# Presentation: 098715

## Tobacco Use Prevention and Cessation

**Teresa Lowery, MD, Regional Medical Consultant**
**Karen Yazzie-Meyer, CATC, TEAP Specialist, San Diego JCC**
**Monika Spinks, RN, Health and Wellness Manager, San Diego JCC**
**Rowan Torrey, Center Director, Mississippi JCC**
- Job Corps National Health and Wellness Conference
- April 27, 2007
- Denver, Colorado

## Overview

- Tobacco Use Prevention and Education: How to Strengthen Your Center’s Tobacco Use Prevention Program (TUPP)
- TUPP at San Diego JCC
- TUPAC

## Tobacco Use Prevention and Education: How to Strengthen Your Center’s Tobacco Use Prevention Program (TUPP)

- Teresa Lowery, MD, MPH
- Regional Medical Consultant

- 3

## TUPP PRH Requirements

- Implement a program to prevent the onset of tobacco use and to promote tobacco free environments and individuals. To support this program, a TUPP coordinator shall be appointed (he or she need not be a health service staff member). At minimum, this program shall include:
- Educational materials and activities that support delay and/or cessation of tobacco use
- A smoke free tobacco free environment that prohibits the use of all tobacco products in center buildings and center operated vehicles
- Designated outdoor smoking areas located away from the building entrance
- Prohibition of the sale of tobacco on center
- Adherence to federal and state laws regarding the use of tobacco products by minors

## The Importance of TUPP

- Cigarette smoking is the greatest cause of preventable death and disability in the US
- Tobacco use kills more Americans each year than alcohol, illicit drugs, suicide, AIDS, and accidents combined
- More than 3,000 children in the US begin smoking each day
- 90% of adult smokers initiated smoking before the age of 18 and 70% were daily smokers before this age

## The Importance of TUPP

- Evidence indicates the period of nicotine addiction is greater during adolescence
- Cigarette smoking during adolescence reduces the rate of lung growth, decreases maximum lung function, increases the risk of respiratory problems and reduces overall fitness levels
- Cotinine, a by-product of nicotine, has been found at harmful levels in infants and children who live with smokers

## What We’re Up Against: Adolescent Attitudes and Behaviors

- 85% of adolescents who smoke think about quitting and 80% of current smokers made a quit attempt during the past year
- Youth may not grasp the long-term consequences of cigarette use, focus may have to include and emphasize the short-term rewards of cessation
- A series of focus groups with high school students found the motivation to quit stemmed from disliking the smell of cigarettes, cost, and a decline in artistic/athletic performance

## What We’re Up Against: Adolescent Attitudes and Behaviors

- Risk Factors for Adolescent Smokers
- Low educational aspirations
- Poor or uneducated families
- Friends and/or Family members who smoke
- Other health-risk behaviors
- Low self esteem or poor self image
- Low perception of self-efficacy
- Depression
- Acceptance by peers
- Desire to seem more adult or mature

## Why Try??

- Cigarette use and its consequences impacts employability
- The most common form of drug addiction is nicotine dependency, which causes more death and disease than all other addictions combined
- Many adolescents lack the skills and  knowledge to quit on their own
- Because the PRH says so !

## What Can We Do??

- Once adolescents are motivated to stop smoking, we need to have developmentally appropriate interventions available and accessible to them
- Various programs and interventional models have been studied
- Most have low rates of success, anticipate several attempts at quitting
- Relapse must be addressed
- Nicotine withdrawal symptoms should be anticipated and addressed in daily users

## Basic Elements of aCognitive-Behavioral Intervention

- Establish Self-Awareness of Tobacco Use
- Record tobacco use behaviors
- Discuss thoughts, beliefs, and reasons for using and not using tobacco
- Learn about the physical and psychological effects of tobacco use

## Basic Elements of aCognitive-Behavioral Intervention

- Prepare to Quit
- Set a specific and reasonable quit date
- Choose a quit method (e.g., cold turkey, gradual reduction), and set short- and long-term goals appropriate to quit method
- Learn about the physical and psychological symptoms of withdrawal

## Basic Elements of aCognitive-Behavioral Intervention

- Provide Strategies to Maintain Abstinence
- Use problem-solving techniques to minimize effects of situational triggers
- Develop coping skills (thoughts and actions)
- Seek social support from family and peers
- Develop strategies to monitor and reinforce progress

## Pharmacological Interventions: Considerations

- The following are important considerations regarding the use of medications with youths:
- No over-the-counter or prescription products have been approved by the FDA for use by individuals under the age of 18
- None of the youth clinical trials that used pharmacotherapy for cessation have shown effectiveness (not true for adults)
- Risks associated with the use of medications should outweigh the determined risks of continuing use of the tobacco product

