Quitting Tobacco: Why is it so hard? What works?

8/9/2019 Quitting Tobacco: Why is it so hard? What works?

1/46


2/46

Quitting Tobacco: Why isit so hard? What works?

Harry A. LandoUniversity of Minnesota

March !" #$ %


3/46

& have no disc'osures or con(icts of interestwith the )ateria' *resented in this ta'k


4/46

+icotine Addiction

htt*s:,,www.youtube.co),watch?v-yd !Hs/*Tow

https://www.youtube.com/watch?v=yd46Hs7pTowhttps://www.youtube.com/watch?v=yd46Hs7pTowhttps://www.youtube.com/watch?v=yd46Hs7pTowhttps://www.youtube.com/watch?v=yd46Hs7pTow


5/46

Those who have tried to give u* s)oking

usua''y know the )eaning of beinghooked

0ven those who initia''y succeed in 1uittingsu2er the sa)e re'a*se rate as recoveringa'coho'ics and heroin addicts

344 U.5. 5urgeon 6enera' 7e*ort:cigarettes and other for)s of tobacco are

addicting


6/46

• 7eco))ended warning 'abe's aboutaddiction

• 8ower of desire for cigarettes

• 8hysio'ogica' need that is )ore than)ere urge

• Like )any drugs that sti)u'ate the

nervous syste)" nicotine at the sa)eti)e sti)u'ates and re'a9es the body


7/46

• ecause it is inha'ed" it on'y takesseven to ten seconds to reach the

brain;twice as fast as heroin• Mi)ics so)e of the e2ects of

adrena'ine" a hor)one" andacety'cho'ine" a *owerfu'neurotrans)itter

• After a few *u2s" the 'eve' of nicotinein the b'ood increases dra)atica''y


8/46

• Heart beats faster and b'ood *ressureincreases

• 7esu't: s)okers beco)e )ore a'ertand )ay react faster

• &n addition" nicotine )ay *roduce aca')ing e2ect by triggering there'ease of natura' o*iates ca''ed beta<endor*hins


9/46

• ecause nicotine cannot be stored in the

body" s)okers )aintain a re'ative'yconstant 'eve' in the b'ood by continuingto s)oke

•

ecause a s)oker takes #$$ to $$ *u2s*er day" there is a 'ot of reinforce)ent

• +icotine is se'f ad)inistered" and it

a2ects )ood and *erfor)ance


10/46

• That )akes it *owerfu''y addicting

• +ew research shows that addictioncan occur very 1uick'y

• 0ven 'i)ited e9*osure to nicotine canchange the brain" )odifying neuronsin a way that sti)u'ates the craving to

s)oke


11/46

• 5tudies have indicated that so)e s)okerse9*erience withdrawa' sy)*to)s after

s)oking as few as one to four cigarettes• =unctiona' )agnetic resonance i)aging

>fM7& was used to )easure 'eve's of

)etabo'ic activity in brains of rats given adose of nicotine on @ve consecutive days

• 7es*onse to the @rst dose was re'ative'y

'i)ited


12/46

• rain activity was )uch )ore intenseand wides*read after the @fth dose

• These @ndings indicate that the brain1uick'y beco)es sensiti ed to nicotine"enab'ing addiction to occur after Bust afew doses

7eference: DiFranza, J. Hooked from the rst cigarette,Scienti c American May 2008, 82 8!.


