Self Care Exam Iii Tobacco

Front 1

what percent of people in the US are currently smokers

Back 1

20.6% (46 million)

Front 2

smoking leads to how many preventable deaths each year?

Back 2

440,000

Front 3

how many New Yorkers smoke?

Back 3

18.9%

Front 4

consequences of smoking
cancer:

Back 4

Acute myeloid leukemia
Bladder and kidney
Cervical
Esophageal
Gastric
Laryngeal
Lung
Oral cavity and pharyngeal
Pancreatic

Front 5

consequences of smoking
pulmonary disease:

Back 5

Acute (e.g., pneumonia)
Chronic (e.g., COPD)

Front 6

consequences of smoking
cardiovascular disease:

Back 6

Abdominal aortic aneurysm
Coronary heart disease
Cerebrovascular disease
Peripheral arterial disease

Front 7

consequences of smoking
reproductive effects:

Back 7

Reduced fertility in women
Poor pregnancy outcomes (e.g., low birth weight, preterm delivery)
Infant mortality

Front 8

consequences of smoking
other:

Back 8

cataract, osteoporosis, periodontitis, poor surgical outcomes

Front 9

there are an estimated 4,800 compounds in tobacco smoke,
including 11 proven human carcinogens

Back 9

true

(60 known carcinogens)

Front 10

gases in tobacco smoke

Back 10

Carbon monoxide
Hydrogen cyanide
Ammonia
Benzene
Formaldehyde

Front 11

particles in tobacco smoke

Back 11

Nicotine
Nitrosamines
Lead
Cadmium
Polonium-210

Front 12

Nicotine is the addictive component of tobacco products,
but it does NOT cause the ill health effects of tobacco use

Back 12

true

Front 13

quitting health benefits
2 weeks to 3 months:

Back 13

Circulation improves,
walking becomes easier
Lung function increases up to 30

Front 14

quitting health benefits
1 to 5 months

Back 14

Lung cilia regain normal function
Ability to clear lungs of mucus increases
Coughing, fatigue, shortness of breath decrease

Front 15

quitting health benefits
1 year

Back 15

Excess risk of CHD decreases to half that of a continuing smoker

Front 16

quitting health benefits
5 years

Back 16

Risk of stroke is reduced to that of people who have never smoked

Front 17

quitting health benefits
10 years

Back 17

Lung cancer death rate drops to half that of a continuing smoker
Risk of cancer of mouth, throat, esophagus, bladder, kidney, pancreas decrease

Front 18

quitting health benefits
after 15 years

Back 18

Risk of CHD is similar to that of people who have never smoked

Front 19

surgeon general report on second hand smoke
children:

Back 19

Increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma

Front 20

surgeon general report on second hand smoke
adults:

Back 20

Increased risk for coronary heart disease and lung cancer

Front 21

how many deaths are attributed to second hand smoke annually?

Back 21

50,000

Front 22

tobacco use and cessation should be addressed as:

Back 22

a CHRONIC disease not an acute condition

Front 23

tobacco use behavior

Back 23

Physical addiction

Habit

Psychological dependence

Front 24

targets of tobacco cessation
environment/habit

Back 24

Coping strategies
Modifying daily routines
Social interactions

Front 25

targets of tobacco cessation
physical addiction

Back 25

Alleviation of withdrawal symptoms
Use of Medications
Additional focus on behavioral changes

Front 26

targets of tobacco cessation
psychological

Back 26

Healthy alternatives
Stress
Weight control
Pleasure/relaxation

Front 27

2008 clinical practice guidelines

Back 27

Reinforced 5A’s and 5R’s
Counseling and the use of medications are more effective than either intervention alone
7 First line agents (Addition of the nicotine lozenge and varenicline)
Specific considerations when counseling special populations

Front 28

2008 clinical practice guidelines
special populations:

Back 28

Pregnant patients
Light smokers
Adolescents
Smokeless tobacco users

Front 29

2008 clinical practice guidelines
recommendations

Back 29

To utilize counseling cessation interventions rather than medications to assist in the quit process

Front 30

5 A's

Back 30

Ask
Advise
Assess
Assist
Arrange

Front 31

step 1 - ASK

Back 31

Ask every patient if he or she uses tobacco
--Vital part of a complete medical history

