BTIS Principles

 Please Remember:
 Don’t be discouraged by people who fail to quit.
 Many tobacco users have other substance
addictions.
 Be aware of the physical and social environment
that “frames” your cessation message.
 Use local resources!

1
 BTIS Principles
TRADITIONAL BTIS APPROACH
 Patient Encounter  Short intervention
 Personal and Social during patient
History counseling
 Family History  Smoking or exposure is
linked to present illness
 Living Condition or state of health
 Smoking History

2
 Levels of Intensity in Tobacco
Interventions

Minimal Intervention: Less than three minutes

Brief Intervention: Lasts 3 to 10 minutes
Intensive Intervention:
 Trained (preferably certified) provider
 Four or more sessions - longer than 10 minutes
 Total contact/session - longer than 30 minutes
 Over at least 2 weeks; preferably 8 or more weeks
 Includes education on medical treatment

3
Building a Cessation System

Medical
treatment

Intensive
counseling

Brief Advice
4
 Module Two:
Tobacco Basics
Tobacco Basics

 Knowledge is not enough.

 You do make a difference!

 Substantial evidence that brief

tobacco dependence treatment is
effective.

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Physiologic Effects of
Smoking
 Objectives
 General
v To describe physiologic effects of smoking

 Specific
v To enumerate contents of tobacco smoke
v To describe effects of tobacco smoke to smoker
v To discuss effects of second – hand and third-hand
smoke
v To explain the tobacco addiction
 Tobacco Smoke
 There are more than 7000 chemicals in
tobacco smoke
v at least 250 are known to be harmful
 Nicotine, Ammonia, Carbon monoxide. Lead

v more than 70 are known to cause cancer

 Tar, Cadmium, Arsenic

WHO Fact Sheet on Tobacco May

2010
 Tobacco Additives and Its Effects
 Isovaleric acid – prehormone influencing sexual
behavior
 Menthol – local anesthetics to mask noxious sensory
stimuli
 Theobromine – bronchodilation enhancing penetration
of smoke into lungs
 GVL – decrease nicotine metabolism by inhibiting CYP
246 metabolism
 AT, NH4OH – increase free base nicotine
 DAP, MAP, levulinic acid – increase nicotine levels in
smoke
 Sugars, vanillin, cocoa – enhance taste and addiction
 Toxic Effects of Tobacco

 Tobacco kills up to half of its users.

 The annual death toll of more than 5
million could rise to more than 8 million by
2030.
 It kills more than 5 million people a year
v one person every 6 seconds
v one in 10 adult deaths.

WHO Fact Sheet on Tobacco May

2010
 Toxic Effects of Tobacco

 Every cigarette smoked

cuts at least five minutes of
life on average - about the
time taken to smoke it.
HARMFUL EFFECTS OF CIGARETTE
SMOKING
IMMEDIATE EFFECTS
 Repeated cough &
colds, asthma attacks
 Bad breath

 Infections of teeth and

gums
 Staining of teeth and
gums
 Easy fatigability

 Nicotine addiction
LONG-TERM EFFECTS

 Heart disease & hypertension

 Cancer of the lungs, throat or
mouth
 Peptic ulcer disease
 Early wrinkles
 Hair loss
 Contributes to cancer of the
pancreas and kidneys
 Toxic Effects of Tobacco
 Increased risk of lung and heart
disease
v At least a quarter of all deaths from
heart diseases and about three-
quarters of world's chronic bronchitis
are related to smoking.
 Toxic Effects of Tobacco

 At least 240 Filipinos die each day - 87,600 a

year - from smoking-related diseases such as
lung cancer, cardiac arrest, stroke and other
chronic-obstructive lung failures

2005-2006 Tobacco and Poverty Study in the Philippines. UP CPH, NEC DOH and WHO.
 Toxic Effects of Tobacco

 For women, additional risks

v osteoporosis
v cervical cancer
v early menopause
v during pregnancy, increase the risk
[ growth retardation
[ fetal death and neonatal death

National Statistics Office (NSO) [Philippines], and ICF Macro. 2009. National Demographic and
Health Survey 2008. Calverton, Maryland: National Statistics Office and ICF Macro.
 Second – Hand Smoke

 Mainstream smoke is smoke that is

inhaled through a smoker’s mouth
 Sidestream smoke is smoke that drifts off
at the end of cigarettes

A secondhand smoker or passive smoker

is one who inhales sidestream smoke
 Second – Hand Smoke

 No safe level of second-hand tobacco

smoke.

WHO Fact Sheet on Tobacco May

 Second – Hand Smoke
 Second-hand smoke causes 600,000 premature
deaths per year.
 In 2004, children accounted for 28% of the
deaths attributable to second-hand smoke.
 In infants, it causes sudden death.
 It causes increased rates of pneumonia, otitis
media, asthma, and other short- and long-term
pediatric conditions.

