strategies to promote tobacco cessation.pptx [read-only] · the health consequences of smoking—50...
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8/9/2018
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Strategies to promote tobacco cessation
Sarah E. Vordenberg, PharmD, MPH, BCACP
Clinical Assistant Professor
University of Michigan College of Pharmacy
Pharmacist learning objectives
• Identify patients who are appropriate candidates for tobacco cessation.
• Recommend appropriate pharmacologic and nonpharmacologictherapy.
• Counsel patients who are interested in quitting tobacco products.
• Formulate an appropriate strategy to monitor for the safety and efficacy of recommended therapy.
Pharmacy technician learning objectives
• Summarize the prevalence of tobacco use and it’s negative health implications.
• Identify patients who are appropriate candidates for tobacco cessation.
• List over‐the‐counter, prescription, and behavioral therapies for tobacco cessation.
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Prevalence of tobacco use in United States
Centers for Disease Control and Prevention. Infographics. https://www.cdc.gov/tobacco/infographics/adult/index.htm#down. Accessed August 6, 2018.
E‐cigarettes among youth
U.S. Department of Health and Human Services. E‐Cigarette use among youth and young adults: A report of the surgeon general – Executive summary. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health, 2016. https://e‐cigarettes.surgeongeneral.gov/documents/2016_SGR_Exec_Summ_508.pdf Accessed August 6, 2018.
Deaths in United States
U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Accessed August 6, 2018.
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Health effects from tobacco use
U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Accessed August 6, 2018.
United States Preventive Services Task Force
• Adults• Ask all adults about tobacco use
• Advise them to stop using tobacco• Behavioral interventions
• Pharmacotherapy
• Children and teens• Provide interventions to prevent initiation of tobacco use• Education
• Brief counseling
U.S. Preventive Services Task Force. USPSTF A and B Recommendations. https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf‐a‐and‐b‐recommendations/. Accessed August 6, 2018.
Approaches
5 A’s
1. Ask about tobacco use.
2. Advise to quit.
3. Assess readiness to quit.
4. Assist with quitting.
5. Arrange follow‐up counseling.
AAR
1. Ask about tobacco use.
2. Advise to quit.
3. Refer to tobacco cessation services.
1. Ask about tobacco use.
2. Advise to quit.
3. Connect to tobacco cessation services.
AAC
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Ask
• Do you smoke cigarettes or use other tobacco products?
• Have you in the past?
Advise
Advice should be…• Clear: Direct expression for need for smoking cessation
• Strong: Highlighting importance of cessation
• Personalized: Linking the patient’s health goals to cessation
As a pharmacist, I have to tell you that quitting smoking is the most
important thing you can do for your health.
I thinking quitting smoking is very important for you because of your
asthma.
Larzelere MM and Williams DE. Promoting smoking cessation. Am Fam Physician. 201 Mar 15;85(6):591‐598.
Role play
• Roles: • Patient
• You currently smoke.
• Pharmacist• Practice the ask and advise steps.
• Switch roles
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Assess
• Step 1• Willingness to quit
Have you ever tried to cut back or quit smoking?
Are you willing to quit smoking
now?
Stages of change
Stage of Change Description Action Item
Precontemplation Not ready to discuss quitting
Encourage them to start thinking about quitting, such as by asking about the function of them smoking
Contemplation Considering quitting, but unsure
Build confidence and motivation to quit
Preparation Ready to set a quit date Develop a specific quit plan and brainstorm coping strategies
Action Recently quit Review how quit plan is working and discuss strategies to prevent relapse
Maintenance Quit at least 6 months ago Encourage sustained action
Clinician’s guide: Conducting an intake, assessment and treatment planning session for tobacco cessation. http://quitworks.makesmokinghistory.org/uploads/Intake%20Assess%20Guide%209.6.10.pdf. Accessed August 6, 2018.
Question
• What stage of change would an individual be in if she cut back from 22 to 19 cigarettes per day?A. Precontemplation
B. Contemplation
C. Preparation for action
D. Action
E. Maintenance
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Assess
Step 2• Smoking history
• Other substance use
• Relevant medical history
• Current medications
• Environmental/social history
• Past successes
• Reasons to quit
• Concerns about quitting
• Readiness to quit
• Drug interactions
Selected drug interactions
Clinician’s guide: Conducting an intake, assessment and treatment planning session for tobacco cessation. http://quitworks.makesmokinghistory.org/uploads/Intake%20Assess%20Guide%209.6.10.pdf. Accessed August 6, 2018.
