Transcript Smoking Cessation Training, Al Ain 21 September 2011

Management of Tobacco Addiction
Dr. Ahmed Yousif Ali , MRCPsych, UK
Head of Psychiatry ,Consultant Psychiatrist National Rehab Center , Abu
Dhabi , UAE
Editor, Journal of Substance Abuse Treatment , USA
Member of American Society of addiction Medicine
Member of International Society of Addiction Medicine
Prepared for HAAD CME Accreditation August 2011
objectives
Nicotine pharmacology and neurobiology
of addiction.
 Health effects of smoking and benefits of
quitting.
 Assessment and monitoring
 Helping patients quit : Motivational
interviewing & relapse prevention.
 Pharmacological interventions.

Nicotine & Its Principal Metabolites
NEUROCHEMICAL and RELATED
EFFECTS of NICOTINE
N
I
C
O
T







Dopamine
Norepinephrine
Acetylcholine
Glutamate
Serotonin
-Endorphin
GABA







Pleasure, reward
Arousal, appetite suppression
Arousal, cognitive enhancement
Learning, memory enhancement
Mood modulation, appetite suppression
Reduction of anxiety and tension
Reduction of anxiety and tension
I
N
E
Benowitz. (1999). Nicotine Tob Res 1(Suppl):S159–S163.
•Dopamine
Medial Forebrain Bundle “I feel good”
•Acetylcholine
•Serotonin
Anti-depressant
•Epinephrine
Adrenal gland
Ventral Tegmental Area
http://www.nida.nih.gov/researchreports/nicotine/nicotine3.html#how
NICOTINE
PHARMACODYNAMICS
Nicotine binds to receptors in
the brain and other
sites in the body.
Cardiovascular system
Gastrointestinal system
Other:
Neuromuscular junction
Sensory receptors
Other organs
Central nervous system
Exocrine glands
Adrenal medulla
Peripheral nervous system
Nicotine has predominantly stimulant effects.
NICOTINE EXCRETION


Half-life
 Nicotine t½ = 2 hr
 Cotinine t½ = 19 hr
Excretion
 Occurs through kidneys (pH dependent;
h with acidic pH)
 Through breast milk
NICOTINE ABSORPTION:
BUCCAL (ORAL) MUCOSA
The pH inside the mouth is 7.0.
Acidic media
(limited absorption)
Alkaline media
(significant absorption)
Cigarettes
Pipes, cigars,
spit tobacco,
oral nicotine products
Beverages can alter pH, affect absorption.
NICOTINE DISTRIBUTION
Nicotine reaches the brain within 11 seconds.
Plasma nicotine (ng/ml)
80
Arterial
70
60
50
40
30
Venous
20
10
0
0
1
2
3
4
5
6
7
8
9
10
Minutes after light-up of cigarette
Henningfield et al. (1993). Drug Alcohol Depend 33:23–29.
NICOTINE
PHARMACODYNAMICS:
WITHDRAWAL EFFECTS

Depression

Insomnia

Irritability/frustration/anger

Anxiety

Difficulty concentrating

Restlessness

Increased appetite/weight gain

Decreased heart rate

Cravings*
* Not considered a withdrawal symptom by DSM-IV criteria.
Most symptoms
peak 24–48 hr
after quitting and
subside within
2–4 weeks.
HANDOU
T
American Psychiatric Association. (1994). DSM-IV.
Hughes et al. (1991). Arch Gen Psychiatry 48:52–59.
Hughes & Hatsukami. (1998). Tob Control 7:92–93.
What’s in a Cigarette?

Tobacco smoke: ~4000 chemicals, ~250 toxic
or carcinogenic1
Chemical in tobacco smoke2
Also found in
Acetone
Paint stripper
Butane
Lighter fluid
Arsenic
Ant poison
Cadmium
Car batteries
Carbon monoxide
Toluene

Car exhaust fumes
Industrial solvent
Smoking cigarettes with lower tar and
nicotine provides no clear health benefit3
1. National Toxicology Program. 11th Report on Carcinogens; 2005. Available at: http://ntp-server.niehs.nih.gov.
2. Mackay J, Eriksen M. The Tobacco Atlas. 2nd ed. Atlanta, American Cancer Society; 2006.
3. The Health Consequences of Smoking: A Report of the Surgeon General. Washington, DC, US Department of Health and Human Services; 2004. Available at:
http://www.surgeongeneral.gov/library/smokingconsequences/.
WHAT IS ADDICTION?
”Compulsive drug use, without
medical purpose, in the face of
negative consequences”
Alan I. Leshner, Ph.D.
Former Director, National Institute on Drug Abuse
National Institutes of Health
How Many Of These
Illicit drugs Users
Eventually Develop The
Dependence Syndrome?
Inhalant
drugs, 1 in 20
Psychedelic
drugs, 1 in 20
Analgesic
Drugs, 1 in 11
Anxiolytic,
sedative, &
hypnotic
drugs, 1 in 11
Tobacco, 1 in 3
Estimated
fraction
of drug users
who have
become
drug
dependent
Cannabis,
1 in 9-11
Heroin, 1 in 4-5
Crack + HCl, 1 in 5 (??)
Cocaine HCl, 1 in 6
Alcohol, 1 in 7-8
Stimulants other
than cocaine, 1 in 9
(Adapted from Anthony et al., 1994; Chen & Anthony, 2004)
NICOTINE ADDICTION
 Tobacco
users maintain a minimum serum nicotine
concentration in order to
◦ Prevent withdrawal symptoms
◦ Maintain pleasure/arousal
◦ Modulate mood
 Users
self-titrate nicotine intake by
◦ Smoking/dipping more frequently
◦ Smoking more intensely
◦ Obstructing vents on low-nicotine brand cigarettes
Mechanism of Action of Nicotine in the
Central Nervous System
2 2
a4 2 a4
a42
nicotinic
acetylcholi
ne
receptor
(nAChR)
Nicotine binds preferentially to nAChRs in the central nervous system;
one key area is the α4β2 nicotinic receptor in the VTA
 After nicotine binds to the α4β2 nAChR in the VTA, dopamine is released
in the nAcc which is believed to be linked to reward

