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Addiction Medicine: Introduction to Smoking Cessation. Edward Anselm, M.D. Chief Medical Officer, FidelisCare, New York Assistant Professor of Medicine, Mount Sinai School of Medicine EdwardAnselmMD.com eanselm@msn.com. Smoking Today. 1.3 Billion smokers worldwide 47% of men; 12% of women
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Addiction Medicine:Introduction to Smoking Cessation Edward Anselm, M.D. Chief Medical Officer, FidelisCare, New York Assistant Professor of Medicine, Mount Sinai School of Medicine EdwardAnselmMD.com eanselm@msn.com
Smoking Today • 1.3 Billion smokers worldwide • 47% of men; 12% of women • 45 Million adults (21% of adults) • 23.4% of men; 18.5% of women • Significant state to state variation • 50% decline in US smokers since 1965
Findings and Recommendations of the Panel I 1. Tobacco dependence is a chronic condition that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long term abstinence. 2. It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting 2008 Clinical Practice Guideline: Treating Tobacco Use and Dependence
Vital Signs Stamp VITAL SIGNS Blood Pressure: Pulse: Weight: Temperature: Respiratory Rate: Tobacco Use: Current Former Never (circle one)
Effect of General Practitioners’ Advice Against SmokingRussell, MAH et al, , BMJ 1979 2, 231-5
Findings and Recommendations of the Panel II 3. Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use the counseling treatments and medications recommended in this Guideline. 4. Brief tobacco dependence is effective. Every clinician should offer every patient who uses tobacco at least the brief treatments shown to be effective in this Guideline. 2008 Clinical Practice Guideline: Treating Tobacco Use and Dependence
Findings and Recommendations of the Panel III 5. Individual, group, and telephone counseling are effective and their effectiveness increases with treatment intensity. To components of counseling are especially effective, and clinicians should use them when counseling patients to make a quit attempt: Practical Counseling (problem solving/skills training)Social Support delivered as part of treatment 2008 Clinical Practice Guideline: Treating Tobacco Use and Dependence
Findings and Recommendations of the Panel IV 6. Numerous effective medications are available for tobacco dependence, and clinicians should encourage their use with all patients attempting to quit smoking-except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e. Pregnant women, smokeless tobacco users, light smokers, and adolescents). Seven first-line pharmacotherapies were identified that reliably increase smoking abstinence rates; Buproprion SR Nicotine Gum, Nicotine Inhaler, Nicotine Lozenge Nicotine Nasal Spray Nicotine patch Varenciline Clinicians should also consider the use of certain combinations of medications identified as effective in this guideline. 2008 Clinical Practice Guideline: Treating Tobacco Use and Dependence
Findings and Recommendations of the Panel V 7. Counseling and medication are effective when used by themselves. The combination of medication and counseling, however is more effective than either alone. Thus clinicians should encourage all individuals making a quit attempt to use both counseling and medication. 2008 Clinical Practice Guideline: Treating Tobacco Use and Dependence
Findings and Recommendations of the panel VI 8.Telephone quitline counseling is effective with diverse populations and has broad reach. Therefore, both clinicians and health care delivery systems should insure patient access to quitlines and promote quitline use 9. If a tobacco user is unwilling to make a quit attempt then clinicians should use motivational treatments shown in this Guideline to be effective in increasing future quit attempts. 2008 Clinical Practice Guideline: Treating Tobacco Use and Dependence
Findings and Recommendations of the panel VII 10 Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders. Insurers and purchasers should ensure that all insurance plans include as the counseling and medications identified as effective in this guideline as covered benefits. 2008 Clinical Practice Guideline: Treating Tobacco Use and Dependence
Role of the Physician Ask about smoking Advise tobacco users to quit Assess readiness to quit Assist with a plan for quitting Arrange follow-up
Addictive elements of smoking • Nicotine • Nicotine mediated dopamine release • Menthol and other anesthetics • Mono-amine oxidase inhibitors • Sensory cues • Oro-pharygeal • Tactile • Brand identification and loyalty • Flavorings (honey, licorice, cocoa) • Physiologic
The smokers point of view What does smoking do for me? • Pleasure • Stress management • Habit • Social habit • Brand Identification • Part of self-concept
The Behavior of Smoking I Early Experimentation Brand Identification Regular Smokers Chippers Light Smokers Heavy Smokers Interest in quitting
The Behavior of Smoking II Nicotine delivery in eight seconds Most smokers maintain a steady level of nicotine 10-12 puffs per cigarette 20 cigarettes per day (200 puffs) 7300 cigarettes per year (73,000 puffs)
The Behavior of Smoking III Oft repeated habit Social situations Stress management Associated with food, alcohol Low awareness of risk Fear of failure
Nicotine Withdrawal Anxiety irritability anger restlessness difficulty concentrating craving
Nicotine Dependency First cigarette within 30 minutes of awakening. Smoke more within the first few hours of awakening than the rest of the day Smoke when sick in bed Smoke in places where prohibited One or more pack per day
Choices in smoking cessation interventions • Counseling only • Drug only • Counseling and drug • Which drug • How to manage side effects • What to do after relapse
Smoking History • Years smoking • Daily usage • Brand identification • Current diagnoses and treatments • Never quit-a marker for mental illness? • Past quit attempts • Longest duration of abstinence • Reason(s) for relapse • Nicotine dependency
Psychiatric Co-morbidities • Depression/Past Depression • Alcohol • Substance Abuse • Anxiety Disorders • Schizophrenia • OCD • Situational anxiety-self medication
The Natural History of Smoking Cessation 50 Million former smokers 3-5 efforts to quit smoking each effort resulted in longer periods of abstinence from smoking process over several years
Methods of Smoking Cessation Self Help Physician Advice Counseling Social Support Hypnosis/Acupuncture Smoking Cessation Classes Medication
Stages of Change Pre-contemplation 85% of smokers Contemplation 15% Action Maintenance Relapse
Smoking Cessation and Weight Gain Smokers weigh less than non-smokers 5-10 pound gain, on average Less initial weight gain with use of medication
Cultural self-efficacy • Tobacco use is declining • Taxes increasing • Smoke-free environments • Physicians are trained in smoking cessation interventions • Effective treatment is available
Harm Reduction Low Nicotine Cigarettes Nicotine Replacement Buproprion
Lessons from Tobacco Advertising and Marketing • Create Brand Identification and Loyalty • Understand your audience • Tailor your message on a local level • Repetition • Incentives and Rewards • Counter-advertising • Normalization • Disinformation
A Brief History of Tobacco Control I • Early warnings 1948 • First Surgeon General’s Report 1964 • Fairness Doctrine 1967-1970 • Removal of Tobacco advertisement from television and radio 1970 • Tobacco Warning labels • Role of the Tobacco Institute
A Brief History of Tobacco ControlII • Marketing of light cigarettes • Indoor pollution control 1987 • First Clinical Practice Guideline on smoking cessation 1996 • Master Settlement Agreement, 1998
A Brief History of Tobacco ControlIII • Media-based interventions • Medications for smoking cessation • Telephonic quit lines • Local and state interventions • CDC documents best practices, 1999 • sets funding targets @$15-20 per capita, 2007 • FDA Regulation of nicotine, 2009