Interactions of smoking and prescription drugs. Harrison’s Principles of Internal Medicine. https://accesspharmacy‐mhmedical‐com.proxy.lib.umich.edu/ViewLarge.aspx?figid=192534222&gbosContainerID=0&gbosid=0&groupID=0. Accessed August 9, 2018.
Drug/class Interaction
Amitriptyline ↑ clearance
Benzodiazepines ↓ seda on
Beta blockers ↓ lowering of HR and BP
Duloxetine ↓ serum concentrations
Estrogens (oral) ↑ hepa c clearance
Fentanyl ↑ clearance
Insulin Delayed absorption due to skin vasoconstriction
Warfarin ↑metabolism > lower serum levels
Withdrawal symptoms
• Craving for cigarettes
• Feeling down or sad
• Difficulty sleeping
• Irritable, on edge, or grouchy
• Restless or jumpy
• Slower heart rate
• Hungry of gaining weight
• Trouble thinking clearly or concentrating
Managing withdrawal. Smokefree.gov. https://smokefree.gov/challenges‐when‐quitting/withdrawal/managing‐withdrawal. Accessed August 9, 2018.
Mechanism of action
Foulds J. The neurobiological basis for partial agonist treatment of nicotine dependence: Varenicline. Int J Clin Pract 2006;60(5):571‐576.
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Assist
FDA‐approved medications
Over‐the‐counter Prescription
Nicotine gum Nicotine inhaler
Nicotine lozenge Nicotine nasalspray
Nicotine patch Sustained‐releasebupropion
Varenicline
Non‐pharmacologic strategies
Referrals for over‐the‐counter medications
• Less than 18 years of age• Pregnant• Breastfeeding• Heart disease or irregular heartbeat
• Recent heart attack• Uncontrolled hypertension• Stomach ulcers
• Diabetes• History of seizures
Nicotine gum and lozenge (Nicorette™)
• Strengths: 2mg and 4 mg
• Selecting the correct strength• First cigarette ≤ 30 minutes after waking: 4 mg
• First cigarette > 30 minutes after waking: 2 mg
• Frequency and duration • Weeks 1‐6: 1 piece every 1‐2 hours
• Weeks 7‐9: 1 piece every 2‐4 hours
• Weeks 10‐12: 1 piece every 4‐8 hours
• Maximum pieces/day• Gum: 24
• Lozenge: 20
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Nicotine gum
• Counseling points• Recommend chew and park technique (repeat until tingle gone)
• Do not eat or drink for 15 minutes before or during use
• Use at least 9 pieces/day during weeks 1‐6 to effectiveness
• Do not use continuously as it increases risk of side effects• Hiccups, heartburn, nausea, jaw pain
• Contraindications/ cautions• Active temporomandibular disease (TMJ)
• Diabetes
• Stomach ulcers
Nicotine lozenge
• Counseling points• Allow lozenge to dissolve over 20‐30 minutes. Minimize swallowing.• Occasionally move lozenge from one side of mouth to the other• May feel a warm or tingling sensation• Do not eat or drink for 15 minutes before or during use• Use at least 9 pieces/day during weeks 1‐6 to effectiveness• Do not use continuously as it increases risk of side effects
• Hiccups, heartburn, nausea, mouth irritation
• Contraindications/ cautions• Diabetes• Stomach ulcers
Question
JP is a 30 year‐old male who smokes about 20 cigarettes a day for over 10 year. When queried about his first morning cigarette, he says this is the first thing he does when he wakes up. He indicates that he would prefer the nicotine lozenge. What is the appropriate starting dose?
