What’s new in tobacco cessation

1. What’s new in tobacco cessation Lynne J. Goebel, MD, FACP Professor Internal Medicine Joan C. Edwards School of Medicine Marshall University

2. Tobacco Cessation Provider Training • Thanks to a grant from the WV Department of Health and Human Resources Division of Tobacco Prevention

3. Study Pre and post lecture questions 3 month brief follow up survey – mail or email link to anonymous survey Evaluation forms for CE credit

4. What is your age? • 20-30 • 31-40 • 41-50 • 51-60 • 61 or more :00 Answer Now

5. What is your gender? • Male • Female :00 Answer Now

6. What is your profession? • Physician • Dentist • Dental hygienist • Nurse practitioner /physician assistant • Nurse • Other :00 Answer Now

7. How often do you recommend pharmacotherapy to your patients trying to quit tobacco use? • Very frequently • Frequently • Average • A little • Not at all :00 Answer Now

8. ObjectivesBy the end of this presentation you will be able to: • Recall the tobacco cessation guidelines • Counsel your patients using motivational interviewing techniques • Recommend pharmacotherapy for tobacco cessation • Recall procedures for reimbursement for tobacco cessation counseling

9. Guidelines: the 5 A’s • Ask- every visit • Advise – clear and personalized • Assess –Ready to quit in next 30 days? • Assist – Counsel/Handouts/Drugs • Arrange- follow up http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf

10. Guidelines - Modified • Ask • Advise • Refer to quitline

11. Counseling

12. Stages of Behavioral Change • Precontemplation • Contemplation • Preparation • Action • Relapse • Maintenance • Termination

13. Stage of Change • Precontemplation = Says “I’m taking them to the grave” • Not willing to “hear” risks • Often labeled “hopeless case”

14. How do you counsel a patient in the precontemplation stage? • Advise him in a clear and personalized manner to quit. • Argue that smoking is causing his problems even if he denies it. • Avoid talking about it since it only aggravates the patient. • Tell him that he may get cancer if he doesn’t quit. :00 Answer Now

15. Counseling Strategy for Precontemplation Stage • Advise to quit in a clear and personalized manner • Give a supportive statement, “Let me know when you are ready to quit and I will help you.” • Give an empowering statement: “Only you can decide when it’s right for you to quit.”

16. Precontemplation counseling • Motivational interviewing - a way to have a conversation about the problem behavior that may lead the patient to make a change (increases patient’s likelihood of making a future quit attempt.) • EX. Decision analysis

18. Contemplation Stage of Change • Says, “I know I should quit, but it’s just not the right time.” • Considering changing in the next 6 months • Often labeled as procrastinators

19. Motivational Interviewing Use your OARS Open ended questions – “What concerns you about your smoking?” “What do you think would be the hardest part of quitting?”

20. OARS Affirm – recognize the patient’s strengths – “It’s great that you were able to quit for a few months. You were able to make it through the worst withdrawal symptoms.”

21. OARS cont’d Reflect – Restate what the patient said, 3:1 ratio (3 patient reflections to one provider comment). “So you use smoking as something to do when you are bored.. . .” Comment “I have some suggestions, would you like to hear them?”

22. OARS Summarize your reflections: “Let me see if I have this correct. . .You know you need to quit but you are too stressed to make a quit attempt right now. . .” and then: “What’s the next step?” “Do you see yourself making any changes in the next month?” (Change smoking pattern.) Create a change plan if pt. is ready.

24. Motivational Interviewing tips for success • Express empathy (“It must be hard for you to quit when your spouse smokes too.”) • Develop discrepancy (“It sounds like you are very devoted to your children. Have you thought about how your smoking affects your children?”) • Roll with Resistance – back off and redirect – go for the money! • Let the decision to change come from the patient

26. Contemplation • 45 year old male s/p recent MI. He knows he needs to quit. Last time he tried he gained 20 lbs. He scored 6/10 for ready, 10/10 important, 5/10 successful. He says that if it wasn’t for the gain in weight he would be ready to try again.

27. What is the best counseling strategy regarding weight gain and smoking cessation? • All of the smoking cessation drugs cause weight gain so avoid these. • Weight gain is only 30 pounds on average. • Go on a strict diet at the same time you quit smoking to avoid weight gain. • Exercise can help counteract weight gain and does not affect success at smoking cessation. :00 Answer Now

28. Video example

29. Modified Guidelines • Ask • Advise • Refer (to Quitline if ready to set quit date)

30. Resources • State Quitline • 1-877-966-8784 (1 877 Y NOT QUIT) • Free nicotine replacement –gum, patches, lozenges for most WV residents • 2-4 telephone counseling sessions with a trained cessation counselor • http://ynotquit.workbetter.net/

