314 -Special Series Tobacco Treatment Specialist Training Part 3
Counselor Toolbox

 
 
00:00 / 49:17
 
1X

Health Education
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs Counselor Education
Podcast Host: Counselor Toolbox and Happiness Isn’t Brain Surgery
Objectives
~ 1.Describe the prevalence and patterns of tobacco use
~ 2.Explain the role of a comprehensive tobacco control program.
~ 3.Utilize the findings of national reports and guidelines on tobacco treatment.
~ 4.Explain the factors that prevent tobacco use and dependence.
~ 5.Explain the health consequences of tobacco use and benefits of quitting, and the basic mechanisms of the more common tobacco induced disorders.
~ 6.Describe how tobacco dependence develops
~ 7.Summarize valid and reliable diagnostic criteria for tobacco dependence.
~ 8.Describe the chronic relapsing nature of tobacco dependence
~ 9.Provide information that is culturally sensitive and appropriate to learning style
~ 10.Identify evidence-based treatment strategies
~ 11.Be able to discuss alternative therapies

Prevalence and Patterns
~ Describe the prevalence and patterns of tobacco use, and how rates vary across demographic, economic and cultural subgroups.
~ Tobacco cigarettes: Nearly 90 percent of adult smokers began smoking before age 18 and 11 percent of high school seniors reported smoking in the last month.
~ Smokeless tobacco: Use of smokeless tobacco among adolescents is less common than cigarette smoking.
~ Hookahs: Hookahs are no safer than other forms of tobacco smoking and may deliver even higher levels of toxic substances.
~ Flavored little cigars: Of middle and high school students who used tobacco products in 2014, more than 60 percent smoked flavored little cigars.
Prevalence
~ Describe the prevalence and patterns of tobacco use, and how rates vary across demographic, economic and cultural subgroups.
~ E-cigarettes:
~ From 2011 to 2016, the percentage of 12th-grade students who had ever used an e-cigarette increased from 4.7 to 13 percent, down from a peak in 2015 of 16 percent.2
~ For the first time in 2014, more teenagers used e-cigarettes or vaped nicotine than smoked cigarettes—a trend that continues. In 2017, 8 percent of high school students reported vaping nicotine at least once in the past 30 days.

Prevalence
~ American Indians/Alaska Natives have a higher risk of experiencing tobacco-related disease and death due to high prevalence of cigarette smoking and other commercial tobacco use.
~ The risk of developing diabetes is 30–40% higher for smokers than nonsmokers.10
~ More American Indian/Alaska Native women smoke during their last 3 months of pregnancy—26.0% compared to other ethnicities.
~ Cigarette smoking varies by Asian American subgroups as a result of a number of cultural, social, environmental, and individual factors.
~ Cigarette smoking during pregnancy is less common among Asian American/Pacific Islander women compared to other racial/ethnic groups.11
Comprehensive Tobacco Control
~ Explain the role of treatment for tobacco use and dependence within a comprehensive tobacco control program.
~ Primary Prevention: Prevent a problem
~ Secondary Prevention aims to reduce the impact of a disease or injury that has already occurred and prevent secondary problems.
~ Treatment to reduce cancer, lung problems, reduce absenteeism, reduce effects of second hand smoke, improve health of babies
~ Tertiary prevention aims to help people learn to live with the issue
~ Treatment to help people quit smoking after a diagnosis like emphysema

National Reports
~ Utilize the findings of national reports, research studies and guidelines on tobacco treatment.
~ Office on Smoking and Health
~ The Health Consequences of Smoking—50 Years of Progress. Surgeon General
~ Cochrane Reviews
~ Tobacco, Nicotine and E-Cigarettes Consumer Education (NIDA)

Prevention Strategies
~ Explain the societal and environmental factors that prevent tobacco use and dependence.
~ Attitudes
~ Reduction in advertising and visual triggers
~ Youth stress management and health promotion programs
~ Family-based interventions can prevent children and adolescents from starting to smoke
~ Adding a family-based component to a school intervention may be effective.
~ The common feature of the effective interventions was encouraging authoritative parenting (which is usually defined as showing strong interest in and care for the adolescent, often with rule setting). This is different from authoritarian parenting (do as I say) or neglectful or unsupervised parenting.

Consequences of Smoking
~ Health consequences of tobacco use
~ Cancer
~ Heart Disease
~ Stroke
~ COPD
~ Pregnancy complications
~ Diabetes
~ Increased systemic inflammation
~ Increased sickness and absenteeism
~ Erectile dysfunction
~ Decreased fertility
~ Osteoporosis

Benefits of Quitting
~ Benefits of Quitting
~ Heart rate and blood pressure return to normal.
~ Improved circulation
~ Produce less phlegm, and don’t cough or wheeze as often.
~ Lower risks of cancer, heart disease, and other chronic diseases than if they had continued to smoke.
~ Substantial gains in life expectancy
~ Before age 40 reduce their chance of dying prematurely from smoking-related diseases by about 90%

Development of Dependence
~ Describe how tobacco dependence develops and be able to explain the biological, psychological, and social causes of tobacco dependence.
~ 3 Phases
~ Acquisition: Euphoria, increased arousal, decreased fatigue
~ Withdrawal after neuroadaptations
~ Relapse Vulnerability
~ Nicotine influences mood, cognition, and body function by binding of nicotine to receptors located on excitatory glutamatergic which causes the release of dopamine
~ Binding of nicotine to receptors located on inhibitory GABAergic projections leads to the release of gamma aminobutyric acid (GABA), which in turn inhibits dopaminergic neurons.

