Tobacco Cessation:

Essential Steps for Success

Dr. Janie Heath, Georgetown University

Dr. Jeannette Andrews, Medical College of Georgia Dr. Claudia Barone, University of Arkansas Medical Sciences

Objectives

Identify the importance of integrating tobacco cessation in DAILY practice Identify key strategies / approaches for integrating tobacco cessation in DAILY practice Identify essential resources for integrating tobacco cessation in DAILY practice

Why Make Tobacco Cessation a Standard for Practice?

QUALITY OUTCOMES = PAYMENT and HEALTH HEIDIS says to do it!

JCAHO says to do it!

The Surgeon General says to do it! The wife says to do it! http://www.surgeongeneral.gov/tobacco/

TRENDS in ADULT SMOKING, by SEXU.S., 19552004

Trends in cigarette current smoking among persons aged 18 or older
60 50 40

Male

20.9% of adults are current smokers

23.4% 18.5%

Percent

30 20 10 0
1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999 2003

Female

44.5 Million Adults are Addicted to Cigarettes

Year

The BAD News: < 36% News: Receive70% Information The GOOD want on to HOW quit to quit
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 19652001 NHIS. Estimates since 1992 include some-day smoking.

STATE-SPECIFIC PREVALENCE of SMOKING among ADULTS, 2004

California 14.8% Kentucky 27.6%

Nevada 23.2% Utah 10.5% Ark 25.7% VA 20.9% GA 20.1%

Centers for Disease Control and Prevention. (2005). MMWR 54:11241127.

PREVALENCE of ADULT SMOKING, by RACE/ETHNICITYU.S., 2004

33.4% American Indian/Alaska Native 22.2% White, non-Hispanic 20.2% Black, non-Hispanic 15.0% Hispanic

11.3% Asian
0% 10% 20% 30% 40% 50%

Centers for Disease Control and Prevention. (2005). MMWR 54:11211124.

Prevalence and Harm of SMOKING during PREGNANCY

Miscarriage Stillbirth

Preterm delivery
Low birth weight

BABY ALERT: 27% OF Tobacco Dependent WOMEN Continue to SMOKE THROUGHOUT PREGNANCY

PREVALENCE of ADULT SMOKING, by EDUCATIONU.S., 2004

26.2% No high school diploma 39.6% GED diploma 24.0% High school graduate 22.2% Some college 11.7% Undergraduate degree 8.0% Graduate degree
0% 10% 20% 30% 40% 50%

Centers for Disease Control and Prevention. (2005). MMWR 54:11211124.

Annual Causes of Death from Smoking Compared to Other PREVENTABLE Causes

440 400 360 320 280 240 200 160 120 80 40 0
Number of Deaths (thousands)

430

81 17
A ID S oh ol

41

19
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14
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30

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ic id

ic id

eh

In du

A lc

Sources: (AIDS) HIV/AIDS Surveillance Report, 1998; (Alcohol) McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States.JAMA 1993;270:2207-12; (Motor vehicle) National Highway Transportation Safety Administration, 1998; (Homicide, Suicide) NCHS, vital statistics, 1997; (Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995

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Su

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D ru g

Sm

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ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, 19972001

Percentage of all smokingattributable deaths*

Cardiovascular diseases Lung cancer Respiratory diseases Second-hand smoke Cancers other than lung Other

137,979 123,836 101,454 38,112 34,693 1,828

32% 28% 23% 9% 8% <1%

TOTAL: 437,902 deaths annually

Centers for Disease Control and Prevention. (2005). MMWR 54:625628.

FINANCIAL IMPACT of SMOKING

Buying cigarettes every day for 50 years @ $4.12 per pack Money banked monthly, earning 1.5% interest

$331,467

$220,978
Packs per day

$110,489
0 100 200 300 400

Hundreds of thousands of dollars lost

COMPOUNDS in TOBACCO SMOKE

An estimated 4,800 compounds in tobacco smoke
Gases (~500 isolated)

Particles (~3,500 isolated)

Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde

Nicotine Nitrosamines Lead Cadmium Polonium-210

Marketing Strategy: Light and Ultra-Light Cigarettes

The difference between Marlboro and Marlboro Lights

15mg tar, 1.1 mg nicotine

10mg tar, 0.8 mg nicotine

an extra row of ventilation holes

Image courtesy of Mayo Clinic Nicotine Dependence Center - Research Program / Dr. Richard D. Hurt
The Marlboro and Marlboro Lights logos are registered trademarks of Philip Morris USA.

