1 / 97

Chapter 10 Tobacco Cessation and Education

leighton
Download Presentation

Chapter 10 Tobacco Cessation and Education

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. Tobacco Education and Cessation 1 Chapter 10 Tobacco Cessation and Education Today’s training will be an overview of the upcoming revisions to the Healthy Start Standards and Guidelines relating to tobacco cessation. Today’s training will be an overview of the upcoming revisions to the Healthy Start Standards and Guidelines relating to tobacco cessation.

    2. Tobacco Education and Cessation 2 Training Objectives Upon completion of this training the participant will: Know the Healthy Start Standards and Guidelines standards related to providing tobacco cessation services. Understand the criteria for coding tobacco cessation services on the HMS. Be able to list who is eligible for tobacco cessation services. Be able to list the 5 A's of the 5 A's approach to tobacco education and cessation services. List the stages of behavior change. This training is not a Make Yours a Fresh Start training.This training is not a Make Yours a Fresh Start training.

    3. Tobacco Education and Cessation 3 Program Goals For Healthy Start families To reduce the number of pregnant women who smoke during pregnancy To increase the number of women who do not resume smoking after delivery To reduce exposure of the pregnant woman, fetus and infant to environmental tobacco smoke To reduce the incidence of tobacco use by all household members We have these standards for the Healthy Start tobacco cessation and education program because we want to ......We have these standards for the Healthy Start tobacco cessation and education program because we want to ......

    4. Tobacco Education and Cessation 4 Smoking Harms Every Phase of Reproduction* Before Pregnancy, women who smoke have more difficulty becoming pregnant and have a higher risk of never becoming pregnant. Source: Centers for Disease Control http://www.cdc.gov/tobacco/sgr/sgr_2004/consumerpiece/page5.htm

    5. Timing of Health Benefits In addition to the reproductive health benefits, there are other immediate and more long term benefits to quitting smoking. This chart is very effective in showing participants the benefits of stopping. In addition to increasinThis chart is very useful in showing the health benefits to the mom.In addition to the reproductive health benefits, there are other immediate and more long term benefits to quitting smoking. This chart is very effective in showing participants the benefits of stopping. In addition to increasinThis chart is very useful in showing the health benefits to the mom.

    6. Smoking Harms Every Phase of Reproduction During pregnancy, nicotine freely crosses the placenta and has been found in amniotic fluid and the umbilical cord blood of newborn infants. (It is found in breast milk too.) Source: American Cancer Society http://www.cancer.org/docroot/PED/content/PED_10_2x_Smokeless_Tobacco_and_Cancer.asp?sitearea=PED Once the woman becomes pregnant...........Once the woman becomes pregnant...........

    7. Smoking during Pregnancy Higher risk of gestational diabetes 5 to 6 % of perinatal deaths 7 to 10 percent of preterm deliveries More likely to be overweight than children of nonsmoking mothers Asthma - 25% higher rate in children whose mother smoked less than 10 cigarettes per day 36% higher in children whose mothers smoked more than 10 cigarettes per day.

    8. Tobacco Use During Pregnancy - Maternal Harm Possible causal association -placenta previa -spontaneous abortion Probable causal association -ectopic pregnancy -preterm PROM Causal association -abruptio placenta Smoke Free Families shows us some of the reasons for these poor outcomes. even more reasons to quit smoking. Some of the outcomes related to fetal exposure to nicotine are.... Basically, there is an increased chance of miscarriage, premature delivery or growth retardation. Approximately 22% of pregnant women smoke during pregnancy. Smoking during pregnancy is associated with serious adverse events for the mother and child both during and after pregnancy. Complications during pregnancy include ectopic pregnancy, intrauterine growth restriction, placenta previa, placental abruption, premature rupture of membranes, spontaneous abortion, and preterm delivery. Women and Smoking: A Report of the Surgeon General—2001. Centers for Disease Control Web site. Available at: http://www.cdc.gov/tobacco/sgr/sgr_forwomen/Executive_Summary.htm. Accessed October 5, 2001. Smoke Free Families shows us some of the reasons for these poor outcomes. even more reasons to quit smoking. Some of the outcomes related to fetal exposure to nicotine are.... Basically, there is an increased chance of miscarriage, premature delivery or growth retardation. Approximately 22% of pregnant women smoke during pregnancy. Smoking during pregnancy is associated with serious adverse events for the mother and child both during and after pregnancy. Complications during pregnancy include ectopic pregnancy, intrauterine growth restriction, placenta previa, placental abruption, premature rupture of membranes, spontaneous abortion, and preterm delivery. Women and Smoking: A Report of the Surgeon General—2001. Centers for Disease Control Web site. Available at: http://www.cdc.gov/tobacco/sgr/sgr_forwomen/Executive_Summary.htm. Accessed October 5, 2001.

    9. Call to Action Smoking is the most modifiable risk factor for poor birth outcomes Successful treatment of tobacco dependence can achieve: 20% reduction in low–birth-weight babies 17% decrease in preterm births Average increase in birth weight of 28 g Source: Lumley J, Oliver S, Waters E. Interventions for promoting tobacco cessation during pregnancy. Cochrane Database Syst Rev 2000;(2):CD001055. Goldenberg RL, Dolan-Mullen P. Convincing pregnant patients to stop smoking. Contemp Ob Gyn 2000;35–44. tobacco cessation During Pregnancy. American College of Obstetricians and Gynecologists. ACOG Educational Bulletin Number 260. September 2000. So why is this a problem? ACOG was so concerned about the damaging effects of smoking during pregnancy that they issue the following Call to Action saying: “Smoking during pregnancy is the most modifiable risk factor for poor birth outcomes. Successful treatment of tobacco use and dependence can significantly affect pregnancy-related outcomes, achieving, for example, a 20% reduction in the number of low birth weight babies, a 17% decrease in preterm births, and an average increase in birth weight of 28 g. Pregnant women who quit smoking as late as the 30th week of gestation can still positively affect their babies’ birth weight.” Lumley J, Oliver S, Waters E. Interventions for promoting tobacco cessation during pregnancy. Cochrane Database Syst Rev 2000;(2):CD001055. Goldenberg RL, Dolan-Mullen P. Convincing pregnant patients to stop smoking. Contemp Ob Gyn 2000;35–44. tobacco cessation During Pregnancy. American College of Obstetricians and Gynecologists. ACOG Educational Bulletin Number 260. September 2000.So why is this a problem? ACOG was so concerned about the damaging effects of smoking during pregnancy that they issue the following Call to Action saying: “Smoking during pregnancy is the most modifiable risk factor for poor birth outcomes. Successful treatment of tobacco use and dependence can significantly affect pregnancy-related outcomes, achieving, for example, a 20% reduction in the number of low birth weight babies, a 17% decrease in preterm births, and an average increase in birth weight of 28 g. Pregnant women who quit smoking as late as the 30th week of gestation can still positively affect their babies’ birth weight.” Lumley J, Oliver S, Waters E. Interventions for promoting tobacco cessation during pregnancy. Cochrane Database Syst Rev 2000;(2):CD001055. Goldenberg RL, Dolan-Mullen P. Convincing pregnant patients to stop smoking. Contemp Ob Gyn 2000;35–44. tobacco cessation During Pregnancy. American College of Obstetricians and Gynecologists. ACOG Educational Bulletin Number 260. September 2000.

    10. An Analysis completed by the Department of Health Maternal and Child Health evaluation team concluded that: Approximately 500 premature births could be avoided annually if all women who gave birth did not smoke We often analyze our health outcomes in relation to how much “excess” poor outcome could be reduced by public health interventions. Here are examples of the projected reduction in prematurity if our program efforts were to achieve success in the areas of tobacco cessation and early prenatal care. We often analyze our health outcomes in relation to how much “excess” poor outcome could be reduced by public health interventions. Here are examples of the projected reduction in prematurity if our program efforts were to achieve success in the areas of tobacco cessation and early prenatal care.

