Tobacco Update:
New products to addict.
New strategies to quit!
Linda Hancock, FNP, PhD
VCU Student Health Services
Director, Wellness Resource Center
(804) 828-7815
or
quit@vcu.edu
Who am I?
• FNP – and local “smoking cessation guru”
• PhD – I count a lot of things
• College Health for 20 years
• Every semester we help over 200 students work on
tobacco cessation
• 2005 - attended Mayo Clinic week long
Nicotine Dependence Training
• I love working with tobacco users!
Goals for session
• You aren’t a tobacco
cessation specialist..
but you can be a
CHEERLEADER!
• Get your patients to
call 1 800 QUIT NOW
• The QUIT NOW
counselors are
cessation experts…
it’s all they do!
• You are prescribers so
you need to be the
medication expert!
• PLEASE encourage every
smoker to keep trying
medications and
strategies until they quit.
• POST POSTERS in your
waiting room and exam
rooms!!!
• Be vigilant about NEW
tobacco products!
What percent of adult Virginians
are daily smokers? CDC 2008 BRFSS data
12% 12.4%
15%
20%
25%
30%
35%
40%
26%
22%
17%
17%
13%
4%
%
40
%
35
%
30
%
25
%
20
%
15
%
0%
12
1.
2.
3.
4.
5.
6.
7.
Most VCU students
(7 of 10)
didn’t smoke at all in
the past month.
Only about 8-12%
smoke daily.
FREE
Quit Kits at
OHP
smoking cessation
pills Chantix
www.lgbtsmokefree.org
A high-risk population
for smoking!
LGBTs smoke at rates
40% to almost 200%
higher than the general
population
Please post this poster
“Genetic Snowflakes” & tobacco
• Research on genes such as CYP 2A6
• About 1 in 4 are missing genetic ability make
enzymes to break down nicotine
• 3 in 4 people can metabolize nicotine and if
used are at high risk for addiction
Understanding a smokers struggle
-adapted from Mayo Clinic Nicotine Dependency Center publication 2005
= Withdrawal - empty receptors
= Craving chemicals – triggered by environment
The tobacco epidemic, like the “flu” is
always mutating.
-Jack Henningfield, PhD
Tobacco Companies and others out
to make money on nicotine are
always changing•What they market
•How they market
•To whom they market
Virginia Slims introduces
“Purse Packs”
• In October 2008 Phillip Morris
introduced "Purse Packs" for
select Virginia Slims brands
• The “Purse Pack” is pink,
sleek rectangular
packaging with square
ends. It holds 20 sticks
that are smaller in
diameter than a typical
smoke.
What is this?
Not..
Hookah
Water pipe
Water Pipes
also called “Hookah”
Hookah Materials
Maassel or mu’essel
(assal means honey in Arabic)
Moist paste like mixture with 30%
crude cut tobacco
Fermented with approximately 70%
honey, molasses and pulp of
different fruits.
Toxin Content of smoke
(single hookah session compared to a single cigarette)
Chemical
HOOKAH
CIGARETTE
COMPARISON
“Tar”
802mg
22.3 mg
36 times the
tar
Nicotine
2.96 mg
1.74 mg
1.7 times the
nicotine
Carbon
Monoxide
145 mg
17.3 mg
8.4 times the
carbon
monoxide
Please post this poster!
What is Snus?
•
•
•
•
•
•
•
Rhymes with "goose"
Cynics might say "noose“
Swedish type of “spitless-smokeless” tobacco
Comes in teabag-like pouches
User sticks between the upper lip and gum
Use 30 minutes
Then discard without spitting
Snus:
A form of Swedish smokeless tobacco
Usually placed in upper lip
Where is Snus most popular?
• Snus is the Swedish word for moist snuff.
• It is manufactured and mainly consumed in
Sweden and Norway.
• Snus is subjected to a heating treatment
process that sharply reduces
microorganism content; no fermentation
has been used in its production
• This processing method and refrigerated
storage reduce the formation of nitrates
and nitrosamines, resulting in a product low
in TSNAs.
Nicogel
New smokeless, dissolvable tobacco
products from R.J. Reynolds
Test marketing in Columbus, OH, Portland, OR, and
Indianapolis, IN starting in January 2009
My personal biases…
• We need to be prepared to get smokers
at “reachable moments”
• Smokers get sick frequently!
• ALL STAFF who can prescribe must be
intervene with tobacco users.
– Every clinic needs a
“tobacco cessation guru”
There are currently
7 MEDICATIONS for first line use
5 NRT products
2 Smoking Cessation PILLS
Bupropion HCL
( Wellbutrin or Zyban)
Varenicline
(Chantix or Champix)
Blocks Nicotinic
receptors, not advised to
use with NRT
(nicotine replacement therapy)
Combination
Therapy
Patch
Gum
Nasal Spray
Puffers
Lozenges
Neurobiology of nicotine addiction
• Nicotine ACh Receptors are all over the body
• There are several subtypes
– Alpha4Beta2 receptors predominate in the brain
• (site of action for Varenicline)
– Alpha 7 receptors (link to schizophrenia?)
• These receptors affect brain reward, mood,
cognition, etc.
• SMOKERS have UPREGULATED but poorly
functioning receptors.
Shoes
Analogy
You know how you try on shoes and
some fit and some don’tbut you don’t give up wearing shoes.