WHO Fact Sheet on Tobacco May

2010
 SECOND-HAND TOBACCO SMOKE
Children whose mothers smoke:
 70% more respiratory problems
 Pneumonia and hospitalization in year 1 is 38%
higher
 Infant mortality is 80% higher
 20% of all infant deaths could be avoided if all
pregnant smokers stopped by the 16th week of
gestation
 5 times higher risk of sudden infant death syndrome
(SIDS)

WHO 2005
 Second – Hand Smoke
 In adults, second-hand smoke causes
serious cardiovascular and respiratory
diseases, including coronary heart disease
and lung cancer.

 In pregnant women, it causes low birth

weight.
 Third – Hand Smoke
 Residue from second-hand smoke nicotine
that lingers on surfaces and react with
ambient nitrous acid to form potent
carcinogen, tobacco-specific nitrosamines
(TSNAs)
Sleiman M et. al.(Feb 2010) Proc. Natl. Acad. Sci. USA 107(15):6576-81.

 Babies and toddlers are susceptible to

exposure because they can inhale near,
crawl and play on, or touch and mouth
contaminated surfaces.
 But for the addicted,
quitting is hard

For patients who have been smoking for a

long time, it takes time, patience, practice
and support to quit smoking. Sometimes,
several attempts are needed. The
important thing is not to give up.
Nicotine is ADDICTIVE

Smoking changes
the brain
chemistry
The brain has nicotine
receptors. But unless you
smoke, these are “asleep”.

Nicotine Receptor
 When you smoke

The nicotine Nicotine

attaches to
Nicotine Receptor
the nicotine
receptor.
 This results in
Dopamin
Dopamine release e
that gives a Nicotine

good feeling for a few

minutes Nicotine Receptor
The more one smokes…more receptors
are awakened…multiplying the good
feeling.

Dopamin
e
Dopamin Dopamin
e Dopamin e
e
Nicotine Nicotine
Nicotine

Nicotine Receptor Nicotine Receptor Nicotine Receptor

 Loss of
When the effect of Dopamine
smoking diminishes,
dopamine is lost,
resulting in a Nicotine Receptor
“low feeling.”
The “low feeling” can shift to anxiety,
irritability, anger, uneasiness, hunger

Loss of
Dopamine

Nicotine Receptor
 When several receptors feel loss of
dopamine, this results in “craving” for
nicotine

Loss of
Dopamine

Nicotine Receptor Nicotine Receptor Nicotine Receptor Nicotine Receptor

 Nicotine Withdrawal
DSM IV
 Dysphoric or depressed mood

 Insomnia

 Irritability, frustration or anger

 Anxiety

 Difficulty concentrating

 Restlessness

 Decreased heart rate

 Increased appetite or weight gain

By smoking more cigarettes, more dopamine is released, the
good feeling is restored, BUT more nicotine receptors are now
activated

Dopamin
e
Dopamin Dopamin
e Dopamin e
e
Nicotine Nicotine
Nicotine

Nicotine Receptor Nicotine Receptor Nicotine Receptor

Learning Objectives and Goals:

 Identify a person’s readiness to quit, using

the “Readiness to Change” model;
 Name the “Five A’s” and give a brief
explanation to each;
 Identify the contents of the Brief
Intervention Flow Chart.

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Readiness to Change Model

 Not ready to quit

 Thinking about
quitting
 Ready to quit
 Quitting
 Staying quit
 *Relapse

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The Five A’s

 Ask
 Advise
 Assess
 Assist
 Arrange
 *Anticipate

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ASK

Ask about tobacco use at EVERY

encounter.
 For health facilities: tobacco use as a “vital
sign”
 Keep it simple:
 Do you use tobacco?
 Does anyone else in your home use tobacco?

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ADVISE

Urge EVERY tobacco user to quit.

 Remember the 5 “Rs”:
 Relevant
 Risks
 Rewards – refer to the “Benefits of Quitting” sheet
 Roadblocks
 Repetition

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ASSESS

Determine the tobacco user’s willingness to

make a quit attempt.
 Within the next 30 days

 If willing, ASSIST.

 If not willing, provide non-judgmental support

and information to get the person thinking
about quitting - “Benefits of Quitting” hand-
out.

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ASSIST

Assist the tobacco user in quitting.

 Develop a Quit Plan:
 Set a quit date.
 Identify social support.
 Provide specific problem-solving suggestions.
 Give information on medications, if appropriate.
 Provide self-help materials.
 Refer for intensive counseling, if available.

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ARRANGE

Arrange for follow-up whenever possible.

