Tobacco Cessation

1. Tobacco Cessation Ask your patients about tobacco use. Act to help them quit.

2. The Problem • Tobacco use is a chronic disease. • 24% of American men and 19% of American women smoke. • Smoking-related diseases claim 440,000 American lives each year. • Smoking costs the United States approximately $97.2 billion each year in health-care costs and lost productivity.

3. The Problem • Only 70% of family physicians ask their patients if they use tobacco. • Only 40% take action.

4. Why don’t doctors act? • Too busy • Lack of expertise • No financial incentive • Think smokers can’t or won’t quit • Don’t want to appear judgmental • Respect for patient’s privacy • Negative message might scare patients away

5. Opportunity for physicians • 70% of smokers see a physician each year. • 70% of smokers want to quit. • Physician’s advice to quit is an important motivator. • Patients are more satisfied with their health care if their provider offers smoking cessation interventions - even if they’re not yet ready to quit.

6. Physicians crucial to successful cessation • Even brief tobacco dependence treatment is effective and should be offered to every patient who uses tobacco. • Tobacco-cessation counseling is effective in improving tobacco quit rates among adults and has been recommended for adolescents. PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

7. Ask and Act • Ask every patient about tobacco use • Act to help them quit • On- or off-site counseling • Quitlines • Patient education materials • Self-help guides or Websites • Cessation classes • Pharmacotherapy

8. Change the system to identify and document tobacco use status

9. Make system changes • Incorporate into vital signs • Use chart stickers or computer prompts to document status: current, quit or never smoker • Develop templates for EHRs

10. Make system changes • Let patients know you can help -- posters, lapel pins, brochures • Ask office staff for ideas how to “Ask and Act” • Develop incentives for staff interventions with patients-teams, time off or special recognition

11. Make system changes • Offer tobacco cessation group visits and place sign-up sheets in the waiting room • Maintain tobacco cessation patient registry • Plan for follow-up calls by office staff after tobacco quit date

12. Counseling and brief interventions

13. Stages of change Precontemplation Don’t want to quit Contemplation Want to quit sometime Preparation Will quit in next 30 days Am quitting now Action Maintenance Termination Relapse Adapted from Knight, 1997

14. Encouraging patients who aren’t yet ready to quit • Relevance • Risks • Rewards • Roadblocks • Repetition

15. Develop a treatment plan • Help create a quit plan • Provide practical counseling • Provide social support • Recommend pharmacotherapy • Provide supplementary materials

16. Counseling Even brief tobacco dependence treatment is effective and should be offered to every patient who uses tobacco. Tobacco-cessation counseling is effective in improving tobacco quit rates among adults and has been recommended for adolescents. PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

17. Counseling • Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. • Especially effective • Practical counseling (problem solving/skills training) • Social support PHS Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update

18. Counseling • Counseling adds significantly to the effectiveness of tobacco cessation medications • Counseling increases abstinence among adolescent smokers

19. Types of counseling • Practical counseling • Teach problem-solving skills • Identify danger situations for smoker • Suggest coping skills to use with danger situations and how to avoid temptation • Provide basic information about smoking dangers, withdrawal symptoms and addiction

20. Types of counseling • Intra-treatment support • Talk about treatment options • Communicate care and concern • Encourage patient to talk about quitting process

21. Types of counseling • Extra-treatment support • Help patient learn how to ask for social support • Help patient identify additional support options • Arrange for outside support

22. Counseling patients with mental illness • Counseling is critical to success - more and longer sessions often necessary • Patients may need more time to prepare for quit • Quit dates should be flexible • Include problem-solving skills training

23. Quitlines • It only takes 30 seconds to refer a patient to a toll-free tobacco-cessation quitline. • Quitlines are staffed by trained cessation experts who tailor a plan and advice for each caller. • Calling a quitline can increase a smoker’s chance of successfully quitting.

