Smoking Cessation Kevin Scott Ferentz, M.D

Smoking CessationSmoking Cessation

Kevin Scott Ferentz, M.D.

Associate Professor

Department of Family Medicine

University of MD School of Medicine

Cigarette smoking is the single most

important cause of disease and

premature death in the United States

Cigarette smoking is the single most

important cause of disease and

premature death in the United States

Cigarette-related deaths

440,000 per year 12 million dead since first surgeon

general’s report in 1964 Smokers die 13-14 years earlier Medical costs: $ 75 billion Lost productivity: $ 82 billion Costs: $ 40/pack

Smoking in the U.S. - 2006Smoking in the U.S. - 2006 21% of adults (43% in 1966)

Kentucky 27.4%, Utah 10.5% men (24%) women (18%)

< HS education 3X likely than w/ college degree rate dropped little in 1990’s Rate dropping by < 1% per year 1.3 million quit each year 3,000 teens start each day

adolescent smoking may be dropping more ex-smokers than current smokers 2010 goal: 12% smokers

Grade 9

Grade 10

Grade 11

Grade 12

Male

Female

Grade 10

Grade 11

Grade 12

Grade 9

Current cigarette smoking among HS students by sex, frequency, and grade level: US, 2003

Current smoking = smoked on 1 or more days of the 30 days preceding survey; Frequent smoking = smoked on 20 or more of the 30 days preceding the survey. Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

Percent

Frequent smoking

0 10 20 30 40

The politics of tobacco States that grow tobacco:

– lowest taxes, highest rates of smoking Most Tobacco Restitution Funds are NOT

going to tobacco control California: 1988

– 23% smoking rate– Voters approve 25¢ tax for anti-smoking

campaign California: 2003

– 15% smoking rate– 13% of HS students smoke (22% nationally)

Phillip Morris profits up 10% in 2004

Smoking worldwide

1.3 billion smokers Expected to rise to 1.7 in 2025 Kills 5 million yearly 1 death every 6.5 seconds May double in 20 years 84% of smokers are in developing countries 95 billion cigarettes sold in India each year!

World Health Organization – 2004

Increased Cancer RiskIncreased Cancer Risk

90% of lung cancer deaths 40% of all cancers mouth, larynx, esophagus, stomach kidney, bladder Pancreas Cervix Acute myeloid leukemia more women die of lung than breast cancer!

Heart disease

leading cause of death smoking is major risk factor 3 times more likely to die of heart disease step-wise increase with other risk factors

Lung Disease

90% of COPD deaths asthma bronchitis pneumonia

Female smokersFemale smokers

infertility earlier menopause osteoporosis birth control pills vaginitis

Pregnant smokersPregnant smokers

spontaneous abortion placenta previa placental abruption premature rupture of membranes preterm labor restricted fetal growth increased fetal respiratory rate placental abnormalities

Children of smokersChildren of smokers

respiratory illness SIDS cognitive development behavioral development cancer increased risk of smoking

Involuntary smoking is a cause of disease in

non-smokers

Involuntary smoking is a cause of disease in

non-smokers

Smokeless tobaccoSmokeless tobacco

“spit” tobacco cancer of mouth, pharynx, esophagus tooth discoloration gingival recession periodontal bone destruction death from juice ingestion

Other problems

fire accidents gingivitis skin wrinkles impotence decreased stamina colds, flu

Health effects from smoking Heart disease Lung disease – COPD,

asthma Cancer

– Lung, ENT, pancreas– Cervix– Skin (squamous cell)

Vascular disease – impotence, AAA

Stroke Cataracts Macular degeneration Gum disease Tooth decay

Osteoporosis Wound healing Anxiety & Depression Miscarriage SIDS Hearing loss Rheumatoid arthritis Lupus Dementia Multiple sclerosis

Smoking kills more people each year than

alcohol cocaine crack heroin

homicide suicide car accidents fires AIDS

C O M B I N E D!!!

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What’s in a cigarette?

4,000 chemicals tar carbon monoxide nicotine

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“...cigarettes and other forms of tobacco are addicting in the

same sense as are drugs such as heroin and cocaine.”

C. Everett Koop, MD 1988 Surgeon General’s

Report

Criteria for addicting drug

Dependence Tolerance Withdrawal

Nicotine yield/cig increased 11% from 1998-20051

1Harvard School of Public Health, 2007

Nicotine - immediate effects

sympathetic stimulation parasympathetic stimulation feelings of:

stimulation better concentration pain tolerance

The effects on health from smoking are reversible if a smoker stops

smoking

The effects on health from smoking are reversible if a smoker stops

smoking

Health benefits after quitting cough, DOE resolve in weeks exercise tolerance improves rapidly bladder cancer: 50% reduction in 5 years lung cancer: 50% reduction in 10 years heart disease: 50% reduction in 1 year! No increased risk of heart disease by 10-15 yrs vascular disease: 50% reduction in 5 years mortality rates same as never smokers by 10-15 yrs

How are we doing with our patients?

