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SMOKING CESSATION IN CLINICAL SETTINGS Sponsored by the

SMOKING CESSATION IN CLINICAL SETTINGS Sponsored by the Medical Society of the State of New York in conjunction with the Medical Educational and Scientific Foundation

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SMOKING CESSATION IN CLINICAL SETTINGS Sponsored by the

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  1. SMOKING CESSATION IN CLINICAL SETTINGS Sponsored by the Medical Society of the State of New York in conjunction with the Medical Educational and Scientific Foundation of New York, Inc. Grant support: NY State Dept. of Health Modified (with permission) for the Association of Program Directors in Internal Medicine, NY Special Interest Group. 2004 - 2005

  2. SMOKING CESSATION IN CLINICAL SETTINGS • OBJECTIVES: • At the end of this program, the learner will: • Have an understanding of a simple systematic approach to identifying and counseling current and former tobacco users using the Five A’s model. • Double cessation rates through brief advice to their patients. • Identify the biology of addiction and its pharmacologic treatment. • Have a familiarity with the national guidelines on effective tobacco dependence treatment.

  3. AHRQ 1-800-358-9295 Clinical Practice Guideline “Treating Tobacco Use and Dependence” NEW YORK STATE QUIT LINE www.nysmokefree.com “fax back” program 866-697-8487 866 NY-QUITS

  4. SMOKING CESSATION IN CLINICAL SETTINGS Introduction

  5. Tobacco Dependence Outline • Why Provide Treatment? • What is the Evidence it Works? • Public Health Service Guidelines • How can you do all this?

  6. Health effects of tobacco: • Cancer: Lung, Head and Neck, Bladder, Esophagus, Pancreas, Cervix • Coronary Artery Disease, Stroke, PVD, AAA • Chronic Lung Disease • Ulcer Disease • Osteoporosis • Low-birth weight, SIDS and URI’s in children • Leading cause of fatal home fires

  7. Actual Causes of Death 2000 Mokdad et al., JAMA 2004; 291:1238-1245

  8. Smoking in Perspective • Kills more than 440,000 Americans each year • 23% of adult Americans smoke • 3,000 children and adolescents become regular tobacco users every day • Causes cancer, heart disease, stroke, pulmonary disease, adverse pregnancy out-comes, and shortens life expectancy 14 years • Adds $157 billion in costs per year • One-third of all tobacco users in U.S. will die prematurely

  9. Environmental Tobacco Smoke(Second-hand Smoke) • Causes all the diseases that primary smoking causes. • Responsible for approximately 40,000 US deaths annually (most from CAD). • Leads to 1 million ER visits/yr for asthma. ASK PATIENTS ABOUT EXPOSURE TO ENVIRONMENTAL TOBACCO SMOKE!

  10. Health Benefits of Quitting • Cancers: Lung - after 10 years, former smokers have 70% lower risk compared to smokers Oral & Esophageal - 50% risk after 5 years • Cardiovascular disease: • CHD - 50% reduction in 12 months • Stroke - in 10 years risk is that of nonsmoker • PVD - 50% reduction in risk for former • smokers

  11. Clinical Preventive Services Priorities • In spite of best intentions, adult patients have an average of 12 risk factors requiring 24 preventive services. • Resources are limited, and knowledge that an intervention is effective is not sufficient to set priorities. • Therefore, interventions were assessed on two criteria.

  12. Clinically Preventable Burden (CPB) & Cost Effectiveness (CE) • CPB is the product of the burden of disease targeted by the service and its effectiveness and is represented as Quality Adjusted Life Years (QALY) • Proportion of disease and injury prevented if delivered to 100% of the target population • CE=costs of prevention - costs averted divided by the QALY’s saved expressed in 1995 dollars

  13. CPB and CE

  14. Priorities Among Services

  15. Cost Per Life Year Saved

  16. Summary • Screening and brief counseling for behavior change regarding tobacco use, problem drinking, and physical activity are delivered to less than 50% of the eligible US population. • Tobacco cessation services are highly cost-effective and can result in a significant reduction in disease burden. • Regular counseling is expected to improve patient health substantially.

