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Smoking cessation
1. “Smoking Cessation - What’s my
Role?”
Daniel “Scotty” Silva, RRT, RCP
- Director of Pulmonary Services,
University of New Mexico Hospital
- Consultant,
New Mexico Medical Society -
Clinical Prevention Initiative
NMMRA – Hospital-initiated
Tobacco Cessation Program
2. Course Objectives
• To become familiar with the addictive
properties on nicotine and to identify the
barriers to effective smoking cessation.
• To define the role of the respiratory
therapist in a smoking cessation program.
• To identify the process of incorporating
smoking cessation into your everyday
clinical practice.
3. Educational Objectives
• What can the attendee expect to learn in this meeting?W
– Understand the tobacco problem in New Mexico
– Learn about the Tobacco Use Prevention & Control program’s
funding of various programs to combat the tobacco problem
– Learn about the different types of nicotine replacement therapy
available to tobacco users
– Learn how to conduct a tobacco cessation counseling session
utilizing the motivational interviewing techniques
– Learn how to use motivational interviewing tools: Listening
statements, Readiness Ladders, Accomplishment Story,
Sidestepping
4. Tobacco in New Mexico
American Lung Association :
• State of Tobacco Control: 2006
Report Card Grades:
• Youth Access F
• Tobacco Prevention and Control Spending F
• Cigarette Tax D
• Smokefree Air F
5. Tobacco in New Mexico
American Lung Association :
• State of Tobacco Control: 2009
Report Card Grades:
• Youth Access
• Tobacco Prevention and Control Spending F
• Cigarette Tax D
• Smokefree Air A
• Cessation Coverage C
6. Chemical Make-up of a Cigarette
• > 4000 Chemicals found in tobacco;
1.) Fertilizers and Pesticides.
2.) Production of cigarettes.
3.) By-product or end-product.
- Primary
- Secondary
• 60 are known Group A Carcinogens (found to cause
cancer in humans). Group A Carcinogens include;
- Acetylene - Copper - Hexamine - Nickel
- Arsenic - DDT - Mercury - Phenol
- Asbestos - Ethanol - Methane - Radon -
Benzene - Formaldehyde - Methanol - Toluene
- Butane - Vinyl Cloride - Naphthalene - Urethane
7. What Do They Say About It?
“The cigarette should be conceived not as a
product, but as a package. The product is
nicotine…Think of the cigarette pack as a
storage container for a day’s supply of
nicotine… Think of a puff of smoke as the
vehicle of nicotine and the cigarette the most
optimized dispenser of smoke.”
William Dunn,
Tobacco Researcher , Philip Morris,
1972
8. What Are the Facts?
• An estimated, 20.8% of all adults (45.3 million people)
smoke cigarettes in the United States.
• Cigarette smoking estimates by age are as follows: 18–24
years (23.9%), 25–44 years (23.5%), 45–64 years (21.8%),
and 65 years or older (10.2%).4
• Cigarette smoking is more common among men (23.9%)
than women (18.0%).4
• Prevalence of cigarette smoking is highest among
American Indians/Alaska Natives (32.4%), followed by
(non-Hispanic) Blacks (23.0%), (non-Hispanic) Whites
(21.9%), Hispanics (15.2%), and Asians [excluding Native
Hawaiians and other Pacific Islanders] (10.4%).4
9. More Facts!
• Cigarette smoking estimates are highest for adults with a
General Education Development (GED) diploma (46.0%)
or 9–11 years of education (35.4%), and lowest for adults
with an undergraduate college degree (9.6%) or a graduate
college degree (6.6%).4
• Cigarette smoking is more common among adults who live
below the poverty level (30.6%) than among those living
at or above the poverty level (20.4%).4
10. Nicotine - What is it?
• Nicotiana tabacum
• First cultivated in the Americas as early as 6000 BC.
• Originally touted for its “medicinal properties”.
• C10H14N2 is a naturally occurring liquid alkaloid and
makes up about 5% of the actual tobacco plant, by weight.
