Clinician’s Guide to Treating Tobacco Dependence Produced by members of the AARC Tobacco-Free Lifestyle Roundtable with a forward by Dr. Steven Schroeder American Association for Respiratory Care 1 Clinician‘s Guide to Tobacco Dependence Clinician’s Guide to Treating Tobacco Dependence Produced by members of the AARC Tobacco-Free Lifestyle Roundtable With a Foreword by Dr. Steven Schroeder Copyright ©2014 by the American Association for Respiratory Care Produced by the American Association for Respiratory Care 2 Clinician‘s Guide to Tobacco Dependence Table of Contents Foreword ................................ 5 The Evidence and Special Populations ........ 31 Effect of Nicotine on the Human Body ......... 6 Myocardial Infarction and Cardiac Issues Cardiopulmonary Involvement Pregnant Smokers Psychoactive Involvement Hospitalized Tobacco Users Effect on Weight and Appetite Secondhand and Thirdhand Smoke Other Effects Teen and Pre-teen Tobacco Products ......................... 8 System-wide Implementation and Policy Development ................... 39 The Cigarette as a Drug-delivery System The Joint Commission’s New Menthol Tobacco Measure Set Light Cigarettes Steps to Implementing a Tobacco-cessation Program Cigars and Cigarillos Respiratory Care Educator Role Miscellaneous Products .................... 10 Reimbursement for Smoking and Electronic Cigarettes Tobacco Cessation and Counseling ........... 45 Hookah Smoking Referral: Outpatient and Community Programs . 48 Smokeless Tobacco and Snus References .............................. 50 Neurochemistry of Addiction ............... 13 Acronyms ............................... 53 Chain of Addiction ....................... 14 List of Figures and Tables DSM 5 Nicotine Dependence Criteria ......... 15 Table 1 . DSM 5 Severity of Disorder Criteria . 16 Starting the Conversation .................. 17 Table 2 . Nicotine Replacement Therapy (NRT) 5 A’s, 5 R’s, and the Condensed Over-the-Counter Pharmacotherapy Options . 28 AAR Tobacco Intervention ................. 18 Table 3 . Nicotine Replacement Therapy (NRT) Motivational Interviewing . 23 Prescription Pharmacotherapy Options . .29 What Is Motivational Interviewing? Table 4 . Non-NRT Pharmacotherapy Options . .. 30 How Does Motivational Interviewing Table 5 . Pharmacotherapy Options for Patients Work? with Cardiovascular Disease . 32 Example of a Brief Motivational Table 6 . Suggested Interventions for Interviewing Conversation Hospitalized Patients . .. 36 Pharmacotherapy ........................ 27 Table 7 . Tobacco Measure Set Specifications . 40 Nicotine Replacement Therapy Figure 1 . 5 A’s . 18 Bupropion Figure 2 . Stages of Change . 20 Varenicline Figure 3 . Example of Readiness to Change/Confidence to Change Now Scale . .. 24 3 Clinician‘s Guide to Tobacco Dependence Program Faculty Georgianna Sergakis, PhD, RRT, CTTS Courtney Seibert, BS, RRT-NPS Chairperson, Clinician’s Guide to Treating Dayton Children’s Hospital Tobacco Dependence Dayton, OH The Ohio State University Columbus, OH Shawna Strickland, PhD, RRT-NPS, AE-C, FAARC American Association for Respiratory Care Erna Boone, DrPH, RRT, FAARC Irving, TX University of Arkansas for Medical Sciences Little Rock, AR Jay Taylor, RRT, CTTS Sanford Medical Center Scott Cerreta, BS, RRT Fargo, ND COPD Foundation Washington, DC Sarah Varekojis, PhD, RRT The Ohio State University Crystal Dunlevy, EdD, RRT Columbus, OH The Ohio State University Columbus, OH Jonathan Waugh, PhD, RRT, RPFT, CTTS, FAARC University of Alabama at Birmingham Robert Fluck Jr., MS, RRT, FAARC Birmingham, AL SUNY Upstate Medical University, Retired Syracuse, NY With a foreword written by Steven Schroeder, MD Susan Rinaldo-Gallo, MEd, RRT, CTTS, FAARC Professor, Department of Medicine Duke University Hospital Director, Smoking Cessation Leadership Center Durham, NC Distinguished Professorship in Health and Health Care Grace Howard, BSRT, RRT University of California, San Francisco Cleveland Clinic San Francisco, CA Cleveland, OH Kathryn Ickes, BS, RRT, RPFT, AE-C Cleveland Clinic Cleveland, OH Gaylene Lee, MEd, RRT-NPS, TTS Concorde Career College San Antonio, TX Mary Martinasek, PhD, RRT-NPS, CHES, AE-C University of Tampa Tampa, FL Karen S. Schell, DHSc, RRT-NPS, RRT-SDS, RPFT, RPSGT, AE-C, CTTS Newman Regional Health Emporia, KS 4 Clinician‘s Guide to Tobacco Dependence Foreword 2014 was a landmark year in tobacco control in the United are available over the States, marking the 50th anniversary of the first Surgeon counter, while the spray and General’s Report on Smoking and Health. In the intervening inhaler require a prescrip- five decades, the United States has seen great progress in tion. Two oral medications, reducing smoking rates and the ravages of smoking-related bupropion and