practical advice for managing smokers - cyberport

Upload: yus97

Post on 06-Apr-2018

221 views

Category:

Documents


0 download

TRANSCRIPT

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    1/35

    Practical Advice For

    Managing Smokers

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    2/35

    How can a Doctor Advice?

    5 As (ask, assess, advise, assist, arrange)

    European Society of Cardiology

    Assess dependency

    Personaling benefits of cessation Boosting Motivation

    Recommending medication

    Set Quit Date

    Arrange follow-ups

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    3/35

    3

    Determining smoking history, including:

    Number and methods of previous quitattempts

    Previous lengths of abstinence

    achieved Whether smokers who quit recently are

    calling themselves non-smokers

    Usually patients visit for another health

    problem So, a link might be made between

    smoking and other health problems

    But be careful not to accuse or

    alienate

    Outcomes of Asking About Smoking

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    4/35

    Assessing Dependency

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    5/35

    Assessing Dependency

    There are smokers who will still smokeafter a serious illness

    Use Fagerstroms test for Nicotine Dep

    How many cigarettes do you smoke? How long after awakening do you

    smoke your first cigarette?

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    6/35

    6

    Advice To Stop Smoking:Common Elements

    Systematically asking about smoking atevery visit

    Strongly advising a smoker to quit

    Offering treatment to aid the quitattempt

    Providing or arranging for support

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    7/35

    7

    Personally relevant to the patients

    situation

    Unambiguous

    Non-judgmental Empathic

    Advice to Quit Smoking Should Be:

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    8/35

    8

    Give Strong Advice to Quit Smoking

    Comparison

    N

    Trials

    N

    Participants

    Pooled OR*

    (95% CI)

    Physician advice1

    Minimal vs no advice (usual care)Intensive vs minimal advice

    1715

    13,7249775

    1.66 (1.42-1.94)1.37 (1.20-1.56)

    1. Lancaster T, Stead LF. Cochrane Database Syst Rev. 2004;(4):CD000165.

    Abstinence rates in the table below are assessed at least 6 monthsfollowing intervention for quitting smoking

    Minimal advice Single session lasting 1 follow up

    Other materials besides a pamphlet

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    9/35

    9

    Give a reason to quit

    Acknowledge quitting can be difficult(may take many attempts)

    Motivate the smoker by offeringassistance

    Strong Advice to Stop Smoking:Examples of What You Can Say

    Stopping smoking is the single best

    thing that you can do to improve

    your current and future health

    Tobacco is very

    addictive, so it can bevery difficult to give

    up, and many peoplehave to try severaltimes before theysucceed

    The important thing

    is to keep trying

    If you would like to

    give up smoking, I canhelp you succeed with

    support and proveneffective medication

    If you are interested in

    stopping smoking, thereare services and

    medications which canhelp you in your quitattempt

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    10/35

    Benefits of Cessation

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    11/35

    Benefits of Cessation

    We have to be direct and clear

    As your doctor, I strongly advise you to

    stop..

    Show them models of heart disease Show them studies that smoking cessation

    reduces heart disease

    Smoking cessation can increase the HDL

    Less LDL oxidation when stop smoking

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    12/35

    Motivational Support

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    13/35

    Motivational Support

    Motivational Counseling

    Empower the patient to make decision

    We guide them to making the decision

    It is the patient and NOT THE DOCTOR that isresponsible for the change in behavior

    Help patient to explore and see ambivalence

    Rate 1-10 why are you a 3 on the scale andnot 10?

    Change is likely when patients are helped to makedecisions for themselves

    If there is low scale use level of motivation todetermine the next step.

    Once willing set Quit Date!

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    14/35

    Motivational Support

    Express empathy and avoid arguments

    Use I understand, I am sorry, OK ..

    Ask also What you like/dislike aboutsmoking?

    What are your concerns aboutsmoking?

    Summarize

    Where does that leave you now?

    What will you do now? Raise Self EfficacyWill you quit now

    rate 1-10?

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    15/35

    Motivational Support

    Talk about roadblocks to stopping smoking Tie in potential advantages in quitting

    Saving cost make them count how much theywill save

    Example to children/grandchildren

    Being in good health can exercise better

    If they express poor desire to stop smoking donot stop giving support.

    Continue to give support Tell them when theywant to stop to come and see you

    Probably medication might help offer them Assure weight gain is better than smoking

    It takes about 40kg excess to equal theharm of 10 cigarette per day

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    16/35

    Pharmacotherapy

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    17/35

    NRT and Non Nicotine Drugs

    NRT make sure we know how to use it

    Counsel and follow-up is important

    Any one can do sometimes using 2 NRT will be

    good. Guide patient on dose reduction

    If not use properly restart and make sure it is doneproperly

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    18/35

    NRT and Non Nicotine Drugs

    Non Nicotinic Drugs

    Varenicline

    Usual Course is 12 weeks

    First determine QUIT DATE before startingVarenicline

    Patient should be monitored for neuropsychiatriceffects ( depression, suicidal, behavior)

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    19/35

    Champix: Starter Pack (2 weeks)

