brief tobacco interventions for opioid maintenance providers susan bradshaw, md, mph tobacco control...
TRANSCRIPT
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Brief Tobacco Interventions for
Opioid Maintenance ProvidersSusan Bradshaw, MD, MPH
Tobacco Control and Prevention ProgramSeptember 18, 2013
Los Angeles County Department of Public HealthChronic Disease and Injury Prevention Division
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Outline
• Burden of Tobacco Use
• Tobacco Products
• Tobacco Addiction
• Brief Intervention (Ask, Advise, Refer)
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• Native Americans used tobacco prior to the arrival of Columbus
• Consumption was for medicinal and ceremonial purposes
• Commonly smoked in peace pipes
Introduction
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John Rolfe (1585–1622) ….
• Married Pocahontas
• First to cultivate tobacco as an commercial export and cash crop
• Until 1883, taxes from tobacco accounted for 1/3 of IRS revenue
Introduction
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1881: Cigarette machine
1882: Ten million cigarettes sold
1887: One billion cigarettes sold
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Introduction
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IntroductionAnti-Tobacco
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1798: Benjamin Rush….
• First surgeon general
• Signer of the Declaration of Independence
• “Tobacco use supports excess alcohol consumption”
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IntroductionAnti-Tobacco
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1870: Tobacco ….
• Harmful addictive substance
• Contributing factor in relapse from alcoholism and drug dependence
• Treated along with alcoholism and other addictions in asylums
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Founding father of AA movement, Bill W., died
from tobacco-related disease.
Stop drinking to die from smoking?
1930s: Tobacco use is no longer viewed as an addiction and becomes embedded in
recovery programs.
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BURDEN of TOBACCO
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• Leading cause of preventable and unnecessary death, disability and disease
• Causes more deaths than homicide, suicide, heroin, cocaine and alcohol combined each year
•Everyday, approximately 1,200 people die from tobacco-related diseases
Burden of Tobacco UseMorbidity and Mortality
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Burden of Tobacco UseMorbidity and Mortality
For every 8 smokers who die, one non-smoker dies from exposure to secondhand smoke (SHS).
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Secondhand Smoke (SHS)
• Causes 50,000 deaths annually
• Mainstream smoke is exhaled by a smoker
• Side stream smoke comes from the end of a burning tobacco product
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Question?
True or False. Secondhand smoke contains more than 7,000 chemicals.
True. Secondhand smoke is a toxic mixture of gases, chemicals and particles. It contains about 70 carcinogens.
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Secondhand Smoke
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There is no safe level of exposure to secondhand smoke.
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Burden of Tobacco UseThirdhand smoke?
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• Residue left on a variety of surfaces by tobacco smoke. It builds up on surfaces and resists normal cleaning.
• Can't be eliminated by airing out rooms, opening windows, using fans or air conditioners, or confining smoking to only certain areas
• The only way to protect nonsmokers from thirdhand smoke is to create a smoke-free environment
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Burden of Tobacco UseEconomic
Which state charges the most for a pack of cigarettes?
New York. It costs $11.90 for one pack of cigarettes.
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• Cigarette butts are the most littered item in US
• 153 million pounds of cigarette butts are dumped each year
• 26,400 smoking- related fires occur annually
Burden of Tobacco UseEnvironment
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Smoking RatesMental Illness (MI)
Schizophrenia 62-90%
Bipolar Disorder 51-70%
Heavy drinkers 65-90%
Depression or Anxiety 40-50%
Post-traumatic Stress Disorder 45-60%
Substance Use Disorder (SUD) 49-98%
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Burden of Tobacco UseMI/SUD
Compared to general population …..
Begin smoking earlier
Smoke more cigarettes each day
Smoke cigarettes them down to the filter
Inhale deeper
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Burden of Tobacco UseMI/SUD
• Consume 44% of all cigarettes sold
• Spend 30% of their income
• Poorer tobacco cessation outcomes
• Want to quit
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Smoking cessation does not interfere with
recovery
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Burden of Tobacco UseKey Points
Compared to general population, MI/SUD…..
