Tobacco Addiction, Tobacco Addiction, Why is It so Powerful?Why is It so Powerful?

Gaylene Mooney, M.Ed, RRT-NPSGaylene Mooney, M.Ed, RRT-NPS

Points to CoverPoints to Cover Tobacco Use StatisticsTobacco Use Statistics Two Forms of Nicotine Two Forms of Nicotine Monoamineoxidase (MAO)Monoamineoxidase (MAO) Definition of AddictionDefinition of Addiction Maslow’s Hierarchy of NeedsMaslow’s Hierarchy of Needs Triangle of AddictionTriangle of Addiction Neurobiology of AddictionNeurobiology of Addiction Stages of ChangeStages of Change The Association for the Treatment of Tobacco Use and The Association for the Treatment of Tobacco Use and

Dependence (ATTUD)Dependence (ATTUD) Brief discussion of the new Medicare reimbursementBrief discussion of the new Medicare reimbursement

Tobacco Use StatsTobacco Use Stats

46 Million Adults 46 Million Adults

15.6% 5.3%

23.9%

54.9%

One Approximately Every One Approximately Every Two Minutes Two Minutes

Http://phil.cdc.gov/Phil/default.asp >430,000 (1178/day)

It Isn’t Breast Cancer?It Isn’t Breast Cancer?

Sir Richard DollSir Richard Doll Died in June at age 92Died in June at age 92 1950 study linking 1950 study linking

smoking to lung cancersmoking to lung cancer 1954: Doll and Hill 1954: Doll and Hill

published “The Mortality published “The Mortality of Doctors and Their of Doctors and Their Smoking Habits” in BMJ Smoking Habits” in BMJ (lead to most M.D. giving (lead to most M.D. giving up smoking)up smoking)

Follow-up study in 2004Follow-up study in 2004 ½ - 2/3 of all individuals ½ - 2/3 of all individuals

who begin smoking in who begin smoking in youth will die because of ityouth will die because of it

Two Forms of Nicotine Two Forms of Nicotine

Bound to tobacco leaf Bound to tobacco leaf Free (altered by pH of the smoke)Free (altered by pH of the smoke)

Results when ammonia is added Results when ammonia is added Immediate impactImmediate impact More satisfactionMore satisfaction

http://tobaccodocuments.org/product_design/00044522-4523.htmlhttp://tobaccodocuments.org/product_design/00044522-4523.html

pHpH Cigarette: 5.5 – 6.0 (filter & carbon actually increases pH, Cigarette: 5.5 – 6.0 (filter & carbon actually increases pH,

verified by tobacco documents)verified by tobacco documents) Spit: up to 8.3 (Source: CDC)Spit: up to 8.3 (Source: CDC) Cigar: 6.2 – 8.2Cigar: 6.2 – 8.2

http://cancercontrol.cancer.gov/tcrb/monographs/9/m9_6.PDFhttp://cancercontrol.cancer.gov/tcrb/monographs/9/m9_6.PDF

Absorption of NicotineAbsorption of Nicotine

Rate of AbsorptionRate of Absorption Cigarette : fastest routeCigarette : fastest route Cigar : slower than cigarettesCigar : slower than cigarettes Spit : slowest rateSpit : slowest rate

http://cancercontrol.cancer.gov/tcrb/monographs/9/m9_6.PDFhttp://cancercontrol.cancer.gov/tcrb/monographs/9/m9_6.PDF

How much Nicotine?How much Nicotine?

10mg of nicotine/cigarette10mg of nicotine/cigarette 1 to 2 mg of nicotine/cigarette absorbed1 to 2 mg of nicotine/cigarette absorbed

10 puffs over 5 minutes10 puffs over 5 minutes 1 ½ pack/day = 300 hits1 ½ pack/day = 300 hits

Cigar = up to 1 ½ packs of cigarettesCigar = up to 1 ½ packs of cigarettes Spit = 1 can = 3 packs of cigarettesSpit = 1 can = 3 packs of cigarettes

http://www.nida.nih.gov/researchreports/nicotine/nicotine2.html

When is it Addiction?When is it Addiction?Three or more of the following:Three or more of the following: Preoccupation with getting tobaccoPreoccupation with getting tobacco Compulsive useCompulsive use Difficulty with controlling intakeDifficulty with controlling intake Persistent, even with health problemsPersistent, even with health problems RelapseRelapse Tolerance Tolerance WithdrawalWithdrawal

References: World Health OrganizationReferences: World Health Organization Diagnostic and Statistical Manual - IV (DSM-IV) Diagnostic and Statistical Manual - IV (DSM-IV)

How long does it take to become dependent?How long does it take to become dependent? Can be after the first cigarette!Can be after the first cigarette!http://cancercontrol.cancer.gov/tcrb/monographs/9/m9_6.PDFhttp://cancercontrol.cancer.gov/tcrb/monographs/9/m9_6.PDF

What Initiates Tobacco Use?What Initiates Tobacco Use?