The Safer Cigarette NOT!

Unveiling the SMOKING gun about Safe Cigarettes!

Other Tobacco Products

Chewing tobacco

Looseleaf Plug Twist

Snuff

Moist Dry

The Copenhagen and Skoal logos are registered trademarks of U.S. Smokeless Tobacco Company, and Red Man is a registered trademark of Swedish Match.

BENEFICIAL EFFECTS of QUITTING: PULMONARY EFFECTS

AT ANY AGE, there are benefits of quitting.
FEV1 (% of value at age 25)
100

Heres how to do it!

Breaking the NICOTINE DEPENDENCE Cycle
Smoked regularly and susceptible to effects of smoke Disability

Never smoked or not susceptible to smoke

75 A COMPREHENSIVE APPROACH = A Successful Framework for Quitting Stopped smoking at 45 (mild COPD)

50

25

The BEHAVIOR

The EMOTIONAL

The PHYSICAL
Stopped smoking at 65 (severe COPD)

Death 0 25
Automatic learned behavior with cigarettes

50
Role of cigarettes in life pleasure, stress, social

75

Age (years)

Physical addiction of cravings & withdrawals

Adapted from Legacys GSD&M Presentation 12/5/03 COPD = chronic obstructive pulmonary disease

Reprinted with permission. Fletcher & Peto. (1977). BMJ 1(6077):16451648.

Breaking the NICOTINE DEPENDENCE Cycle

A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

The BEHAVIOR

The EMOTIONAL

The PHYSICAL

Automatic learned behavior with cigarettes

Role of cigarettes in life pleasure, stress, social

Physical addiction of cravings & withdrawals

Adapted from Legacys GSD&M Presentation 12/5/03

DOPAMINE REWARD PATHWAY

Prefrontal cortex

Dopamine release

Nucleus accumbens Ventral tegmental area

Stimulation of nicotine receptors Nicotine enters brain

NICOTINE BEHAVIORAL EFFECTS: Do the Math!

An individual smokes 1 pack per day x 20 yrs 20 cigarettes / pack 10 puffs / cigarette = ?? puffs / day
200 HITS of THATs ____ NICOTINE per DAY

Now Multiply that # by days / year 73,000 THEN multiply that number by years smoking! 1.4 million

YIKES! No wonder it is SO difficult to QUIT

NEUROCHEMICAL and RELATED EFFECTS of NICOTINE

N Dopamine I
Pleasure, reward Arousal, appetite suppression Arousal, cognitive enhancement Learning, memory enhancement Mood modulation, appetite suppression Reduction of anxiety and tension Reduction of anxiety and tension

Norepinephrine
Acetylcholine Glutamate Serotonin

C
O T I E

N -Endorphin
GABA

Benowitz. (1999). Nicotine Tob Res 1(Suppl):S159S163.

NICOTINE PHARMACODYNAMICS: WITHDRAWAL EFFECTS

Depression Insomnia Irritability/frustration/anger Anxiety Difficulty concentrating Restlessness Increased appetite/weight gain Decreased heart rate Cravings*
American Psychiatric Association. (1994). DSM-IV. Hughes et al. (1991). Arch Gen Psychiatry 48:5259. Hughes & Hatsukami. (1998). Tob Control 7:9293.

Most symptoms peak 2448 hr after quitting and subside within 24 weeks.

* Not considered a withdrawal symptom by DSM-IV criteria.

ASSESSING NICOTINE DEPENDENCE

How soon after you wake up do you smoke your first cigarette

Do you find it difficult to refrain from smoking in restricted areas Which cigarette do you hate to give up most How many cigarettes do you smoke per day Do you smoke more frequently during the first hours after waking Do you smoke if you are so ill that you are in bed most of the day

Fagerstrm Test for Nicotine Dependence (FTND)

Scores range from 0 to 10; a score of greater than 5 indicates substantial dependence

The 5 As
ASK
ADVISE ASSESS ASSIST ARRANGE
HANDOUT

Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

If LIMITED Time Provide BRIEF COUNSELING: ASK, ADVISE, ASSESS, REFER

Brief interventions have been shown to be effective In the absence of time or expertise:

Ask, advise, assess, and refer to other resources, such as local programs or the toll-free quitline 1-800-QUIT-NOW
This brief intervention can be achieved in 30 seconds.

