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Successfully Addressing Tobacco Use in our Patients – 2016
F.S.A.C.O.F.P.Friday July 29 , 2016
Dennis H. Penzell, D.O., M.S., F.A.C.P
Associate Professor of Medicine
Nova Southeastern University
Health Professions Division
College of Osteopathic Medicine
NO DISCLOSURES
There may be off label info.
IQuit with AHEC1-877-848-6696
ahectobacco.com
• Free In-person Tobacco Cessation Groups• Receive tools/strategies to quit and stay tob-free• Programs in English and Spanish• Friendly, respectful, supportive group setting• Free nicotine replacement therapy
FLORIDA QUIT LINE 1-877-U-CAN-NOW
• Counseling via phone or on-line services available.
• Quitline services in English, Spanish, Haitian Creole.
• Translation services for all other languages.
• Free starter kit of nicotine replacement therapy.
HOW CAN AHEC HELP YOU?
• The Florida Area Health Education Centers (AHEC) Network is an extensive,
statewide system for health professional education and support .
• Each AHEC is supported by an AHEC program at one of the state's five medical
schools.
• The Florida AHEC Network has, over this past decade, addressed the
primary health care needs of Florida's most vulnerable populations
through a series of innovative strategies designed to:
-Extend academic health resources.
-Provide information and support for community providers.
-Influence health professions education.
-Influence the future health professional workforce.
AUDIENCE
-Educating and training health professions students.
-Offering cme to practicing health professionals.
-Providing cessation services for tobacco users.
- Clin. Prac. Guidelines into Practice: Tobacco.
Use the Fax Referral Form!
Why make referrals to AHEC?
• Provides opportunity to engage smoking pts.
• Discussion and signature promote commitment .
• Involve family members for ongoing support.
• Trained Tobacco Specialist calls patient.
• Curricula are evidence-based.
• Follow-up is provided at regular intervals.
WHAT IS ADDICTION?
”Compulsive drug use, without
medical purpose, in the face of
negative consequences”
Alan I. Leshner, Ph.D.Former Director, National Institute on Drug Abuse
National Institutes of Health
Power of Intervention
• Cold turkey: yields 2% - 4% x
• Brief:1- 3 min. intervention= 3% - 6% quit
• Behavioral counseling: -dose related - quit rate increases with time spent
-yields 10% - 15% quit rate
• Meds and counseling yields: 20% - 30%
©2004 Seton Health System
NICOTINE
• Nicotine is psychoactive, producing transient dose-related changes in mood and feeling.
• It is a euphoriant that produces dose-related increases in scores on standard measures of euphoria.
• It is a reinforcer (or reward, in both human and animal intravenous self-administration paradigms, functioning as do other drugs of abuse. Nicotine activates the receptors which lead to an increase in “dopamine” release.
PHARMACOTHERAPY
Why Pharmacotherapy?
Alleviates withdrawal
Eliminates reinforcing effect of nicotine
Gives time to break habits/routines
Nicotine Patch
•Pros: All are available over the counter; administered qd.
•Cons: Slow-acting; doesn't respond instantly; possibility of rash; may require daily
change of patch location; may require patch be removed at bedtime to avoid vivid
dreams or nightmares.
•Comments: May need to use adhesive tape .
•Sources: Grocery store, pharmacy, drugstore
Nicotine Patch
24 hr (21, 14, 7mg) Nicoderm/generic
The first time, use at bedtime
A new patch is applied each morning
Nicotine Patch
wean – 8-12 weeks
rashes, abnormal dreams
no euphoria - no stimulant effect
no increased risk of MI
May combine w gum/losenge/Zyban
What about combining long acting NRT and short
acting?
