Tobacco Cessation Counseling: A Protocal for Practicing Pharmacists Tuesday, October 18, 2005

National Community Pharmacists Association (NCPA) 107th Annual Convention & Trade Expo Greater Fort Lauderdale/Broward County Convention Center Fort Lauderdale, Florida

Participant’s Handout

American Society of Health-System Pharmacists 7272 Wisconsin Avenue Bethesda, MD 20814

© 2005 American Society of Health-System Pharmacists ASHP ® is a service mark of the American Society of Health-System Pharmacists, Inc. Registered in the U.S. Patent and Trademark Office

Tobacco Cessation Counseling: A Protocal for Practicing Pharmacists Program Description This program is designed to provide pharmacists in all practice sites with the knowledge and skills needed to begin the cessation process for any patient who uses tobacco. During the program pharmacists will learn how to motivate the tobacco user to think about quitting by clearly connecting the presenting diagnosis with tobacco use, by informing the patient of the importance behavior change plays in a successful quit, and by reviewing past and present cessation medication use. Then pharmacists will be encouraged to refer patients to appropriate intensive interventions including the national quit line. In almost all cases, these interactions can be done within the context of a regular patient interaction and should take less than five minutes. As such, this counseling protocol can and should fit into the existing practice milieu of almost every pharmacist.

Abstract In recent years, many pharmacists expressed a desire to become more involved in tobacco cessation but did not know how to incorporate the counseling into their practice or even what to say to a patient who wanted to quit. Educational organizations responded by creating training programs that positioned the pharmacist as the provider of the entire cessation program, from start to finish. However, in the real world almost no pharmacist had the time to do this, no matter how much they desired to become involved. As a result, many pharmacists resorted to doing nothing about cessation. They feared that if they even brought up the subject, they would become involved in complex, hour long discussions that would interfere with their other duties. This training, on the other hand, seeks to reposition the pharmacist as the all important beginning of the process, not the sole provider of services. As such, pharmacists will learn how to motivate smokers to think about quitting by educating them on specific topics and then referring them to appropriate intensive interventions. In almost all cases, this counseling protocol can be done within the context of a regular patient interaction and should take less than five minutes.

Program Objectives: 1. Describe a new, redefined role for pharmacists in the tobacco cessation process, positioning them as the initiators of the quit, not the sole provider of services. 2. Summarize how pharmacists can serve as motivators and educators for cessation. 3. Explain the importance of pharmacists referring all patients to appropriate intensive interventions after initiating the cessation process

Continuing Education Accreditation ACPE Program Number: 204-000-05-086-L04 (1.5 Contact Hours (0.15 CEU s)

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Tobacco Cessation Counseling: A Protocal for Practicing Pharmacists

