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SMOKING CESSATION

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SMOKING CESSATION Stages of Change PRECOMTEMPLATION Unaware or unwilling to change CONTEMPLATION Ambivalent, but thinking about changing PREPARATION Decided to change ... – PowerPoint PPT presentation

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Title: SMOKING CESSATION


1
  • SMOKING CESSATION

2
Learning Objectives
  • Understand the hazards of smoking
  • Recognize the health benefits of smoking
    cessation
  • Describe the rationale for treating tobacco
    dependence
  • Explain why tobacco dependence is a chronic
    disease
  • Initiate clinical interventions for tobacco users
    who are willing to quit as well as users who are
    not willing to make a quit attempt
  • Assist users attempting to quit with strategies
    designed to prevent relapse

3
The smoking epidemic
  • 1 billion smokers
  • Smoking represents the most readily preventable
    risk factor for morbidity and mortality.
  • 5 million people die every year because of
    smoking related illnesses.
  • By 2030, if current trends continue, smoking will
    kill one in 6 people.
  • ( world health organization. 2008.

4
The smoking epidemic
  • 75 of smokers want to quit
  • lt2 of smokers quit each year

5
The smoking epidemic
  • Effective government policy
  • Bans on tobacco advertising and sponsorship
  • Regular price rises
  • Stronger public health warning labels
  • Smoking bans in all public places

6
Prevalence of Smoking in Saudi Arabia
  • 2.4-52.3 (median 17.5)
  • School students 12-29.8 (median 16.5),
  • University students 2.4-37 (median 13.5),
  • Adults 11.6-52.3 (median 22.6).
  • Elderly people 25.
  • Males 13-38 (median 26.5)
  • Females 1-16 (median 9).

7
Prevalence of Smoking in Saudi Arabia
  • 17 of primary health care physicians in Riyadh
    city were current smokers, 20 ex-smoker.
  • Al- shahri M, Al Almaie S. promotion of
    non-smoking The role of primary health care
    physicians. Ann Saudi Med 199717515-17

8
Smoking Health Risks
  • Short-term
  • Shortness of breath
  • Worsening asthma or bronchitis
  • Increased risk of respiratory infection
  • Harm to pregnancy
  • Impotence
  • Infertility

9
Smoking Health Risks
  • Long-term
  • Heart attack and stroke
  • Lung and other cancers
  • Chronic obstructive pulmonary disease (COPD)
  • Osteoporosis
  • Disability (chronic bronchitis and emphysema)
  • Need for extended care
  • larynx
  • oral cavity
  • pharynx
  • esophagus
  • pancreas
  • stomach
  • kidney
  • bladder
  • cervix
  • acute myelocytic leukemia

10
Tobacco-based products
  • Cigarettes
  • pipes
  • cigars
  • hookahs ((shisha/ narghile/ argileh/ hubble
    bubble and goza))
  • chewing tobacco etc.

11
Why do people continue to smoke?
  • Addiction to nicotine
  • Perceived benefits (relaxation, stress relief,
    weight loss)
  • Social context
  • Mental health issues

12
Smoking Cessation Barriers
  • Withdrawal symptoms
  • Fear of failure
  • Weight gain
  • Lack of support
  • Depression
  • Enjoyment of tobacco
  • Being around other users
  • Limited knowledge of effective treatment options

13
Physician Barriers to Helping Patients Stop
Smoking
  • Time constraints of practice
  • Lack of office systems
  • Low expectation of success
  • Lack of knowledge of what to do
  • Reimbursement issues
  • Frustration with smokers

14
Smoke vs. Quit
  • Common Reasons not to Quit
  • Common Reasons to Quit
  • Family and friends smoke
  • Withdrawal symptoms
  • Inability to cope with stress
  • Connection with smoking
  • Previous unsuccessful attempts to quit
  • Encouragement from family and friends
  • Health improvements
  • To save money
  • Pregnancy
  • Smoke-free environment policies
  • Desire to be a role model
  • Medical treatment that requires abstinence

