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Dispelling Myths About Treating Patients Who Smoke

Dispelling Myths About Treating Patients Who Smoke. Steven A. Schroeder, MD UCSF World No Tobacco Day, May 29, 2009 Presentation courtesy of The Smoking Cessation Leadership Center and Rx for Change. Tobacco’s Deadly Toll. 443,000 deaths in the U.S. each year

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Dispelling Myths About Treating Patients Who Smoke

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  1. Dispelling Myths About Treating Patients Who Smoke Steven A. Schroeder, MD UCSF World No Tobacco Day, May 29, 2009 Presentation courtesy of The Smoking Cessation Leadership Center and Rx for Change

  2. Tobacco’s Deadly Toll 443,000 deaths in the U.S. each year 4.8 million deaths world wide each year 10 million deaths estimated by year 2030 50,000 deaths in the U.S. due to second-hand smoke exposure 8.6 million disabled from tobacco in the U.S. alone

  3. * Also suffer frommental illness and/or substance abuse Behavioral Causes of Annual Deaths in the United States, 2000 435 Number of deaths (thousands) * * Sexual Alcohol Motor Guns Drug Obesity/ Smoking Behavior Vehicle Induced Inactivity Source: Mokdad et al, JAMA 2004; 291:1238-1245 Mokdad et al; JAMA. 2005; 293:293 3

  4. Health Consequences of Smoking Cancers Acute myeloid leukemia Bladder and kidney Cervical Esophageal Gastric Laryngeal Lung Oral cavity and pharyngeal Pancreatic Pulmonary diseases Acute (e.g., pneumonia) Chronic (e.g., COPD) Cardiovascular diseases Abdominal aortic aneurysm Coronary heart disease Cerebrovascular disease Peripheral arterial disease Type 2 diabetes mellitus Reproductive effects Reduced fertility in women Poor pregnancy outcomes (e.g., low birth weight, preterm delivery) Infant mortality Other effects: cataract, osteoporosis, periodontitis, poor surgical outcomes, cognitive decline U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2004.

  5. Compounds in Tobacco Smoke An estimated 4,800 compounds in tobacco smoke, including 11 proven human carcinogens Gases Particles • Carbon monoxide • Hydrogen cyanide • Ammonia • Benzene • Formaldehyde • Nicotine • Nitrosamines • Lead • Cadmium • Polonium-210 Nicotine does NOT cause the ill health effects of tobacco use.

  6. TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2007 Trends in cigarette current smoking among persons aged 18 or older 19.8% of adults are current smokers Male Percent Female 22.3% 17.4% Year 70% want to quit Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2005 NHIS. Estimates since 1992 include some-day smoking.

  7. PREVALENCE of ADULT SMOKING, by EDUCATION—U.S., 2007 24.8% No high school diploma 44.0% GED diploma 23.7% High school graduate 20.9% Some college 11.4% Undergraduate degree 6.2% Graduate degree Centers for Disease Control and Prevention. (2008). MMWR 57:1221–1116.

  8. STATE-SPECIFIC PREVALENCE of SMOKING among ADULTS, 2006 Prevalence of current smoking (2006) < 18.0% 18.0 – 19.9% 20.0 – 21.9% 22.0 – 23.9% ≥ 24.0% Centers for Disease Control and Prevention. (2007). MMWR 56:993–996.

  9. Heavy, Medium and Light/Nondaily Smokers in California 1990-2005 45 67 Source: California Tobacco Surveys (CTS) and University of California San Diego

  10. Smoking Cessation: Reduced Risk of Death • Prospective study of 34,439 male British doctors • Mortality was monitored for 50 years (1951–2001) On average, cigarette smokers die approximately 10 years younger than do nonsmokers. Years of life gained Among those who continue smoking, at least half will die due to a tobacco-related disease. Age at cessation (years) Doll et al. (2004). BMJ 328(7455):1519–1527.

  11. Reduction in Cumulative Risk of Death from Lung Cancer in Men Cumulative risk (%) Age in years Reprinted with permission. Peto et al. (2000). BMJ 321(7257):323–329.

