2. Interventions for Tobacco Users Sandra Villalaz, MPH, RN, CHES

3. Learning Objectives  By the end of the presentation, you will be able to: Explain the magnitude of the problem of tobacco use. Discuss the role of the school nurse in encouraging students to quit use of tobacco products. Discuss Clinical Practice Guidelines related to tobacco cessation techniques. Describe evidence based practices for obtaining patient follow through on tobacco cessation. Identify tobacco cessation-related community resources for school health nurses to use in assisting students.

4. The Problem

5. Individual and Social Costs  Smoking tobacco is the single largest preventable cause of disease and premature death in the United States (U.S.).  In U.S., between 2000-2004, tobacco use contributed to: 443,000 premature deaths (9,637 in TX) Over 5.1 million years of potential life lost $193 Billion cost to society (>$12 Billion in TX) (Cancer Prevention and Early Detection Facts and Figures[ACS], 2011) (Texas Cancer Facts & Figures [ACS] 2008)

6. Three Jumbo Jets Crashing every day.

7. Individual and Social Costs continued  Environmental Tobacco Smoke (ETS) now one of the leading causes of preventable death in U.S. 3400 lung cancer deaths 46,000 death from heart disease (nonsmokers) 150,000-300,000 respiratory infections in U.S. infants and children, 18 months of age. 430 infant deaths related to Sudden Infant Death Syndrome (SIDS) (U.S. Surgeon General Report, 2006) (ACS 2010)

8. Smoking Prevalence  Cigarette consumption rates  National 20.6% adults aged 18 and older* (19.5% HSS  Texas 17.9% ^ Prevalence highest among  Non-Hispanic white and other Asian/API and Native Americans  Least educated  Cigar consumption rates  National 5.4% of adults aged 18 and older Prevalence highest among  African Americans (8%) and American Indian/Alaska Natives (6%) (*Cancer Prevention and Early Detection Facts & Figures, ACS 2011) (^TDSHS, Behavioral Risk Factor Surveillance System, 2009)

9. Tobacco Use and Texas High School Students Cigarette use in last 30 days:  21 % report use at least 1 day  6% report use on 20 or more days  5% report smoked on school property  53% report did not try to quit Other tobacco use in last 30 days:  7% used chew tobacco, snuff or dip at least 1 day  4% used chew tobacco, snuff or dip on school property at 1 day  16% smoked cigars, cigarillos or little cigars at least 1 day Any tobacco use in last 30 days :  27% reported use of any tobacco at least 1 day

10. Smokeless Tobacco Use Prevalence  Adults (2009) 3.5% adults 18 years of age and older Usage highest among:  American Indian and Alaskan Natives and Whites  In the South and North Central states  Blue collar occupations and service/labor jobs  Unemployed  High school students (2007) 13% male (Centers for Disease Control and Prevention, [CDC] 2009)

11. Physical Impact of Smoking  Smoking “damages nearly every cell in your body.” ( Surgeon General Richard Carmona, USPHS, 2004)  It can cause: Cancers Chronic Obstructive Pulmonary Disease Heart Disease Cardiovascular Disease Gastrointestinal ulcers/periodontal disease Reproductive effects Eye disorders (U.S. Surgeon General Report, 2004)

12. Physical Impact of Smokeless Tobacco Use Causes:  Cancers  Leukoplakia  Mouth and teeth disorders  Reproductive disorders  Nicotine addiction and dependence (CDC 2009)

13. Role of the School Health Nurse

14. School Nurses Can Make a Difference  Nurses are an invaluable resource.  Nurses are a trusted professional.  Patients are more likely to quit successfully with the nurses’ support. (Good, Frazier, Wetta-Hall, Ablah, & Molgaard, 2004)  We are failing our patients if we don’t offer smoking cessation help. (Roberts, 2002)

15. Common Barriers to Intervening  Lack of interest or motivation on behalf of patient  Invasion of patient privacy  Lack of time of the nurse  Lack of knowledge and resources of nurse (Good, et al, 2004)

16. Best Practice Guidelines

17. Comprehensive Tobacco Prevention Program  Tobacco Free School Environment  Evidence based curriculum  Link to community-wide programs.

18. Provider Reminder System  What is it?  Why is it considered important?  How effective is it? (USPHS, 2008)

19. USPHS Treating Tobacco Use and Dependence Updated May 2008

20. 3 Factors Affecting Tobacco Addiction  Nicotine addiction  Habitual behavior  Emotional dependence

21. Nicotine Addiction Temporary Condition

22. Habitual Behavior  Health Belief Model Potential susceptibility Potential seriousness Perceived costs Cue to action (Green,2002)

23. Emotional Dependence For Adults  Best Friend  Social environment is prime. For Adolescents  Cool  Adult-like

24. 5A’s for Those Ready to Quit 1. Ask 2. Advise 3. Assess 4. Assist 5. Arrange (USPHS, 2008)

25. 5 R’s for those unwilling to quit 1. Relevance 2. Risks 3. Rewards 4. Roadblocks 5. Repetition (USPHS, 2008)

26. 5 A’s & R’s CARD  Tools to identify and assess tobacco use effectively  5 A’s Quick Guide: Treat tobacco users willing to quit  5 R’s Quick Guide: Treat tobacco users unwilling to quit

27. Behavioral Interventions and Five month Quit Rates - Adults (Hopkins, D 2008) Self Help12.3% Proactive telephone counseling 13.1% Group Counseling13.9% Individual counseling 16.8%

28. Pharmacotherapy  Nicotine replacement Various methods of administration No prescription is required All increase success rates for quit attempts  Tablets Bupropion and Varenicline Prescription required Increase success rates for quit attempts (Dougherty, P.,2008) Recommended for adolescent tobacco users only with clinician order and tight follow-up.

