Tobacco Use Prevention and Cessation

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Tobacco Use Prevention and Cessation

• Teresa Lowery, MD, Regional Medical Consultant
• Karen Yazzie-Meyer, CATC, TEAP Specialist, San
  Diego JCC
• Monika Spinks, RN, Health and Wellness Manager,
  San Diego JCC
• Rowan Torrey, Center Director, Mississippi JCC
• Job Corps National Health and Wellness Conference
• April 27, 2007
• Denver, Colorado

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Overview

• Tobacco Use Prevention and Education How to
  Strengthen Your Centers Tobacco Use Prevention
  Program (TUPP)
• TUPP at San Diego JCC
• TUPAC

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Tobacco Use Prevention and Education How to
Strengthen Your Centers Tobacco Use Prevention
Program (TUPP)

• Teresa Lowery, MD, MPH
• Regional Medical Consultant

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TUPP PRH Requirements

• Implement a program to prevent the onset of
  tobacco use and to promote tobacco free
  environments and individuals. To support this
  program, a TUPP coordinator shall be appointed
  (he or she need not be a health service staff
  member). At minimum, this program shall include
• Educational materials and activities that support
  delay and/or cessation of tobacco use
• A smoke free tobacco free environment that
  prohibits the use of all tobacco products in
  center buildings and center operated vehicles
• Designated outdoor smoking areas located away
  from the building entrance
• Prohibition of the sale of tobacco on center
• Adherence to federal and state laws regarding the
  use of tobacco products by minors

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The Importance of TUPP

• Cigarette smoking is the greatest cause of
  preventable death and disability in the US
• Tobacco use kills more Americans each year than
  alcohol, illicit drugs, suicide, AIDS, and
  accidents combined
• More than 3,000 children in the US begin smoking
  each day
• 90 of adult smokers initiated smoking before the
  age of 18 and 70 were daily smokers before this
  age

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The Importance of TUPP

• Evidence indicates the period of nicotine
  addiction is greater during adolescence
• Cigarette smoking during adolescence reduces the
  rate of lung growth, decreases maximum lung
  function, increases the risk of respiratory
  problems and reduces overall fitness levels
• Cotinine, a by-product of nicotine, has been
  found at harmful levels in infants and children
  who live with smokers

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What Were Up Against Adolescent Attitudes and
Behaviors

• 85 of adolescents who smoke think about quitting
  and 80 of current smokers made a quit attempt
  during the past year
• Youth may not grasp the long-term consequences of
  cigarette use, focus may have to include and
  emphasize the short-term rewards of cessation
• A series of focus groups with high school
  students found the motivation to quit stemmed
  from disliking the smell of cigarettes, cost, and
  a decline in artistic/athletic performance

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What Were Up Against Adolescent Attitudes and
Behaviors

• Risk Factors for Adolescent Smokers
• Low educational aspirations
• Poor or uneducated families
• Friends and/or Family members who smoke
• Other health-risk behaviors
• Low self esteem or poor self image
• Low perception of self-efficacy
• Depression
• Acceptance by peers
• Desire to seem more adult or mature

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Why Try??

• Cigarette use and its consequences impacts
  employability
• The most common form of drug addiction is
  nicotine dependency, which causes more death and
  disease than all other addictions combined
• Many adolescents lack the skills and knowledge
  to quit on their own
• Because the PRH says so !

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What Can We Do??

• Once adolescents are motivated to stop smoking,
  we need to have developmentally appropriate
  interventions available and accessible to them
• Various programs and interventional models have
  been studied
• Most have low rates of success, anticipate
  several attempts at quitting
• Relapse must be addressed
• Nicotine withdrawal symptoms should be
  anticipated and addressed in daily users

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Basic Elements of aCognitive-Behavioral
Intervention

• Establish Self-Awareness of Tobacco Use
• Record tobacco use behaviors
• Discuss thoughts, beliefs, and reasons for using
  and not using tobacco
• Learn about the physical and psychological
  effects of tobacco use

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Basic Elements of aCognitive-Behavioral
Intervention

• Prepare to Quit
• Set a specific and reasonable quit date
• Choose a quit method (e.g., cold turkey, gradual
  reduction), and set short- and long-term goals
  appropriate to quit method
• Learn about the physical and psychological
  symptoms of withdrawal

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Basic Elements of aCognitive-Behavioral
Intervention

• Provide Strategies to Maintain Abstinence
• Use problem-solving techniques to minimize
  effects of situational triggers
• Develop coping skills (thoughts and actions)
• Seek social support from family and peers
• Develop strategies to monitor and reinforce
  progress

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Pharmacological Interventions Considerations