    11. Tobacco Use During Pregnancy - Infant Harm Causal association -low birth weight -small for gestational age -preterm delivery -Sudden Infant Death Syndrome (SIDS) -stillbirths

    12. Harms of Tobacco Exposure during Infancy and Early Childhood Causal association -otitis media -new and exacerbated cases of asthma -bronchitis and pneumonia -wheezing and lower respiratory illness

    13. Annual Smoking-Related Child Morbidity and Mortality This slide from ACOG shows that exposure to cigarette smoking is associated with childhood disease and injury. It is estimated that in the United States, annual smoking-related morbidity and mortality among children include: 354,000 to 2.2 million episodes of otitis media 1.3 million to 2 million physician visits for coughs 529,000 physician visits for asthma 260,000 to 436,000 episodes of bronchitis 115,000 to 190,000 episodes of pneumonia 5,200 to 165,000 tympanostomies 14,000 to 21,000 tonsillectomies and/or adenoidectomies 284 to 360 deaths from smoking-related lower respiratory tract illnesses and fires 300 fire-related injuries from smoking materials DiFranza JR, Lew RA. Morbidity and mortality in children associated with the use of tobacco products by other people. Pediatrics 1996;97:560–568.This slide from ACOG shows that exposure to cigarette smoking is associated with childhood disease and injury. It is estimated that in the United States, annual smoking-related morbidity and mortality among children include: 354,000 to 2.2 million episodes of otitis media 1.3 million to 2 million physician visits for coughs 529,000 physician visits for asthma 260,000 to 436,000 episodes of bronchitis 115,000 to 190,000 episodes of pneumonia 5,200 to 165,000 tympanostomies 14,000 to 21,000 tonsillectomies and/or adenoidectomies 284 to 360 deaths from smoking-related lower respiratory tract illnesses and fires 300 fire-related injuries from smoking materials DiFranza JR, Lew RA. Morbidity and mortality in children associated with the use of tobacco products by other people. Pediatrics 1996;97:560–568.

    14. Tobacco Education and Cessation 14 Risks to Children Who have Mothers that Smoke More likely to be hospitalized during the first two years of life

    15. Tobacco Education and Cessation 15 Risks to Children Who Have Mothers that Smoke SUDDEN INFANT DEATH SYNDROME RISK NEARLY TRIPLES WITH MATERNAL SMOKING DURING AND AFTER PREGNANCY

    16. Maternal Smoking During Pregnancy Increases Risk of Offspring Behavior Problems 1-2 day old infants - elevated scores on measures of stress and excitability Toddlers - at increased risk for aggressive behavior, negativity and hyper activity Teenagers - at risk for memory problems and other cognitive difficulties. cognitive difficulties and an increase in risk for cigarette addiction during adolescence.

    17. Prevalence of Smoking During Pregnancy, PRAMS

    18. 2007 data is through June2007 data is through June

    19. Want More Information on the Effects of Tobacco Exposure during Pregnancy? Go to Dept. of Health website at http://www.doh.state.fl.us/Family/mch/SubstanceAbuse/Tobacco/tobacco.html The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General, 2006 http://www.surgeongeneral.gov/library/secondhandsmoke/ Each one of you could probably give me more information on why smoking is harmful for the mother, the baby she is carrying and for her children. To find more information you may go to ......Each one of you could probably give me more information on why smoking is harmful for the mother, the baby she is carrying and for her children. To find more information you may go to ......

    20. Standard 10.1 All providers receiving Healthy Start funding to provide prenatal care will ask about tobacco use, advise to quit, assist in quit attempt, arrange follow-up, and advise about the dangers of ETS to the pregnant woman, those in her home, and to infants. This is a new standard. Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.This is a new standard. Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.

    21. Conclusions from Behavioral Intervention Studies Pregnancy is a good time to intervene Brief counseling works better than simple advice to quit Counseling with self-help materials offered by a trained clinician can improve cessation rates by 30% to 70% This brief intervention works best for moderate (<20 cigarettes/day) smokers We know tobacco cessation services work. A review of studies of behavioral intervention strategies to help pregnant women stop smoking found that: Pregnancy is an appropriate time to initiate tobacco cessation intervention Brief cessation counseling is more effective than simple advice to quit Brief cessation counseling offered with pregnancy-specific self-help materials by a trained clinician can improve cessation rates by 30% to 70% compared with cessation rates achieved with simple advice to quit Intervention involving brief counseling sessions was found to be most effective in light to moderate smokers—ie, fewer than 20 cigarettes per day Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service. June 2000. Melvin CL, Dolan-Mullen P, Windsor RA, Whiteside HP Jr, Goldenberg RL. Recommended cessation counseling for pregnant women who smoke: a review of the evidence. Tob Control 2000;9(suppl III):iii80–iii84. Mullen PD. Maternal smoking during pregnancy and evidence-based intervention to promote cessation. Prim Care 1999;26:577–589. We know tobacco cessation services work. A review of studies of behavioral intervention strategies to help pregnant women stop smoking found that: Pregnancy is an appropriate time to initiate tobacco cessation intervention Brief cessation counseling is more effective than simple advice to quit Brief cessation counseling offered with pregnancy-specific self-help materials by a trained clinician can improve cessation rates by 30% to 70% compared with cessation rates achieved with simple advice to quit Intervention involving brief counseling sessions was found to be most effective in light to moderate smokers—ie, fewer than 20 cigarettes per day Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service. June 2000. Melvin CL, Dolan-Mullen P, Windsor RA, Whiteside HP Jr, Goldenberg RL. Recommended cessation counseling for pregnant women who smoke: a review of the evidence. Tob Control 2000;9(suppl III):iii80–iii84. Mullen PD. Maternal smoking during pregnancy and evidence-based intervention to promote cessation. Prim Care 1999;26:577–589.

    22. Tobacco Education and Cessation 22 Are Women Getting the Message? During any of your prenatal care visits, did a doctor, nurse, or other healthcare worker talk with you about how smoking during pregnancy could affect your baby? 74% Answered Yes. Source: Florida PRAMS 2005 Are women getting the message about the dangers of smoking during pregnancy?Are women getting the message about the dangers of smoking during pregnancy?

    23. Tobacco Education and Cessation 23 44% of FL Women Smokers Atttempted to Quit in 2003 Note: Every Day Smokers who quit smoking cigarettes for >1 day during the past year. Source: Behavioral Risk Factor Surveillance System (BRFSS)

    24. Treating Tobacco Use & Dependence Surgeon General recommended “5 A’s” approach Source: http://www.surgeongeneral.gov/tobacco/clinpack.html

    25. Prenatal Care Provider Tools for Tobacco Cessation Counseling ACOG model-Smoking and Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking Make Yours a Fresh Start Family Model The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General, 2006. http://www.surgeongeneral.gov/library/secondhandsmoke/ 2A’s & R

    26. Clinical Practice Guidelines for Brief tobacco cessation Counseling 5 A’s =Make Yours a Fresh Start Family Ask = Survey Advise = Tailor health message Assess = Assess Assist = Give materials & plan Arrange = Evaluate progress at followup There are several prenatal tobacco cessation models which incorporate the 5 A’s, but may call them by different terms. There are several prenatal tobacco cessation models which incorporate the 5 A’s, but may call them by different terms.

    27. Step 1: Survey = Ask Identify and document tobacco use for every participant at every visit Identify smokers and recent quitters Determine possible barriers to quitting Identify other smokers in the home Source: Pennsylvania Chapter American Academy of PediatricsSource: Pennsylvania Chapter American Academy of Pediatrics

    28. Step 1: Survey = Ask Identify and document tobacco use for every participant at every visit -Can ask participant to choose the statement that best describes them a. I have never smoked or have smoked less than 100 cigarettes in my life. b. I stopped smoking before I found out I was pregnant, and I am not smoking now. c. I stopped smoking after I found out I was pregnant, and I am not smoking now. d. I smoke some now, but I have cut down since I found out I was pregnant. e. I smoke regularly now, about the same as before I found out I was pregnant. Source: The American College of Obstetricians and Gynecologists, Smoking Cessation during Pregnancy tent card. Source: Pennsylvania Chapter American Academy of PediatricsSource: Pennsylvania Chapter American Academy of Pediatrics

    29. Step 2: Tailor a Health Message Acknowledge the difficulty of quitting Give information about the effects of smoking on the fetus, child, smoker Stress benefits of quitting – relate to motivations person may have mentioned Give clear recommendation to quit Positively reinforce recent quit attempts/success at quitting Source: Make Yours a Fresh Start Family Training Manual, p.26.