Flag the patient records of tobacco users:
--For subsequent visits
--To monitor progress

Front 32

step 2- ADVISE

Back 32

Initiate the quitting process:
--Provide strong advice to quit
--Motivate the patient
--Educate the patient on the benefits of quitting

Front 33

step 3- ASSESS

Back 33

Assess a patient’s readiness to quit
--Not ready to quit
--Ready to quit
--Recent quitter or former user

Front 34

step 3- ASSESS (cont)
based on their rediness to quit:

Back 34

Not ready to quit--> Utilize the 5 R’s
Ready to quit-->Continue 5 A’s
Recent quitter or former user -->Continue 5 A’s

Front 35

step 4- ASSIST

Back 35

Assess tobacco use history
Discuss key issues or triggers
Facilitate quit process
--Discuss pharmacotherapy options
--Discuss cognitive and behavioral coping strategies (Handbook of Nonprescription Drugs- Table 50-4)

Front 36

step 5- ARRANGE

Back 36

Arrange for a follow up visit

In NY call 1-800- QUITNOW

Front 37

5 R's

Back 37

Relevance
Risks
Rewards
Roadblocks
Repetition

*personalize *

Front 38

the difficult decision to quit

Back 38

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

Front 39

effects of clinician interventions at 5+ months
no clinician:

Back 39

10.2

Front 40

effects of clinician intervention at 5 + months
self help material:

Back 40

10.9

Front 41

effects of clinician intervention at 5+ months
non physician clinician

Back 41

15.8

Front 42

effects of clinician intervention at 5 + months
physician clinician

Back 42

19.8


** with help from clinician, the success rate almost doubles **

Front 43

Compared to smokers who receive assistance from no clinicians, smokers who receive assistance from two or more clinicians are 2.4–2.5 times as likely to quit successfully for 5 or more months.

Back 43

true

Front 44

tobacco cessation treatments
NRT's

Back 44

Gum
Patch
Lozenge
Nasal spray
Inhaler

Front 45

tobacco cessation treatments
non NRT's (medications)

Back 45

Bupropion SR (Zyban®)

Varenicline (Chantix®)

Front 46

how does nicotine work?

Back 46

Core neurotransmitter
Nicotene attaches onto the receptors
Pleasurable neurotransmitter
Makes you want to keep doing it

Front 47

pharmacotherapy

Back 47

“Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations* for which there is insufficient evidence of effectiveness.”

Front 48

NRT rationale

Back 48

Reduces withdrawal symptoms
Allows patient to focus on behavioral and psychological aspects

**improves success rate **

Front 49

NRT precautions

Back 49

Patients with underlying cardiovascular disease
Recent myocardial infarction (within past 2 weeks)
Serious arrhythmias
Serious or worsening angina

*may be used if monitored by MD*

Front 50

NRT drug interactions

Back 50

none known

Front 51

Nicotene Gum

Back 51

Nicorette Gum- OTC
2mg, 4mg
Original, orange, mint,
cinnamon and fruit

Front 52

nicotene gum
dosing (what mg)

Back 52

> 25 = 4mg
< 25 = 2mg

Front 53

chewing technique for nicotene gum

Back 53

1.chew slowly
2. stop chewing when you notice a peppery taste or tingle
3. park between cheek and gum
4. chew again when no taste or tingle

Front 54

nicotene gum
dosing (how long and how many)

Back 54

week 1 to 6= 1 q1 - 2h

week 7 to 9= 1 q2 - 4h

week10 to 12= 1 q4 - 8h

** max of 24 pieces in a day **

Front 55

how long should you wait to eat or drink while using this NRT?

