Tobacco Cessation Course

Tobacco Cessation Course


– Hi. My name is Dr. Yavar Moghimi
and I’m a psychiatrist who specializes
in the care of HIV patients.
I wanted to talk to you
today about tobacco use
in individuals with HIV.
In the US, 19% of the population
uses tobacco on a regular basis,
but that percentage is
two to three times higher
in HIV positive individuals.
While that seems like
a high rate of smoking
among HIV positive individuals,
two-thirds of those patients
express a desire to quit smoking.
Patients with HIV who
use tobacco are not only
susceptible to the
traditional risks of smoking,
which include cardiovascular
disease, stroke, and cancer,
but also to opportunistic infections.
This is because the body’s
immunological response
to antiretroviral therapy
is weakened with tobacco.
With more patients with HIV living longer,
they are more likely to be
burdened by their tobacco use
than by their HIV.
Inquiring about smoking
habits is an important part
of ensuring patients live
longer, healthier lives.
Brief interventions
less than three minutes
have been proven to be effective
to help curb tobacco use
and ensure cessation.
– I’ve been HIV positive almost 30 years.
I received it from a blood transfusion.
I had a serious operation
in the beginning of the AIDS episodes.
I got stabbed in my back.
And at that time they weren’t
testing blood in the hospital.
So we do believe that’s
where it came from.
At that particular time I assumed
that I had AIDs from my doctor because
it was beginning, he wasn’t
experience in it and everything.
And I truly didn’t really
find out the difference
until I became a patient
here with Whitman Walker.
And that’s when my doctor
here did the blood work,
and he literally said,
“You’re HIV positive, but
you’re non-detectable.”
And I’m assuming that that’s
been, like I say, 30 years,
because the average person that have AIDS
would have died before 30 years.
I was a smoker closely to 40 years
because I started smoking
at the end of high school.
That was a thing back in the ’70s.
Once you graduated and was in high school
you became an adult when
you starting smoking.
So that’s when I started smoking.
I smoked actually up until last year.
I tried several times to quit before then
but I totally quit last year.
– There are several tools for physicians
and healthcare providers to assess
whether tobacco cessation
is right for their patient.
One of these tools is the five A’s.
Ask, advise, assess, assist, and arrange.
The first step of this tool
is to ask your patient whether they smoke.
This can be done when checking
patient’s vital signs.
One quick way for
determining whether a patient
has developed an addiction to nicotine
is the Fagerstrom Test
for Nicotine Dependence.
The second step of the five
A’s tool is to advise patients
using strong, personalized,
direct messaging
that explains to them the harmful effects
of tobacco use on their body.
In particular, on opportunistic infections
in persons living with HIV.
Then assess whether the
patient is ready to quit.
If not, motivational
interviewing can be used
to spark their interest in quitting.
Then assist patients in creating a plan
for their tobacco cessation.
This plan should include
setting a quit date
within two weeks of the
initial appointment,
changing daily patterns of smoking,
and changing the environment
that encouraged smoking previously,
like getting rid of ashtrays, lighters,
and other related paraphernalia.
Finally, mental health care providers
should arrange the tobacco cessation plan.
This may include tobacco cessation groups,
meeting with a counselor,
and regularly scheduled follow-up
to monitor their progress.
– On average I smoked a
pack of cigarettes a day.
When I was out socializing
and going to a club–
And to me, alcohol had a very,
very big factor to smoking
because if you were a smoker,
you know, once you
started drinking alcohol
to some degree, you want
that cigarette also.
And that was a big thing too, yes,
going to the clubs and smoking.
And even down to the later years here,
before I quit, it was a thing of
when they made it that you
couldn’t smoke inside anywhere,
then you would go outside, but it was nice
because you really met a lot of people
and you all became more
friendly and mingled more
by standing outside
smoking compared to inside.
I really wanted to quit,
it was in my mind for,
I could almost say a year.
Because I knew, you hear
everything about the cigarettes.
Then the cost of the cigarettes, you know,
how high they’ve become.
And, you know, now you learn
that they’re not good for your body,
so I started trying to quit
over the course of the last year.
And every time I tried
I would go for a period
but then I wouldn’t succeed.
What made me successful
was when I heard about
that we had a smoking
cessation class here.
My doctor mentioned it to me because I had
mentioned it to him that I
really wanted to quit smoking,
and he’d know that I tried
several times and couldn’t do it.
So he said, “Well, why don’t you go to the
“smoking cessation class
that they have here?”
And I said, “Okay, I’ll think about it.”
And I went home and I
thought about it, and I said,
“You know what? I’m going.”
The moment I actually walked in the door
and there was other people
there that was just like me,
that really wanted to quit,
then I said to myself,
“I’m gonna beat you.”
(laughs) So that’s when I
actually started to quit,
that particular day.
– While many patients
with HIV want to quit,
they have lower rates
of success in cessation
compared to the general
population because of
the multiple barriers associated