Faculty Information Frank Vitale National Director Pharmacy Partnership for Tobacco Cessation Pittsburgh, PA 412-383-7206 [email protected] Faculty Biography Frank Vitale received a B.A. in Liberal Arts from St. Vincent College in 1974 and a Master’s Degree in Psychology from Duquesne University in 1988. He has worked in the field of smoking cessation research since 1987, first as a Health Educator, then as Clinic Coordinator for the Lung Health Study, researching the differential effects of smoking cessation and an inhaled medication (Atrovent) on the prevention of COPD in identified high risk individuals. He has run numerous groups for the I Quit Project of the Smoking Research Group at the University of Pittsburgh as well as designed the intervention for some of these programs. He counseled over one thousand individuals by phone for the Smoke Free Challenge, a smoking cessation program run by the Health Education Center of Blue Cross of Western Pennsylvania and contributed to the information packets sent to program participants. He has designed smoking cessation programs for the Comprehensive Lung Center at the University of Pittsburgh Medical Center and assisted in the creation of a program to train pharmacist to do smoking cessation counseling by phone for National Rx (Medco) in Columbus OH. He contributed content material for the smoking cessation manuals that accompany the Nicoderm CQ patches in the U.S., Brazil, Mexico and China. In all, he has counseled well over eight thousand people attempting to quit smoking. While at the University of Pittsburgh Medical School, Frank was Project Director of Lung Health Study II, a multicenter research program examining the efficacy of Azmacort in helping individuals with mild to severe COPD regain lung capacity lost to smoking. In his position as director of the International Smoking Cessation Specialist program at the University’s Pharmacy School, Frank created a six-hour CE program designed to teach pharmacists how to do smoking cessation counseling, writing the patient support booklets that accompany this training as well as all auxiliary materials. This program has been presented throughout the U.S., Puerto Rico, Spain and the United Kingdom to well over 14,000 pharmacists and other healthcare professionals. Frank has also been involved in the creation of a CE program for Pennsylvania physicians and dentists as well as a project incorporating smoking cessation material into the medical school curriculum. Recently he designed a group cessation program for the UPMC Health System and trained over fifty facilitators to present the program at each of the system’s nineteen hospitals. Frank is currently the National Director of the Pharmacy Partnership for Tobacco Cessation, a project developed under the auspicious of The Smoking Cessation Leadership Center of the Robert Wood Johnson Foundation and ASHP. The partnership is dedicated to creating and providing the tools to help pharmacists become involved in cessation counseling with all patients who use tobacco.

Tobacco Cessation Counseling: A Protocal for Practicing Pharmacists Program Outline for Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists

1.

Introduction o

Barriers to Counseling

o

Overcoming Barriers

2.

The Role of the Pharmacist in Tobacco Cessation

3.

Tobacco Use Behavior

4.

Quitting: What Works o

Ask-Advise-Assess

o

Motivate-Educate-Refer

5.

Current Tobacco Cessation Medications

6.

Referral Sources

7.

Conclusion

8.

Questions, Answers, and Discussion

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

Tobacco Cessation Counseling:

A Protocol for Practicing Pharmacists

SPONSORED BY The Pharmacy Partnership for Tobacco Cessation A national program funded by the Robert Wood Johnson Foundation and the University of California San Francisco Smoking Cessation Leadership Center

OBJECTIVES „ Describe a new, redefined role for the

pharmacist in the tobacco cessation process, positioning them as the initiator of the quit not the sole provider of services. „ Summarize how the pharmacist can serve as a motivator and educator for cessation. „ Explain the importance of pharmacists referring all patients to appropriate intensive interventions after initiating the cessation process

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale) TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2003 Trends in cigarette current smoking among persons aged 18 or older, by sex 60

21.6% of adults are current smokers

Male

50

Percent

40 30

24.1%

Female 20

19.2%

10 0 1955

1959

1963

1967

1971

1975

1979

1983

1987

1991

1995

1999

2003

Year

70% want to quit Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2001 NHIS. Estimates since 1992 include some-day smoking.

CLINICIAN-ASSISTED TOBACCO CESSATION: WHY BOTHER? „ Single-most effective strategy to lengthen and

improve patients’ lives

„ Quitting tobacco has immediate and long-term

benefits for all patients

„ It is inconsistent to provide health care and, at

the same time, remain silent (or inactive) about a major health risk. TOBACCO CESSATION is an important component of PATIENT CARE.

WHY PHARMACISTS? „ Long term, established relationships with

many patients

„ High degree of trust „ Easily accessible „ Point-of-sale contact:

Patients filling prescriptions for tobaccorelated illnesses „ Patients purchasing cessation medications „

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale) WHY PHARMACISTS DON’T COUNSEL for CESSATION „ “ I don’t have the time.” „ “ It’s not relevant.” „ “ I don’t get reimbursed to counsel.” „ “ Patients are unlikely to quit.” „ “ I want to respect my patients’ privacy.” „ “ I don’t know what to do.”

“I don’t have the time” „ Simply advising someone to quit can have an

impact „ In surveys, 70% indicate that a health-care professional has never told them to quit „ You may be the person they will listen to!