Combination TherapiesKEY POINT
• 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
• European Heart Journal (2000) 21, 438–445
NICOTINE PATCH THERAPYINITIAL DOSING GUIDELINES
(Off Label)
Based on Baseline Cigarettes/Day
• <10 CPD 7-14 mg/d
• 10-20 CP 14-21 mg/d
• 21-40 CP 22-42 mg/d
• >40 CPD 42+ mg/dHughes et al:Nicotine and Tobacco Research (1999)I.169-174
Dale et al: Mayo Clinic Proceedings: 2000;75:1311-1316
HIGHER DOSE NICOTINE PATCH
There is a dose-response effect
*Cochrane Database of Systematic Reviews 2005
Nicotine Gum(nicotine polacrilex, Nicorette®)
2 mg (<25 cigs) vs. 4 mg (>24 cigs) –max 24/day
1-2 per hour for first 6 weeks-taper
“chew, park, chew, park”-30 minutes
Absorbed in a basic environment, avoid acidic
beverages 15 minutes pre and during dose.
Side effects: dyspepsia, mouth soreness
NICOTINE LOZENGE
• Efficacy: Doubles to triples 12 month cessation
• Dosage (max 20/day)– 2 mg-for those smoking >30 min after waking
– 4 mg-for those smoking <30 min after waking
• First 6 weeks- 1 lozenge every 1-2 hrs
• Weeks 7-10- 1 lozenge every 2-4 hrs
• Weeks 11-12- 1 lozenge every 4-8 hrs
• Avoid eating or drinking for 15 minutes before
Smoking Cessation Methods: Nicotine Inhaler
Pros: Self-administered dosing satisfies
the hand-to-mouth component of
cigarette smoking.
Cons: Requires a prescription; looks and is used much like a
cigarette, so may be conducive to overuse; can cause throat
irritation and coughing.
Nicotine Inhaler
Rx---2 mg absorbed per insert.
Continuous 20 minutes/dose
(80 puffs = 4 mg)/ 80 puffs in 20 minutes
6-16 cartridges per day for 12 weeks.
Use 3 months then wean over 3 months
40% throat irritation
20% quit at 6 months, 13% at 1 year
Nicotine Nasal Spray (NS)
•Pros: Gets nicotine into bloodstream much faster than the patch
or gum; relieves acute cravings instantly.
•Cons: Requires a prescription; nasal irritation, throat irritation,
runny nose, lightheadedness, odd taste.
•Comments: Use in public is not attractive.
Bupropion/Wellbutrin
• Bupropion, Wellbutrin/ Bupropion SR(Zyban®)
• Pros: Can be used with the patch; can alleviate symptoms of
depression during withdrawal.
• Cons: Requires a prescription; should not be used for those
who suffer from epilepsy, have histories of eating disorders,
dry mouth, insomnia; can cause tremors.
Bupropion , Wellbutrin
Blocks neural reuptake: dopamine norepinephrine
ZYBAN®Wellbutrin/Bupropion
• Side effects– Dry mouth
– Insomnia
– NEJM 2002 – seizure induced by bupropion – case report of adolescent who crushed six 150mg tablets and snorted them
.5
VARENICLINE
CHANTIX®
Varenicline
• Pros: Provides nicotine effects to ease withdrawal symptoms,
and blocks effects of nicotine.
• Cons: Nausea, headache, vomiting, insomnia, abnormal
dreams, change in taste perception
Varenicline• Rx. For one or two 12 wk. blocks
• Day 1-3: You will take one 0.5 mg tablet;
• Day 4-7: You will take a 0.5 mg tablet twice daily
May smoke for the first week
QUIT SMOKING ON DAY 8
• Day 8-28: you will take a 1 mg tablet twice daily
• Continuing Months: Wk. 2 to end of treatment: 1 mg tablet twice daily.
Side Effects…
• Side effects with VARENICLINE– Headaches
– Nausea
– Vomiting
– Trouble sleeping/unusual dreams
Chantix (Varenicline)
• Behavior, mood changes, drowsiness
• Contraindicated with CrCl<30
• Still have about 60% dopamine produced.
