Naval Tobacco Cessation Program: An Overview

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Naval Tobacco Cessation Program An Overview

• Captain Larry Williams, Dental Corps, US Navy
• Navy Medicine Clinical Champion for Tobacco
  Cessation
• Co-Chair, BUMED Tobacco Cessation Action Team
  (TCAT)
• Member, DoD Alcohol and Tobacco Advisory Council
  (ATAC)

U.S. Naval Aeromedical Conf 2009
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2008 GW Fire Improper smoking in spaces with
hazardous, improperly stored materials
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Objectives

• Review new SECNAV 5100.13E
• Discuss Navy Tobacco Cessation Program
• Update hazards and military issues with tobacco
• Briefly discuss tobacco cessation
  pharmacotherapies
• Discuss training opportunities for providers
  wishing to learn more about tobacco cessation.

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Bottom Line- Up Front

• The medication must fit the patients needs
• The patient must fit the medication
• Cessation must fit the patients desires and
  address ad lib use of NRT and habit substitution
• The patients medical history must be taken into
  account when choosing meds

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New Navy Guidance SECNAVINST 5100.13E

• Military Personnel shall not use tobacco products
  and walk from point to point while in uniform
• All tobacco use areas shall prominently display
  tobacco use warnings and availability of tobacco
  cessation programs.
• Tobacco cessation is not the cessation of a
  habit, but rather the treatment of an addiction.
• Access to tobacco treatment should be as easy as
  purchasing tobacco products.

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SECNAVINST 5100.13E (contd)

• Break periods for tobacco users will be the same
  as for non-users.
• Smokeless tobacco is not a safe alternative to
  smoking. Smokeless tobacco use is only permitted
  in designated tobacco use areas and its residue
  shall be disposed of in a sanitary manner which
  prevents public exposure.
• Commanders need to encourage a tobacco-free
  lifestyle provide leadership by personal
  example creating a tobacco-free command
  climate.

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DoD/VA TUC CPG Guiding Principles

• We have to make cessation support as accessible
  as buying cigarettes for those patients who want
  to quit.
• Recent surveys showed 62 of tobacco users want
  to quit in the next 6 months
• Cessation support must have a range of intensity
• One size of tobacco cessation will not cover
  all patients who wish to quit

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TUC Background
Tobacco-Free Continuum
Classroom Program
Clinical Treatment Intervention
Clinical Brief Advice/ Self-resourced
Minimal Intervention Advice only, Literature,
Phone contact, Internet, Quit Line
Increasing Intensity Brief AdviceMeds,
MedsClinical Counseling MedsClinical Follow-up
Intense Intervention Classroom, Behavior
modification, Mental Health screening

• Tobacco Cessation must be a continuum
• One size or method of cessation does not fit
  all those wishing to become tobacco free

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Tobacco Products Know the Facts

• General tobacco facts
• Cigarettes
• Smokeless
• Cigars
• Health Concerns
• Gender differences
• Weight gain concern
• Depression
• Withdrawal symptoms

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1 Tobacco Fact

• Here is a really significant issue for our young
  people
• Based on national average of tobacco costs,
• a one pack/can per day habit is equal to ONE
  months minimum-wage pay for a year
• Tobacco has a major impact on the quality of life
  for our young people and their families
• They are the ones who can least afford it!

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Tobacco damages every single mouth that it
touches. How do you want your teeth to look?
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Health Concerns

• New Less Harmful Tobacco Products
• There are NO SAFE(R) FORMS OF TOBACCO!
• No proven health benefit!- must be prepared to
  defend this statement as there are no evidenced
  based studies that show this
• No medicolegal ground to support switching to a
  less harmful form of tobacco

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Health Concerns

• 4 million children are sick each year due to
  second hand smoke
• 307,000 cases of asthma
• 354,000 cases of middle ear infections
• Greater risk of tooth decay
• Even limited exposure to second-hand smoke (SHS)
  can lead to significant disease

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Military-specific Tobacco-related Health Issues

• Smoking and Military Readiness Top 5 List
• Smoking is one of the best predictors of military
  training failure.
• Smoking among young troops is associated with
  significant increased hospitalization and lost
  workdays. Sick and hospitalized troops are not
  ready for duty.
• Smokers are more likely to perform poorly on
  military fitness evaluations. Smokers are more
  likely to sustain injuries, particularly
  musculoskeletal injuries.
• Smoking is a strong marker for other causes of
  low readiness, such as alcohol abuse, low
  physical activity, and illicit drug use.
• Note A much larger literature exists on smoking
  health readiness-related factors in civilian
  populations (e.g., physical activity, physical
  fitness, lost work time, etc).