## Pharmacological Interventions:Considerations

- The average cigarette contains approximately 9 mg of nicotine
- Smoking one pack per day yields about 180 mg of nicotine accompanied by 4,000 compounds with 43 known carcinogens
- Nicotine is the addictive component in cigarettes, and smokers experience cravings similar to those experienced by heroin and cocaine addicts
- The primary pharmacological efforts involve either replacing nicotine or reducing the craving for nicotine through receptor site interactions

## Pharmacological Interventions:Considerations

- Remember to educate students on what to expect:
- Quitting is difficult since the nicotine addict will experience withdrawal symptoms
- These symptoms peak by day 3 and gradually diminish thereafter
- Symptoms include: increase cravings, hunger, irritability, restlessness, difficulty concentrating, mood disturbance and urge to smoke

## Pharmacological Interventions

- Bupropion (Wellbutrin, Zyban) by prescription only
- MOA: still unknown, but postulated to  reduce craving for nicotine and may be combined with replacement products
- Dosage: (immediate release) 150mg Qam for 3 days, then 150 mg bid (begin treatment 1-2 weeks prequit)
- Duration: 12 weeks, may be extended
- Cost: 150 mg, 60 each, $97.00
- Side effects: nausea, seizures, tremors, agitation, dry mouth, and insomnia
- Caution: drug interactions have been reported with other antidepressants and psychotropic compounds

## Pharmacological Interventions

- Nicotine Gum (Nicorette) available over the counter
- MOA: releases nicotine buccally, (not to be chewed like a gum)
- Each piece of gum last between 20-30 minutes
- Dosage: one to two pieces per hour, with the 2mg dose used for those who smoke less than one pack per day; 4mg dose for those who smoke more than one pack per day
- Cost: 2mg, 48 each, $29; 4mg, 48 each, $33
- Side Effects: headache, indigestion, mouth irritation or sores, and nausea
- Initially use one piece of gum q1-2 hrs, rather than treating emergent cravings

## Pharmacological Interventions

- Nicotine Inhaler (Nicotrol) by prescription only
- MOA: a 10 mg cartridge delivers 4mg of vaporized nicotine to the oral mucosa
- Dosage: Each smoker should individualize the dose to between 6 and 16 cartridges daily to minimize withdrawal symptoms
- Cost: 10mg cartridge, 42 each, $41
- Side effects: local irritation, coughing, rhinitis, dyspepsia and headache
- An advantage to the inhaler is that it substitutes some of the behavior effects of smoking by the administration of puffing

## Pharmacological Interventions

- Nicotine Nasal Spray (Nicotrol NS) by prescription
- MOA: delivers 0.5mg of nicotine per dose to the nasal mucosa via an aqueous solution
- Dosage: one to two doses intranasally per hour for a total of 8-40 inhalations per day
- Cost: 10ml, $41
- Side Effects: nasal and throat irritation, sneezing, runny nose, and watery eyes
- An advantage of this system is that it delivers nicotine more rapidly to the systemic circulation than other nicotine replacement products

## Pharmacological Interventions

- Nicotine Patch (Habritrol, Nicoderm, and Nicotrol) by prescription
- MOA: useful in reducing nicotine withdrawal symptoms and are intended as a temporary aid in the early stages of smoking cessation
- Provides nicotine through the skin and require 1-2 hours from the time of administration to reach peak levels in the bloodstream
- Dosages: 21mg, 14mg, 7mg (all per 24 hrs)
- The recommended starting dose is 21 mg patch applied QD for 4-8wks; followed by a 14mg patch QD for 2-4wks, and a 7mg patch QD for 2-4wks

## Pharmacological Interventions

- Nicotine Patch (cont’d)
- Students who smoke less than 1 ppd (packs per day) may receive a patch delivering between 15-22mg of nicotine replacement daily
- Those smoking between 1-2 ppd may start with  21-35mg patches
- Those smoking more than 2 ppd should receive a patch or patches delivering between 42-44mg daily
- The student should commit to stop smoking on initiation of therapy; however, relapses do not warrant discontinuation of the patch
- Cost: 30 each, range between $112-125 depending on  dosage

