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NTI Nursing Grand Rounds: Integrating an Evidence-Based Approach for Tobacco Cessation Interventions in Acute & Crit

NTI Nursing Grand Rounds: Integrating an Evidence-Based Approach for Tobacco Cessation Interventions in Acute & Critical Care Settings. Janie Heath PhD, APRN-BC, ANP, ACNP Georgetown University, Washington, DC Jeannette Andrews PhD, APRN-BC, FNP, ACNP Medical College of Georgia, Augusta, GA

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NTI Nursing Grand Rounds: Integrating an Evidence-Based Approach for Tobacco Cessation Interventions in Acute & Crit

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  1. NTI Nursing Grand Rounds: Integrating an Evidence-Based Approach for Tobacco Cessation Interventions in Acute & Critical Care Settings Janie HeathPhD, APRN-BC, ANP, ACNP Georgetown University, Washington, DC Jeannette AndrewsPhD, APRN-BC, FNP, ACNP Medical College of Georgia, Augusta, GA Claudia BaroneEdD, RN, LNC, CPC University of Arkansas Medical Sciences, Little Rock, AR

  2. Objectives • Identify the importance of integrating tobacco cessation in DAILY practice • Identify key strategies / approaches for integrating tobacco cessation in DAILY practice • Identify essential resources for integrating tobacco cessation in DAILY practice

  3. Acknowledgments • UCSF Smoking Cessation Leadership Center • UCLA Tobacco Free Nurses Colleagues • UCSF Rx for Change Colleagues VISIT: www.tobaccofreenurses.org VISIT: www.rxforchange.ucsf.edu

  4. Why Make Tobacco Cessation a Standard for Practice? • QUALITY OUTCOMES = PAYMENT and HEALTH • HEIDIS says to do it! • JCAHO says to do it! • The Surgeon General says to do it! • The “wife” says to do it! http://www.surgeongeneral.gov/tobacco/

  5. TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2004 Trends in cigarette current smoking among persons aged 18 or older 20.9% of adults are current smokers Male Percent 23.4% Female 18.5% 44.5 Million Adults are Addicted to Cigarettes Year The GOOD News: 70% want to quit The BAD News: < 36% Receive Information on HOW to quit Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2001 NHIS. Estimates since 1992 include some-day smoking.

  6. STATE-SPECIFIC PREVALENCE of SMOKING among ADULTS, 2004 California 14.8% Kentucky 27.6% Nevada 23.2% VA 20.9% Utah 10.5% GA 20.1% Ark 25.7% Centers for Disease Control and Prevention. (2005). MMWR 54:1124–1127.

  7. PREVALENCE of ADULT SMOKING, by RACE/ETHNICITY—U.S., 2004 33.4% American Indian/Alaska Native 22.2% White, non-Hispanic 20.2% Black, non-Hispanic 15.0% Hispanic 11.3% Asian Centers for Disease Control and Prevention. (2005). MMWR 54:1121–1124.

  8. Prevalence and Harm of SMOKING during PREGNANCY • Miscarriage • Stillbirth • Preterm delivery • Low birth weight BABY ALERT: 27% OF Tobacco Dependent WOMEN Continue to SMOKE THROUGHOUT PREGNANCY

  9. PREVALENCE of ADULT SMOKING, by EDUCATION—U.S., 2004 26.2% No high school diploma 39.6% GED diploma 24.0% High school graduate 22.2% Some college 11.7% Undergraduate degree 8.0% Graduate degree Centers for Disease Control and Prevention. (2005). MMWR 54:1121–1124.

  10. Annual Causes of Death from Smoking Compared to Other PREVENTABLE Causes AMAZING Sources: (AIDS) HIV/AIDS Surveillance Report, 1998; (Alcohol) McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States.JAMA 1993;270:2207-12; (Motor vehicle) National Highway Transportation Safety Administration, 1998; (Homicide, Suicide) NCHS, vital statistics, 1997; (Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995

  11. ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, 1997–2001 Percentage of all smoking-attributable deaths* 32% 28% 23% 9% 8% <1% TOTAL: 437,902 deaths annually Centers for Disease Control and Prevention. (2005). MMWR 54:625–628.