Picciotto MR et al. Nicotine Tob Res 1999; 1(Suppl 2):S121-5.
Natural Rewards Elevate Dopamine Levels
200
% of Basal DA Output
NAc shell
150
100
50
0
Empty
Box Feeding
200
‫ الجنس‬SEX
150
100
15
10
5
0
0
60
120
Time (min)
Source: Di Chiara et al.
180
ScrScr
BasFemale 1 Present
Sample 1 2 3 4 5 6 7 8
Number
Scr
Scr
Female 2 Present
9 10 11 12 13 14 15 16 17
Mounts
Intromissions
Ejaculations
Source: Fiorino and Phillips
17
Copulation Frequency
DA Concentration (% Baseline)
‫ الغذاء‬FOOD
‫األمفيتامين‬
DA
DOPAC
HVA
0
1
2
3
4
Time After Amphetamine
Accumbens
Caudate
150
100
0
1
2
3 hr
‫الكوكايين‬
DA
DOPAC
HVA
200
100
250
% of Basal Release
200
Accumbens
300
0
5 hr
‫النيكوتين‬
250
0
400
% of Basal Release
Accumbens
1100
1000
900
800
700
600
500
400
300
200
100
0
% of Basal Release
% of Basal Release
‫تأثير المواد االدمانية على مستوى الدوبامين‬
0
1
2
3
4
Time After Cocaine
Accumbens
5 hr
‫الكحول‬
Dose (g/kg ip)
200
0.25
0.5
1
2.5
150
100
0
Time After Nicotine
Source: Di Chiara and Imperato
0
1
2
3
Time After Ethanol
4hr
18
Partial Recovery in an Abstinent
Partial Recovery of Brain Dopamine
Transporters
Methamphetamine
Abuser
in Methamphetamine Abuser
after Long Abstinence
3
0
ml/gm
Abuser
Normal Control Normal Control MethMETH
Abuser
1 month detox
1 month detox
METHSame
Abuser
2 years detox
Source: Volkow et al (2001) J Neurosci 21:9414-8
Volkow et al (2001) J Neurosci 21:9414-8
Meth Abuser
2 years detox
CHRONIC ADMINISTRATION of
NICOTINE: EFFECTS on the BRAIN
Human smokers have increased nicotine
receptors in the prefrontal cortex.
High
Low
Nonsmoker
Smoker
Image courtesy of George Washington University / Dr. David C. Perry
Perry et al. (1999). J Pharmacol Exp Ther 289:1545–1552.
DSM IV Definition of Tobacco Dependence
Tolerance.
Withdrawal. Requires daily use for at least
several weeks. A minimum of 4 withdrawal
symptoms are required. The withdrawal
symptoms must "cause clinically significant
distress or impairment in social, occupational,
or other important areas of functioning."
 The substance is used in larger amounts or over
a longer period than was initially intended.
 Unsuccessful efforts to cut down, regulate, or
discontinue use.


21
DSM IV Definition of Tobacco Dependence (con’t)
A great deal of time spent obtaining the
substance, using the substance, or recovering
from its effects.
 Important social, occupational, or recreational
activities may be given up or reduced because
of substance use.
 Substance use continues despite the individual's
realization that the substance is contributing to
a psychological or physical problem.
 (3 or more criteria must be met for diagnosis of
tobacco dependence)

22
Emotional Components

After repeated use, tobacco is used as
primary emotional coping strategy
◦
◦
◦
◦
◦
◦
Depression, sadness
Anxiety, nervousness, stress
Boredom
Fatigue, hunger
Reward for task completion
Make good feelings last longer
Behavioral components

With repeated pairing tobacco use
becomes associated with environmental
triggers:
◦
◦
◦
◦
◦
◦
Drinking coffee and alcohol
Driving
Taking breaks
After meals
After sex
Starting and completing tasks
Framework Convention on Tobacco
control (FCTC).
In an effort to co-ordinate the international responses to combat the
tobacco epidemic, the World Health Organization (WHO) succeeded in
2002 to get 168 out of its 192 member states to sign the world’s first
global public health treaty, the Framework Convention on Tobacco control
(FCTC).
Further, the treaty came into force in 2005 with 156 member states becoming
parties to the convention. 2
Numerous efforts have looked at tobacco control policies before and after
the (FCTC), and the consensus opinion of features of a comprehensive
policy are:
 Should target prevention of use in youth and young adults
 Should be broad to allow for each county’s diversity of cultural, social,
political and economic factors.
 Should include a wide range of interventions.
 Should secure public support through education, awareness campaigns and
other pressure groups and other strategies.
 Should look at measures to decrease demand and also reduce supply of
tobacco products and installing the mechanisms to protect the
environment.

The Law in UAE

federal law no 15 of 2009 banning import of tobacco
and its by-products into the country unless specific
standard requirements accredited in the UAE are
met.
The law also prohibits smoking on modes of public
transport and public closed places. Under the
provisions of the law, no license will be issued to cafes
or similar outlets serving any types of tobacco or its
products inside residential buildings or quarters or
near them. Smoking will also be banned during vehicle
driving in the company of a child under 12 years.
The law sets a series of penalties against offenders
reaching in some cases up to Dh 1 million in addition
to a jail term of not less than two years.
Objectives: smoking cessation
pharmacology and neurobiology of
nicotine addiction.
 Health effects of smoking and benefits of
quitting.
 Assessment and monitoring
 Helping patients quit : Motivational
interviewing & relapse prevention.
 Pharmacological interventions.