FIVE STAGES THAT DESCRIBE a PERSONS READINESS to CHANGE

STAGE 1: Precontemplation = No way STAGE 2: Contemplation = Possibly ready STAGE 3: Preparation = Definitely ready STAGE 4: Action = Doing it now STAGE 5: Maintenance = Changed already

METHODS for INCREASING MOTIVATIONFIVE Rs

FOR INDIVIDUALS NOT READY TO QUIT YET: Tailor messages

with Motivational Interviewing Techniques

RELEVANCE RISKS REWARDS

ROADBLOCKS
REPETITION

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, 2000.

STRATEGIES for Successful Tobacco Cessation

PRAISE the individuals readiness Facilitate the quitting process ESTABLISH THE PLAN

Set a quit date!

Help Build Tools for a QUIT Kit to Success

Emotional - Cognitive Tools Behavioral - Tools Physical - Biological Tools

Cognitive STRATEGIES
#1 Individualize the plan #2 Assess MOTIVATION to quit (0-10) #3 Assess CONFIDENCE to quit (0-10) #4 Assess triggers for tobacco use Routines/situations associated with tobacco use Tobacco Log

#5 Assess social support

#6 Advise a daily affirmation slay the dragon /

nicotine demon- I can do this

Behavioral STRATEGIES
#7 Discuss how the to change routine Breaking QUITTING isNICOTINE hard to do. Non-food / healthy items instead of cigarettes DEPENDENCE Cycle Tea instead of coffee / Exercise instead of smoking ALL cycles must be addressed for SUCCESS! A COMPREHENSIVE APPROACH = A Successful Framework for Quitting #8 Discuss coping skills for situational and/or emotional triggers
The The The Withdrawal concerns the 4 Ds PHYSICAL BEHAVIORThe EMOTIONAL The The

Weight gain concerns

Relapse concernsEMOTIONAL BEHAVIOR

PHYSICAL

#9 Discuss how to prepare for QUIT day

Home Car - Office Automatic learned Role of cigarettes in life Treats for SELF behavior with cigarettes pleasure, stress, social
Physical addiction of cravings & withdrawals

#10 Discuss pharmacotherapy options

Adapted from Legacys GSD&M Presentation 12/5/03

Breaking the NICOTINE DEPENDENCE Cycle

A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

The BEHAVIOR

The EMOTIONAL

The PHYSICAL

Automatic learned behavior with cigarettes

Role of cigarettes in life pleasure, stress, social

Physical addiction of cravings & withdrawals

Adapted from Legacys GSD&M Presentation 12/5/03

Nicotine Replacement Therapy (NRT): RATIONALE for USE

Reduces physical withdrawal from nicotine Allows patient to focus on behavioral and psychological aspects of tobacco cessation It is NOT substituting ONE negative health behavior for another IMPROVES SUCCESS RATES!

LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS

30 25

Active drug Placebo

19.5 16.4

23.9 20.0 17.1

Percent quit

20 15

14.6 11.5 11.8 8.6 8.8 9.1 10.2

10 5 0 Nicotine gum

Nicotine patch

Nicotine lozenge

Nicotine nasal spray

Nicotine inhaler

Bupropion

Data adapted from Silagy et al. (2004). Cochrane Database Syst Rev and Hughes et al., (2004). Cochrane Database Syst Rev.

FDA APPROVALS: SMOKING CESSATION

Rx transdermal nicotine patch

2002 1997 1996

OTC nicotine lozenge

Rx nicotine gum

1991

Rx nicotine inhaler; Rx bupropion SR

OTC nicotine gum & patch; Rx nicotine nasal spray

1984

NICOTINE ABSORPTION
Absorption is pH dependent

In acidic media

Ionized poorly absorbed across membranes Nonionized well absorbed across membranes

In alkaline media

At physiologic pH (7.37.5), nicotine is readily absorbed.

