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Management of Tobacco Use Part 1
Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Executive Director,
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery
Based on the VA/DoD Guidelines
~ Gain information on the assessment of tobacco use
~ Identify clinical interventions, both for patients willing and unwilling to make a quit attempt at this time
~ Identify intensive interventions for motivated patients
~ Examine systems interventions for health care administrators, insurers, and purchasers
~ Review the scientific evidence supporting the Guideline recommendations
~ Explore information relevant to specific populations

Why Do I Care
~ Clinicians can make a difference with even a minimal (less than 3 minutes) intervention
~ A relation exists between the intensity of intervention and tobacco cessation outcome
~ Even when patients are not willing to make a quit attempt at this time, clinician-delivered brief interventions enhance motivation and increase the likelihood of future quit attempts
~ Tobacco users are being primed to consider quitting by a wide range of societal and environmental factors
Why Do I Care
~ There is growing evidence that smokers who receive clinician advice and assistance with quitting report greater satisfaction with their health care than those who do not
~ Tobacco use interventions are cost effective
~ tobacco use has a high case fatality rate (up to 50% of long-term smokers will die of a smoking-caused disease

3 Truths About Tobacco Use
~ All tobacco products—not just cigarettes—exact devastating costs on the Nation’s health and welfare
~ For most users, tobacco use results in true drug dependence, comparable to the dependence caused by opiates, amphetamines, and cocaine.
~ Both chronic tobacco use and dependence warrant clinical intervention and, as with other chronic disorders, these interventions may need to be repeated

Variables to Consider
~ Success
~ High motivation
~ Ready to change
~ Moderate to high self-efficacy
~ Supportive social network
~ Relapse
~ High nicotine dependence
~ Psychiatric comorbidity and/or substance use
~ High stress level
~ Exposure to other smokers

Motivation Enhancement
~ Why do I want to quit? (Rewards, risk reduction, RML)
~ Why do I use?
~ Mental: Concentration, obsessive thoughts, rationalizing
~ Emotional: Boredom, dysphoria
~ Environmental: Access, triggers
~ Physical: Dependence, pain, weight management
~ Social: Peers smoke
~ You can add stop-gaps, but you need to address the underlying issues for use
Develop a Plan
~ Obstacles to quitting (Roadblocks)
~ Triggers
~ Mental
~ Unhook and urge surf
~ Radical acceptance of thoughts
~ Decisional balance
~ Efficacious self talk

Develop a Plan
~ Obstacles to quitting
~ Triggers
~ Emotional
~ Distress Tolerance Exercises
~ Stress Management
~ Deep Breathing
~ Work toward acceptance of the loss/dialectics
~ Keep active (boredom, distract don’t react)

Develop a Plan
~ Obstacles to quitting
~ Triggers
~ Environmental
~ Times of day/activities Change your routine
~ Morning
~ Driving
~ Football
~ Avoid things linked to smoking (Alcohol)
~ Remove sensory triggers (Sounds (Willie Nelson, Pink Floyd), smells, sights)
~ Have an emergency or exit plan

Develop a Plan
~ Obstacles to quitting
~ Triggers
~ Physical
~ Withdrawal
~ Medication (Cravings or mood issues)
~ Good sleep hygiene
~ Pain Pain management techniques
~ Oral fixation  Have something else in your mouth (toothpick, gum, straw)

Develop a Plan
~ Obstacles to quitting
~ Triggers
~ Social
~ Avoid being around people when they are smoking or vaping
~ Don’t sit next to people who smell like smoke
~ Find alternative activities to smoke breaks
~ Have something else to do with your hands

~ Use of approved cessation medication, except when contraindicated
~ The first-line medications include
~ Bupropion SR
~ NRT: Nicotine gum, lozenge, patch or nasal spray
~ Varenicline
~ Second-line medications include
~ Clonidine
~ Nortriptyline
~ Alco consider medications for any underlying mood disorders in the short term

Medications cont…
~ The higher-dose preparations of nicotine gum, patch, and lozenge have been shown to be effective in highly dependent smokers.
~ Combination NRT therapy may be particularly effective in suppressing tobacco withdrawal symptoms and increasing long term abstinence rates.
~ the nicotine patch long-term ( > 14 weeks) with either nicotine gum or nasal spray
~ the nicotine patch with the nicotine inhaler
~ nicotine patch with bupropion SR

More Meds.
~ Bupropion SR and nicotine replacement therapies, in particular 4-mg nicotine gum and 4-mg nicotine lozenge, delay—but do not prevent—weight gain
~ In patients with depression, Bupropion SR and nortriptyline appear to be effective, especially in combination with nicotine replacement medications
~ Prescribing and dosing information is included in the guideline.
***Note that nicotine cannot effectively be absorbed in the presence of acidic food or drinks(coffee, soda, citrus fruits)

Getting Ready: STAR
~ Set a quit date within 2 weeks.
~ Tell family, friends, and coworkers about quitting, and request understanding and support.
~ Anticipate challenges to the upcoming quit attempt, particularly during the critical first few weeks.
~ Remove tobacco products from your environment.
~ TIP: Prior to quitting, avoid smoking in places where you spend a lot of time (e.g., work, home, car).
~ TIP: Make your home smoke-free

Intensive Interventions
~ Individual, group, and telephone counseling are effective treatment formats.
~ Particular types of counseling strategies are especially effective.
~ Practical counseling (problemsolving/skills-training approaches)
~ Social support
~ Various institutional policies would facilitate these interventions
~ Implement a tobacco user identification program in every clinic—part of the assessment
~ Provide adequate training, resources and feedback to providers
~ Dedicate staff to tobacco dependence treatment
~ Ensure covered and or cost-effective treatments are available.

Special Populations
~ Pregnant
~ Increased HR
~ Reduced circulation
~ Low birth weight
~ Withdrawal
~ Substance Dependent

Special Populations
~ Elderly
~ Circulation improves immediately
~ Lungs begin to repair damage
~ In one year, the added risk of heart disease is cut almost in half, and risk of stroke, lung disease, and cancer diminish.
~ Among smokers who quit at age 65, men gained 1.4 to 2.0 years of life and women gained 2.7 to 3.4 years

Special Populations
~ Low SES
~ Environmental factors (immobility)
~ Access to NRT
~ Access to medical care
~ Identification and intervention of tobacco use should be a priority in all settings
~ Effective interventions are dose-dependent
~ A combination of NRT is often helpful for heavy smokers
~ Long term abstinence is most strongly related to a combination of practical counseling and medication assisted therapies in motivated patients