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Tuberculosis and TobaccoOverlapping Epidemics in Nunavut
ᐋᓐᓂᐊᖃᕐᓇᙱᑦᑐᓕᕆᔨᒃᑯᑦDepartment of Health
Munaqhiliqiyitkut Ministère de la Santé
Brought to you by…• Tuberculosis (TB) Program
– Educates and supports health care providers.– Promotes TB awareness in Nunavut.– Supports research for more effective TB treatments.
• Tobacco Reduction Program– Educates and supports community health and wellness workers.– Produces and distributes tobacco reduction resources.– Manages quit supports, like the QuitLine and Tobacco Has No
Place Here Facebook page.– Oversees enforcement of the Tobacco Control Act.
Presenters
Sandy Finn, RNTerritorial Tuberculosis Educator
James Smith-Sparling, RRT, CTEClinical Cessation Educator
Learning Objectives
• To understand the history of TB and tobacco use in Nunavut.
• To review TB and treatments.• To understand the importance of reducing and
quitting smoking in patients with TB.• To review the resources available to help
patients with TB to reduce or quit smoking.
Pre-European contact 1576Post-European contact
Martin Frobisher arrives
1820-1860 Whaling industry began.
Fur Tradelikely first
opportunity for exposure
to TB
Thousands of years, Inuit and their ancestors lived nomadic lives in
the Canadian Arctic
1920’sRCMP arrived in the
Arctic
1950’sForced settlement into
communities, residential schools, forced evacuation to TB
sanatoria and dog slaughter
CD Howe, Pangnirtung (July 1951)
The TB EpidemicAge Standardized rates of active TB, Nunavut and the rest of Canada
History of Tobacco In Nunavut
• Inuit have a history with tobacco that is different than that of other Indigenous people of Canada.
• Tobacco was never part of Inuit culture.
• Tobacco was first introduced by European whalers and fur traders.
• Nicotine in tobacco is very addictive and caused the widespread tobacco use we see today.
– 2016 data indicates nearly 75% of Nunavummiut aged 16 and older use tobacco.
What is Tuberculosis?• Tuberculosis (TB) is a bacterial infection caused by
Mycobacterium tuberculosis.– Most often present in the lungs, but can be extrapulmonary.
• TB is a serious condition that is highly contagious (active TB) or may be dormant and not presently contagious (latent TB).
• TB is curable with medications.
• Worldwide, 10.4 million people became ill with TB in 2015; 1.8 million died from TB.
Why is there so much TB in Nunavut?
• Social determinants of health (and TB)Examples include:– Overcrowded housing– Food insecurity– Addictions, including tobacco use
• Health System Challenges• Large pool of people with untreated Latent TB Infection (LTBI)
in Nunavut.• Population Demographics
– Over 30% of Nunavummiut are under 15.
• Fear and Stigma
Why Does Smoking Matter?• Smokers have a greater chance of
being infected and developing TB.
• Smoking increases the risk of getting TB by 2.5 times!
• Smoking increases the chance of recurrence and mortality from TB.
• Continuing to smoke while on TB treatment makes treatment less effective.
• Children exposed to second-hand smoke have greater risk of developing active TB.
Opportunity!• In Nunavut, all TB medications are administered at
Community Health Centers through local TB programs.
• All medications including ACTIVE and LATENT treatment is provided by DOT:• Directly• Observed • Therapy
• DOT is good time to support your patient to quit smoking.
Suggested Approach to Tobacco and DOT
• Rapport and relationships are integral to successful TB treatment.
• Smoking cessation can be introduced at any point during DOT, if patient is ready.
• Avoid pressure to DOT relationship by establishing low barrier approach to smoking cessation supports.
Use a Trauma Informed Approach• Trauma awareness is important.• Emphasis on safety and trustworthiness.• Opportunity for choice, collaboration and connection.• Identifying strengths and skill-building.
