Tobacco Cessation:Curb the Deadliest Epidemic
Keith Bradley, MD
Director,
Research Associates Program at St. Vincent’s
National Alliance of Research Associates Programs
(NARAP)
Nicotine-Related Pathology
• coronary artery • peripheral vascular disease• hypertension • peptic ulcer disease• fetal mortality and morbidity• cancer
Lung Cancer
All lung cancers begin as small focus of
uncontrolled cell division
→ thickening/piling up of bronchial mucosa.
Lung Cancer
• Small cell
• Adenocarcinoma
• Squamous carcinoma
• Large cell carcinoma
Small Cell Carcinoma
Small Cell Carcinoma
• 20% of all lung cancers
Small Cell Carcinoma
• 20% of all lung cancers
• highly aggressive, metastasizing early.
Small Cell Carcinoma
• 20% of all lung cancers
• highly aggressive, metastasizing early.
• only 1% of cases occur in non-smokers
Small Cell Carcinoma
• 20% of all lung cancers
• highly aggressive, metastasizing early.
• only 1% of cases occur in non-smokers
• incurable by surgery
Small Cell Carcinoma
• 90% of small cell carcinomas begin in central airways
Small Cell Carcinoma
• 90% of small cell carcinomas begin in central airways– consistent with smoking association
Small Cell Carcinoma
• 90% of small cell carcinomas begin in central airways– consistent with smoking association
• Small cell staged as limited
or extensive (spread outside chest)
Small Cell Carcinoma
• 90% of small cell carcinomas begin in central airways– consistent with smoking association
• Small cell staged as limited
or extensive (spread outside chest) – 70% are extensive at diagnosis
Adenocarcinoma
Adenocarcinoma
• About 40% of lung cancer cases in the US
Adenocarcinoma
• About 40% of lung cancer cases in the US • The most common lung cancer among
women
Adenocarcinoma
• About 40% of lung cancer cases in the US • The most common lung cancer among
women– number of new cases is increasing
Adenocarcinoma
• About 40% of lung cancer cases in the US • The most common lung cancer among
women– number of new cases is increasing
• Usually starts near the outer edges of the lungs
Adenocarcinoma
• About 40% of lung cancer cases in the US • The most common lung cancer among
women, – number of new cases is increasing
• Usually starts near the outer edges of the lungs
• Often metastasized at diagnosis
Squamous Carcinoma
Squamous Carcinoma
• 25-30% of lung cancer cases in the US
Squamous Carcinoma
• 25-30% of lung cancer cases in the US • Occurs most frequently in men and the
elderly
Squamous Carcinoma
• 25-30% of lung cancer cases in the US • Occurs most frequently in men and the
elderly • Usually starts in one of the larger breathing
tubes
Squamous Carcinoma
• 25-30% of lung cancer cases in the US • Occurs most frequently in men and the
elderly • Usually starts in one of the larger breathing
tubes • Tends to grow relatively slowly
Squamous Carcinoma
• 25-30% of lung cancer cases in the US • Occurs most frequently in men and the
elderly • Usually starts in one of the larger breathing
tubes • Tends to grow relatively slowly • Tends to remain localized in the chest longer
than other types of lung cancer
Squamous Carcinoma
• 25-30% of lung cancer cases in the US • Occurs most frequently in men and the
elderly • Usually starts in one of the larger breathing
tubes • Tends to grow relatively slowly • Tends to remain localized in the chest longer
than other types of lung cancer • Does not metastasize early
Large Cell Carcinoma
Large Cell Carcinoma• “Other”
– tend to have larger cells than other types of lung cancer
Large Cell Carcinoma• “Other”
– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing
– may be due to improvements in determining the types of lung cancer
Large Cell Carcinoma• “Other”
– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing
– may be due to improvements in determining the types of lung cancer
• 10-15% of lung cancer cases in the US
Large Cell Carcinoma• “Other”
– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing
– may be due to improvements in determining the types of lung cancer.
• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes
Large Cell Carcinoma• “Other”
– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing
– may be due to improvements in determining the types of lung cancer
• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes • May occur in any part of the lung
Large Cell Carcinoma• “Other”
– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing
– may be due to improvements in determining the types of lung cancer.
• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes • May occur in any part of the lung • Tumors are usually large at diagnosis
Large Cell Carcinoma• “Other”
– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing
– may be due to improvements in determining the types of lung cancer.
• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes • May occur in any part of the lung • Tumors are usually large at diagnosis• Tends to invade the mediastinum
(chest area behind the breastbone)
Large Cell Carcinoma• “Other”
– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing
– may be due to improvements in determining the types of lung cancer.
• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes • May occur in any part of the lung • Tumors are usually large at diagnosis• Tends to invade the mediastinum
(chest area behind the breastbone)• Metastasizes to the central nervous system
Nicotine Addiction
Nicotine Addiction
• Psychoactive
Nicotine Addiction
• Psychoactive– dose-related changes in mood and feeling
Nicotine Addiction
• Psychoactive– dose-related changes in mood and feeling – transient
Nicotine Addiction
• Psychoactive– dose-related changes in mood and feeling – transient
• Euphoriant
Nicotine Addiction
• Psychoactive– dose-related changes in mood and feeling – transient
• Euphoriant – dose-related increases in scores on standard
measures of euphoria. •
Nicotine Addiction
• Psychoactive– dose-related changes in mood and feeling – transient
• Euphoriant – dose-related increases in scores on standard
measures of euphoria. • Reinforcer
Nicotine Addiction
• Psychoactive– dose-related changes in mood and feeling – transient
• Euphoriant – dose-related increases in scores on standard
measures of euphoria. • Reinforcer• Neuroadaptation
Nicotine Addiction
• Psychoactive– dose-related changes in mood and feeling – transient
• Euphoriant – dose-related increases in scores on standard
measures of euphoria. • Reinforcer• Neuroadaptation
– leading to tolerance and physiologic dependence.
Nicotine Addiction
nicotine from the use of tobacco has
≈ physical addiction potential as morphine
Nicotine Addiction
nicotine from the use of tobacco has
≈ physical addiction potential as morphine
≈ psychic dependence as cocaine
Smokeless Tobacco
• pharmacokietics of nicotine
(i.e., absorption, distribution, and elimination)
from smoking and from smokeless tobacco
→ magnitude of nicotine exposure similar
Tobacco Cessation
Tobacco Cessation
• Treating Tobacco Use and Dependence. U.S. Public Health Service. http://www.surgeongeneral.gov/tobacco/smokesum.htm
• Guideline, Treating Tobacco Use and Dependence– based on the literature review and expert panel
opinion
Which Smokers Offered Cessation ?
• Because effective tobacco dependence treatments are available,
every patient who uses tobacco should be offered at least one of these treatments:– Patients willing to try to quit tobacco use should
be provided treatments identified as effective in this guideline.
– Patients unwilling to try to quit tobacco use should be provided a brief intervention designed to increase their motivation to quit.
Which Smokers Offered Cessation ?
“It is essential that clinicians and
health care delivery systems …
institutionalize the consistent
identification, documentation, and
treatment
of every tobacco user seen in a health
care setting.”