15
  • Tobacco Dependence as a chronic disease

16
What is a cigarette?
  • Delivers nicotine to the lungs and brain within 7
    sec each time a smoker inhales
  • Frequent, small-dose stimulation makes smoking
    highly addictive
  • Most cigarettes contain 10 mg of nicotine
  • Average smoker absorbs 1-2 mg of nicotine per
    cigarette
  • Cigarettes release carbon monoxide which adheres
    to red blood cells faster than oxygen
  • Reduced oxygen in the body causes increased heart
    rate

17
Whats in a Cigarette?
  • 4000 chemicals many of which are highly toxic.
  • 40 known cancer-causing substances.
  • Tobacco
  • Carbon monoxide
  • Hydrogen cyanide
  • Nitrogen oxide
  • Ammonia (sub-micron sized particles)
  • Nicotine, phenol, polyaromatic hydrocarbons,
    tobacco specific nitrosamines.
  • Tar total particulate matter (nicotine and water)
  • Filter with titanium oxide accelerant
  • Flavours
  • Liquid vapour
  • Benzene
  • Formaldehyde
  • Acrolein
  • N-nitrosamines
  • Non-particulate matter

18
What is Nicotine Dependence?
  • Chronic Nicotine consumption with the following
    characteristics
  • Substance abuse
  • Continues self-administer substance despite
    perceived negative effects
  • High tolerance towards the substance
  • Manifests withdrawal symptoms when trying to stop
    use

19
Effects of Nicotine
  • Highly toxic drug
  • Increase HR, BP
  • Decrease body temp
  • Slows circulation
  • Affects appetite
  • Increase BMR
  • changes brain activity - improving reaction
    times, ability to pay attention and brings on
    euphoria Addiction
  • Increases dopamine levels Creates a
    feeling of pleasure

20
The addiction pathways
Reward pathway(mesolimbic dopamine system)
Withdrawal pathway(locus coeruleus)
21
Reward Pathway
  • Mesolimbic dopamine system has been characterized
    as a reward "pathway
  • Nicotine produces a dopamine surge in the nucleus
    accumbens
  • Smoking cessation is followed by pathophysiologic
    withdrawal and craving

22
Withdrawal
  • Chronic drug use affects brainstem structures
  • (locus ceruleus)
  • Noradrenergic cells become more excitable
  • When a person abstains, the firing rates become
    abnormally high a possible basis of withdrawal
    symptoms

23
Nicotine withdrawal syndrome
  • acute/uncontrollable need to smoke (craving)
  • irritability
  • restlessness, anger, anxiety feelings
  • tiredness
  • increased appetite, especially for sweets and
    resultant weight gain
  • trouble to concentrate and focus memory
  • depression
  • headaches
  • insomnia
  • dizziness

24
Benefits of Quitting
  • blood pressure and pulse rate return to normal
  • blood nicotine CO halved, oxygen back to normal
  • CO eliminated lungs start to clear mucus etc.
  • nicotine eliminated senses of taste smell much
    improved.
  • breathing easier bronchial tubes begin to relax
    energy levels increase
  • 20 mins
  • 8 hours
  • 24 hours
  • 48 hours
  • 72 hours

25
Benefits of Quitting
  • circulation improves
  • lung function increased by lt10 coughs, wheezing
    decrease
  • risk of heart attack halved
  • risk of lung cancer halved compared to continued
    smoking
  • risk of heart attack equal to never-smokers
  • 2-12 weeks
  • 3-9 months
  • 5 years
  • 10 years

26
Quitting- other benefits
  • Improved health and physical performance
  • Improved taste of food and sense of smell
  • Better appearance, including reduced
    wrinkling/aging of skin and whiter teeth
  • Healthier families, babies and children
  • A good example for children and others
  • More money in your pocket

27
Treatment of Nicotine Addiction
  • Combination of counseling and pharmacotherapy is
    more effective than either option alone
  • The more intense the intervention, the better the
    outcome of abstinence

28
Pharmacologic Options
  • Clients/patients attempting to quit smoking
    should always be encouraged to use effective
    medications unless they are contraindicated in
    specific populations
  • eg. pregnant women, smokeless tobacco users,
    light smokers, adolescents (Fiore, et al)
  • Two categories of pharmaceutical options
  • Nicotine replacement therapy (NRT)
  • Non-nicotine replacement therapy