13/46

Tobacco &ndustry 5ecrets• The industry acknow'edged

nicotineCs addictive *ro*ertiesinterna''y by 3!D

• Law @r) advised that entire )atterof addiction is the )ost *otent

wea*on a *rosecuting attorney canhave in a 'ung cancer cigarette case


14/46

• Eannot defend continued s)oking asFfree choiceG if the *erson wasaddicted

•

5ir Ehar'es 0''is" scienti@c advisor toritish A)erican Tobacco: FAs a resu'tof these various researches" we now*ossess a know'edge of the e2ects ofnicotine far )ore e9tensive thane9ists in the *ub'ished 'iterature.G


15/46

• Addictive *otentia' of a drug isenhanced by de'ivery syste)s thatcause it to reach the brain )ore 1uick'y

• This conce*t was fu''y a**reciated by

tobacco industry scientists• enia'" rationa'i ation" and

reinforce)ent are key e'e)ents in the

addictive *rocess


16/46

• E'ear'y the s)oker is concernedabout s)oking and hea'th

• This factor can be used to advantagein )arketing Ient and True brands

• Eonsu)er faith in safer s)oking ordenia' of anti


17/46

• =or cigarettes as with a'' drugde'ivery devices critica' to ensurethat the drug is de'ivered within anacce*tab'e dose range

• 8ro*osa' to reduce abso'ute 'eve' ofnicotine in cigarettes be'ow addicting'eve's


18/46

• =or decades" industry scientists"e9ecutives" and 'awyers have knownthat nicotine is addicting and thatthey are in the business of se''ing adrug de'ivery device

• The cigarette is a so*histicated drugde'ivery device

•

The s)oker can contro' the nicotinedose by a'tering s)oking behavior


19/46

• This )akes the cigarette one of the)ost techno'ogica''y so*histicateddrug de'ivery devices avai'ab'e

W.L. unn: Think of a cigarette as a

dis*enser for a dose unit ofnicotineJs)oke is Jthe )osto*ti)i ed vehic'e of nicotine and thecigarette is the )ost o*ti)i eddis*enser of s)oke


20/46

The 5ca): Low


21/46

• 5)oking with greater intensity"dee*er inha'ation" 'arger *u2 vo'u)e

•

&ndustry recogni ed that those whos)oke 'ow tar and nicotine cigarettesgenera''y be'ieve that such cigarettes*ose 'ess risk


22/46

=reebasing +icotine•

A))onia and *H )ani*u'ation" the higherthe *H the )ore e9tractab'e nicotine

• 8erha*s )ost sur*rising @nding in

docu)ent review was evidence ofindustry


23/46

•

A 3!! AT re*ort noted: &t wou'da**ear that the increased s)okerres*onse is associated with nicotinereaching the brain )ore 1uick'y

From H"rt, #. $rying o%en the door to the to&accoind"stry's secrets JAMA (cto&er !, )**8


24/46

Quitting: What Works?

U5 E'inica' 8ractice 6uide'ine #$$4

$ Iey reco))endations:

.Tobacco de*endence is a chronicdisease that often re1uires re*eatedintervention


25/46

#. &t is essentia' that c'inicians and hea'thcare de'ivery syste)s consistent'y

identify and docu)ent tobacco use statusand treat every tobacco user

D. Tobacco de*endence treat)ents are

e2ective across a broad range of*o*u'ations

. rief tobacco de*endence treat)ent is

e2ective


26/46

%. &ndividua'" grou*" and te'e*honecounse'ing are e2ective and theire2ectiveness increases withtreat)ent intensity. Twoco)*onents of counse'ing that are

es*ecia''y e2ective are *ractica'counse'ing >*rob'e) so'ving,ski''straining and socia' su**ort

de'ivered as *art of treat)ent


27/46

!. +u)erous )edications are avai'ab'e fornicotine de*endence: u*ro*ion 57"

Karenic'ine" nicotine gu)" nicotine inha'er"nicotine 'o enge" nicotine nasa' s*ray"nicotine *atch >A'so )ore recent evidencefor cytisine

/. Eounse'ing and )edication are e2ectivewhen used by the)se'ves" but co)binationof counse'ing and )edication is )ore

e2ective than either a'one4.


