2. Brief Tobacco Interventions for Opioid Maintenance Providers Susan Bradshaw, MD, MPH Tobacco Control and Prevention Program September 18, 2013 Los Angeles County Department of Public Health Chronic Disease and Injury Prevention Division

3. Outline Burden of Tobacco Use Tobacco Products Tobacco Addiction Brief Intervention ( Ask, Advise, Refer) 2

4. Native Americans used tobacco prior to the arrival of Columbus Consumption was for medicinal and ceremonial purposes Commonly smoked in peace pipes Introduction 3

5. John Rolfe (1585–1622) …. Married Pocahontas First to cultivate tobacco as an commercial export and cash crop Until 1883, taxes from tobacco accounted for 1/3 of IRS revenue Introduction 4

6. 1881: Cigarette machine 1882: Ten million cigarettes sold 1887: One billion cigarettes sold 5 Introduction

7. Anti-Tobacco 6 1798: Benjamin Rush…. First surgeon general Signer of the Declaration of Independence Tobacco use supports excess alcohol consumption

8. Introduction Anti-Tobacco 7 1870: Tobacco …. Harmful addictive substance Contributing factor in relapse from alcoholism and drug dependence Treated along with alcoholism and other addictions in asylums

9. Founding father of AA movement, Bill W., died from tobacco-related disease. Stop drinking to die from smoking? 1930s: Tobacco use is no longer viewed as an addiction and becomes embedded in recovery programs.

10. 9 BURDEN of TOBACCO

11. Leading cause of preventable and unnecessary death, disability and disease Causes more deaths than homicide, suicide, heroin, cocaine and alcohol combined each year Everyday, approximately 1,200 people die from tobacco-related diseases Burden of Tobacco Use Morbidity and Mortality 10

12. Burden of Tobacco Use Morbidity and Mortality For every 8 smokers who die, one non-smoker dies from exposure to secondhand smoke (SHS).

13. Secondhand Smoke (SHS) Causes 50,000 deaths annually Mainstream smoke is exhaled by a smoker Side stream smoke comes from the end of a burning tobacco product 12

14. Question? True or False. Secondhand smoke contains more than 7,000 chemicals. True. Secondhand smoke is a toxic mixture of gases, chemicals and particles. It contains about 70 carcinogens. 13

15. Secondhand Smoke 14 There is no safe level of exposure to secondhand smoke.

16. Burden of Tobacco Use Thirdhand smoke? 15 Residue left on a variety of surfaces by tobacco smoke. It builds up on surfaces and resists normal cleaning. Can't be eliminated by airing out rooms, opening windows, using fans or air conditioners, or confining smoking to only certain areas The only way to protect nonsmokers from thirdhand smoke is to create a smoke-free environment

17. Burden of Tobacco Use Economic Which state charges the most for a pack of cigarettes? New York. It costs $11.90 for one pack of cigarettes. 16

18. Cigarette butts are the most littered item in US 153 million pounds of cigarette butts are dumped each year 26,400 smoking- related fires occur annually Burden of Tobacco Use Environment 17

19. Smoking Rates Mental Illness (MI) Schizophrenia 62-90% Bipolar Disorder 51-70% Heavy drinkers 65-90% Depression or Anxiety 40-50% Post-traumatic Stress Disorder 45-60% Substance Use Disorder (SUD) 49-98%

20. Burden of Tobacco Use MI/SUD Compared to general population ….. Begin smoking earlier Smoke more cigarettes each day Smoke cigarettes them down to the filter Inhale deeper

21. Burden of Tobacco Use MI/SUD Consume 44% of all cigarettes sold Spend 30% of their income Poorer tobacco cessation outcomes Want to quit 20

22. Smoking cessation does not interfere with recovery 21

23. Burden of Tobacco Use Key Points Compared to general population, MI/SUD….. Smoke more Suffer more Spend more 22

24. Benefits of Quitting Health Recovery Wealth Environment Pets 23

25. 24 TOBACCO PRODUCTS Update

26. Question? What is the name of the President who started smoking a pipe after he was diagnosed with throat cancer? 25 President Grant It is alleged he thought smoking a pipe was safer than smoking cigars.

27. Smoked Tobacco Cigarettes Photo source: FACT collection 26 Natural & Deadly Cheap & Toxic Expensive & Unhealthy

28. 27

29. Smoked Tobacco Cigarette, Little Cigar, Cigarillo and Cigar 28 Cigarette: wrapped in paper not containing tobacco Cigar and cigarillo: wrapped in substance containing tobacco

30. Smoked Tobacco Little Cigars and Cigarillos Many flavors Package Tip or no tip Examples: Black & Mild Swisher Sweets White Owl 29

31. Smoked Tobacco Other Photo source: FACT collection 30 Blunts Bidis Hookah

32. New Smokeless Tobacco May be in pouch Marketed as energizing May contain: Caffeine Vitamin C Flavor 31

33. Smokeless Tobacco Snus Variety of flavors Packaged in small pouches Addresses smoke-free policies 32

34. Smokeless Tobacco Dissolvables Strips Sticks Mints (Orbs) 33

35. Electronic Nicotine Devices Smoke and tobacco free 34

36. TOBACCO PRODUCTS Key Points Cigarettes are the most common form of tobacco used in the U.S. All tobacco products are harmful Screen patients for different tobacco products 35

37. TOBACCO ADDICTION

38. Nicotine Cigarettes and other forms of tobacco contain nicotine Research suggests that nicotine may be as addictive as heroin, cocaine, or alcohol 37

39. Nicotine enters brain Stimulation of acetylcholine receptors Dopamine release Prefrontal cortex Nucleus accumbens Ventral tegmental area Nicotine and the Brain : 38

