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Management of nicotine dependent inpatients An evidence-based treatment model Tobacco and Health Branch NSW Centre for Health Promotion July 2002.

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Presentation on theme: "Management of nicotine dependent inpatients An evidence-based treatment model Tobacco and Health Branch NSW Centre for Health Promotion July 2002."— Presentation transcript:

1 Management of nicotine dependent inpatients An evidence-based treatment model Tobacco and Health Branch NSW Centre for Health Promotion July 2002

2 The purpose of this presentation is for use in training clinicians working with inpatients who smoke, in the context of the NSW Health Smoke Free Workplace Policy (1999) (please note: all references for the content of this presentation are included in the Guide for the management of nicotine dependent inpatients (page 19) except for lozenge study)

3 In this presentation we will cover: Tobacco use in the community Health policy Assessment of nicotine dependence Nicotine withdrawal Nicotine replacement therapy (NRT) Frequently asked questions Brief intervention Discharge & referral

4 Background to tobacco use in the community

5 The World Health Organisation describes smoking as an: epidemic that will cause 1/3 of all adult deaths world- wide by 2020 (WHO 1999)

6 Overall in 2001 – daily smoking prevalence was 19.5% males – 21% females -18% Prevalence was higher among younger people, daily smoking rates peaked in the year age group The mean number of cigarettes smoked per week increased with age peaking at 140 cigarettes by age Prevalence of smoking in Australian population

7 Prevalence of smoking in Australian population in 2001 Age groups % of age group (Adapted from AIHW 2002 report)

8 Prevalence of inpatient smoking in NSW Between 18% - 23% of patients admitted to NSW hospitals are current smokers (self-reported) The actual figure may be higher than this………. In one study, a further 18% self-reported non-smokers tested positive for salivary cotinine, suggests theyre current smokers A Central Sydney study found that 1 in 5 inpatients were highly dependent on nicotine (using Fagerstrom Test)

9 Burden of disease caused by tobacco - NSW Tobacco is the major cause of drug-related death & the single greatest preventable cause of premature death & disease In 2000, smoking caused 4,316 male deaths & 2,255 female deaths (18.5% & 10.3% of all male & female deaths respectively) In 1998/99 smoking caused 50,023 hospitalisations among males and 30,045 hospitalisations among females (5.7% & 3% of all male & female hospitalisations respectively).

10 Health Policy

11 Recommends that: - all health care facilities and their immediate surroundings should be smoke free. - and that hospital staff should: - ask about smoking status prior to or on admission; - offer brief advice & pharmacotherapy to those who need it; and: - provide assistance to those interested in stopping. The World Health Organisation WHO (2001)

12 Goal: To prohibit smoking throughout all buildings, vehicles and property controlled by NSW Health Rationale: To reduce the harm associated with smoking among staff, patients, visitors, especially exposure to passive smoking To provide a clear message to staff, patients, visitors, community about the health risks of smoking To provide leadership in the community about reducing harm associated with smoking NSW Health Smoke Free Workplace Policy 1999

13 The guide for the management of nicotine dependent inpatients Developed within the context of the NSW Health Smoke Free Workplace Policy (1999) Aim: to assist clinicians in the management of nicotine dependence in inpatients confined to smoke-free environment Two parts: a laminated flowchart for use on the ward a booklet summarising the international evidence Is not about smoking cessation, although some patients may use the opportunity of hospitalisation to attempt to quit smoking

14 Managing nicotine dependence The NSW Health Smoke Free Workplace Policy provides a supportive environment for abstinence during hospitalisation The guide proposes that hospital staff: identify nicotine dependent patients give patients information about the smoke free policy provide prompt and appropriate treatment to patients experiencing nicotine withdrawal provide brief intervention for smoking cessation advise patients at discharge on options for permanent cessation

15 Early identification of smoking status and swift provision of an adequate level of NRT may reduce the potential for a highly dependent smoker to become irritable or aggressive due to nicotine withdrawal Reduction of withdrawal symptoms may in turn reduce the amount of work and time required to manage the patient NSW Health recommends that AHSs develop specific protocols appropriate for local settings to clarify role delineation & ensure prompt delivery of treatment to patients Managing nicotine dependence