with their HIV status.
Many patients with HIV
are linked to communities
with a high prevalence of tobacco use.
In addition, comorbidities
of mental health and
substance abuse issues are an
added barrier to cessation.
In addition, patients may go into recovery
from other drugs and alcohol,
but their tobacco use will persist.
Many patients with HIV are
also in groups or populations
that can suffer social marginalization,
stigma, and prejudice.
This can cause stress that leads to
negative health behaviors,
such as smoking.
Tobacco use is also
prevalent in communities
affected by HIV/AIDS such
as the LGBT community,
where 27% identify as smokers,
compared to 18% in the
heterosexual counterparts.
Another barrier to accessing
smoking cessation programs
is healthcare coverage.
Although the Affordable
Care Act guarantees
tobacco cessation as a part
of preventative services,
many patients still do not
receive the help that they need.
The final barrier to consider
when treating patients
with HIV for tobacco
cessation is false beliefs.
Many patients continue to
smoke because of beliefs
that the smoking is helping
with their somatic complaints
and calming their
nerves, when in actuality
they are treating their
nicotine withdrawals.
– The first thing I did was,
that particular day, was
I actually went home,
and I’d taken all of my
ashtrays out of the house.
And I said, “Now, okay, I’m
gonna actually pay attention
to how many cigarettes I’m smoking.”
I had only one ashtray outside.
And when you literally
walk from inside of a house
and you’re thinking and you’ve
gotta go all the way outside,
I don’t care what the weather or whatever,
you don’t want that cigarette as much,
or you don’t smoke as much.
So I would actually
start saying to myself,
“Okay. I can cut back this.
“I’m gonna do it little
by little this time.”
Because I’d previously
tried and it didn’t work.
So as I was trying, I
noticed, I said, “Wow,
“I’m succeeding at this.” (laughs)
You go to the meeting every week
and they ask you how
you’re doing, and I’ll say,
“I’ve gone from a pack a
week down to a half a pack.”
The other patients that’s
there, okay, they’re trying,
but honestly they didn’t do as
good at that particular time
so I said, “Oh, wow,” so
I said, “You know what?
“I’m gonna continue. I’m gonna beat them.”
So I went little by little that way
until I actually stopped, and then
I also joined a meditation class.
And that dealt with breathing a lot.
So when I actually wanted
the cigarette at times,
since I’d begin then to
slow down the smoking,
I would say, “Okay, I’m
gonna try to breathe,
“and let it go through my mind,”
and maybe in a minute or
so I will not want it.
And I started meditating
myself, just at home.
And actually that helped.
I took it step by step.
I just didn’t actually
go cold turkey or quit;
I took it step by step that time.
To me personally the reason
I say that was helpful
was because I was trying my best
to quit along with someone else,
because all the other times that I tried,
actually I went back to
smoking, I couldn’t quit.
– There are several different options
for HIV patients who want to quit smoking.
Nicotine replacement therapy
through gum, lozenges,
inhalers, spray, and patches,
can be an effective tool
for quitting smoking.
In addition, primary care
physicians or psychiatrists
can also prescribe two medications:
buproprion, or varenicline.
The combination of these medications
with nicotine replacement
therapy has been shown
to be the most effective
treatment for quitting smoking.
However, physicians should
be aware when prescribing
varenicline that in patients
with a mental illness
this medication could potentially
worsen their condition.
Cognitive behavior
therapy through individual
and group counseling has
also proven to be effective.
If patients have trouble
traveling to the clinic
or are interested in other resources,
each state has a call line, 1-800-QUITNOW,
where they can receive
additional counseling
and nicotine replacement therapy.
In addition there are
multiple phone apps available
which can assist patients
in their cessation plan.
It’s important to maintain follow-up
during the course of the treatment.
Follow-up is recommended one week after
the initial quit date,
and then a month later.
This can be done in person
or through phone calls.
Physicians should congratulate patients
if they’re successfully
able to quit smoking,
but they should also anticipate relapse.
If the patient relapsed,
the cessation strategy that
was used may not have been the right fit.
Follow-up visits should
include new strategies
for helping the patient to quit smoking.
– As I begin to do it,
I started to notice that
I could breathe better,
and I started to notice that
the taste of food was different.
And I was saying to myself, “Wow.”
I said, you know, “This is
truly, really happening,”
because you had the less
nicotine in your system.
It’s made a big difference in my life.
Seriously, I mean, I feel better.
I have more energy.
Believe it or not, something
you might never think about,
I say I feel cleaner,
because I don’t have that
smoke smell on me anymore.
I don’t have that smoke
smell in my house anymore.
But you have to be strong.
You literally have to be strong.
And I would tell anybody, you know,
don’t give up on yourself.
Because like I said with myself,
I tried three or four times previously
and I didn’t succeed at it.
But you have to keep trying.
Just like with anything in this world,
if you want it, keep trying,
and at the end you will succeed.

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