Introduction to Tobacco Use Prevention, Protection & Cessation

1. Introduction to Tobacco Use Prevention, Protection & Cessation Created by the Registered Nurses’ Association of Ontario

2. Nurses’ important role in smoking cessation • Largest health-care provider group in Canadian health system (Canadian Institute for Health Information, 2008) • Highly trusted by the public (Leger Marketing, 2004) • Well-situated to influence and motivate smokers to quit • Nursing intervention increases likelihood of abstinence from smoking (Rice & Stead, 2008)

3. Statistics on Tobacco Use In Canada: • 18 % of people aged 15 years and older smoke cigarettes (Health Canada, 2008) - Almost 5 million people

4. Statistics on Morbidity and Mortality • Smoking related illnesses cause 47,000 deaths per year in Canada (Health Canada, 2008) • Single most preventable cause of morbidity and death in the world today according to the World Health Organization • Significant costs to the health care system • One in every two smokers will die earlier than they otherwise would have, as a result of smoking • Contributes to chronic diseases • Cardiovascular disease • Chronic obstructive pulmonary disease(COPD) (WHO, 2008)

5. Primary cause of lung cancer (leading cause of cancer related death for men and women) (Canadian Cancer Society/National Cancer Institute of Canada, 2009) • Contributes to many forms of cancer • Pancreatic, stomach, kidney, cervical, esophageal, laryngeal, oral and leukemia (U.S. Department of Health and Human Services, 2004) • 1 in 5 deaths are due to smoking (5 times those due to motor vehicle accidents, suicides, other drug abuse, murder & HIV combined!) (Health Canada, 2008; Ontario Ministry of Health Promotion, 2006)

6. Tobacco Products • Cigarettes  dominant form of tobacco used in North America • Cigarette Alternatives: • Chewing tobacco • Snus • Shisha • Cigars & Cigarillos

7. What is a cigarette? • Delivers nicotine to the lungs and brain within 7 seconds each time a smoker inhales • Frequent, small-dose stimulation makes smoking highly addictive • Most cigarettes contain ≥ 10 mg of nicotine • Average smoker absorbs 1-2 mg of nicotine per cigarette • Cigarettes release carbon monoxide which adheres to red blood cells faster than oxygen • Reduced oxygen in the body causes increased heart rate

8. What’s in a Cigarette? • Tobacco • Carbon monoxide • Hydrogen cyanide • Nitrogen oxide • Ammonia (sub-micron sized particles) • Nicotine, phenol, polyaromatic hydrocarbons, tobacco specific nitrosamines. • Tar total particulate matter (nicotine and water) • Filter with titanium oxide accelerant • Flavours • Liquid vapour • Benzene • Formaldehyde • Acrolein • N-nitrosamines • Non-particulate matter There are approximately 50 known carcinogens in cigarettes (Canadian Cancer Society, 2007b)

9. Cigarette Alternatives

10. Prevention: Youth & Adolescents • Most smokers began smoking before age 18 • Many people start smoking at an age when they are easily influenced by peers and advertising • Young adults (between the ages 20 – 24 years) • Highest smoking rate (27%) • Relatively brief smoking history • Often identify themselves as “social smokers” • Social smokers are at risk of becoming regular smokers (Gilpin, White & Pierce, 2005)

11. On-campus Student Smoking Cessation Programs • Most campuses have smoking cessation programs • Student health services in campus clinics • Peer-to-peer programs and activities • Advocate for improved campus smoking policies • Example: Leave the Pack Behind (LTPB) in Ontario http://www.leavethepackbehind.org/

12. Protection: Second-hand smoke • Second-hand smoke: • Also known as environmental tobacco smoke • Combination of: • Side stream smoke (smoke from the end of a cigarette) • Smoke exhaled by the smoker • 67% of smoke from a burning cigarette is not inhaled by the smoker and ends up in the surrounding environment (Health Canada, 2007)

13. Second-hand smoke (cont.) • 4000 chemicals have been identified in second-hand smoke • 50 of these are known carcinogens (United States Environmental Protection Agency, 2000) • Examples:

14. Second-hand smoke (cont.) • Labeled as a known human carcinogen • Labeled as a class A cancer-causing substance (Class A = most dangerous) • Causes at least 1000 deaths annually in Canada

15. Cessation: Smokers and Quitting Smoking • Why do people continue to smoke? • Addiction to nicotine • Perceived benefits (relaxation, stress relief, weight loss) • Social context • Mental health issues