Mechanisms of Action:
How Smoking Causes Disease

Lung cancer
◦ Direct interaction of respiratory cell DNA to exposure of potent
mutagens and carcinogens in tobacco smoke

Ischemic heart disease
◦ Toxic products in the bloodstream create a
pro-atherogenic environment
◦ Smoking leads to endothelial injury and dysfunction, thrombosis
and inflammation

COPD (i.e., emphysema, chronic bronchitis
or both)
◦ Accelerated decline in respiratory function
DNA = deoxyribonucleic acid; COPD = chronic obstructive lung disease
The Health Consequences of Smoking: A Report of the Surgeon General. Washington, DC, US Department of Health and Human Services; 2004. Available at:
http://www.surgeongeneral.gov/library/smokingconsequences/.
Sir Richard Doll
1950 study linking smoking
to lung cancer
 1954: Doll and Hill
published “The Mortality of
Doctors and Their Smoking
Habits” in BMJ (lead to
most M.D. giving up
smoking)
 Follow-up study in 2004

◦ ½ - 2/3 of all individuals who
begin smoking in youth will die
because of it
Cancer Death Rates*, for Men, US,1930-2003
Rate Per 100,000
100
Lung
80
60
Stomach
Prostate
Colon & rectum
40
Pancreas
20
*Age-adjusted to the 2000 US standard population.
US Mortality Public Use Data Tapes 1960-2003, US Mortality Volumes 1930-1959,
National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.
2000
1995
1990
1985
1980
1975
1970
1965
Liver
1960
1955
1950
1945
1940
1935
0
1930
Leukemia
What does secondhand
smoke do?





Lung cancer risk estimated to increase by 20% to 30%1
Believed to worsen diseases such as asthma, COPD
and emphysema2
Increases risk for developing heart disease by 25% to 30%1
Increases risk of non-fatal acute MI in a graded manner to exposure3
In infants and children, secondhand smoke:
◦ Causes middle-ear infections2
◦ Induces and exacerbates asthma and respiratory problems2
◦ Increases disease burden and hospitalization4-6
◦ Can have deleterious affects on hemoglobin and coronary arteries2
◦ Has been linked to sudden infant death syndrome2
MI = myocardial infarction
News release, June 27, 2006; US Department of Health and Human Services. Available at: http://www.hhs.gov/news/press/2006pres/20060627.html.
Mackay J et al. The Tobacco Atlas. 2nd ed. Atlanta, American Cancer Society; 2006.
Teo KK et al. Lancet 2006; 368(9536):647-58.
Fagerström K. Drugs. 2002; 62(Suppl 2):1-9.
Leung GM et al. Arch Pediatr Adolesc Med 2004; 158(7):687-93.
Objectives: smoking cessation
pharmacology and neurobiology of
nicotine addiction.
 Health effects of smoking and benefits of
quitting.
 Assessment and monitoring
 Helping patients quit : Motivational
interviewing & relapse prevention.
 Pharmacological interventions.

Quitting at Any Age May Increase Life Expectancy Age
Stopped Smoking:
35-44 Years Old
Results from a Study of Male Physician Smokers in the UK
Nonsmok
ers
Age stopped: 35–44
Cigarette
smokers
Percentage
survival from age
40
100
90
80
70
60
50
40
30
20
10
0
40
50
60
70
Age (years)
Quitting sooner appears most beneficial
UK = United Kingdom
Doll R et al. BMJ 2004; 328(7455):1519-27.
80
90
100
Health Benefits of Quitting
Smoking Start Immediately1
Time
After Quitting
15 years
CHD risk same as
a nonsmoker`
20 minutes
Heart rate drops
10 years
Lung cancer death rate
half that of smoker;
decreased risk of mouth,
throat, oesophagus,
bladder, kidney and
pancreas cancer
12 hours
Blood CO levels
return to normal
2 wks – 3 mo
Heart attack risk begins to
drop, lung function
increases
1 year
1 – 9 months
Excess CHD risk half
that of a smoker
Coughing and shortness of
breath decrease
1. US Department of Health and Human Services. The health consequences of smoking: What
it means to you. US Department of Health and Human Services, Centers for Disease 35
Why Quit?
Potential Health Benefits of Quitting Smoking
Coronary artery disease risk is similar to never smokers
Lung cancer risk is 30% to 50% that of continuing smokers
Stroke risk returns to the level of people who have never
smoked at 5 to 15 years post-cessation
Coronary artery disease: excess risk is reduced by
50% among ex-smokers
Guide to Quitting Smoking. American Cancer Society. Available at: http://www.cancer.org.
The Health Consequences of Smoking: A Report of the Surgeon General. Washington, DC, US Department of Health and Human Services;
2004. Available at: http://www.surgeongeneral.gov/library/smokingconsequences/.
15 years
10 years
5 years
1 year
3
months
Cessation
Lung function may start to improve with
decreased cough, sinus congestion, fatigue
and shortness of breath
Objectives: smoking cessation
pharmacology and neurobiology of
nicotine addiction.
 Health effects of smoking and benefits of
quitting.
 Assessment and monitoring
 Helping patients quit : Motivational
interviewing & relapse prevention.
 Pharmacological interventions.

Initial Intake Questions
Smoking history
◦ How long have you been smoking?
◦ How much do you smoke?
◦ Ever tried to quit?
◦ Used anything to help you quit?
◦ Longest you’ve ever been quit?
 Motivation level
◦ On a scale of 1-10, with 10 being most ready to quit, where would you
say you are?***
◦ Would you be willing to set a quit day in the next 30 days?
*** If 5 or below, probe further:
If you weren’t at all concerned that you might not be successful
at quitting, would that number change?
 Program description
 Discussion of possible medications
◦ Motivation levels can change after patients hear about the program

38
Assess Motivation and Readiness
to Change
Precontemplation
Doesn't acknowledge behaviour
as a problem. Unwilling to change.
Contemplation
Relapse
Lapses and conducts
self-reflection.
Stages of Change Model
Maintenance
Sustains the changed
behaviour and tries to
avoid relapse.
Preparation
Action
Puts a plan into motion.
Takes personal ownership
of the change.
Prochaska JP et al. Am Psych 1992; 47(9):1102-14.
Zimmerman GL et al. Am Fam Physician. 2000; 61(5):1409-16.
Understands the need
to modify behaviour.
Willing to change,
but ambivalent.
Develops a plan to
make a change.
Fagerström test for nicotine dependence
Score:
3
2
1
0
<5
5 –30
31- 60
>60
2. Do you find it difficult not to smoke
where you shouldn’t - such as bus or
school
Yes
No
3. Which cigarette would you most hate
to give up?
First
Any
other
11 –
20
<10
5. Do you smoke more frequently during
the first hours after waking up?
Yes
No
6. Do you still smoke if you are so sick
that you are in bed most of the day?
Yes
No
1. Time to first cigarette after waking
(minutes)
4. How many cigarettes do you smoke
each day?
>31
21- 30
Multiple Quit Attempts
May Be Necessary

