An Ounce of Prevention is Worth a Pound of Cure Assisting Patients with Smoking Cessation

1. An Ounce of Prevention is Worth a Pound of CureAssisting Patients with Smoking Cessation Dana L. Cole, BScPharm, PharmD Regional Clinical Pharmacy Specialist Northern Health Authority Partners in Cancer Care Conference November 2003

2. Tobacco • Killed 4.9 million worldwide last year • AIDS, TB, maternal mortality, murder, suicide combined kill < tobacco • In Canada, 21% of deaths are due to tobacco • Deaths in Canada from tobacco are equivalent to a Boeing 747 crashing daily

3. Harm Reduction • If adult consumption cut in ½ in next 20 years. 200 million lives will be saved • In Quebec, added NRT & bupropion to pharmacare in 1998 • Smoking rates  from 38% to 24% • Smoking rates in men have declined • Lung Ca in males peaked in early 90’s and now declining • Tobacco industry normalized smoking • Need to denormalize and resensitize

4. Quitting After Cancer Diagnosis Improves Survival • Retrospective review in 186 patients • 42% smoking, 58% abstaining during CHT/RT • Median survival: • Former smokers – 18 mon • Current smokers – 13.6 mon • 5 yr survival 8.9% vs 4% Videtic GMM, et al. J Clin Oncol 2003;21:1544-9.

5. Lung Cancer Risk Reduction after Smoking Cessation • Used data from Iowa Women’s Health Study (prospective cohort of 41 836 women 55-69 yrs) • Age-adjusted ling cancer incidence through 1999 according to years of smoking abstinence Ebbert JO, et al. J Clin Oncol 2003;21:921-6.

6. Smoking Cessation Campaigns • Advertise to counter industry ads • BC 1st jurisdiction in world to require list of ingredients in cigarettes • Fear arousal good strategy • If combined with clear advice • Aim to campaign • To move “some day” to “today” • By communicating skills, • Reassessing importance • Identifying personal relevance, and • Increasing confidence in ability to carry out behaviours

7. NICC Program at NHA • Counsellors have all received training in motivational interviewing and smoking cessation strategies • Targets employees, cardiac, diabetes, inpatients • Initial visit – motivational interviewing • Follow-up visit encouraged, phone call if not possible • Follow-up phone calls at 1 month, 3 months, 6 months and 1 year. • Provides starter supply of NRT or reimbursement for bupropion up to cost of NRT

8. NICC Program at NHA

9. Stages of Change • Pre-Contemplative • Contemplative • Preparation • Action • Maintenance • Relapse

10. Pre-Contemplation • Defensive • Uncommitted or passive in treatment • Rationalizing, Minimizing • Consciously or Unconsciously avoiding steps to change behaviour • Often pressured by others, feels coerced • Goal: Instill doubt

11. Contemplative • Thinking about making change • Distressed • Desires control • Evaluating pros & cons of behaviour and of making changes • May be statements of future change • No active or preparative language • Goal: Create more doubt; elicit motivation

12. Preparation • Intent to change behaviour • More focused, somber • On the verge of taking action • Engaged in change process • Reduction in resistance • Goal: Encourage thought that behaviour change is needed

13. Action • Decided to make change • Verbalized and demonstrated firm commitment to making change • Efforts to modify behaviours taken • Motivated and involved with change process • Goal: Assist with plan for action. Directive.

14. Maintenance • Working to sustain changes achieved to date • Considerable attention focused on avoiding slips or relapses • May describe fear or anxiety regarding relapse • Less frequent but often intense temptations to use substance may be faced • Goal: Support decision; assist problem-solving

15. Relapse • Loss of desire or resolve to maintain recovery regime • Return of helpless/hopelessness when confronted by a slip • Feel the “need” for substance based on environmental causes • Return to an earlier stage of motivation such as contemplation or pre-contemplation • Goal: Assess stage of motivation; support through external stressors.

16. Motivational Interviewing • Developed by William R Miller & Stephen Rollnick • Provides strategies to promote movement through stages of change • Based on brief intervention strategies • Collegial vs expert/client role • Persuasion rather than coercion • Develop internal motivators rather than external punishment/motivators

17. General Principles of Motivational Interviewing • Express Empathy • Develop Discrepancy • Avoid Arguments • Roll with Resistance • Support Self-Efficacy

18. Express Empathy • Meet the client at the level they present • Use reflective listening techniques • Spend time here to ensure success • Understand and accept that ambivalence to change is normal and acceptable

19. Develop Discrepancy • Identify “doubt” in a situation to facilitate change • Goal is to amplify the doubt to tip decisional balance towards action • Need to find internalized doubts not external • Try to always have client make the argument to change behaviour

20. Life Costs Benefits Tools Short-term • Decisional Balance • Importance, Confidence and Desire-to-Change Scales Long-term “Most important” “Completely confident” “Excited about making change” “Not at all important” “Not at all confident” “Dread making the change”