16 Recognising and Assessing Nicotine Dependence

17 Tobacco dependence is: a chronic disease with remission and relapse* Nicotine dependence warrants medical treatment as does any drug dependence disorder or chronic disease Fiore et al, U.S. Dept of Health and Human Services, June 2000

18 Indeed, it is difficult to identify any other condition that presents such a mix of lethality, prevalence, and neglect, despite effective and readily available interventions Fiore et al, U.S. Dept of Health and Human Services, June 2000

19 Identification of smoking status Swift identification of smokers on admission increases rates of intervention and guides appropriate treatment The Alcohol and Other Drugs Policy for Nursing Practice in NSW: Clinical Guidelines recommends recording a patients substance use history (including tobacco) upon admission Moderate to heavily dependent smokers should also be screened for depression Patients with depressed mood and a history of problem drinking are more likely to be nicotine dependent and may have greater difficulty in abstaining during hospitalisation

20 Nicotine A psychoactive drug affecting mood and performance The source of addiction to tobacco More addictive than heroin or cocaine (WHO) Binds to nicotinic cholinergic receptors found on cell bodies and at nerve terminals in the brain and autonomic ganglia Activation (smoking) facilitates release of neurotransmitters- acetylcholine, norephinephrine, dopamine, serotonin, B- endorphin and glutamate

21 Manipulation of dose Arterial blood nicotine concentrations may be up to 100ng/mL - venous concentrations typically 20%-30% of this Concentrations in the heart and brain may be up to ng/mL immediately after a cigarette Regular cigarette smoking plateaus at daily plasma concentrations of ng/mL (& 5 -10% carboxyhemoglobin) Smoker can titrate the dose of nicotine to regulate a particular level Intake of nicotine from a given product depends on puff volume, depth of inhalation, rate and intensity of puffing Smokers titrate higher levels of nicotine from light cigarettes or reduced number by breathing in deeper & holding smoke in lungs longer (Ng/mL = nannograms per millilitre)

22 Nicotine dependence Tobacco use produces tolerance to nicotine, withdrawal symptoms and difficulty in controlling future use The bolus of nicotine to the brain achieved by smoking is one of the key reinforcers of dependence Nicotine in blood in 4 seconds, in brain in 7 seconds Nicotine dependence and withdrawal can develop with use of all forms of tobacco Neuro-adaptation (tolerance) can occur within a few doses of the drug, depending on rate and route of dosing

23 Nicotine dependence (DSM-IV) Features of nicotine dependence include: smoking soon after waking smoking when ill difficulty refraining from smoking reporting the first cigarette of the day to be the one most difficult to give up smoking more in the morning than in the afternoon

24 Assessment of nicotine dependence The Fagerstrom Test for Nicotine Dependence (FTND) is based on criteria in DSM-IV (6 questions) (for questions &scoring see page 9 of Guide) 2 questions consistently match valid biochemical indicators of dependence: how soon after waking up do you smoke? how many cigarettes per day do you smoke? (for scoring see page 10 of Guide)

25 Time to first cigarette (TTFC) Due to widespread smoking restrictions, many highly dependent smokers may not be able to smoke as many cigarettes per day as they need to get adequate nicotine Smoke fewer cigarettes – but smoke them more thoroughly ie: suck harder, deeper, down to filter etc. Wake up extremely nicotine deprived 1 question may suffice to determine level of dependence: how soon after waking up do you smoke? First cigarette within or =30 minutes after waking – high dependence More than 30 minutes after waking – low dependence

26 Time to first cigarette (TTFC) TTFC Less than or equal to 30 minutes after waking = HIGH DEPENDENCE TTFC More than 30 minutes after waking = LOW DEPENDENCE Wake up 0 30 minutes (Adapted from presentation by Saul Shiffman)