## Pharmacological Interventions

- Nicotine Patch (cont’d)
- Side effects: erythematic, pruritis, local irritation, diarrhea, dyspepsia, arthralgias, myalgias, sweating, somnolence, and abnormal dreams
- Sleep disturbances can be minimized by using a16-hour patch or by removing the patch before bedtime
- There is an OTC Nicotine patch; 15mg dosage/ 24 hour
- Cutaneous reactions can be minimized by rotating application sites and using a specific site no more than once a week
- Local reactions may be caused by the adhesive in the patch rather than the nicotine, and can be symptomatically treated with hydrocortisone cream

## Teen Smoking Cessation Studies:What’s Worked? What Hasn’t?

- Nicotine replacement therapy (NRT)
-  Success rates overall low
- Long term cessation rates around 5-10%
- Overall found to be safe and well tolerated
- Usually high relapse rate
- **Many  adolescents continued to smoke while on the patch!!
- Of note, some non-smokers or “light” smokers (less than one cigarette per week) also use the patch (usually bought over the counter)

## Teen Smoking Cessation Studies:What’s Worked? What Hasn’t?

- School-Based Health Programs
- Generally ineffective for long term in terms of prevention (when used alone), but are more effective when combined with other approaches such as media and smoke-free policies
- For cessation: may be very helpful for support if includes cognitive-behavioral approaches, with emphasis on coping skills training, and alternative ways of handing situations or negative moods without smoking (programs should be fun and enjoyable)
- More effective for volunteer students, but not  for those for whom  program is mandated (i.e., in lieu of school suspension)

## Teen Smoking Cessation Studies:What’s Worked? What Hasn’t?

- Peer leadership
- Peer led group vs. adult-led group
- Both were equally effective when compared with control group with 18.1% quit rate at one month reported by participants
- Focused on immediate consequences of smoking
- Bad smelling breath and hands, stained fingernails, shortness of breath in sports and recreation, and cost
- What students found most helpful
- Learning the negative consequences of smoking, tips for quitting, learning coping behaviors, encouragement from leaders to quit, spending more time with nonsmoking friends, and learning the reasons for smoking

## Teen Smoking Cessation Studies:What’s Worked? What Hasn’t?

- Peer Support Programs
- “Buddy System” for pregnant adolescents
- Buddy had to be a nonsmoking female friend in the same age range
- Buddy to provide encouragement and support, as well attend all sessions
- Used materials from the Teen Fresh Start Program  developed by the American Cancer Society
- 30% reported quitting smoking completely

## Teen Smoking Cessation Studies:What’s Worked? What Hasn’t?

- Computer Intervention Programs
- Several models exist
- i.e., Action Oriented based on a program developed by the American Lung Association
- Capitalize on student’s interest in working with computers
- Students usually respond to questions on the computer screen regarding smoking cessation and receive immediate feedback on the screen
- Students reported quit attempts after session, but long term outcome has been disappointing
- **May be better used as an adjunct to other smoking cessation programs

## Conclusion of Teen Smoking Cessation Studies

- No one program experienced great success
- May give insight into the development of future cessation programs
- Variety may be the key to success
- Using peer leaders and buddies may reduce the cost of programs while providing intensive support
- Teens with a higher level of nicotine addiction may need NRT incorporated into their program
- Incorporating computer programs may increase students’ interest and participation in programs

## Ideas From Job Corps Centers

- Incentive Programs from Oral Health and Wellness Programs
- Tooth whitening
- Oral health care product give-a-ways
- ???Other prizes???
-  Essay contests
- Frequent cleanings

## Internet Resources for TUPP

- Free tobacco cessation resources available at: _[http://www.askandact.org](http://www.askandact.org/)_
- Campaign for Tobacco-Free Kids
- Quitline Referral Cards
- Posters
- PowerPoint Presentation
- Patient Education Materials
- Lapel Pins
- Quit Smoking Prescription Pads
- CME

## Conclusion

- Strengthening your center’s TUPP is a comprehensive task that will involve health and wellness staff, oral health providers, TUPP specialists, as well as center staff. Recruitment and use of nonsmoking peers for support and leadership may also prove to be invaluable. The most effective programs offer a variety of models which grab and maintain the students’ interests.
- Whatever it takes, WE CAN DO IT!!

