Tobacco Update:New products to addict.New strategies to quit!

Linda Hancock, FNP, PhDVCU Student Health Services

Director, Wellness Resource Center

(804) 828-7815 or quit@vcu.edu

Who am I?• FNP – and local “smoking cessation guru”• PhD – I count a lot of things

• College Health for 20 years• Every semester we help over 200 students work on

tobacco cessation

• 2005 - attended Mayo Clinic week long Nicotine Dependence Training

• I love working with tobacco users!

Goals for session

• You aren’t a tobacco cessation specialist.. but you can be a CHEERLEADER!

• Get your patients to call 1 800 QUIT NOW

• The QUIT NOW

counselors are cessation experts… it’s all they do!

• You are prescribers so you need to be the medication expert!

• PLEASE encourage every smoker to keep trying medications and strategies until they quit.

• POST POSTERS in your waiting room and exam rooms!!!

• Be vigilant about NEW tobacco products!

What percent of adult Virginians are daily smokers? CDC 2008 BRFSS data

12%

15%

20%

25%

30%

35%

40%

4%

22%

17%

0%

17%

13%

26%12.4%1. 12%

2. 15%

3. 20%

4. 25%

5. 30%

6. 35%

7. 40%

Most VCU students (7 of 10)

didn’t smoke at all in the past month.

Only about 8-12% smoke daily.

FREE Quit Kits at

OHPsmoking cessation

pills Chantix

www.lgbtsmokefree.org

A high-risk population for smoking!

LGBTs smoke at rates 40% to almost 200%

higher than the general population

Please post this poster

“Genetic Snowflakes” & tobacco

• Research on genes such as CYP 2A6

• About 1 in 4 are missing genetic ability make enzymes to break down nicotine

• 3 in 4 people can metabolize nicotine and if used are at high risk for addiction

Understanding a smokers struggle-adapted from Mayo Clinic Nicotine Dependency Center publication 2005

= Withdrawal - empty receptors

= Craving chemicals – triggered by environment

The tobacco epidemic, like the “flu” is always mutating.

-Jack Henningfield, PhD

Tobacco Companies and others out to make money on nicotine are always changing-

•What they market •How they market•To whom they market

Virginia Slims introduces “Purse Packs”

• In October 2008 Phillip Morris introduced "Purse Packs" for select Virginia Slims brands 

• The “Purse Pack” is pink, sleek rectangular packaging with square ends. It holds 20 sticks that are smaller in diameter than a typical smoke.

What is this?

Not..

Hookah

Water pipe

Water Pipes

also called “Hookah”

Maassel or mu’essel (assal means honey in Arabic)

Moist paste like mixture with 30% crude cut tobacco

Fermented with approximately 70% honey, molasses and pulp of different fruits.

Hookah Materials

Toxin Content of smoke(single hookah session compared to a single cigarette)

Chemical HOOKAH CIGARETTE COMPARISON

“Tar” 802mg 22.3 mg 36 times the tar

Nicotine 2.96 mg 1.74 mg 1.7 times the nicotine

Carbon

Monoxide

145 mg 17.3 mg 8.4 times the carbon monoxide

Please post this poster!

What is Snus?

• Rhymes with "goose"

• Cynics might say "noose“

• Swedish type of “spitless-smokeless” tobacco

• Comes in teabag-like pouches

• User sticks between the upper lip and gum

• Use 30 minutes

• Then discard without spitting

Snus:A form of Swedish smokeless tobacco

Usually placed in upper lip

Where is Snus most popular?

• Snus is the Swedish word for moist snuff. • It is manufactured and mainly consumed in

Sweden and Norway. • Snus is subjected to a heating treatment

process that sharply reduces microorganism content; no fermentation has been used in its production

• This processing method and refrigerated storage reduce the formation of nitrates and nitrosamines, resulting in a product low in TSNAs.

Nicogel

New smokeless, dissolvable tobacco products from R.J. Reynolds

Test marketing in Columbus, OH, Portland, OR, and Indianapolis, IN starting in January 2009

My personal biases…

• We need to be prepared to get smokers at “reachable moments”• Smokers get sick frequently!

• ALL STAFF who can prescribe must be intervene with tobacco users.– Every clinic needs a

“tobacco cessation guru”

There are currently 7 MEDICATIONS for first line use

Bupropion HCL ( Wellbutrin or Zyban)

PatchGumNasal SprayPuffersLozenges

Varenicline (Chantix or Champix)

Blocks Nicotinic receptors, not advised to

use with NRT

2 Smoking Cessation PILLS5 NRT products

(nicotine replacement therapy)

Combination Therapy

Neurobiology of nicotine addiction

• Nicotine ACh Receptors are all over the body

• There are several subtypes– Alpha4Beta2 receptors predominate in the brain

• (site of action for Varenicline)

– Alpha 7 receptors (link to schizophrenia?)

• These receptors affect brain reward, mood, cognition, etc.

• SMOKERS have UPREGULATED but poorly functioning receptors.

Shoes Analogy

You know how you try on shoes and some fit and some don’t-

but you don’t give up wearing shoes.

