silica) and decrease of workers compensation for these conditions. Death and injury from fire, motor vehicle accident, or industrial accident Impaired wound healing (white blood cells affected, decreased blood and oxygen supply), increased failure of plastic surgery skin grafts, failure of artificial joint implantation, longer hospital stays. In pregnancy: Risk to mother: abnormal delivery placenta previa, abruptio, premature rupture of membranes. Risk to child: disorders of placenta, decreased oxygen supply, low birth weight, sudden infant death syndrome, higher future cancer risk, attention deficit or related learning problems, increased risk of nicotine addiction later in life. Risk to children exposed to environmental tobacco smoke: ear infection, bronchitis, pneumonia, increased hospitalization below age 2, asthmatic attacks. CTIP Generalist Module Oct2011 Version Page 43

44 Benefits of Quitting Getting rid of, or avoiding, tobacco addiction. Not exposing children, family, friends, and co workers to second hand smoke. Saving money (one pack a day at $8.50 per pack will cost more than $15,000 in 5 years). Improving the body s capacity to heal wounds and recover from surgery. Feeling better about oneself and more in control of life. Lessening chance of heart attack and stroke (one year after quitting, a smoker's increased risk of heart attack is cut in half). Reducing chances of cancer (15 years after quitting, a smoker loses increased risk of cancer). Improving chances of conceiving a child and of having a healthy child. Reducing the probability of a complicated pregnancy. Improving circulation. Preserving lung function and fitness. Avoiding hidden costs: e.g. life insurance, burns in furniture and clothing. Being more attractive to companions. Preserving job opportunities (non smokers are often hired over smokers). Benefiting the environment: less indoor air pollution, not supporting use of agricultural land for growing tobacco. CTIP Generalist Module Oct2011 Version Page 44

45 Effectiveness of Interventions and Cessation Resources As a health professional, you can have a lasting influence on the tobacco users you see every day simply by showing an interest in how they are doing, encouraging them to quits, and offering options for stopping and providing referrals to cessation programs and services. You play a pivotal role by providing information and support to patients. Did you know that: Patients listen to all health professionals when they talk about the dangers of smoking and the advisability of stopping? Most tobacco users try to stop 5 15 times before they stay smoke free long term? Every serious quit attempt increases the chance of long term quitting? The US Department of Health and Human Services Clinical Practise Guideline Panel, Treating Tobacco Use and Dependence recommend that all patients be offered NRT (Nicotine Replacement Therapy) and/or pharmacotherapy for tobacco cessation except where contra indicated. Changing the duration or combining medications can also increase the odds ratio for success. INTERVENTION COMPONENT ODDS RATIO* Total counselling time (>300 minutes) 2.8 Two clinicians intervening (e.g. doctor and medical office assistant) 2.5 High intensity counselling (>10 minutes and >8 sessions) 2.3 Intensive intervention by physician st line stop smoking medications (NRT/bupropion/varenicline) Having a tobacco use identification system (sticker/computer based) 2.0 Intensive intervention by non physician clinician 1.7 Physician advise to quite 1.3 Group counselling 1.3 Pro active telephone counselling 1.6 Self help 1.1 Pamphlets/booklets/manuals (no effect alone) 1.0 CTIP Generalist Module Oct2011 Version Page 45

46 *the higher the ratio, the more effective; 1.0 = same effect as control group CTIP Generalist Module Oct2011 Version Page 46

47 Fagerstrom Test for Nicotine Dependence [7] 1. How soon after you wake up do you smoke your first cigarette? After 60 minutes (0) minutes (1) 6 30 minutes (2) Within 5 minutes (3) 2. Do you find it difficult to refrain from smoking in places where it is forbidden? No (0) Yes (1) 3. Which cigarette would you hate most to give up? The first in the morning (1) Any other (0) 4. How many cigarettes per day do you smoke? 10 or less (0) (1) (2) 31 or more (3) 5. Do you smoke more frequently during the first hours after awakening than during the rest of the day? No (0) Yes (1) 6. Do you smoke even if you are so ill that you are in bed most of the day? No (0) Yes (1) SCORING: 0 2 Very low dependence 3 4 Low dependence 6 7 High dependence 8 10 Very high dependence My Score is: My level of dependence on nicotine is: CTIP Generalist Module Oct2011 Version Page 47