• Readily diffused into the body through skin, lungs, and
mucous membranes.
• Half-life of Nicotine is 60 minutes.
12. Is It Addiction?
Psychological: Continued and compulsive use of
a product, without regard for it’s effects on health
or life.
Physiological: Anything that turns on the reward
pathway in the brain. Stimulation of this neural
circuitry makes a person feel good and thus will do
it again and again to “get that feeling”.
Tolerance: The development of tolerance to the
product which results in needing more and more in
order to illicit the same effect.
13. Why Smoking Cessation?
• 438,000 smoking related deaths annually in the US.
• 2100 smoking related deaths annually in the New Mexico.
• 1 in 5 or 20% of all deaths in the US are attributable to
cigarette smoking.
• Leading cause of cancer death in both men and women, it
surpassed breast cancer in 1987 as the # 1 cancer killer
of women!
• 66% ALL myocardial infarctions are related to cigarette
smoking.
• 75 Billion dollars in Direct annual medical related costs.
• 92 Billion dollars in lost productivity.
14. Because They Want To Quit!
• Among current U.S. adult smokers,
– 70% report that they want to quit completely.
– In 2006, an estimated 19.2 million (44.2%) adult
smokers had stopped smoking for at least 1 day during
the preceding 12 months because they were trying to
quit.
– More than 54% of current high school cigarette
smokers in the United States tried to quit smoking
within the preceding year.
16. Can We Make a Difference?
“If you treat an individual as he is, he will
stay as he is, but if you treat him as if he
were what he ought to be and could be, he
will become what he ought to be and could
be”
Johann Wolfgang von Goethe
17. Components of Change
• Importance of change
• Confidence in the ability to change
• Readiness to change
“Motivation is fundamental to change”
18. Motivational Interviewing
• Collaboration (Not Confrontation):
– Working in partnership and consultation with
the patient
• Evocation (Not Education):
– Listening more than talking
• Autonomy (Not Authority):
– Being respectful and honoring the patients
autonomy, resourcefulness, and ability to
choose
19. Contemplation Ladder
• 10 = Taking action to quit NOW.
• 8 = Starting to think about how to quit.
• 5 = Think that I should quit, unsure
if I am ready too.
• 2 = Will consider quitting someday.
• 0 = Absolutely NO thoughts of
quitting.
20. Motivation to Change?
• DARN
D = DESIRE to Change
A = ABILITY to Change
R = REASON to Change
N = NEED to Change
21. Explore Their Ambivalence!
• What is AMBIVALENCE?
Webster’s defines ambivalence as;
“Simultaneous conflicting feelings”
– “I want to quit smoking and I don’t want to quit
smoking”
– “I know that my smoking effects my asthma, but I
really love to smoke”!
– DEVELOP DISCREPANCY – Differentiate between
the patient’s present state and their desired goals.
– Without discrepancy there is no ambivalence and if
there is no ambivalence, there is no potential for
change!
– You can’t have Motivational Interviewing without
ambivalence.
22. The 5 A’s Ask Tobacco use as
Smoking status
a vital sign
Advise
To quit Brief, informative,
clear, personalized
Assess Weigh pros and cons
Willingness to quit Assess importance, readiness,
and confidence
Assess st age of readiness to quit
Assist
Aid in quitting Offer help: e.g.
- refer to counseling, quitline
- analyze past attempt s
- develop quit plan,
- provide pharmacotherapy
Arrange
Follow-up
37
23. The 5 A’s
• ASK - Does EVERY patient get asked about their
smoking history?
• ADVISE – Do we actively advise our smoking
patient’s to quit?
• ASSESS – Do we incorporate smoking cessation
into our assessment and provide opportunities for
our patient to pursue quitting options.
• ASSIST – Do we incorporate smoking cessation
into the treatment / care plan?