That’s they way it is with medications.
You try them on. Some fit. Some don’t.
But you don’t give up trying to quit.
Recommendations:
Dr. Richard Hurt, Director,
Mayo Clinic Nicotine Dependency Center
• Varenicline should be considered a first line
medication for the treatment of tobacco
dependence.
• It has not been tested in adolescent, pregnant or
breastfeeding smokers.
• Varenicline is cleared almost entirely by the
kidneys and dose adjustments are necessary in the
presence of severe renal failure (creatinine
clearance < 30 ml/min.) and patients receiving
hemodialysis.
• Nausea can be minimized by taking the medication
with a large glass of water after eating.
• If patients are intolerant of 1.0 mg twice a day, a
trial of 0.5 mg twice a day should be encouraged.
Varenicline 0.5 mg and 1mg pills
and ways to and adjust the dosing
Bupropion
•
•
•
•
•
•
On the market for cessation since 1997
Found by accident
Originally an antidepressant
Generic 100 mg tab, SR 150 mg tab = Zyban
Category B in pregnancy (safer than the patch- D)
CONTRAINDICATIONS- don’t prescribe if…
–
–
–
–
–
History of Seizure Disorder
Head Trauma with LOC > 30min in past 5 years
History of an Eating Disorder
On other meds that lower seizure potential
Heavy drinkers (a hangover is a seizure prone state)
Main Side effects on bupropion
•
•
•
•
•
•
You’re not depressed
You have extra energy
Seems to limit weight gain with cessation
Treatment for ADHD
May improve ability to orgasm
Cigarettes may taste different
Nicotine Patch BEFORE cessation
doubles success rates
Jed Rose, PhD, Feb 1, 2006 issue of Nicotine and Tobacco Research
• Duke University Center for Nicotine
Research & Smoking Cessation
– 96 smokers attempting to quit
• Half wore patch 2 weeks before quitting
• Half wore a placebo patch
• AFTER 4 weeks
– NO adverse effects from smoking & using patch
– 23% with placebo patch had quit
– 50% with real patch had quit
“Cigarettes are less rewarding and satisfying when there is
already a level of nicotine in the system provided by the patch.”
- Jed Rose, PhD
New ways to use
Nicotine Replacement Therapy
(NRT)
1. Starting NRT before stopping tobacco
2. Matching dose to daily use
3. Combination Therapy
Motivational
Interviewing
(MI)
William Miller, PhD
First Game Challenge
• The Name of the Game is…
–WIN AS MUCH
AS YOU CAN!!!
– Stand up
– Find a partner
– place right feet side by side
– “shake” right hands
How you ask the questions influences
how the patient will answer…
• NOT EFFECTIVE
“Do you want to quit smoking?”
• Not very effective because often they have
tried quitting and they haven’t succeded.
• MORE EFFECTIVE
“Where are you in your love/hate
relationship with your tobacco?”
Prochaska & DiClemente’s
Transtheoretical Model of Change
Work smarter, not harder.
•
•
•
•
•
A. Pre-contemplation
B. Contemplation
C. Preparation
D. Action
E. Maintenance & Relapse Prevention
2 MI Mnemonics
• EPE
– Elicit
“Is it okay with you if I tell you what we know?”
– Provide “Folks have found…” “Research suggests…”
– Elicit
“Where does this leave you? “How can I help?”
• RULE
–
–
–
–
Righting Reflex Avoided
Understanding
Listen
Empathy
What if you hit resistance?
Are you
dancing
or
wrestling?
If you feel or hear resistance,
step back and reflectively listen some
more!
Importance Ruler
On a scale of 1 to 10
• How motivated are you to quit tobacco?
• Not at all
Extremely
1 2 3 4 5 6 7 8 9 10
• Go 2 Down…. “What makes it a 6 and not a 4?”
• How confident are you that you can quit tobacco?
Not at all
Extremely
1 2 3 4 5 6 7 8 9 10
• Go 2 up- what would it take to make it a five & not a 3?
QUIT KITS -5 A’s in a bag
Ask
Assess
Advise
Assist
Arrange follow-up
quit@vcu.edu
1 800 QUIT-NOW
FREE
Telephone quit line
SMOKING CESSATION
ASSEMENT
&
MANAGEMENT
FORM
I’ll send you an electronic version you can
adapt for your clinical use
Email quit@vcu.edu and ask for it.
3 steps for relapse prevention
1. When quitting create a tangible SYMBOL of
what you want more than tobacco. Keep it
on your body or very near you for years.
2. Write a small paragraph about what you
HATE about tobacco and why you are
never quitting again.
3. Keep some medication at home. If you start
thinking about tobacco or feeling close to a
relapse… restart your meds for a few days
until the neuro-receptors go back to sleep.
The bottom line
Be methodical about assessing BEFORE
recommending meds.
BUT…remember medications greatly increase
quitting success.
Please support patients with prescriptions
where appropriate.
Implementing an Effective Smoking Cessation Strategy in Medical Practice
RESOURCES FOR PATIENTS
QUITLINES
– trained phone counselors provide practical
counseling, support, materials, relapse prevention, etc:

Quit Now Virginia 1-800-QUIT NOW
(1-800-784-8669, English or Spanish speaking.
8AM-Midnight, seven days a week)
 Great Start Quitline 1-866-66-START
(For pregnant women, English or Spanish speaking)