27 Nicotine Withdrawal Usually worst in the first hours, then decline in intensity gradually over next 2 weeks. Symptoms may include four (or more) of the following within 24 hours of cessation, often causing significant distress : Dizziness Coughing Tingling sensations in extremities Appetite changes Constipation D ecreased heart rate Insomnia Craving for tobacco Depressed mood Increased appetite or weight gain Irritability, frustration or anger Anxiety Difficulty in concentrating Restlessness

28 Pharmacotherapy

29 Nicotine Replacement Therapy (NRT) Available in gum, lozenge, patch and inhaler Aims to replace the nicotine obtained from cigarettes, reducing withdrawal symptoms when stopping smoking Use of NRT is preferable to smoking, because it does not: contain non-nicotine toxic substances such as carbon monoxide and 'tar' produce dramatic surges in blood nicotine levels produce strong dependence

30 Nicotine Replacement Therapy (NRT) (cont.) Odds ratio for abstinence with NRT compared to control is 1.73 (patch 1.76, gum 1.66, inhaler 2.08) (4mg lozenge 3.69)* Odds are independent of intensity of additional support provided to smoker or setting in whichNRT offered In highly dependent smokers there is significant benefit of 4mg gum over 2mg gum (odds ratio 2.67) (NB:lozenge also) Increases quit rates fold, regardless of setting NRT is safe, should be routinely recommended to smokers, product choice depends on practical & personal considerations ( Cochrane review) ( * large RCT)

31 Level of nicotine dependence and NRT dosage As a general rule, smokers who are nicotine dependent will have less intense withdrawal symptoms if provided with an adequate dosage of NRT For example: The trial for the nicotine lozenge used the TTFC (time to first cigarette) measure of dependence to allocate dosage: those who smoke within 30 mins of waking - 4mg lozenge those who wait longer than 30 mins - 2mg lozenge (Note: the lozenge provides 25% more nicotine than the gum as it dissolves completely)

32 Nicotine Toxicity Recent quitters using NRT often confuse withdrawal with nicotine toxicity Nicotine withdrawal symptoms similar to toxic effects of nicotine Extremely rare in smokers – more likely not enough nicotine Rapid tolerance to nicotine (within several cigarettes or few days of smoking) toxicity symptoms would not occur in smoker NRT only provides the body with nicotine levels close to the low trough level reached between cigarettes when smoking

33 Minutes Increase in nicotine concentration ( ng/ml ) Cigarette Gum 4 mg Gum 2 mg Inhaler Patch Smoking produces much higher nicotine levels than NRT Source: Balfour DJ & Fagerström KO. Pharmacol Ther :51-81.

34 NRT Dosage Plasma nicotine levels significantly lower from NRT than smoking MIMS recommended dosages: Gum: maximum 40 per day Lozenge:maximum 15 per day Patch: healthy people > 10 cigs/day >45 kgs: one patch daily 21mg/24 hr or 15mg/16hr cardiovascular disease <10 cigs/day, <45 kgs: one patch daily 14mg/24hr or 10mg/16hr Inhaler: Self-titrate dose, according to withdrawal symptoms cartridges/day.

35 Directions for use of NRT products Gum:nicotine absorbed through oral mucosa, chew till a peppery/tingling feeling, flatten gum and park between gum & cheek, or under tongue Lozenge:nicotine absorbed through oral mucosa, move around mouth from time to time and suck until dissolved (takes minutes) Patch:nicotine absorbed through skin, place on clean, non-hairy site on chest or upper arm on waking, place new patch on new site each day to prevent skin reaction Inhaler: nicotine absorbed through oral mucosa, inhale air through cartridge for 20 minutes

36 Bupropion (Zyban) First non-nicotine medication shown effective forcessation Blocks neural re-uptake of dopamine and/or noradrenaline Start one week prior to quit day, limited application for inpatients An option for patients after discharge and patients can be referred to their GP to discuss their options The only pharmacotherapy available on PBS Contraindications include patients with seizure disorder, current or prior bulimia or anorexia nervosa, use of a MAO inhibitor within the previous 14 days