  12. FINANCIAL IMPACT of SMOKING Buying cigarettes every day for 50 years @ $4.12 per pack Money banked monthly, earning 1.5% interest $331,467 $220,978 Packs per day $110,489 0 100 200 300 400 Hundreds of thousands of dollars lost

  13. Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde Nicotine Nitrosamines Lead Cadmium Polonium-210 COMPOUNDS in TOBACCO SMOKE An estimated 4,800 compounds in tobacco smoke Gases (~500 isolated) Particles (~3,500 isolated)

  14. Marketing Strategy: “Light and Ultra-Light” Cigarettes The difference between Marlboro and Marlboro Lights… 15mg tar, 1.1 mg nicotine 10mg tar, 0.8 mg nicotine an extra row of ventilation holes Image courtesy of Mayo Clinic Nicotine Dependence Center - Research Program / Dr. Richard D. Hurt The Marlboro and Marlboro Lights logos are registered trademarks of Philip Morris USA.

  15. The Safer Cigarette – NOT! Unveiling the SMOKING gun about “Safe Cigarettes”!

  16. Other Tobacco Products Chewing tobacco • Looseleaf • Plug • Twist Snuff • Moist • Dry The Copenhagen and Skoal logos are registered trademarks of U.S. Smokeless Tobacco Company, and Red Man is a registered trademark of Swedish Match.

  17. Other Tobacco Products CIGARS KRETEKS / CLOVE CIGARETTES

  18. Other Tobacco Products BIDIS HOOKAH PIPE

  19. BENEFICIAL PULMONARY EFFECTS of QUITTING Never smoked or not susceptible to smoke 100 75 Stopped smoking at 45 (mild COPD) Smoked regularly and susceptible to effects of smoke FEV1 (% of value at age 25) 50 Disability 25 Stopped smoking at 65 (severe COPD) Death 0 25 50 75 Age (years) COPD = chronic obstructive pulmonary disease Reprinted with permission. Fletcher & Peto. (1977). BMJ 1(6077):1645–1648.

  20. Breaking the NICOTINE DEPENDENCE Cycle at ANY age! A COMPREHENSIVE APPROACH = A Successful Framework for Quitting The PHYSICAL The BEHAVIOR The EMOTIONAL Automatic learned behavior with cigarettes Physical addiction of cravings & withdrawals Role of cigarettes in life—pleasure, stress, social Adapted from Legacy’s GSD&M Presentation 12/5/03

  21. DOPAMINE REWARD PATHWAY Prefrontal cortex Within 7 – 11 seconds “…I feel good…” Dopamine release Stimulation of nicotine receptors Nucleus accumbens Ventral tegmental area Nicotine enters brain

  22. Now Multiply that # by days / year THEN multiply that number by years smoking! YIKES! No wonder it is SO difficult to QUIT NICOTINE BEHAVIORAL EFFECTS: Do the Math! • An individual smokes 1 pack per day x 20 yrs • 20 cigarettes / pack • 10 puffs / cigarette • = ?? puffs / day • THAT’s ____ HITS of NICOTINE per DAY 73,000 1.4 million 200

  23. Dopamine Norepinephrine Acetylcholine Glutamate Serotonin -Endorphin GABA Pleasure, reward Arousal, appetite suppression Arousal, cognitive enhancement Learning, memory enhancement Mood modulation, appetite suppression Reduction of anxiety and tension Reduction of anxiety and tension NEUROCHEMICAL and RELATED EFFECTS of NICOTINE N I C O T I N E Benowitz. (1999). Nicotine Tob Res 1(Suppl):S159–S163.