• Smoke more
• Suffer more
• Spend more
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Benefits of Quitting
Health
Recovery
Wealth
Environment
Pets23
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TOBACCO PRODUCTS
Update
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Question?
What is the name of the President who started
smoking a pipe after he was diagnosed with throat
cancer?
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President GrantIt is alleged he thought smoking a pipe was
safer than smoking cigars.
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Smoked TobaccoCigarettes
Photo source: FACT collection
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Natural & Deadly Cheap & Toxic
Expensive & Unhealthy
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Smoked TobaccoCigarette , Little Cigar, Cigarillo and Cigar
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Cigarette: wrapped in paper not containing tobacco
Cigar and cigarillo: wrapped in substance containing tobacco
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Smoked TobaccoLittle Cigars and Cigarillos
• Many flavors
• Package
• Tip or no tip
• Examples: Black & Mild Swisher Sweets White Owl
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Smoked TobaccoOther
Photo source: FACT collection
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Blunts
Bidis
Hookah
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New Smokeless Tobacco
• May be in pouch
• Marketed as energizing
• May contain: Caffeine Vitamin C Flavor
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Smokeless TobaccoSnus
• Variety of flavors
• Packaged in small pouches
• Addresses smoke-free policies
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Smokeless Tobacco
Dissolvables
•Strips•Sticks•Mints (Orbs)
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Electronic Nicotine DevicesSmoke and tobacco free
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TOBACCO PRODUCTSKey Points
• Cigarettes are the most common form of tobacco used in the U.S.
• All tobacco products are harmful
• Screen patients for different tobacco products
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TOBACCO ADDICTION
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Nicotine
• Cigarettes and other forms of tobacco contain nicotine
• Research suggests that nicotine may be as addictive as heroin, cocaine, or alcohol
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Nicotine enters brain
Stimulation of acetylcholine receptors
Dopamine release
Prefrontal cortex
Nucleus accumbens
Ventral tegmental
area
Nicotine and the Brain:
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Nicotine Hijacks the Brain
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Smokers feel normal with nicotine
When nicotine levels decrease, smokers may experience nicotine withdrawal symptoms (NWS)
NWS include irritability, anxiety, difficulty concentrating, and increased appetite
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Nicotine AddictionEasy to Start, Hard to Quit
In general:
• Ninety percent of smokers began using tobacco before age 18
• Smokers often relapse because of stress, weight gain, and withdrawal symptoms
• Numerous quit attempts are usually necessary to stop successfully
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Nicotine AddictionEasy to Start, Hard to Quit
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• Each day, approximately 3,500 U.S. kids smoke their first cigarette
• Of every three young smokers: o One will quit o One will die from a tobacco-related
disease
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Treatment OptionsExamples
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Non-Pharmacological Pharmacological
Behavioral issues Withdrawal symptoms
• Self-help • Nicotine Replacement
• Advice • Non-Nicotine
• Counseling
• OtherCombination is BEST.
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Nicotine Replacement Therapy (NRT)
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• Reduces withdrawal symptoms
• Few contraindications and side effects
• Toxicity and abuse are rare
• Does not contain toxins
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Nicotine Replacement Therapy Update
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• Instructions on label will change
• Recommendations by experts differ from label
Combination NRT Higher dosage Treat withdrawal symptoms Taper based on patient’s preference
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Nicotine Replacement Therapy (NRT)
Delivery time
NRT therapy • Nicotine gum• Lozenge• Patch• Nasal spray• Inhaler
Onset of Action20 to 60 minutesFaster than gum6-8 hours 5 to 10 minutes10 minutes
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NRT Patch
• Apply to skin that is clean, dry and non-hairy. Press onto skin for 10 seconds.
• Rotate placement on different parts of the body each week
• Avoid cutting
7,14,& 21 mg/24 hr5,10 & 15 mg/16 hr
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• Bite gum slowly
• Stop at first sign of mild tingling or peppery taste
• “Park” between the cheek and gum
• Bite again when tingling or peppery sensation fades (20 minutes)
NRT Gum (Chew and Park)
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NRT Lozenge
• Easier to use and delivers ~25% more nicotine compared to NRT gum
• Allow to dissolve slowly. Rotate in mouth until it dissolves ( 20 minutes).
