9/29/2016 Objectives TOBACCO CESSATION: A REVIEW • Discuss the “5 A’s” model for treating tobacco use and OF CURRENT PRACTICES AND AN dependence. • Given a patient case, identify a patient’s readiness to UPDATE TO E ‐ CIGARETTES quit smoking or using tobacco products. Jessica Kerwin, PharmD • Evaluate a patient case to determine the best smoking PGY ‐ 2 Ambulatory Care Resident cessation product based on patient ‐ specific factors. UNM College of Pharmacy • Describe recent updates to the regulation of jlkerwin@salud.unm.edu electronic cigarettes and how these could impact smoking cessation. Tobacco Use 1 Tobacco Use 1 • Prevalence of cigarette smoking is highest • Leading cause of preventable among lower socioeconomic youth and premature death • Smokeless tobacco use is increasing among • Kills an estimated 443,000 white high school males Americans each year • Rates lower in women but gap is decreasing • Costs $96 billion in direct • Concurrent use of multiple tobacco products is medical costs annually common, with 50% of White and Hispanic • Every day in the US, 3,800 Americans under the males reporting using more than one product age of 18 smoke their first cigarette • Nearly 7 out of every 10 adult cigarette users • Decreases in smoking rates have stalled reports that they want to quit smoking entirely Benefits of Quitting 2 • Lowered risk of lung cancer • Reduced risk of heart disease, stroke, and peripheral vascular disease • Reduced heart disease risk within 1 ‐ 2 years of quitting • Reduced respiratory symptoms • Reduced risk of developing some lung conditions (COPD) • Women of child ‐ bearing age: reduced risk of infertility 1
9/29/2016 Smoking Status Assessment 3 • 1995: Smoking status is identified in 65% of clinic visits • 22% of patients received counseling on smoking cessation • Treatment typically only offered to those with tobacco ‐ related illness ASSESSING TOBACCO USE • 2005: Smoking status is identified in 90% of clinic visits • 70% of patients received counseling on smoking cessation • Among current smokers who attempted to stop smoking in last year, only 21.7% utilized medication Barriers to Smoking Status Assessment 3 Readiness to Change 4 Precontemplation Not ready – patient does not intend to take action in the • Lack of knowledge foreseeable future (the next 6 months) • How to identify smokers quickly and easily Contemplation Getting ready – patient is aware of the pros and cons of • Which treatments are effective change and intends to make a change in the next 6 • How treatments can be delivered months • Relative effectiveness of treatments Preparation Ready – patient intends to take action in the immediate • Inadequate clinic support for assessment and treatment of future (within the next month); making preparations for tobacco use their change • Time constraints Action Patient has made specific, overt modifications to lifestyle within the last 6 months • Limited training in tobacco cessation interventions Maintenance Patient made specific, overt modifications to lifestyle >6 • Lack of insurance coverage for tobacco use treatment months ago and is working to prevent relapse • Inadequate payment for treatment The Five A’s 3 The Five A’s – Ask Ask Identify and document tobacco use in every patient at every visit • Implement an office ‐ wide system that ensures Advise In a clear, strong, and personalized manner, urge every tobacco that every patient is asked about tobacco use user to quit status at every visit Assess Is the tobacco user willing to make a quit attempt at this time? Assist For the patient willing to make a quit attempt, offer medication • Incorporate into vital signs and provide or refer for counseling or additional treatment to help • Add to clinic templates the patient quit. For patients unwilling to quit at the time, provide interventions designed to increase future quit attempts. Arrange For the patient willing to make a quit attempt, arrange for followup contacts, beginning within the first week after the quit date. For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit. 2
9/29/2016 The Five A’s ‐ Advise The Five A’s ‐ Assess • Advise patient: • Are you willing to give tobacco cessation a try? • If patient is willing, provide assistance • Clear – upfront, to the point • Is patient is not willing to make a quit attempt at • Strong – use your expertise, be a support this time, provide an intervention shown to increase system future quit attempts • Personalized – tie in current health, symptoms, • Motivational interviewing techniques social, or economic concerns specific to the • The Five R’s patient The Five A’s ‐ Assist The Five A’s – Arrange • Set a quit date • Follow ‐ up contact should be soon after the scheduled quit date • Tell family, friends, and • Within first week coworkers about quitting • Within first month • Anticipate challenges in • During visit: upcoming quit attempt, • Identify problems already encountered during quit attempt especially in initial period • Assess medication use, medication related problems • Remove tobacco products from your • Determine tobacco use environment • Congratulate on abstinence • If patient relapsed, go over circumstances and strategies to prevent in future The Five R’s Motivational Interviewing – General Principles • Express empathy • Relevance • Use open ‐ ended questions • Risks • Reflective listening • Develop Discrepancy • Rewards • Highlight differences in behavior and priorities • Support “change talk” and “commitment” language • Roadblocks • Roll with Resistance • Repetition • Back off and reflect • Ask permission • Support self ‐ efficacy • Point out previous successes • Provide resources 3
9/29/2016 Patient Case Patient Case • JG is a 27 yo male who presents to your clinic for medication • ML is a 67 yo female with past medical history of HTN, CAD, management. He states he has smoked 1 pack per day for the T2DM, and a recent diagnosis of COPD. She states that she has last 7 years. He mentions that he has noticed that it has smoked since she was 13 years old and smokes anywhere from become increasingly more difficult for him to exercise because 1 ‐ 2 packs per day. She has recently increased her daily he spends a lot of time coughing and trying to catch his breath. smoking because her daughter and grandkids moved out of It is his personal goal to run a marathon before the age of 30 state and she has been lonely. She states that she is not willing and he feels that he has to stop smoking in order to achieve to stop smoking because she has tried to in the past and it is this goal. He plans to quit by Halloween this year. too hard. Also, she says that because she now has COPD, there is not point in quitting because “the damage is already done”. • Assess JG’s readiness to quit smoking • What support can you provide during this time? • Assess ML’s readiness to quit • What are some strategies you can use to motivate patient? FDA Approved Medications for Tobacco Cessation • Nicotine Replacement Therapy (NRT) MEDICATIONS FOR TOBACCO • Patch, gum, lozenge, inhaler, nasal spray CESSATION • Varenicline • Bupropion SR Nicotine Replacement 3,5 Nicotine Patch 3,5 • Dosing • MOA: deliver nicotine with the intent to replace, at • Available in 21 mg/day, 14 mg/day, and 7 mg/day transdermal patch least partially, the nicotine obtained from cigarettes • For patients smoking >10 cigarettes per day: and reduce the severity of nicotine withdrawal • Begin with 21 mg/day patch x 6 weeks, followed by 14 mg/day patch x 2 weeks, symptoms followed by 7 mg/day patch x 2 weeks • For patients smoking < 10 cigarettes per day: • Use with caution in patients with significant • Begin with 14 mg/day patch x 6 weeks, followed by 7 mg/day patch x 2 weeks cardiovascular risk or recent history of cardiovascular • Remove at bedtime if patient experiences sleep disturbances disease • Apply to clean, dry, relatively hairless area • Rotate sites to avoid skin reactions; use steroid cream to • Pregnancy Category: D treat local reactions 4
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