Transcript Clinician Training - American Academy of Pediatrics

If Not Now, When?
How to Influence Youth Use
of Tobacco Products
Your name, institution, etc. here
YOUR LOGO HERE
(can paste to each slide)
…dedicated to eliminating children’s
exposure to tobacco and secondhand
smoke
Objectives
• Understand social influences for teen tobacco use
• Develop strategies to increase teachable
moments in patient encounters
• Learn how to incorporate Asking, Advising, and
Referring into patient encounters
Teen Tobacco Use is a Big Problem
• Typically, tobacco use begins before
age 18 years
• Every day, 3,450 people age
12 – 17 years initiate smoking in the
US
Teen Tobacco Users- 2010
The Social Cycle of Tobacco Use
Influences
to Start
Smoking: Media,
Household Members,
Peers
Childhood
Infancy
In utero
Adolescence
Adulthood
Alienation from peers
who don’t use tobacco
Teen Tobacco Users Are…
• More likely to be psychologically distressed,
abuse other substances
• Less likely to be attached to parents, do well in
school, participate in extracurricular activities,
know the adverse effects of smoking
Tobacco Use Progresses Faster Than
Anyone Expected
Experimentation
Nicotine dependence, as indicated by
craving, starts BEFORE daily or regular
use!
Regular Use
Interventions may be delivered at any stage
Hooked on Nicotine Checklist
 Nicotine dependence can be identified as soon as a
smoker has developed any symptom that presents a
barrier to quitting.
 When quitting requires an effort, the smoker has lost
some degree of autonomy over his or her tobacco use!
 Symptoms of dependence can appear within days of
the onset of use, when youths are smoking as little as
one cigarette per week.
 Many youths are hooked before they even think of
themselves as smokers…
The Hooked on Nicotine Checklist
1. Have you ever tried to quit but couldn't?
2. Do you smoke now because it is really hard to quit?
3. Have you ever felt like you were addicted to tobacco?
4. Do you ever have strong cravings to smoke?
5. Have you ever felt like you really needed a cigarette?
6.
Is it hard to keep from smoking in places where you are not
supposed to, like school?
In answering the last four questions, when you tried to stop
smoking, or when you have not used tobacco for a while ...
7.
Did you find it hard to concentrate?
8.
Did you feel more irritable?
9.
Did you feel a strong need or urge to smoke?
10.
Did you feel nervous, restless or anxious because you
couldn't smoke?
Scoring/Discussion
Have you ever tried to quit, but couldn’t?
A failed cessation attempt is an obvious indication of diminished autonomy.
If quitting was effortless, the patient would no longer be smoking.
Do you smoke now because it is really hard to quit?
This item is included to capture those who do not want to smoke, but have
not made an “official” effort to quit, often out of a fear of failure. Since they
are doing something they don’t want to, they have diminished autonomy.
Have you ever felt like you were addicted to tobacco?
A person with full autonomy over his or her tobacco use would not feel
addicted.
Do you ever have strong cravings to smoke?
Strong cravings make quitting difficult and unpleasant.
Have you ever felt like you really needed a cigarette?
Smokers feel they really need a cigarette because of cravings, withdrawal
symptoms, or psychological dependence. Whatever the reason, quitting is
more difficult.
Is it hard to keep from smoking in places where you are not supposed to?
An autonomous smoker would have no difficulty refraining from smoking,
especially where it is forbidden.
Teen Tobacco Addiction
• Dependence is more severe if use begins in
adolescence
• Those who begin as teens are more likely to
become dependent, use for more years, and user
more heavily
• Increased vulnerability may be due to stilldeveloping brain
Teen Cessation: What Works?
The 5 As
Ask about tobacco use and SHS exposure
Advise to quit
Assess readiness to quit
Assist in quit attempt
Arrange follow-up
The 5 As
Ask
“2As and an R”
Ask
Advise
Assess
Advise
Assist
Arrange
Refer
Treating Teens
• Ask about tobacco as part of psychosocial history
• Privacy and confidentiality a must
• Use the same techniques used for adults, tailored
to the values of the teen
Counseling Teens
• Most teen smokers are interested in quitting
• Even occasional users may be addicted
• Provide education on nicotine addiction and quitting
strategies
• No evidence that quitting is easier for teens than
adults
– It takes the average adolescent daily smoker 18
YEARS to successfully complete cessation!!!
Ask: The Concept
• Ask about tobacco use and SHS exposure at every
visit
– Include current tobacco use, SHS exposure
– Teens who live with smokers are more likely to
start smoking themselves…
• Make asking routine, consistent, and systematic
• Document as a “vital sign”
– Use standardized documentation
• Just asking can double quit attempts
Advise: The Concept
 Quitting smoking is the best thing you can do to
help protect your health and the health of your
child.
 I can help you.
 Have you thought about quitting (Assess)?
• No- exposure reduction
• Yes- exposure reduction and Assist/Arrange
Now What Do You Say?