    31. Step 3: Assess Readiness to Quit=Assess Offer help Ask if willing to try to quit Build confidence in ability to quit Before we can counsel the smoker, we need to know where he/she is on the “quitting spectrum”. This is the step that requires our knowledge of the process of behavior change. Is he/she a pre-contemplator, a contemplator, or in preparation? Has he/she recently quit or relapsed? The proper assessment will determine what we say and how we say it to the participant. Proper assessment is crucial so that the appropriate message is deliveredBefore we can counsel the smoker, we need to know where he/she is on the “quitting spectrum”. This is the step that requires our knowledge of the process of behavior change. Is he/she a pre-contemplator, a contemplator, or in preparation? Has he/she recently quit or relapsed? The proper assessment will determine what we say and how we say it to the participant. Proper assessment is crucial so that the appropriate message is delivered

    32. Assess: Key Questions Are You Interested in Quitting With My/Our Assistance? Are You Ready to Quit in the Next 4-6 Weeks? The quickest and easiest way to discover his/her position on the “quitting spectrum” is to ask him/her if he/she would be receptive to your assistance in helping him/her quit smoking. If he/she does not respond receptively, he/she is not interested or ready (pre-contemplator) If he/she responds receptively, then he/she is interested in your help. You will need to ask him/her if he/she would be ready to quit within the next few weeks. If he/she is not, he/she is not ready (contemplator). If he/she responds that he/she is ready to take action then he/she is considered to be in the preparation stage.The quickest and easiest way to discover his/her position on the “quitting spectrum” is to ask him/her if he/she would be receptive to your assistance in helping him/her quit smoking. If he/she does not respond receptively, he/she is not interested or ready (pre-contemplator) If he/she responds receptively, then he/she is interested in your help. You will need to ask him/her if he/she would be ready to quit within the next few weeks. If he/she is not, he/she is not ready (contemplator). If he/she responds that he/she is ready to take action then he/she is considered to be in the preparation stage.

    33. The Process of Behavior Change From your discussion with the person, who may have gotten an idea of the person’s readiness to quit smoking. This is a flowchart that shows the various phases that a person progresses through when changing a behavior. This has been adapted from an original model developed by DiClemente and Prochaska. Pre-contemplator: This is someone who loves to smoke and loves everything about the habit, including what brand is smoked, how he/she smokes the cigarette, when and with whom he/she smokes, etc. This person has no intention to quit. This person might be very aware of the health risks but will deny these risks. This person could also be unaware of the health risks. Contemplator: This person is more or less “wishy-washy” about smoking. While this person likes to smoke, he/she is also interested in quitting because of one or more reasons. However, this person lacks the confidence to quit for good, thus will not be ready to quit in the next month. Barriers, such as unsuccessful quit attempts, are preventing the person from quitting. Preparation: This person is ready and willing to try to quit. This person will typically be researching available quitting options and will want to attempt cessation in the near future. Action: The quit day and period of six months afterward. Maintenance: The period of time following six months of being smoke-free. Relapse: The return to the smoking habit. Ex-Smoker: Smoke-free status for at least one year Source: American Academy of Pediatrics, Pennsylvania ChapterFrom your discussion with the person, who may have gotten an idea of the person’s readiness to quit smoking. This is a flowchart that shows the various phases that a person progresses through when changing a behavior. This has been adapted from an original model developed by DiClemente and Prochaska. Pre-contemplator: This is someone who loves to smoke and loves everything about the habit, including what brand is smoked, how he/she smokes the cigarette, when and with whom he/she smokes, etc. This person has no intention to quit. This person might be very aware of the health risks but will deny these risks. This person could also be unaware of the health risks. Contemplator: This person is more or less “wishy-washy” about smoking. While this person likes to smoke, he/she is also interested in quitting because of one or more reasons. However, this person lacks the confidence to quit for good, thus will not be ready to quit in the next month. Barriers, such as unsuccessful quit attempts, are preventing the person from quitting. Preparation: This person is ready and willing to try to quit. This person will typically be researching available quitting options and will want to attempt cessation in the near future. Action: The quit day and period of six months afterward. Maintenance: The period of time following six months of being smoke-free. Relapse: The return to the smoking habit. Ex-Smoker: Smoke-free status for at least one year Source: American Academy of Pediatrics, Pennsylvania Chapter

    34. PRECONTEMPLATION - NOT READY TO THINK ABOUT CHANGE Some participants will be polite and not interested, some will make it clear they don’t want to talk about changing tobacco use behavior. Many who are not interested and have adequate resources will be closed to care coordination, because they are level 1. Wraparound service can be offered at any time until they are terminated from Healthy Start.Some participants will be polite and not interested, some will make it clear they don’t want to talk about changing tobacco use behavior. Many who are not interested and have adequate resources will be closed to care coordination, because they are level 1. Wraparound service can be offered at any time until they are terminated from Healthy Start.

    35. CONTEMPLATION - Will listen to new information and consider the idea of changing behavior - moves slowly toward change. Health care providers can have an impact with people who are interested in hearing information about tobacco and how it is harmful. They may try to quit or at least cut down, with repeated educational interventions.Health care providers can have an impact with people who are interested in hearing information about tobacco and how it is harmful. They may try to quit or at least cut down, with repeated educational interventions.

    36. PREPARATION - Taking a series of steps toward quitting including setting a quit date. ABOUT TO LEAP INTO CHANGE. Emphasize that service delivery time increases at this stage as participant is close to quitting. Participants who begin to focus on a quit date and/or a way to cut down so that they can quit in the near future, need to have repeated reinforcement and intervention to maintain and increasr their motivation and to provide concrete assistance with the issues that impede their success.Emphasize that service delivery time increases at this stage as participant is close to quitting. Participants who begin to focus on a quit date and/or a way to cut down so that they can quit in the near future, need to have repeated reinforcement and intervention to maintain and increasr their motivation and to provide concrete assistance with the issues that impede their success.

    37. ACTION - The first day one stops tobacco use, and the daily struggle over the next few months to maintain cessation. Emphasize that during the action stage contact with the participant must be frequent. It is very individualized as each quitter will have unique challenges. It is helpful to review what is difficult, make concrete suggestions, offer medication as appropriate, be aware of support services in the community, and continually encourage and motivate.Emphasize that during the action stage contact with the participant must be frequent. It is very individualized as each quitter will have unique challenges. It is helpful to review what is difficult, make concrete suggestions, offer medication as appropriate, be aware of support services in the community, and continually encourage and motivate.

    38. MAINTENANCE - sustains cessation over a period of time A notation in the record must be made even during this stage. This is particularly critical with pregnant women who have quite during the pregnancy and are VERY vulnerable to relapse(70%) post partum.A notation in the record must be made even during this stage. This is particularly critical with pregnant women who have quite during the pregnancy and are VERY vulnerable to relapse(70%) post partum.

    39. RELAPSE - part of the recovery process in addiction - when old behavior returns, use learned behavior change skills that worked HOOKED AGAIN Relapse will not often be reported voluntarily, so inquiry into participant’s tobacco use status must be made at each contact.Relapse will not often be reported voluntarily, so inquiry into participant’s tobacco use status must be made at each contact.

    40. MAINTENANCE - The ability to sustain cessation over the course of time A notation in the record must be made even during this stage. This is particularly critical with pregnant women who have quite during the pregnancy and are VERY vulnerable to relapse(70%) post partum.A notation in the record must be made even during this stage. This is particularly critical with pregnant women who have quite during the pregnancy and are VERY vulnerable to relapse(70%) post partum.