Brief Tobacco Dependence Tx
Brief Tobacco Dependence Tx
• should be: – effective
Brief Tobacco Dependence Tx
• should be: – effective– offered to every patient who uses tobacco
Brief Tobacco Dependence Tx
• should be: – effective– offered to every patient who uses tobacco
• Quitlines
Brief Tobacco Dependence Tx
• should be: – effective– offered to every patient who uses tobacco
• Quitlines:– mandated by tobacco company settlements
Brief Tobacco Dependence Tx
• should be: – effective– offered to every patient who uses tobacco
• Quitlines:– mandated by tobacco company settlements– about 30-40% effective
Tx Dose-Response Relationship
Tx Dose-Response Relationship
• strong relationship between intensity of tobacco dependence counseling and its effectiveness
Tx Dose-Response Relationship
• strong relationship between intensity of tobacco dependence counseling and its effectiveness
• person-to-person treatments (individual, group, or telephone counseling)
Tx Dose-Response Relationship
• strong relationship between intensity of tobacco dependence counseling and its effectiveness
• person-to-person treatments (individual, group, or telephone counseling):– consistently effective
Tx Dose-Response Relationship
• strong relationship between intensity of tobacco dependence counseling and its effectiveness
• person-to-person treatments (individual, group, or telephone counseling):– consistently effective– effectiveness increases with treatment intensity
(e.g., minutes of contact)
Types of Counseling and Behavioral Tx
Types of Counseling and Behavioral Tx
1. Provision of practical counseling
(problem solving/skills training)
Types of Counseling and Behavioral Tx
1. Provision of practical counseling
(problem solving/skills training)
2. Provision of social support as part of tx
(intra-treatment social support)
Types of Counseling and Behavioral Tx
1. Provision of practical counseling
(problem solving/skills training)
2. Provision of social support as part of tx
(intra-treatment social support)
3. Help in securing social support outside of tx (extra-treatment social support)
Pharmacotherapies
Pharmacotherapies
Reliably increase long-term smoking abstinence
Pharmacotherapies
Reliably increase long-term smoking abstinence• Nicotine
– gum– inhaler – nasal spray– patch
Pharmacotherapies
Reliably increase long-term smoking abstinence• Nicotine
– gum– inhaler – nasal spray– patch
“Over-the-counter nicotine patches are effective relative to placebo, and their use should be encouraged.”
Pharmacotherapies
Reliably increase long-term smoking abstinence• Nicotine
– gum– inhaler – nasal spray– patch
“Over-the-counter nicotine patches are effective relative to placebo, and their use should be encouraged.”
• Bupropion (Wellbutrin) SR • Other anti-depressants
Effective Pharmacotherapies
Except in the presence of contraindications,
these should be used with all patients
attempting to quit smoking.
$ ?
$ ?
Insurers should include as a reimbursed
benefit:
$ ?
Insurers should include as a reimbursed
benefit:• counseling and pharmacotherapeutic
treatments identified as effective in this guideline.
$ ?
Insurers should include as a reimbursed
benefit:• counseling and pharmacotherapeutic
treatments identified as effective in this guideline.
• clinicians for providing tobacco dependence treatment just as they are reimbursed for treating other chronic conditions.
Clinicians and Tobacco Cessation
• About 20 years ago, data indicated that clinicians too frequently failed to intervene with their patients who smoke.
Clinicians and Tobacco Cessation
• About 20 years ago, data indicated that clinicians too frequently failed to intervene with their patients who smoke.
• Recent data confirm this has not changed markedly over the past two decades.
Clinicians and Tobacco Cessation
One recent study reported: • only 15 percent of smokers who saw a
physician in the past year
were offered assistance with quitting
Clinicians and Tobacco Cessation
One recent study reported: • only 15 percent of smokers who saw a
physician in the past year
were offered assistance with quitting • only 3 percent were given a follow-up
appointment to address this topic.
Bottom Line
These evidence-based guidelines reveal:
Bottom Line
These evidence-based guidelines reveal: 1. multiple efficacious tobacco cessation tx exist
Bottom Line
These evidence-based guidelines reveal: 1. multiple efficacious tobacco cessation tx exist 2. these tx can double or triple the likelihood of long-
term cessation
Bottom Line
These evidence-based guidelines reveal: 1. multiple efficacious tobacco cessation tx exist 2. these tx can double or triple the likelihood of long-
term cessation 3. many cessation tx are appropriate for the
primary care setting
Bottom Line
These evidence-based guidelines reveal: 1. multiple efficacious tobacco cessation tx exist 2. these tx can double or triple the likelihood of long-
term cessation 3. many cessation tx are appropriate for the
primary care setting4. cessation tx are more cost-effective than many
other reimbursed clinical interventions
Bottom Line
These evidence-based guidelines reveal: 1. multiple efficacious tobacco cessation tx exist 2. these tx can double or triple the likelihood of long-
term cessation 3. many cessation tx are appropriate for the
primary care setting4. cessation tx are more cost-effective than many
other reimbursed clinical interventions5. utilization and impact of cessation treatments can
be increased by supportive health system policies (e.g., coverage through insurance)
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