• “Smoking isn’t good for you (or your child). I can
help you quit. Are you ready?”
• 54% of high school smokers want to quit
• A smoker quits 5-7 times before it is for good…
Is the Tobacco User
Ready to Quit?
• The Stages of Change model can help you figure
out what to say and how to help
• Regardless of what stage the teen is in, provide
information about cessation to all tobacco users
Your Goal: Help the Tobacco
User Take the Next Step
Help a precontemplator become a contemplator…
…a contemplator start to make plans…
…someone who relapsed become “ready for
action”…
And so on….
Be Specific
• Use clear, strong messages
• Anticipate challenges
– Ask about cues to use tobacco
– There are fewer cues in smoke free homes and cars
• Practice problem-solving
– enlisting help from friends or parents, quitting with a
friend, getting parents to quit
• Prescribe or provide information about pharmacotherapy
– Pharmacotherapy can be used, but has not been shown
effective with teens (Mixed results…)
• Help the teen set a quit date
• Document your advice
What Do You Say?
• Clear: “I’m really concerned about you, and I strongly
advise you to quit smoking.”
• Personalized: Emphasize the impact on health,
finances, family or the teen.
– “Your lungs are still developing, and teens who smoke
aren’t able to use their lungs as well. I think you’ll do better
in basketball if you quit. I can help you… are you ready?”
An Intermediate Goal
• Cutting down
• Making a Smoke Free Home
– “Secondhand smoke is bad for you and your
family. Is it possible for you to make your home
and car tobacco free now?”
• Smokers who live in tobacco free homes smoke
fewer cigarettes, which can help the next quit
attempt succeed
Pharmacotherapy and NRT
• Nicotine replacement therapy (NRT) is not
currently FDA-approved under 18
• PHS Clinical Practice Guideline: pharmacotherapy
may be used in addicted teens interested in
quitting
• Monitor those on Zyban closely for adverse
effects related to antidepressants
• Varenicline (Chantix) – FDA-approved May 2006
but not approved under 18
Rationale for Pharmacological Treatment
• Nicotine addiction
• Mood and affect modulation
• Cognitive decrements during withdrawal
• Tobacco-free lifestyle coping skills take time to
acquire
Tobacco Withdrawal
• Cigarette craving
• Constipation
• Anxiety
• Increased appetite
• Irritability
• Poor attention
• Headache
• Impaired cognitive
performance
• Insomnia
• Drowsiness
• Decreased heart rate
Symptoms occur within hours of stopping smoking,
and may persist for weeks
Knowledge is a Good Thing…
• Even if you never prescribe NRT or cessation
medications, familiarity with the medications
typically used can be helpful
– Comfort with talking to patients and their parents about
what is “out there”
• But I encourage you to remove the barrier to
pharmacotherapy and prescribe them!
Pharmacotherapy Types
• Nicotine replacement therapy (NRT) (many
brands, some generics)
– Many OTC
– Some states reimburse, even for OTC (prescription
may be required)
• Bupropion SR (Zyban, Wellbutrin)
• Varenicline (Chantix)
Using NRT: Treatment Goals
• Overall reduction of nicotine withdrawal
symptoms – not to replace tobacco!
• Help with momentary urges
• Modify habitual behavior
– Breaking the cigarette habit with use of NRT
has been shown to increase likelihood of
quitting
• Postponement of smoking
– May be used to defer smoking when in
environment in which smoking is not
allowed
Nicotine Replacement Therapy
• All forms of NRT appear to be equally effective
(increase quit rates by ~1.5-2 fold)
– Heavier smokers should start with higher dosing
• Effectiveness of NRT increased with amount of
behavioural support
• Choice of medication is based mainly on susceptibility
to side effects, patient preference and availability
Nicotine Polacrilex Gum (OTC)
Dosage
– CPD < 25 use 2 mg, CPD  25 use 4 mg, Use enough , Use
long enough (for full 12 weeks)
Side Effects: taste, jaw pain, nausea, dyspepsia, constipation, headache,…
Advantages
– Flexible dosing
– Rapid blood level
Disadvantages
– Poor compliance and Under-dosing
– Dietary influence
Nicotine Lozenge (OTC)
Dosage
– 1mg, 2 mg and 4 mg (delivering 2 mg of nicotine if
properly used)
Side effects: oral irritation
Advantages
– Flexible dosing
– Rapid blood level (4mg lozenge give 25% higher blood
level than 4 mg gum)
– No chewing (discrete)
Disadvantages
– Under-dosing
– Oral pH
Nicotine Transdermal Patch (OTC)
Dosage
– 21mg, (16mg Day patch)- 14 mg, 7 mg, place the patch
always at the beginning of the day
Side effects: redness, itching, sleep disturbance
Advantages
– Good compliance
– Sustained blood levels
Disadvantages
– Skin irritation