• Should not be chewed or swallowed
Do not eat or drink 15 minutes before using NRT gum or lozenge.
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NICOTINE ADDICTION Key points
Nicotine addiction can be a chronic and relapsing condition that usually begins in adolescence
Successful treatment often requires multiple quit attempts and interventions as well as long-term monitoring
Pharmacotherapy and behavioral interventions should be offer to all tobacco users who want to quit
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ASK, ADVISE, REFER (AAR)
Brief, Effective and Low Cost
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Ask, Advise, Refer
Ask all patients about tobacco use
Advise all tobacco users to quit
Refer all tobacco users to 1-800-NO-BUTTS
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Step One
Ask…..
all patients about tobacco use
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Strategies to Identify and Document
• Vital sign• Stamp• Chart stickers• Medical record flow sheets• Checklists• Electronic medical records• Computer prompts
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Example of Vital Sign
Blood Pressure: ______Pulse: _______ Weight: _____Temperature: ________ Respiratory Rate: ________Tobacco Use: Current ____ Former ____ Never____SHS exposure: Home____ Work_____ Car_____
[ ] Advice given [ ] Referral provided
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Step Two
Advise…
all tobacco users to quit
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Advise….
• Studies have shown that healthcare providers can be effective in advising tobacco users to quit
• Your advice approximately doubles the chance that patients will make a quit attempt
• The way a healthcare provider talks to patients can substantially influence motivation to quit
Thereafter, assess willingness to quit
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Step Three
Refer…
all tobacco users to….
1-800-NO-BUTTS California Smokers’ Helpline
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ReferLet all tobacco users know:
• “You can double your chances of quitting successfully by calling 1-800-NO-BUTTS”
• “They will help you through the quitting process and the services are FREE”
• “FREE samples of NRT are available to Los Angeles County residents “
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Free and confidential services include:
Up to 6 counseling sessions
Personalized quit plan
Self-help materials and referral to local services
Services for former smokers, teens, pregnant women, tobacco chewers and people unwilling to quit
California Smokers’ Helpline1-800-NO-BUTTS or www.nobutts.org
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California Smokers’ Helpline1-800-NO-BUTTS or www.nobutts.org
Coaching by trained counselors is available in six different languages and for hearing impaired
Financial information: o FREE NRT to Los Angeles County residents o $20 gift card for Medi-Cal memberso Health insuranceo Cost is similar to buying cigarettes
Monday-Friday: 7am to 9pmSaturday: 9am to 1pm
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Examples of Brief Clinical Interventions
Willing to Quit
Refer to 1-800-NO-BUTTS
If time permits: • Discuss medications• Set Target Quite Date
(TQD)• Develop quit plan• Contact 3 days after TQD
and follow-up monthly
Unwilling to Quit
Refer to 1-800-NO-BUTTS
If time permits:
• Provide motivational interventions (5 R’s)
• Encourage smoking journal
• Promote healthier lifestyle
• Defer, if patient requests 61
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ResourcesPatient
Internet• Smokefree.gov• Becomeanex.org
Mobile app/Text • QuitSTART and QuitPal• SmokefreeTXT• QuitNowTXT
Nicotine Anonymous• Quitnowla
Provider
Training/Outreach materials• Nobutts.org
• Smokingcessationleadership.ucsf.edu
• Askadviserefer.org
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Ask Advise ReferKey Points
A brief intervention should be implemented at each visit:
•ASK all patients about tobacco use
•ADVISE all tobacco users to quit
•REFER all tobacco users to 1-800-NO-BUTTS and recommend pharmacotherapy to those who want to quit
AAR + Quitline + Meds
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AAR Demonstratio
n
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Questions?
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Thank you!
Susan Bradshaw, MD, MPH(213) 351-7319
Los Angeles County Department of Public HealthChronic Disease and Injury Prevention Division
Tobacco Control & Prevention Program
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