Transcript Approach to Smoking Patient

Approach to Nicotine Dependent
Patient
Assocc Prof Dr Hülya AKAN
Department of Family Medicine
Aims and objectives
At the end of this lesson every student should
be able to:
- Explain the effects of nicotine dependence on
health
- Explain the importnace of legislative measures
- Explain the major steps of nicotine
dependence treatment
- Tell the major drugs and their mechanisms
used in nicotine dependence treatment
Cigarette /pipe
Snus
Nargile
Bidi, Gunthar, Kreteks
Facts
• Smoking causes cancer, heart disease, stroke,
and lung diseases (including emphysema,
bronchitis, and chronic airway obstruction).
• On average, smokers die 13 to 14 years earlier
than nonsmokers
• COPD will be third leading cause of death by 2030
• For every person who dies from a smokingrelated disease, 20 more people suffer with at
least one serious illness from smoking.
FACTS
• Tobacco use, primarily cigarette smoking, is
the leading cause of preventable morbidity
and mortality in all over the world.
• Goals of the Healthy People 2013 initiative
include increasing to 75 percent the
proportion of family physicians who routinely
provide smoking cessation counseling
What is going on Turkey about tobacco
use?
Küresel Yetişkin Tütün Araştırması;
GATS; Global Adult Tobacco Survey
Küresel Gençlik Tütün Araştırması
(GYTS; Global Youth Tobacco
Survey)
Before 1983
• Tobacco enters Ottoman about 1600
• Major surgeon of palace İbrahim Efendi tried
to limit– unsuccessful
• Sultan IV. Murat- heavy punishment to
smokers
• 19. century- import was forbidden
• 1872 : industry and sales rights were sold to
Rum bankers
• 1883: consesssion of tobacco industry was
sold to Reji managed by English. So an
important income of rural people sold to
foreign industry.
• 1923: Turkish Republic
• 1925: TC get back industry from Reji
• Turkish State Liquor and Tobacco Monopoly
• Besim Ömer Paşa (Akalın): 1888 – academic
manuscripts about tobacco risks for health
• 1990: first academic manuscripts abouth the
health risks of tobacco use
1983 – 1996
• General Directorate of Monopoly
• 19.10.1983 : İmport get free (forbidden on
1862)
• 1987 : foreign firms allowed to import
• 1983 -1999 :80% increase in tobacco use
• 1995 : “Sigara ve Sağlık Ulusal Komitesi
(SSUK)” (National Comittee of Tobacco and
Health)
• 1996 : 4207 no. law “Law on Prevention of
Hazards of Tobacco Products” accepted
After 1996
• 2003 : WHO general assembly: Framework
Convention on Tobacco Control
• Turkey signed the contract in 2004
• National Tobacco Control Programm and
2008–2012 National Act Plan
• Legislative changes: 3 january 2008 “Law on
Prevention of Hazards of Tobacco Products”
Chronic Diseases and Risk factors
survey of Turkey 2013
•
•
•
•
24% regular , 6% irregular smoker,
9%past smoker
37% of men regular smoker
17% of females regular smoker
http://www.thsk.saglik.gov.tr/dosya/kronik_hastaliklar/chroni
c_english/chronic-diseases-risk-foctors-survey-in-turkey.html
Main approach strategy
Turkish acronyms
ASK
ÖĞREN (SOR)
DEĞERLENDİR
Her görüşmede
sigara kullanımını
sor
ADVICE
ÖNER
DOĞRU BİLGİ/KESİN Sigara kullananların
TAVSİYE
tümüne bırakmayı
öner
ASSESS
ÖLÇ
(DEĞERLENDİR)
DERECELENDİR
Bırakma girişimi
konusunda ki
isteğini değerlendir
ASSIST
ÖNDERLİK ET
(YARDIMCI OL)
DESTEK OL
Bırakma konusunda
yardımcı ol
ARRANGE
ÖRGÜTLE
(DÜZENLE)
DÜZENLİ
OLARAK İZLE
Hastanın bırakma
çabalarını
destekleyecek
düzenli izlemi yap
STEP 1: ASK Screen every patient for
tobacco use
•Ask your patient if he/she currently or has ever smoked cigarettes or used
other tobacco products. Document the response in the patient’s chart.