Risk Factors
~ Relatively low SES
~ Relatively high accessibility and availability of tobacco products
~ Perceptions by adolescents that tobacco use is normative or acceptable
~ Use of tobacco by significant others
~ Lack of parental support
~ Low levels of academic achievement and school involvement
~ Lack of skills required to resist influences to use tobacco
~ Relatively low self-efficacy for refusal
~ Previous tobacco use and intention to use tobacco in the future
~ Relatively low self-image
~ Belief that tobacco use is functional or serves a purpose.
Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General.

Dignosis
~ Summarize and be able to apply valid and reliable diagnostic criteria for tobacco dependence.
~ Use of tobacco products over 1 year resulting in at least 2 of the following
~ Larger quantities of tobacco over a longer period then intended
~ Unsuccessful efforts to quit or reduce intake of tobacco
~ Inordinate amount of time acquiring or using tobacco products
~ Cravings for tobacco
~ Failure to attend to obligations due to tobacco use
~ Continued use despite adverse social or interpersonal consequences
~ Forfeiture of social, occupational or recreational activities in favor of tobacco use
~ Continued use despite awareness of physical or psychological problems directly attributed to tobacco use

Diagnosis
~ Summarize and be able to apply valid and reliable diagnostic criteria for tobacco dependence.
~ B.Tolerance for nicotine, as indicated by: Need for increasingly larger doses of nicotine in order to obtain the desired effect or a noticeably diminished effect from using the same amounts of nicotine
~ C. Withdrawal symptoms upon cessation of use as indicated by
~ The onset of typical nicotine associated withdrawal symptoms is present
~ More nicotine or a substituted drug is taken to alleviate withdrawal symptoms
Diagnosis
~ Summarize and be able to apply valid and reliable diagnostic criteria for tobacco dependence.
~ The clinician may also add the following specifiers
~ 1. Early remission- no use of Tobacco products for 3-13 months.
~ 2. Sustained remission- no use of Tobacco products for > 12 mos.
~ 3. On maintenance therapy- e.g., transdermal nicotine.
~ 4. In a controlled environment- e.g., hospital or correctional facility where smoking is forbidden.

Relapse
~ Describe the chronic relapsing nature of tobacco dependence, including typical relapse patterns, and predisposing factors.
~ Drops in self-efficacy
~ Increases in post-lapse guilt
~ Less than 1 year since quitting, female, white, overweight, low education, low ses, employed, good health, 1.25 stressful life events in the prior 12 months Probability and predictors of relapse to smoking: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)
~ Reexposure to the pharmacological effects of nicotine reinstates drug seeking behavior
~ The abstinence violation effect attributing use to internal, stable, and global factors
~ Exposure to drug-associated cues
Culturally Responsive Learning
~ Provide information that culturally sensitive and appropriate to learning style and abilities.
~ Auditory, Kinesthetic, Visual
~ Active vs. reflective
~ Relevancy
~ Relation to past experiences
~ Active Involvement
~ Sense of self-direction and personal empowerment
~ Immediate application
Culturally Responsive Learning
~ Provide information that culturally sensitive and appropriate to learning style and abilities. (Reasoned action)
~ Cultural Issues
~ Latino:
~ Familismo; collectivism; simpatía; personalismo; and respeto
~ The bad smell of cigarettes, improving relationships with the family, weight gain, breathing more easily, harming children’s health, setting a good example, and having a better taste most strongly discriminated between those Hispanics intending and not intending to quit.
~ Among Native Americans, tobacco is used for spiritual purposes and even for healing, so the cultural attitude to smoking differs substantially. Native Americans don’t generally condone habitual, everyday use of tobacco, though’-
~ White: Effects of withdrawal from cigarettes including weight gain, cost,
Evidence Based Treatment
~ Identify evidence-based treatment strategies and the pros and cons for each strategy.
~ NRT for Smoking Cessation (Cochrane)
~ NRT increases chances of smoking by 50-70%
~ No overall difference in effectiveness of different forms of NRT
~ The choice of which form to use should reflect patient needs, tolerability, and cost considerations.
~ Patches are likely to be easier to use than gum or nasal spray or inhaler but patches cannot be used for relief of acute cravings.
~ No benefit for using patches beyond 8 weeks***
~ NRT works with or without additional counselling
Evidence Based Treatment
~ Identify evidence-based treatment strategies and the pros and cons for each strategy.
~ NRT for Smoking Cessation (Cochrane)
~ Increased chance of success by using a combination of the nicotine patch and a faster acting form
~ Starting to use NRT shortly before the planned quit date may increase the chance of success.
~ Adverse effects from using NRT are related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets.
~ quitting using bupropion or nortriptyline appears to be similar to that for nicotine replacement therapy, but the likelihood of quitting using bupropion appears to be lower than the likelihood of quitting using varenicline (Antidepressants for smoking cessation)

Alternative Therapies
~ Be able to discuss alternative therapies such as
~ Harm reduction (E-cigarettes, NRT)
~ Hypnosis
~ Acupuncture
~ Cigarette tapering

More Information
~ Demonstrate ability to access information on the above topics
~ Pub Med
~ Cochrane
~ Tobacco cessation guidelines
~ SAMHSA
~ SAMHSA 2
~ SAMHSA Store
~ Smoking cessation free resources
Summary
~ An effective tobacco control strategy includes multiple levels of prevention that keep people from starting nicotine use, help them prevent further problems caused by nicotine use and help them manage existing conditions caused by nicotine use (i.e. COPD)
~ NRT and certain antidepressants are first line treatments and provide a 50-70% greater chance of quitting than cold turkey or counseling alone.
~ Tobacco control strategies must be culturally sensitive and use motivators which are culturally appropriate.
~ The Cochrane database, SAMHSA, CDC, NIDA, NHS and other organizations can provide useful (free) information for people desiring to quit using tobacco products.