„ Interventions can take as little as 30 seconds „

Powerful motivational counseling can be provided in fewer than 5 minutes

“It’s not relevant” „ Smoking adversely affects every smoker. It

can: „ Cause the illness you are treating „ Exacerbate the symptoms „ Impair immune response/delay healing „ Drug interactions „ More than 20 categories of drugs

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale) DRUG INTERACTIONS with SMOKING: Pharmacokinetic „ Alprazolam „ Caffeine „ Clozapine „ Heparin „ Insulin „ Theophylline

DRUG INTERACTIONS with SMOKING: Pharmacodynamic „ Benzodiazepines „

Diazepam

„

Chlordiazepoxide

„ Beta-blockers „

Propranodol

„ Opioids „

Propoxyphene

„

Pentazoline

DRUG INTERACTIONS: Oral Contraceptives „ Oral combined contraceptive use is

contraindicated in all woman, particularly those: „ > 35 years of age and „ Who smoke more than 15 cigarettes/day

„ Significantly increased risk of serious adverse

cardiovascular effects: „ Stroke „ Myocardial infarction „ Thromboembolism

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale) “I don’t get reimbursed to counsel” „ Smoking cessation should be part of basic

pharmaceutical care

„ Counseling might be reimbursable in some

situations „

Many states now reimburse pharmacists through medical assistance

„

Many practitioners charge fee-for-service

„

Can charge in conjunction with disease state management services

“Patients are unlikely to quit” „ With help from a clinician, the odds of quitting

Estimated abstinence at 5+ months

approximately doubles 30

n = 29 studies

20

10

1.7

1.0

1.1

No clinician

Self-help material

2.2

0 Nonphysician clinician

Physician clinician

Type of Clinician

“I want to respect my patients’ privacy” „ Tobacco users expect to be encouraged to quit by

health professionals „

Studies suggest that patients, even those who plan to continue using tobacco, prefer that health professionals advise them to quit

„ Most tobacco users want to quit and want support and

encouragement to do so, especially from those they respect and trust Failure to address tobacco tacitly implies that “quitting is not important”

Barzilai et al. Does health habit counseling affect patient satisfaction? Prev Med 2001;33:595-9.

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

“I don’t know what to do” „ This training will fill the gap „ A basic protocol for all pharmacists:

Ask „ Advise „

„

Motivate and educate

Refer „ Additional training is available for those who would like to do more „

The PHARMACIST’S ROLE „ Ask about tobacco use „ Advise patients to quit „ Motivate the patient to consider quitting by educating patients regarding: „ „ „

Link between current illness and tobacco use Proper use of cessation medications The benefits of behavioral counseling

„ Refer to a more formal cessation program „ The pharmacist does not need to create or

conduct the entire quitting program… just start it!

The PHARMACIST’S ROLE „ Create a supportive atmosphere „ Encourage: „

Emphasize “Quitting is possible.”

„ Address ambivalence: „

“Ambivalence is normal. Getting stuck there is not!”

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

Tobacco Use Behavior

WHAT is TOBACCO USE? „ Physical addiction „ Habit „ Psychological dependence

ADDICTION „ Reinforcer „ Nicotine reaches the brain within 11 sec „ Withdrawal syndrome „ Irritability, anxiety, impatience, etc. „ Individuals self-titrate nicotine delivery: „ Smoking more frequently „ Smoking more intensely „ Obstructing vents on low nicotine/cigs

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

HABIT „ “Automatic

smoking”

Repeatedly pairing smoking with other situations or behaviors „ The paired behavior creates unconscious urges to smoke „ “Pavlovian” response „