More than 70% of US smokers want to quit1
◦ Approximately 44% try to quit each year
◦ Only 4% to 7% who try to quit achieve abstinence

Similar percentages in countries with established tobacco control
programmes (e.g., Australia, Canada, UK)2
◦ 30% to 50% try to quit; <5% achieve long-term
abstinence unaided
Most smokers will attempt to quit 6 to 9 times in their lifetimes3
 Some smokers succeed after making several attempts4

◦ Past failure does not prevent future success
◦ Length of prior abstinence is related to quitting success
1. Fiore MC et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update.
US Department of Health and Human Services. Public Health Service; 2008. Available at: www.surgeongeneral.gov/tobacco/default.htm.
2. Foulds J et al. Expert Opin Emerg Drugs 2004; 9(1):39-53.
3. Women and Smoking: A Report of the Surgeon General. Washington, DC, US Department of Health and Human Services; 2001. Available at:
http://www.surgeongeneral.gov/library/womenandtobacco/.
4. Grandes G et al. Br J Gen Pract 2003; 53(487):101-7.
CO Monitors

Available in several models at various price
ranges (www.bedfont.com)
Bedfont Micro 4
The Micro™ has become the clinically proven worldwide benchmark for
breath CO monitors. It provides a digital read-out of COppm on an easy to
read LCD display together with simple traffic light LEDs and an audible
tone.
The superior sensor and low cross-interference from hydrogen make the
Micro™ ideal for clinical trials and research.
Bedfont Pico
Low cost and visually motivational, the piCO+™ is a leader in a new
generation of breath CO monitors. The monitor has user profiles for
adult smokers, young smokers and pregnant women, as well the ability
to easily create custom profiles when used alongside the COdata+ PC
software, making it a favourite with group smoking cessation clinics
.
42
Rationale for CO Monitoring
Carbon monoxide is an odorless and colorless
gas, that when inhaled combines with
hemoglobin to form carboxyhemoglobin
(COHb), reducing oxygen levels in the blood
 End-expired breath CO, as measured by parts
per million, relates directly to blood levels of
COHb (%).
 Clinical studies have identified the typical levels
of exhaled CO that differentiate smokers from
non-smokers
 Breath CO testing takes about 1 minute.

43
Advantages of CO Monitoring
Motivational tool as it gives smokers a quick,
individualized indicator of the harmful effects of
smoking on their cardiovascular system
 Fantastic reinforcement for abstinence as level
returns to normal within about 24 hours of
quitting smoking
 Biochemical verification of self-reported
abstinence for clinical and research use

44
Objectives: smoking cessation
pharmacology and neurobiology of
nicotine addiction.
 Health effects of smoking and benefits of
quitting.
 Assessment and monitoring
 Helping patients quit : Motivational
interviewing & relapse prevention.
 Pharmacological interventions.

IS a PATIENT READY to QUIT?
Does the patient now use tobacco?
Yes
Is the patient now
ready to quit?
No
Promote
motivation
No
Did the patient once
use tobacco?
Yes
Yes
Provide
treatment
The 5 A’s
Prevent
relapse*
No
Encourage
continued
abstinence
*Relapse prevention interventions not
necessary if patient has not used tobacco
for many years and is not at risk for reinitiation.
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS.
The (DIFFICULT) DECISION
to QUIT
Faced with change, most people are not ready to act.
 Change is a process, not a single step.
 Typically, it takes multiple attempts.

HOW CAN I LIVE
WITHOUT TOBACCO?
HELPING SMOKERS QUIT IS a
CLINICIAN’S RESPONSIBILITY
TOBACCO USERS DON’T PLAN TO FAIL.
MOST FAIL TO PLAN.
Clinicians have a professional obligation
to address tobacco use and can have
an important role in helping patients
plan for their quit attempts.
THE DECISION TO QUIT LIES IN THE
HANDS OF EACH PATIENT.
ASSESSING
READINESS to QUIT
Patients differ in their readiness to quit.
STAGE 1: Not ready to quit in the next month
STAGE 2: Ready to quit in the next month
STAGE 3: Recent quitter, quit within past 6 months
STAGE 4: Former tobacco user, quit > 6 months ago
Assessing a patient’s readiness to quit enables clinicians to
deliver relevant, appropriate counseling messages.
ASSESSING
READINESS to QUIT
(cont’d)
For most patients, quitting is a cyclical process, and their
readiness to quit (or stay quit) will change over time.
Relapse
Former
tobacco
user
Not
thinking
about it
Thinking
about it,
not ready
Recent
quitter
Ready to quit
Not ready
to quit
Assess readiness
to quit (or to
stay quit) at each
patient contact.
ASSESSING
READINESS to QUIT
(cont’d)
STAGE 1: Not ready to quit
Not thinking about quitting in the next
month
◦
◦
◦
◦
Some patients are aware of the need to quit.
Patients struggle with ambivalence about change.
Patients are not ready to change, yet.
Pros of continued tobacco use outweigh the cons.
GOAL: Start thinking about quitting.
STAGE 1: NOT READY to QUIT
Counseling Strategies
DOs
DON’Ts

Strongly advise to quit

Persuade

Provide information

“Cheerlead”