“Do you smoke cigarettes or use other tobacco products?
Have you in the past?”
•If your patient is a former smoker remind them of the many health benefits
of not smoking.
“Quitting smoking is the most important thing you can do for your health.”
STEP 2 ADVICE your patient to quit smoking.
A clinician’s advice to quit is an important motivator for patients attempting to quit
smoking. The advice must be clear, strong, and personalized
“As your doctor and someone who cares about you and your health, I’d like to help you
quit smoking because it’s the best thing you can do for your health and anyone
who lives with you.”
Discuss some of the health problems associated with smoking:
Emphysema/COPD
High blood pressure
Heart disease and heart attack Stroke
Cancer
Gum disease
Bad breath
Tooth loss
Decreased circulation to the hands and feet
Remind patients:
“Quitting at anytime is the best thing to do for your health.”
Action
In a clear, strong, and personalized
manner, urge every tobacco user to quit.
Strategies for Implementation
Advice should be:
• Clear—"I think it is important for you to
quit smoking now and I can help you."
"Cutting down while you are ill is not
enough."
• Strong—"As your clinician, I need you to
know that quitting smoking is the most
important thing you can do to protect
your health now and in the future. The
clinic staff and I will help you."
• Personalized—Tie tobacco use to
current health/ illness, and/or its social
and economic costs, motivation
level/readiness to quit, and/or the impact
of tobacco use on children and others in
the household.
STEP 3 ASSESS readiness to quit.
•Ask your patient whether she/he would like to quit. Most
smokers would like to stop smoking, but fear they will be unable
to quit.
“Would you like to quit smoking?”
•A provider’s advice and support may be a strong motivator.
Document the patient’s response in the medical chart.
•If a patient is ready to quit, provide counseling
•If a patient is not ready to quit, reassess his/her smoking status
at the next visit and all subsequent visits. During each visit, the
provider should assess for tobacco
dependence, advise to quit, and assess readiness to quit.
Assess Readiness of Patient
• I don’t think to quit
• It will be good to quit, but I am not sure if I
can
• I have decided to quit
• I do not smoke
• I keep on not smoking
• I have started again
Assess Contemplation
• Before contemplation
• Contemplation
• Aim (prepare): Decision level
• Action
• Maintanence
• Relaps
Assess dependency level
STEP 3 ASSESS nicotine dependence for current smokers using
the Heavy Smoking Index (HSI), consisting of 2 simple questions:
“To better understand your smoking habits, I’d like to ask you a few questions.”
a. How many cigarettes, on average, do you smoke per day?
1-10 (score 0)
11-20 (score 1)
21-30 (score 2)
31+ (score 3)
b. How soon after waking do you smoke your first cigarette?
Within 5 minutes (score 3) 6-30 minutes (score 2)
31-60 minutes (score 1)
61+ minutes (score 0)
Document the HSI score in the patient’s chart. An HSI score ≥4 indicates a high level of
nicotine dependence and the need for specific strategies to combat acute nicotine
withdrawal symptoms.
Assess dependency level:
Fagerstrom Test for Nicotine Dependence
0
1
2
3
How soon after you wake up do you smoke
your first cigarette?
After 60
Min.
31 – 60
Min.
6-30
min.
Within
5 min.
Do you find it difficult to refrain from
smoking in places where it is forbidden,
e.g., in church, at the library, cinema, etc?
No
Yes
Which cigarette would you hate most to
give up?
All others
First one
in the
morning
How many cigarettes/day do you smoke?
10 or less
11-20
21-30
31 or
more
Do you smoke more frequently during the
No
first hours of waking than during the rest of
the day?
Yes
Do you smoke if you are so ill that you are
in bed most of the day?
Yes
No
Scoring the Fagerstrom Test for
Nicotine Dependence (FTND)
• In scoring the Fagerstrom Test for Nicotine
Dependence, the three yes/no items are scored 0 (no)
and 1 (yes). The three multiple-choice items are scored
from 0 to 3.
• The items are summed to yield a total score of 0-10.