• ARRANGE – Do we provide the patient with the
necessary resources to be successful after
discharge? (community resources, relapse plan,
support)
25. Nicotine Replacement Therapy
• CHANTIX™ (varenicline)
• Indication: Smoking Cessation / Nicotine Inhibitor
• Dose: (Day 1-3) White Tablet / 0.5mg / Qday
– (Day 4-7) White Tablet / 0.5 mg / Bid
– ( Daily) Blue Tablet / 1 mg / Bid
• Mode of Action: CHANTIX contains no nicotine, but it
targets the same receptors that nicotine does. CHANTIX is
believed to block nicotine from these receptors.
• Quit Rate: 44%
26. Nicotine Replacement Therapy
• Bupropion (Wellbutrin XL / Wellbutrin SR / Zyban)
• Indication: Depression / Smoking Cessation
• Dose: 150 mg once daily for three days, and then the dose
is increased if the patient tolerates the starting dose to 300
mg daily. Smoking is discontinued one -two weeks after
starting bupropion therapy.
• Mode of Action: Bupropion is an antidepressant
medication that affects chemicals within the brain that
nerves use to send messages to each other, therefore,
reducing the cravings or urges to smoke.
• Quit Rate: 32%
27. Nicotine Replacement Therapy
• Nicotine Patch
• Indication: Smoking Cessation
• Dose: 21mg, 14mg, 7mg (all available over-the-counter)
• Mode of Action: Delivers a steady dose of nicotine
through the skin over a 24-hour period to lessen / taper the
symptoms of nicotine withdrawal. Requires a gradual taper
in dose over a 6 - 8 week period. May be used concurrently
with other NRT under supervision.
• General Rule: “1 Mg per Cig.”
• Quit Rate: 23%
28. Nicotine Replacement Therapy
• Nicotine Gum
• Indication: Smoking Cessation
• Dose: 2mg and 4mg (mint, orange, & wild berry flavor)
• Mode of Action: Delivers nicotine to the bloodstream
through the lining of the mouth (buccal mucosa) to lessen
nicotine withdrawal symptoms.
• General Rule: Chew It & Park It! This will help to
eliminate the headache and nausea associated with this
NRT.
• Quit Rate 21%
29. Nicotine Replacement Therapy
• Nicotine Lozenge
• Indication: Smoking Cessation
• Dose: 2mg and 4 mg
• Mode of Action: Delivers nicotine to the bloodstream
through the lining of the mouth (buccal mucosa) to lessen
nicotine withdrawal symptoms.
• General Rule: Suck It & Park it! This will help to
eliminate the headache and nausea associated with this
NRT. (TTFC) Time To First Cigarette.
• Quit Rate: 22%
30. Nicotine Replacement Therapy
• Nicotine Inhaler
• Indication: Smoking Cessation in particular those with a
multi-pack habit with associated oral fixation.
• Dose: 4mg puncture pack per inhaler providing 15-20
minutes of nicotine with active puffing.
• Mode of Action: Delivers nicotine to the bloodstream
through the lining of the mouth (buccal mucosa) to lessen
nicotine withdrawal symptoms.
• General Rule: Inhaler is a VAPOR, not aerosol, and will
dissipate relatively quickly.
• Quit Rate: 23%
31. Nicotine Replacement Therapy
• Nicotine Nasal Spray
• Indication: Rapid relief of nicotine withdrawal symptoms.
• Dose: 1 puff per nare (0.5mg) at the onset of symptoms.
• Mode of Action: The spray delivers nicotine directly to the
bloodstream through the lining of the nose (nasal mucosa)
and is extremely fast -acting.
• General Rule: Highly addictive and should be used only
with supervision and for NO longer than 3 months. High
association with nasal irritation, sinusitis, and burning
eyes. Only use this NRT with careful consideration.
• Quit Rate: 21%
32. It’s Up To You!
"In any moment of decision the best thing you
can do is the right thing, the next best thing
is the wrong thing, and the worst thing you
can do is nothing."
Theodore Roosevelt