    41. Step 4: Give Materials and a Plan of Action = Assist PURPOSE: To Assist client To help the client take positive action toward quitting which is appropriate to her readiness to quit This step provides the foundation for further follow-up and reinforcement This step involves referring the participant to the self help booklets and instructing her to read at least one or more sections. Source: Pennsylvania Chapter American Academy of PediatricsThis step involves referring the participant to the self help booklets and instructing her to read at least one or more sections. Source: Pennsylvania Chapter American Academy of Pediatrics

    42. Give Materials: Key Notes Give support Offer the appropriate handouts and review Assist with developing a plan of action Discuss pharmacotherapy Make appropriate referrals (Quitline, groups, etc.) Optional materials Follow-up appointment if possible Part of assisting is giving materials that may be useful. You can refer the participant to a section(s) within the appropriate booklet that is conducive to her readiness to quit. You want to be sure to direct her to the appropriate page(s) and fold back the pages that she is to read to make it very easy for her. In addition to referring her to the appropriate page(s) in the booklet, it is important to state that at her next visit you will discuss what she has read, go over any concerns and answer any questions that she might have.Part of assisting is giving materials that may be useful. You can refer the participant to a section(s) within the appropriate booklet that is conducive to her readiness to quit. You want to be sure to direct her to the appropriate page(s) and fold back the pages that she is to read to make it very easy for her. In addition to referring her to the appropriate page(s) in the booklet, it is important to state that at her next visit you will discuss what she has read, go over any concerns and answer any questions that she might have.

    43. Make Yours A Fresh Start Family ..a magazine for pregnant women who smoke Make Yours A Fresh Start Family...a magazine for pregnant women who smokeThis magazine is for use by those who have been trained in the Make Yours a Fresh Start Family model and are designed to be used as a counseling tool. They are not designed to be put in waiting rooms or handed out at health fairs. This magazine can be ordered from the Department of Health warehouse. Title #Stock #Make Yours a Fresh Start Family Magazine for Pregnant Women Who Smoke DH 150-387, 4/98HMI JH57303870150125/PG Make Yours A Fresh Start Family...a magazine for pregnant women who smokeThis magazine is for use by those who have been trained in the Make Yours a Fresh Start Family model and are designed to be used as a counseling tool. They are not designed to be put in waiting rooms or handed out at health fairs. This magazine can be ordered from the Department of Health warehouse. Title #Stock #Make Yours a Fresh Start Family Magazine for Pregnant Women Who Smoke DH 150-387, 4/98HMI JH57303870150125/PG

    44. Make Yours A Fresh Start Family ..a magazine for mothers who smoke Make Yours A Fresh Start Family...a magazine for mothers who smokeThis magazine is for use by those who have been trained in the Make Yours a Fresh Start Family model and are designed to be used as a counseling tool. They are not designed to be put in waiting rooms or handed out at health fairs.This magazine can be ordered from the Department of Health warehouse. Title #Stock #Make Yours a Fresh Start Family Magazine for Mothers Who Smoke DH 150-386, 4/98HMI Make Yours A Fresh Start Family...a magazine for mothers who smokeThis magazine is for use by those who have been trained in the Make Yours a Fresh Start Family model and are designed to be used as a counseling tool. They are not designed to be put in waiting rooms or handed out at health fairs.This magazine can be ordered from the Department of Health warehouse. Title #Stock #Make Yours a Fresh Start Family Magazine for Mothers Who Smoke DH 150-386, 4/98HMI

    45. Consumer Guide May order from Agency for Healthcare Research and Quality (AHRQ) 1-800-358-9295

    46. Translations services for other languages are available through the AT&T language line.Translations services for other languages are available through the AT&T language line.

    47. Florida Quit for Life Line Referral Form PROVIDER Complete all of the following: Advised no tobacco in pregnancy and postpartum Assessed that patient wants to quit in the next 30 days Obtained permission to refer to the Quit for LifeLine Patient Name_________________________________________Date____________________ Referring Provider_____________________________________________________________ Practice Name________________________________________________________________ Practice address______________________________________Zip Code_________________ Telephone___________________________________________Fax_____________________ PATIENT Assistance from the Quit for Life Line will increase your chances for success in quitting tobacco. The LifeLine provides: Friendly, respectful support Expertise in tobacco and nicotine No-pressure, helpful counseling Ways to boost your confidence Best day and time for Quitline staff to call me: Day___________________________________Time__________________________________ My signature gives permission for my provider to FAX this form to the Florida Quit for Life Line. I understand that a Quitline specialist will call me within the next week. Patient Signature______________________________________________________________ Patient telephone_______________________________________Zip Code________________ FAX THIS FORM TO (877) 747-9528 Questions? Call the Florida Quit for Life Line, 1-(877) U CAN NOW Research has shown that women are more likely to participate in Quitline counseling if they complete this form with their healthcare provider and the health care provider faxes this form to the Quitline.Research has shown that women are more likely to participate in Quitline counseling if they complete this form with their healthcare provider and the health care provider faxes this form to the Quitline.

    48. Step 5: Evaluate Progress at Follow-Up Visits Praise positive steps Rephrase initial messages where needed Direct to appropriate pages in materials Build motivation Document status & next steps planned This step involves referring the participant to the self help booklets and instructing her to read at least one or more sections. Source: Pennsylvania Chapter American Academy of PediatricsThis step involves referring the participant to the self help booklets and instructing her to read at least one or more sections. Source: Pennsylvania Chapter American Academy of Pediatrics

    49. 2 A’s + R 3 MINUTE VERSION ASK – every patient about tobacco use and document in their medical record – 1 minute ADVISE – urge every tobacco user to quit; employ the teachable moment and link visit findings with advice – 1 minute REFER – patients to quitline or cessation classes and document in medical record – 1 minute So what is a 2A’s and R approach? The 5 A’s model is the most effective. For times when doctors do not have 5 minutes for the 5 A’s approach, ACOG and CDC support the use of the “2 A’s and R” 3 minute cessation model.So what is a 2A’s and R approach? The 5 A’s model is the most effective. For times when doctors do not have 5 minutes for the 5 A’s approach, ACOG and CDC support the use of the “2 A’s and R” 3 minute cessation model.

    50. Patients Who Decline to Quit: Using the 5 R’s A patient who declines to make a quit attempt may have reasons for not quitting that she is unable or unwilling to express. Or, she may think smoking risks do not apply to her. The 5 R’s are useful for identifying issues that are of most concern to the patient who is reluctant to try to quit. Motivational interventions are most likely to be successful when the clinician is empathetic, promotes patient autonomy (ie, choice among options), avoids arguments, and supports the patient’s self-efficacy—for example, by reminding her of previous successes in behavior change efforts. It is not necessary to cover all of the 5 R’s at each patient visit. Colby SM, Barnett NP, Monti PM, et al. Brief motivational interviewing in a hospital setting for adolescent smoking: a preliminary study. J Consult Con Psychol 1999;66:574–578. Miller W, Rolnick S. Motivational interviewing: preparing people to change addictive behavior. New York: Guilford, 1991. Prochaska J, Goldstein MG. Process of smoking cessation. Implication for clinicians. Clin Chest Med 1991;12:727–735.A patient who declines to make a quit attempt may have reasons for not quitting that she is unable or unwilling to express. Or, she may think smoking risks do not apply to her. The 5 R’s are useful for identifying issues that are of most concern to the patient who is reluctant to try to quit. Motivational interventions are most likely to be successful when the clinician is empathetic, promotes patient autonomy (ie, choice among options), avoids arguments, and supports the patient’s self-efficacy—for example, by reminding her of previous successes in behavior change efforts. It is not necessary to cover all of the 5 R’s at each patient visit. Colby SM, Barnett NP, Monti PM, et al. Brief motivational interviewing in a hospital setting for adolescent smoking: a preliminary study. J Consult Con Psychol 1999;66:574–578. Miller W, Rolnick S. Motivational interviewing: preparing people to change addictive behavior. New York: Guilford, 1991. Prochaska J, Goldstein MG. Process of smoking cessation. Implication for clinicians. Clin Chest Med 1991;12:727–735.