• The following are important considerations
  regarding the use of medications with youths
• No over-the-counter or prescription products have
  been approved by the FDA for use by individuals
  under the age of 18
• None of the youth clinical trials that used
  pharmacotherapy for cessation have shown
  effectiveness (not true for adults)
• Risks associated with the use of medications
  should outweigh the determined risks of
  continuing use of the tobacco product

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Pharmacological InterventionsConsiderations

• The average cigarette contains approximately 9 mg
  of nicotine
• Smoking one pack per day yields about 180 mg of
  nicotine accompanied by 4,000 compounds with 43
  known carcinogens
• Nicotine is the addictive component in
  cigarettes, and smokers experience cravings
  similar to those experienced by heroin and
  cocaine addicts
• The primary pharmacological efforts involve
  either replacing nicotine or reducing the craving
  for nicotine through receptor site interactions

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Pharmacological InterventionsConsiderations

• Remember to educate students on what to expect
• Quitting is difficult since the nicotine addict
  will experience withdrawal symptoms
• These symptoms peak by day 3 and gradually
  diminish thereafter
• Symptoms include increase cravings, hunger,
  irritability, restlessness, difficulty
  concentrating, mood disturbance and urge to smoke

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Pharmacological Interventions

• Bupropion (Wellbutrin, Zyban) by prescription
  only
• MOA still unknown, but postulated to reduce
  craving for nicotine and may be combined with
  replacement products
• Dosage (immediate release) 150mg Qam for 3 days,
  then 150 mg bid (begin treatment 1-2 weeks
  prequit)
• Duration 12 weeks, may be extended
• Cost 150 mg, 60 each, 97.00
• Side effects nausea, seizures, tremors,
  agitation, dry mouth, and insomnia
• Caution drug interactions have been reported
  with other antidepressants and psychotropic
  compounds

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Pharmacological Interventions

• Nicotine Gum (Nicorette) available over the
  counter
• MOA releases nicotine buccally, (not to be
  chewed like a gum)
• Each piece of gum last between 20-30 minutes
• Dosage one to two pieces per hour, with the 2mg
  dose used for those who smoke less than one pack
  per day 4mg dose for those who smoke more than
  one pack per day
• Cost 2mg, 48 each, 29 4mg, 48 each, 33
• Side Effects headache, indigestion, mouth
  irritation or sores, and nausea
• Initially use one piece of gum q1-2 hrs, rather
  than treating emergent cravings

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Pharmacological Interventions

• Nicotine Inhaler (Nicotrol) by prescription only
• MOA a 10 mg cartridge delivers 4mg of vaporized
  nicotine to the oral mucosa
• Dosage Each smoker should individualize the dose
  to between 6 and 16 cartridges daily to minimize
  withdrawal symptoms
• Cost 10mg cartridge, 42 each, 41
• Side effects local irritation, coughing,
  rhinitis, dyspepsia and headache
• An advantage to the inhaler is that it
  substitutes some of the behavior effects of
  smoking by the administration of puffing

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Pharmacological Interventions

• Nicotine Nasal Spray (Nicotrol NS) by
  prescription
• MOA delivers 0.5mg of nicotine per dose to the
  nasal mucosa via an aqueous solution
• Dosage one to two doses intranasally per hour
  for a total of 8-40 inhalations per day
• Cost 10ml, 41
• Side Effects nasal and throat irritation,
  sneezing, runny nose, and watery eyes
• An advantage of this system is that it delivers
  nicotine more rapidly to the systemic circulation
  than other nicotine replacement products

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Pharmacological Interventions

• Nicotine Patch (Habritrol, Nicoderm, and
  Nicotrol) by prescription
• MOA useful in reducing nicotine withdrawal
  symptoms and are intended as a temporary aid in
  the early stages of smoking cessation
• Provides nicotine through the skin and require
  1-2 hours from the time of administration to
  reach peak levels in the bloodstream
• Dosages 21mg, 14mg, 7mg (all per 24 hrs)
• The recommended starting dose is 21 mg patch
  applied QD for 4-8wks followed by a 14mg patch
  QD for 2-4wks, and a 7mg patch QD for 2-4wks

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Pharmacological Interventions

• Nicotine Patch (contd)
• Students who smoke less than 1 ppd (packs per
  day) may receive a patch delivering between
  15-22mg of nicotine replacement daily
• Those smoking between 1-2 ppd may start with
  21-35mg patches
• Those smoking more than 2 ppd should receive a
  patch or patches delivering between 42-44mg daily
• The student should commit to stop smoking on
  initiation of therapy however, relapses do not
  warrant discontinuation of the patch
• Cost 30 each, range between 112-125 depending
  on dosage

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Pharmacological Interventions

• Nicotine Patch (contd)
• Side effects erythematic, pruritis, local
  irritation, diarrhea, dyspepsia, arthralgias,
  myalgias, sweating, somnolence, and abnormal
  dreams
• Sleep disturbances can be minimized by using
  a16-hour patch or by removing the patch before
  bedtime
• There is an OTC Nicotine patch 15mg dosage/ 24
  hour
• Cutaneous reactions can be minimized by rotating
  application sites and using a specific site no
  more than once a week
• Local reactions may be caused by the adhesive in
  the patch rather than the nicotine, and can be
  symptomatically treated with hydrocortisone cream

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Teen Smoking Cessation StudiesWhats Worked?
What Hasnt?