PLASMA NICOTINE CONCENTRATIONS for NICOTINECONTAINING PRODUCTS

25

Cigarette

Cigarette
20

Moist snuff

Plasma nicotine (mcg/l)

Moist snuff
Nasal spray
15

Inhaler
10

Lozenge (2mg)

Gum (2mg)
5

Patch
0 1/0/1900 0 1/10/1900 10 1/20/1900 20 1/30/1900 30 2/9/1900 40 2/19/1900 50 2/29/1900 60

Time (minutes)

NICOTINE GUM: Nicorette;

generic

(GlaxoSmithKline; Watson Labs)

Dose = 1 every 1-2 hrs;

No food/beverage 15 min
Max = 24 / day

prior - during or 15 min post

Available: 2 mg, 4 mg; regular, mint, orange NOT recommended if use dentures

NICOTINE GUM: CHEWING TECHNIQUE SUMMARY

Chew slowly Chew again when the taste or tingle fades
Stop chewing at first sign of peppery, minty, or citrus taste or tingle

Park

TRANSDERMAL NICOTINE PATCH

Dose = 1 patch every day (16 hrs or 24 hrs) Best if ROTATE patch different areas Preferred sites above the waist Avoid if acute / chronic skin condition If problems sticking apply TEGADERM dressing over patch May bathe/swim with patch Do NOT cut patch

NICOTINE LOZENGE Commit (GlaxoSmithKline)

Dose = 1every 1-2 hrs No food/beverage 15 min prior - during or 15 min post MAX = 20 per day Delivers ~25% more nicotine than equivalent gum dose Available: 2 mg, 4 mg Let dissolve 20-30 minutes; NO chewing/biting of product

NICOTINE NASAL SPRAY

Nicotrol NS (Pharmacia)

Dose = 1 dose (2 sprays per nostril) every hr MAX = 5 doses/hr OR 40 doses /day Each dose delivers -50 L spray = 0.5 mg nicotine per spray Rapidly absorbed across nasal mucosa --faster onset of action (1113 minutes) compared to the gum, patch, or inhaler

NICOTINE INHALER
Dose = 6- 16 cartridges / d

Nicotrol Inhaler (Pharmacia)

Puff as lighting a cigar/pipe best if puff for ~ 20 minutes

MAX = 16 cartridges / d
Delivers 4 mg nicotine vapor, which is absorbed across buccal mucosa - ~ 20 minutes of puffing = 1 cartridge

BUPROPION SR (ZYBAN)
(GlaxoSmithKline)

Non-nicotine agent Sustained release antidepressant

Dose = 150mg every a.m. x 3 days then 150mg twice a day IMPORTANT to start 2 wks prior to QUIT date

COMBINATION PHARMACOTHERAPY

Combination NRT
Long-acting formulation (patch)

Produces relatively constant levels of nicotine

PLUS Short-acting formulation (gum, lozenge, inhaler, nasal spray)

Allows for acute dose titration as needed for withdrawal symptoms

Bupropion SR + NRT
Reserve for patients unable to quit using monotherapy.

HELP on the HORIZON for SMOKING CESSATION

Georgetown Pilot RCT with Quest Cigarettes Phase II RCT with NicVAX (nicotine vaccine) Phase III RCT soon to be released Pfizers Varenicline / Champix QUITKEY for individuals who cannot or should not use NRT

COMPARATIVE DAILY COSTS of PHARMACOTHERAPY

Inhaler Gum Lozenge Bupropion SR Cigarettes (1 pack/day) Patch Nasal spray

$6.07 $5.81 $5.31 $5.24

$4.12
$3.93 $2.66

Cost per day, in U.S. dollars

Breaking the NICOTINE DEPENDENCE Cycle

A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

The BEHAVIOR

The EMOTIONAL

The PHYSICAL

Automatic learned behavior with cigarettes

Role of cigarettes in life pleasure, stress, social

Physical addiction of cravings & withdrawals

Adapted from Legacys GSD&M Presentation 12/5/03

WHAT IF
a patient asks you about your use of tobacco?

The RESPONSIBILITY of HEALTH PROFESSIONALS

If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.
DR. GRO HARLEM BRUNTLAND, FORMER DIRECTOR-GENERAL of the WHO
USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS.

THANK YOU
Time for Questions & Interactive Cases
Workshop resources available at
http://rxforchange.ucsf.edu http://snhs.georgetown.edu
http://tobaccofreenurses.org