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Title: Naval Tobacco Cessation Program: An Overview


1
Naval Tobacco Cessation Program An Overview
  • Captain Larry Williams, Dental Corps, US Navy
  • Navy Medicine Clinical Champion for Tobacco
    Cessation
  • Co-Chair, BUMED Tobacco Cessation Action Team
    (TCAT)
  • Member, DoD Alcohol and Tobacco Advisory Council
    (ATAC)

U.S. Naval Aeromedical Conf 2009
2
2008 GW Fire Improper smoking in spaces with
hazardous, improperly stored materials
3
Objectives
  • Review new SECNAV 5100.13E
  • Discuss Navy Tobacco Cessation Program
  • Update hazards and military issues with tobacco
  • Briefly discuss tobacco cessation
    pharmacotherapies
  • Discuss training opportunities for providers
    wishing to learn more about tobacco cessation.

4
(No Transcript)
5
Bottom Line- Up Front
  • The medication must fit the patients needs
  • The patient must fit the medication
  • Cessation must fit the patients desires and
    address ad lib use of NRT and habit substitution
  • The patients medical history must be taken into
    account when choosing meds

6
New Navy Guidance SECNAVINST 5100.13E
  • Military Personnel shall not use tobacco products
    and walk from point to point while in uniform
  • All tobacco use areas shall prominently display
    tobacco use warnings and availability of tobacco
    cessation programs.
  • Tobacco cessation is not the cessation of a
    habit, but rather the treatment of an addiction.
  • Access to tobacco treatment should be as easy as
    purchasing tobacco products.

7
SECNAVINST 5100.13E (contd)
  • Break periods for tobacco users will be the same
    as for non-users.
  • Smokeless tobacco is not a safe alternative to
    smoking. Smokeless tobacco use is only permitted
    in designated tobacco use areas and its residue
    shall be disposed of in a sanitary manner which
    prevents public exposure.
  • Commanders need to encourage a tobacco-free
    lifestyle provide leadership by personal
    example creating a tobacco-free command
    climate.

8
DoD/VA TUC CPG Guiding Principles
  • We have to make cessation support as accessible
    as buying cigarettes for those patients who want
    to quit.
  • Recent surveys showed 62 of tobacco users want
    to quit in the next 6 months
  • Cessation support must have a range of intensity
  • One size of tobacco cessation will not cover
    all patients who wish to quit

9
TUC Background
Tobacco-Free Continuum
Classroom Program
Clinical Treatment Intervention
Clinical Brief Advice/ Self-resourced
Minimal Intervention Advice only, Literature,
Phone contact, Internet, Quit Line
Increasing Intensity Brief AdviceMeds,
MedsClinical Counseling MedsClinical Follow-up
Intense Intervention Classroom, Behavior
modification, Mental Health screening
  • Tobacco Cessation must be a continuum
  • One size or method of cessation does not fit
    all those wishing to become tobacco free

10
Tobacco Products Know the Facts
  • General tobacco facts
  • Cigarettes
  • Smokeless
  • Cigars
  • Health Concerns
  • Gender differences
  • Weight gain concern
  • Depression
  • Withdrawal symptoms

11
1 Tobacco Fact
  • Here is a really significant issue for our young
    people
  • Based on national average of tobacco costs,
  • a one pack/can per day habit is equal to ONE
    months minimum-wage pay for a year
  • Tobacco has a major impact on the quality of life
    for our young people and their families
  • They are the ones who can least afford it!

12
Tobacco damages every single mouth that it
touches. How do you want your teeth to look?
13
Health Concerns
  • New Less Harmful Tobacco Products
  • There are NO SAFE(R) FORMS OF TOBACCO!
  • No proven health benefit!- must be prepared to
    defend this statement as there are no evidenced
    based studies that show this
  • No medicolegal ground to support switching to a
    less harmful form of tobacco

14
Health Concerns
  • 4 million children are sick each year due to
    second hand smoke
  • 307,000 cases of asthma
  • 354,000 cases of middle ear infections
  • Greater risk of tooth decay
  • Even limited exposure to second-hand smoke (SHS)
    can lead to significant disease

15
Military-specific Tobacco-related Health Issues
  • Smoking and Military Readiness Top 5 List
  • Smoking is one of the best predictors of military
    training failure.
  • Smoking among young troops is associated with
    significant increased hospitalization and lost
    workdays. Sick and hospitalized troops are not
    ready for duty.
  • Smokers are more likely to perform poorly on
    military fitness evaluations. Smokers are more
    likely to sustain injuries, particularly
    musculoskeletal injuries.
  • Smoking is a strong marker for other causes of
    low readiness, such as alcohol abuse, low
    physical activity, and illicit drug use.
  • Note A much larger literature exists on smoking
    health readiness-related factors in civilian
    populations (e.g., physical activity, physical
    fitness, lost work time, etc).