• Nicotine replacement therapy (NRT)
• Success rates overall low
• Long term cessation rates around 5-10
• Overall found to be safe and well tolerated
• Usually high relapse rate
• Many adolescents continued to smoke while on
  the patch!!
• Of note, some non-smokers or light smokers
  (less than one cigarette per week) also use the
  patch (usually bought over the counter)

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Teen Smoking Cessation StudiesWhats Worked?
What Hasnt?

• School-Based Health Programs
• Generally ineffective for long term in terms of
  prevention (when used alone), but are more
  effective when combined with other approaches
  such as media and smoke-free policies
• For cessation may be very helpful for support if
  includes cognitive-behavioral approaches, with
  emphasis on coping skills training, and
  alternative ways of handing situations or
  negative moods without smoking (programs should
  be fun and enjoyable)
• More effective for volunteer students, but not
  for those for whom program is mandated (i.e., in
  lieu of school suspension)

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Teen Smoking Cessation StudiesWhats Worked?
What Hasnt?

• Peer leadership
• Peer led group vs. adult-led group
• Both were equally effective when compared with
  control group with 18.1 quit rate at one month
  reported by participants
• Focused on immediate consequences of smoking
• Bad smelling breath and hands, stained
  fingernails, shortness of breath in sports and
  recreation, and cost
• What students found most helpful
• Learning the negative consequences of smoking,
  tips for quitting, learning coping behaviors,
  encouragement from leaders to quit, spending more
  time with nonsmoking friends, and learning the
  reasons for smoking

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Teen Smoking Cessation StudiesWhats Worked?
What Hasnt?

• Peer Support Programs
• Buddy System for pregnant adolescents
• Buddy had to be a nonsmoking female friend in the
  same age range
• Buddy to provide encouragement and support, as
  well attend all sessions
• Used materials from the Teen Fresh Start Program
  developed by the American Cancer Society
• 30 reported quitting smoking completely

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Teen Smoking Cessation StudiesWhats Worked?
What Hasnt?

• Computer Intervention Programs
• Several models exist
• i.e., Action Oriented based on a program
  developed by the American Lung Association
• Capitalize on students interest in working with
  computers
• Students usually respond to questions on the
  computer screen regarding smoking cessation and
  receive immediate feedback on the screen
• Students reported quit attempts after session,
  but long term outcome has been disappointing
• May be better used as an adjunct to other
  smoking cessation programs

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Conclusion of Teen Smoking Cessation Studies

• No one program experienced great success
• May give insight into the development of future
  cessation programs
• Variety may be the key to success
• Using peer leaders and buddies may reduce the
  cost of programs while providing intensive
  support
• Teens with a higher level of nicotine addiction
  may need NRT incorporated into their program
• Incorporating computer programs may increase
  students interest and participation in programs

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Ideas From Job Corps Centers

• Incentive Programs from Oral Health and Wellness
  Programs
• Tooth whitening
• Oral health care product give-a-ways
• ???Other prizes???
• Essay contests
• Frequent cleanings

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Internet Resources for TUPP

• Free tobacco cessation resources available at
  http//www.askandact.org
• Campaign for Tobacco-Free Kids
• Quitline Referral Cards
• Posters
• PowerPoint Presentation
• Patient Education Materials
• Lapel Pins
• Quit Smoking Prescription Pads
• CME

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Conclusion

• Strengthening your centers TUPP is a
  comprehensive task that will involve health and
  wellness staff, oral health providers, TUPP
  specialists, as well as center staff. Recruitment
  and use of nonsmoking peers for support and
  leadership may also prove to be invaluable. The
  most effective programs offer a variety of models
  which grab and maintain the students interests.
• Whatever it takes, WE CAN DO IT!!