5As:Evidence based approach to tobacco
cessation
• ASK patient with TB about tobacco use• ADVISE them of the benefits of quitting• ASSESS their willingness to attempt a quit• ASSIST with their quit attempt• ARRANGE follow up with the patient
ASSIST with Advice• Suggest trying to quit for just one day. Then increase to two
days next time and so on.• Talk to someone close to you who has quit smoking.• Develop a quit plan:
– Set a quit day.– Tell family and friends. Ask for their support and to not use tobacco
around you.– Anticipate triggers and challenging situations.
ASSIST with Advice
• Use the 4 Ds to overcome cravings:– Drink water– Distract yourself – Do something else– Deep breathe
• Cut caffeine intake in half
ASSIST with Medications• Nicotine Replacement
Therapy (NRT)– Help lessen withdrawal
symptoms and cravings.– Combination of patch and
short acting gum/lozenge/inhaler works best.
– Taper every 2 to 3 weeks, as symptoms allow.
– Patch, gum and inhaler are Health Centre stock as per Nunavut Drug Formulary:
NRT Specifics
• Patch: – Applied every 24 hours
• Can be removed at bedtime if sleep disturbances occur (insomnia/bad dreams).
– Change application area each day to avoid skin irritation (any hairless area on torso ok).
• Inhaler:– Used as needed; 1 cartridge equivalent to 1 cigarette.– Short frequent puffs allows buccal absorption.– Throat irritation possible.
NRT Specifics
• Gum:– Comes in 2 and 4 mg strengths; mint or fruit flavour.– Used as needed or regularly (eg. every 2 hours) to
treat/prevent cravings.– BITE BITE PARK chewing method to avoid nausea.
• Lozenge:– Comes in 1 and 2 mg strengths; mint or fruit flavour.– Used as needed or regularly (eg. Every 2 hours) to
prevent/treat cravings.– Good option for patients with poor oral health.
Documentation for Chart
• Paper based order set
• Meditech version
TB Medications and Cessation Medications
• Can be safely combined.• Try NRT first.• Other options:
– Zyban™ (Bupropion SR): Metabolized by liver.
– Champix™ (Varenicline): Renally eliminated.
TB Medications (first line)
• CAUTION: All have hepatotoxic potential.– Monitor for nausea/vomiting, abdominal pain, loss of appetite, jaundice.
• Additional monitoring: monthly weight, TB symptom resolution, rash.• Do not combine with Acetaminophen; use Ibuprofen instead.• Give with a small meal if stomach upset occurs.• Rifampin causes majority of drug interactions:
– Before giving any new drug, check with the TB physician or pharmacist.
Drug Name Common Adverse Effects
Isoniazid Peripheral neuropathy; pyridoxine given as preventative
Rifampin Orange/red urine
Ethambutol Visual impairment
Pyrazinamide Joint pain
Cessation Resources for Patients• NRT Guide
– Reviews nicotine gum, lozenge, inhaler and patch and how to use them.
• Tobacco Quit Guide – The Quit Guide provides
helpful tips and ideas on how to quit for life.
Cessation Resources for Patients• Tobacco Has No Place Here Facebook page
– Get answers to your questions on quitting tobacco from trained counsellors.
Cessation Resources for Health Care Providers
• Intermediate Tobacco Cessation Module for Health Care Providers in Nunavut– Visit http://www.nuquits.gov.nu.ca/resources/healthcare-
providers– Also on USB sticks sent to each Health Centre labelled
TOBACCO CESSATION
Cessation Resources for Health Care Providers
• NRT Fact Sheet • 5As / Stages of Change Guide
• Laminated and on metal ring in all Health Centres.• Available for download on nuquits.ca.
Sources
• Oakes, Dana. “Oakes’ Respiratory Home Care: An On-Site Reference Guide”. Health Educator Publishing, Inc. 2006. Orono, Maine, USA.
• Centers for Disease Control and Prevention. “Tuberculosis: Data and Statistics”. https://www.cdc.gov/tb/statistics/default.htm
• World Health Organization. 2009. “Tuberculosis and Tobacco”. • Centre for Addictions and Mental Health. “Tuberculosis and Smoking: Key messages for
health care providers and policy makers”.• World Health Organization. 2014. “A guide for tuberculosis patients to quit smoking”.
Questions?
Thank You!!