Consensus Recommendations from an Expert Panel

1. Adult Smoking Cessation: Intervention Strategies for Primary Care Providers Consensus Recommendations from an Expert Panel

2. Learning ObjectivesUpon completion of the program, the health care provider should be able to: • Asses an adult smoker’s readiness to quit smoking. • Implement the “5 A’s” of intervention • Describe the effectiveness of FDA-approved first-line pharmacotherapies for smoking cessation (e.g., nicotine-replacement therapy, bupropion) • Recognize the efficacy of behavioral therapies for smoking cessation • Implement the basic elements of a counseling intervention for smoking cessation

3. Sponsor Sponsored by the Illinois Academy of Family Physicians / Family Practice Education Network (IAFP/FPEN) Accreditation The Illinois Academy of Family Physicians / Family Practice Education Network is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Support This medical education program, Adult Smoking Cessation: Intervention Strategies for Primary Care Providers, is made possible through a grant from the Illinois Department of Public Health, Illinois Tobacco Free Communities Program.

4. Expert Panel

5. Introduction

6. Introduction • Surgeon General’s widely-used guideline for treatment of tobacco use and dependence in clinical settings: • Barriers to cessation intervention: • Less than one-quarter of smokers who attempted to quit use any type of cessation aid. Treating Tobacco Use and Dependence

7. You know the numbers • Since 1964, 12 million premature deaths attributed to smoking, nicotine dependence and its sequelae • For every smoking premature death each year, at least 20 smokers suffer a smoking-related disease • Rate of decline in adult smoking slowed in recent years. • 25% of Americans, 12 years and older smoke. • American Indians/Alaskan natives (37%) • Persons of two or more races (34%) • College grads (15%), no high school diploma (35%) • Children whose parents smoke are more likely to smoke

8. Smoking-Related Health Risks and the Benefits of Quitting

9. Smoking kills and maims • Harms nearly every organ in the body • New information, losses in renal filtration rate • 50% of current smokers will die of smoking related disease if they don’t quit

11. Source: The Office of the U.S. Surgeon General. The Health Consequences of Smoking. 2004 (Online at http://www.surgeongeneral.gov/library/smokingconsequences).

12. Cessation helps • The “Peter Jennings” story • Substantial reduction in risk of all-cause mortality among patients with CAD • Decrease in mortality among patients who had MI • Decreases cancer risk

13. Practice Recommendation Clinicians should encourage patients with coronary heart disease who smoke to quit, since smoking cessation isassociated with a substantial reduction in risk of all-cause mortality among patients with coronary heart disease. EBM Source: Cochrane Database of Systematic Reviews: Smoking cessation for the secondary prevention of coronary heart disease (Cochrane Review) Cochrane Database Syst Rev 2004. http://www.cochrane.org/cochrane/revabstr/AB003041.htm Strength of Evidence Results from 20 prospective cohort studies (12,600 patients) that measured smoking status on two or more occasions to ascertain those smokers who had quit, and followed-up on patients for 2 years or longer.

14. Try, try and try again • Slightly more than half who want to stop will attempt in a given year • Of those only 3% abstinent for 12 months • Typical “quitter” cycles through several periods of remission and relapse.

15. Patient Evaluation in the Primary Care Setting

16. The magic 3 questions • How much do you smoke (such as how often, how many cigarettes/day) • When do you smoke your first cigarette of the day? • What is the longest period of time between cigarettes before you crave another cigarette?

17. Nicotine addiction – likely • Smoke more than 20 cigarettes per day • Smoke 10-20 cigarettes per day with first cigarette within 30 minutes of waking Nicotine addiction – less so • 10-20 cigarettes per day • First cigarette more than 30 minutes after waking

18. Social smokers • Less than 10 cigarettes per day • However, moderate amounts of addiction may be demonstrated

19. Precontemplation Contemplation Preparation Action Relapse Maintenance Termination Adapted from: Knight J. Contemp Pediatr. 1997:14:45-72.

