Brief Tobacco Interventions for Opioid Maintenance Providers

1. Los Angeles County Department of Public Health Chronic Disease and Injury Prevention Division Brief Tobacco Interventions for Opioid Maintenance Providers Susan Bradshaw, MD, MPH Tobacco Control and Prevention Program September 18, 2013

2. Outline Burden of Tobacco Use Tobacco Products Tobacco Addiction Brief Intervention (Ask, Advise, Refer)

3. Introduction • Native Americans used tobacco prior to the arrival of Columbus • Consumption was for medicinal and ceremonial purposes • Commonly smoked in peace pipes

4. Introduction • John Rolfe (1585–1622) …. • Married Pocahontas • First to cultivate tobacco as an commercial export and cash crop • Until 1883, taxes from tobacco accounted for 1/3 of IRS revenue

5. Introduction 1881: Cigarette machine 1882: Ten million cigarettes sold 1887: One billion cigarettes sold

6. Introduction Anti-Tobacco • 1798: Benjamin Rush…. • First surgeon general • Signer of the Declaration of Independence • “Tobacco use supports excess alcohol consumption”

7. Introduction Anti-Tobacco • 1870: Tobacco …. • Harmful addictive substance • Contributing factor in relapse from alcoholism and drug dependence • Treated along with alcoholism and other addictions in asylums

8. Stop drinking to die from smoking? Founding father of AA movement, Bill W., died from tobacco-related disease. 1930s: Tobacco use is no longer viewed as an addiction and becomes embedded in recovery programs.

9. BURDEN of TOBACCO

10. Burden of Tobacco Use Morbidity and Mortality • Leading cause of preventable and unnecessary death, disability and disease • Causesmore deaths than homicide, suicide, heroin, cocaine and alcohol combined each year • Everyday, approximately 1,200 people die from tobacco-related diseases

11. Burden of Tobacco UseMorbidity and Mortality For every 8 smokers who die, one non-smoker dies from exposure to secondhand smoke (SHS).

12. Secondhand Smoke (SHS) • Causes 50,000 deaths annually • Mainstream smoke is exhaled by a smoker • Side stream smokecomes from the end of a burning tobacco product

13. Question? True or False. Secondhand smoke contains more than 7,000 chemicals. True. Secondhand smoke is a toxic mixture of gases, chemicals and particles. It contains about 70 carcinogens.

14. Secondhand Smoke There is no safe level of exposure to secondhand smoke.

15. Burden of Tobacco UseThirdhand smoke? Residue left on a variety of surfaces by tobacco smoke. It builds up on surfaces and resists normal cleaning. Can't be eliminated by airing out rooms, opening windows, using fans or air conditioners, or confining smoking to only certain areas The only way to protect nonsmokers from thirdhand smoke is to create a smoke-free environment

16. Burden of Tobacco UseEconomic Which state charges the most for a pack of cigarettes? New York. It costs $11.90 for one pack of cigarettes.

17. Burden of Tobacco Use Environment • Cigarette butts are the most littered item in US • 153 million pounds of cigarette butts are dumped each year • 26,400 smoking- related fires occur annually

18. Smoking RatesMental Illness (MI) • Schizophrenia 62-90% • Bipolar Disorder 51-70% • Heavy drinkers 65-90% • Depression or Anxiety 40-50% • Post-traumatic Stress Disorder 45-60% • Substance Use Disorder (SUD) 49-98%

19. Burden of Tobacco UseMI/SUD Compared to general population ….. Begin smoking earlier Smoke more cigarettes each day Smoke cigarettes them down to the filter Inhale deeper

20. Burden of Tobacco UseMI/SUD Consume 44% of all cigarettes sold Spend 30% of their income Poorer tobacco cessation outcomes Want to quit

21. Smoking cessation does not interfere with recovery

22. Burden of Tobacco UseKey Points Compared to general population, MI/SUD….. Smoke more Suffer more Spend more

23. Benefits of Quitting • Health • Recovery • Wealth • Environment • Pets

24. TOBACCO PRODUCTS Update

25. Question? What is the name of the President who started smoking a pipe after he was diagnosed with throat cancer? President Grant It is alleged he thought smoking a pipe was safer than smoking cigars.