TYPICAL SMOKING TRIGGERS „ Morning routine

„ Stress

„ Coffee

„ Anger

„ After meals

„ Anxiety

„ In the car

„ Boredom

„ On the phone

„ Celebration

„ Alcohol

PSYCHOLOGICAL DEPENDENCE „ The mistaken belief that cigarettes are

doing something positive for the smoker

„ The additional belief that this positive

impact is something the smoker cannot do on his or her own

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale) PERCEIVED BENEFITS of SMOKING „ It helps me deal with stress „ It helps me manage my weight „ It helps me regulate my moods „ It’s my best friend „ Others

QUITTING: WHAT WORKS? „ Combining a cessation medication with

a behavior modification program „ Evidence-based „ Many

practice tools available to clinicians

„ Pharmacists are in an excellent position „ To

promote effective strategies „ To begin this process!

Helping patients quit STEP 1: ASK ABOUT TOBACCO USE

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

ASK ABOUT TOBACCO USE „ Ask every patient if he or she uses

tobacco „

Vital part of a complete medical history

„ Document possible drug interactions „ Flag the patient records of tobacco users: „ For „ To

subsequent visits monitor progress

ASK (cont’d) Key target populations: „ Inhaled agents: „ Anticholinergics, β2-agonists, corticosteroids „ Lipid-lowering agents „ Anticoagulants/antiplatelet agents „ Oral hypoglycemics/insulin „ Nitrates

Smokers receiving these drugs will derive significant benefit from smoking cessation

Helping patients quit STEP 2: ADVISE PATIENTS TO QUIT

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

ADVISE „ Initiate the quitting process: „ Provide

strong advice to quit

„ Motivate „ Educate

ADVISE (cont’d) „ Initiate the quitting process: „ Provide

strong advice to quit

„ Motivate „ Educate

PROVIDE STRONG ADVICE TO QUIT “Quitting smoking is the most important thing you can do to protect and improve your health now and in the future.” “It is important that you quit now. Cutting down because you are ill is not enough. I can help you as well as refer you to other resources.”

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

ADVISE (cont’d) „ Initiate the quitting process: „ Provide

strong advice to quit

„ Motivate „ Educate

MOTIVATE: What to do „ Help the patient to identify a powerful,

internal reason to quit „

Clearly link diagnosis with tobacco use

„

Explore other reasons to quit

MOTIVATE: What to do „ Link diagnosis with tobacco use „ For

each patient:

„

How does tobacco use cause their illness?

„

How does tobacco use exacerbate symptoms?

„

How does tobacco use interfere with healing?

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

MOTIVATE: What to do „ Explore other reasons to quit: „ Money „ Social „ Family „ Other

MOTIVATE: What to do „ “I’m not ready to quit!” „ Possible responses: What would have to happen for you to consider quitting? „ “Smoking is a very risky behavior. Consider what might happen to you as a result. Can you live with the consequences of your behavior?”……. „

„

„

Not being able to walk more than a few feet because of emphysema Lying in bed for years because of a stroke

MOTIVATE: What NOT to do „ Lecture „ Nag „ Finger wag „ Scare „ “Cheerlead”

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

ADVISE (cont’d) „ Initiate the quitting process: „ Provide

strong advice to quit

„ Motivate „ Educate

EDUCATE Help the smoker understand that quitting is doable and the odds of success are increased with behavioral counseling and pharmacotherapy.

EDUCATE: WHAT to DO „ Review past quit attempts „

“What did you learn about yourself?”

„ Promote behavioral counseling „

Planning is the key to a successful quit

„ Discuss cessation medications „ „

Address any misconceptions Counsel on proper usage

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

EDUCATE: Review Past Attempts „ What worked? „ What were the challenges? „ Discuss behavior change strategies: „ What changes were made? „ If none, why not? „ Discuss past use of cessation medications: „ What/how did patient use? „

If no use, why not?

EDUCATE: Promote Behavior Change „ “Quitting smoking is like learning any new

behavior.” „ Trying to “will” yourself to quit does not work! „ You need: „ A plan!! „ Pertinent information „ Powerful skills „ A good teacher

EDUCATE: Address Misconceptions „ “The products don’t work!” „ “I’m just trading one addiction for another.” „ “Who needs it?” „ “NRT is harmful.”