• Classification of dependence:
0-2 Very low
3-4 Low
5 Moderate
6-7 High
8-10 Very high
Assess: Previous attempts
•
•
•
•
•
How many times?
How long?
The longest quitting time?
Used methods? Porfessional help?
Triggers to relapse?
STEP 4 ASSIST
Counsel patients to quit.
•Just 3 to 5 minutes of firm, specific counseling by a clinician can double quit
rates.
Clinician counseling should include:
Practical suggestions for quitting.
Managing withdrawal symptoms.
Getting support.
During counseling, use motivational interviewing techniques, including:
* Open-ended questions: “What are some of the reasons you would like to
quit smoking?”
* Affirming statements: “It’s great that you are motivated to quit smoking.”
* Reflective listening: “It sounds like trying to quit smoking has been
frustrating for you.”
Strategies for patient ready to quit
Action
Strategies for Implementation
Help the patient with A patient's preparations for quitting:
a quit plan.
• Set a quit date—ideally, the quit date should be within 2
weeks.
• Tell family, friends, and coworkers about quitting and request
understanding and support.
• Anticipate challenges to planned quit attempt, particularly
during the critical first few weeks. These include nicotine
withdrawal symptoms.
• Remove tobacco products from your environment. Prior to
quitting, avoid smoking in places where you spend a lot of
time
(e.g., work, home, car).
Strategies for patient ready to quit
Provide practical
counseling
(problemsolving/
training).
• Abstinence—Total abstinence is essential. "Not even a single
puff after the quit date."
• Past quit experience—Review past quit attempts including
identification of what helped during the quit attempt and what
factors contributed to relapse.
• Anticipate triggers or challenges in upcoming attempt—
Discuss challenges/triggers and how patient will successfully
overcome them.
• Alcohol—Because alcohol can cause relapse, the patient
should consider limiting/abstaining from alcohol while
quitting.
• Other smokers in the household—Quitting is more difficult
when there is another smoker in the household. Patients
should encourage housemates to quit with them or not smoke
in their presence.
Strategies for patient ready to quit
Provide intratreatment
social
support.
Provide a supportive clinical environment while
encouraging the patient in his or her quit attempt.
"My office staff and I are available to assist you."
Help patient obtain
extra-treatment
social support.
Help patient develop social support for his or her quit
attempt in his or her environments outside of
treatment. "Ask your spouse/partner, friends, and
coworkers to support you in your quit attempt."
Recommend the use of
approved pharmacotherapy,
except in special
circumstances.
Recommend the use of pharmacotherapies found to
be effective.
Explain how these medications increase smoking
cessation success and reduce withdrawal symptoms.
The first-line pharmacotherapy medications include:
bupropion SR, nicotine gum, nicotine inhaler, nicotine
nasal spray, and nicotine patch.
Provide supplementary
materials.
Sources—Federal agencies, nonprofit agencies, or
local/state health departments.
Type—Culturally/racially/educationally/age
appropriate for the patient.
Common elements of practical
counselling
Recognize danger situations—
Identify events, internal states,
or activities that increase the
risk of smoking or relapse.
• Negative affect.
• Being around other smokers.
• Drinking alcohol.
• Experiencing urges.
• Being under time pressure.
Develop coping skills—
Identify and practice coping or
problem solving skills.
Typically, these skills are
intended to cope with danger
situations.
Learning to anticipate and avoid temptation.
• Learning cognitive strategies that will reduce
negative moods.
• Accomplishing lifestyle changes that reduce stress,
improve quality of life, or produce pleasure.
• Learning cognitive and behavioral activities to
copewith smoking urges (e.g., distracting attention).
Provide basic information—
Provide basic information
about smoking and successful
quitting.
• Any smoking (even a single puff) increases the
likelihood of full relapse.
• Withdrawal typically peaks within 1-3 weeks after
quitting
• Withdrawal symptoms include negative mood,
urges to smoke, and difficulty concentrating.
Nicotine withdrawal symptoms
•
•
•
•
•
•
Anxiety:
87%
Irritability: 87%
Decreased heart rate: 80%
Difficulty in concentration: 73%
Increased apetite and weight gain: 73%
Urges to smoking: 62%
STEP 5 ARRANGE Follow up with patients who are trying to quit.