29
Nicotine Replacement Therapy (NRT)
  • Nicotine Patch
  • Nicotine Lozenges
  • Nicotine Gum
  • Nicotine Inhalers
  • Provide nicotine to reduce withdrawal symptoms
  • Take between 1-4 hours to reach maximum blood
    levels (unlike cigarettes, 7 seconds)
  • Do not cause sudden boost to nicotine blood
    levels (prevents addiction to product)
  • Dose depends on habits of the smoker but is
    reduced over a 12 week period

30
Non-nicotine Therapy
  • Bupropion Hydrochloride (Zyban)
  • Also marketed as the anti-depressant medication
    Wellbutrin
  • Presumed to alleviate cravings associated with
    nicotine withdrawal affecting noradrenaline and
    dopamine
  • Varenicline Tartrate (Champix)
  • Targets nicotinic acetylcholine receptors to
    decrease cravings and withdrawal
  • Clonidine Nortriptyline
  • Second-line medications used in smoking cessation
  • All of these medications require a prescription

31
Counselling
  • Intensive intervention that last a minimum of 10
    minutes
  • Commonly conducted by nurses in various
    health-care settings
  • Motivational Interviewing
  • Directive and client-centred standard counselling
    techniques
  • Stages of Change theory

32
Other options of treatment
  • Hypnosis
  • Herbal remedies
  • Acupuncture
  • Laser treatment
  • No clinical evidence to verify results from
    these treatments
  • Some clients/patients report that they are
    beneficial (Fiore, et al., 2008)

33
Protection Second-hand smoke
  • Second-hand smoke
  • Also known as environmental tobacco smoke
  • Combination of
  • Side stream smoke (smoke from the end of a
    cigarette)
  • Smoke exhaled by the smoker
  • 67 of smoke from a burning cigarette is not
    inhaled by the smoker and ends up in the
    surrounding environment

34
Second-hand smoke (cont.)
  • 4000 chemicals have been identified in
    second-hand smoke
  • 50 of these are known carcinogens
  • (United States Environmental Protection Agency,
    2000)
  • Examples
  • - Arsenic compounds
  • - Benzene
  • - Chromium compounds
  • - Ethylene oxide (chemical to sterilize medical
    devices)
  • - Vinyl Chloride (chemical used in plastics
    manufacture)
  • - Polonium 210 (radioactive species)

35
Second-hand smoke (cont.)
  • Labeled as a known human carcinogen
  • Labeled as a class A cancer-causing substance
    (Class A most dangerous)

36
Model for treatment of tobacco use and
dependence
General Population
Patient presents to healthcare setting
Relapse
Yes, willing
Current users
ASK screen all patients for tobacco use
ADVISE to quit
ASSESS willingness to quit
ASSIST with quitting
ARRANGE a follow-up
No, unwilling
Non users
Abstinent
Promote motivation to quit
Patient now willing to quit
Primary prevention
Prevent relapse
37
Where to begin?
  • ASK- about smoking understand your patient
  • ASSESS - what is the next step?
  • ADVISE - why cessation is important
  • ASSIST - offer to help
  • ARRANGE- follow-up process

38
The 5 As apply to
  • Those who
  • are willing to quit,
  • arent willing to quit, and
  • recently quit.

39
Smoking Cessation Treatment
  • Smoking Cessation Treatment for Those Willing to
    Quit

40
Smoking Cessation Treatment for Those Willing to
Quit
  • ASK Identify and document tobacco use status of
    every patient at every visit.
  • Example When recording vital signs, include an
    area to note tobacco use.

41
Smoking Cessation Treatment for Those Willing to
Quit
  • ADVISE In a clear, strong, and personalized
    manner advise every tobacco smoker to quit.

42
Smoking Cessation Treatment for Those Willing to
Quit
  • Advise examples
  • Clear I think its important for you to
    quit smoking now, and I can help you.
  • Strong As your clinician, I need you to
    know that quitting smoking now is the most
    important thing you can do to protect your
    health.
  • Personalized Continuing to smoke makes your
    asthma worse.