37 Combination therapy Highly dependent smokers may benefit from combining patch with self-administered form of NRT (lozenge/gum/inhaler) More effective than single form of NRT Use combined treatments if unable to remain abstinent or if still experiencing withdrawal symptoms using single therapy Increased success depends on the use of two distinct delivery systems: one passive (ie: patch) + one active or at liberty (ie: gum/lozenge/inhaler)

38 Contraindications (*MIMS 2001) NRT is currently contraindicated for some patient groups and use by these patients requires special consideration Gum* non-tobacco users, pregnancy, lactation, children (< 12 yrs) Patch* non-tobacco users, acute MI, unstable angina, severe arrhythmias, recent CVA, skin disease, children (< 12 years) pregnancy, lactation Inhaler* non-tobacco users, hypersensitivity to menthol, pregnancy, children (< 12 years) Lozenge non-tobacco users, phenylketonurics, pregnancy, lactation, recent heart attack or stroke, severe irregular heartbeat unstable or resting angina, (from pack info) (NB: while NRT is contraindicated during pregnancy, if patient unable to abstain, then gum, lozenge or inhaler are preferable to smoking)

39 Frequently asked questions

40 Is NRT suitable for cardiovascular patients? No evidence of increased cardiovascular risk with NRT NRT delivers plasma nicotine concentrations below those produced by smoking and does not expose the smoker to carbon monoxide or other harmful substances Clinical trials of NRT in patients with underlying, stable coronary disease suggest that nicotine does not increase cardiovascular risk The health risks of using NRT to assist such patients to stop, or significantly reduce, smoking far outweigh any treatment-related risks

41 Is NRT safe for pregnant or lactating women? NRT should be considered when a pregnant woman is otherwise unable to quit Potential benefits of quitting outweigh the risks of the NRT & potential continued smoking NRT less harmful than smoking during pregnancy - lower total nicotine dose and no exposure to carbon monoxide & other toxic substances NRT clearly beneficial to highly dependent smokers, more at risk of adverse reproductive outcome & less likely to quit when pregnant

42 Is NRT safe for pregnant or lactating women? (cont.) A maternal 10% blood carboxyhemoglobin level (40 cigs per day) can cause % higher carboxyhemoglobin level in the foetus than in the mother (= 60% reduction in foetal blood flow) If clinician and patient decide to use NRT, consider forms that yield intermittent nicotine (lozenge/inhaler/gum) rather than continuous drug exposure (patch) due to potential neurotoxicity in the foetus of continuous exposure to nicotine A pregnant smoker should receive encouragement and assistance in quitting throughout her pregnancy

43 Is pharmacotherapy safe for patients with psychiatric comorbidity? Always in patients best interests to quit smoking Tobacco use is associated with affective disorders and depressive symptoms Depression decreases likelihood that abstinence will be successful and depressed mood is a common symptom of nicotine withdrawal Antidepressants may aid abstinence in those with symptoms of depression Possible that smoking increases risk of depression perhaps by affecting neuro-transmitter systems

44 Is pharmacotherapy safe for patients with psychiatric comorbidity? (cont) Patients with a history of major depression who quit may be 7 times more likely to have a recurrence of major depression than people who continue to smoke Current smokers have higher rates of anxiety disorders & may find it more difficult to remain abstinent. Evidence suggests that anxiolytics are not effective smoking cessation aids Quitting may affect the pharmacokinetics of psychiatric medications (eg anti-psychotic medications) Monitor actions or side effects of psychiatric medications in smokers attempting abstinence Mental health patients demonstrate a preference for nicotine inhaler over the transdermal patch

45 Is NRT safe for adolescents? Young people can become addicted to tobacco very quickly NRT provides lower dose of nicotine than smoking, no carbon monoxide and other toxins While there are no LEGAL restrictions, the info on the NRT pack states: Do not use if you are under 18 years of age – a condition of registration of product by Commonwealth When treating adolescents, clinicians may consider pharmacotherapy when there is evidence of nicotine dependence Factors such as: degree of dependence, number of cigarettes per day and body weight should be considered Prescription guidelines from pharmaceutical companies recommend 21 mg patch if >45 kilos, 14 mg patch if <45 kilos