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

“The products don’t work!” „ Let’s review how you used “ fill in the blank”

the last time you quit. „

Most individuals who make this statement have used the product incorrectly in the past. „ Wrong strength „ Under dosed „ Stopped too soon

„

Review concurrent smoking and product use Explain proper usage

„

“I’m just trading one addiction for another!” „ Cessation medications provide nicotine much

more slowly than cigarettes and therefore are less likely to result in physical addiction. When nicotine is absorbed through the lungs, it reaches the brain in fewer than 11 seconds. This is what makes smoking so addicting. „ Compared to cigarettes, it’s less difficult to gradually wean off of the products. „

“Who needs it?” „ Research shows that cessation medications

approximately double patients’ chances of quitting

„ The cessation medications make it less

uncomfortable to quit „ „

„

“What will not using a product accomplish?” “If you broke your leg, would it heal better if you turned down pain medication? What makes you think the quit will go better without a medication? “ “Think of quitting as learning a new behavior. And remember that most people who quit without a product go through withdrawal, including irritability, anxiety, and impatience. Could you learn anything if you felt this way all day?”

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

“NRT is harmful” „ Nicotine is not the harmful component of

tobacco. Harm results from the thousands of toxic chemicals found in cigarette. “NRT is a safe, ‘clean’ form of nicotine that eliminates exposure to the toxins found in tobacco.” „ “People don’t die from using NRT, but thousands of people die every day from smoking.” „

Educate: Proper Medication Use

WHY USE PHARMACOTHERAPY? „ Alleviates withdrawal „

Maintains nicotine serum concentration at or above patient’s comfort level

„ Eliminates the reinforcing effect of nicotine

that is achieved through smoking

„ Provides patients an opportunity to

comfortably break the habit and the psychological dependency

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

PHARMACOTHERAPY “All patients attempting to quit should be encouraged to use effective pharmacotherapies for cessation except in the presence of special circumstances.”

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, 2000.

CURRENTLY AVAILABLE PHARMACOTHERAPY PRODUCTS „ Nicotine polacrilex gum

Nicotine nasal spray Nicorette (OTC) „ Nicotrol NS (Rx) „ Generic nicotine gum (OTC) Nicotine inhaler „ Nicotine lozenge „ Commit (OTC) „ Nicotrol (Rx) „ Nicotine transdermal patch Bupropion SR „ Nicoderm CQ (OTC) „ Nicotrol (OTC) „ Zyban (Rx) „ Generic/Private Label (OTC, Rx) „

Pharmacotherapy is not indicated for women who are pregnant or lactating or for persons who are less than 18 years of age.

PLASMA NICOTINE CONCENTRATIONS for NICOTINE-CONTAINING PRODUCTS 25

Cigarette

Cigarette

Moist snuff

Plasma nicotine (mcg/L)

20

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)

Schneider et al., Clinical Pharmacokinetics 2001;40(9):661–684.

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

NRT: PRECAUTIONS for USE „ Patients with underlying cardiovascular disease „ Recent myocardial infarction „ Life-threatening arrhythmias „ Severe or worsening angina „ Patients with other underlying conditions „ Active temporomandibular joint disease (gum only) „ Pregnancy or lactation

Minimum age for FDA-approved NRT use: 18 years

NICOTINE GUM „ Nicorette „ Flavors: Original, Mint, Orange, Fresh Mint Coated „ Generic available „ Strengths: „

2 mg, 4 mg

„ Sugar-free gum base „

Contains sorbitol

NICOTINE GUM: Dosing regimens Dosage based on current smoking patterns: If patient smokes

Recommended strength

≥25 cigarettes/day

4 mg

30 min of waking „ 4 mg: if 1st cigarette within 30 min of waking Recommended Usage Schedule for Nicotine Lozenge