  12. Physicians Under-treat Smokers* AAMC survey of 3012 physicians representing FM, GIM, Ob-Gyn, Psych Only 1% were current smokers 84% asked about smoking 86% advised to quit 31% recommended NRT 17% arranged follow-up 7% referred to quitlines *AAMC-Legacy survey: Physician behavior and practice patterns related to smoking cessation, 2007.

  13. Pharmacologic Methods: First-line Therapies* Three general classes of FDA-approved medications for smoking cessation: Nicotine replacement therapy (NRT) -- nicotine gum, patch, lozenge, nasal spray, inhaler Partial nicotine receptor agonist -- varenicline Psychotropics -- sustained-release bupropion * Counseling plus meds better than either alone Currently, no medications have an FDA indication for use in spit tobacco cessation.

  14. Combination NRT Combination NRT Long-acting formulation (patch) Produces relatively constant levels of nicotine PLUS Short-acting formulation (gum, lozenge, inhaler, nasal spray) Allows for acute dose titration as needed for withdrawal symptoms Bupropion SR + NRT The safety and efficacy of combination of varenicline with NRT or bupropion has not been established. • Because many of the remaining smokers are very addicted, use of combination therapies is becoming normalized.

  15. VARENICLINE Chantix, marketed by Pfizer Partial nicotinic receptor agonist Approved by the FDA May 2006, hit the market in the fall of 2006 Much DTC marketing in fall of 2007 Early trials (JAMA) show better results than bupropion Lessens withdrawal symptoms and inhibits the “buzz” from a smoke

  16. VARENICLINE: Warning In 2008, Pfizer added a warning label advising patients and caregivers: Patients should stop taking varenicline and contact their healthcare provider immediately if agitation, depressed mood, or changes in behavior that are not typical for them are observed, or if the patient develops suicidal ideation or suicidal thoughts.

  17. Caveats About Cessation Literature Smoking should be thought of as a chronic condition, yet drug treatment often short (12 weeks) in contrast to methadone maintenance Great spectrum of severity and addiction; treatment should be tailored accordingly Volunteers for studies likely to be more motivated to quit Placebo and drug groups tend to have more intensive counseling than found in real practice world Most drug trials exclude patients with mental illness Sharon Hall (UCSF) studies show 50% 52-wk point-prevalence cessation after long-term drug use plus extended counseling (“cold turkey rates <5%, most drug trials <25%)

  18. LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS 23.9 20.2 19.0 18.0 17.1 16.1 15.8 11.3 11.8 11.2 Percent quit 10.3 9.1 9.9 8.1 Data adapted from Cahill et al. (2008). Cochrane Database Syst Rev;Stead et al. (2008). Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev

  19. UCSF Then and Now Thanks to Gina Intinarelli and Suzanne Harris

  20. Adult Smoking Cessation Counseling for CHF Patients

  21. Treating Tobacco Dependence: 2003 • Hospital-Based • Inpatient Program • Behavioral Health/CD • Health System • Research > $800K • Leadership: ATMC • RWJF, CDC, AAHP • Formal HSI Program • Community • TOFCO • Oregon Quitline • Business Case • Target Groups • Disease Management • PHS employees • Web-Based • Women & Children • Clinical Programs SMOKER (who wants to quit) • Cessation • Group Classes • Free Medications • Telephone Support • Self-Help Materials • Prov-RN • Providers • 5 A’s Training/Education • Reimbursement • Physician Leadership • Clinics • 5 A’s Training • EMR Resources • Dissemination (TAR) • Resources: Primary Care, • Specialties, Pediatrics, OB/GYN • Evaluation • C.O.R.E. • Utilization • Grant Writing

  22. Counseling from the UCSFSmoking Cessation Team Rationale: Patients who want to quit may benefit from additional counseling and medications other than NRT High risk patients may require more intensive interventions For patients that were unable to be identified during the admission process or for urgent referrals page: 443-QUIT

  23. Nursing Workflow

  24. UCSF Medical Center Smoking Cessation Counseling DataApril 2009 Percent of all adult smokers counseled by nursing area Screening and preliminary counseling are done by Nursing. Upon request, follow-up smoking cessation counseling is done by Respiratory Care Services. The rate of patients unassessed for smoking status was 15% in March and April. Overall and Core Measure Smoking Counseling With preliminary data, core measure compliance is at 100% for February and 89% overall for April 2009.