48 The 5A's Flowchart CTIP Generalist Module Oct2011 Version Page 48

49 Ask Flowchart: determining Tobacco use status CTIP Generalist Module Oct2011 Version Page 49

50 The 5 R s Motivation for Tobacco Users Not Willing to Quit at This Time The "5 R's," Relevance, Risks, Rewards, Roadblocks, and Repetition, are designed to motivate tobacco users who are unwilling to quit at this time. Tobacco users may be unwilling to quit due to misinformation, concern about the effects of quitting, or demoralization because of previous unsuccessful quit attempts. Therefore, after asking about tobacco use, advising the tobacco user to quit, and assessing the willingness of the tobacco user to quit, it is important to provide the"5 R's" motivational intervention. [20] Relevance Encourage the patient to indicate why quitting is personally relevant. Be as specific as possible. Motivational information has the greatest impact if it is relevant to a patient's disease status or risk, family or social situation (e.g., having children in the home), health concerns, age, gender, and other important patient characteristics (e.g., prior quitting experience, personal barriers to cessation). Risks The clinician should ask the patient which negative consequences of tobacco use are most relevant to them. The clinician can affirm and acknowledge these. The clinician should emphasize that smoking low tar/low nicotine cigarettes or use of other forms of tobacco (e.g., smokeless tobacco, cigars, and pipes) will not eliminate these risks. Rewards The clinician should ask the patient to identify potential benefits of stopping tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. Some examples of rewards follow: Improved health Save money Set a good example for children Not worry about exposing others to second hand smoke Feel better physically CTIP Generalist Module Oct2011 Version Page 50

51 Perform better in physical activities Reduced wrinkling/aging of skin Roadblocks The clinician should ask the patient to identify barriers or impediments to quitting and note elements of treatment (problem solving, pharmacotherapy) that could address barriers. Typical barriers might include: Withdrawal symptoms Weight gain Lack of support Depression Enjoyment of tobacco Repetition The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting. Asking the patient if they would like to talk about their tobacco use reinforces the importance of the issue. It is a good idea to emphasize that stopping tobacco use is a personal experience and that the process will be very unique and may require several quit attempts. CTIP Generalist Module Oct2011 Version Page 51

52 Clinical Tobacco Intervention Checklist for Practitioners Once you have labelled the chart to reflect the patient s current stage of stopping smoking, use this checklist to guide your interaction with the patient. Always express your confidence in the patient s ability to stop smoking or to remain cigarette free. CTIP Generalist Module Oct2011 Version Page 52

53 Stop Smoking Medications Treatment Stop Smoking Medications work best if used with a behavioural plan, educational materials, supportive counseling (by a trained health professional), and long term follow up by all relevant health care providers. Nicotine Replacement Therapy (NRT) Clean Nicotine. Nicotine replacement therapy (NRT), (patch, gum, lozenge, inhaler, nasal spray) provides a clean form of nicotine to the body. There is no carbon monoxide, no tar, and no poisonous particles to breathe in. Nicotine from NRT gets to the brain in a much less addictive manner. Nicotine travels from a cigarette to the brain in seconds and reaches peak blood levels in 5 10 minutes. The nicotine hit delivered from inhaling cigarette smoke contributes to its highly addictive nature. While NRT products deliver nicotine more slowly and in some cases consistently. (The Patch) Nicotine delivery method Time to peak blood level Route of delivery to brain Cigarette 5 10 minutes lungs to heart to arterial system Spit tobacco 30 minutes oral mucosa to venous system Nicotine gum 30 minutes oral mucosa to venous system Nicotine patch 2 5 hours epidermis to venous system Nicotine inhaler minutes nasal mucosa to venous system Nicotine nasal spray 4 15 minutes nasal mucosa to venous system Reducing the amount of tobacco used by substituting with NRT can reduce health risks and the intensity of the addiction. Prescription medications. Bupropion (Zyban) and Varenicline (Champix) go to the same parts of the brain that are aroused by inhaling cigarette smoke containing nicotine. Bupropion increases the brain chemicals that help tobacco users concentrate and cope with upsetting thoughts and feelings. Varenicline partially blocks a receptor to which nicotine attaches to drive the addictive process. Bupropion and Varenicline act continuously at key places in the brain to help block cravings and withdrawal symptoms. CTIP Generalist Module Oct2011 Version Page 53