43
Smoking Cessation Treatment for Those Willing to
Quit
  • ASSESS
  • Is the user willing to make a quit attempt at
    this time?
  • Provide assistance to dependence treatments.
  • Provide an intervention shown to increase future
    quit attempts, such as nicotine gum, quit lines
    and behavioral counseling.

YES
NO
44
Smoking Cessation Treatment for Those Willing to
Quit
  • ASSIST
  • Offer medication. Provide or refer for
    counseling or additional behavioral treatment.
  • Medication examples
  • Nicotine lozenge
  • Varenicline

45
Smoking Cessation Treatment for Those Willing to
Quit
  • ASSIST
  • Behavioral treatment examples
  • Recommend a quit plan, such as STAR.
  • Set a quit date.
  • Tell family, friends and coworkers.
  • Anticipate challenges.
  • Remove tobacco products.

46
Smoking Cessation Treatment for Those Willing to
Quit
  • ARRANGE
  • Arrange for follow-up soon after quit date, a
    second follow-up within the first month and
    others as needed.
  • Identify problems and anticipate challenges.
  • Remind patients of available sources, such as
    quit lines.
  • Provide encouragement.

47
Smoking Cessation Treatment
  • Smoking Cessation Treatment for Those NOT Willing
    to Quit

48
Smoking Cessation Treatment for Those NOT Willing
to Quit
  • ASK, ADVISE ASSESS
  • Use the same 5As for users unwilling to quit
    as those willing to quit.

49
Smoking Cessation Treatment for Those NOT Willing
to Quit
  • ASSIST
  • Provide motivational interventions designed
    to increase future quit attempts.

50
Smoking Cessation Treatment for Those NOT Willing
to Quit
  • ASSIST Motivational examples
  • The 5 Rs
  • Relevance
  • Identify why it is personally relevant to get
    the patient to quit.
  • Risks
  • Ask the patient to identify negative
    consequences of smoking.
  • Rewards
  • Ask the patient to identify the benefits of
    stopping.
  • Roadblocks
  • Identify the patients barriers to success and
    how to approach them.
  • Repetition
  • Repeat motivational interventions.

51
Smoking Cessation Treatment for Those NOT Willing
to Quit
  • ASSIST
  • Motivational examples Express empathy
  • Use open-ended questions. How
    important do you think it is for you to quit?
  • Use reflective listening. So you think
    smoking helps you maintain your weight.
  • Normalize patients feelings. Many
    people worry about managing without cigarettes.
  • Support their right to choose. Im here to
    help you when you are ready. t to choose.

52
Smoking Cessation Treatment for Those NOT Willing
to Quit
  • ASSIST
  • Motivational examples Develop discrepancy
  • Highlight the discrepancy between the patients
    smoking versus the patients stated values.
    Youre devoted to your family. How do you
    think your smoking affects them?
  • Reinforce change talk. So, you realize
    how smoking is making it hard to keep up with
    your kids.
  • Deepen the commitment to change. We
    would like to help you avoid a stroke like the
    one your father had.

53
Smoking Cessation Treatment for Those NOT Willing
to Quit
  • ASSIST
  • Motivational examples Roll with resistance
  • Back off and use reflection. Sounds
    like youre feeling pressured about your tobacco
    use.
  • Express empathy. I understand its
    hard to quit.
  • Ask permission to provide information.
    Would you like to hear about some strategies
    that can help you quit?

54
Smoking Cessation Treatment for Those NOT Willing
to Quit
  • ASSIST
  • Motivational examples Support self-efficacy
  • Help patients build on past successes. You
    were fairly successful last time you tried to
    quit.
  • Offer options for small, achievable steps toward
    change. Can you try smoking one less
    cigarette a day? A quit line can help you.

55
Smoking Cessation Treatment for Those NOT Willing
to Quit
  • ARRANGE
  • More than one motivational intervention may be
    needed.
  • Provide follow-up at the next visit.
  • Offer additional interventions to motivate and
    support.

56
Smoking Cessation Treatment
  • Treatment for Those Who Recently Quit

57
Treatment for Those Who Recently Quit
  • ASK
  • Determine if the smoker is still smoke-free.
    then,
  • ASSESS
  • relapse potential.