Nicotine Nasal Spray (Rx)
Dosage
– 1 dose yields 1 mg of nicotine (2 sprays, one/nostril)
Side effects: cough, nasal /throat irritation
Advantages
– Flexible dosing
– Rapid blood level (5-10 minutes)
Disadvantages
– Tolerance
– Expensive
Nicotine Vapor Inhaler (Rx)
Dosage
– 10 mg/cartridge, 6-16 cartridges/day, MAX: 16/day, each
puff yields about 13 μg, compared to 100μg per cigarette
puff
Side effects: throat irritation
Advantages
– Flexible dosing, “habit replacement”
– Sensory cues (menthol, throat irritant)
Disadvantages
– ineffective if used alone
Increase in nicotine concentration
(ng/ml
14
Plasma nicotine concentrations for
smoking and NRT
12
10
8
Cigarette
Gum 4 mg
6
Gum 2 mg
4
Inhaler
Nasal spray
Patch
2
0
5
10
15
Minutes
20
25
30
Bupropion (Rx)
Non-nicotine aid to smoking cessation
Chemically unrelated to nicotine
Atypical antidepressant
Pharmacodynamics: relatively weak inhibitor of the neuronal
uptake of norepinephrine, serotonin, and dopamine –
mechanism of action unknown, stimulant-like
T1/2: 21 hours, peak plasma concentrations within 3 hours
hydroxybupropion active metabolite
Bupropion (Rx)
Dosage
150 mg QAM for 3 days, then increase to 150 mg BID
Doses should be at least 8 hours apart
Use for 7-12 weeks after quit date; longer use possible
Side effects
Dry mouth, headache, sleep disturbance, dizziness
Advantages
May be combined with NRT
Disadvantages
Need to pre-load: Start 2 weeks BEFORE quit date
The New Drug:
Varenicline (Chantix®)
Dosage
Start 1 week BEFORE quit date
0.5 mg QD for 3 days, then 0.5 mg BID for 4 days, then 1 mg BID for 12
weeks or longer
After a meal with a full glass of water
Use for 12 weeks after quit date; longer use possible
Side effects
Nausea, sleep problems
Advantages
May be more effective than Bupropion
Disadvantages
Can not combine with NRT
African-Americans & Smoking
21.3% of African-American adults smoke
Males (24%) > females (19%)
HS students – 7.4% smoke; Middle School – 5.2%
African-American youth are more likely to start smoking at a
later age
Menthol cigarettes are popular among African-Americans
including HS and MS students
Menthol Cigarettes
83 % of African-American smokers use mentholated brands
compared with 24% of white smokers
Menthol is a local anesthetic – used to relieve minor throat
irritation
Menthol may help the absorption of toxins
Cooling, numbing properties may permit larger puffs, deeper
inhalation or allow smoke to stay in the lungs for a longer
period of time
Following Up
Plan to follow up on any behavioral commitments made
Just asking at the next visit makes a big impression
If they set a quit date
Schedule follow-up in person or by telephone soon after the
quit date
Look for “teachable moments” in the future
Refer
To quit line, 1-800-QUIT NOW
To community and Internet resources
Give every tobacco user something that contains information
about quitting, the harms of tobacco use, etc.
What Do You Say?
• “I recommend that you call this number. It’s a free
service – and the person on the other end of the
telephone can help you get ready to quit.”
• “One thing that helps a lot is to learn as much as you
can about quitting – the more you know, the more
successful you’ll be. The quit line staff can help.”
Create a Tobacco-free Office
and Waiting Room
• Replace tobacco ads in magazines with health
promotion, tobacco free magazines
• Make cessation materials readily available in
waiting room and exam room
• Provide risk awareness educational material and
self help literature
• Posters and signage
You Can Advocate for
Some Protective Factors
• Individual, family, and environmental factors can
guard against risky behaviors
– Close communication with parents
– Parental support
– High self-esteem
– Regular church attendance
Counseling Their Parents
Advise parents to
• Express disapproval of tobacco use
• Discourage friends who are smokers
• Keep the home smoke free – even if parents smoke
• Make tobacco products inaccessible
• Limit access to R-rated movies!
Home Smoking Bans Are
More Effective with Teens than
Smoking Bans in Public Places
Odds Ratios for Association of Smoking Restrictions
with 30-Day Smoking Prevalence, High School Students
OR
95%CI
P value
Total Home Ban
0.79
Some Home Restrictions
School Ban
Enforced School Ban
0.85
0.99
0.67 - 0.91 <.001
0.74 - 0.95 <.01
.86
0.85 - 1.13
0.86
0.77 - 0.94
<.001
0.91
0.83 - 0.99
.03
Other Public Restrictions
Need more information?
The AAP Richmond Center
www.aap.org/richmondcenter
Audience-Specific Resources
State-Specific Resources
Cessation Information
Funding Opportunities
Reimbursement Information
Tobacco Control E-mail List
Pediatric Tobacco Control Guide
Questions?