    51. 5 R’s: Relevance Ask patient to identify why quitting might be personally relevant, such as: children in her home need for money history of smoking- related illness Relevance. Encourage the patient to discuss why quitting might be personally relevant. This will help her link the motivation to quit to her situation. Some suggestions include the presence of children in her home, cost of smoking, or a history of frequent respiratory illness in herself or her family members.Relevance. Encourage the patient to discuss why quitting might be personally relevant. This will help her link the motivation to quit to her situation. Some suggestions include the presence of children in her home, cost of smoking, or a history of frequent respiratory illness in herself or her family members.

    52. 5 R’s: Risks Ask, “What have you heard about smoking during pregnancy?” Reiterate benefits for her unborn baby and her other children Tell her that a previous trouble-free pregnancy is no guarantee that this pregnancy will be the same Risks. Make sure that the patient understands the risks of continued smoking by asking her what she considers to be potential negative consequences. One way to begin this part of the discussion is to ask, “Although you do not want to or are not ready to quit now, what have you heard about smoking during pregnancy?” If the patient seems unaware of the risks, this is a good time to give her pregnancy-specific information about risks.Risks. Make sure that the patient understands the risks of continued smoking by asking her what she considers to be potential negative consequences. One way to begin this part of the discussion is to ask, “Although you do not want to or are not ready to quit now, what have you heard about smoking during pregnancy?” If the patient seems unaware of the risks, this is a good time to give her pregnancy-specific information about risks.

    53. 5 R’s: Rewards Your baby will get more oxygen after just 1 day Your clothes and hair will smell better You will have more money Food will taste better You will have more energy Rewards. Ask the patient to identify benefits of quitting smoking. Depending on her situation, she may need some direction, such as “Your clothes and house will smell better,” or “You’ll set a good example for your children and their friends.”Rewards. Ask the patient to identify benefits of quitting smoking. Depending on her situation, she may need some direction, such as “Your clothes and house will smell better,” or “You’ll set a good example for your children and their friends.”

    54. 5 R’s: Roadblocks Negative moods Being around other smokers Triggers and cravings Time pressures Roadblocks. Most patients can readily identify barriers to quitting, giving you the opportunity to address them and to reassure the patient that assistance and encouragement are available. She needs to know that roadblocks such as withdrawal symptoms, weight gain, another smoker in the house, and emotional consequences can be overcome. Problem-solving strategies and tools can be applied to many situations once roadblocks are identified.Roadblocks. Most patients can readily identify barriers to quitting, giving you the opportunity to address them and to reassure the patient that assistance and encouragement are available. She needs to know that roadblocks such as withdrawal symptoms, weight gain, another smoker in the house, and emotional consequences can be overcome. Problem-solving strategies and tools can be applied to many situations once roadblocks are identified.

    55. Overcoming Roadblocks: Negative Moods Suck on hard candy Engage in physical activity Express yourself (write, talk) Relax Think about pleasant, positive things Ask others for support Hard candy: Because they keep the mouth occupied, fat-free hard candies are good substitutes for a cigarette, assuming no dietary restrictions against sucrose. The sugar boost can counter negative emotions. Physical activity: Walking, housework, going shopping, or gardening can direct thoughts away from negative emotions. Self-expression: Writing down feelings, talking with a friend, or just expressing feelings out loud in private are a few ways to release negative emotions and prevent their accumulation. Relaxation: A hot bath or shower, soothing music, deep breathing, meditation, or stroking a pet all diffuse negative feelings. Redirect negative thoughts: Thinking about a good time, an accomplishment, or anything enjoyable or funny can change a bad mood. Support system: Make friends and family aware that this is a difficult time, prepare them for occasional moodiness or irritability, and ask for help with routine tasks.Hard candy: Because they keep the mouth occupied, fat-free hard candies are good substitutes for a cigarette, assuming no dietary restrictions against sucrose. The sugar boost can counter negative emotions. Physical activity: Walking, housework, going shopping, or gardening can direct thoughts away from negative emotions. Self-expression: Writing down feelings, talking with a friend, or just expressing feelings out loud in private are a few ways to release negative emotions and prevent their accumulation. Relaxation: A hot bath or shower, soothing music, deep breathing, meditation, or stroking a pet all diffuse negative feelings. Redirect negative thoughts: Thinking about a good time, an accomplishment, or anything enjoyable or funny can change a bad mood. Support system: Make friends and family aware that this is a difficult time, prepare them for occasional moodiness or irritability, and ask for help with routine tasks.

    56. Overcoming Roadblocks: Other Smokers Ask a friend or relative to quit with you Ask others not to smoke around you Assign nonsmoking areas Leave the room when others smoke Keep hands and mouth busy Trying to quit when a household member smokes or when social or work activities permit smoking increases the risk of relapse. Strategies for dealing with other smokers depend on who the other smoker is and how comfortable the patient feels asking that person to modify his or her behavior to help support her decision to quit. Only the patient can make the decision about how she would like to prepare to be around other smokers. Choices range from asking a member of the household to quit to asking that person to step outside to smoke. A woman who socializes with smokers may ask others not to smoke around her for the benefit of the baby. If she is uncomfortable making that request, she can leave the area where people are smoking or distract herself with some preplanned activity to keep her hands busy.Trying to quit when a household member smokes or when social or work activities permit smoking increases the risk of relapse. Strategies for dealing with other smokers depend on who the other smoker is and how comfortable the patient feels asking that person to modify his or her behavior to help support her decision to quit. Only the patient can make the decision about how she would like to prepare to be around other smokers. Choices range from asking a member of the household to quit to asking that person to step outside to smoke. A woman who socializes with smokers may ask others not to smoke around her for the benefit of the baby. If she is uncomfortable making that request, she can leave the area where people are smoking or distract herself with some preplanned activity to keep her hands busy.

    57. Overcoming Roadblocks: Triggers and Cravings Cravings will lessen within a few weeks Anticipate “triggers”: coffee breaks, social gatherings, being on the phone, waking up Change routine—for example, brush your teeth immediately after eating Distract yourself with pleasant activities: garden, listen to music The craving for a cigarette is part of the nicotine withdrawal picture, and will lessen within a few weeks. The patient can be counseled to anticipate situations when cravings will be strongest, or that she most strongly associates with smoking, and prepare for them. At a social gathering, she might keep her hands and mouth busy with raw vegetables, or by assisting the host with serving and clean-up. If she habitually smokes upon waking up, she might consider changing her morning routine.The craving for a cigarette is part of the nicotine withdrawal picture, and will lessen within a few weeks. The patient can be counseled to anticipate situations when cravings will be strongest, or that she most strongly associates with smoking, and prepare for them. At a social gathering, she might keep her hands and mouth busy with raw vegetables, or by assisting the host with serving and clean-up. If she habitually smokes upon waking up, she might consider changing her morning routine.

    58. Overcoming Roadblocks: Time Pressures Change your lifestyle to reduce stress Increase physical activity If a stressful schedule is triggering the desire to smoke, encourage the patient to make some lifestyle changes that will relieve some of the pressure—for example, she might get up 15 minutes earlier in the morning, or ask friends and family members to assume more responsibility for chores and tasks. Increasing physical activity will improve her stamina and her outlook.If a stressful schedule is triggering the desire to smoke, encourage the patient to make some lifestyle changes that will relieve some of the pressure—for example, she might get up 15 minutes earlier in the morning, or ask friends and family members to assume more responsibility for chores and tasks. Increasing physical activity will improve her stamina and her outlook.