26. Expensive & Unhealthy Smoked TobaccoCigarettes Cheap & Toxic Natural & Deadly Photo source: FACT collection

28. Smoked TobaccoCigarette , Little Cigar, Cigarillo and Cigar Cigarette: wrapped in paper not containing tobacco Cigar and cigarillo: wrapped in substance containing tobacco

29. Many flavors • Package • Tip or no tip • Examples: • Black & Mild • Swisher Sweets • White Owl Smoked TobaccoLittle Cigars and Cigarillos

30. Blunts Hookah Smoked TobaccoOther Bidis Photo source: FACT collection

31. New Smokeless Tobacco • May be in pouch • Marketed as energizing • May contain: • Caffeine • Vitamin C • Flavor

32. Smokeless TobaccoSnus • Variety of flavors • Packaged in small pouches • Addresses smoke-free policies

33. Smokeless TobaccoDissolvables Strips Sticks Mints (Orbs)

34. Electronic Nicotine DevicesSmoke and tobacco free

35. TOBACCO PRODUCTSKey Points Cigarettes are the most common form of tobacco used in the U.S. All tobacco products are harmful Screen patients for different tobacco products

36. TOBACCO ADDICTION

37. Nicotine • Cigarettes and other forms of tobacco contain nicotine • Research suggests that nicotine may be as addictive as heroin, cocaine, or alcohol

38. Nicotine and the Brain: Prefrontal cortex Dopamine release Stimulation of acetylcholine receptors Nucleus accumbens Ventral tegmental area Nicotine enters brain

39. Smokers feel normal with nicotine • When nicotine levels decrease, smokers may experience nicotine withdrawal symptoms (NWS) • NWS include irritability, anxiety, difficulty concentrating, and increased appetite Nicotine Hijacks the Brain

40. Nicotine AddictionEasy to Start, Hard to Quit In general: Ninety percent of smokers began using tobacco before age 18 Smokers often relapse because of stress, weight gain, and withdrawal symptoms Numerous quit attempts are usually necessary to stop successfully

41. Nicotine AddictionEasy to Start, Hard to Quit • Each day, approximately 3,500 U.S. kids smoke their first cigarette • Of every three young smokers: • One will quit • One will die from a tobacco-related disease

42. Treatment OptionsExamples Combination is BEST.

43. Reduces withdrawal symptoms • Few contraindications and side effects • Toxicity and abuse are rare • Does not contain toxins Nicotine Replacement Therapy (NRT)

44. Instructions on label will change • Recommendations by experts differ from label • Combination NRT • Higher dosage • Treat withdrawal symptoms • Taper based on patient’s preference Nicotine Replacement Therapy Update

45. Nicotine Replacement Therapy (NRT)Delivery time NRT therapy • Nicotine gum • Lozenge • Patch • Nasal spray • Inhaler Onset of Action 20 to 60 minutes Faster than gum 6-8 hours 5 to 10 minutes 10 minutes

46. NRT Patch Apply to skin that is clean, dry and non-hairy. Press onto skin for 10 seconds. Rotate placement on different parts of the body each week Avoid cutting 7,14,& 21 mg/24 hr 5,10 & 15 mg/16 hr

47. Bite gum slowly Stop at first sign of mild tingling or peppery taste “Park” between the cheek and gum Bite again when tingling or peppery sensation fades (20 minutes) NRT Gum (Chew and Park)

48. NRT Lozenge Easier to use and delivers ~25% more nicotine compared to NRT gum Allow to dissolve slowly. Rotate in mouth until it dissolves ( 20 minutes). Should not be chewed or swallowed Do not eat or drink 15 minutes before using NRT gum or lozenge.

49. NICOTINE ADDICTION Key points Nicotine addiction can be a chronic and relapsing condition that usually begins in adolescence Successful treatment often requires multiple quit attempts and interventions as well as long-term monitoring Pharmacotherapy and behavioral interventions should be offer to all tobacco users who want to quit

50. ASK, ADVISE, REFER (AAR)Brief, Effective and Low Cost