Weeks 1–6

Weeks 7–9

Weeks 10–12

1 lozenge

1 lozenge

1 lozenge

q 1–2 h

q 2–4 h

q 4–8 h

DO NOT USE MORE THAN 20 LOZENGES PER DAY

TRANSDERMAL NICOTINE PATCH „ Nicotine is well absorbed across the skin „ Delivery to systemic circulation avoids

hepatic first-pass metabolism „ Plasma nicotine levels are lower, fluctuate

less than with smoking

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

TRANSDERMAL NICOTINE PATCH Generic

Product

Nicotrol

Nicoderm CQ

Nicotine delivery

16 hours

24/16 hours

24 hours Rx/OTC

(formerly Habitrol)

Availability

OTC

OTC

Strengths

5 mg

7 mg

7 mg

10 mg

14 mg

14 mg

15 mg

21 mg

21 mg

TRANSDERMAL NICOTINE PATCH: Dosing regimens Product

Light Smoker

Heavy Smoker

≤10 cigarettes/day Not indicated

>10 cigarettes/day Step 1 (15 mg x 6 weeks) Step 2 (10 mg x 2 weeks) Step 3 (5 mg x 2 weeks)

≤10 cigarettes/day Step 2 (14 mg x 6 weeks) Step 3 (7 mg x 2 weeks)

>10 cigarettes/day Step 1 (21 mg x 6 weeks) Step 2 (14 mg x 2 weeks) Step 3 (7 mg x 2 weeks)

Generic ≤10 cigarettes/day (formerly Habitrol) Step 2 (14 mg x 6 weeks) Private Label Step 3 (7 mg x 2 weeks)

>10 cigarettes/day Step 1 (21 mg x 4 weeks) Step 2 (14 mg x 2 weeks) Step 3 (7 mg x 2 weeks)

Nicotrol

Nicoderm CQ

TRANSDERMAL NICOTINE PATCH: Patient counseling „ Apply promptly after removing from pouch „ Apply a new patch every day to a different

dry, hairless, place

„ Rotate sites over a 7-day period „ Do not leave on for more than 24 hrs

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale) TRANSDERMAL NICOTINE PATCH: Side effects „ Sleep disturbances „ Vivid dreams „ Insomnia „ Localized skin reaction (rash, purities) „ Up to 50% of patients may have mild form „ Incidence higher with 24-hr products „

Fewer than 5% discontinue therapy

NICOTINE ORAL INHALER „ Nicotrol Inhaler „ Oral inhalation system

consists of „

2-part mouthpiece enclosing 10 mg nicotine cartridge

„ Delivers 4 mg nicotine

vapor, which is absorbed across buccal mucosa „ Mimics oral aspect of

smoking „ Use 6 to 16 cartridges/day,

puffing as needed for up to 12 weeks

NICOTINE NASAL SPRAY „ Nicotrol NS „ 10 mL spray bottle „ Each spray delivers 0.5 mg nicotine „ ~100 doses/bottle „ Rapidly absorbed across nasal mucosa „ One spray in each nostril per hour initially,

increase as needed „ No more than 5 doses/hour or 40 doses/day „ Use for 6 to 8 wks, then taper for 4 to 6 wks

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

ZYBAN TABLETS (Bupropion SR) „ May increase CNS dopamine levels „ Begin one week prior to quitting „ 150 mg daily X 3 days „ 150 mg B.I.D. thereafter „ 7-10 weeks of therapy: no taper

ZYBAN: Contraindications „ Seizure disorder „ Current or prior diagnosis of bulimia or

anorexia nervosa

„ Patients treated with: „ Wellbutrin; Wellbutrin SR; Wellbutrin XL „ MAO inhibitor in the past 14 days „ Patients undergoing abrupt discontinuation

of alcohol or sedatives (including benzodiazepines)