21. Avoid Arguments • Confrontational but if argumentative, will increase resistance and may empower client to maintain behaviour, not change. • May be one of client’s resistance strategies which worked in past • Resistance is signal to you to change strategies

22. Roll With Resistance • Resistance is your friend • Clarifies the client’s starting point • Allows the counsellor to put the problem back to the client, encouraging self-efficacy • New interpretations of resistance are invited but NOT imposed • “Therapy Dance”

23. Support Self-Efficacy • A person’s belief in his/her own ability to carry out and succeed in a specific task • Concept of personal responsibility • “You can do it”; “You can succeed” • Belief in the possibility of change is an important motivator • Client responsible for choosing and implementing the personal change

24. Tips • Use open-ended questions if questions are necessary especially at the beginning • Invite the client to talk • Do not rush the change process • Reflective listening • Offer support and encouragement for the smallest change or statement of efficacy • Summarize discussion and motivators identified

25. Eliciting Self-Motivational Statements • Evocative questions: • Problem recognition • Expression of concern • Intention to change • Expression of optimism

26. The Ten-Minute Contact Nine questions to ask: • Ask about smoking use in detail • Ask about typical smoking day • Ask about lifestyles and stress • Ask about health, then tobacco use • Ask about the good things and the less good things

27. The Ten-Minute Consult cont’d • Ask about cigarette use in the past and now • Provide information and ask “What do you think?” • Ask about concerns directly • Ask about the next step.

28. Resources • Canadian Cancer Society • One Step at a Time booklets: • For smokers who want to quit • For smokers who don’t want to quit • University of Pittsburg Medical Center Health System • http://patienteducation.upmc.com/Pdf/QuitSmoking.pdf

29. Non-Pharmacological Strategies • Relaxation • Deep breathing • Oral substitutes • Patterns in the day • Socialization patterns

30. Will usually begin if <5 cigarettes daily Cravings Emotional labile Irritable, impatient, sad Anxiety, tense, nervous Difficulty concentrating Increased appetite Sleep disturbances Headache Nausea, constipation Light-headedness, dizziness Tingling in arms or legs Dry mouth, tight or sore throat Tiredness Cough Nicotine Withdrawal

31. Pharmacological Therapies • Nicotine patches • Nicotine gum • Bupropion

32. Nicotine Patches • Dose: ~ 1 mg per cigarette • 21mg, 14mg, 7mg patches • Safe to use more than one patch • Common side effects: • Local irritation • Headache • Sleep disturbances • Decrease slowly

33. Nicotine Gum • Dose: ~1 mg per cigarette • Usually used as adjunct, not sole therapy • Bite and park technique • Buccal absorption • Useful at high-craving moments • Side effects: • Nausea • Jaw soreness • Hiccups • Mouth sores

34. Bupropion (Zyban or Wellbutrin) • Sustained release tablet • Start with 150mg po daily x 3 d then 150mg bid • 150 mg po daily may be enough • Do not use in patients with poor oral consumption, eating disorder, seizure disorder or MAO-I in last 14 d • Can be combined with NRT (improved effect) • Side effects: • Insomnia • Dry mouth • Tremors, nervousness • Skin rash • Constipation • Continue for 12 weeks minimum Hurt RD, et al N Engl J Med 1997;337:1195-1202 and Jorenby DE, et al N Engl J Med 1999;340:685-91.

35. After quitting… • Within 2 days • Sense of taste and smell improve • Within 4 weeks • Blood circulation breathing improves • Within 1 year • Risk of heart disease decreases to ½ that of someone who continues to smoke • Within 3 years • Risk of MI same as someone who never smoked • Within 10 years • Risk of lung cancer cut in half

36. Summary • Identify Stage of Change • Don’t move ahead of the patient • Use motivational interviewing to encourage change • Support with non-pharmacological and pharmacological therapies • Support maintenance phase to prevent relapse

37. Case #1 • Jane is a 35 yr old real estate agent, mother of 2 children and has been diagnosed with breast cancer. She is in clinic today for teaching prior to receiving BRAJAC adjuvant chemo in 2 days time. You see her as part of the teaching and as part of you history you learn she is a smoker. She volunteers that her doctor told her she should quit but she thought breast cancer had nothing to do with smoking. • Assign: Jane, Pharmacist, observers • What is Jane’s stage of change today? • What is your approach? • 8 minutes (role play and discussion)

38. Case #2 • Robert is a 52 year old carpenter who has been diagnosed with Stage III NSCLC and is being treated in your clinic. You learn from his chart that he has smoked for the last 34 years and is currently smoking 2 ppd. He has voiced to the nurse that he had always planned to quit but “sees no point in quitting now – he already has cancer”. • What stage of change is Robert in? • What is your approach?

39. Case #3 • Albert is a 45 year old man who has been diagnosed with testicular cancer. His prognosis is excellent and he conveys to you during his med teaching session that he plans to make a number of changes in his life. He would like to quit smoking and is wondering if you have any advice for him. He’s heard about Zyban and wonders if it might work for him. • Identify Albert’s stage of change? • What is your approach?