Transcript Training Pediatricians in Smoking Cessation Counseling

Promoting Smoke Free Homes:
Counseling Patients and Their Families about
Second Hand Tobacco Smoke and Tobacco Use
in the Primary Care Setting
Your name, institution, etc. here
YOUR LOGO HERE
(paste to each slide)
…dedicated to eliminating children’s exposure to tobacco
and secondhand smoke
Today’s Workshop
• Motivational Interviewing 101:
– Goals, techniques and PRACTICE!
• We will break down MI and practice,
taking a longer period of time to
become comfortable with the language
and techniques, breaking into
groups of three
• Effective MI can occur in just a few minutes!
• Helpful techniques for all kinds of behavior change
• Helping Patients and Families
– Pharmacotherapy nuts and bolts
Learning Objectives
• By the end of this session, participants will
– Describe how to incorporate an assessment of SHS
exposure into every provider visit
– Apply Motivational Interviewing techniques to facilitate
open conversations with parents or family members
that smoke
– Explain practical tips for smoking cessation and
pharmacological agents available
– Describe how to help families move towards a tobacco
free home and car
The Health Effects of Tobacco Use
Asthma
Otitis Media
Fire-related Injuries
SIDs
Bronchiolitis
Meningitis
Childhood
Infancy
In utero
Low Birth Weight
Stillbirth
Neurologic Problems
Influences
to Start
Smoking
Adolescence
Nicotine Addiction
Adulthood
Cancer
Cardiovascular Disease
COPD
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
The Economic Cycle of Tobacco Use
Decreased lifetime
earnings
A pack-a-day smoker
Spends over $2000/year
Childhood
Infancy
In utero
Increased likelihood of
Living in poverty
Adolescence
Adulthood
47 Years After the 1st Surgeon General’s
Report –
People Still Smoke!
• 21% of US adults are smokers
• More than 30% of U.S. children live with at least
one smoker
Why Do People Use Tobacco?
• Nicotine is physically addictive
– Tolerance develops
– Withdrawal symptoms occur
• Nicotine is a potent drug, causing dopaminergic
activation and CNS stimulation
• Use is reinforced by social cues and habits
Youth Are
Especially Susceptible
• For many youth, symptoms of dependence
develop before daily use begins, and can begin
within a day after inhalation!
• There is no minimum requirement of number
smoked, frequency, or duration of use!
That First Puff…
• The nicotine in 1-2 puffs occupies 50% of nicotinic
receptors in the brain
• A single dose increases
– Noradrenaline synthesis in the hippocampus
– Neuronal potentiation lasting > month (meaning that
neurons discharge action potentials at lower
threshold)
What Can We Do?
Principles of Tobacco Dependence
Treatment
• Nicotine is addictive
• Tobacco dependence is a chronic
condition
• Effective treatments exist
• Every person who uses tobacco should be
offered treatment
Smokers Want to Quit
• 70% of tobacco users report wanting to quit
• Most have made at least one quit attempt
• Cite health expert advice as important
• Regardless of type! THIS MEANS YOU!
Pediatrician Intervention
is Important
• > 80% child exposure to tobacco in home is due to parental smoking
• Pediatricians see 25% of the population of smokers through child visits –
and smoking is highly heritable
• Many parents see their child’s health care provider more often than their
own (# QA increases with more episodes of advice)
• Counseling interventions in the pediatric office setting have been
successful:
– Decreased number of cigarettes smoked and home cotinine levels
– Increases in parent-reported smoke-free homes and parent-reported quit
rates
Counseling 101
• Patients and families expect you to discuss tobacco
use
• If counseling is delivered in a non-judgmental
manner, it is usually well-received
• Even small “doses” are effective - and cumulative!
• Strength of Evidence = A
Counseling IS Effective
• As little as 3 minutes of counseling doubles quit attempts
and successes
• Intensive counseling is more effective
– Dose-response relationship
• Most effective:
– Problem-solving skills
– Support from clinician
– Active referral
– Social support outside of treatment
How To Counsel
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
Ask: The Concept
• Ask about tobacco use and SHS exposure at every visit
– Include current tobacco use, SHS exposure
– If appropriate, ask about tobacco use prior to and during
pregnancy
• Make asking routine, consistent, and systematic
• Document as a “vital sign”
– Use standardized documentation
• Just asking can double quit attempts
We Can Learn Better
Ways to Ask
• “…if someone comes at you with an accusatory tone [you’re]
going to be defensive.”