20. Stages of Change Focus on progression and change, not on immediate cessation

21. Adapted from: Velicer WF, et. Al. Addict Behav 1995; 20:299-320; Goldberg D, et.al. Dis Mon 2002;48:445-485.

23. Practice Recommendation Clinicians should screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. EBM Source: Agency for Healthcare Research and Quality: U.S. Preventive Services Task Force (USPSTF) Guideline: Tobacco Use and Counseling , 2003. http://www.ahrq.gov/clinic/uspstf/uspsbac.htm Strength of Evidence “A” Level of Evidence: The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

24. Motivating and Counseling Patients Who are Ready to Quit Smoking

25. Source: Hughes JR. CA Cancer J Clin 2000;50:147.

26. 5 R’s of Quitting • Relevance • Risks • Rewards • Roadblocks • Repetition R R R R R

27. Relapse • Most often in first three months of abstinence, with first few days crucial • Partner support may increase success • Enhance supportive behaviors, minimize critical behaviors

28. Smoking Cessation in Special Populations

29. Special populations Pregnant Women • Smoking cessation interventions during pregnancy reduce low birth weight and incidence of pre-term birth Hospitalized persons • High-intensity behavioral interventions including one month follow up Substance abuse treatment or recovery

30. Practice Recommendation Clinicians should encourage women who smoke to quit,since active smoking increases breast cancer risk; whenwomen stop smoking the risk disappears. EBM Source: Bandolier: Does Exposure to Smoke Increase Risk of Breast Cancer? (Original Citation: Reynolds P, et al. J National Cancer Inst 2004).http://www.jr2.ox.ac.uk/bandolier/booth/hliving/smobrca.html Strength of Evidence Study of 116,544 women (smoking statuses: never, former, and current) who had no diagnosis of breast cancer at the outset of study; follow-up of 5 years

31. Intervention— Pharmacotherapy

32. Nicotine replacement therapy • Gum, dermal patch, inhaler, nasal spray, lozenge • Doubles chance that quit attempt will be successful

33. Source: Hughes JR. CA Cancer J Clin 2000;50:147.

34. NRT • Effectiveness appears independent of intensity of support programs • No evidence of significant side effects • Caution with those who had recent MI (in past 2 weeks) • Recommended for pregnant women • Recommended for all who smoke 10 or more cigarettes per day. • Use regimen not ad lib

35. Practice Recommendation Healthcare providers should recommend nicotine-replacement therapy (NRT) to patients who wish to stop smoking, since all of the commercially-available forms of NRT are effective as part of a strategy to promote smoking cessation and increase the odds of quitting approximately 1.5 to 2-fold regardless of setting. EBM Source: Cochrane Database of Systematic Reviews: Nicotine Replacement Therapy for Smoking Cessation (Silagy C, et. al. Cochrane Database Syst Rev 2004. Issue 3. Article #: CD000146). http://www.cochrane.org/cochrane/revabstr/AB000146.htm Strength of Evidence Results from 103 randomized clinical trials that compared NRT to placebo or no treatment for a follow-up period of 6 months or greater.

36. Bupropion • Doubles odds of cessation as compared to placebo • Works better in men than women • Effectiveness undiminished by previous NRT use • On its own works better than NRT, except nasal spray NRT (equal) • Side effects mild, including insomnia, dry mouth, tremor and rash • Contraindicated for persons using MAOI, with seizure disorders, anorexia and bulimia • Can be used with NRT • Not contraindicated for pregnant women

37. Practice Recommendation Healthcare providers should recommend bupropion to patients who wish to stop smoking, since bupropion aids in long-term smoking cessation and doubles the odds of quitting relative to alternative therapies EBM Source: Cochrane Database of Systematic Reviews: Antidepressants for Smoking Cessation (Cochrane Review) Cochrane Database Syst Rev 2004. http://www.cochrane.org/cochrane/revabstr/AB000031.htm Strength of Evidence Meta-analysis of 25 randomized clinical trials, each with a follow-up of 6 months or greater, that compared bupropion to an alternative therapy for smoking cessation.

38. Second line therapies Not FDA approved • Clonidine • Mecamylamine • Opioid antagonists • Anxiolytics • Antidepressants

39. Practice Recommendation Healthcare providers should recommend individualbehavioral counseling to smokers who wish to quit, as such counseling has been shown to assist smokers who are trying to quit. EBM Source: Cochrane Database of Systematic Reviews: Individual Behavioral Counseling for Smoking Cessation (Cochrane Review) Cochrane Database Syst Rev 2002. http://www.cochrane.org/cochrane/revabstr/AB001292.htm Strength of Evidence Meta-analysis of 18 clinical trials with a follow up of 6 months or greater.

41. Costs and reimbursements

42. Costs and reimbursments • Buproprion: $3 to $5 per day • NRT: $5 to $10 per day • ICD-9 305.1 Tobacco dependence • Medicare now covers tobacco cessation counseling

45. Adult Smoking Cessation: Intervention Strategies for Primary Care Providers Consensus Recommendations from an Expert Panel