  25. Myth + Answer • Myth: UCSF has no resources for its employees who smoke • Answer: UCSF offers cessation counseling and treatment for employees

  26. Tobacco Dependence Treatment Benefits for UCSF Medical Center andCampus Employees Reimbursement per participant (for what health insurance does not cover) includes: One 4-week Cessation Program ($55 value) Relapse Prevention visits up to 10 visits ($5 per visit) One physician visit ($140 value) Medication assistance such as patch, gum, varenicline, etc. (up to $75 with receipts)

  27. Tobacco Education Center (TEC)UCSF Helen Diller Family Comprehensive Cancer Center Founded 1999 Staffed by physicians trained in treating tobacco dependence, a nurse who is a former smoker and Certified Tobacco Treatment Specialist and pharmacists trained to assist smokers to stop smoking Contact Suzanne Harris, RN, CTTS suzanne.harris@ucsfmedctr.org 415-885-7895 (phone) 415-885-3852 (fax)

  28. TEC Services Cessation Group Program: Meets for 2 hours weekly for 4 consecutive weeks. Sessions cover issues related to smoking or health, information about medications, addiction and the brain, and tools for building motivation. Relapse Prevention Support Group: Meets weekly for 1 ¼ hours and is available to graduates of the Cessation Program, whether or not they are smoke free. Individual consultations:with physicians available by appointment.

  29. Myth + Answer • Myth: UCSF employees cannot do anything about smoking on campus • Answer: UCSF became smoke-free in November 2008. Employees can report violations to their department and/or police

  30. Knowledge of Tobacco Cessation Programs Among California Smokers† † Data from the California Tobacco Survey, 1999. For the unaided recall question, survey respondents were asked, “Can you name up to 3 programs that are helpful to people who are trying to quit smoking?” The aided recall question was asked only in reference to the quitline: “Have you ever heard of the 1-800-NO-BUTTS (or, in Spanish, 1-800-45-NO-FUME) phone number?” * CI = confidence interval.

  31. Referrals by Type to the California Smokers’ Helpline, 2004-2007

  32. Smoking and Mental Illness: The Heavy Burden 200,000 of the 435,000 annual deaths from smoking occur among patients with CMI and/or substance abuse This population consumes 44% of all cigarettes sold in the United States -- higher prevalence -- smoke more -- more likely to smoke down to the butt People with CMI die on average 25 years earlier than others, and smoking is a large contributor to that early mortality Social isolation from smoking compounds the social stigma

  33. MH/SA Myths “They can’t quit” “They don’t want to quit” “Clinicians don’t have time to do this on top of everything else” “I’ve always heard smoking helps symptoms. I don’t want to make their symptoms worse.” “They will lose their sobriety if they also try to quit smoking” University of Colorado Denver Behavioral Health and Wellness Program

  34. MH/SA Myths (2) “Smoke breaks are a time when I build relationships with clients” “I don’t have the training necessary” “Why spend time on this when there are more important psychiatric, substance abuse, and medical issues?” “This is one of their last personal freedoms” “If we go tobacco-free, behavioral problems will increase on the unit” “The issues we face are unique” University of Colorado Denver Behavioral Health and Wellness

  35. Rx for Change: Provider Curricula

  36. Tobacco Policy Update, 2009 • Taxes -62 cent federal tax increase -many recent state increases, with more to come • FDA regulation: passed the House, Senate pending • Continued expansion of smoke-free areas • SAMHSA interest in cessation for mental illness/substance abuse population • Stimulus package--$1 billion for prevention

  37. Unresolved Issues Treatment of light/intermittent smokers? Chronic use of cessation medications? Best treatment for MI/SA populations? Greater clinician involvement? Third hand smoke? How low can prevalence go? 1.3 million returning combat vets, 1/3 of whom smoke

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