54 Nicotine Withdrawal The amount (dosage) of nicotine from the patch, gum, lozenge, inhaler and/or nasal spray should be adjusted to match the tobacco nicotine levels of the tobacco user. This will help manage the symptoms of nicotine withdrawal which can include anxiety, inability to concentrate, strong cravings, and a reduced pulse rate. Heavily addicted tobacco users often are treated with a combination of stop smoking medications. Nicotine Toxicity Symptoms include nausea, salivation, cold sweat, paleness and an increased pulse rate. NRT should be stopped immediately if these symptoms appear. Headache, insomnia and nervousness can appear in both nicotine withdrawal and nicotine toxicity. Nicotine Replacement Therapy (NRT) Nicotine Patch Nicotine from the patch travels from the skin to the blood and to the brain. The steady, low level of nicotine helps the tobacco user avoid withdrawal symptoms. Recommendations for use: A new patch should be applied every 24 hrs usually after bathing. Place the new patch on a new area of skin each day. If an allergic skin reaction occurs remove and contact your doctor. Hydrocortisone cream can help reduce the rash. CAUTION: remove patch immediately and contact your doctor in case of: sudden onset of chest pain, heart attach, sudden irregularity in heart beat, severe high blood pressure, increase in ulcer symptoms or the sudden appearance of any other worrisome symptom. Nicotine Gum Nicotine from the gum travels through the cheek to the blood and to the brain. Chew and park the gum for 3 5 chews and then park it against the cheek for nicotine absorption. When the peppery taste disappears repeat chewing and parking procedure. Dosage depends on tobacco use. A package a day tobacco user would normally use the 2 mg gum while someone who is heavily addicted and smoking more than a package a day would try the 4mg gum. This is best discussed with a physician or health care provider. Do not rush to discontinue use of the gum it is far safer to use it for the long term than to use tobacco. CTIP Generalist Module Oct2011 Version Page 54

55 CAUTION: do not drink juices, soft drinks or coffee before using the gum (can reduce the effectiveness) or rinse with water prior to using the gum. Nicotine Gum should not be used by persons with temporomandibular joint disease nor by persons with symptoms of nicotine toxicity. Pregnant women should consider using the gum and particularly if they re still using tobacco in the 4 th month. While Health Canada does not recommend its use for pregnant women it is a safer alternative to smoking. Nicotine Lozenge Allow the lozenge to slowly dissolve in the mouth while occasionally switching it from side to side. It should not be chewed or swallowed. It may produce warm or tingling sensations. CAUTION: do not eat or drink 15 minutes prior to use or during use. Nicotine Inhaler Nicotine is inhaled into the back of the throat through the mouthpiece which holds a nicotine cartridge. CAUTION: Persons with severe heart problems, stomach ulcers, high blood pressure, an overactive thyroid, kidney or liver disease, or other concerns should discuss with their doctor. Nicotine Nasal Spray (Not currently available in Canada). Administer with the spray bottle with the head tilted back being careful not to sniff, swallow or inhale. Recommended to stop using tobacco products before using and to use for 6 months maximum. The dose should be individualized to the person's nicotine dependence level. One dose is 1 mg of nicotine. ( = one spray in each nostril) Max of 5 doses per hour and 40 doses per day. CAUTION: Not recommended for persons with chronic nasal disorders (allergy, rhinitis, nasal polyps and sinusitis). Should not be used by persons during the immediate post myocardial infarction period, nor by persons with serious arrhythmias or with severe or worsening angina. Should be used with caution by persons with hyperthyroidism, pheochromocytoma, insulin dependent diabetes, active peptic ulcers, accelerated hypertension, severe renal impairment or asthma. CTIP Generalist Module Oct2011 Version Page 55