• “…putting me down about it doesn't help. If they talk down to
me, making me feel small, it makes it so I don't want to quit.
It…makes me feel bad.”
When We Don’t Ask in the
Right Way…
• We elicit social desirability bias
• Parents may modify tobacco use reporting to
avoid lectures
– Not divulge “slips”
– Underreport tobacco use
– Modify where and when smoking occurs
Ask: How
• Say: “Does your child live with anyone who uses
tobacco?”
• Avoid judgement – check your body language, tone
of voice, the phrasing of the question
• Avoid leading: “You don’t smoke, do you?”
• Depersonalize the question
Ask:
If No One Uses Tobacco
• Explore: “You say no one smokes around your son.
What does that mean?”
• Congratulate and Document
Ask:
If Someone Uses Tobacco
•
•
•
•
“Who is it?”
“How do they use tobacco?”
“Where do they smoke?”
“Is that inside the house?”
– Many people perceive that smoking away from the
children is sufficient to protect them… or that a fan is
helpful…
If at First You Find No Smoking…
ASK NEXT TIME!
• Families who were initially identified as non-smoking on entry
to a practice were not asked again about smoking status (in
spite of a parent relapsing)
• Child Care situations are often in flux, so repeat the full ASK
step at all health care encounters…
Advise: The Concept
• Ask for permission to make suggestions and offer help
– “May I make a suggestion…?”
– Offer help – not “rules”
• Elicit ideas from the parent
• Offer alternatives or preparatory steps, such as making the
home and car tobacco free
• Help the parent to set their own goals for behavior change
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 parent or patient is in,
provide information about cessation to all tobacco users
The Stages of Change Model
Precontemplation
Behavior change
occurs in stages
– not all at once.
Contemplation
Relapse
Ready for Action
Maintenance
Action
Requirements for Change
X
Motivation
(Should I?)
=
Self-Confidence
(Can I?)
Commitment
(Will I?)
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….
Motivational Interviewing 101
Clinician view of patient change
•
A clinician views patient health behavior change from two
perspectives:
1.
Importance: a clinician has beliefs about health behavior
change counseling and his or her role in the process
2.
Confidence: a clinician has expectations about the power of
his or her skills to promote health behavior change
Low Importance - Low Confidence
10
Importance
Unaware or Cynical :
“It’s not my role to
counsel patients. Plus,
it’s too difficult to do this
kind of counseling.”
0
Confidence
10
High Importance - Low Confidence
10
Importance
0
Frustrated :
“I believe it is important
for me to help patients
change, but I don’t know
how to do it”
Confidence
10
Low Importance - High Confidence
10
Importance
Skeptical :
“I could work with
patients on behavior
change, but it’s just not
proven to work.”
0
Confidence
10
High Importance - High Confidence
10
Importance
0
Moving, Helping :
“I believe it is important
for me to work with
patients on health
behaviors no matter what
the obstacles are.”
Confidence
10
Importance - Confidence
10
Importance
0
Frustrated :
“I believe it is important
for me to help patients
change, but I don’t know
how to do it”
Moving, Helping :
“I believe it is important
for me to work with
patients on health
behaviors no matter what
the obstacles are.”
Unaware or Cynical :
“It’s not my role to
counsel patients. Plus,
it’s too difficult to do this
kind of counseling.”
Skeptical :
“I could work with
patients on behavior
change, but it’s just not
proven to work.”
Confidence
10
The Challenge
• People don’t follow physicians’ advice and recommendations
– 50% don’t follow long term medication regimens
– Many don’t follow advice to change health behavior
• Patients often do not recall anticipatory advice given
Research has shown:
• Clinician-patient interactions influence the behavior
change process.
• When given the tools to help motivate patients to
change health behaviors, good doctors become even
more effective.
• When patients arrive at action plans that fit within their
personal goals and values, change is more likely.
Motivational Interviewing (MI):
Key Elements
• Use key counseling skills (open ended questions, reflective
listening, empathy)
• “Roll with resistance”
– The MI encounter resembles a dance rather than a wrestling match
Assess importance and confidence
• Develop discrepancy between the patient’s goals and current
behaviors
• Support patient’s change efforts
Overview of the MI Encounter
• Set the agenda
– Collaborative process
• Use key counseling skills to understand the patient’s experience
• Determine importance and confidence
• Enhance importance and confidence
• Elicit patient’s “change language”, reinforce it, and build on it
• Help patient develop action steps
Agenda Setting
• Elicit items patient wishes to discuss
– “What were you hoping to talk about today?”
