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Tobacco Cessation: Essential Steps for Success

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

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Tobacco Cessation: Essential Steps for Success

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  1. 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

  2. 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

  3. 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/

  4. TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2004 Trends in cigarette current smoking among persons aged 18 or older 20.9% of adults are current smokers Male Percent 23.4% Female 18.5% 44.5 Million Adults are Addicted to Cigarettes Year The GOOD News: 70% want to quit The BAD News: < 36% Receive Information on HOW to quit Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2001 NHIS. Estimates since 1992 include some-day smoking.

  5. STATE-SPECIFIC PREVALENCE of SMOKING among ADULTS, 2004 California 14.8% Kentucky 27.6% Nevada 23.2% VA 20.9% Utah 10.5% GA 20.1% Ark 25.7% Centers for Disease Control and Prevention. (2005). MMWR 54:1124–1127.

  6. PREVALENCE of ADULT SMOKING, by RACE/ETHNICITY—U.S., 2004 33.4% American Indian/Alaska Native 22.2% White, non-Hispanic 20.2% Black, non-Hispanic 15.0% Hispanic 11.3% Asian Centers for Disease Control and Prevention. (2005). MMWR 54:1121–1124.

  7. 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

  8. PREVALENCE of ADULT SMOKING, by EDUCATION—U.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 Centers for Disease Control and Prevention. (2005). MMWR 54:1121–1124.

  9. Annual Causes of Death from Smoking Compared to Other PREVENTABLE Causes 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

  10. ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, 1997–2001 Percentage of all smoking-attributable deaths* 32% 28% 23% 9% 8% <1% TOTAL: 437,902 deaths annually Centers for Disease Control and Prevention. (2005). MMWR 54:625–628.

  11. 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

  12. Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde Nicotine Nitrosamines Lead Cadmium Polonium-210 COMPOUNDS in TOBACCO SMOKE An estimated 4,800 compounds in tobacco smoke Gases (~500 isolated) Particles (~3,500 isolated)

  13. 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.

  14. The Safer Cigarette – NOT! Unveiling the SMOKING gun about “Safe Cigarettes”!

  15. 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.

  16. BENEFICIAL EFFECTS of QUITTING: PULMONARY EFFECTS AT ANY AGE, there are benefits of quitting. Here’s how to do it! Never smoked or not susceptible to smoke 100 75 Stopped smoking at 45 (mild COPD) Smoked regularly and susceptible to effects of smoke FEV1 (% of value at age 25) 50 Disability 25 Stopped smoking at 65 (severe COPD) Death 0 25 50 75 Age (years) COPD = chronic obstructive pulmonary disease Reprinted with permission. Fletcher & Peto. (1977). BMJ 1(6077):1645–1648.

  17. Breaking the NICOTINE DEPENDENCE Cycle A COMPREHENSIVE APPROACH = A Successful Framework for Quitting The PHYSICAL The BEHAVIOR The EMOTIONAL Automatic learned behavior with cigarettes Physical addiction of cravings & withdrawals Role of cigarettes in life—pleasure, stress, social Adapted from Legacy’s GSD&M Presentation 12/5/03

  18. DOPAMINE REWARD PATHWAY Prefrontal cortex Dopamine release Stimulation of nicotine receptors Nucleus accumbens Ventral tegmental area Nicotine enters brain

  19. Now Multiply that # by days / year THEN multiply that number by years smoking! YIKES! No wonder it is SO difficult to QUIT NICOTINE BEHAVIORAL EFFECTS: Do the Math! • An individual smokes 1 pack per day x 20 yrs • 20 cigarettes / pack • 10 puffs / cigarette • = ?? puffs / day • THAT’s ____ HITS of NICOTINE per DAY 73,000 1.4 million 200

  20. Dopamine Norepinephrine Acetylcholine Glutamate Serotonin -Endorphin GABA 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 NEUROCHEMICAL and RELATED EFFECTS of NICOTINE N I C O T I N E Benowitz. (1999). Nicotine Tob Res 1(Suppl):S159–S163.

  21. NICOTINE PHARMACODYNAMICS: WITHDRAWAL EFFECTS • Depression • Insomnia • Irritability/frustration/anger • Anxiety • Difficulty concentrating • Restlessness • Increased appetite/weight gain • Decreased heart rate • Cravings* Most symptoms peak 24–48 hr after quitting and subside within 2–4 weeks. American Psychiatric Association. (1994). DSM-IV. Hughes et al. (1991). Arch Gen Psychiatry 48:52–59. Hughes & Hatsukami. (1998). Tob Control 7:92–93. * Not considered a withdrawal symptom by DSM-IV criteria.

  22. ASSESSINGNICOTINE DEPENDENCE Fagerström Test for Nicotine Dependence (FTND) • How soon after you wake up do yousmoke 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 Scores range from 0 to 10; a score of greater than 5 indicates substantial dependence

  23. The 5 A’s ASK ADVISE ASSESS ASSIST ARRANGE HANDOUT Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

  24. 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 quitline1-800-QUIT-NOW This brief intervention can be achieved in 30 seconds.