56 Prescription Medications Bupropion Available in 150 mg pills. Recommended to begin using at least 1 2 weeks before stopping tobacco use and to continue using for at least 7 12 weeks. Dosage: Take 1 per day for 3 days 2 per day with at least 8 hrs between pills Bupropion is an alternative or a supplement to nicotine. Using combinations of Bupropion and nicotine products can be appropriate for the heavily addicted smoker when recommended by their doctor. CAUTION: Side effects include insomnia, dry mouth, shakiness, and rash. Can cause severe anxiety. Increases the risk of seizures in persons who have a history of seizures and in persons with anorexia or bulimia. Should not take Bupropion if taking Wellbutrin or MAO inhibitors. Varenicline Available in 0.5 and 1.0 mg tablets. Begin using 1 2 weeks before stopping tobacco use. Dosage: 0.5 mg for 3 days 0.5 mg twice a day for 4 days 1.0 mg twice daily for the duration of the treatment If not using tobacco products at the 12 th week of treatment, renewing a prescription for a second 12 weeks of Varenicline improves the odds of long term cessation. In clinical trials Varenicline appears to be more effective than Bupropion. CAUTION: Stop using if allergic reaction to medication. Common side effect is mild or moderate nausea. Reduce dosage to 1.0 a day from day 8 to end of treatment if persistent CTIP Generalist Module Oct2011 Version Page 56

57 NRT Myths and Facts It s tough to quit smoking. Many smokers must try many times before they are able to quit for good. Your best chance for success occurs when you make a plan. Start by talking to your healthcare provider. They can help you decide what options you should consider. Research shows the best results are obtained when nicotine replacement therapies are combined with counselling. The following myths and facts are taken from the Ontario Medical Association position paper, Rethinking Stop Smoking Medications: myths and facts, prepared by Nicole de Guia, project manager and researcher, with direction and support from Dr. Ted Boadway, Patricia North, and Carol Jacobson of the Ontario Medical Association (OMA) Health Policy Department, and Michael Perley of the Ontario Campaign for Action on Tobacco. Last Updated: Tuesday, August [ Myth: Stop smoking medications are not effective in helping people quit. Fact: Nicotine Replacement Therapy (NRT) and bupropion (prescription drug) are effective, government approved medications available to help smokers. NRT and bupropion have each been found to approximately double quitting rates compared to placebo. Myth: Nicotine is the harmful substance in cigarettes. Fact: It s not nicotine, but the thousands of toxins present in tobacco and its products, that are responsible for the vast majority of tobacco caused disease. Myth: Nicotine's addictive potential is the same regardless of whether nicotine is obtained through nicotine gum, the patch, or cigarettes. Fact: Cigarettes are far more addictive than nicotine gum or the patch primarily because of the way in which they deliver nicotine. Myth: Nicotine replacement therapy is hazardous for smokers. Fact: Nicotine replacement therapy is safe for smokers. Myth: Use of the nicotine patch and gum should not exceed 3 months. Fact: The nicotine patch and gum should be used as long as needed to maintain or prolong tobacco abstinence. Myth: Smoking while on the patch increases the risk of a heart attack. Fact: Use of NRT while smoking does not increase the smoker's cardiovascular risk. CTIP Generalist Module Oct2011 Version Page 57

58 Myth: Patients with heart disease should not use the nicotine patch or gum. Fact: Given the seriousness of their medical condition, cardiac patients who cannot quit should be among those first considered for NRT. However, NRT dosage should be closely monitored by the physician. Myth: Pregnant women should not use nicotine gum or the patch. Fact: NRT use may be considered for pregnant women who are unable to quit. However, as with all drugs used by pregnant women, NRT use during pregnancy should be closely monitored by the physician. Myth: Smokers under 18 should not use NRT. Fact : Most daily smokers begin smoking before age 18. The nicotine patch and gum are far safer than smoking. NRT should be considered for all smokers who need NRT to quit, including those under 18. As with other medications for adolescents, the NRT dosage should be modified to the smoker s needs. Myth: The nicotine patch and gum should not be used at the same time and/or in combination with bupropion. Fact: The nicotine patch and gum may be used at the same time and/or in combination with bupropion. People using a combination of stop smoking medications should be monitored by their healthcare provider. Myth: NRT should only be taken in recommended doses. Fact: Smokers should be in control of how they use NRT and should vary the dose according to their own nicotine needs. Like smoking, it takes time to learn how best to use NRT in a manner that maximizes its benefits. Myth Nicotine gum or the patch should only be used to quit smoking. Fact: Nicotine gum or the patch can be used by people who are not yet ready or able to quit as, for some individuals, being tobacco free is not a foreseeable goal. NRT may help these smokers take a "cigarette holiday" or, in some cases, substantially reduce their smoking as an interim, achievable step toward tobacco abstinence. CTIP Generalist Module Oct2011 Version Page 58