## TUPP at San Diego JCC

- Karen Yazzi-Meyer, CATC,
- TEAP Specialist
- Monika Spinks, RN, HWM

- 33

## TUPP Program Overview

- 8-week program, based on the “Transtheoretical Model”
- Health and Employability
- California Smoke-Free Workplace Labor Law
- Secondhand Smoke (SHS)
- Co-occurring Nicotine and Alcohol Dependence

## Smoking Cessation Program

- Educate trainees about the negative health effects of tobacco
- Education and assistance provided
- Video presentations, materials, and group discussions

## Responsibilities

- Trainees will not use tobacco in any form on this center, including smokeless tobacco
- Trainees are informed of this policy on admission
- Those trainees violating the smoke-free center policy will be held accountable

## Transtheoretical Model

- Pre-contemplation
- Contemplation
- Preparation
- Action
- Maintenance

## Annual Events

- Christmas “Holiday Parade of Lights”
- Earth Day
- Great American Smoke-Out
- Halloween Pumpkin Carving Contest
- Kick-Butts Day
- San Diego Padre games

## Outreach and Community Resources

- American Cancer Society
- American Lung Association
- BUILT
- EAPA
- Nicotine Anonymous and A.A.
- SAMHSA
- San Diego County Mental Health
- San Diego County Tobacco Coalition
- Smoke-Free California
- Tobacco Education Clearinghouse of California
- Tobacco-Free Kids

## TUPAC

## Tobacco Use Prevention and Cessation

- Rowan Torrey, Center Director
- Mississippi JCC

- 41

## Goals and Objectives

*The goal is to establish a *
***No Smoking Center***
**OBJECTIVES**
- 1.	Eliminate smoking completely on center
- 2.	Eliminate effects of second-hand smoke on 	non-smokers.
- 3.	Promote life-long health
- 4. Enhance employability of students and staff
- 5. Prepare students for the smoke-free workplace

## Today’s Situation

- Many JC enrollees enter the program with long-term addictions to nicotine
- Tobacco use adversely affects their health, finances, and employability
- Addictive tobacco use is an example of poor self-control and failure

## Available Options

**Do nothing!!**
- Advantages: No cost, no fuss, no work!
- Disadvantage: No change in health and career outlook, employability suffers

## Available Options

**Restrictive Smoking!!**
- Advantages:  Fairly easy to do, shows an attempt to effect change, no revolt of the masses, low to no costs
- Disadvantage: Not a strong enough message, will not impact addicted and motivated smokers, easy to abuse policy

## Available Options

**No smoking!!**
- Advantages:  Clear mission, clear air, initiates a new center culture, promotes health and employability, prepares students for the new workplace, reduces staff sick days*, no ifs, ands or butts
- Disadvantage: Requires perpetual education, causes negative morale among some staff and students, reduces enrollee pool, requires consistent enforcement management, will create a new contraband for students and staff

## What we did, or“How to Become a Smoke-Free Center”

- 1. Establish a time table
- One year minimum, maybe more
- Publicize, promote, push, promulgate
- 2. Announce intentions
- State why.... Health, employability, economics, applicable laws

## What we did, or“How to Become a Smoke-Free Center”

- 3. Establish “ No Smoking” committee
- Students and staff, smokers and non-smokers, professionals:
- Heart Association
- Lung Association
- American Cancer Society

## What we did, or“How to Become a Smoke-Free Center”

- 4. Restrict smoking opportunities gradually as education increases and proliferates
- Cut designated smoking areas by one-half
- Cut the half in half
- Reduce down to one area for smoking
- Limit smoking to breaks (staff/students)
- Limit smoking to after the training day
- Limit smoking  to designated times during after training day and weekends

## What we did, or“How to Become a Smoke-Free Center”

- 5. Start Education Cessation Programs before and concurrent to applying restrictions
- Staff and student focus groups
- Heart and lung classes
- Posters, flyers, bulletins
- Center wide meetings

## What we did, or“How to Become a Smoke-Free Center”

- 6. Implement Policy in Career Preparation Phase
- Identify individual challenges
- Introduce to TOBACCO USE AND PREVENTION PROGRAM---TUPP
- Career Success Standards Activities
- No Smoking Rally

## What we did, or“How to Become a Smoke-Free Center”

- 7. Celebrate “quitters”
- Center wide announcements
- Pizza parties
- T- SHIRTS
- Freedom activities
- Post on web-site

## What we did, or“How to Become a Smoke-Free Center”

- 8.Develop progressive sanctions for non-compliance
- Staff
- Warning
- Reprimands
- Suspensions
- Termination

## What we did, or“How to Become a Smoke-Free Center”

- 8. Develop progressive sanctions for
- 	 non-compliance
- Students
- Verbal Reprimand
- Written Reprimand
- Incident Report
- TUPP Program
- Suspended Pass
- Restriction
- Center Review Board

## What we did, or“How to Become a Smoke-Free Center”

- 9. Continuing Education
- Never stop teaching cessation!
- 	Advertise
- 	Reinforce in wellness area
- 	Career Success Standards