A. 2mg
B. 4 mg
C. 8 mg
D. 12 mg
E. He is not an appropriate candidates for lozenges
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Nicotine patch (Nicoderm CQ)
• Strengths: 7, 14, and 21 mg
• Selecting the correct strength• > 10 cigarettes/day
• 21 mg/day x 6 weeks
• 14 mg/day x 2 weeks
• 7 mg/day x 2 weeks
• ≤ 10 cigarettes/day• 14 mg/day x 6 weeks
• 7 mg/day x 2 weeks
• Clinical pearl• Consider combination therapy
• Patch = consistent nicotine delivery
• Gum/lozenge = strong cravings
Nicotine patch
• Counseling points• Apply one patch every 24 hours to skin that is dry, clean and hairless• Rotate sites• Wash hands before and after• Dispose of used patches by folding sticky ends together and putting in original pouch
• Remove the patch at bedtime if you have vivid dreams• Remove patch before MRI to avoid possible burns
• Contraindications/cautions• Adhesive allergy• Skin conditions that may be irritated by patch
Nicotine inhaler (Nicotrol Inhaler™)
• Mouthpiece (reuseable) and plastic cartridge• 80 deep inhalations over 20 minutes: 4 mg of nicotine (2 mg absorbed)
• Significant buccal absorption (slow!)
• Counseling points• Keep out of reach of children and pets due to poisoning (including used cartridge which contains 6 mg of nicotine!)
• Use at least 6 cartridges/day for the first 3‐6 weeks (max 16/day)
• Adverse reactions include mild mouth and throat irritation, cough, rhinitis
• Contraindications/ cautions• Allergy to menthol
• Bronchospastic disease
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Nicotine nasal spray (Nicotrol NS™)
• 1 device delivers approximately 200 applications• Each spray contains 0.5 mg of nicotine• 1 dose = 1 spray in each nostril (i.e. 2 sprays)• Absorption is more similar to pattern from cigarette than via inhaler
• Counseling points• Keep out of reach of children and pets due to poisoning (full bottle contains 100 mg of nicotine!)
• Do not sniff while administering product.• Common side effects include nose and throat irritation (peppery sensation), watery eyes, sneezing, or coughing
• Contraindications/ cautions• Allergy to product• Bronchospastic disease
Sustained‐released bupropion (Zyban™)
• Mechanism of action• Exact MOA unclear• Noncompetitively binds to several nicotinic acetylcholine receptors which may lead to noradrenergic and/or dopaminergic mechanism
• Contraindications• Seizure disorder• Anorexia or bulimia nervosa• Undergoing abrupt discontinuation of alcohol or sedatives
• MAOI with past 14 days
• Dosing• 150 mg every morning x 3 days then twice daily for 7‐12 weeks
• Side effects• Common: Constipation, nausea, insomnia, dizziness, headache, dry mouth
• Rare but serious: cardiac dysrhythmia, psychiatric changes
• Counseling points• Set quit date 1‐2 weeks after starting therapy
Varenicline (Chantix™)
• Mechanism of action• Binds with high affinity and selectivity at alpha‐4‐beta‐2 neuronal nicotinic acetylcholine receptors
• Agonist activity at a sub‐type of the nicotinic receptor
• Prevents nicotine binding at alpha‐4‐beta 2 receptors
• Cautions• Cardiovascular disease
• Psychiatric disturbances
• Seizures
• Dosing• Days 1‐3: 0.5 mg daily
• Days 4‐7: 0.5 mg twice daily
• Weeks 2‐12: 1 mg twice daily
• Side effects• Common: nausea, vomiting, constipation, flatulence, dream disorder, headache, insomnia
• Rare but serious: angina, myocardial infarction, psychiatric changes
• Counseling points• Set quit date 1 weeks after starting therapy
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QuestionAB is a 35 year‐old man who used to smoke over a pack of cigarettes (>20 cigarettes) a day for about 15 years and who recently started nicotine replacement therapy with a transdermal system (patch) 21mg/24h. He is now on his first week of treatment and he calls you at the pharmacy to say that this week has been very stressful at work and that he is on the verge of starting to smoke again because he has strong cravings. What do you recommend?
A. Provide behavioral counselingB. Recommend that he combines the patch with gum or lozenge 2 mg when he
feels cravingsC. Refer him to his primary care physician for a nasal spray prescription to
more quickly relieve the cravingsD. Recommend that he smokes a cigarette every time he has a craving up to a
maximum of 5 cigarettes a dayE. Use one and one‐half patches daily to increase the dose of nicotine
Alternative therapies
• Lobelia inflate• Herbal alkaloid with partial nicotinic agonist properties• No evidence to support its role as an aid for smoking cessation (meta‐analysis and multicenter trial)
• Hypnosis and acupuncture: controlled trials did not demonstrate efficacy
• Electronic cigarettes: limited evidence regarding safety or efficacy in reducing or stopping smoking• Typically have fewer chemicals than traditional cigarettes• May contain heavy metals (e.g., lead), flavorings linked to lung disease, small particles that can be inhaled deeply, and carcinogens.
