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Improving Children's Health by Addressing Family Tobacco Use

Improving Children's Health by Addressing Family Tobacco Use. Your name, institution, etc. here. YOUR LOGO HERE (paste to each slide). …dedicated to eliminating children’s exposure to tobacco and secondhand smoke. Today’s Goals. To train clinicians in:

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Improving Children's Health by Addressing Family Tobacco Use

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  1. Improving Children's Health by Addressing Family Tobacco Use Your name, institution, etc. here YOUR LOGO HERE(paste to each slide)

  2. …dedicated to eliminating children’s exposure to tobacco and secondhand smoke

  3. Today’s Goals • To train clinicians in: • Effective ways to educate parents and caregivers on the effects tobacco use has on children. • Counseling strategies to promote smoke-free homes and cars. • The role of medications in cessation. • Creating and implementing practice systems to identify and treat tobacco use and exposure.

  4. The Health Effects of Tobacco Use Asthma Otitis Media Fire-related Injuries Influences to Start Smoking SIDs Bronchiolitis Meningitis Childhood Adolescence Infancy Nicotine Addiction In utero Adulthood Low Birth Weight Stillbirth Neurologic Problems Cancer Cardiovascular Disease COPD

  5. 47 Years After the 1st Surgeon General’s Report –People Still Smoke! • 21% of US adults are smokers • More than 30% of U.S. children live with at least one smoker

  6. Why Do People Use Tobacco? • Nicotine is physically addictive • Tolerance develops • Withdrawal symptoms occur • Nicotine is a potent drug, causing dopaminergic activation and CNS stimulation • Use is reinforced by social cues and habits

  7. Youth AreEspecially Susceptible • For many youth, symptoms of dependence develop before daily use begins, and can begin within a day after inhalation! • There is no minimum requirement of number smoked, frequency, or duration of use!

  8. That First Puff… • The nicotine in 1-2 puffs occupies 50% of nicotinic receptors in the brain • A single dose increases • Noradrenaline synthesis in the hippocampus • Neuronal potentiation lasting > month (meaning that neurons discharge action potentials at lower threshold)

  9. What Can We Do?

  10. Principles of Tobacco Dependence Treatment Nicotine is addictive Tobacco dependence is a chronic condition Effective treatments exist Every person who uses tobacco shouldbe offered treatment

  11. Smokers Want to Quit 70% of tobacco users report wanting to quit Most have made at least one quit attempt Cite health expert advice as important Regardless of type! THIS MEANS YOU!

  12. Counseling 101 • Patients and families expect you to discuss tobacco use • If counseling is delivered in a non-judgmental manner, it is usually well-received • Even small “doses” are effective - and cumulative! • Strength of Evidence = A

  13. The Theory… Assessing Stage of Readiness Precontemplation Contemplation Ready for Action Relapse Action Maintenance Behavior change occurs in stages – not all at once

  14. Your Goal: Help the Tobacco User Take the Next Step Help a precontemplator become a contemplator… …a contemplator start to make plans… …someone who relapsed become “ready for action”… And so on….

  15. Counseling IS Effective • As little as 3 minutes doubles quit attempts and successes • Intensive counseling is more effective • Dose-response relationship • Most effective: • Problem-solving skills • Support from clinician • Social support outside of treatment

  16. Minimal interventions lasting less than 3 minutes increase overall tobacco use abstinence rates. Strength of Evidence = A Every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to an intensive intervention. Brief Intervention

  17. The 5 As Ask Advise Assess Assist Arrange “2As and an R” Ask Advise Refer

  18. 2 As and an R: ASK Ask about tobacco use and SHS exposure at every visit Make asking routine, consistent, and systematic Use standardized documentation Document as a “vital sign” Just asking can double quit attempts

  19. How Do You Ask? Don’t lead: “You don’t smoke, do you?” Depersonalize the question: “Does anyone living in your home use tobacco in any way?” “Who is it?” “Where do they smoke?” “Is that inside the house?” Explore: “You say no one smokes around your son. What does that mean?” Don’t judge – check your body language, tone of voice, the phrasing of the question

  20. 2 As and an R: ADVISE Strongly advise every tobacco user to quit Provide information about cessation to all tobacco users Strongly urge smoke free homes and cars Look for “teachable moments” Personalize health risks Document your advice

  21. What Do You Say? Clear: “I advise you to quit smoking.” Strong: “Eliminating smoke exposure of your son is the most important thing you can do to protect the health of your child.” Personalized: Emphasize the impact on health, finances, the child, family, or patient. “Smoking is bad for you (and your child/family). I can help you quit.” “Tobacco smoke is bad for you and your family. You should make your home and car smoke free.”

  22. Be Specific… Having a smoke free home means no smoking ANYWHEREinside the home or car! It DOES NOTmean smoking: Near a window or exhaust fan In the car with the windows open In the basement Inside only when the weather’s bad Cigars, pipes, or hookahs On the other side of the room

  23. 2 As and an R: REFER To quit line, 1-800-QUIT-NOW To community and Internet resources Give every tobacco user something that contains information about quitting, the harms of tobacco use, etc.

  24. What Do You Say? “You should call this number. It’s a free service – and the person on the other end of the telephone line can help you get ready to quit.” “You should learn as much as you can about quitting – the more you know, the more successful you’ll be.”