Back 55

15 minutes before and during use

Front 56

advantages of nicotene gum

Back 56

Satisfies oral cravings
Delays weight gain
Flexible titration

Front 57

disadvantages of nicotene gum

Back 57

“Park and chew” may not be socially acceptable
Use may be difficult
Proper chewing technique necessary to minimize adverse effects (nausea, hiccups)

Front 58

nicotene lozenge

Back 58

Commit Lozenge- OTC
2mg, 4mg

“Time to first
cigarette” dosing

Front 59

Nicotine Lozenge: Dosing

Back 59

Dosage is based on the “time to first cigarette” (TTFC) as an indicator of nicotine addiction

Front 60

use commit lozenge 2mg if:

Back 60

you have your first cigarette after 30 minutes of waking up

Front 61

use commit 4mg lozenge if:

Back 61

if you smoke the first cigarette within 30 minutes of waking up

Front 62

nicotene lozenge dosing (how many days and how much) is the same as for nicotene gum

Back 62

true

Front 63

advantages of nicotene lozenges

Back 63

Satisfies oral cravings
Easy to use
Flexible titration

Front 64

disadvantages of nicotene lozenges

Back 64

Gastrointestinal side effects (nausea, hiccups, and heartburn)

Front 65

NRT patches

Back 65

Nicoderm CQ- OTC
7mg, 14mg, 21mg (24 hour)

** 1 pack/day = 21mg **
step down method

Front 66

NRT patches
dosing for light smokers

Back 66

<10 cigarettes per day
step 2 (14mg for 6 weeks)
step 3 (7mg for 2 weeks)

Front 67

NRT patches
dosing for heavy smokers

Back 67

>10 cigarettes per day
step 1 (21mg for 6 weeks)
step 2 (14mg for 2 weeks)
step 3 (7mg for 2 weeks)
** typical duration is 12 weeks **

Front 68

directions for use of NRT patches

Back 68

Choose an area of skin on the upper body or upper outer part of the arm
Make sure skin is clean, dry, hairless, and not irritated
Apply patch to different area each day
Do not use same area again for at least 1 week

Front 69

advantages of NRT patches

Back 69

Consistent nicotine levels
Easy to use
Good compliance

Front 70

disadvantages of NRT patches

Back 70

Unable to titrate the dose
Local skin reactions

Doesn't help with "oral" cravings

Front 71

how much nicotine in a cigarette

Back 71

1mg

Front 72

nicotine nasal spray

Back 72

Nicotrol NS- Prescription
0.5mg nicotine per spray

One dose = 1 mg nicotine (2 sprays,
one 0.5 mg spray in each nostril)

Recommended use-
1-2 doses/hour

Maximum- 5 doses/hour

Duration= 3 months

Front 73

nicotine nasal spray
dosing and administration

Back 73

One dose = 1 mg nicotine
(2 sprays, one 0.5 mg spray in each nostril)

For best results, patients should use at least 8 doses daily for the first 6–8 weeks

Termination:
Gradual tapering over an additional 2–4 weeks

Front 74

nicotine nasal spray
advantages

Back 74

Convenient titration
Effective relief of cravings

Front 75

nicotine nasal spray
disadvantages

Back 75

Nasal/throat irritation
Dependence concerns

Front 76

nicotine inhaler

Back 76

Nicotrol Inhaler- Prescription
10mg cartridge delivers 4mg of nicotine

Start with 6 cartridges to a maximum of 16 cartridges/day

Duration= 3 months

Front 77

nicotine inhaler: dosing

Back 77

Start with at least 6 cartridges/day during the first 3-6 weeks of treatment

Gradually reduce daily dosage over the following 6–12 weeks

Front 78

nicotine inhaler
directions for use

Back 78

Inhale into back of throat or puff in short breaths

Nicotine in cartridges is depleted after about 20 minutes of active puffing
Cartridge does not have to be used all at once
Open cartridge retains potent for 24 hours

Inhaling lightly, not doing a deep inhalation

Release the nicotene into the mouth

Front 79

nicotine inhaler
other facts:

Back 79

The inhaler may not be as effective in very cold (<59F) temperatures—delivery of nicotine vapor may be compromised

Use the inhaler longer and more often at first to help control cravings (best results are achieved with frequent continuous puffing over 20 minutes)

Front 80

nicotine inhaler
advantages

Back 80

Easy titration
Mimics hand-to-mouth routine

Front 81

disadvantages of nicotine inhaler

Back 81

Throat or mouth irritation
Cartridges should not be stored in very warm or cold conditions.
High frequency of use

Front 82

Bupropion SR

Back 82

Atypical antidepressant thought to affect levels of various brain neurotransmitters
Dopamine (Inhibits reuptake of dopamine)
Norepinephrine
Clinical effects
- craving for cigarettes
- symptoms of nicotine withdrawal