  25. FIVE STAGES THAT DESCRIBE a PERSON’S 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

  26. METHODS for INCREASING MOTIVATION—FIVE R’s • 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.

  27. STRATEGIES for Successful Tobacco Cessation • PRAISE the individual’s readiness • Facilitate the quitting process • ESTABLISH “THE PLAN” • Set a quit date! • Help Build Tools for a “QUIT Kitto Success” • Emotional -Cognitive Tools • Behavioral - Tools • Physical - Biological Tools

  28. Cognitive STRATEGIES #1Individualize the plan #2 Assess MOTIVATION to quit (0-10) #3 Assess CONFIDENCE to quit (0-10) #4Assess triggers for tobacco use • Routines/situations associated with tobacco use – Tobacco Log #5Assess social support #6Advise a daily affirmation – slay the dragon / nicotine demon- “I can do this”

  29. Behavioral STRATEGIES QUITTING is hard to do. ALL cycles must be addressed for SUCCESS! #7Discuss how to change routine • Non-food / healthy items instead of cigarettes • Tea instead of coffee / Exercise instead of smoking #8Discuss coping skills for situational and/or emotional triggers • Weight gain concerns • Withdrawal concerns – the 4 “Ds” • Relapse concerns #9Discuss how to prepare for QUIT day • Home – Car - Office • Treats for SELF #10Discuss pharmacotherapy options The PHYSICAL The BEHAVIOR The EMOTIONAL

  30. Breaking the NICOTINE DEPENDENCE Cycle A COMPREHENSIVE APPROACH = A Successful Framework for Quitting The PHYSICAL The BEHAVIOR The EMOTIONAL Automatic learned behavior with cigarettes Physical addiction of cravings & withdrawals Role of cigarettes in life—pleasure, stress, social Adapted from Legacy’s GSD&M Presentation 12/5/03

  31. 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!

  32. LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS 23.9 20.0 19.5 17.1 16.4 14.6 Percent quit 11.8 11.5 10.2 9.1 8.8 8.6 Data adapted from Silagy et al. (2004). Cochrane Database Syst Rev and Hughes et al., (2004). Cochrane Database Syst Rev.

  33. FDA APPROVALS: SMOKING CESSATION 2002 Rx transdermal nicotine patch 1997 1996 OTC nicotine lozenge 1991 Rx nicotine inhaler; Rx bupropion SR Rx nicotine gum OTC nicotine gum & patch;Rx nicotine nasal spray 1984

  34. NICOTINE ABSORPTION Absorption is pH dependent • In acidic media • Ionized  poorly absorbed across membranes • In alkaline media • Nonionized well absorbed across membranes At physiologic pH (7.3–7.5), nicotine is readily absorbed.

  35. PLASMA NICOTINE CONCENTRATIONS for NICOTINE-CONTAINING PRODUCTS Cigarette Moist snuff 0 10 20 30 40 50 60 Time (minutes)

  36. NICOTINE GUM: Nicorette; generic (GlaxoSmithKline; Watson Labs) • Dose = 1 every 1-2 hrs; • No food/beverage 15 min prior - during or 15 min post • Max = 24 / day • Available: 2 mg, 4 mg; regular, mint, orange • NOT recommended if use dentures

  37. NICOTINE GUM:CHEWING TECHNIQUE SUMMARY Chew slowly Stop chewing at first sign of peppery, minty, or citrus taste or tingle Chew again when the taste or tingle fades Park

  38. TRANSDERMAL NICOTINE PATCH • Dose = 1 patch every day (16 hrs or 24 hrs) • Best if ROTATE patchdifferent 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

  39. NICOTINE LOZENGECommit (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

  40. NICOTINE NASAL SPRAYNicotrol NS(Pharmacia) • Dose = 1 dose (2 sprays per nostril) every hr • MAX = 5 doses/hr OR 40 doses /day • Each dose delivers -50 µL spray = 0.5 mg nicotine per spray • Rapidly absorbed across nasal mucosa --faster onset of action (11–13 minutes) compared to the gum, patch, or inhaler

  41. NICOTINE INHALERNicotrol Inhaler (Pharmacia) • Dose = 6- 16 cartridges / d • 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

  42. 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

  43. 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.

  44. HELP on the HORIZON for SMOKING CESSATION • Georgetown Pilot RCT withQuest Cigarettes • Phase II RCT with NicVAX (nicotine vaccine) • Phase III RCT soon to be released Pfizer’s Varenicline / Champix • QUITKEY for individuals who cannot or should not use NRT

  45. COMPARATIVE DAILY COSTS of PHARMACOTHERAPY $6.07 $5.81 $5.31 $5.24 $4.12 $3.93 $2.66 Cost per day, in U.S. dollars

  46. Breaking the NICOTINE DEPENDENCE Cycle A COMPREHENSIVE APPROACH = A Successful Framework for Quitting The PHYSICAL The BEHAVIOR The EMOTIONAL Automatic learned behavior with cigarettes Physical addiction of cravings & withdrawals Role of cigarettes in life—pleasure, stress, social Adapted from Legacy’s GSD&M Presentation 12/5/03

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

  48. 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.

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

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