31. WV QUITLINE • Since 2000, enrolled over 43,000 people or 11% of the state’s smokers • Average 1 yr quit rate 25.3% • Expanded hours 8AM-9PM M-F and 8AM-5PM Sat and Sun • New fax referral

32. Pharmacotherapy for Tobacco Cessation • Nicotine replacement • Non-nicotine medication • Bupropion (Zyban, Wellbutrin SR) • Varenicline (Chantix)

33. Nicotine Replacement • Nicotine gum – OTC • Nicotine patch –OTC • Nicotine nasal spray – Rx • Nicotine Inhaler – Rx • Nicotine Lozenge – OTC

34. Limitations of Nicotine Replacement Rx • Nicotine gum: Not used properly. Chew and park. Avoid acidic beverages. • Nicotine nasal spray: Burns your nose. ?addiction potential in 15-20% • Nicotine inhaler: Looks funny. • Transdermal patch preferred treatment option. 8 weeks of treatment max. 4/2/2 • One year success rate 20 - 30%. Berrettini et al: Pharmacotherapy and pharmacogenetics of nicotine dependence. American Journal of Psychiatry. Vol. 62; 1441-1451; August 2005

35. Nicotine replacement • Safe in patients with heart disease, but not in first two weeks after MI, unstable angina or serious arrhythmias • If insomnia, remove patch before bed or use the 16 hour patch • Combining patch with gum/lozenge/spray may increase success rate

36. NEW: Pre-cessation NRT • One study used patches 2 wks prior to quitting and then 12 wks after, increase in abstinence at 6 months • Another study increased abstinence at 4 weeks but not at 6 months • Conflicting results

37. NEW: Use of NRT to decrease smoking • Gum, inhaler or patch or a combination of these in patients not ready to quit • Use of NRT to cut down smoking resulted in twice as many smokers being abstinent at 12 months – but only 8.4% abstinence rate (OR 2.5 CI 1.7-3.7) • Needs more research

38. Bupropion SR • Antidepressant • Increases dopamine – reward pathway • Start at 150 SR daily for three days then increase to twice daily if tolerated • Quit smoking after 1-2 weeks on drug • Treat for 2 - 6 months or longer

39. Bupropion: Summary ADVANTAGES • Bupropion is an oral formulation with twice-a-day dosing. • Bupropion might be beneficial for patients with depression. DISADVANTAGES • Contraindications: seizure disorder, anorexia nervosa, MAO inhibitor use. • Caution: Cytochrome P450 drugs, alcohol or benzodiazepine use, hepatic disease, HTN

40. Bupropion side effects • Insomnia (35%) and dry mouth (10%) most common • If insomnia, cut back to just daytime dose or take the PM dose earlier but at least 8 hours after the AM dose

41. Varenicline • Brand name Chantix • Partial agonist to receptor in the brain that controls release of dopamine (reward system)

43. Chantix (vareniciline) dosing • Start pills 1 week before quit date. • Chantix Starter Pak • Chantix Continuation Pak: 1 mg twice a day • Dosing: Renal Impairment: • CrCl 30 mL/minute: No adjustment required • CrCl <30 mL/minute: Initiate: 0.5 mg once daily; maximum dose: 0.5 mg twice daily • Hemodialysis: Maximum dose: 0.5 mg once daily

44. Varenicline: Summary ADVANTAGES • Varenicline is an oral formulation with twice-a-day dosing. • No significant drug-drug interaction • Overall discontinuation rate reported in studies is only 3% DISADVANTAGES • May induce nausea in up to one third of patients. • Post-marketing surveillance suggestive of suicidal ideation.

45. Chantix (varenicline) • If nausea cut dose in half for a week and then try to increase again. • If patient successful during the first 12 weeks, may continue for another 12 weeks for highest success rate.

46. Special Populations • Pregnant women • Adolescents • Smokeless tobacco users

47. Maternal Smoking in WV • In 2005, 26.6% of mothers smoked during pregnancy • Low birth weight higher among smokers 15% compared to non smokers 7.6% • Preterm births higher among smokers 14.1% compared to non smokers 11.9%

48. Stats on WV babies • Infant mortality/SIDS rate higher - 11.1 per 1000 live births among smokers compared to 6.8 for non smokers

49. Pregnant women • Nicotine patch (Wisborg et al, 2000) • 250 smokers, placebo controlled trial • Used 15 mg patch (16 hr) then 10 mg patch • No significant difference in quit rates on patch • Higher birthweight on patch • Smaller study patch (Kapur et al, 2001) 38% stayed off smoking until after delivery-short term benefit?

50. Pregnant women • 181 women randomized to NRT plus counseling vs. counseling – stopped early due to increase in adverse events in NRT group (preterm labor) 30% vs. 17%