16. Smoke vs. Quit

17. Nicotine • Causes a release of adrenaline from the adrenal glands providing a ‘hit’ or ‘kick’ from each puff of a cigarette • Adrenaline stimulates the body causing the release of glucose, increased blood pressure, respiration and heart rate • Suppresses insulin output • smokers are often in a hyperglycemic state • Increases dopamine levels • Creates a feeling of pleasure (National Institute on Drug Abuse [NIDA], 2006)

18. Definition of Addiction “Addiction is a primary, chronic disease characterized by impaired control over the use of a psychoactive substance and/or behaviour. Clinically, the manifestations occur along biological, psychological, social and spiritual dimensions. Common features of addiction are: change in mood, relief from negative emotions, provision of pleasure, preoccupation with use of substance(s) or ritualistic behaviour(s); and continued use of substance(s) and/or engagement in behaviour(s) despite adverse physical, psychological and/or social consequences.” (The Canadian Society of Addiction Medicine, 1999)

19. General Characteristics of Nicotine Addiction • People who smoke more than 20 cigarettes/day and have their first cigarette within 30 minutes of waking • indicates high nicotine dependence • Causes a release of adrenaline from the adrenal glands providing a ‘hit’ or ‘kick’ from each puff of a cigarette • Dependence develops fairly rapidly • often within 60 days of regular use • Withdrawal syndrome occurs when blood levels fall sharply • Severity of dependence depends more on the difficulty the person has in quitting smoking than on the amount and pattern of smoking • Chronic disease  it can be progressive, relapsing and fatal (Fiore, Jaen, Baker, et al, 2008)

21. Withdrawal Symptoms

22. Treatment Options for Nicotine Addiction • Combination of counseling and pharmacotherapy is more effective than either option alone (Fiore, et al., 2008) • The more intense the intervention, the better the outcome of abstinence (Cairney & Lawrence, 2002)

23. Pharmacologic Options • Clients/patients attempting to quit smoking should always be encouraged to use effective medications unless they are contraindicated in specific populations • eg. pregnant women, smokeless tobacco users, light smokers, adolescents (Fiore, et al) • Two categories of pharmaceutical options: • Nicotine replacement therapy (NRT) • Non-nicotine replacement therapy

24. Nicotine Replacement Therapy (NRT) Non-prescription  available over-the-counter • Nicotine Patch • Nicotine Lozenges • Nicotine Gum • Nicotine Inhalers • Provide nicotine to reduce withdrawal symptoms • Take between 1-4 hours to reach maximum blood levels (unlike cigarettes, 7 seconds) • Do not cause sudden boost to nicotine blood levels (prevents addiction to product) • Dose depends on habits of the smoker but is reduced over a 12 week period

25. Non-nicotine Therapy • Bupropion Hydrochloride (Zyban) • Also marketed as the anti-depressant medication Wellbutrin • Presumed to alleviate cravings associated with nicotine withdrawal affecting noradrenaline and dopamine • Varenicline Tartrate (Champix) • Targets nicotinic acetylcholine receptors to decrease cravings and withdrawal • Clonidine & Nortriptyline • Second-line medications used in smoking cessation All of these medications require a prescription

26. Counselling • Intensive intervention that last a minimum of 10 minutes • Commonly conducted by nurses in various health-care settings • Motivational Interviewing • Directive and client-centred standard counselling techniques • Stages of Change theory

27. Alternative Therapies • No clinical evidence to verify results from these treatments • Some clients/patients report that they are beneficial (Fiore, et al., 2008)

28. Self-help • Most smokers want to quit on their own • Self-help material should be provided • Based on the health behaviour change model • Tailored to specific population • Commonly used resources • One Step at a Time smoking cessation guide (Canadian Cancer Society) • Smokers’ Helpline

29. Phone • Counselling • Online • Self-help • Tips, tools & support • Text messaging • Supportive messages

30. Assessing Readiness to Quit

31. Benefits of Quitting • It’s never too late to quit smoking and experience the benefits • Immediate Rewards: • Improved health • Stop worrying about quitting • Food will taste better • Set a good example for children • Improved sense of smell • Have healthier babies and children • Feel better about yourself • Feel better physically • Breath, home and car will smell better • Reduce wrinkling/aging of skin

32. Immediate & Long-term Health Benefits of Smoking Cessation

33. Key Points • Smoking causes many chronic illnesses and death • Nurses play an important role in helping patients/clients to quit smoking • There are effective treatment options to help people quit smoking • There are considerable immediate and long-term benefits to smoking cessation