  17. Tobacco use presents a rare confluence of circumstances • A highly significant health threat • A disinclination among clinicians to intervene consistently • The presence of effective interventions

  18. Tobacco Dependence as a Chronic Disease • Tobacco dependence demonstrates features of a chronic disease: • Long-term disorder • Periods of relapse and remission • Requires ongoing rather than acute care

  19. Opportunity for Intervention • 70% of smokers have made at least one unsuccessful quit attempt. • 46% of smokers try to quit each year. • More than 70% of smokers visit a health care setting each year. • Effective treatments exist which produce long-term or permanent abstinence.

  20. Perceived Health Risks Among Cigarette Smokers Ayanian & Cleary JAMA 1999;281:1091-1021

  21. Treatment of Smokers by MDs Thorndike et al., JAMA 1998;279:604-608

  22. RECOMMENDATIONS

  23. RECOMMENDATIONS It is essential that clinicians and health care delivery systems (including administrators, insurers, and purchasers) institutionalize the consistent identification, documentation, and treatment of every tobacco user seen in a health care setting.

  24. RECOMMENDATIONS Brief tobacco dependence treatment is effective, and every patient who uses tobacco should be offered at least brief treatment.

  25. Impact of Physician’s Advice to Quit (n = 7 studies) Odds Ratio (95%) CI Estimated Abstinence Rate Advice No advice to quit (reference group) 1.0 7.9% 1.3 (1.1-1.6) 10.2% Physician advice to quit

  26. Efficacy of Interventions Delivered by Various Types of Clinicians (n = 29 studies) Odds Ratio (95%) CI Estimated Abstinence Rate Type of Clinician No clinician (reference group) 1.0 10.2% 1.1 (0.9-1.3) 10.9% Self-help Non-physician clinician 1.7 (1.3-2.1) 15.8% 2.2 (1.5-3.2) Physician clinician 19.9%

  27. Efficacy of Various Intensity Levels of Person-to-Person Contact (n = 43 studies) Odds Ratio (95%) CI Estimated Abstinence Rate Level of Contact No contact (reference group) 1.0 10.9% 1.3 (1.01-1.6) Minimal counseling (< 3 minutes) 13.4% 1.6 (1.2-2.0) Low intensity counseling (3-10 minutes) 16.0% Higher intensity counseling (> 10 minutes) 2.3 (2.0-2.7) 22.1%

  28. CONCLUSION There is a strong dose-response relation between the intensity of tobacco dependence counseling and its effectiveness. Treatments involving person-to-person contact (via individual, group, or proactive telephone counseling) are consistently effective, and their effectiveness increases with treatment intensity (e.g., minutes of contact).

  29. RECOMMENDATION Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking. • Six first-line pharmacotherapies reliably increase long-term smoking abstinence rates: • Bupropion SR • Nicotine Nasal Spray • Nicotine Gum • Nicotine Patch • Nicotine Inhaler • Nicotine Lozenge

  30. Modes of Assistance

  31. Pharmacotherapeutic Interventions • All patients attempting to quit smoking should be encouraged to use pharmacotherapy except under special circumstances such as: • Medical contraindications • Smoking fewer than 10 cigarettes/day • Pregnant/breastfeeding women • Adolescents

  32. Effects of Nicotine • Release of dopamine & norepinephrine • Boost of energy and euphoria • Improved concentration, hand-eye coord. • Anorexia • Regular use creates physiologic dependence withdrawal, and cravings

  33. Nicotine Addiction • Per milligram dose, nicotine is the most addictive substance known to man. • Nicotine acts in the locus ceruleus which controls arousal, concentration, stress reduction, and appetite. • Nicotine is a stimulant in the reward pathway causing dopamine release creating dependency.

  34. Assessing nicotine addiction: • How soon after you wake up do you smoke your first cigarette? • How many cigarettes do you smoke in a day?