If possible, follow up with your patient either in person or by telephone
within a week of her quit date. A second follow-up is recommended within
the first month.
“How is it going?”
“How are you feeling?”
If the patient has not smoked, offer congratulations and encouragement.
“You’re doing a great job. This is such an important step to take.”
If the patient has smoked, consider revisiting previous steps above.
“Quitting can be very difficult. It can often take someone several tries to
successfully quit. Would you like to try again?”
Assess for relapse with patients who
have quit
The first weeks after the quit attempt are most important because relapse rates are
high. The patient’s visits 3 months to a year after the quit attempt are ideal times to
screen for relapse.
“The first few weeks after quitting can be very stressful, and many former smokers
are tempted to smoke again during this time. Have you felt the urge to smoke?”
If your patient has felt the urge to smoke, but resisted, congratulate her/him. Reiterate
the benefits of remaining abstinent for their health.
“You’re doing a great job. This is such an important step to take for your health.”
If your patient has smoked, encourage him/her to make another quit attempt.
“Quitting can be very difficult. It can often take someone several tries to successfully
quit. Would you like to try again?”
You can also emphasize the harmful effects of secondhand smoke on infants, children,
household members, and pets. This message can motivate patients who have
remained abstinent, as well as those who may have begun to smoke again.
“It’s important that no one smokes in your home. Babies who breathe secondhand
smoke are more likely to have asthma, ear infections, or upper respiratory infections.
They are also more likely to die from SIDS—Sudden Infant Death Syndrome. To protect
your baby’s health, keep him/her away from smoke.”
Nicotine replacement therapy
• Nicotine patch :30 cm2’/21 mg, 20 cm2/14 mg,
10 cm2/ 7 mg nicotine
• Nicotine gum: It's available in a 2-milligram (mg)
dose for regular smokers and a 4-mg dose for
heavy smokers. It can be used up to 20 pieces a
day as needed.
• Nicotine lozenge :This is a tablet that dissolves in
mouth and, like nicotine gum, delivers nicotine
through the lining of mouth. The lozenges are
available in 2- and 4-mg doses, for regular or
heavier smokers.
Nicotine replacement therapy
• Nicotine nasal spray (Nicotrol NS). The nicotine in
this product, sprayed directly into each nostril, is
absorbed through nasal membranes. The nasal
spray delivers nicotine a bit quicker than gum,
lozenges or the patch, but not as rapidly as
smoking a cigarette. Side effects may include
nasal irritation.
• Nicotine inhaler (Nicotrol). This device is shaped
something like a cigarette holder. Common side
effects are mouth or throat irritation and
occasional coughing.
Bupropion
•
•
•
•
•
Antidepressant that inhibits neuronal reuptake of dopamine and
noradrenaline, and is a noncompetitive nicotine antagonist at
nicotinic cholinergic receptors
The drug is commenced while the person is still smoking, and a
quitting date should be set in the second week of therapy (eg day 8)
300 mg /day- 12 wks
Side effects: nausea, rashes, facial swelling, insomnia and dry
mouth. Serum sickness–like reactions can occur, and bupropion can
precipitate mania in patients with bipolar disorder
Seizure: The risk of seizure is increased in patients with known risk
factors for seizures (such as head injury) and in patients taking
other drugs known to reduce the seizure threshold (eg other
antidepressants, including the selective serotonin reuptake
inhibitors, and antipsychotics).
Varenicline
• Nicotinic acetylcholine–receptor partial
agonist/ In the absence of nicotine it has
agonist activity (activates nicotinic
acetylcholine receptors), whereas in the
presence of nicotine it has antagonist activity
(blocks nicotine's ability to bind with these
receptors)
• A quit date should be set, and varenicline
started one to two weeks before the quit date
• Dose: day 1 to 3: 0.5 mg daily
day 4 to 7: 0.5 mg twice daily
day 8 and ongoing: 1 mg twice daily until
the end of the 12 week course
Side effects: nausea, drawsiness, dizziness,
exacerbations of underlying psychiatric illness (eg
schizophrenia, bipolar disorder)
Don’t use with nicotine replacement therapy
Don’t use with bupropion