16
Nicotine and PTSD
  • Researchers found that those with a pre-existing
    nicotine dependence who were then exposed to
    trauma had twice the risk of developing PTSD,
    compared to non-smokers who experienced trauma.
  • Nicotine stimulates some of the same
    neurobiological pathways the dopaminergic
    pathway associated with reward and fear
    implicated in stress and addiction. Smoking may
    sensitize these pathways, so a
    subsequent severe stressor is more likely to give
    someone PTSD.
  • Archives of General Psychiatry (vol 62, p
    1258) November, 2005

17
Impairs Patient Recovery
  • Recovery room stays are 20 longer for smokers
    than non-smokers. (Handlin DS, Baker T. Woolrich
    J Effect of smoking on duration in recovery
    room. Anesthesiology 1990)
  • Patients who smoked regularly before surgery had
    twice the risk of wound infections as
    non-smokers. (Jones, RM Smoking before surgery
    The case for stopping. BR Med J 1985)
  • Smoking will retard wound healing, whether the
    wound is surgical or the result of trauma or
    burns. (Smoking and wound healing. Am J Med. 1992
    Jul 15/93(1A)22S-24A. Review. PMID 1323208
    PubMed-indexed for MEDLINE

18
Injury Recovery
  • Cigarette smoke delays the formation of healing
    tissue and sets the stage for increased scarring
    at the edges of a wound…
  • Nothing messes up the timing (of the healing
    process) like cigarette smoke. Clinical studies
    have consistently shown that individuals exposed
    to cigarette smoke whether first- or
    second-hand heal poorly and are more likely to
    develop scarring and associated diseases.

Cigarette Smoke A Culprit in Poor Healing and
Increased Scarring UC Riverside Research Showing
How Smoke Complicates Healing Process (December
3, 2004)
19
Weight Gain
  • Smoking depresses body weight
  • Nicotine acts as an appetite suppressant
  • Many women fear quitting because of weight gain
  • Teens start smoking to avoid weight gain
  • Use of patch, gum, and bupropion limit weight gain


?
?
20
Pregnancy
  • Smoking during pregnancy is the most preventable
    cause of poor pregnancy outcomes
  • Maternal smoking is linked to a greater risk of
    pre- and peri-natal mortality
  • Current studies underway to look at NRT use
    during pregancy

21
Co-factors
  • Depression, anxiety, and binge-eating disorder
    are major co-factors
  • Tobacco users with co-factors often use nicotine
    to control behavioral disorders
  • Studies indicate 1/3rd of tobacco users have
    undiagnosed major depressive disorder
  • May be necessary to treat (by referral) the
    cofactor as well as the addiction to nicotine
  • Enhanced vigilance with varenicline (Chantix)

22
TUC Pharmacotherapy
  • Brief Medication review
  • Indications and Limitations
  • Lessons learned

23
TUC Pharmacotherapy
  • Three first-line types of pharmacotherapy (FDA
    approved) are nicotine replacement therapy,
    bupropion and varenicline
  • Whether medications are prescribed via formal TUC
    programs or via clinical care visits, providers
    should be aware of the medications and the need
    to follow those patients who are using the
    medications.
  • Patients receiving TUC medications along with
    behavioral support have the best chance of
    quitting.
  • Natural/herbal/hypnosis/acupuncture/laser not
    proven in evidenced-based studies
  • Be aware of Atropine clinics

24
Provider Staff Training
  • MedScape- Clinical Providers
  • Treating Tobacco Use and Dependence
  • http//cme.medscape.com/viewprogram/17710
  • Management of High-Risk Tobacco Users Where
    Practice Guidelines and Clinical Judgment Meet
  • http//cme.medscape.com/viewprogram/8486
  • Smoking Cessation Approaches for Primary Care
  • http//www.medscape.com/viewprogram/3468?srcsearc
    h
  • American Society of Health-System Pharmacists
  • http//media.ashp.org/tobacco/
  • Health Care Education Training, Inc.- Nursing
  • http//www.hcet.org/training/psc.html
  • Nurse Practitioner
  • http//www.nphealthcarefoundation.org/ce/smoking

25
Team up
  • Pharmacy
  • http//www.ashp.org/s_ashp/cat1c.asp?CID504DID5
    46
  • http//media.ashp.org/tobacco/
  • Nursing services
  • http//www.tobaccofreenurses.org/resources/
  • Health promoters
  • CHPPM
  • http//chppm-www.apgea.army.mil/dhpw/Population/To
    baccoCessation.aspx
  • NMCPHC (NEHC)
  • http//www-nmcphc.med.navy.mil/hp/tobacco/index.ht
    m
  • States (example)
  • New York
  • http//www.nysmokefree.com/newweb/CME1View.aspx?p
    20
  • California
  • http//www.projectuniform.org/

26
New DoD and NCI Anti Marketing Tools
  • DoD Make Everyone Proud
  • NCI 1-800-Quit-Now
  • ACS and ALA both active with cessation support
  • Many civilian insurance programs offer cessation
    coverage
  • Proprietary support also available

27
DoD Marketing Quit Tobacco ? Make Everyone
Proud
  • TMA/DoD sponsored www.ucanquit2.org
  • Can order materials
  • Free online support

28
New NIH/NCI Patient Provider Resources
  • WWW.Smokefree.gov
  • 1-800-QUITNOW (1-800-784-8669)
  • Patient education portal

29
New initiative www.1800quitnow.org/
  • New NCI effort to get 18-24 year olds involved
  • Web portal available
  • Provider materials will be available for patient
    support and education

30
www.1800quitnow.org/ Or 1-800-QUITNOW (784-8669)
31
Navy and Marine Corps Resources
  • Navy and Marine Corps Public Health Center
  • Tobacco Cessation website and toolkit
  • Access to Tobacco Cessation Action Team (TCAT)
    materials, policy statements, and guidance
  • http//www-nmcphc.med.navy.mil/hp/tobacco/index.ht
    m

32
TRICARE Benefit
  • Passed in 2009 NDAA
  • Now being developed
  • Meds and care are now a covered benefit

33
Questions ????
34
Contact Information
  • Captain Larry Williams
  • E-mail (W) Larry.Williams_at_MED.Navy.MiL
  • (H) LW704_at_Comcast.Net
  • (Work) 847-688-3331
  • (Cell) 847-975-3767
  • Please feel free to contact me if you have any
    questions or future needs.
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