Escolar Documentos
Profissional Documentos
Cultura Documentos
Integrating an Evidence-Based Approach for Tobacco Cessation Interventions in Acute & Critical Care Settings
Janie Heath PhD, APRN-BC, ANP, ACNP
Georgetown University, Washington, DC
Objectives
Identify the importance of integrating tobacco cessation in DAILY practice Identify key strategies / approaches for integrating tobacco cessation in DAILY practice Identify essential resources for integrating tobacco cessation in DAILY practice
Acknowledgments
UCSF Smoking Cessation Leadership Center UCLA Tobacco Free Nurses Colleagues
VISIT: www.rxforchange.ucsf.edu
Male
Percent
30 20 10 0
1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999 2003
Female
Year
The BAD News: < 36% News: Receive70% Information The GOOD want on to HOW quit to quit
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 19652001 NHIS. Estimates since 1992 include some-day smoking.
11.3% Asian
0% 10% 20% 30% 40% 50%
BABY ALERT: 27% OF Tobacco Dependent WOMEN Continue to SMOKE THROUGHOUT PREGNANCY
430
AMAZING
81 17
A ID S oh ol
41
19
e
14
ce d
30
ic l
ic id
ic id
eh
In du
A lc
Sources: (AIDS) HIV/AIDS Surveillance Report, 1998; (Alcohol) McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States.JAMA 1993;270:2207-12; (Motor vehicle) National Highway Transportation Safety Administration, 1998; (Homicide, Suicide) NCHS, vital statistics, 1997; (Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995
H om
Su
ot o
D ru g
Sm
rV
ok in
Cardiovascular diseases Lung cancer Respiratory diseases Second-hand smoke Cancers other than lung Other
$331,467
$220,978
Packs per day
$110,489
0 100 200 300 400
Snuff
Moist Dry
The Copenhagen and Skoal logos are registered trademarks of U.S. Smokeless Tobacco Company, and Red Man is a registered trademark of Swedish Match.
CIGARS
BIDIS
HOOKAH PIPE
100
75 Smoked regularly and susceptible to effects of smoke Disability 25 Death 0 25 50 75 Stopped smoking at 65 (severe COPD) Stopped smoking at 45 (mild COPD)
50
Age (years)
The BEHAVIOR
The EMOTIONAL
The PHYSICAL
Dopamine release
An individual smokes 1 pack per day x 20 yrs 20 cigarettes / pack 10 puffs / cigarette = ?? puffs / day
Now Multiply that # by days / year 73,000 THEN multiply that number by years smoking! 1.4 million
Norepinephrine
Acetylcholine Glutamate Serotonin
C
O T I E
N -Endorphin
GABA
Depression Insomnia Irritability/frustration/anger Anxiety Difficulty concentrating Restlessness Increased appetite/weight gain Decreased heart rate Cravings*
American Psychiatric Association. (1994). DSM-IV. Hughes et al. (1991). Arch Gen Psychiatry 48:5259. Hughes & Hatsukami. (1998). Tob Control 7:9293.
Most symptoms peak 2448 hr after quitting and subside within 24 weeks.
How soon after you wake up do you smoke your first cigarette
Do you find it difficult to refrain from smoking in restricted areas Which cigarette do you hate to give up most How many cigarettes do you smoke per day Do you smoke more frequently during the first hours after waking Do you smoke if you are so ill that you are in bed most of the day
Scores range from 0 to 10; a score of greater than 5 indicates substantial dependence
ASSIST ARRANGE
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.
In the absence of time or expertise. ask, advise, assess, and refer to other resources, such as local programs or the toll-free quitline 1-800-QUIT-NOW
VISIT EXHIBIT BOOTH #2785 for FREE samples
ROADBLOCKS
REPETITION
Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, 2000.
Acute and critical care admissions = HIGHLY TEACHABLE MOMENTS Tobacco cessation starts STAT for most admissions
Provide structures/systems (chart prompts, standing orders, dedicated counselors) to facilitate success in breaking the nicotine cycles of addiction
INTERDISCIPLINARY APPROACH ESSENTIALS: collaboration, effective decision making AND compassionate caring practices
Remove triggers
Do the 3 As with their pts and REFER 1-800-QUIT NOW Return back to work and have the tobacco conversation Are we meeting JCAHO measures for tobacco cessation counseling Where can we refer pts for on-site help Where can our nursing colleagues get help
The PHYSICAL
The BEHAVIOR
The EMOTIONAL
The PHYSICAL
Reduces physical withdrawal from nicotine Allows patient to focus on behavioral and psychological aspects of tobacco cessation It is NOT substituting ONE negative health behavior for another IMPROVES SUCCESS RATES!
Percent quit
20 15
10 5 0 Nicotine gum
Nicotine patch
Nicotine lozenge
Nicotine inhaler
Bupropion
Data adapted from Silagy et al. (2004). Cochrane Database Syst Rev and Hughes et al., (2004). Cochrane Database Syst Rev.
Rx nicotine gum
1991
1984
In acidic media
Ionized poorly absorbed across membranes Nonionized well absorbed across membranes
In alkaline media
Cigarette
Cigarette
20
Moist snuff
Moist snuff
Nasal spray
15
Inhaler
10
Lozenge (2mg)
Gum (2mg)
5
Patch
0 1/0/1900 0 1/10/1900 10 1/20/1900 20 1/30/1900 30 2/9/1900 40 2/19/1900 50 2/29/1900 60
Time (minutes)
No food/beverage 15 min
Max = 24 / day
Available: 2 mg, 4 mg; regular, mint, orange NOT recommended if use dentures
Park
Dose = 1 patch every day (16 hrs or 24 hrs) Best if ROTATE patch different areas Preferred sites above the waist Avoid if acute / chronic skin condition If problems sticking apply TEGADERM dressing over patch May bathe/swim with patch Do NOT cut patch
Dose = 1every 1-2 hrs No food/beverage 15 min prior - during or 15 min post MAX = 20 per day Delivers ~25% more nicotine than equivalent gum dose Available: 2 mg, 4 mg Let dissolve 20-30 minutes; NO chewing/biting of product
Dose = 1 dose (2 sprays per nostril) every hr MAX = 5 doses/hr OR 40 doses /day Each dose delivers -50 L spray = 0.5 mg nicotine per spray Rapidly absorbed across nasal mucosa --faster onset of action (1113 minutes) compared to the gum, patch, or inhaler
Dose = 6- 16 cartridges / d
MAX = 16 cartridges / d
Delivers 4 mg nicotine vapor, which is absorbed across buccal mucosa - ~ 20 minutes of puffing = 1 cartridge
BUPROPION SR (ZYBAN)
(GlaxoSmithKline)
$4.12
$3.93 $2.66
Varenicline (Chantix-Pfizer)
Partial nicotinic receptor agonist Available end of July Promising results compared to Bupropion
The BEHAVIOR
The EMOTIONAL
The PHYSICAL
WHAT IF
The RESPONSIBILITY of HEALTH PROFESSIONALS If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.
DR. GRO HARLEM BRUNTLAND, FORMER DIRECTOR-GENERAL of the WHO
USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS.
Contact Information