PRACTICAL QUESTIONS
Should I Recommend Stopping Tobacco before surgery?
• Recent Smoking Cessation: No Increase Pulmonary Complics. (1)
• Smoking status does not affect changes in perceived stress. ---
perceived stress measured from before surgery up to one week
postoperatively (2)
1.. Barrera et al, Chest 127:1977, 2005
2.. Warner et al, Anesthesiology 199:1125, 2004
3.. Shi Y, Warner DO: Anesth Analg. 2011 Dec;113(6):1348-51.
Epub 2011 Sep 29.
Cigarettes and Surgery
Pts should be advised to stop smoking as early as possible.
No evidence not to advise quitting prior to surgery.
•ARCH INTERN MED: ONLINE MARCH 14, 2011-Katie Myers, MSc, CPsychol; Peter Hajek, PhD; Charles Hinds, FRCP, FRCA; Hayden
McRobbie, MBChB, PhD
CIGARETTES AND SURGERY
• Available evidence does not support a detrimental effect of
NRT in surgical patients.
• Especially when compared with the consequences of
continued smoking.(1, 2)
(1) Forrest CR, Xu N, Pang CY:. Can J Physiol Pharmacol 1994;72:30–8.
(2) Warner, D.O. :Anesth Analg 2005;101:481–7
Effect of smoking, smoking cessation, and nicotine patch on wound dimension,
vitamin C, and systemic markers of collagen metabolism.
Anecdotal evidence suggests that some surgeons believe that providing cancer
patients with NRT will diminish the effect of surgery because of vasoconstriction.
Found that smoking abstinence using NRT had no effect on collagen synthesis or
wound size after seven days of healing, when compared to smoking abstinence with a
placebo patch.
Sorensen LT, et al. Surgery. 2010; 148:982–990.
Can I get a CAT Scan?
Patients should be asked about their smoking history. Patients who meet ALL of the
following criteria may be candidates for lung cancer screening:
55 to 74 years old (ACS), 80(CDC)
Have at least a 30 pack-year smoking history
Are either still smoking or have quit within the last 15 years
“I have not been successful with a patch”
RECOMMENDED PRACTICE IS TO USE
A NICOTINE PATCH AND A PRN NICOTINE.
CURRENT RECOMMENDED PRACTICE :
A NICOTINE PATCH AND A PRN NICOTINE.
“But I smoke Lights”
• A concern with reducing cigarette nicotine
content is that smokers may compensate, or
increase their smoking frequency/intensity
(e.g., increased daily consumption and/or
puffing).
“Will I go crazy on these meds?”
Neuropsych Safety of Smoking Cess Meds
Lancet; ePub 2016 Apr 22; Anthenelli, Benowitz, et al
• There was no significant increase in
neuropsychiatric adverse events
associated with varenicline or bupropion
relative to patch or placebo.
How many attempts needed to quit?
A recent study estimated 6-142!
30 was most reasonable answer.
• (BMJ 2016, 6, )
My friends say pick yourself up and do it!
Reluctance to seek treatment is that quitting is all about willpower.
This is how people thought about depression and alcoholism.
ITS AN ADDICTION!!!
Can I Still Drink?
Smoking is associated with ETOH use.
I am quitting what about my meds?May Decrease Effectiveness
• Beta Blockers
• Furosemide
• Nifedipine
• Warfarin
• H2 Blockers
• Anticonvulsants
NRT and Cardiovascular Ds.
Effect of Nicotine Replacement Therapy on Cardiovascular Outcomes After Acute Coronary
SyndromesOctober 2012-Volume 110, Issue 7, Pages 968–970
Wolfe MD et al.
The aim of the study was to determine the relationship between NRT use and adverse cardiovascular outcomes after ACS.
NRT use was not associated with an increased risk of
adverse cardiovascular events in the first year after
ACS.