58
Treatment for Those Who Recently Quit
  • ASSESS
  • Most relapses occur within the first two weeks,
    but the risk can persist for a long time
    therefore,
  • Identify and address challenges, including
  • lack of support for cessation,
  • negative mood or depression,
  • strong or prolonged withdrawal symptoms,
  • weight gain and
  • smoking lapses.

59
Treatment for Those Who Recently Quit
  • ASSIST
  • Provide encouragement and relapse prevention
    to address the challenges of staying smoke-free.
  • Challenge example
  • Lack of support
  • Depression
  • Prevention response
  • Schedule follow-ups, urge use of quit lines,
    identify source of support
  • Counsel or refer to counseling/support groups

60
Smoking is a Complex Phenomenon
Social
Psychological
Spiritual
Bio- physiological
61
Physical and Psychological
  • When down, smoking energizes
  • When anxious, smoking calms
  • Smoking focuses attention and conveys a sense of
    well-being, every time

62
Psychological/Behavioural
  • Conditioning occurs over many years after
    exposure to things in the environment which
    stimulate the smoker to want a cigarette
  • People learn to manage their emotions with
    tobacco
  • Patterns of behaviour are very difficult to
    change

63
Physical and Emotional
  • Pleasure, arousal, relaxation and the relief of
    tension and anxiety are therapeutic effects of
    nicotine
  • Smoking also treats effects of withdrawal
  • All of these effects are biological and molecular

64
Emotional, Social Spiritual
  • A comforting completion of pleasurable rituals
    friends, drinks, sex, meals and breaks
  • A close, comforting friend that has always been
    there
  • A way to cement certain social relationships and
    repel unwanted ones
  • Part of identity and sense of self

65
Bio-physiologic
  • Nicotine is an addictive substance. The chemical
    effects of nicotine are strongly related to the
    conditioning that occurs in many smokers. It is
    this link between stimulation/triggers in the
    environment and the immediate chemical,
    pleasurable effect on the body that often makes
    stopping smoking so difficult

66
Stages of Change
  • PRECOMTEMPLATION
  • Unaware or unwilling to change
  • CONTEMPLATION
  • Ambivalent, but thinking about changing
  • PREPARATION
  • Decided to change and taking steps
  • ACTION
  • Started to do things differently
  • MAINTENANCE
  • Changed for sometime and integrating the change
    into their routine

  • Prochaska and DiClemente

67
Contemplation Thinking of quitting in the next
six months
Precontemplation Not thinking of quitting in the
next six months
Preparation Planning to quit in the next month
Relapse
Maintenance Quit for more than six months
Action Quit in the last six months
2
68
Myths you may encounter as you work with your
patients to help them stop smoking
  • Myth 1 Smoking is just a bad habit.
  • Fact Tobacco use is an addiction. According to
    the U.S. Public Health Service
  • Clinical Practice Guideline, Treating
    Tobacco Use and Dependence, nicotine is a very
    addictive drug. For some people, it can be as
    addictive as heroin or cocaine.
  • Myth 2 Quitting is just a matter of willpower.
  • Fact Because smoking is an addiction, quitting
    is often very difficult. A number of treatments
    are available that can help.
  • Myth 3 If you cant quit the first time you try,
    you will never be able to quit.
  • Fact Quitting is hard. Usually people make two
    or three tries, or more, before being able to
    quit for good.

69
Myths you may encounter as you work with your
patients to help them stop smoking
  • Myth 4 The best way to quit is cold turkey.
  • Fact The most effective way to quit smoking is
    by using a combination of counseling and nicotine
    replacement therapy (such as the nicotine patch,
    inhaler, gum, or nasal spray) or non-nicotine
    medicines (such as bupropion SR).
  • Myth 5 Quitting is expensive.
  • Fact Treatments cost from 3 to 10 a day. A
    pack-a-day smoker spends almost 1,000 per year.
    Check with your health insurance plan to find out
    if smoking. cessation medications and/or
    counseling are covered.
  • Source http//www.surgeongeneral.gov/tobacco
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