Ask noninvasive questions; identify
reasons for tobacco use

Raise awareness of health
consequences/concerns

Demonstrate empathy, foster
communication

Leave decision up to patient


Tell patient how
bad tobacco is, in
a judgmental
manner
Provide a
treatment plan
STAGE 1: NOT READY to QUIT
Counseling Strategies (cont’d)
The 5 R’s—Methods for increasing
motivation:
◦ Relevance
◦ Risks
◦ Rewards
◦ Roadblocks
Tailored,
motivational
messages
◦ Repetition
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD:
USDHHS, PHS.
IS a PATIENT READY to QUIT?
Does the patient now use tobacco?
Yes
Is the patient now
ready to quit?
No
Promote
motivation
No
Did the patient once
use tobacco?
Yes
Yes
Provide
treatment
The 5 A’s
Prevent
relapse*
No
Encourage
continued
abstinence
*Relapse prevention interventions not
necessary if patient has not used tobacco
for many years and is not at risk for reinitiation.
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS.
ASSESSING
READINESS to QUIT
(cont’d)
STAGE 2: Ready to quit
Ready to quit in the next month
◦ Patients are aware of the need to, and the benefits of,
making the behavioral change.
◦ Patients are getting ready to take action.
GOAL: Achieve cessation.
A Brief Intervention
The 5 A’s
Ask
… about smoking status
Advise
… to quit
Assess
… willingness to quit
Assist
… by offering treatment
Arrange
… follow-up
Fiore MC et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update.
US Department of Health and Human Services. Public Health Service; 2008. Available
at: www.surgeongeneral.gov/tobacco/default.htm.
STAGE 2: READY to QUIT
Assess Tobacco Use History
 Praise
the patient’s readiness
 Assess tobacco use history
◦ Current use: type(s) of tobacco, brand, amount
◦ Past use: duration, recent changes
◦ Past quit attempts:
 Number, date, length
 Methods used, compliance, duration
 Reasons for relapse
STAGE 2: READY to QUIT
Three Key Elements of Counseling

ASSIST

Discuss key issues

Facilitate quitting process
The 5 A’s (cont’d)

ADVISE tobacco users to quit (clear, strong,
personalized, sensitive)


“It’s important that you quit as soon as possible, and I
can help you.”
“I realize that quitting is difficult. It is the most
important thing you can do to protect your health now
and in the future. I have training to help my patients
quit, and when you are ready, I will work with you to
design a specialized treatment plan.”
The 5 A’s (cont’d)

Arrange
ARRANGE follow-up care
Number of sessions
Estimated quit rate*
0 to 1
12.4%
2 to 3
16.3%
4 to 8
More than 8
20.9%
24.7%
* 5 months (or more) postcessation
PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.
Rockville, MD: USDHHS, PHS.
STAGE 2: READY to QUIT
Discuss Key Issues
 Reasons/motivation
 Confidence
 Triggers
to quit (or avoid relapse)
in ability to quit (or avoid relapse)
for tobacco use
◦ What situations lead to temptations to use tobacco?
◦ What led to relapse in the past?

Routines/situations associated with tobacco use





When drinking coffee
While driving in the car
When bored or stressed
While watching television
While at a bar with friends




After meals
During breaks at work
While on the telephone
While with specific friends or family
members who use tobacco
STAGE 2: READY to QUIT
Discuss Key Issues (cont’d)
Stress-Related Tobacco Use
THE MYTHS
THE FACTS

“Smoking gets rid of all my
stress.”

There will always be stress in
one’s life.

“I can’t relax without a
cigarette.”

There are many ways to relax
without a cigarette.
Smokers confuse the relief from withdrawal
with the feeling of relaxation.
STRESS MANAGEMENT SUGGESTIONS:
Deep breathing, shifting focus, taking a break.
STAGE 2: READY to QUIT
Discuss Key Issues (cont’d)
Social Support for Quitting
ADVISE PATIENTS TO DO THE FOLLOWING:

Ask family, friends, and coworkers for support, for example,
not to smoke around them and not to leave cigarettes out

Talk with their health care provider

Get individual, group, or telephone counseling
Patients who receive social support and
encouragement are more successful in quitting.
HERMAN ® is reprinted with permission from
LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.
Most smokers gain fewer than 10 pounds,
but there is a wide range.
STAGE 2: READY to QUIT
Discuss Key Issues (cont’d)
Concerns about Weight Gain

Discourage strict dieting while quitting
◦
◦
◦
◦
Recommend physical activity
Encourage healthful diet, planning of meals, and inclusion of fruits
Suggest increasing water intake or chewing sugarless gum
Recommend selection of nonfood rewards

Maintain patient on pharmacotherapy shown to delay
weight gain

Refer patient to specialist or program
STAGE 2: READY to QUIT
Discuss Key Issues (cont’d)
Concerns about Withdrawal Symptoms


Most pass within 2–4 weeks after
quitting
Cravings can last longer, up to
several months or years

Often can be ameliorated with cognitive
or behavioral coping strategies
Most symptoms
peak 24–48 hours
after quitting and
subside within
2–4 weeks.
STAGE 2: READY to QUIT
ASSIST Quitting Process
 Discuss
methods for quitting
◦ Discuss pros and cons of available methods
◦ Pharmacotherapy: a treatment, not a crutch!
◦ Importance of behavioral counseling
 Set
a quit date
◦ Make sure it’s set to coincide with obtaining
medication and reaching therapeutic dose (Champix
and Zyban)
STAGE 2: READY to QUIT
ASSIST Quitting Process (cont’d)

Discuss coping strategies
◦ Cognitive coping strategies
 Focus on retraining the way a patient thinks
◦ Behavioral coping strategies
 Involve specific actions to reduce risk for relapse
STAGE 2: READY to QUIT
ASSIST Quitting Process (cont’d)
Cognitive Coping Strategies
◦
Review commitment to quit
◦
Distractive thinking
◦
Positive self-talk
◦
Relaxation through imagery
◦
Mental rehearsal and visualization
STAGE 2: READY to QUIT
ASSIST Quitting Process (cont’d)
Cognitive Coping Strategies: Examples

Thinking about cigarettes doesn’t mean you have to smoke
one:
◦ “Just because you think about something doesn’t mean you have to do
it!”
◦ Tell yourself, “It’s just a thought,” or “I am in control.”
◦ Say the word “STOP!” out loud, or visualize a stop sign.

When you have a craving, remind yourself:
◦ “The urge for tobacco will only go away if I don’t use it.”