– Always ask permission before discussing a topic
• Raise items you wish to discuss and ask permission
– “I’m concerned about your child’s frequent asthma attacks. Would it be
okay if we talked about it today?”
• Prioritize multiple concerns
• Agree on what you’re going to talk about
Key Counseling Skills:
Open-Ended Questions
• Goal-understand meaning rather than collect facts
• Use “How” and “What” questions
– Caution: “Why” questions can sound judgmental
• Examples:
–
–
–
–
Tell me about…
Could you help me understand more about…
What have you tried before?
How was that for you?
Key Counseling Skills:
Reflective Listening
• Listening is often considered the passive part of
conversation
• Reflective listening is an active process
• Reflect the meaning of what your patient said
• Every reflection opens a possibility
– The patient may verify, correct, add to, or refine their message
– The clinician can clarify, correct misinterpretations, and learn
about their own assumptions and distortions
Key Counseling Skills:
Reflective Listening (continued)
• Stems:
–
–
–
–
–
–
It sounds like you…
So what I hear you saying is…
You’re wondering if…
You feel…and that makes you want to…
It seems like…
You are…
Practice Exercise 1: Open-Ended Inquiry &
Reflective Listening
Task: In groups of 3, practice using open-ended inquiry
and reflective listening skills
– Interviewer: Interview your colleague about something
he/she has been motivated to do
– Interviewee: Tell your story
– Observer: Observe and jot down open-ended questions and
reflections that the interviewer uses
You will have 3 minutes to conduct each interview, then get
2 minutes of feedback from observer, then rotate!
Key Counseling Skills:
Expressing Empathy
• Empathy:
– Understand the experience of another at a deeper level
– Acknowledge and value the other person’s perspective and feelings
– Empathy communicates to your patient that what they say, think, and
feel is important to you.
• Empathy is NOT:
– Sympathy - Shared suffering
– Pity - A condescending relationship which separates physician and
patient
– Reassurance
Key Counseling Skills:
Expressing Empathy
• “You seem pretty frustrated”
• “So you’re just not sure what to do next.”
• “So you really want to change your eating habits, but its
overwhelming because you’re not sure where to start.”
• “Most people I know would feel anxious in that situation.”
• “It sounds like deciding to take that first step is a little scary for
you.”
Practice Exercise 2:
Expressing Empathy
Task: In groups of 3, develop an understanding of the
interviewee’s perceptions about working with a challenging
patient
– Interviewer: Practice open-ended inquiry, reflective listening skills,
and expressing empathy
– Interviewee: Share your story
– Observer: Observe and jot down examples of open-ended inquiry,
reflective listening and empathic communication
You will have 3 minutes to conduct each interview, then get
2 minutes of feedback from observer, then rotate!
Exchanging Information vs.
Advice on Empty Ears
•
Exchanging information is different from advice, which is a
one-way process
•
Always ask permission before giving information
•
Elicit-Provide-Elicit Process
– ELICIT interest
• “Would you like to know more about…?”
– PROVIDE feedback neutrally
• “What happens to some people is…Other people find…”
– ELICIT the patient’s interpretation and follow it
• “What do you make of this?”
• “How do you see the connection between smoking and your health?”
Assessing Importance and Confidence
• Goal: Understand how the patient feels and
thinks about changing their current behavior
• Strategy: Scaling questions
• In order to move toward change, the patient may
need to:
– Further explore the importance of change
– Build the confidence to undertake change
– Enhance both importance and confidence
Assessing Importance
Not at all
important
0 1 2 3 4 5 6 7 8 9 10
Extremely
important
• “On a scale of 0 to 10, how is important is it to you to
_________ (make this change)?
• “What makes you say a 5?”
• “What led you to say 5 and not zero?”
• “What would it take to move it to a 6 or a 7?”
• “What could I do to help you make it a 6 or 7?”
Strategies for Enhancing Importance:
Examining Pros and Cons
• Examining pros and cons gives a lot of information about
how the patient views the issue (Ex.: all cons and no pros)
• Patients often experience ambivalence about the value of
change
– There are costs and benefits to changing as well as staying the
same
– New behaviors can be hard to do
• There are 2 ways of examining pros/cons:
– Look at the current behavior
– Look at change
Current Behavior
Change
Pros
Pros
“What are some of the good things about
eating so much junk food?”