  25. It only takes 30 seconds to refer a patient to a toll-free tobacco use cessation quitline. Quitlines are staffed by trained cessation experts who tailor a plan and advice for each caller. 1-800-QUIT-NOW callers are routed to state-run quitlines Quitlines

  26. Accessibility Appeal to those who are uncomfortable in a group setting Smokers more likely to use a quitline than face-to-face program No cost to patient Easy intervention for healthcare professionals Fax-back referral services Advantage of Quitlines

  27. MedicationsWork!

  28. Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment. Except where contraindicated or for specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). Pharmacotherapy

  29. Clinician familiarity with medications Contraindications Patient preference Previous patient experience Patient characteristics (history of depression, weight gain concerns, etc.) Factors to Consider…

  30. Buproprion SR Nicotine Replacement Therapies (NRT) Nicotine gum Nicotine inhaler Nicotine nasal spray Nicotine patch Nicotine lozenge Varenicline First-line Pharmacotherapies

  31. First-line Pharmacotherapies Varenicline (Chantix®) agonizes and blocks α4β2 nicotinic acetylcholine receptors. Buproprion SR (Zyban®) mechanism for smoking cessation unknown; inhibits neuronal uptake of norepinephrine, serotonin and dopamine. NRT: binds to CNS and peripheral nicotinic-cholinergic receptors.

  32. Varenicline (Chantix®) $4.00 - $4.22 per day Start 0.5 mg daily for 1-3 days, then increase to twice daily for 1-4 days Increase to 1 mg twice daily on quit date. Most common side effects are nausea and vivid dreams Monitor for psychiatric symptoms Do not combine with NRT!

  33. Bupropion SR (Zyban®) $3.62 - $6.04 per day Start 150 mg once daily for 3 days, then twice per day for 7-12 weeks Plan quit date around day 7 of treatment Common side effects include insomnia and dry mouth May be combined with NRT

  34. Nicotine Gum $3.28 - $6.57 per day for 2 mg $4.31 - $6.51 per day for 4mg Weeks 1-6: one every 1-2 hoursWeeks 7-9: one every 2-4 hoursWeeks 10-12: one every 4-8 hours Common side effects are jaw pain and mouth soreness

  35. Nicotine Inhaler $5.29 per day 6-16 cartridges per day, initially one every 1-2 hours Common side effects are mouth and throat irritation

  36. Nicotine Nasal Spray $3.57 per day 1-2 doses (sprays) per hour Common side effects are nose and eye irritation Most addictive form of NRT

  37. Nicotine Patch $1.90 - $3.89 per day >25 cigarettes per day: 21 mg every 24 hours for 4 weeks, then 14 mg for 2 weeks, then 7 mg for 2 weeks Common side effects Skin irritation Sleep problems if worn at night

  38. Nicotine Lozenge $3.66 - $5.25 per day Weeks 1-6: one every 1-2 hoursWeeks 7-9: one every 2-4 hoursWeeks 10-12: one every 4-8 hours If first cigarette smoked within thirty minutes of awakening, use 4 mg; others use 2 mg. Common side effects include mouth soreness and dyspepsia

  39. Clonidine: mechanism for smoking cessation unknown; stimulates α2-adrenergic receptors (centrally-acting antihypertensive) Nortripyline: mechanism for smoking cessation unknown; inhibits norepinephrine and serotonin uptake Second-line Pharmacotherapies* *”off label”

  40. Pharmacotherapy for Lighter Smokers Medications have not been shown to be beneficial to light smokers If NRT is used, consider reducing the dose No adjustments are necessary when using Bupropion SR or Varenicline

  41. Bupropion SR and NRT (especially gum and 4 mg lozenge) may delay, but not prevent weight gain The average weight gain after quitting is less than 10 pounds, more common in women Patients Concerned with Weight Gain

  42. Bupropion SR Nortriptyline NRT Patients with History of Depression

  43. Most will need medication Patients with bipolar disorder or eating disorders should not use Bupropion SR Patch effective for those with schizophrenia Varenicline safety not established Quitting can increase the effect of some psychiatric medications Check for relapse to mental illness with changes in smoking status Patients with Mental Illness

  44. No association between the nicotine patch and acute cardiovascular events even in patients who continue to smoke while on the patch NRT packaging recommends caution in patients with acute cardiovascular disease Patients with Cardiovascular Disease

  45. Counseling is best choice Risks of premature birth or stillbirth caused by smoking may be higher than the potential risk of birth defects caused by NRT use Bupropion SR and Varenicline are pregnancy category C Prescription NRT is pregnancy category D Pregnant Smokers

  46. Helpful with smokers with persistent withdrawal systems Long-term use of NRT does not present a known health risk Bupropion SR approved for for up to 6 months Varenicline recommended for 12 weeks. May repeat for 12 more. Long-term Pharmacotherapy

  47. Patch + gum or nasal spray = increases long-term abstinence Patch + inhaler are effective Patch + Bupropion SR is more effective than patch alone Patch + nortriptyline increases long-term abstinence Combining Varenicline with NRT is not recommended Combining Medications

  48. The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore…both counseling and medication should be provided to patients trying to quit smoking. Strength of Evidence = A Combining Counseling and Medications

  49. Role Playing Exercises

  50. The Rules • Role playing exercises can help you become “comfortable” with new language • Role playing exercises DON’T work if you DON’T say the words out loud • Be silly. Have fun!

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