As soon as you get up in the morning, look in the mirror and
say to yourself:
◦ “I am proud that I made it through another day without tobacco.”
STAGE 2: READY to QUIT
ASSIST Quitting Process (cont’d)
Behavioral Coping Strategies
◦ Control your environment
 Tobacco-free home and workplace
 Remove cues to tobacco use; actively avoid trigger situations
 Modify behaviors that you associate with tobacco: when, what, where,
how, with whom
◦ Substitutes for smoking
 Water, sugar-free chewing gum or hard candies (oral substitutes)
◦ Take a walk, diaphragmatic breathing, self-massage
◦ Actively work to reduce stress, obtain social support, and
alleviate withdrawal symptoms
STAGE 2: READY to QUIT
ASSIST Quitting Process (cont’d)
 Provide
medication counseling
◦ Promote compliance
◦ Discuss proper use, with demonstration
 Discuss
concept of “slip” versus relapse
◦ “Let a slip slide.”
 Offer
to assist throughout quitting (ARRANGE)
◦ Follow-up contact #1: first week after quitting
◦ Follow-up contact #2: in the first month
◦ Additional follow-up contacts as needed
 Congratulate
the patient!
ASSESSING
READINESS to QUIT
(cont’d)
STAGE 3: Recent quitter
Actively trying to quit for good
◦ Patients have quit using tobacco sometime in the past 6
months and are taking steps to increase their success.
◦ Withdrawal symptoms occur.
◦ Patients are at risk for relapse.
GOAL: Remain tobacco-free for at least 6 months.
STAGE 3: RECENT QUITTERS
Evaluate the Quit Attempt

Status of attempt
◦ Ask about social support
◦ Identify ongoing temptations and triggers for relapse
(negative affect, smokers, eating, alcohol, cravings, stress)
◦ Encourage healthy behaviors to replace tobacco use

Slips and relapse
◦ Has the patient used tobacco at all—even a puff?

Medication compliance, plans for termination
◦ Is the regimen being followed?
◦ Are withdrawal symptoms being alleviated?
◦ How and when should pharmacotherapy be terminated?
STAGE 3: RECENT QUITTERS
Facilitate Quitting Process
Relapse Prevention
 Congratulate success!
 Encourage continued abstinence
◦ Discuss benefits of quitting, problems encountered, successes achieved,
and potential barriers to continued abstinence
◦ Ask about strong or prolonged withdrawal symptoms (change dose,
combine or extend use of medications)
◦ Promote smoke-free environments

Social support
◦ Discuss ongoing sources of support
◦ Schedule additional follow-up as needed; refer to support groups
ASSESSING
READINESS to QUIT
(cont’d)
STAGE 4: Former tobacco user
Tobacco-free for 6 months
◦ Patients remain vulnerable to relapse.
◦ Ongoing relapse prevention is needed.
GOAL: Remain tobacco-free for life.
STAGE 4:
FORMER TOBACCO USERS

Assess status of quit attempt

Slips and relapse

Medication compliance, plans for termination

Has pharmacotherapy been terminated?

Continue to offer tips for relapse prevention

Encourage healthy behaviors

Congratulate continued success
Continue to assist throughout the quit attempt.
Individual Counseling
Visit 1- Pre-Target Quit Date (TQD)













Patient Information
Why you smoke? Reasons and barriers to quitting
Past quit attempts: what worked and what didn’t?
Assess importance, confidence and readiness to quit
Nature of nicotine addiction: physical, behavioral, emotional
Nicotine and the brain
Medication options and making a medication plan
The importance of support
Set a quit date
Assignments
◦ Wrap sheets – look at how you use cigarettes
◦ Change brands
◦ Switch hands and how you light cigarette
CO level – if in person
Set next visit
Handouts
◦ Why Do You Smoke?
◦ Wrap Sheets, Pencil and Rubber band
◦ Medication Information Sheet
◦ Things to do to get Ready for Your Quit Day
◦ Support handout
78
Individual Counseling
Visit 2 - Preparing to Quit



Review Medications
Review Wrap Sheets—lessons learned
Identify triggers, high risk situations and develop coping strategies



Fill out “My Quit Day Plan”
How to deal with friends and family—using your support team
Assignments:
◦ Difference between physical (walking) and thinking
strategies (“The urge will pass, I Can do this”, etc.)
◦
◦
◦
◦
◦
Isolate smoking from all activities (smoke to smoke)
Craving level “5” or below, don’t smoke
Craving level above a “5”, delay by 15 minutes
Make cigarettes inaccessible
Make an emergency 911 Kit (Goody bag)
79
Individual Counseling
Visit 2 - Preparing to Quit (con’t)







Night before Quit Date—getting rid of smoking paraphernalia
Plan for Day One smoke-free
Relaxation skills (deep breathing)
CO Level
Plan to call on TQD or 1-3 days after TQD for support
Set next visit
Handouts:
◦
◦
◦
◦
More things to do to get ready
My Quit Day Plan (completed)
Day before Quit Day/The Big Day
Inner benefits of quitting/withdrawal
symptoms
◦ Success Calendar and stickers and Steps to
Success Card
◦ Large “Urge will Pass”
◦ Goody bag
80
Individual Counseling – Quit Day

If smoking:
◦ WHAT HAPPENED? SITUATIONS, PEOPLE, TRIGGERS, STRESS
◦ TRY ANY COPING STRATEGIES?
◦ HOW COULD YOU HANDLE IT NEXT TIME?
◦ REVIEW REASONS YOU WANT TO BE TOBACCO FREE
◦ STILL MOTIVATED TO QUIT?
◦ READY TO SET A NEW QUIT DATE?
◦ REMIND THAT QUITTING SMOKING IS A PROCESS AND JUST
BECAUSE THEYHAVEN’T QUIT TODAY DOES NOT MEAN THEY
WON’T QUIT

If not smoking:
◦ CONGRATULATE
◦ NOTICE ANY BENEFITS (ie: breathe easier, sense of smell)
◦ ASK ABOUT SUCCESSES
◦ COPING STRATEGIES THAT WORKED
◦ THINGS STILL STRUGGLING WITH AND POSSIBLE SOLUTIONS
◦ ANTICIPATE NEW TRIGGERS AND NEW COPING STRATEGIES
◦ DEALING WITH POSSIBLE WITHDRAWAL SYMPTOMS
◦ REMIND THAT MOST RELAPSES OCCUR IN THE FIRST FEW WEEKS, SO STAY
STRONG!
81
Individual Counseling
Visit 3 – 6 Post-Target Quit Day




Adverse events
Review medications
Cravings level (1-10) Withdrawal symptoms (1-10)
CO level if in person