That’s they way it is with medications.You try them on. Some fit. Some don’t.

But you don’t give up trying to quit.

Recommendations: Dr. Richard Hurt, Director,

Mayo Clinic Nicotine Dependency Center

• Varenicline should be considered a first line medication for the treatment of tobacco dependence.

• It has not been tested in adolescent, pregnant or breastfeeding smokers.

• Varenicline is cleared almost entirely by the kidneys and dose adjustments are necessary in the presence of severe renal failure (creatinine clearance < 30 ml/min.) and patients receiving hemodialysis.

• Nausea can be minimized by taking the medication with a large glass of water after eating.

• If patients are intolerant of 1.0 mg twice a day, a trial of 0.5 mg twice a day should be encouraged.

Varenicline 0.5 mg and 1mg pills and ways to and adjust the dosing

Bupropion

• On the market for cessation since 1997• Found by accident• Originally an antidepressant• Generic 100 mg tab, SR 150 mg tab = Zyban• Category B in pregnancy (safer than the patch- D)• CONTRAINDICATIONS- don’t prescribe if…

– History of Seizure Disorder– Head Trauma with LOC > 30min in past 5 years– History of an Eating Disorder – On other meds that lower seizure potential– Heavy drinkers (a hangover is a seizure prone state)

Main Side effects on bupropion

• You’re not depressed

• You have extra energy

• Seems to limit weight gain with cessation

• Treatment for ADHD

• May improve ability to orgasm

• Cigarettes may taste different

Nicotine Patch BEFORE cessation doubles success rates

Jed Rose, PhD, Feb 1, 2006 issue of Nicotine and Tobacco Research • Duke University Center for Nicotine

Research & Smoking Cessation– 96 smokers attempting to quit

• Half wore patch 2 weeks before quitting• Half wore a placebo patch• AFTER 4 weeks

– NO adverse effects from smoking & using patch– 23% with placebo patch had quit– 50% with real patch had quit

“Cigarettes are less rewarding and satisfying when there is already a level of nicotine in the system provided by the patch.”

- Jed Rose, PhD

New ways to use Nicotine Replacement Therapy

(NRT)

1. Starting NRT before stopping tobacco 2. Matching dose to daily use

3. Combination Therapy

Motivational Interviewing

(MI)

William Miller, PhD

First Game Challenge

• The Name of the Game is…

–WIN AS MUCH AS YOU CAN!!!

– Stand up– Find a partner– place right feet side by side– “shake” right hands

How you ask the questions influences how the patient will answer…

• NOT EFFECTIVE“Do you want to quit smoking?”

• Not very effective because often they have tried quitting and they haven’t succeded.

• MORE EFFECTIVE

“Where are you in your love/hate relationship with your tobacco?”

Prochaska & DiClemente’s Transtheoretical Model of Change

Work smarter, not harder.

• A. Pre-contemplation

• B. Contemplation

• C. Preparation

• D. Action

• E. Maintenance & Relapse Prevention

2 MI Mnemonics

• EPE– Elicit “Is it okay with you if I tell you what we know?”– Provide “Folks have found…” “Research suggests…”– Elicit “Where does this leave you? “How can I help?”

• RULE– Righting Reflex Avoided– Understanding– Listen– Empathy

What if you hit resistance?

Are you dancing

or wrestling?

If you feel or hear resistance,

step back and reflectively listen some more!

Importance RulerOn a scale of 1 to 10

• How motivated are you to quit tobacco?• Not at all Extremely 1 2 3 4 5 6 7 8 9 10

• Go 2 Down…. “What makes it a 6 and not a 4?”

• How confident are you that you can quit tobacco?

Not at all Extremely 1 2 3 4 5 6 7 8 9 10• Go 2 up- what would it take to make it a five & not a 3?

QUIT KITS -5 A’s in a bagAskAssessAdviseAssistArrange follow-up

quit@vcu.edu1 800 QUIT-NOW

FREE Telephone quit line

SMOKING CESSATIONASSEMENT

& MANAGEMENT

FORM

I’ll send you an electronic version you can adapt for your clinical use

Email quit@vcu.edu and ask for it.

3 steps for relapse prevention

1. When quitting create a tangible SYMBOL of what you want more than tobacco. Keep it on your body or very near you for years.

2. Write a small paragraph about what you HATE about tobacco and why you are never quitting again.

3. Keep some medication at home. If you start thinking about tobacco or feeling close to a relapse… restart your meds for a few days until the neuro-receptors go back to sleep.

The bottom line

Be methodical about assessing BEFORE recommending meds.

BUT…remember medications greatly increase quitting success.

Please support patients with prescriptions where appropriate.

Implementing an Effective Smoking Cessation Strategy in Medical Practice

RESOURCES FOR PATIENTS

QUITLINES – trained phone counselors provide practical

counseling, support, materials, relapse prevention, etc:

Quit Now Virginia 1-800-QUIT NOW(1-800-784-8669, English or Spanish speaking.8AM-Midnight, seven days a week)

Great Start Quitline 1-866-66-START(For pregnant women, English or Spanish speaking)