What we know about electronic cigarettes. Smokefree.gov. https://smokefree.gov/quit‐smoking/ecigs‐menthol‐dip/ecigs. Accessed August 9, 2018.
Handbook of Nonprescription Drugs: An Interactive Approach to Self‐Care. 18th. Edition.
Cognitive changes
• Consciousness raising: Help patients learn more about consequences of tobacco use
• Emotional arousal: Encourage patients to experience and express feelings about tobacco use and quitting
• Environmental re‐evaluation: Encourage patients to think about how it effects children, environment, etc.
• Social liberation: Discuss ways that society makes it easier for non‐smokers (e.g., workplace, restaurants, access to cigarettes)
• Self re‐evaluation: explore how being a smoker may contradict with their health and personal wellbeing goals
The quitting process: Experiential and behavioral strategies. Rx for Change. http://rxforchange.ucsf.edu/file_downloads/PA7%20COPING.pdf. Accessed August 9, 2018.
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Behavioral changes
• Self‐liberation: Develop a quit plan. Encourage self‐talk like “I can do this.”• Helping relationships: Identify friends, family, and/or co‐workers who can provide encouragement and support.
• Reinforcement management: Praise patients throughout quit attempts. Encourage patient to set up a reward system.
• Stimulus control: Help patients develop a plan to avoid stimuli that elicit tobacco use (e.g., throw out smoking paraphernalia, avoid tobacco users, change routine).
• Counter conditioning: Substitute alternatives (e.g., relaxation techniques, distractive thinking, abstinence from drugs/other substances, oral substitutes, exercise). • Dieting may decrease changes of quitting.
The quitting process: Experiential and behavioral strategies. Rx for Change. http://rxforchange.ucsf.edu/file_downloads/PA7%20COPING.pdf. Accessed August 9, 2018.
Arrange, Refer, or Connect
Michigan Tobacco QuitLine
• Website: michigan.quitlogix.org• Phone: 1‐800‐QUIT‐NOW• Free program with 5 coaching sessions• Coaching• Coordinate NRT therapy• Additional support• Educational materials
• Special populations• Pregnant/post‐partum women• Youth• American Indian/Alaskan Native
• Languages: English, Spanish, & Arabic and all other languages are offered through interpreter
• High success rate (37%) and participant satisfaction (90%)
• Referral• Web• Fax• Give patient phone number to call• eReferral program (uses health system electronic health record)
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Quitspiration
QuitGuide Mobile App
• Free app to help understand smoking patterns and build skills needed to become and stay smokefree
• Track cravings and slips by time of day and location
• Track mood and smoking triggers
• Inspirational messages
• Tips for dealing with cravings
Smokefree.gov
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SmokefreeTXT
You want to learn more about smoking and how it affects your babies as they
develop.
SmokefreeTXT47848 ‐ CRAVE
You are having a bad craving and need a reminder of why you shouldn’t pick up that cigarette.
SmokefreeMOM222888 ‐ FACT
You’re having feelings of distress, crisis, or of
harming yourself or others. Call the Veterans Crisis Line immediately. This keyword will give you the contact
information for the Veterans Crisis Line.
SmokefreeVet – Crisis47848 ‐ CRISIS
Take a time out for yourself. Breathe in for five seconds. Hold for five seconds. Breathe out for five more.
Repeat until the craving passes.
Role play
• Roles• Patient
• Pretend that you currently smoke. Create a realistic scenario that includes
• Readiness to quit
• Smoking history
• Relevant medical history
• Current medications
• Pharmacist• Use either 5A’s, AAR, or AAC
• Switch roles
References for medications
• Handbook of nonprescription drugs: An interactive approach to self‐care. 18th edition.
• MicoMedex http://www.micromedexsolutions.com/
• Package inserts from DailyMedhttps://dailymed.nlm.nih.gov/dailymed/
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Strategies to promote tobacco cessation
Sarah E. Vordenberg, PharmD, MPH, BCACP
Clinical Assistant Professor
University of Michigan College of Pharmacy