“What are some of the good things about
changing the way you eat?”
I like how it tastes
If lose weight, will feel more attractive
Going out with my friends-we like to hang out It would be easier to fit into the kinds of clothes I
at McDonalds
want to wear
I’d feel good about accomplishing it
Cons
Cons
“What are the not so good things about
eating junk food?”
“What are some of the not so good things about
changing the way you eat?”
I don’t like how I look-I think its making me
heavy and it also make my skin greasy
I’d have to think about what I can and can’t eat
all of the time
I can’t run as well as I used to, so I’m doing
badly on my field hockey team
I’d have to give up my favorite junk food
It would be hard to go out with my friends
How would you summarize both sides of what you hear?
Responding to Ambivalence
• Return to a reflective statement
• Double-sided reflection
– “So, on the one hand…while on the other hand…”
• Roll with resistance
– Patient: “I know you expect me to quit eating all the things I like. I want
to lose weight, but I don’t plan on sticking to some strict diet where you
can only eat salad!”
– Clinician: “A lot of people feel the same way you do when they start
thinking about changing the way they eat. Tell me more about your
concerns.”
Assessing Confidence
Not at all
confident
0 1 2 3 4 5 6 7 8 9 10
Totally
confident
• “On a scale of 0 to 10, how confident are you that you can
_______ (make this change)?
• “What makes you say a 6?”
• “What led you to rate your confidence 6 and not 2?”
• “What would help you move your confidence from a
6 to a 7 or 8?”
Strategies for Enhancing Confidence
• Recall times in the past when the patient has been
successful making changes
– Explore role of family and peers in supporting change
– Affirm persistence-often many attempts
• Break it down
– Define small, realistic, and achievable steps
• Identify specific barriers and problem-solve
– “What might get in the way?”
– “What might help you get past that?”
– “Here’s what others have done.”
The Ingredients of Readiness to Change
Importance
(Why should
I change?)
Readiness
Confidence
(Can I do it?)
Change Talk
• Change talk includes desire, ability, reasons, need
–
–
–
–
“I really want to start eating healthier”
“I’m sure that I can turn the TV off after school”
“I need to cut back on junk food because I am starting to gain weight”
“It’s important for me to take my asthma medicine”
• Listen carefully for change talk throughout the interview
• Acknowledge, appreciate, affirm, and express support for
change talk
How Do We Help the Patient Turn
Interest Into Action?
• Most people need help picking one do-able step that’s not
too big
• More likely to be successful if they come up with the options
rather than you
– You can prime the pump if they are stuck
– Limit the number of changes to be attempted
• Convey optimism and belief in their strengths
• Write it down for the patient
The Paradox of Change
When a person feels accepted for who they are and
what they do-no matter how unhealthy-it allows
them the freedom to consider change rather than
needing to defend against it.
Assess Readiness for Change
• Ask permission:
– “Would it be okay if we spent a few minutes talking about _____?”
• Understand their view of the problem. (“Tell me…”) :
• Ask about readiness:
– “On a scale of 0-10, how ready are you to consider ____?”
• Ask scaling questions:
– Backward: “What makes it a 5 and not a 2?”
– Forward: “What would help you move it from a 5 to a 7?”
Assess Readiness (continued)
• Pay attention to change talk
– Change talk includes desire, ability, reasons, need
– Change talk give clues about readiness to change
– People are more persuaded by what they hear themselves say than by
what someone tells them Summarize change talk
• Confirm:
– “Did I get it all?”
• Ask about the next steps:
– “Where does _______ fit into your future?”
• Show appreciation:
– “Thank you for your willingness to talk about ___ with me.”
• Voice confidence:
– “I’m confident that if and when you make a firm decision and
commitment to ___ you will find a way to do it.”
Ready for Action?
• Not ready to attempt change
– Goal: Raise awareness
– Tasks: Inform & encourage
• Unsure about change
– Goal: Build importance and/or confidence
– Tasks: Explore ambivalence
• Ready for Action
– Goal: Agree on action steps and strategies
Not Ready - Inform & Encourage
• Always ask permission before giving information
• Elicit-Provide-Elicit Process
– ELICIT interest
• “Would you like to know more about…?”
– PROVIDE feedback neutrally
• “What happens to some people is…Other people
find…”
– ELICIT the patient’s interpretation and follow it
• “What do you make of this?”