29. Preventing Relapse On every visit that follows:  Provide congratulation  Offer support with community resources  Encourage student to verbalize benefits  Encourage student to make appointment if relapse or temptation occurs (Fiore,2008)

30. Resources for Students  Quit For Life - a quitline In Texas: 1-877-YES-QUIT (877-937-7848)  American Cancer Society www.cancer.org 1-800-ACS-2345  American Heart Association www.heart.org  American Lung Association www.lungusa.org Not–On-Tobacco –School-based teen stop smoking program

31. Resources for Professionals  National Institute on Drug Abuse (NIDA) – Parent & Teachers Guides and materials http://www.drugabuse.gov/parents-teachers  Guide for Treating Tobacco Use & Dependence www.surgeongeneral.gov  Quick Guide to Helping Tobacco Users www.dshs.state.tx.us/tobacco/default http://www.dshs.state.tx.us/Layouts/ContentPage.aspx?PageID=34575&i d=1651&terms=tobacco+cessation+toolkit  American Cancer Society www.cancer.org 1-800-ACS-2345

32.  Centers for Disease Control and Prevention (CDC) – Adolescent and School Health  http://www.cdc.gov/HealthyYouth/tobacco/index.htm http://www.cdc.gov/HealthyYouth/tobacco/index.htm  http://cdc.gov/tobacco/quit_smoking/cessation/youth_tobacco_ cessation http://cdc.gov/tobacco/quit_smoking/cessation/youth_tobacco_ cessation o Youth Tobacco Cessation: A Guide for Making Informed Decisions  American Lung Association  www.lungusa.org www.lungusa.org  Youth Tobacco Cessation Collaborative  http://youthtobaccocessation.org/resources/programs.htm Resources for Professionals

33. Conclusion

34. Final points  Tobacco cessation improves life and prevents death.  Be part of the solution.  Be sure you address tobacco use with every visit.

35. References  American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2009. Atlanta: American Cancer Society; 2009.  American Cancer Society. Cancer Facts & Figures 2010. Atlanta:American Cancer Society; 2010.  Dougherty,P. A new pharmaceutical approach to smoking cessation, Nursing for women’s health, 12(1), 66-69.  Fiore MC, Bailey, Cohen SJ, et. al. Treating Tobacco Use and Dependence. Rockville, MD: US Department of Health and Human Services. Public Health Service. 2008.

36. References  Good, M, Frazier,L, Wetta-Hall, R, Ablah, E, and Molgaard, C. Kansas office-based nurses’ evaluation of patient tobacco cessation activities. Journal of community health nursing, 21(2), 2004. 77-85.  Green, L. (2002). Health Belief Model. Lester Breslow. Gale Cengage Ed., 2002. Encyclopedia of Public Health. eNotes.com. 2006. Retrieved 28 Oct, 2010 http://www.enotes.com/public-health- encyclopedia/health-belief-model  Hopkins, David, Briss, Ricard, et. al. Review of Evidence Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke. American Journal of Preventive Medicine. 2008; 35(2):158-176. Review.

37. References  Hopkins, D, Briss, P, Ricard, C, et. al. Review of Evidence Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke. American Journal of Preventive. 2001;20 (2S); 16-66. A report on findings and evidence.  Roberts, June. Kicking the habit. Aberdeen, UK: Primary health care, 12(9), Nov 2002., 27-32.  Smokeless Tobacco Fact sheet.(2009) retrieved October 27,2010. http://www.cdc.gov/tobacco/data_statistics/fact_she ets/smokeless/smokeless facts/index.htm http://www.cdc.gov/tobacco/data_statistics/fact_she ets/smokeless/smokeless

38. References  U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Rockville, MD. Healthy people 2010 report. 2000. Retrieved 28 Oct 2010. http://www.health.gov/healthypeople/ http://www.health.gov/healthypeople/  U.S. Public Health Service. (2004). The health consequences of smoking: A report of the Surgeon General. Washington, DC: U.S. Department of Health and Human Services. Retrieved October 25, 2010, from http://www.surgeongeneral.gov/library/smokingconseque nces/index.html http://www.surgeongeneral.gov/library/smokingconseque nces/  U.S. Public Health Service. (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Washington, DC: U.S. Department of Health and Human Services. Retrieved October 25, 2010, from http://www.surgeongeneral.gov/library/secondhandsmoke/index.html