ZYBAN: Warnings and precautions „ Use with extreme caution in: „ Patients with a history of seizure „ Patients with a history of cranial trauma „ Patients treated with medications that lower the seizure threshold „ Antipsychotics „ Antidepressants „ Theophylline „ Patients with severe hepatic cirrhosis

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale) ZYBAN: Side effects „ Insomnia „ Avoid

bedtime dosing

„ Dry mouth „ Side effects can be minimized by

reducing dose to once a day

COMBINATION THERAPIES „ Clinical trials show using the nicotine patch

with Zyban increases quit rates over using either product alone. „

Best for heavy smokers, at least 2 packs per day

„ Can use nicotine patch or Zyban as “base”

therapy „

Nicotine gum, lozenge, oral inhaler, or nasal spray can then be used PRN in specific problem situations.

Combination therapy is generally used only for patients unable to quit using monotherapy.

OTHER PRODUCTS „ Clonidine and nortriptyline: „ Second-line agents, some clinical evidence of efficacy „ Lack FDA-approved indication for smoking cessation „ Other products with no demonstrated efficacy „ Nicotine lollypops „ Nicotine lip balm „ Nicotine water „ Herbal remedies „ Spit tobacco

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale) COMPARATIVE DAILY COSTS of PHARMACOTHERAPY Inhaler

$6.07

Gum

$5.81

Lozenge

$5.31

Bupropion SR

$4.54

Cigarettes (1 PPD)

$4.12

Patch

$3.91

Nasal spray

$3.40

0

2

4

6

8

Cost per day, in U.S. dollars, Drug Topics Redbook 2005

Source: Rx for Change: Clinician-Assisted Tobacco Cessation program

OTHER TREATMENT MODALITIES „ Minimal to no effect:

Hypnosis Acupuncture „ Ear clips „ Cigarette-like devices „ Tapering „ Nicotine fading „ Aversive techniques „ „

Helping patients quit STEP 3: REFER

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

REFER „ Help tobacco users to access available

resources „ Telephone quit lines „ 1-800-QUIT NOW „ Individual & group counseling „ Product behavior change programs „ Web-based cessation programs „ www.quitnet.com „ www.tobaccoschool.com „ www.smokeclinic.com

QUIT LINES: A WELL-KEPT SECRET „ Available to all Americans with access to a

telephone „ Provide tobacco users with free cessation

services, including counseling, self-help kits, and cessation information. „ Success rates double for patients who use a

quitline, compared with quitting on their own Zhu et al. Evidence of real-world effectiveness of a telephone quitline for smokers. New Engl J Med 2002; 347:1087-93.

WHY TELEPHONE COUNSELING? „ Convenient for patients, and thus preferred

over clinic setting by 75-85% „ U.S. is covered by network of state, regional

and national quit lines „ Well trained cessation experts „ Services available in several languages „ Simple for clinicians to promote: „ „

Ask, Advise, Refer This minimal intervention takes 30 seconds

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

WHAT ELSE CAN I DO? „ Quitting is a process that occurs over time,

not a discrete, one-time event.

Provide support to keep the quit attempt on track „ Schedule follow-up for all patients „

„

„

Either in person or by phone

Actions: „ „ „

Reinforce success Strategize about challenges Review pharmacotherapy

“CIGARETTE SMOKING… is the chief, single, avoidable cause of death in our society and the most important public health issue of our time.” C. Everett Koop, M.D., former U.S. Surgeon General

This statement remains true today, more than 2 decades later. Clinicians must take a more active role in promoting health through tobacco cessation.

FINAL THOUGHTS „ Many pharmacists have hesitated to provide

cessation advice due to the mistaken belief that they would have to conduct the complete quitting program.

„ Rather, pharmacists can play a vital role by initiating

the quitting process and then referring the patient to cessation programs.

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocol for Practicing Pharmacists (Speaker: Frank Vitale)

At a minimum, make a commitment to incorporate brief tobacco interventions as part of routine patient care. Ask, Advise, and Refer. It only takes 30 seconds to save a life.