    59. tobacco cessation during Pregnancy: Postpartum Maintenance Woman’s health Next pregnancy Child’s health This rate of tobacco cessation maintained after pregnancy is higher than achieved in virtually all non-pregnant populations and should be looked upon as a success (up to 35% quit) rather than as a failure (65% return to smoking). Those women who remain quit will be healthier over their lifetimes, their children will be healthier, and in their next pregnancies, their fetuses will be healthier. This rate of tobacco cessation maintained after pregnancy is higher than achieved in virtually all non-pregnant populations and should be looked upon as a success (up to 35% quit) rather than as a failure (65% return to smoking). Those women who remain quit will be healthier over their lifetimes, their children will be healthier, and in their next pregnancies, their fetuses will be healthier.

    60. Tobacco Education and Cessation 60 Forever Free...For Baby and Me: A Guide to Remaining Smoke Free “up to 70% relapse after they give birth” Moffitt Cancer Center developed 10 booklets for pregnant and postpartum women based on previous research and interviews with women includes a booklet for the woman’s partner pilot testing Spanish version http://moffitt.org/Site.aspx?spid=C140C11B4963415ABD1417520E2D9B85 Source: http://moffitt.org/Site.aspx?spid=C140C11B4963415ABD1417520E2D9B85

    61. Tobacco Education and Cessation 61

    62. Tobacco Education and Cessation 62 Smoking Cessation Cost Savings Cost of intervention $24-$34 Neonatal cost savings $881 per maternal smoker Source: Costs of a tobacco cessation Counseling Intervention for Pregnant Women: Comparison of Three Settings, Ayadi, Et al, pages 120-126, Public Health Reports / March–April 2006 / Volume 121. In additional to the health and emotional costs, of course, there is a financial cost.In additional to the health and emotional costs, of course, there is a financial cost.

    63. Standard 10.2 Pregnant women who smoke or use other forms of tobacco will be enrolled in Healthy Start and will receive tobacco cessation services. The services will also be offered to smokers in the home of pregnant women or children 0-3. This is a new standard. Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.This is a new standard. Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.

    64. Standard 10.2 Clarifies that pregnant women who use tobacco will be enrolled in Healthy Start tobacco cessation services or attempts to engage will be documented Extent of services are based on local funding and resources Services are provided with consideration of culture, language, education, & access

    65. Tobacco Education and Cessation 65 Tobacco Cessation Services Provided To reduce the incidence of prenatal and post-partum tobacco use To reduce the incidence of tobacco use by all household members To reduce exposure of the pregnant woman, fetus and infant to environmental tobacco smoke Why offer Healthy Start tobacco cessation services?Why offer Healthy Start tobacco cessation services?

    66. Tobacco Education and Cessation 66 Who is Eligible for Healthy Start tobacco cessation Services? Anyone who says they smoked during pregnancy Pregnant woman Parent Any smoker in the home of a pregnant woman or child up to age 3 Mother who smoked during pregnancy To refer someone for Healthy Start tobacco cessation services, contact your local Healthy Start provider or Healthy Start coalition. You have lists of these in your packets.To refer someone for Healthy Start tobacco cessation services, contact your local Healthy Start provider or Healthy Start coalition. You have lists of these in your packets.

    67. Tobacco Education and Cessation 67 Women who smoke during pregnancy are eligible for Healthy Start services. New moms who smoked are eligible for Healthy Start services.

    68. Tobacco Education and Cessation 68 What if the woman does not score 4 or more on the Healthy Start Risk Screen? The person is eligible regardless of risk score. Anyone who says they smoked during pregnancy Pregnant woman Parent Any smoker in the home of a pregnant woman or Healthy Start child Because a smoker creates a high risk for the fetus or the infant, the woman or smokers in the home are eligible for Healthy Start services.Because a smoker creates a high risk for the fetus or the infant, the woman or smokers in the home are eligible for Healthy Start services.

    69. Tobacco Education and Cessation 69 What if the woman or infant was not screened for Healthy Start Risk? Who is eligible? Anyone who says they smoked during pregnancy Pregnant woman Parent Anyone smoker in the home of a pregnant woman or Healthy Start child

    70. Tobacco Education and Cessation 70 What if the woman quit smoking recently? The person is eligible regardless of risk score. Anyone who says they smoked during pregnancy Pregnant woman Parent Anyone smoker in the home of a pregnant woman or Healthy Start child Some data shows up to a 90% relapse rate. So continue providing services even if the woman has quit.Some data shows up to a 90% relapse rate. So continue providing services even if the woman has quit.

    71. In Florida, we found that Healthy Start tobacco cessation services worked.In Florida, we found that Healthy Start tobacco cessation services worked.

    72. Tobacco Education and Cessation 72 Standard 10.3 The Healthy Start participant’s stage of readiness for change (based on Prochaska and DiClemente’s Stages of Change Model) will be reviewed during each tobacco cessation service in order to offer the appropriate service. This is a new standard. Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.This is a new standard. Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.

    73. Tobacco Education and Cessation 73 Standard 10.4: The provider of tobacco cessation services will provide follow-up to the Healthy Start care coordinator Submit documentation in 30 days Receipt of referral Initial service date Initiated assessment/plan for services Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.

    74. Tobacco Education and Cessation 74 Standard 10.5: Providers of tobacco cessation services will offer and initiate services in a timely manner Initiate services within 30 days of referral OR Initiate within a time frame negotiated between the provider and coalition Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.

    75. Tobacco Education and Cessation 75 Standard 10.6: Nicotine replacement therapy (NRT) and pharmaceutical aids may be prescribed for any family or household member when deemed an appropriate intervention For pharmaceutical aid use (Criteria 10.6.a-c) Minimum 5 individual, group or class sessions Classes or groups are at least one hour in length Address minimum components of counseling listed in 10.6d Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.

    76. Tobacco Education and Cessation 76 Minimum Components of Counseling Criteria 10.6.d include Consequences of tobacco use Nicotine addiction Pharmaceutical products available for tobacco cessation Side effects and contraindications Reasons for quitting Breastfeeding education for tobacco users Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.

    77. Tobacco Education and Cessation 77 Minimum Components of Counseling Criteria 10.6.d include Awareness of habits associated with tobacco use Stress reduction methods Exercise and nutrition Relapse and relapse prevention Appropriate disposal Danger of smoking while using NRT Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.

    78. Tobacco Education and Cessation 78 Changes Standard 10.5 is changed to 10.6 3 additional components added to components of counseling when person is using nicotine replacement therapy Appropriate method for disposal of patches Danger of smoking while wearing the patch Side effects and contraindications listed in the corresponding prescribing information of the transdermal nicotine patch prescribed. Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.

    79. Tobacco Education and Cessation 79 Nicotine Replacement Therapy (NRT) in keeping the person more comfortable while suffering withdrawal symptoms. Along with NRT, provide behavioral/cognitive counseling Cessation support Give materials Can offer other resources – Quitline, American Lung Association classes Members of household who smoke are also eligible to get NRT. Those eligible for Medicaid services can access NRT and prescription medication that helps some people to quit tobacco. Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement. Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.

    80. Tobacco Education and Cessation 80 Pharmaceutical Aids* Nicotine patch Nicotine gum Nicotine nasal spray Nicotine inhaler Bupropion SR (Zyban) Lozenge *Unless contraindicated Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement. Medicaid requires that health care providers provide smoking cessation. Healthy Start programs may offer to assist them in meeting this requirement.