If smoking:
◦ WHAT HAPPENED? SITUATIONS, PEOPLE, TRIGGERS, STRESS

If not smoking:
◦ CONGRATULATE.
82
Individual Counseling
Visit 3 – 6 Post-Target Quit Day

Possible Topics:
◦
◦
◦
◦
◦
◦
◦
◦
◦

Weight management
Stress management
Relaxation skills
Grief, loss and depression
Rationalizations and setting self up to smoke
High risk situations
Coping with a slip and how to handle it
Avoiding relapse and how to cope with relapse
New self-image
Visit 6 Only:
◦ Discuss phone follow-up phone schedule
◦ Go over relapse prevention handout
83
Definition of Motivational
Interviewing

A directive client-centered counseling style that
enhances motivation for change by helping the
client clarify and resolve ambivalence about
behavior change
84
General Principles of MI


Express empathy
◦
Best defined as acceptance. Through reflective listening (being able to repeat
back what the patient has expressed), you come to understand where your
patient is coming from without judging, criticizing or blaming. Acceptance is NOT
the same thing as approval!
Develop discrepancy
◦ The goal here is to help your patient perceive for themselves a discrepancy
between their present behavior and where they want to be. Their own goals, not
someone else’s!

Roll with resistance
◦ Arguing with your patient to change their behaviors is the least effective
thing you can do. Showing new ways to look at things and allowing your
patient to find answers themselves (with your help) works best

Support self-efficacy
◦ This refers to encouraging your patients belief in the possibility of
change; that they are in control and have control. Your expressed belief in
the person’s ability to change becomes a self-fulfilling prophecy!NOT: I
will change you…but, I will help you change!
85
Spirit of MI


What it is:
◦ Client autonomy—the responsibility for change
rests with the client
◦ Collaborative—a partnership between counselor
and client
◦ Evocation—to elicit information rather than
impart it
What it isn’t:
◦ Confrontational—overriding clients’ beliefs
◦ Educational—client is believed to be uninformed
◦ Authoritative—telling the client what to do
86
OARS
Ask Open-ended questions
 Affirmation
 Reflective listening
 Summarize

87
Elements of Brief MI Intervention






Feedback--medical
Responsibility—is patient’s
Advice
Menu of options—for ways to change behavior
Empathy
Self-efficacy
88
Defining Success


1. Clinicians must adjust their definition of
success when treating the tobacco-dependent
patient
2. Clinicians are accustomed to near 100%
success with some other conditions
◦
◦

e.g., vaccinating a patient against rubella
e.g., treating a bacterial infection with antibiotics
3. For the dependent tobacco user – learn to
consider a 10% to 20% quit rate
as success
Huber GL, Mahajan VK. Dis Manage Health Outcomes 2008; 16(5):335-43.
Tobacco Dependence Support:
“ABC”

The 2007 New Zealand Smoking Cessation
Guidelines recommend a modified version of
the 5 A’s
◦ Ask about tobacco use at every visit
◦ Brief advice to stop smoking
◦ Cessation support to help with the quit attempt
(support should use evidence-based techniques)
McRobbie H et al. N Z Med J 2008; 121(1276):57-70.
Objectives: smoking cessation
pharmacology and neurobiology of
nicotine addiction.
 Health effects of smoking and benefits of
quitting.
 Assessment and monitoring
 Helping patients quit : Motivational
interviewing & relapse prevention.
 Pharmacological interventions.

US PHS Guideline – Treating Tobacco Use and Dependence: 2008 Update
First-Line Pharmacotherapies for
Tobacco Dependence
FDA Approved Smoking Cessation Pharmacotherapies

NRT
◦
◦
◦
◦
◦
Patch
Gum
Inhaler
Nasal spray
Sublingual tablets/lozenges
Bupropion SR
 Varenicline

Fiore MC et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update.
US Department of Health and Human Services. Public Health Service; 2008.
Available at: www.surgeongeneral.gov/tobacco/default.htm.
UK NICE: Cost-Effectiveness of Smoking
Cessation Therapies1


NICE modelled a hypothetical cohort of 1,000 smokers to determine
the cost-effectiveness of smoking cessation
NICE considered 11 smoking cessation interventions:
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦

Minimal counselling (3 minutes provided by GP)
Minimal counselling plus self-help material
Minimal counselling plus self-help material plus NRT
Minimal counselling plus self-help material plus NRT plus specialist clinic
8 weeks of bupropion plus self-help material plus 5-10 minute scripted call
8 weeks of bupropion plus self-help material plus 5- minute calls with smoking specialist
5 weeks of NRT
5 weeks of NRT plus 5 group visits
5 weeks of NRT plus 5 clinic visits
5 weeks of NRT plus 5 pharmacist consultations
5 weeks of NRT plus 5 pharmacist consultations plus
5 behavioural consultations
All interventions were considered cost-effective.
UK = United Kingdom; NRT = nicotine replacement therapy
NICE. Cost-Effectiveness of Interventions for Smoking Cessation. Available at:
http://www.nice.org.uk/nicemedia/pdf/CostEffectivenessModel%20Aug07SCS.pdf.
Meta-analysis
of First-line Smoking Cessation Pharmacotherapies
US PHS Guideline – Treating Tobacco Use and Dependence: 2008 Update

Effectiveness and abstinence rates for various medications compared with
placebo 6 months after quitting
Medication
Placebo
Varenicline (2 mg/day)
Nicotine nasal spray
High-dose nicotine patch (>25 mg)
Long-term nicotine gum (>14 weeks)
Varenicline (1 mg/day)
Nicotine inhaler
Bupropion SR
Nicotine patch (6-14 weeks)
Long-term nicotine patch (>14 weeks)
Nicotine gum (6–14 weeks)
Estimated OR
(95% CI)
1.0
3.1 (2.5, 3.8)
Estimated abstinence rate
(95% CI)
13.8
33.2 (28.9, 37.8)
2.3 (1.7, 3.0)
2.3 (1.7, 3.0)
2.2 (1.5, 3.2)
2.1 (1.5, 3.0)
2.1 (1.5, 2.9)
2.0 (1.8, 2.2)
1.9 (1.7, 2.2)
1.9 (1.7, 2.3)
1.5 (1.2, 1.7)
26.7 (21.5, 32.7)
26.5 (21.3, 32.5)
26.1 (19.7, 33.6)
25.4 (19.6, 32.2)
24.8 (19.1, 31.6)
24.2 (22.2, 26.4)
23.4 (21.3, 25.8)
23.7 (21.0, 26.6)
19.0 (16.5, 21.9)
Fiore MC et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update.
US Department of Health and Human Services. Public Health Service; 2008.
Available at: www.surgeongeneral.gov/tobacco/default.htm.
Nicotine delivery
Royal College of Physicians, Nicotine in Britain, 2000
Bupropion SR

