Introduction to Introduction to Tobacco Use Prevention, Tobacco Use Prevention,

Protection & CessationProtection & CessationCreated by the Registered Nurses’ Association of

Ontario

Nurses’ important role in smoking Nurses’ important role in smoking cessationcessationLargest 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)

Statistics on Tobacco UseStatistics on Tobacco Use

In Canada:18 % of people aged 15 years and older

smoke cigarettes (Health Canada, 2008)

- Almost 5 million people

Statistics on Morbidity and Statistics on Morbidity and MortalityMortalitySmoking 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)

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)

Tobacco Products Tobacco Products

Cigarettes dominant form of tobacco used in North America

Cigarette Alternatives: ◦Chewing tobacco◦Snus◦Shisha◦Cigars & Cigarillos

What is a cigarette?What is a cigarette?Delivers nicotine to the lungs and brain

within 7 seconds each time a smoker inhalesFrequent, small-dose stimulation makes

smoking highly addictiveMost cigarettes contain ≥ 10 mg of nicotineAverage smoker absorbs 1-2 mg of nicotine

per cigaretteCigarettes release carbon monoxide which

adheres to red blood cells faster than oxygen• Reduced oxygen in the body causes increased

heart rate

What’s in a Cigarette?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 There are approximately

50 50 known known carcinogenscarcinogens

in cigarettesin cigarettes

(Canadian Cancer Society, 2007b)

Cigarette AlternativesCigarette AlternativesChewing Tobacco

• Frequently used by people in sports• Various flavours• Chewed in the mouth• Nicotine absorbed through buccal mucosa• Frequent users are subject to cancers of the mouth, gums and face

Snus • New product to North America• Similar to chew or spit tobacco (small pouch placed between upper lip and gum)• Purported by tobacco companies to be a milder alternative to cigarette smoking

Shisha • AKA hookah, narg-eelay, hubble-bubble or gooza• Water pipe with smoke from flavoured, burning tobacco • Social activity, pipe passed from person to person

Cigars and Cigarillos

• Stronger than cigarettes, very addictive• Not subject to the same commercial marketing regulations as cigarettes

Prevention: Youth & AdolescentsPrevention: Youth & AdolescentsMost 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)

On-campus Student Smoking On-campus Student Smoking Cessation ProgramsCessation 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/

Protection: Second-hand smokeProtection: Second-hand smokeSecond-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)

Second-hand smoke (cont.)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:

- Arsenic compounds - Benzene

- Chromium compounds - Ethylene oxide (chemical to sterilize medical devices)

- Vinyl Chloride (chemical used in plastics manufacture)

- Polonium – 210 (radioactive species)

Second-hand smoke (cont.)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

Cessation: Cessation: Smokers and Quitting SmokingSmokers and Quitting Smoking

Smoke vs. QuitSmoke vs. QuitCommon Reasons not to Quit

Common Reasons to Quit

• Family and friends smoke • Withdrawal symptoms • Inability to cope with stress• Connection with smoking • Previous unsuccessful attempts to quit

• Encouragement from family and friends • Health improvements • To save money • Pregnancy • Smoke-free environment policies • Desire to be a role model • Medical treatment that requires abstinence

NicotineNicotine 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)

Definition of AddictionDefinition 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)

General Characteristics of General Characteristics of Nicotine AddictionNicotine 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)

Withdrawal SymptomsWithdrawal Symptoms•Irritability •Anxiety

•Headache •Restlessness

•Coughing •Nausea

•Insomnia •Dizziness

•Depression •Difficulty concentrating

• Physical and psychological dependency

Treatment Options for Treatment Options for Nicotine AddictionNicotine 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)

Pharmacologic OptionsPharmacologic 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

Nicotine Replacement Therapy Nicotine Replacement Therapy (NRT)(NRT)Nicotine Patch Nicotine Lozenges Nicotine Gum Nicotine Inhalers

Provide nicotine to reduce withdrawal symptomsTake 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

Non-prescription available over-the-

counter

Non-nicotine TherapyNon-nicotine TherapyBupropion 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 withdrawalClonidine & Nortriptyline

• Second-line medications used in smoking cessation

All of these medications require a prescription

CounsellingCounsellingIntensive 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

Alternative TherapiesAlternative Therapies

No clinical evidence to verify results from these treatments

Some clients/patients report that they are beneficial (Fiore, et al., 2008)

• Hypnosis • Herbal remedies

• Acupuncture • Laser treatment

Self-helpSelf-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

1. Phone• Counselling

2. Online• Self-help• Tips, tools & support

3. Text messaging• Supportive messages

Assessing Readiness to QuitAssessing Readiness to QuitQuestion: Have you quit smoking cigarettes?

Answer:Yes, I have, for more than 6 months.

Defines maintenance.

Yes, I have, but for less than 6 months.

Defines action.

No, but I intend to in the next 30 days and have tried for at least 24 hours in the past year.

Defines preparation.

No, but I intend to in the next 6 months.

Defines contemplation.

No, and I do not intend to in the next 6 months.

Defines pre-contemplation.

Benefits of QuittingBenefits of QuittingIt’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

Immediate & Long-term Health Immediate & Long-term Health Benefits of Smoking CessationBenefits of Smoking CessationTiming Health Benefits

Within 20 minutes of last cigarette

Blood pressure, pulse rate, and body temperature reduce to within normal range

Within 8 hours Carbon monoxide levels in blood decrease and oxygen levels increase

Within 24 hours

Risk of heart attack decreases

Within 48 hours

Food tastes and smells better

Within 2 weeks

Coughing, congestion, fatigue, shortness of breath are reduced

Within 1 year Risk of heart disease decreases by 50 %

Within 10 – 15 years

Risk of dying prematurely approaches that of a person who has never smoked

Key PointsKey PointsSmoking 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