Nicotine Replacement Therapy for Patients With Coronary Artery
Disease
• Transdermal nicotine did not affect angina frequency,
overall cardiac symptom status, nocturnal events,
arrhythmias, or episodes of ischemic ST segment
depression.
• Arch Intern Med. 1994;154(9):989-995.
NRT and The Heart
• No increase in CV events using NRT
• NRT plus smoking equivalent to smoking
Benowitz NL, Gourlay SG J Am Coll Cardiol 1997;29:1422-31
Benowitz-Progs in Cardiovascular Diseases, V. 46, No. 1, (July/August) 2003: pp 91-111
Tzivoni-Cardiovascular Drugs and Therapy 1998;12:239–244
Doc, I know about lung cancer and heart
attacks but what else?
STROKE
Est. incr. in risk for stroke from exposure to SHS is 20–30%.
• The Health Consequences of Smoking – 50 years of progress: a report of the Surgeon General. – Atlanta, GA. : U.S. Department of Health and Human
Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health,
2014. p. 944
COLORECTAL CANCER
Causal relationship between smoking and
colorectal adenomatous polyps/colorectal
cancer.
DIABETES
• The risk of developing dm is 30–40% higher for smokers.
• There is a positive dose-response relationship between the
number of cigarettes smoked and the risk of developing DM.
CAN I USE THESE MEDS LONGER?
Extended Use of Medications
NRTs do not contain nicotine toxic substances (e.g., “tar,”
carbon monoxide, formaldehyde, benzene).
They do not produce sharp surges in blood nicotine levels;
and/or produce strong dependence.
Doc, are E Cigs better than smoking?
AEROSOL
VAPOR??? AEROSOL???
E-CIG “SMOKE’
is a suspension of fine particles of liquid, solid or
both in a gas. gaseous state of a substance.
Electronic Cigarette
No data on delivery of nicotine .
No data on the blood nicotine levels achieved.
FDA shown that e-cigs contain carcinogens.
Benzaldehyde is found in E Cig vapors
Thorax. January 28, 2016. Kosmider L, Sobczak A, Prokopowicz A, et al.
E Cigs: What We Need to Know
• If you don't smoke, don't start vaping.
• You're better off with an FDA-approved method of quitting, like the
nicotine patch or gum. There's good evidence that they help.
• E-cigarettes may turn out to be an effective way to quit, but we don't
have the proof yet.
• If you're not planning to quit, would it be healthier to switch from
tobacco products to e-cigarettes? Maybe. Talk to your doctor about the
risks and benefits.
JOURNAL OF CIRCULATIONBENOWITZ
Circulation. 2014;129:1972-1986
Health claims and claims of efficacy for quitting smoking are unsupported
by the scientific evidence to date.
How can I talk to pts in a short time?
USPHS TASK FORCE Guidelines
•Ask –Identify tobacco users at every visit
•Advise - Strongly urge all smokers to quit
•Refer- to AHEC etc.
Treating Tobacco Use and Dependence:USPHS Taskforce: 2008 Update
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 =as never smoked by 10-15 yrs
Little or No Efficacy:
– Hypnosis
– Acupuncture
– Nicotine water/lollypops/lip balm/hand gel
– Cigarette-like devices
– Unassisted tapering/nicotine fading
– Laser
– Herbal remedies
Typical Trigger Situations
• Morning
• Coffee
• After meals
• In the car
• On the phone
• Stress
• Anger
• Anxiety
• Celebration
• Alcohol
“The most important thing you can do for your
health is to quit smoking. If you need help or
feel you cannot quit on your own, there are
programs staffed by qualified professionals
who can help you.”
SUMMARY
1. Its an addiction2. It’s a chronic disease!3. QUIT LINE, Referral lines.4. Meds help- withdrawal: Double NRT.5. Long term meds might be indicated.6. Remind them, "Quitting smoking is the most important
action they can take to improve their health now and in the future."
THE END!!!