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    20/35

    Behavioral Advice

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    21/35

    21

    Smoking Cessation Behaviouralor Supportive Therapy1

    Quitlines Group Counselling

    Individual Counselling

    Self-help

    1. Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice

    Guideline.US Department of Health and Human Services. Public Health Service; May2008. Available at: www.surgeongeneral.gov/tobacco/default.htm

    Internet Resources

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    22/35

    Behavioral Advice

    Combining Drugs and Counseling increases Quit rates

    Make smokers think of high risk situation and think ofalternative coping strategies

    Social events stay away or come prepare Announce Quit Date with at least 1 relative/friend

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    23/35

    Behavioral Advice

    Quit Date

    Should be within 4 weeks from a Doctors Visit

    Date should be free of stress

    If using with medication, make sure you plan the dateswell.

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    24/35

    Follow Up

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    25/35

    Follow-Up

    The most important part in Smoking Cessation

    Offer as much as possible and try to make sure thatphysician do not put barriers to follow-up

    Any kind of follow-up is possible

    Any Health Care personnel can do it.

    A health care personnel associated with the doctor ora stop smoking clinic is more effective.

    Health Care needs to be trained for smokingcessation clinic.

    Make it a regular schedule

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    26/35

    26

    Developing a System:Long-term Follow Up

    Who carries out long-term follow up andwhat form should this take?

    How do you optimize the system to help arelapsed patient who is still willing to quit?

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    27/35

    Relapse Patient

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    28/35

    28

    Keep the patient motivated

    Schedule follow up (even minimalcontact)

    Praise periods of abstinence Explain to patients that a lapse is not a

    failure (continue the quit attempt)

    Offer the patient other support (eg,

    quitlines, group therapy)

    Office- or hospital-based systems can helpthe healthcare provider improve support

    Providing or Arranging Support

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    29/35

    Relapse Patient

    Keep data of all smokers who haveenrolled in your stop smoking clinic

    Contact them once a year WNTD

    Tell them you are still there for them.

    Encourage them to quit smoking again.

    Learn from the relapse to cope better

    Better to use medication and closer follow-

    ups

    Developing a ystem:

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    30/35

    30

    Developing a ystem:Identification and Documentationof Smokers

    30% of smokers say they are not askedabout smoking status at a clinic visit1

    How do you proactively identify anddocument patients in your practice who

    should quit smoking?

    How could a system improve thisidentification and documentation?

    1.

    Reid RD et al (2009) Patient Educ Couns76:99-105

    Example of a Successful Tobacco

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    31/35

    Example of a Successful TobaccoDependence Treatment System:The Ottawa Model

    Reid RD, Pipe AL, Quinlan B. Can J Cardiol2006;22:775780

    http://www.ottawamodel.ca

    31

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    32/35

    32

    The Systematic Approach of theOttawa Model

    Patient Registration/Assessment

    Physician AdmittingOrders

    Nursing History

    Patient Care Maps Critical Pathways Kardex

    Ottawa Model SmokingCessation Consult Form

    Standard Orders forPharmacotherapy

    Self-help Material

    IVR* System and NurseCounselling for 6 Months

    Community Cessation

    Identification &Documentation

    Counselling &Pharmacotherapy

    Follow Up

    and/or and/or

    and/or and/or

    *IVR = Interactive Voice Response Follow-up System and Databasehttp://www.ottawamodel.ca/en_about.php#1

    Quit Lines Programmes

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    33/35

    33

    Roadblocks to Treating TobaccoDependence

    In spite of practical, effective therapies,why isnt smoking cessation more common in clinical

    practice?Physician-perceived barriers1

    Lack of patients interest

    Lack of reimbursement

    Lack of time Lack of access to other support

    resources

    Lack of training

    Treat other diseases beforesmoking

    Believes cessation heightensother symptoms

    Not their job to treat smoking

    Patient-perceived barriers

    Enjoyment of smoking

    Craving

    Stress relief

    Withdrawal symptoms

    Weight gain

    Fear of failure

    Costs

    Discouragement

    Timing of classes

    Disrupt social relations

    1. American Legacy Foundation. Physician Behavior and Practice Patterns Related toSmoking.AAMC; 2007. Available at: http://www.aamc.org/workforce/smoking-

    cessation-full.pdf2. UW-CTRI. Barriers to Quitting Smoking. 2005. Available at:http://www.ctri.wisc.edu/Publications/publications/BarrierstoQuitting.2.28.pdf

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    34/35

    34

    How Would You Manage aSmoker

    1. Making a first quit attempt?

    2. Who has repeatedly failed to quit?

    3. With past history of depression?

    4. With a physical comorbidity (eg, COPD)?

    5. Who claims that medications are not working?6. Who considers successful reduction in daily

    smoking as a success, but who has not quit?

    7. Who is teenager?

    8. Who is concerned about drug interactions with an

    existing medication for another disorder?

    9. Who has never been willing to quit?

  • 8/3/2019 Practical Advice for Managing Smokers - Cyberport

    35/35

    Thank you.