Physiological Needs

Security & Safety Needs

Social Needs

Esteem Needs

SelfActualization Being Need

Deficit Needs

A. H. Maslow. A Theory of Human Motivation. Psychological Review, 50, 370-396. (1943)

Maslow’s Hierarchy of Need

Triangle of AddictionTriangle of Addiction

Emotion (emotional need)

Environmental or social (relieves stress)

Physiologic (changes to

need of nicotine)

Spiritual (Best Friend)

Other Risk Factors for Initiation Other Risk Factors for Initiation

1.1. Children of Moms who smoke regularly Children of Moms who smoke regularly 2.2. Risk of nicotine addiction increased more if Risk of nicotine addiction increased more if

smoked during pregnancysmoked during pregnancy3.3. Co-Twin (within two years)Co-Twin (within two years)4.4. Same Sex Sibling who smokesSame Sex Sibling who smokes5.5. Older Sibling who smokesOlder Sibling who smokes6.6. Adolescents more vulnerable to addictionAdolescents more vulnerable to addictionEur Addict Res. 2003 Jul;9(3):120-30 Twin Res. 2003 June;6(3):209-17Eur Addict Res. 2003 Jul;9(3):120-30 Twin Res. 2003 June;6(3):209-17 J Adolesc Health. 2003 Jul;33 (1): 25-30 J Adolesc Health. 2003 Jul;33 (1): 25-30 J Neurosci. 2003 Jun 1;23(11):4712-6J Neurosci. 2003 Jun 1;23(11):4712-6

Can School Outcome Predict Can School Outcome Predict Smoking Behavior?Smoking Behavior?

Low gradesLow grades Poor teachers’ prognosesPoor teachers’ prognoses Early unemploymentEarly unemployment

Scand J Public Health.2003;31 (3):229-32Scand J Public Health.2003;31 (3):229-32

Risk Factors for Risk Factors for InitiationInitiation

Count Down from TenCount Down from Ten

•DopamineDopamine““I feel good”I feel good”

•AcetylcholineAcetylcholine•Serotonin Serotonin

Anti-depressantAnti-depressant•EpinephrineEpinephrine

Adrenal glandAdrenal glandVentral Tegmental Area

Medial Forebrain Bundle

http://www.nida.nih.gov/researchreports/nicotine/nicotine3.html#how

Is Nicotine the Only Chemical Is Nicotine the Only Chemical Causing the Addiction?Causing the Addiction?

Marked reduction of Monoamineoxidase Marked reduction of Monoamineoxidase (MAO)(MAO) Enzyme that breaks dopamine downEnzyme that breaks dopamine down Something other than nicotine causing the Something other than nicotine causing the

change in MAOchange in MAO

http://www.nida.nih.gov/researchreports/nicotine/nicotine2.html

Stages of Change ModelStages of Change Model

Prochaska, J. & DiClemente, C. (1983). Stages and processes of self-change in smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390-395.

Pre-Contemplation StagePre-Contemplation Stage

Not ready to quitNot ready to quit Not interested in Not interested in

changingchanging Are defensiveAre defensive ““I can’t quit”I can’t quit” ““It will not happen to me”It will not happen to me” ““I enjoy it to much”I enjoy it to much”

Stages of Change

Contemplation & Contemplation & Determination StagesDetermination Stages

Seriously thinking about Seriously thinking about changingchanging

Aware of the Aware of the needneed to quit to quit Taking small steps to quitTaking small steps to quit ““I know I need to quit”I know I need to quit” ““You know, I should quit”You know, I should quit” ““I I wantwant to quit within the to quit within the

next 30 days”next 30 days”

Stages of Change

Action StageAction Stage Ready for changeReady for change Prepared mentally to Prepared mentally to

changechange ““I am going to quit I am going to quit

smoking”smoking” ““I want to live to see my I want to live to see my

grandchildren”grandchildren”