1991: – < 50% of patients reported ever being told to stop1

1998: – 67% Ask, 74% Advise, 35% Assist, 8% Follow-up2

2003: (patients that got prescription)3

– 36% told to set quit date, 25% counseled,

13% advised to follow up

Many smokers do not get the

advice and help they need!!!1Frank,E., Winkleby, M.A.,Altman, D.G., et al. JAMA 1991;266:3139-3134. 2Goldstein MG, et al. Preventive Medicine. 27(5 Pt 1):720-9, 1998 Sep-Oct.3Solberg LI, et al. Archives of internal medicine, 2005;165:656

Why counsel all smokers?Why counsel all smokers? 90% want to quit minimal physician input almost doubles quit rate1

most quit without intensive assistance once they make the decision

moving patients through the process2

precontemplation contemplation preparation action maintenance

1Cochrane Database of Systematic Reviews. 2004 2J of Cons & Clin Psych. 51(3):390-5, 1983 Jun

Physician influencePhysician influence

position of authority credible source personalize health effects face-to-face counseling multiple contacts good role models

Patient resources

• printed materials (still need counseling)• National Cancer Institute

(1-800-4-CANCER)• www.smokefree.gov• Smokingstopshere.com• 1–800–QUIT–NOW (quit lines improve chances of quitting)

A minimum amount of time spent with more

smokers will yield more ex-smokers

than intensive efforts with a few

A minimum amount of time spent with more

smokers will yield more ex-smokers

than intensive efforts with a few

Minimum counselingMinimum counseling

firm, unambiguous advice written materials set a quit day set follow-up visit

(or warn patient you will ask about

progress at a future visit)

Factors which influence smokers to make an attempt

to quit

Factors which influence smokers to make an attempt

to quit

Influence to quitInfluence to quit

firm, unambiguous advice “as your doctor, I’m telling you to

QUIT!” personalize damaging health effects effects reversible with quitting

Personalizing effects - historyPersonalizing effects - history

shortness of breath cold hands and feet fatigue decreased stamina colds and flu bronchitis, sinusitis teeth, gums kids’ problems

Personalizing effects - physicalPersonalizing effects - physical

gingivitis tar stains bad breath diminished breath sounds wheezing, rhonchi peripheral pulses fundal height wrinkling

Personalizing effects - labsPersonalizing effects - labs

carboxyhemoglobin pulmonary function tests peak flow chest x-ray

Influence to quitInfluence to quit

firm, unambiguous advice “as your doctor, I’m telling you to QUIT!” personalize damaging health effects effects reversible with quitting non-health reasons

Non-health reasons for quittingNon-health reasons for quitting

COST!!! inconvenience self-esteem role model

Influence to quitInfluence to quit

firm, unambiguous advice “as your doctor, I’m telling you to QUIT!” personalize damaging health effects effects reversible with quitting non-health reasons confidence

Building confidenceBuilding confidence

express your confidence millions of others have quit more ex-smokers than smokers most try many times before succeeding past attempts are learning experiences ways to deal with physical and

psychological dependence

Influence to quitInfluence to quit

firm, unambiguous advice “as your doctor, I’m telling you to QUIT!” personalize damaging health effects effects reversible with quitting non-health reasons confidence address concerns

Common concernsCommon concerns

Withdrawal short lived

Cravings last 3-5 minutes, diminish rapidly

Tension validate, normalize find other ways to cope

Weight gain - not inevitable! 1/3 gain: 5-8 lbs.

At a minimum, tell all patients how

important you feel it is that they quit(not cut down)

At a minimum, tell all patients how

important you feel it is that they quit(not cut down)

Refer patients who are interested to a

group program

Refer patients who are interested to a

group program

Accentuate the positive aspects of quitting rather than dwelling on the dangers of

continuing to smoke

Factors which help smokers quit once the

decision is made

Behavior Modification

Components of addiction

physiological psychological behavioral

Behavior modification

review reasons for quitting (index card) identify triggers (4 day diary) plans to avoid or cope with each trigger

Sample plan

Triggerafter meals

on the phone

in the car

at desk

tension

coffee breaks

other smokers

crisis

Techniqueleave table

draw

chew gum

carrot sticks

deep breathing

juice

non-smokers

self-talk

Behavior modification

review reasons for quitting (index card) identify triggers (4 day diary) plans to avoid or cope with each trigger change habit: packs only, different brands develop support system (tell everyone) self rewards (day, week, month, year) written commitment to quit day