Front 83

Bupropion SR
dosing:

Back 83

Initial treatment
150 mg po q AM x 3 days
Then…
150 mg po bid
Duration, 7–12 weeks

** should start 1 to 2 weeks before quitting **

Front 84

Bupropion SR
advantages

Back 84

Easy oral option (Twice daily can address compliance)
Benefit in depressed patients

Front 85

Bupropion SR
disadvantages

Back 85

Common side effect (insomnia)
Seizure risk
Precaution/Contraindications
--History of seizures
--Anorexia or bulimia nervosa
--Medications that lower seizure threshold

Front 86

Bupropion in the news

Back 86

July 2009, Bupropion received a black-box warning for neuropsychiatric events.

Front 87

Varenicline

Back 87

Binds at the alpha4 beta2 neuronal nicotinic acetylcholine receptors
Stimulates low-level agonist activity
Competitively inhibits binding of nicotine
Clinical effects
-decrease craving for cigarettes
-decrease symptoms of nicotine withdrawal

Front 88

Varenicline
dosing:

Back 88

day 1 to 3 = 0.5mg daily
day 4 to 7 = 0.5mg bid
day 8 to end = 1mg bid
* for up to 12 weeks *

** begin therapy 1 week prior to quitting **

Front 89

Varenicline
advantages

Back 89

Easy to use oral formulation.
Twice daily dosing might reduce compliance problems.
Offers a new mechanism of action for persons who have failed other agents

Front 90

Varenicline
disadvantages

Back 90

May induce nausea in up to one third of patients.
Post-marketing surveillance data indicate potential for neuropsychiatric symptoms.

Front 91

varenicline in the news

Back 91

In 2008, Pfizer added a warning label advising patients and caregivers:
Patients should stop taking varenicline and contact their healthcare provider immediately if agitation, depressed mood, or changes in behavior that are not typical for them are observed, or if the patient develops suicidal ideation or suicidal thoughts.

July 2009, Varenicline received a black-box warning for neuropsychiatric events.

Front 92

Combination Pharmacotherapy

Back 92

Combination NRT
Long-acting formulation (patch)
Produces relatively constant levels of nicotine
PLUS
Short-acting formulation (gum/lozenge, inhaler, nasal spray)
Allows for acute dose titration as needed for nicotine withdrawal symptoms
Bupropion SR + Nicotine Patch

Front 93

evaluating patients

Back 93

ASK every patient about their tobacco use
ADVISE patients on the risks of tobacco use and the benefits of quitting
ASSESS patient’s level of readiness
--Not ready to quit
--Ready to quit
--Recent quitter
ASSIST patient in facilitating in the quit process
ARRANGE for follow up

Front 94

what can YOU do

Back 94

Quitting is a process that occurs over time, not a discrete, one-time event.
ASK every patient about their tobacco use

Provide support to help the patient’s
quit attempt stay on track

Arrange for follow up

Front 95

Step 1 and 2 - gather information

subjective and objective information

Back 95

CC
PMH
Current medications
Allergies
SH
FH

pqrssta - N/A

Front 96

Step 3 - Identify MRP

Back 96

Indication without treatment
Treatment without indication
Drug Interaction
Adverse drug reaction
Overdose
Underdose
Wrong treatment
Failure to receive treatment
Inappropriate monitoring

Front 97

Step 4 - exclusions for self care

Back 97

All patients should be provided with smoking cessation counseling.

Front 98

Step 5 - Identify Alternative Solutions/Treatment Options Available

Back 98

Before deciding which treatment approach is appropriate for our patient, we need to utilize the 5 _A’s______.

Front 99

Step 6 -Recommend a Treatment option and Rationale

Back 99

targets of smoking cessation
1.Physical addiction
2. Habit
3. Pscychological

?? Slides posted

Front 100

Step 7- 11- Patient Education and Monitoring/Follow up

Back 100

Educate patient on the dosing and administration for the pharmacotherapy option chosen

Discuss ways to reduce cravings and stay on track for a successful quit process
Cognitive and behavioral coping strategies

Arrange for follow up