• “How do you see the connection between smoking
and your health?”
Unsure - Explore Ambivalence
• Ask permission
– “It seems that you have a lot of thoughts about this, Can we talk a little more
about it?”
• Ask “disarming” open-ended question:
– “What are some of the advantages for keeping things just the way they are?”
• Ask “reverse” open-ended question:
– “On the other hand, what are some of the reasons for making a change?”
• Summarize both sides of ambivalence
– Start with the reasons for not changing, followed by reasons for changing
Unsure - Explore Ambivalence (cont.)
• Ask about the next step:
– “What’s the next step, if any?”
• Show appreciation:
– “Thank you for your willingness to talk with me about _____.”
• Voice confidence:
– “I’m confident that if and when you make a firm decision and commit
to making a change, you’ll find a way to do it.”
Ready - Agree on Action Steps
• Many people need help picking one do-able step that’s not
too big
• People are more likely to be successful if they come up with
the options rather than you
– You can prime the pump if they are stuck
– Involve both mother and child
• Show appreciation
• Convey optimism and belief in their strengths
• Write down one simple next step
What if the Patient Can’t Come up With
Any Ideas?
• Ask permission:
– “If you’re interested, I have an idea for you to consider. Would you like
to hear it?”
• Offer advice:
– “Based on my experience, I would encourage you to consider
_________.”
• Emphasize choice:
– “Of course, it is totally up to you.”
• Elicit response:
– “What do you think about this idea?”
Recap of the MI Encounter
• Set the agenda
– Collaborative process
• Use key counseling skills to understand the patient’s experience
• Determine importance and confidence
• Enhance importance and confidence
• Elicit patient’s “change language”, reinforce it, and build on it
• Help patient develop action steps
Back to Tobacco: YOUR Agenda
• 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
Prescribe or provide information about pharmacotherapy
Help the parent set a quit date
Document your advice
What Do You Say?
• Clear: “I strongly advise you to quit smoking.”
(ok, it’s a one-way statement…but important to say!)
• Strong: “Eliminating smoke exposure of your son is one of the
most important things you can do to protect his health.”
• Personalized: Emphasize the impact on health, finances, the
child, family, or patient.
“Smoking is harmful for you (and your child/family). I can help
you quit.”
An Intermediate Goal
• “Secondhand smoke is harmful 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
What you may hear: Rationalization
• No one wants to believe that they’re hurting their child
– “…if she is there and we are smoking outside at least it's very
open.”
– “Our daughter never goes in that room. We have a fan and a
window and we leave the fan on when we’re smoking.”
– “There is no smoking allowed anywhere near my house, my
husband and I take turns going downstairs.”
Be Specific…
• Remember MI: Ask Permission to give this advice, or it may
fall on deaf ears…
– “There are some things that may be helpful to know about what it
means to have a Smoke Free Home. Can I go through them with you?”
• Having a Smoke Free Home means no smoking ANYWHERE
inside the home or car!
• It DOES NOT mean smoking:
– Near a window or exhaust fan
– In the car with the windows open
– In the basement
– Inside only when the weather’s bad
– Cigars, pipes, or hookahs
– On the other side of the room
Help With Challenges
• Tobacco Use can be a source of family discord
– Smoking by a household member can be a source of
tension
– Not always identified by the parent as a barrier
• Moms are more often the “gatekeepers” for maintaining a
smoke free home
– BUT, they may not be willing to risk a relationship
– Want to maintain peace, may rationalize the risk
Help With Challenges
• Strategize with the parent about ways to deliver the “you
can quit” and “our home and car should be tobacco free”
messages
• Some parents would like to have a Smoke Free Home and
car, but do not feel like they have the POWER to set this
rule.
– ASK if they can set a firm, 100% Smoke Free Rule
– If they don’t have the power, ASK if a note from you
will help!
Assist Through Pharmacotherapy*
• Everyone who uses tobacco should be offered
pharmacotherapies
– Recommend and discuss use
• Many are OTC
– Prescribe if possible
• Even if OTC
• Some Medicaid plans require prescription for reimbursement or
coverage
*More on pharmacotherapies in 5 minutes…
Assist by Following Up
• Plan to follow up on any behavioral commitments made –
they are beginning a process of change!
– Just asking at the next visit makes a big impression
– Need to monitor and reinforce behavior change
• 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: ____ Quitline Referral
• List services, phone number, website, logo, etc. for
that state’s quitline
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.”