  24. NICOTINE PHARMACODYNAMICS: WITHDRAWAL EFFECTS • Depression • Insomnia • Irritability/frustration/anger • Anxiety • Difficulty concentrating • Restlessness • Increased appetite/weight gain • Decreased heart rate • Cravings* Most symptoms peak 24–48 hr after quitting and subside within 2–4 weeks. American Psychiatric Association. (1994). DSM-IV. Hughes et al. (1991). Arch Gen Psychiatry 48:52–59. Hughes & Hatsukami. (1998). Tob Control 7:92–93. * Not considered a withdrawal symptom by DSM-IV criteria.

  25. ASSESSINGNICOTINE DEPENDENCE Fagerström Test for Nicotine Dependence (FTND) • How soon after you wake up do yousmoke your first cigarette • Do you find it difficult to refrain from smoking in restricted areas • Which cigarette do you hate to give up most • How many cigarettes do you smoke per day • Do you smoke more frequently during the first hours after waking • Do you smoke if you are so ill that you are in bed most of the day Scores range from 0 to 10; a score of greater than 5 indicates substantial dependence

  26. The USPHS 5 A’s Framework ASK IF time does not allow….do 3 A’s and REFER ADVISE ASSESS ASSIST ARRANGE Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

  27. Modified Version of 5 A’s = The 3 A’s & REFER • In the absence of time or expertise. ask, advise, assess, and refer to other resources, such as local programs or the toll-free quitline1-800-QUIT-NOW – VISIT EXHIBIT BOOTH #2785 for FREE samples TO ORDER CARDS www.smokingcessationleadership.ucsf.edu

  28. METHODS for INCREASING MOTIVATION—FIVE R’s • FOR INDIVIDUALS NOT READY TO QUIT YET: Tailor messages with Motivational Interviewing Techniques • RELEVANCE • RISKS • REWARDS • ROADBLOCKS • REPETITION Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, 2000.

  29. STRATEGIES for Successful Tobacco Cessation • Acute and critical care admissions = HIGHLY TEACHABLE MOMENTS • Tobacco cessation starts STAT for most admissions • Provide structures/systems (chart prompts, standing orders, dedicated counselors) to facilitate success in breaking the nicotine cycles of addiction • Emotional -Cognitive Tools • Behavioral - Tools • Physical - Biological Tools INTERDISCIPLINARY APPROACH ESSENTIALS: collaboration, effective decision making AND compassionate – caring practices

  30. Cognitive Evidence-Based STRATEGIES USPHS Guideline Recommends the STAR APPROACH Set a Date Tell family, friends, and co-workers Anticipate challenges and temptations Remove triggers

  31. Cognitive Evidence-Based STRATEGIES Continued AT THE VERY LEAST all acute and critical care nurses can… • Do the 3 As with their pts and REFER – 1-800-QUIT NOW • Return back to work and have the “tobacco conversation” • “Are we meeting JCAHO measures for tobacco cessation counseling” • “Where can we refer pts for “on-site” help” • “Where can our nursing colleagues get help” The PHYSICAL

  32. Quitting is HARD to do! A COMPREHENSIVE APPROACH = A Successful Framework for Quitting The PHYSICAL The BEHAVIOR The EMOTIONAL Automatic learned behavior with cigarettes Physical addiction of cravings & withdrawals Role of cigarettes in life—pleasure, stress, social Adapted from Legacy’s GSD&M Presentation 12/5/03

  33. Nicotine Replacement Therapy (NRT): RATIONALE for USE • Reduces physical withdrawal from nicotine • Allows patient to focus on behavioral and psychological aspects of tobacco cessation • It is NOT substituting ONE negative health behavior for another IMPROVES SUCCESS RATES!

  34. LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS 23.9 20.0 19.5 17.1 16.4 14.6 Percent quit 11.8 11.5 10.2 9.1 8.8 8.6 Data adapted from Silagy et al. (2004). Cochrane Database Syst Rev and Hughes et al., (2004). Cochrane Database Syst Rev.

  35. FDA APPROVALS: SMOKING CESSATION 2002 Rx transdermal nicotine patch 1997 1996 OTC nicotine lozenge 1991 Rx nicotine inhaler; Rx bupropion SR Rx nicotine gum OTC nicotine gum & patch;Rx nicotine nasal spray 1984

  36. NICOTINE ABSORPTION Absorption is pH dependent • In acidic media • Ionized  poorly absorbed across membranes • In alkaline media • Nonionized well absorbed across membranes At physiologic pH (7.3–7.5), nicotine is readily absorbed.