varenicline, diseases. Yet, tobacco use remains the number one killer, are also effective. accounting for almost 500,000 annual deaths in the United States and 5 million worldwide. Respiratory therapists (RTs) It is easy to be discour- are uniquely positioned to address this problem, given their aged because many smokers frequent contact with smokers who have smoking-induced dis- are unable to quit, even eases, and their special trusted position as bed-side clinicians those with serious smok- with intimate patient contact. ing-induced diseases such as COPD and coronary disease. What are the facts? There are about 42 million smokers in Even the most successful tri- the United States today, of whom 80% smoke on a daily basis als of counseling combined and 20% only intermittently. Just as the prevalence of adult with medications yield quit smoking has gradually declined—from 42.7% in 1964 to 18% rates of 25% or less. This is today—so too has the amount of daily cigarettes smoked by a great improvement over smokers—from 20 per day to about 13 per day. Tobacco use, the spontaneous “cold turkey” quit rate of about 4%, but still especially combustible tobacco such as cigarettes and cigars, means that success comes hard. But RTs should take this as a exert a devastating toll on personal health, both for smokers challenge. Most successful quitters have previously failed 8 to and for nonsmokers exposed to secondhand smoke. The asso- 12 quit attempts before finally quitting. There are now more ciation between smoking and lung cancer is well known, as ex-smokers than current ones. And the potential health bene- is the linkage between smoking and heart disease and stroke. fits are immense. Not only do former smokers live longer, they The list of other diseases that are more likely to occur in smok- also live healthier lives, as respiratory and cardiac symptoms ers expands every year. It includes multiple types of cancer, recede. An added bonus of quitting is that it eliminates the chronic obstructive pulmonary disease, diabetes, and—most burden of secondhand smoke exposure to family and friends, recently—Alzheimer’s dementia. with the attendant risk of myocardial infarction and stroke. Over time, persons in higher socio-economic classes have RTs may be asked about the electronic cigarette, now avail- abandoned smoking, which is now concentrated in the less able in scores of formats. It is important to note that these fortunate, including populations with mental health and/or products are evolving continuously, and that data about their substance use disorders, the homeless, and those involved risk and potential to help smokers quit are incomplete and also with the criminal justice system. Medical workers now have dated by dint of the changing technology. In general, it is pru- much lower smoking rates than the general population. Only dent to say that the risks and potential benefits of the e-cig- about 1% of physicians smoke, and professions with previous arette are unproven, that it is likely that they are less harmful high rates such as RTs and nurses now have smoking preva- than combustible tobacco but not entirely harmless, and that lence rates of 11% and 7%, respectively. their potential to help smokers quit is unknown but less than the combination of counseling and FDA-approved medications. RTs understand that it is hard to quit smoking, even when patients are motivated to do so. A major reason for this is RTs are in a unique position to help smokers quit. No other the extremely addictive nature of nicotine. But hospitaliza- action they can take compares with the clinical impact of tion provides an excellent opportunity to help smokers quit. stopping smoking. Read this guide carefully, use it for your There are now a number of evidence-based treatments that patients, and thereby improve the health of the nation! have been shown to increase the probability of quitting. These start with the simple recommendation from trusted clinicians. Steven A. Schroeder, MD Counseling, either in-person or via toll-free telephone quitlines, Professor, Department of Medicine accessed via 1-800-QUITNOW, is effective. Seven forms of Director, Smoking Cessation Leadership Center FDA-approved medications have been proven to increase quit Distinguished Professorship in Health and Health Care rates. Five of these are nicotine replacement products—the University of California, San Francisco patch, gum, lozenge, nasal spray, and inhaler; the first three 5 Clinician‘s Guide to Tobacco Dependence Effect of Nicotine on the Human Body Nicotine affects numerous systems and pathways although a majority of the studies excluded in the human body, the consequences of which patients with baseline cardiac disease.3 can be seen in the many patients and clients