ADDITIONAL INFORMATION? Frank Vitale, M.A. National Director Pharmacy Partnership for Tobacco Cessation (412) 383-7206 Or [email protected]

© 2005 The American Society of Health-System Pharmacists

Tobacco Cessation Counseling: A Protocal for Practicing Pharmacists Self-Assessment Questions 1. Pharmacists can initiate the tobacco cessation process for patients by: a. Telling all patients that tobacco use will kill them and that they have to quit immediately b. Asking every patient about tobacco use, strongly advising them to quit and then referring them on to appropriate intensive interventions. c. Scolding the patient for doing something so detrimental to their health and the health of the people they live with 2. Pharmacists are in an ideal position to begin the cessation process because they: a. Have long-term trusting relationships with most patients that prompt the patient to pay attention to offered advice b. Have access to a patient’s medical records and medication history c. Can make recommendations about what medication may be best for a patient d. Could see patients who buy cigarettes or other tobacco products if they work in a retail setting and can intervene right on the spot 3. If for no other reason, pharmacists should ask about the tobacco use status of every patient because: a. They could be sued or loose their job if they do not ask b. There are interactions between smoking and many common medications c. They can get paid for doing cessation counseling 4. A pharmacist can motivate a patient to consider quitting by: a. Showing pictures of individuals with head, neck, or tongue cancer and telling the patient that the same thing could happen to them b. Constantly telling every patient who smokes that smoking is bad c. Clearly linking smoking and the presenting diagnosis while helping the patient find a clear, internal reason to quit 5. Educating someone about the primary components of a successful quit involves teaching a patient that: a. The more will power you have the better your chances of quitting b. Your odds of success double or triple if you engage in a behavior change program while using a cessation medication c. Quitting is very difficult and that everyone fails four or five times before they are successful 6. Pharmacists can promote the need for behavioral counseling by explaining to a patient that: a. Smoking is a very complex behavior and that only those smokers who clearly understand this can quit successfully b. All smokers have psychological problems that require going to a counselor; to quit successfully they need to spend months in therapy c. Quitting smoking is like learning any new behavior; to do it successfully you need a plan that teaches you how to cope with your triggers to smoke 7. If a patient is not ready to quit after you advise them to do so, you should: a Keep trying to convince them to stop by telling them about all the negative health effects of smoking b. Tell them to come back to see you whenever they are ready c. Ask them, “What would have to happen to you for you to consider quitting?”

Tobacco Cessation Counseling: A Protocal for Practicing Pharmacists 8. Pharmacists can increase the efficacy of any cessation medication by: a. Addressing any misconceptions about the product in question and counseling on proper usage b. Thoroughly questioning the patient about what they know about their medication c. Reviewing the interaction between the chosen smoking cessation medication and the other medications a patient is taking 9. The main reason a smoking cessation medication does not work is that: a. Nicotine is a very addictive drug just like heroin or cocaine b. Most patients fail to read the directions and therefore use the product incorrectly c. Patients only use one product when they should be combining two or three together d. Quitting is very difficult no matter what product you use 10. After motivating and educating a patient, a pharmacist should refer that individual to: a. The appropriate behavior change program for that patient b. The national quit line, 1 800 QUIT NOW c. The least expensive program that they can find d. The Internet to do a search for local programs Answers:

1. b 2. a 3. b 4. c 5. b

6. c 7. c 8. a 9. b 10. a

Faculty Disclosure Statement ASHP requires all speakers and faculty members to disclose any relationships (e.g. shareholder, recipient of research grant, consultant or member of an advisory group committee) that they may have with commercial companies whose products or services may be mentioned in their presentations. The existence of these relationships is provided for the information of attendees and should not be assumed to have an adverse impact on faculty presentations. The faculty reports the following relationships: Frank Vitale Frank Vitale reports that he serves on the Speakers Bureau for GlaxoSmithKline