Set a follow-up visit with all patients at

one month

Pharmacological treatment nicotine replacement - “methadone for the

smoker” Gum, Patch, lozenge, nasal spray, inhaler

Bupropion (Zyban®) Varenicline (Chantix®) all decrease cravings, withdrawal 20-25% quit rates at 1 year

Nicotine replacement - gum

available since 1984 2 mg. and 4 mg. strength “chew, park, chew, park” 2 mg. - 30 pieces/day maximum 4 mg. - 20 pieces/day maximum wean after 3 months, 6 months maximum use in conjunction with patches, bupropion

Nicotine replacement - patches

4 patches on market - OTC wean - 8 weeks first patch - night before quit day rashes, abnormal dreams no euphoria - no stimulant effect no increased risk of MI

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Nicotine lozenges (Commit®)

2 and 4 mg strengths 4 mg if smoke w/in 30 minutes of waking 12 week program Weeks 1-6: 1 lozenge every 1 to 2 hours Weeks 7-9: 1 lozenge every 2 to 4 hours Weeks 10-12: 1 lozenge every 4 to 8 hours at least 9 per day for the first 6 weeks hiccups, heartburn, nausea no more than 5 in 6 hours, 20 per day Can work when patch, gum failed

Shiffman S, Dresler CM, et al. Arch Intern Med. 2002;162:1267-1276.

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Nicotine nasal spray

one dose: 2 sprays (1 mg) minimum: 8 doses/day maximum: 40 doses/day (1/2 bottle) if not abstinent by week 4 - stop use for 3 months, six maximum nasal irritation limits use

Nicotine inhaler

nicotine deposited in mouth 2 mg absorbed per insert 80 puffs in 20 minutes 6 - 16 cartridges/day 3 months then wean over 3 months 40% throat irritation 20% quit at 6 months, 13% at 1 year

Nicotine replacement should always be used in conjunction with behavior

modification

Bupropion (Zyban)

Probably works by increasing dopamine in nucleus accumbens

150 mg qd X 3 days, 150 mg b.i.d. X 4 days, then QUIT

continue for 7 - 12 weeks if not stopped by 8 weeks, discontinue Can use with nicotine replacement

Rates of Continuous Abstinence

Buproption and nicotine patchBupropionNicotine patchPlacebo

Jorenby NEJM 1999

Bupropion – cautions/contraindications

insomnia - last dose 6 hours before sleep Activating but well-tolerated seizure disorder prior or current eating disorder concurrent use of Wellbutrin®

Varenicline (Chantix®)

[alpha]4[beta]2 nicotinic acetylcholine receptors reinforce effects of nicotine, maintain smoking

partial agonist, antagonist (blocks binding) 0.5 mg X 3 d, 0.5 mg b.i.d. X 4 d, 1 mg b.i.d. Stop smoking after 7 days on medicine Can use for up to 6 months Probably higher rates of quitting Nausea, constipation, abnormal dreams Costs about $ 4/day

*weeks 9–52: varenicline vs placebo, P<.001; varenicline vs bupropion, P = .004; bupropion vs placebo, P = .08.Jorenby DE, et al JAMA. 296(1):56-63, 2006 Jul 5.

Continuous Smoking Abstinence Rates

Second-line medications

Clonidine: 0.15 – 0.75 mg/d for 3 – 10 weeks Nortriptyline: 75 – 100 mg/d for 12 weeks

Factors which help ex-smokers remain

ex-smokers

Maintenance

Relapse

rates are same as for heroin, alcohol at least 70% relapse within first year

2/3 within first 3 months largest group within first week

factors: early: withdrawal, cravings, habit late: other smokers, food, alcohol, coffee

negative emotions, crisis

Preventing Relapse

use and refinement of coping strategies “if you don’t want to slip, stay away from slippery

places”

positive self-talks in response to slips Slips happen: Hungry, Angry, Lonely Tired

continued commitment (one day at a time) praise and encouragement by physician (“ex-smoker” on problem list)

The future

Nicotine vaccine (NicVAX)– Block nicotine from getting into brain– Phase two trials are promising

Different forms of nicotine replacement Rimonabant

– cannabinoid receptor antagonist– Also treats obesity– Probably won’t be released in US for smoking

AHCPR Guidelines - The 5 “A’s”

ASK - identify tobacco users at all visits ADVISE - strongly urge all smokers to quit ASSESS - willing to make an attempt? ASSIST - information, medication ARRANGE - schedule follow-up visit

For Those Unwilling to Quit – the 5 “R’s”

Relevance - why quitting is personally relevant

Risks - patient identifies negative consequences of tobacco use

Acute, long-term, environmental risks

Rewards - patient identifies benefits of stopping

Roadblocks - patient identifies barriers to quitting

Repetition - motivational intervention every visit