46 How long should NRT be used for? Clinicians advising clients in smoking cessation should tailor the dosage and duration of therapy to fit the needs of patients Patch - 8 weeks of continuous use has been shown to be as effective as longer treatment periods (no need to taper)** Gum – generally should be used for up to 12 weeks** Inhaler – up to 6 months, tapering off during final 3 months** Lozenge –trial suggests 24 weeks of treatment using same product in diminishing doses (however, similar period of use to gum likely to be effective due to similar absorption method) (**Fiore et al, 2000)

47 What is best to prevent weight gain? Smokers weigh on average 4 kg less than non-smokers** When smoker stops, gains average of 2.3kg in next year*** Brings quitters up to similar weights to sex & age matched never- smokers Of great concern to some smokers, especially women and adolescents, can act as motivator to start or continue smoking NRT (particularly gum & lozenge) & bupropion delay, but don't prevent post-cessation weight gain Advise that health risks of moderate weight gain are small compared to risks of continued smoking - concentrate on cessation till confident will not return to smoking Recommend regular exercise program & healthy eating to control weight

48 Brief Intervention

49 The World Health Organisation encourages provision of brief opportunistic interventions delivered by all health professionals in the course of their routine work The purpose of brief intervention for smoking cessation is to increase motivation to quit Same technique can be used during provision of information for management of dependence while hospitalised Hospitalisation is a time when the adverse consequences of smoking are highlighted for the individual – a window of opportunity for a teachable moment

50 Brief Intervention (cont.) Brief advice (approx 3 minutes) by doctors, nurses and other health care workers is effective More intensive interventions only marginally increase the efficacy of brief advice Personalised, non-critical feedback that helps them understand the impact of smoking on their health Motivational interventions most likely to succeed when clinician is empathetic, promotes patient autonomy, encourages self- efficacy & identifies previous successes in behaviour change efforts

51 Discharge & referral

52 Discharge and referral Every patient identified as a smoker should be assessed prior to discharge to determine their interest in quitting 80% of smokers have made past attempts to quit, 50% of male & female current smokers plan to quit in next 6 months (NSW Health Surveys) Patients planning to quit should receive: at least 3 days supply of NRT treatment summary in discharge plan a Quit Kit advice to seek support from GP/pharmacist/Quitline Patients not planning to quit should be encouraged to make a future quit attempt

53 Quit plan For those patients ready to quit, a few key points can increase their chance of success: Set a date to stop and stop completely on that day Use pharmacotherapy (whichever product suits best) Review past periods of abstinence (what helped -what hindered?) Identify future problems and make a plan to deal with them (problem-solving) Enlist support (family, friends, colleagues) Avoid alcohol for first 2 weeks Reduce caffeine consumption by half (more caffeine is absorbed)

54 Relapse Any smoking within the first 2 weeks is a reliable predictor of failure in the quit attempt (95% probability of returning to smoking) Other predictors include: short periods of abstinence in previous quit attempts low motivation to quit low confidence in ability to quit smokers in subject's environment high pre-cessation alcohol consumption Common triggers for relapse include: other people smoking alcohol stressful or negative events depression

55 Prevention of relapse Relapse prevention should include: discussion of high-risk situations developing coping strategies (e.g. using pharmacotherapy, reducing alcohol consumption) reinforcing total abstinence (but relapse is not failure, continue quit attempt) most people make several quit attempts before success Many smokers cannot stop without more intensive help – (often heavier smokers more at risk of smoking related disease) refer to specialist treatment service, such as AHS D&A Services, their GP or the Quitline for telephone counselling outpatient clinics should be advised of hospital treatment

56 Useful web sites Resources about tobacco for non-English speaking patients: Tobacco control super site (Sydney University): US Surgeon General clinical practice guideline: UK clinical practice guideline: Tobacco in Australia: Facts and Issues: Encyclopaedia on tobacco:

57 For more information If you have any queries about: The NSW Smoke Free Workplace Policy (1999) The guide for the management of nicotine dependent inpatients This PowerPoint presentation Please contact: Elayne Mitchell (02)


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