  35. Nicotine withdrawal syndrome has 5 of these sx in 24 hrs. • Depression or dysphoric mood • Insomnia • Irritability, frustration, or anger • Anxiety, restlessness, or impatience • Difficulty concentrating • Decreased heart rate • Increased appetite or weight gain

  36. Efficacy of Nicotine Gum (n = 13 studies) Estimated Abstinence Rate Odds Ratio (95%) CI Pharmacotherapy Placebo (reference group) 1.0 17.1% 1.5 (1.3 - 1.8) 23.7% Nicotine Gum

  37. Efficacy of Nicotine Inhaler (n = 4 studies) Estimated Abstinence Rate Odds Ratio (95%) CI Pharmacotherapy Placebo (reference group) 1.0 10.5% 2.5 (1.7 - 3.6) 22.8% Nicotine Inhaler

  38. Efficacy of Nicotine Nasal Spray (n = 3 studies) Estimated Abstinence Rate Odds Ratio (95%) CI Pharmacotherapy Placebo (reference group) 1.0 13.9% 2.7 (1.8 - 4.1) 30.5% Nicotine Nasal Spray

  39. Efficacy of Nicotine Patch (n = 27 studies) Estimated Abstinence Rate Odds Ratio (95%) CI Pharmacotherapy Placebo (reference group) 1.0 10.0% 1.9 (1.7 - 2.2) 17.7% Nicotine Patch

  40. Efficacy of Over-the-Counter NRT (n = 3 studies) Estimated Abstinence Rate Odds Ratio (95%) CI Pharmacotherapy Placebo (reference group) 6.7% 1.0 Over-the-Counter Nicotine Patch 11.8% 1.8 (1.2 - 2.8)

  41. Efficacy of Combination NRT (n = 3 studies) Odds Ratio (95%) CI Estimated Abstinence Rate Pharmacotherapy One NRT (reference group) 1.0 17.4% Two NRTs 1.9 (1.3 - 2.6) 28.6%

  42. Nicotine Replacement Therapy (NRT) • Nicotine is active ingredient • Supplied as steady dose (patch) or self-administered (gum, inhaler, nasal spray, or lozenge) • Self-administered products should be used on scheduled basis initially before tapered to ad lib use and eventual discontinuation

  43. Nicotine Replacement Therapy • No evidence of increased cardiovascular risk with NRT except with acute disease • Should abstain from smoking from the time you begin using these products • Medical contraindications: • immediate myocardial infarction (< 2 weeks) • serious arrhythmia • serious or worsening angina pectoris • accelerated hypertension

  44. Nicotine Gum • Transmucosal absorption • 2 mg (< 24 cigs/day) & 4 mg (> 24 cigs/day) • Scheduled dosing: every 1-2 hrs, >9/day, up to 24/day • Technique: chew and park • Do not use with acidic foods

  45. Nicotine Patch • Transdermal delivery 24 hr, 16 hr • >10 cig/day: 21mg or 15mg • Apply on Quit Date: trunk, hair-free, waist to neck or upper arm • New Patch daily, different spot • Careful disposal • S.E.’s: rash, insomnia

  46. Nicotine Nasal Spray • Trans nasal mucosa, fastest acting NRT • Dose: 1 spray each nostril = 1mg nicotine • Use: 1-2 doses/hr; total > 7 to <40/day • Technique: clear nose, tilt head, 1 spray each side, NO INHALING • S.E.’s: nasal, eye, throat irritation: tolerance develops

  47. Nicotine Inhaler • Transmucosal absorption, like gum • 10 mg cartridge delivers 4 mg nicotine with rapid inhalations (80/20 minutes) • Use: 6-16 cartridges/day • Technique: puncture cartridge, place in mouthpiece, use over 20 minutes • S.E.’s: throat, nasal, eye irritation: tolerance develops

  48. Nicotine Lozenge • Efficacy: Doubles to triples 12 mo cessation • Dosage: --2mg: smokes > 30 min after waking --4mg: smokes < 30 min after waking • First 6 weeks: 1 lozenge every 1-2 hrs, then taper • Technique: dissolve slowly, move around mouth

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