Attends class or calls a Attends class or calls a quitlinequitline

Quits smokingQuits smoking Last approximately 6 Last approximately 6

monthsmonths

Stages of Change

DSM-IV Criteria for Nicotine DSM-IV Criteria for Nicotine Withdrawal (APA, 2994)Withdrawal (APA, 2994)

Maintenance StageMaintenance Stage

Has quit smokingHas quit smoking Prepares for stress Prepares for stress Handles temptationHandles temptation Reminds themselves Reminds themselves

of what they have of what they have accomplishedaccomplished

Continues to be Continues to be smoke-freesmoke-free

Stages of Change

Relapse StageRelapse Stage

Most experienceMost experience Sees oneself as a Sees oneself as a

failurefailure A normal eventA normal event A person may go A person may go

through the stages of through the stages of change several times change several times before complete before complete cessation.cessation.

Stages of Change

Symptoms of Nicotine Symptoms of Nicotine OverdoseOverdose

upset stomachupset stomach stomach pain stomach pain salivation salivation vomiting vomiting diarrhea diarrhea cold sweat cold sweat

bad headachesbad headaches dizzinessdizziness blurred visionblurred vision hearing difficultieshearing difficulties weakness weakness faintingfainting mental confusionmental confusion

Source: TobaccoFreeKids.org

We MustBreakThe Cycle

Not a

NoAsk: Do you use tobacco?

Have you ever used tobacco?

No No intervention

Encourage continued cessation & re-evaluate next visit

Access Readiness to

quit

Yes Yes

Do you want to quit?

Yes

Advise to quit

Assist and Arrange

Call _____ at ______to make appt.

No

Followup next visit

5 “R’s”RelevanceRisksRewardsRoadblocksRepetition

Do you want to quit within the next 30 days?

Yes

No

Re-evaluate next visit

Tobacco Use Assessment Protocol

The Association for the The Association for the Treatment of Tobacco Use and Treatment of Tobacco Use and

Dependence (ATTUD)Dependence (ATTUD) GoalsGoals

Build and maintain an organization representing providers dedicated to Build and maintain an organization representing providers dedicated to the treatment of tobacco use and dependence. the treatment of tobacco use and dependence.

Establish standards for core competencies, for training, and for credentEstablish standards for core competencies, for training, and for credentialing of tobacco treatment providersialing of tobacco treatment providers. .

Establish multiple forums (e.g., annual meeting, listserv, and journal) Establish multiple forums (e.g., annual meeting, listserv, and journal) for information exchange on best practices, innovations in treatment, for information exchange on best practices, innovations in treatment, and gaps in the empirical base of tobacco treatment. and gaps in the empirical base of tobacco treatment.

Serve as an advocate and voice for tobacco users to promote the Serve as an advocate and voice for tobacco users to promote the awareness and availability of awareness and availability of effectiveeffective tobacco treatments. tobacco treatments.

Serve as a Serve as a reliable and respected resource of evidence-based tobacco reliable and respected resource of evidence-based tobacco use and dependence treatmentuse and dependence treatment for the health care community, for the health care community, regulatory agencies, private foundations, and especially tobacco users. regulatory agencies, private foundations, and especially tobacco users.

Promote the implementation of and increased access to Promote the implementation of and increased access to evidence-evidence-based practicebased practice across the spectrum of treatment modalities via policy, across the spectrum of treatment modalities via policy, funding, and system changes. funding, and system changes.

www.attud.org

The New Medicare PolicyThe New Medicare Policy

AARC reviewAARC review Who is covered?Who is covered? What is covered?What is covered? What is not covered?What is not covered? Who can charge for services?Who can charge for services? Billing CodesBilling Codes

SummarySummary

Be more empatheticBe more empathetic Understand, it Understand, it ISIS all in the head all in the head It is part of your jobIt is part of your job Advise, Assess, & AssistAdvise, Assess, & Assist Every patient, every timeEvery patient, every time Remember, with open hands and not Remember, with open hands and not

pointing fingerspointing fingers RT as Tobacco Treatment Specialist’RT as Tobacco Treatment Specialist’

Do you want to have fun, while reducing stress Do you want to have fun, while reducing stress

and improving your cardiovascular health? and improving your cardiovascular health? Go Ballroom Dancing! 300 – 400 calories/hourGo Ballroom Dancing! 300 – 400 calories/hour