40. Nicotine Hijacks the Brain 39 Smokers feel normal with nicotine When nicotine levels decrease, smokers may experience nicotine withdrawal symptoms (NWS) NWS include irritability, anxiety, difficulty concentrating, and increased appetite

41. Nicotine Addiction Easy to Start, Hard to Quit In general: Ninety percent of smokers began using tobacco before age 18 Smokers often relapse because of stress, weight gain, and withdrawal symptoms Numerous quit attempts are usually necessary to stop successfully 40

42. Nicotine Addiction Easy to Start, Hard to Quit 41 Each day, approximately 3,500 U.S. kids smoke their first cigarette Of every three young smokers: o One will quit o One will die from a tobacco-related disease

43. Treatment Options Examples 42 Non- PharmacologicalPharmacological Behavioral issuesWithdrawal symptoms Self-help Nicotine Replacement Advice Non-Nicotine Counseling Other Combination is BEST.

44. Nicotine Replacement Therapy (NRT) 43 Reduces withdrawal symptoms Few contraindications and side effects Toxicity and abuse are rare Does not contain toxins

45. Nicotine Replacement Therapy Update 44 Instructions on label will change Recommendations by experts differ from label Combination NRT Higher dosage Treat withdrawal symptoms Taper based on patients preferenc e

46. Nicotine Replacement Therapy (NRT) Delivery time NRT therapy Nicotine gum Lozenge Patch Nasal spray Inhaler Onset of Action 20 to 60 minutes Faster than gum 6-8 hours 5 to 10 minutes 10 minutes 45

47. NRT Patch Apply to skin that is clean, dry and non-hairy. Press onto skin for 10 seconds. Rotate placement on different parts of the body each week Avoid cutting 7,14,& 21 mg/24 hr 5,10 & 15 mg/16 hr 46

48. Bite gum slowly Stop at first sign of mild tingling or peppery taste Park between the cheek and gum Bite again when tingling or peppery sensation fades (20 minutes) NRT Gum (Chew and Park) 47

49. NRT Lozenge Easier to use and delivers ~25% more nicotine compared to NRT gum Allow to dissolve slowly. Rotate in mouth until it dissolves ( 20 minutes). Should not be chewed or swallowed Do not eat or drink 15 minutes before using NRT gum or lozenge. 48

50. NICOTINE ADDICTION Key points Nicotine addiction can be a chronic and relapsing condition that usually begins in adolescence Successful treatment often requires multiple quit attempts and interventions as well as long-term monitoring Pharmacotherapy and behavioral interventions should be offer to all tobacco users who want to quit 49

51. ASK, ADVISE, REFER (AAR) Brief, Effective and Low Cost

52. Ask, Advise, Refer Ask all patients about tobacco use Advise all tobacco users to quit Refer all tobacco users to 1-800-NO-BUTTS 51

53. Step One Ask….. all patients about tobacco use 52

54. Strategies to Identify and Document Vital sign Stamp Chart stickers Medical record flow sheets Checklists Electronic medical records Computer prompts 53

55. Example of Vital Sign Blood Pressure: ______Pulse: _______ Weight: _____ Temperature: ________ Respiratory Rate: ________ Tobacco Use: Current ____ Former ____ Never____ SHS exposure: Home____ Work_____ Car_____ [ ] Advice given [ ] Referral provided 54

56. Step Two Advise… all tobacco users to quit 55

57. Advise…. Studies have shown that healthcare providers can be effective in advising tobacco users to quit Your advice approximately doubles the chance that patients will make a quit attempt The way a healthcare provider talks to patients can substantially influence motivation to quit Thereafter, assess willingness to quit 56

58. Step Three Refer… all tobacco users to…. 1-800-NO-BUTTS California Smokers Helpline 57

59. Refer Let all tobacco users know: You can double your chances of quitting successfully by calling 1-800-NO-BUTTS They will help you through the quitting process and the services are FREE FREE samples of NRT are available to Los Angeles County residents 58

60. 59 Free and confidential services include: Up to 6 counseling sessions Personalized quit plan Self-help materials and referral to local services Services for former smokers, teens, pregnant women, tobacco chewers and people unwilling to quit California Smokers Helpline 1-800-NO-BUTTS or www.nobutts.org

61. Coaching by trained counselors is available in six different languages and for hearing impaired Financial information: o FREE NRT to Los Angeles County residents o $20 gift card for Medi-Cal members o Health insurance o Cost is similar to buying cigarettes Monday-Friday: 7am to 9pm Saturday: 9am to 1pm 60

62. Examples of Brief Clinical Interventions Willing to Quit Refer to 1-800-NO-BUTTS If time permits: Discuss medications Set Target Quite Date (TQD) Develop quit plan Contact 3 days after TQD and follow-up monthly Unwilling to Quit Refer to 1-800-NO-BUTTS If time permits: Provide motivational interventions (5 Rs) Encourage smoking journal Promote healthier lifestyle Defer, if patient requests 61

63. Resources Patient Internet Smokefree.gov Becomeanex.org Mobile app/Text QuitSTART and QuitPal SmokefreeTXT QuitNowTXT Nicotine Anonymous Quitnowla Provider Training/Outreach materials Nobutts.org Smokingcessationleaders hip.ucsf.edu Askadviserefer.org 62

64. Ask Advise Refer Key Points A brief intervention should be implemented at each visit: ASK all patients about tobacco use ADVISE all tobacco users to quit REFER all tobacco users to 1-800-NO-BUTTS and recommend pharmacotherapy to those who want to quit AAR + Quitline + Meds 63

65. 64 AAR Demonstration

66. Questions? 65

67. Thank you! Susan Bradshaw, MD, MPH (213) 351-7319 Los Angeles County Department of Public Health Chronic Disease and Injury Prevention Division Tobacco Control & Prevention Program 66