59 Decisional Balance: Pros and Cons [19] Change Stopping tobacco use Good Things Not So Good Things No Change Not stopping tobacco use at this time Good Things Not So Good Things CTIP Generalist Module Oct2011 Version Page 59

60 Change Plan Worksheet [19] Name & Date: Some people like to write about their plans to make change. This is one way to do it. 1) The changes I want to make: 2) The most important reasons why I want to make these changes are: 3) My personal strengths which will help me make this change: 4) The steps I plan to take: CTIP Generalist Module Oct2011 Version Page 60

61 5) The ways other people can help me: People/Program Possible Ways to Help Me 6) I will know if my plan is working if: 7) Some things that could get in my way: Obstacles/surprises Back up plans CTIP Generalist Module Oct2011 Version Page 61

62 Drug Interactions Tobacco smoke constituents induce several drug metabolizing enzymes. The clearance of many drugs may be affected by their interaction with cigarette smoke and thus require changes to the usual dose of medication while the person is smoking and may require further modification after they quit. [17] Many interactions between tobacco smoke and medications have been identified. Note that it is the tobacco smoke not the nicotine that causes these drug interactions. Tobacco smoke may interact with medications through pharmacokinetic or pharmacodynamic mechanisms. Pharmacokinetic interactions affect the absorption, distribution, metabolism, or elimination of other drugs, potentially causing an altered pharmacologic response. The majority of pharmacokinetic interactions are the result of induction of hepatic cytochrome P450 enzymes (primarily CYP1A2). Pharmacodynamic interactions alter the expected response or actions of other drugs. The amount of tobacco smoking needed to have an effect has not been established and the assumption is that any smoker is susceptible to the same degree of interaction. Pharmacokinetic Interactions Drug/class Alprazolam (Xanax) Caffeine Chlorpromazine (Thorazine) Clozapine (Clozaril) Flecainide (Tambocor) Fluvoxamine (Luvox) Mechanism of interaction and effects Plasma concentrations decreased up to 50% among tobacco smokers. Increased metabolism (induction of CYP1A2); clearance increased by 56%. Caffeine levels may increase after cessation. Decreased area under the curve (AUC) (36%) and serum concentrations (24%). Smokers may experience less sedation and hypotension and require higher dosages than non smokers. Increased metabolism (induction of CYP1A2); plasma concentrations decreased 28%. Clearance increased by 61%; trough serum concentrations decreased by 25%. Smokers may require higher dosages. Increased metabolism (induction of CYP1A2); clearance increased by 25%; Decreased plasma concentrations (47%). Dosage modifications not routinely recommended but smokers may require higher dosages. CTIP Generalist Module Oct2011 Version Page 62

63 Drug/class Haloperidol (Haldol) Heparin Insulin Mexiletine (Mexitil) Olanzapine (Zyprexa) Propranolol (Inderal) Tacrine (Cognex) Theophylline (Theo Dur, etc) Tricyclic Antidepressants (TCAs, imipramine, nortriptyline, etc) Mechanism of interaction and effects Clearance increased by 44%; serum concentrations decreased by 70%. Mechanism unknown but increased clearance and decreased half life are observed. Smokers may require higher dosages. Insulin absorption may be decreased secondary to peripheral vasoconstriction; smoking may cause release of endogenous substances that antagonize the effects of insulin. Smokers may require higher dosages. Clearance (via oxidation and glucuronidation) increased by 25%; half life decreased by 36%. Increased metabolism (induction of CYP1A2); clearance increased by 40 98%. Dosage modifications not routinely recommended but smokers may require higher dosages. Clearance (via side chain oxidation and glucuronidation) increased by 77%. Increased metabolism (induction of CYP1A2); half life decreased by 50%; serum concentrations threefold lower. Smokers may require higher dosages. Increased metabolism (induction of CYP1A2); clearance increased by %; half life decreased by 63%. Levels should be monitored if smoking is initiated, discontinued, or changed. Passive smoking (second hand smoke) also increases the clearance. Maintenance doses are considerably higher in smokers. Possible interaction with TCAs in the direction of decreased blood levels, but the clinical importance is not established. CTIP Generalist Module Oct2011 Version Page 63