28/46

4. Te'e*hone 1uit'ine counse'ing is e2ective

with diverse *o*u'ations and has broadreach

3. &f a tobacco user current'y is unwi''ing to

)ake a 1uit atte)*t" c'inicians shou'duse )otivationa' treat)ents

$. Tobacco de*endence treat)ents are

both c'inica''y e2ective and high'y cost


29/46

• 0ven after 'ong *eriods of abstinence"cues in the environ)ent )ay *ro)otecravings

• &f 'ong ti)e abstinent s)oker surrendersto an urge to s)oke" addiction can be1uick'y reestab'ished

• The U5 E'inica' 8ractice 6uide'inesdescribe nicotine de*endence as a chronicre'a*sing condition


30/46

=ETE Artic'e • 0ach *arty sha'' deve'o* and

disse)inate a**ro*riate" co)*rehensiveand integrated guide'ines based on

scienti@c evidence and best *ractices"taking into account nationa'circu)stances and *riorities" and sha''take e2ective )easures to *ro)otecessation of tobacco use and ade1uatetreat)ents for tobacco de*endence


31/46

• Eha''enges to i)*'e)enting Artic'e in'ow


32/46

•

rief tobacco de*endence treat)entis e2ective

• +u)erous )edications have beende)onstrated to be e2ective fortobacco de*endence

• However" cost is a barrier


33/46

• E'inicians often do not treat s)okers

• Too busy• Lack of e9*ertise

• +o @nancia' incentive• e'ieve s)okers cannot or wi'' not 1uit

• o not wish to scare *atients away


34/46

**ortunity: Most s)okers wantto 1uit

• Without assistance on'y % *ercent of1uit atte)*ts are successfu'

• Most try to 1uit on their own;3%

re'a*se• Using evidenced


35/46


36/46

• 0ven when *atients are not ready to 1uit"brief )otivationa' )essages can increase'ike'ihood of future 1uit atte)*ts

• rief treat)ent is e2ective

• Te'e*hone counse'ing is e2ective• Lay *eo*'e can be trained to *rovide

su**ort


37/46

• &ndividua' and grou* counse'ing

• 8rob'e) so'ving,ski''s training

• 5ocia' su**ort as *art of intervention


38/46

• May be readi'y avai'ab'e and 'ow


39/46

• We successfu''y trained 'ayfaci'itators to 'ead )u'ti


40/46

• 5tudies have su**orted e2ectivenessof using trained 'ay hea'thin(uencers and *eer interveners

• Teaching 'ay *eo*'e know'edge and

ski''s for tobacco intervention is bothfeasib'e and *ractica'

• 8roBect 7each in Ari ona


41/46

• +urse


42/46

Wor'd Hea'th rgani ation reco))ends

three ty*es of treat)ent:• Tobacco cessation advice incor*orated

into *ri)ary hea'thcare services

• 0asi'y accessib'e and free 1uit'ines

• Access to 'ow


43/46


44/46

Ask: F o you" or does anyone in yourhouseho'd" ever s)oke or use any ty*e of

tobacco?GAdvise: F& rea'i e 1uitting is diNcu't" but it is

the )ost i)*ortant thing you can do to

*rotect your hea'th now and in the future.G7efer: To other c'inicians for additiona'

counse'ing" 'oca' grou* *rogra)" or 1uit'ine


45/46

Ti*s fro) for)er s)okersU5 Eenters for isease Eontro'

and 8revention

htt*:,,www.cdc.gov,tobacco,ca)*aign,

ti*s,resources,videos,beatrice<videos.ht)'Ocessation

treatobacco.net >eNcacy" *o'icy"hea'th e2ects" resources


46/46

F&f we do not act decisive'y" a hundredyears fro) now our grandchi'dren andtheir chi'dren wi'' 'ook back and serious'y1uestion how *eo*'e c'ai)ing to beco))itted to *ub'ic hea'th and socia'

Bustice a''owed the tobacco e*ide)ic tounfo'd unchecked.G

r. 6ro Har'e) runt'and

=or)er irector

Documents

Quitting Tobacco: Why is it so hard? What works?