 For tobacco users about to make a quit
attempt, arrange follow-up around 1 week
after the quit attempt:
 Ask about tobacco status.
 Congratulate those who are tobacco-free and
encourage them to stay quit.
 Support those who have relapsed and assist them
to make a new quit attempt.

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ANTICIPATE*

For children and adolescents:

 Anticipate exposure to tobacco smoke and
early experimentation with chewing or
smoking tobacco.
 Beginning around age 10, ask about:
 Exposure to second hand smoke
 Actual tobacco use
 At every clinical encounter

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 Module Four:
Not Ready to Quit
Not Ready to Quit

 ASK
 ADVICE
 ASSESS – “Are
you ready to
set a quit date
within the next
30 days?”
“NO.”

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NOT READY TO QUIT
A brief intervention with someone who is
not yet ready to quit may be very short,
perhaps only 30 seconds long.
 DON’T try to convince the person to quit.

 ASSIST – by offering info and educational

materials that describe the benefits of quitting
and the consequences of tobacco use.
 ARRANGE – follow-up and let them know
you will be available when they are ready to
quit
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Module Five:
Ready to Quit
Ready to Quit

 ASK
 ADVICE
 ASSESS – “Are
you ready to
set a quit date
within the next
30 days?”
“YES.”

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ASSIST

6 Basic Elements of a Quit Plan

 Quit Date

 Social Support

 Problem Solving Skills

 Medication Information

 Self-help Materials

 Referral to Other Programs or Services

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Self-Help Materials

 Benefits of Quitting
 Quit Plan
 Problem solving Sheet –Before Quitting
 Problem solving Sheet – After Quitting
 Quit Smoking resources – Always refer to
intensive counseling for help if available.

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Pharmacological treatment

 Nicotine replacement - “methadone for the

smoker”
 gum
 patches
 nasal spray
 inhaler
 Bupropion – “Zyban”; also now “Chantix”
 All decrease cravings, withdrawal
 Up to ~30% quit rates at 1 year

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 Nicotine replacement and
buproprion should always
be used in conjunction with
behavior modification.

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 Module Six:
Staying Quit or Relapse
Relapse
 Majority of tobacco
users cycle through
multiple periods of
relapse and remission.
 Only about 7% of
smokers achieve long-
term success when
trying to quit on their
own
 Relapses are common
and should not be
viewed as a failure.

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Relapse

Some common causes for relapse:

 Nicotine withdrawal discomfort
 Negative emotions (anger, frustration, sadness)
 Interpersonal conflict; traumatic life events
 Social and environmental pressures – lack of support
 Stressful situations at home, work or school
 Loneliness; Depression
 The level of addiction
 Use of drugs or alcohol
 Weight gain

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Relapse Prevention

 Acknowledge, and congratulate success, no

matter how brief!
 Review the benefits of quitting.
 Offer encouragement to remain tobacco-free.
 Assist individuals with problems by referring
them to cessation treatment specialists.

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Relapse Intervention

 ASK about tobacco use.

 ADVISE the person to begin a new quit
attempt. Acknowledge any period spent
tobacco free.
 ASSESS the person’s willingness to make
another quit attempt within the next 30 days.
 ASSIST by referring to other cessation
services.
 ARRANGE follow-up.

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Tips for Follow-up

 Keep it brief!
 Stick to the topic
 Avoid getting into problem-solving
discussions
 Use practical methods
 Telephone
 Personal visit
 Mail/ E-mail
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Timing is everything!

 Most relapses occur early in the quitting

process:
 Follow-up at 1 week and 1 month after quit date.
 Guam DMHSA: 1 week, 1 and 6 month follow-up
 Use reminder tools to remind you who and
when to follow-up.
 Know the cessation services and cessation
providers in your locality.

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 ALGORITHM
 Young Child Less than 5 years old
 Parent/Caregiver
 IMCI approach (Pneumonia, ear infection,
nutrition, fever)
 Older Child (6-9 years old)
 Parent/Caregiver
 Child
 Adolescent
PARENT/CAREGIVER
OLDER CHILD (6-9 YEARS OLD)
ADOLESCENT
The effects are immediate!
 20 minutes after quitting: Heart rate and blood
pressure drops.
 12 hours after quitting: Carbon monoxide level in
your blood drops to normal.
 2 weeks to 3 months after quitting: Circulation
improves and your lung function increases.
 1 to 9 months after quitting: Coughing and
shortness of breath decrease; lungs regain normal
function
 1 year after quitting: The excess risk of coronary
heart disease is half that of a smoker's.
 5 years after quitting: Your stroke risk is reduced to
that of a nonsmoker 5 to 15 years after quitting.
 10 years after quitting: The lung cancer death rate
is about half that of a continuing smoker's.
 15 years after quitting: The risk of coronary heart
disease is that of a nonsmoker's.
THANK YOU