    81. Tobacco Education and Cessation 81 DOH determined that Zyban will not be used with pregnant or breastfeeding women.

    82. Tobacco Education and Cessation 82 Nicotine Vaccine NicVAX™ Early studies on NicVAX®, the Nicotine Vaccine show blocks nicotine's entry into the brain induces production of long-lasting antibodies that helped prevent smoking relapse for up to 2 months in about a quarter of the study participants it to be safe (studies have not confirmed safe use during pregnancy) “this new approach could dramatically enhance the effectiveness of current treatments for nicotine addiction Source: Dr. Nora D. Volkow, NIDA Director Development of a Nicotine Vaccine (Note from Dr. Volkow) Cigarette smoking kills half a million Americans each year and is the leading cause of preventable illness in the world today. Smoking harms nearly every organ in the body, compromising a smoker's general health and causing many diseases. That is because cigarette smoke contains thousands of chemicals, many of them toxic. The key ingredient underlying addiction to cigarettes is nicotine. Drugs of abuse, including nicotine, exert powerful influences over behavior through their actions on the brain, particularly in those circuits involved in reward and motivation. Thus, any therapeutic modality aimed at preventing a drug from ever entering the brain could have tremendous addiction treatment potential. Immunization is a strategy that seems ideally suited to achieve that goal. The concept of immunizing an individual against a specific drug is an approach that has generated new interest among researchers and pharmaceutical companies. An effective anti-smoking vaccine would coax the immune system into producing antibodies that could sequester nicotine molecules in the bloodstream, keeping them from ever entering or affecting the brain. This strategy posits that if smokers find tobacco less rewarding, they can better avoid relapse once they've decided to quit. Seven years ago, NIDA embraced this concept and decided to support and guide a major nicotine vaccine effort in collaboration with Nabi, a Florida-based pharmaceutical company. Early studies on NicVAX®, the Nicotine Conjugate Vaccine that resulted from this joint research endeavor, show it to be safe and capable of generating antibodies that block nicotine's entry into the brain. Today, results from the latest round of phase II clinical studies (on 301 heavy smokers who smoked an average of 24 cigarettes a day) show that NicVAX™ induced the production of long-lasting antibodies that helped prevent smoking relapse for up to 2 months in about a quarter of the study participantsĐĐextraordinary results for a tobacco cessation trial. NIDA's support of this project is part of our continuing commitment to encourage innovative research with the potential to profoundly impact the public's health. Our improved understanding of addiction mechanisms and of nicotine's actions as an addictive drug has been instrumental in the development of tobacco cessation therapies on the market today. These include the nicotine replacement therapies, bupropion (marketed as Zyban®) and most recently varenicline (marketed as Chantix®), which are helping many smokers quit, particularly when assisted by behavioral therapies. Together with persistent and targeted public education campaigns, these advances have significantly contributed to reducing the prevalence of smoking and nicotine addiction in our Nation over the past three decades. Efforts to sustain and extend these successes must not flag, however, particularly on the heels of recent surveys revealing that the previously falling rates of adult smoking have stalled at around 20 percent, a level that foreshadows an enormous human and economic toll. An effective nicotine vaccine would be a much-needed addition to the available toolbox of treatment options. By helping quitting smokers resist the urge to light up, this new approach could dramatically enhance the effectiveness of current treatments for nicotine addiction and improve the prospects of closing the wide gap we face in achieving the Nation's goal of reducing adult tobacco use to 12 percent by 2010. Sincerely, Nora D. Volkow, M.D. Director Source: http://www.nabi.com/pipeline/pipeline.php?id=3 http://www.nabi.com/pipeline/pipeline.php?id=3Development of a Nicotine Vaccine (Note from Dr. Volkow) Cigarette smoking kills half a million Americans each year and is the leading cause of preventable illness in the world today. Smoking harms nearly every organ in the body, compromising a smoker's general health and causing many diseases. That is because cigarette smoke contains thousands of chemicals, many of them toxic. The key ingredient underlying addiction to cigarettes is nicotine. Drugs of abuse, including nicotine, exert powerful influences over behavior through their actions on the brain, particularly in those circuits involved in reward and motivation. Thus, any therapeutic modality aimed at preventing a drug from ever entering the brain could have tremendous addiction treatment potential. Immunization is a strategy that seems ideally suited to achieve that goal. The concept of immunizing an individual against a specific drug is an approach that has generated new interest among researchers and pharmaceutical companies. An effective anti-smoking vaccine would coax the immune system into producing antibodies that could sequester nicotine molecules in the bloodstream, keeping them from ever entering or affecting the brain. This strategy posits that if smokers find tobacco less rewarding, they can better avoid relapse once they've decided to quit. Seven years ago, NIDA embraced this concept and decided to support and guide a major nicotine vaccine effort in collaboration with Nabi, a Florida-based pharmaceutical company. Early studies on NicVAX®, the Nicotine Conjugate Vaccine that resulted from this joint research endeavor, show it to be safe and capable of generating antibodies that block nicotine's entry into the brain. Today, results from the latest round of phase II clinical studies (on 301 heavy smokers who smoked an average of 24 cigarettes a day) show that NicVAX™ induced the production of long-lasting antibodies that helped prevent smoking relapse for up to 2 months in about a quarter of the study participantsĐĐextraordinary results for a tobacco cessation trial. NIDA's support of this project is part of our continuing commitment to encourage innovative research with the potential to profoundly impact the public's health. Our improved understanding of addiction mechanisms and of nicotine's actions as an addictive drug has been instrumental in the development of tobacco cessation therapies on the market today. These include the nicotine replacement therapies, bupropion (marketed as Zyban®) and most recently varenicline (marketed as Chantix®), which are helping many smokers quit, particularly when assisted by behavioral therapies. Together with persistent and targeted public education campaigns, these advances have significantly contributed to reducing the prevalence of smoking and nicotine addiction in our Nation over the past three decades. Efforts to sustain and extend these successes must not flag, however, particularly on the heels of recent surveys revealing that the previously falling rates of adult smoking have stalled at around 20 percent, a level that foreshadows an enormous human and economic toll. An effective nicotine vaccine would be a much-needed addition to the available toolbox of treatment options. By helping quitting smokers resist the urge to light up, this new approach could dramatically enhance the effectiveness of current treatments for nicotine addiction and improve the prospects of closing the wide gap we face in achieving the Nation's goal of reducing adult tobacco use to 12 percent by 2010. Sincerely, Nora D. Volkow, M.D. Director Source: http://www.nabi.com/pipeline/pipeline.php?id=3 http://www.nabi.com/pipeline/pipeline.php?id=3

    83. Tobacco Education and Cessation 83 Standard 10.7: Providers of tobacco cessation services will respond to any additional identified needs Address additional needs by direct referral or referral to care coordinator Communicate with care coordinator Collaborate with interdisciplinary team Ongoing care coordination does not have to be received, if the participant can access other services independently If additional needs are identified or presented by the participant, it is the responsibility of the service provider to assure that needs are met by either direct referral or contacting the care coordinator to assure that the needs are addressed. When an interdisciplinary team is involved with planning for and providing services to a participant, the provider of Tobacco Education and Cessation should participate in the process at what ever level is most appropriate.If additional needs are identified or presented by the participant, it is the responsibility of the service provider to assure that needs are met by either direct referral or contacting the care coordinator to assure that the needs are addressed. When an interdisciplinary team is involved with planning for and providing services to a participant, the provider of Tobacco Education and Cessation should participate in the process at what ever level is most appropriate.

    84. Tobacco Education and Cessation 84 Standard 10.8: Providers of Healthy Start funded tobacco education and cessation services will accurately code service information in a timely manner for HMS data entry DOH and contracted community providers comply with DOH coding requirements If necessary, review specific coding requirements from the Healthy Start Standards and Guidelines. All health department providers and contracted providers that are receiving Healthy Start service dollars should code their services into the Health Management Component reporting system. This system is used to support the planning, budgeting, management, administration and delivery of Healthy Start Services The code for a tobacco service is 8026, whether you are a CHD or private provider.If necessary, review specific coding requirements from the Healthy Start Standards and Guidelines. All health department providers and contracted providers that are receiving Healthy Start service dollars should code their services into the Health Management Component reporting system. This system is used to support the planning, budgeting, management, administration and delivery of Healthy Start Services The code for a tobacco service is 8026, whether you are a CHD or private provider.

    85. Who Can Provide Tobacco Cessation Services? Coalitions do not need to hire another service provider to provide Tobacco cessation. Healthy Start care coordinators and prenatal care providers can provide this service.