64 Resources for Clients & Health Care Professionals List Quitnow call line. 24/7 help. Assistance in over 100 languages Canadian Cancer Society. Self Help resources: One Step At a Time. For Smokers Who Want to Quit, For Smokers who don t want to quit, If you want to help a smoker quit. BC Lung Association. Posters, stickers, resources, fact sheets. Health Canada. BC Ministry of Health. BC Cancer Agency: and TobaccoEd.org First Nation Health Council. Health Authority Tobacco Programs. o o o o o CTIP Generalist Module Oct2011 Version Page 64

65 References 1. Health Canada. Cancer Updates: Lung Cancer in Canada. 1998, p.5. Centers for Disease Control and Prevention. Smoking Attributable Mortality, Years of Potential Life Lost, and Productivity Losses United States, Morbidity and Mortality Weekly Report 2008;57(45): [accessed 2011 Mar 11]. 2. Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May Health Canada. The Canadian Tobacco Use Monitoring Survey. (CTUMS). (2007). Tobacco Use Statistics. 4. Benowitz N, Jones RT. Therapeutics for Nicotine Addiction. Neuropsychopharmacology: The Fifth Generation of Progress. American College of Neuropsychopharmacology Ontario Medical Association [homepage on the Internet]. Toronto: Ontario Medical Association; c1999 [cited 2005 Feb 1]. Rethinking Stop Smoking Medications: myths and facts. Available from: Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom Test for Nicotine. British Journal of Addictions, 1991; 86: Johnston L. Reducing the effects of stress. Colon & Rectal Cancer: a comprehensive guide for patients and families Ch Warnakulasuriya S, Dietrich T, Bornstein MM, Casals Peidro E, Preshaw PM, Walter C, Wennstrom JL,Bergstrom J. Oral health risk of tobacco use and effects of cessation. Int Dent J Feb;60(1): Health Canada [homepage on the Internet]. Ottawa: Health Canada; c2003 [updated 2003 Jan 16; cited 2005 Feb 1]. On the Road to Quitting: Benefits of quitting. Available from: sc.gc.ca/hecssesc/tobacco/quitting/road/benefits.html 11. Therapeutics Initiative. Effective Clinical Tobacco Intervention. Therapeutics Letter 1997: 21a 21b Canadian Nurses Association position Statement: Tobacco: The Role of Health Professional in Smoking Cessation Joint Statement (2201) and Reducing the Use of Tobacco Products (2001). 13. de Guia, Nicole. Rethinking Stop Smoking Medications: Myths and Facts. Position paper prepared for the Ontario Medical Association (OMA). OMA Health Policy Department, Ontario, Canada, June Christie Hospital Patient Information Service. Radiotherapy to the head and neck, guide for patients and families. August CTIP Generalist Module Oct2011 Version Page 65

66 eck.htm 15. National Cancer Institute. Smoking cessation and continued risk in cancer patients onal. 16. Rugg T, Saunders MI, Dische S. Smoking and mucosal reactions to radiotherapy. Br J Rad, 1990; 63: Alberta Alcohol and Drug Abuse Commission. (2008) Tobacco Basics handbook: Third edition. Edmonton, AB: Author. 18. Adapted from Zevin S, Benowitz NL. Drug interactions with tobacco smoking. Clin Pharmacokinet 1999; 36: Copyright The Regents of the University of California, University of Southern California, and Western University of Health Sciences. 19. Adapted from Motivational Interviewing. 2 nd Edition. WR Miller, S. Rollnick Aveyard, Paul. "Keeping Smoking Cessation Interventions Brief & Effective". Smoking Cessation Rounds Volume 3, Issue Carmelli D, Swan GE, Robinette D, et al: Genetic influence on smoking a study of male twins. New Engl J Med : Murray RP, Daniels K. Long Term Nicotine Therapy. In: Benowitz NL, Editor. Nicotine Safety and Toxicity. New York (NY): Oxford University Press; p Jimenex Ruiz C, Kunze M, Fagerstrom K O. Nicotine Replacement: A New Approach to Reducing Tobacco Related Harm. Eur Respir J 1998 Feb; 11(2): Dr. David O Warner. Helping Surgical Patients quit smoking: Why, When, and How. International Anesthesia Research Society. 2005: 101:481 7 CTIP Generalist Module Oct2011 Version Page 66

67 The Clinical Tobacco Intervention Program is available online at: TobaccoEd.org For further information about CTIP, or other BC Cancer Agency Prevention programs, please contact: BC Cancer Agency Prevention Programs Toll Free Telephone: ext Fax: [email protected] Website: TobaccoEd.org