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Tobacco Cessation

A Brief Intervention Makes a Difference!

October 2007

MaryAnne Waters Tobacco Reduction Coordinator - Interior Health

Authority

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THANKS

• Mayo Clinic Nicotine Dependence Center (Rochester Minnesota)

• Calgary Health Region (Alberta)

• Northern Health Authority (BC)

• Ottawa Heart Institute (Ontario)

• Interior Health (BC)

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Tobacco and You

• Your journey

• Values Check

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Why TOBACCO?

Tobacco use remains our number one preventable cause of illness and death

in our society!

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Most tobacco users want to stop!

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“How will historians describe a society that:watches the equivalent of 3 jumbo jets crash every day,and does so little to prevent it?”

Richard Hurt MDMayo Clinic 1999Mayo Clinic slide

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Challenges - Paradigm shifts

– Tobacco use is a chronic disease not “just a bad habit”

– Tobacco users are not bad people with a bad habit, they are good people with a difficult disease Tim Gauvin, Mayo Clinic

– Tobacco is not the “least of the worries”– Secondhand smoke is not just a nuisance, it’s

a health problem. There is NO safe limit of exposure. (Class A carcinogen)

– Effective treatment exists

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Ex-smokersEx-smokers

Risk of Heart Attack Mayo Clinic slide

CM862644-8

Smokers vs. Ex-SmokersSmokers vs. Ex-SmokersCurrentCurrentsmokerssmokers

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1-21-2 2-32-3 3-43-4No. years since quitting smokingNo. years since quitting smoking

NoNoincreasedincreased

riskrisk

MenMenWomenWomen

IncreasedIncreasedriskrisk

Relative Relative risk risk

estimatestimatee

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A Very Powerful Intervention…

InterventionReduction in Mortality

Smoking Cessation

36%

Statin Therapy 29%

Beta-Blockers 23%

ACE Inhibitors 23%

Aspirin 15%

Critchley JA, Capewell S. Critchley JA, Capewell S. JAMAJAMA;2003;290:86-97;2003;290:86-97

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Cost Effectiveness

• Smoking Cessation $ 2,000 – 6,000

• Rx of Hypertension $ 9,000 – 26,000

• Rx of Hyperlipidemia $ 50,000 – 196,000

Cost per life-year saved:Cost per life-year saved:

Benowitz NLBenowitz NL Prog Cardiovasc Dis Prog Cardiovasc Dis 2003;46:91-1112003;46:91-111

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• “The safety of nicotine-replacement therapy in

cardiovascular disease patients is supported by data from randomized

trials, efficacy studies, observational data and physiologic

studies.”Joseph AM, Fu, Progress in Cardiovascular Diseases 2003;45:429-441

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• “Our finding that nicotine patch therapy did not increase mortality in

inpatients admitted with acute coronary syndromes suggests the

likelihood of safety in this population…” Meine TJ, Patel MR, et al Meine TJ, Patel MR, et al Am J CardiolAm J Cardiol 2005;95:976-978 2005;95:976-978

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NRT and CV Risk

“The use of NRT is not associated with any increase in the risk of

myocardial infarction, stroke, or death.”

N = 33,247Hubbard R, Lewis S, et al. Hubbard R, Lewis S, et al. Tobacco ControlTobacco Control 2005;14:416-421 2005;14:416-421

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What can be done?

• Brief Interventions are effective !• ASK, ADVISE, ASSIST• Dose Response• If we don’t address it the silent message

is that “it’s not a problem”• If parents don’t smoke; kids much less

likely to.• “If the 2.2 million working nurses in the U.S.

each helped one person per year quit smoking, nurses would triple the quit rate.” Tobacco Free Nurses

• Don’t forget about secondhand smoke……

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But do BIT work?

BIT are way better than doing nothing

Simple advice adds 2% to baseline quit rates (to 7%)

10 minutes of counseling brings it to 19%

Adding medication results in quit rates as high as

29%

Most smokers do not need complex, long-term, intensive treatment

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Brief Interventions - “Bare Bones”

• Tobacco data tracking on forms is essential

• Provide support options

Sample Scripting:• Do you currently use tobacco? __ Yes __ No

– If yes, are you interested in stopping? __ Yes __ No

– If yes, referral (to Quitline or other local resource) given? __ Yes __ No

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Brief Interventions, Next Steps

3 A’s:•ASK•Advise•Assist

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Changes:• We don’t all see the world

the same!• In any change the person

changing is the “expert”!• We “get by with a little

help from our friends”!• Help is only help if it is

helpful!• We have 2 ears and 1

mouth!• Opportunityisnowhere!

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Spirit of Motivational Interviewing

A dance not a wrestling match!

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Motivational Interviewing

• “… directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Rollnick and Miller, 1995

• Used to enhance positive health-behavior change by placing the client in the center of the change process.

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ASK

• Do you currently use tobacco? • Tell me about where tobacco “fits” for you?• One of the areas of health I always discuss is

tobacco; where does tobacco fit for you?• Are you ready to consider stopping smoking (or

chewing)?

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Advise / Assist

• My experience in cardiac care is that tobacco is closely linked with heart health; I urge you to consider stopping smoking.

• As a nurse I see the effects of tobacco on health, would it be helpful for me to share some possible benefits I see for you, if you were to stop smoking?

• As a …, I know most tobacco users want to quit and effective help exists, would you be interested in finding out what help is available?

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Assist:

• Many smokers are very concerned about nicotine withdrawal. Would you be interested in NRT as a support to help you deal with your cravings?

• If it would be helpful, I could share with you some tips that have worked for others who wanted to stop smoking / chewing…..

• If it would be helpful, we could discuss some “good things” and some “not so good things” about your tobacco use….

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Other “tools”

•Assess readiness for change•Assess Nicotine

Dependence•Assess supports

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Readiness Ruler

• On a scale of 0-10: – How ready are you to stop smoking

(tobacco)?– How important is stopping to you?– How confident are you in your ability

to stop?

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Assessing Dependence

“How soon after waking do you smoke your first cigarette?”

more than 1 hour = low 6-59 minutes = moderate less than 6 minutes = high

“How many cigarettes, on average, do you smoke each day?”

10or less = low 10 -20 = moderate 20 or more = high

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Medications

Nicotine Replacement Therapy (NRT) Control urges by preventing withdrawal symptoms Patch gum or inhaler Dependence, >10 cigarettes per day, and ready to quit; or, Zyban intolerant

Check to see if on local formulary

Bupropion (Zyban) Champix – available April 2007

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Assessing Supports:

• Social support – family and friends• Health Professionals• Local cessation support – groups,

“quit lines” (toll free), web sites• Print resources – CCS, Lung

Association, etc

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Handouts

• “Changes” worksheet• 3A’s sample scripts• Tobacco Cessation Support – NEXT

STEPS• Algorithms• Benefits of Stopping• Scenarios• Canadian Quitlines

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Summary: YOU can MAKE a DIFFERENCE! Brief Interventions are effective!!

Ask, Advise, Assist – basics can be done in less than a

minute. Start with small steps and build (PDSA cycles) “You can do it, we can help” message for patients