• “We’ve got a great state quit line. If you go on line and click a
button, they call YOU back right away!”
Close on Good Terms
• Offer praise and encouragement
– Earnestly praise for work done
• Summarize your patient’s view on importance
and confidence
• Emphasize any agreement that was reached
7th Inning Stretch…
Cessation Pharmacology 101
Everyone Stand Up and STRETCH….
Medications Work!
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
Tobacco Dependence
• Adolescents experience symptoms of nicotine
dependence and withdrawal even prior to becoming daily
smokers, and after exposure to only low doses of nicotine!
• Effects associated with dependence:
–
–
–
–
–
–
Increased numbers of brain nicotine receptors
Changes in regional blood glucose metabolism
EEG changes
Release of catecholamines
Tolerance
Physiological dependence
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)
NRT
• Non-nicotine components of tobacco cause
most of the adverse health effects
– Tars, carbon monoxide, etc.
• The benefits of NRT outweigh the risks, even
in smokers with cardiovascular disease
(remember they already smoke!)
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 Polacrilex Gum (OTC)
Dosage
– CPD < 25 use 2 mg, CPD  25 use 4 mg, Use enough (guidelines), 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 Transdermal Patch (OTC)
Dosage
– 21mg, 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
Nicotine Lozenge (OTC)
Dosage
– 2 mg, 4 mg; 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
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
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
Bupropion SR (Zyban®)
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
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
Combining Nicotine Replacement
• OTC: Gum, Patch, Lozenge
• RX: Inhaler, Nasal spray
• May use together
– E.g., patch for maintenance, gum or lozenge for strong urges
• May be used with Zyban; nausea may be severe if used with
Chantix
• READ AND FOLLOW INSTRUCTIONS!
Pharmacotherapy Comparison
Characteristics
Onset of
action
Frequency of
doses/24hrs
Effort required
Patch
2-12 hr
1
Low
Gum/Lozenge
10 min
9-20
High
5-10 min
13-20
Mod
Inhaler
15 min
6-16
High
Bupropion
1 week
2
Low
Varenicline
1 week
2
Low
Therapy
Spray
Pharmacotherapy Comparison
Characteristics
Availability
Flexible
dosing
Breaks habit
Patch
OTC
No
Yes
Gum/Lozenge
OTC
Yes
No
Spray
Rx
Yes
No
Inhaler
Rx
Yes
No
Bupropion
Rx
No
Yes
Varenicline
Rx
No
Yes
Therapy
Adverse Effects and Contraindications
Product
Adverse Effects
Possible Contraindications
Patch
Skin irritation, insomnia
*Immediate post MI or
unstable angina
Gum/lozenge
Mouth soreness, dyspepsia
Same
Nasal spray
Nasal irritation, sneezing
Same
Inhaler
Coughing, throat irritation
Same
Bupropion
Insomnia, dry mouth,
headaches
Eating disorder, seizure
disorder, MAO inhibitor use
Varenicline
Nausea, nightmares,
agitation, depression?
suicidal ideation?
*Schizophrenia, bipolar
disorder, and major
depressive disorder
Estimated Cost Per Day
Pharmacotherapy
Smoking
Patch
$3.00
1 pack
$5.50
Bupropion
$3.23 to $7.00
1 ½ packs
$8.25
Varenicline
$4.36
2 packs
$11.00
Gum/Lozenge
$3 to $6.50
2 ½ packs
$13.75
Spray
$5.00
3 packs
$16.50
Inhaler
$10.00
More Role Playing Exercises
The Rules
• Role playing exercises can help you become
“comfortable” with new language
• Role playing exercises DON’T work if you DON’T
say the words out loud
• Be silly. Have fun!
Break into Groups of 3
• Using the guidelines listed on your handout and
what you’ve learned today, take turns as the
“clinician” and “patient” or “parent”, and
observer
• Create your own scenarios, but be sure to stay
within the guidelines of motivational interviewing
to elicit information from the patient
Motivational Interviewing
• http://www.motivatehealthyhabits.com/
– Rick Botelho is a family doc who does a fabulous job
• http://www.motivationalinterview.org/
– The website for motivational interviewing trainers; many
good resources from the psychology literature
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??
Skull of a Skeleton with
Burning Cigarette
Antwerp 1885-1886
Van Gogh Museum
Amsterdam