One of two non-nicotine medications
approved by the FDA as an aid to
smoking cessation treatment

Available by prescription only (USA)

Mechanism of action: presumably blocks
neural reuptake of dopamine
Bupropion SR
Contraindications:
−
−
−
−
−
−
Seizure disorder
MAO inhibitor used within previous 2 weeks
Hx of anorexia nervosa or bulimia
Side effects:
Insomnia
Dry mouth
Bupropion SR
Dosing:
−start 1-2 weeks before quit date
−150 mg orally once daily x 3 day
−150 mg orally twice daily x 7-12 weeks
−no taper necessary at end of treatment
Maintenance:
−efficacious as maintenance medication for
<6 months post-cessation
Varenicline’s Mechanism of Action

Through its partial agonist activity at
a42 nicotinic acetylcholine receptors,1,2
varenicline is believed to:
◦ Alleviate some of the craving and withdrawal
symptoms from smoking abstinence (agonist
activity)3
◦ Reduce the rewarding and reinforcing effects
of nicotine during lapses to smoking, by
blocking the ability of nicotine to bind
(antagonist activity)3
1. Champix Summary of Product Characteristics. Sandwich, UK, Pfizer Ltd.; 2008.
2. Coe JW et al. J Med Chem 2005; 48(10):3474-7.
3. Foulds J. Int J Clin Pract. 2006; 60(5):571-6.
Varenicline: A Highly Selective a42 Nicotinic
Acetylcholine Receptor Partial Agonist
Nicotine
Binding of nicotine at the α4β2 nicotinic
acetylcholine receptor (nAChR) in the
VTA is believed to cause release of
dopamine at
1
the
Picciotto
MR etnAcc.
al. Nicotine Tob Res 1999; 1(Suppl 2):S121-5.
1.
2. Coe JW et al. J Med Chem 2005; 48(10):3474-7.
Varenicline
As a partial agonist of α4β2 nAChRs,
varenicline:
• Stimulates dopamine release from the VTA
at a lower level than nicotine
• Blocks nicotine antagonistically from
binding
2 Identically Designed Phase 3 Trials:
Treatment-Emergent AEs Occurring in ≥5% of
Varenicline-Treated Group1,2
Study 1
AE
Nausea
Constipation
Flatulence
Dry mouth
Headache
Abnormal
dreams
Insomnia
Dizziness
Study 2
Varenicline
n=343
%
Bupropion SR
n=340
%
Placebo
n=340
%
Varenicline
n=349
%
Bupropion SR
n=329
%
Placebo
n=344
%
29.4
9.0
5.8
5.6
12.8
7.4
6.5
2.1
7.6
7.9
9.7
1.5
2.4
3.2
12.6
28.1
5.4
5.7
6.6
15.5
12.5
7.0
4.3
8.8
14.3
8.4
3.8
2.9
5.5
12.2
13.1
5.9
3.5
10.3
5.5
5.5
14.3
6.4
21.2
7.4
12.4
7.1
14.0
6.0
21.9
5.8
12.8
5.8
*Values may not total 100% due to rounding
AE = adverse event
1. Jorenby DE et al. JAMA 2006; 296(1):56-63.
2. Gonzales D et al. JAMA. 2006; 296(1):47-55.
controversy

On June 4, 2009, the FDA announced it
was evaluating varenicline for additional
potential side effects. On July 1, 2009, the
Food and Drug Administration required
varenicline and Zyban (bupropion) to
carry a black box warnining, the agency's
strongest safety warning, due to side
effects including depression, suicidal
thoughts, and suicidal actions.
Varenicline Prescribing Information






Indicated for smoking cessation in adults
Patients instructed to set a target quit date
Treatment begins 1 to 2 weeks prior to target quit date
Treatment period is 12 weeks
Varenicline is supplied for oral administration in 2 strengths:
0.5 and 1.0 mg; titrated as below:
Days 1 to 3:
0.5 mg once daily
Days 4 to 7:
0.5 mg twice daily
Day 8 to end of treatment:
1 mg twice daily
An additional course of 12 weeks of treatment may be considered for patients
who have successfully quit at end of 12 weeks
Champix Summary of Product Characteristics. Sandwich, UK, Pfizer Ltd.; 2008.
UK NICE :
Varenicline

UK NICE made the following recommendations for
varenicline:
◦ Considering evidence from direct trials and systematic reviews carried
out by the manufacturer and the Evidence Review Group of NICE,
varenicline has demonstrated superior efficacy than bupropion SR or
nicotine replacement therapy
◦ The NICE Appraisal Committee also noted that the evidence in the
manufacturer’s cost-effectiveness analyses were likely to be cost
effective for the UK National Health Service
◦ Because clinical trials with varenicline have always included brief
counselling, the Appraisal Committee recommended providing
counselling and support along with varenicline
 However, if such support is unavailable or refused by the patient, the
Appraisal Committee did not preclude varenicline treatment
National Institute for Health and Clinical Excellence. Varenicline for Smoking Cessation. 2007. Available at:
http://www.nice.org.uk/nicemedia/pdf/TA123Guidance.pdf.
Conclusions
1.
2.
3.
4.
Smoking is the leading preventable
cause of disease and premature death
However, the prevalence of smoking
remains unacceptably high and in
some areas continues to increase
Quitting improves health outcomes
and can reverse disease progression
Quitting early in life provides the
greatest benefits to overall survival
Conclusions (continued)
5.
6.
7.
A healthcare practitioner having a
dialogue with a smoker is the first
step towards quitting
Even brief counselling can aid in
cessation together with effective
pharmacotherapies
Varenicline , bupropion & NRT are
licensed to treat the addiction.