  37. PLASMA NICOTINE CONCENTRATIONS for NICOTINE-CONTAINING PRODUCTS Cigarette Moist snuff 0 10 20 30 40 50 60 Time (minutes)

  38. NICOTINE GUM: Nicorette; generic (GlaxoSmithKline; Watson Labs) • Dose = 1 every 1-2 hrs; • No food/beverage 15 min prior - during or 15 min post • Max = 24 / day • Available: 2 mg, 4 mg; regular, mint, orange • NOT recommended if use dentures

  39. NICOTINE GUM:CHEWING TECHNIQUE SUMMARY Chew slowly Stop chewing at first sign of peppery, minty, or citrus taste or tingle Chew again when the taste or tingle fades Park

  40. TRANSDERMAL NICOTINE PATCH • Dose = 1 patch every day (16 hrs or 24 hrs) • Best if ROTATE patchdifferent areas • Preferred sites above the waist • Avoid if acute / chronic skin condition • If problems “sticking” apply TEGADERM dressing over patch • May bathe/swim with patch • Do NOT cut patch

  41. NICOTINE LOZENGECommit (GlaxoSmithKline) • Dose = 1every 1-2 hrs • No food/beverage 15 min prior - during or 15 min post • MAX = 20 per day • Delivers ~25% more nicotine than equivalent gum dose • Available: 2 mg, 4 mg • Let dissolve 20-30 minutes; NO chewing/biting of product

  42. NICOTINE NASAL SPRAYNicotrol NS(Pharmacia) • Dose = 1 dose (2 sprays per nostril) every hr • MAX = 5 doses/hr OR 40 doses /day • Each dose delivers -50 µL spray = 0.5 mg nicotine per spray • Rapidly absorbed across nasal mucosa --faster onset of action (11–13 minutes) compared to the gum, patch, or inhaler

  43. NICOTINE INHALERNicotrol Inhaler (Pharmacia) • Dose = 6- 16 cartridges / d • Puff as lighting a cigar/pipe –best if puff for ~ 20 minutes • MAX = 16 cartridges / d • Delivers 4 mg nicotine vapor, which is absorbed across buccal mucosa - ~ 20 minutes of puffing = 1 cartridge

  44. BUPROPION SR (ZYBAN) (GlaxoSmithKline) • Non-nicotine agent • Sustained release antidepressant • Dose = 150mg every a.m. x 3 days then 150mg twice a day • IMPORTANT to start 2 wks prior to QUIT date

  45. COMPARATIVE DAILY COSTS of PHARMACOTHERAPY $6.07 $5.81 $5.31 $5.24 $4.12 $3.93 $2.66 Cost per day, in U.S. dollars

  46. LATE BREAKING NEWS for SMOKING CESSATION • JUST approved by FDA 5/12/06 • Varenicline (Chantix-- Pfizer) • Partial nicotinic receptor agonist • Available end of July • Promising results compared to Bupropion

  47. Breaking the NICOTINE DEPENDENCE Cycle A COMPREHENSIVE APPROACH = A Successful Framework for Quitting The PHYSICAL The BEHAVIOR The EMOTIONAL Automatic learned behavior with cigarettes Physical addiction of cravings & withdrawals Role of cigarettes in life—pleasure, stress, social Adapted from Legacy’s GSD&M Presentation 12/5/03

  48. WHAT IF… a patient asks you about your use of tobacco?

  49. The RESPONSIBILITY of HEALTH PROFESSIONALS “If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.” DR. GRO HARLEM BRUNTLAND, FORMER DIRECTOR-GENERAL of the WHO USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS.

  50. Contact Information Janie Heath: ejh@georgetown.edu Jeannette Andrews: jandrews@mail.mcg.edu Claudia Barone: baroneclaudiap@uams.edu Visit us at BOOTH # 2785

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