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TUPP at San Diego JCC

• Karen Yazzi-Meyer, CATC,
• TEAP Specialist
• Monika Spinks, RN, HWM

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TUPP Program Overview

• 8-week program, based on the Transtheoretical
  Model
• Health and Employability
• California Smoke-Free Workplace Labor Law
• Secondhand Smoke (SHS)
• Co-occurring Nicotine and Alcohol Dependence

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Smoking Cessation Program

• Educate trainees about the negative health
  effects of tobacco
• Education and assistance provided
• Video presentations, materials, and group
  discussions

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Responsibilities

• Trainees will not use tobacco in any form on this
  center, including smokeless tobacco
• Trainees are informed of this policy on admission
• Those trainees violating the smoke-free center
  policy will be held accountable

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Transtheoretical Model

• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance

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Annual Events

• Christmas Holiday Parade of Lights
• Earth Day
• Great American Smoke-Out
• Halloween Pumpkin Carving Contest
• Kick-Butts Day
• San Diego Padre games

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Outreach and Community Resources

• American Cancer Society
• American Lung Association
• BUILT
• EAPA
• Nicotine Anonymous and A.A.
• SAMHSA
• San Diego County Mental Health
• San Diego County Tobacco Coalition
• Smoke-Free California
• Tobacco Education Clearinghouse of California
• Tobacco-Free Kids

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TUPAC
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Tobacco Use Prevention and Cessation

• Rowan Torrey, Center Director
• Mississippi JCC

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Goals and Objectives

• The goal is to establish a
• No Smoking Center
• OBJECTIVES
• 1. Eliminate smoking completely on center
• 2. Eliminate effects of second-hand smoke on
  non-smokers.
• 3. Promote life-long health
• 4. Enhance employability of students and staff
• 5. Prepare students for the smoke-free workplace

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Todays Situation

• Many JC enrollees enter the program with
  long-term addictions to nicotine
• Tobacco use adversely affects their health,
  finances, and employability
• Addictive tobacco use is an example of poor
  self-control and failure

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Available Options

• Do nothing!!
• Advantages No cost, no fuss, no work!
• Disadvantage No change in health and career
  outlook, employability suffers

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Available Options

• Restrictive Smoking!!
• Advantages Fairly easy to do, shows an attempt
  to effect change, no revolt of the masses, low to
  no costs
• Disadvantage Not a strong enough message, will
  not impact addicted and motivated smokers, easy
  to abuse policy

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Available Options

• No smoking!!
• Advantages Clear mission, clear air, initiates
  a new center culture, promotes health and
  employability, prepares students for the new
  workplace, reduces staff sick days, no ifs, ands
  or butts
• Disadvantage Requires perpetual education,
  causes negative morale among some staff and
  students, reduces enrollee pool, requires
  consistent enforcement management, will create a
  new contraband for students and staff

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What we did, orHow to Become a Smoke-Free
Center

• 1. Establish a time table
• One year minimum, maybe more
• Publicize, promote, push, promulgate
• 2. Announce intentions
• State why. Health, employability, economics,
  applicable laws

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What we did, orHow to Become a Smoke-Free
Center

• 3. Establish No Smoking committee
• Students and staff, smokers and non-smokers,
  professionals
• Heart Association
• Lung Association
• American Cancer Society

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What we did, orHow to Become a Smoke-Free
Center

• 4. Restrict smoking opportunities gradually as
  education increases and proliferates
• Cut designated smoking areas by one-half
• Cut the half in half
• Reduce down to one area for smoking
• Limit smoking to breaks (staff/students)
• Limit smoking to after the training day
• Limit smoking to designated times during after
  training day and weekends

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What we did, orHow to Become a Smoke-Free
Center

• 5. Start Education Cessation Programs before and
  concurrent to applying restrictions
• Staff and student focus groups
• Heart and lung classes
• Posters, flyers, bulletins
• Center wide meetings

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What we did, orHow to Become a Smoke-Free
Center

• 6. Implement Policy in Career Preparation Phase
• Identify individual challenges
• Introduce to TOBACCO USE AND PREVENTION
  PROGRAM---TUPP
• Career Success Standards Activities
• No Smoking Rally

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What we did, orHow to Become a Smoke-Free
Center

• 7. Celebrate quitters
• Center wide announcements
• Pizza parties
• T- SHIRTS
• Freedom activities
• Post on web-site

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What we did, orHow to Become a Smoke-Free
Center

• 8.Develop progressive sanctions for
  non-compliance
• Staff
• Warning
• Reprimands
• Suspensions
• Termination

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What we did, orHow to Become a Smoke-Free
Center

• 8. Develop progressive sanctions for
• non-compliance
• Students
• Verbal Reprimand
• Written Reprimand
• Incident Report
• TUPP Program
• Suspended Pass
• Restriction
• Center Review Board

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What we did, orHow to Become a Smoke-Free
Center

• 9. Continuing Education
• Never stop teaching cessation!
• Advertise
• Reinforce in wellness area
• Career Success Standards