    86. Who Can Provide HS Tobacco Cessation Services? Healthy Start staff Whose coalition has approved the smoking cessation curriculum used. Who have received specialized training to provide tobacco education and cessation information, education and support.- Who are smokers or non-smokers Who are nurses, social workers, health educators, nutritionists and respiratory therapists. A paraprofessional, under the supervision of one of the professionals listed above, may provide supportive interventions such as: follow-up phone calls and home visits.

    87. Coding Tobacco Cessation Services To code tobacco cessation, the provider must use a tobacco cessation program approved by the Healthy Start coalition . Healthy Start coalitions may approve a variety of 5 A’s models for use by those providing tobacco cessation services. Some models use a 5 A’s approach though the terminology may be different. The Make Yours A Fresh Start Family model, for ex., uses the STAGE approach which is a 5 A’s approach. Healthy Start coalitions may approve for use by those providing tobacco cessation services. Each of these models uses a 5 A’s approach though the terminologgy may be different. The Make Yours A Fresh Start Family model uses the STAGE approach. Healthy Start coalitions may approve for use by those providing tobacco cessation services. Each of these models uses a 5 A’s approach though the terminologgy may be different. The Make Yours A Fresh Start Family model uses the STAGE approach.

    88. Tobacco Education and Cessation 88 Standard 10.9: Providers of tobacco education and cessation services will document services in the participants existing clinical record or in the absence of a clinical record, in a format determined by the local coalition and provider Document on problem list, progress notes, FSP If a household member receives services on behalf of a participant, document in a separate record and reference support person’s receipt of services in participant’s record Documentation is recorded on forms used by the Department of Health OR in another format approved by the local Healthy Start Coalition. Suggested forms for documentation include: problem list, family support plan, progress notes, additional assessment forms. Confidentiality should be assured on all documentation and a release of confidential information form should be secured before information is shared with other providers. In the case where another household member receives services in connection or on behalf of the participant, information should be recorded in a separate record for the recipient. If a family or household member is having a record opened just for tobacco cessation classes, the record can be brief. The provision of service can be referenced in the participant’s record.Documentation is recorded on forms used by the Department of Health OR in another format approved by the local Healthy Start Coalition. Suggested forms for documentation include: problem list, family support plan, progress notes, additional assessment forms. Confidentiality should be assured on all documentation and a release of confidential information form should be secured before information is shared with other providers. In the case where another household member receives services in connection or on behalf of the participant, information should be recorded in a separate record for the recipient. If a family or household member is having a record opened just for tobacco cessation classes, the record can be brief. The provision of service can be referenced in the participant’s record.

    89. Tobacco Education and Cessation 89 Standard 10.10: Tobacco cessation service providers will develop and implement an internal quality improvement and quality assurance process Develop QI/QA process with coalition Strengths and areas needing improvement Maintenance of quality/ improvement Participant satisfaction Participant behavioral changes Reduction or elimination of tobacco use Rate of post-delivery relapse Positive health and developmental outcomes The Healthy Start Coalition and provider should develop a QI/QA process that looks at strengths, weaknesses, and maintenance of quality service provision. Some of the specific outcomes that are recommended for review in the QI/QA process include those listed above. Additional information on developing a QI/ QA system can be found under the QI/QA section in the Tobacco Education and Cessation chapter or under the Quality Improvement and Assurance chapter of the Healthy Start Standards and Guidelines. The Healthy Start Coalition and provider should develop a QI/QA process that looks at strengths, weaknesses, and maintenance of quality service provision. Some of the specific outcomes that are recommended for review in the QI/QA process include those listed above. Additional information on developing a QI/ QA system can be found under the QI/QA section in the Tobacco Education and Cessation chapter or under the Quality Improvement and Assurance chapter of the Healthy Start Standards and Guidelines.

    90. Tobacco Education and Cessation 90 Standard 10.11: Tobacco education and cessation services will be provided by qualified and trained providers Based on rule 64F-3.006(7), FAC Competency and up-to-date knowledge related to tobacco education and cessation services Provided by individuals that have received particular, specialized training to provide tobacco education and cessation information, and support Providers who do not smoke and those who understand addictive behavior are effective educators Education is offered regularly by the Department of Health, but programs that incorporate the concepts of behavioral change (transtheoretical theory) and how the intervention matches the results of the assessment of stage of change are acceptable. The Healthy Start Standards and Guidelines chapter on this service has extensive provider qualifications and competency descriptions. Updated fact sheets added to the“Make Yours a Fresh Start Family” training enhance the training experience. Review criteria as in-depth as necessary.Education is offered regularly by the Department of Health, but programs that incorporate the concepts of behavioral change (transtheoretical theory) and how the intervention matches the results of the assessment of stage of change are acceptable. The Healthy Start Standards and Guidelines chapter on this service has extensive provider qualifications and competency descriptions. Updated fact sheets added to the“Make Yours a Fresh Start Family” training enhance the training experience. Review criteria as in-depth as necessary.

    91. Tobacco Education and Cessation 91 How are tobacco cessation Services to be Offered? Face to face Until the participant has completed the counseling phase and has entered the follow-up phase.

    92. Tobacco Education and Cessation 92 Participant Focused Service Delivery Community Infrastructure Model The participant focused service delivery model is incorporated in detail in the HSSG The Community Infrastructure Model enables more comprehensive wraparound services thus leveraging service delivery with tobacco settlement and other community dollars.The participant focused service delivery model is incorporated in detail in the HSSG The Community Infrastructure Model enables more comprehensive wraparound services thus leveraging service delivery with tobacco settlement and other community dollars.

    93. Tobacco Education and Cessation 93 Participant Focused Ask tobacco history Ask tobacco status at each contact Find out if other smokers live in home Educate about dangers of second hand smoke Advise to quit Assess readiness to change Advise to smoke outside if not ready to quit Post-partum assess tobacco status and motivation

    94. Tobacco Education and Cessation 94 COMMUNITY PARTNERS Ensure membership on team of tobacco community network Address issues such as ETS in workplace, restaurants, etc. Link with other cessation providers - ALA, ACS, hospitals, managed care, schools The Community Infrastructure Model is a heightened level of service delivery based upon impacting the service delivery system through changing societal norms. This model is being used throughout Florida with some of the funds awarded through the tobacco settlement. Each county now has a community partnership focusing on tobacco issues that impact youth and involve youth. Strategies are being developed throughout Florida based on individual community needs, and Healthy Start representation is important in the development of these partnerships. The Community Infrastructure Model is a heightened level of service delivery based upon impacting the service delivery system through changing societal norms. This model is being used throughout Florida with some of the funds awarded through the tobacco settlement. Each county now has a community partnership focusing on tobacco issues that impact youth and involve youth. Strategies are being developed throughout Florida based on individual community needs, and Healthy Start representation is important in the development of these partnerships.

    95. Tobacco Education and Cessation 95 CONGRATULATIONS FLORIDA Smoking around Infants Much Less In 2005, less than 1 in 100 infants were exposed to secondhand cigarette smoke for one hour per day or more. This is a drop from over 8 infants in 100 in 2000!

    96. Some Factors to Remember Treatable Cycles of relapse and remission Requires ongoing management, just like diabetes or hypertension Person requires counseling, support, and, possibly, pharmacotherapy Clinicians must recognize relapse is common

    97. More Resources DOH Alcohol, Tobacco and Other Drugs website http://www.doh.state.fl.us/Family/mch/SubstanceAbuse/Tobacco/tobacco.html Audio Teleconference training on the ACOG model-Smoking and Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking http://www.gnahec.org/tobacco/ Both websites link you to training and information on the ACOG-Smoking and Pregnancy A Clinician’s Guide to Helping Pregnant Women Quit Smoking resources and Make Yours a Fresh Start Family resources. Both websites link you to training and information on the ACOG-Smoking and Pregnancy A Clinician’s Guide to Helping Pregnant Women Quit Smoking resources and Make Yours a Fresh Start Family resources.

    98. Thanks for All Your Work! Please feel free to contact Trish Mann at the Dept. of Health (850) 245-4465, or SunCom 205-4465 (email) Trish_Mann@doh.state.fl.us

More Related