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Nicotine and PTSD

• Researchers found that those with a pre-existing
  nicotine dependence who were then exposed to
  trauma had twice the risk of developing PTSD,
  compared to non-smokers who experienced trauma.
• Nicotine stimulates some of the same
  neurobiological pathways the dopaminergic
  pathway associated with reward and fear
  implicated in stress and addiction. Smoking may
  sensitize these pathways, so a
  subsequent severe stressor is more likely to give
  someone PTSD.
• Archives of General Psychiatry (vol 62, p
  1258) November, 2005

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Impairs Patient Recovery

• Recovery room stays are 20 longer for smokers
  than non-smokers. (Handlin DS, Baker T. Woolrich
  J Effect of smoking on duration in recovery
  room. Anesthesiology 1990)
• Patients who smoked regularly before surgery had
  twice the risk of wound infections as
  non-smokers. (Jones, RM Smoking before surgery
  The case for stopping. BR Med J 1985)
• Smoking will retard wound healing, whether the
  wound is surgical or the result of trauma or
  burns. (Smoking and wound healing. Am J Med. 1992
  Jul 15/93(1A)22S-24A. Review. PMID 1323208
  PubMed-indexed for MEDLINE

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Injury Recovery

• Cigarette smoke delays the formation of healing
  tissue and sets the stage for increased scarring
  at the edges of a wound
• Nothing messes up the timing (of the healing
  process) like cigarette smoke. Clinical studies
  have consistently shown that individuals exposed
  to cigarette smoke whether first- or
  second-hand heal poorly and are more likely to
  develop scarring and associated diseases.

Cigarette Smoke A Culprit in Poor Healing and
Increased Scarring UC Riverside Research Showing
How Smoke Complicates Healing Process (December
3, 2004)
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Weight Gain

• Smoking depresses body weight
• Nicotine acts as an appetite suppressant
• Many women fear quitting because of weight gain
• Teens start smoking to avoid weight gain
• Use of patch, gum, and bupropion limit weight gain

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Pregnancy

• Smoking during pregnancy is the most preventable
  cause of poor pregnancy outcomes
• Maternal smoking is linked to a greater risk of
  pre- and peri-natal mortality
• Current studies underway to look at NRT use
  during pregancy

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Co-factors

• Depression, anxiety, and binge-eating disorder
  are major co-factors
• Tobacco users with co-factors often use nicotine
  to control behavioral disorders
• Studies indicate 1/3rd of tobacco users have
  undiagnosed major depressive disorder
• May be necessary to treat (by referral) the
  cofactor as well as the addiction to nicotine
• Enhanced vigilance with varenicline (Chantix)

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TUC Pharmacotherapy

• Brief Medication review
• Indications and Limitations
• Lessons learned

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TUC Pharmacotherapy

• Three first-line types of pharmacotherapy (FDA
  approved) are nicotine replacement therapy,
  bupropion and varenicline
• Whether medications are prescribed via formal TUC
  programs or via clinical care visits, providers
  should be aware of the medications and the need
  to follow those patients who are using the
  medications.
• Patients receiving TUC medications along with
  behavioral support have the best chance of
  quitting.
• Natural/herbal/hypnosis/acupuncture/laser not
  proven in evidenced-based studies
• Be aware of Atropine clinics

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Provider Staff Training

• MedScape- Clinical Providers
• Treating Tobacco Use and Dependence
• http//cme.medscape.com/viewprogram/17710
• Management of High-Risk Tobacco Users Where
  Practice Guidelines and Clinical Judgment Meet
• http//cme.medscape.com/viewprogram/8486
• Smoking Cessation Approaches for Primary Care
• http//www.medscape.com/viewprogram/3468?srcsearc
  h
• American Society of Health-System Pharmacists
• http//media.ashp.org/tobacco/
• Health Care Education Training, Inc.- Nursing
• http//www.hcet.org/training/psc.html
• Nurse Practitioner
• http//www.nphealthcarefoundation.org/ce/smoking

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Team up

• Pharmacy
• http//www.ashp.org/s_ashp/cat1c.asp?CID504DID5
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• http//media.ashp.org/tobacco/
• Nursing services
• http//www.tobaccofreenurses.org/resources/
• Health promoters
• CHPPM
• http//chppm-www.apgea.army.mil/dhpw/Population/To
  baccoCessation.aspx
• NMCPHC (NEHC)
• http//www-nmcphc.med.navy.mil/hp/tobacco/index.ht
  m
• States (example)
• New York
• http//www.nysmokefree.com/newweb/CME1View.aspx?p
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• California
• http//www.projectuniform.org/

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New DoD and NCI Anti Marketing Tools

• DoD Make Everyone Proud
• NCI 1-800-Quit-Now
• ACS and ALA both active with cessation support
• Many civilian insurance programs offer cessation
  coverage
• Proprietary support also available

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DoD Marketing Quit Tobacco ? Make Everyone
Proud

• TMA/DoD sponsored www.ucanquit2.org
• Can order materials
• Free online support

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New NIH/NCI Patient Provider Resources

• WWW.Smokefree.gov
• 1-800-QUITNOW (1-800-784-8669)
• Patient education portal

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New initiative www.1800quitnow.org/

• New NCI effort to get 18-24 year olds involved
• Web portal available
• Provider materials will be available for patient
  support and education

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www.1800quitnow.org/ Or 1-800-QUITNOW (784-8669)
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Navy and Marine Corps Resources

• Navy and Marine Corps Public Health Center
• Tobacco Cessation website and toolkit
• Access to Tobacco Cessation Action Team (TCAT)
  materials, policy statements, and guidance
• http//www-nmcphc.med.navy.mil/hp/tobacco/index.ht
  m

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TRICARE Benefit

• Passed in 2009 NDAA
• Now being developed
• Meds and care are now a covered benefit

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Questions ????
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Contact Information

• Captain Larry Williams
• E-mail (W) Larry.Williams_at_MED.Navy.MiL
• (H) LW704_at_Comcast.Net
• (Work) 847-688-3331
• (Cell) 847-975-3767
• Please feel free to contact me if you have any
  questions or future needs.