24. Advantages of quitlines • Accessibility • Appeal to those who are uncomfortable in a group setting • Smokers more likely to use a quitline than face-to-face program • No cost to patient • Easy intervention for healthcare professionals

25. Quitlines • 1-800-QUIT-NOW callers are routed to state-run quitlines or the National Cancer Institute quitline. • Quitline referral cards are free for AAFP members. Go to askandact.org.

26. Pharmacotherapy

27. Pharmacotherapy • Who should receive it? • Nearly all smokers trying to quit, except those with medical contraindications, adolescents and those who smoke fewer than 10 cigarettes per day.

28. First-line pharmacotherapies • Buproprion SR • Nicotine gum • Nicotine inhaler • Nicotine nasal spray • Nicotine patch • Nicotine lozenge • Varenicline

29. Factors to consider when prescribing • Clinician familiarity with medications • Contraindications • Patient preference • Previous patient experience • Patient characteristics (history of depression, weight gain concerns, etc.)

30. First-line pharmacotherapies • Varenicline: agonizes and blocks α4β2 nicotinic acetylcholine receptors. • Buproprion SR mechanism for smoking cessation unknown; inhibits neuronal uptake of norepinephrine, serotonin and dopamine. • NRT: binds to CNS and peripheral nicotinic-cholinergic receptors.

31. Varenecline • $4.00 - $4.22 per day • Start .5mg daily for 1-3 days, then increase to twice daily for 1-4 days. Increase to 1 mg twice daily on quit date. • Most common side effects are nausea and vivid dreams • Monitor for psychiatric symptoms

32. Bupropion SR • $3.62 - $6.04 per day • Start 150mg once daily for 3 days, then twice per day for seven to twelve weeks. Plan quit date around day seven of treatment. • Common side effects include insomnia and dry mouth

33. Nicotine gum • $3.28 - $6.57 per day for 2mg $4.31 - $6.51 per day for 4mg • Weeks 1-6: one every 1-2 hoursWeeks 7-9: one every 2-4 hoursWeeks 10-12: one every 4-8 hours • Common side effects are jaw pain and mouth soreness

34. Nicotine inhaler • $5.29 per day • 6-16 cartridges per day, initially one every 1-2 hours • Common side effects are mouth and throat irritation

35. Nicotine nasal spray • $3.57 per day • 1-2 doses (sprays) per hour • Common side effects are nose and eye irritation • Most addictive form of nicotine replacement therapy

36. Nicotine patch • $1.90 - $3.89 per day • >25 cigarettes per day: 21mg every twenty-four hours for four weeks, then 14mg for two weeks, then 7 mg for two weeks • Common side effects are skin irritation or sleep issues if worn at night

37. Nicotine lozenge • $3.66 - $5.25 per day • Weeks 1-6: one every 1-2 hoursWeeks 7-9: one every 2-4 hoursWeeks 10-12: one every 4-8 hours • Smoke first cigarette within thirty minutes of awakening, use 4mg. Others use 2mg • Common side effects or mouth soreness and dyspepsia

38. Pharmacotherapy for lighter smokers • Medications have not been shown to be beneficial to light smokers • If NRT is used, consider reducing the dose • No adjustments are necessary when using bupropion SR or varenicline

39. Second-line pharmacotherapies (off label) • Clonidine: mechanism for smoking cessation unknown; stimulates α2-adrenergic receptors (centrally-acting antihypertensive) • Nortripyline: mechanism for smoking cessation unknown; inhibits norepinephrine and serotonin uptake

40. For patients concerned with weight gain • Bupropion SR and nicotine replacement therapies (especially gum and 4 mg lozenge) may delay, but not prevent, weight gain • The average weight gain from tobacco cessation is less than 10 pounds, more common in women

41. For patients with past history of depression • Bupropion SR • Nortriptyline • Nicotine replacement medications

42. Patients with mental illness Most will need medication Patients with bipolar disorder or eating disorders should not receive bupropion Patch is effective for those with schizophrenia Varenecline safety not yet established

43. Patients with mental illness • Quitting can increase the effect of some psychiatric medications Dose adjustments may be needed • Check for relapse to mental illness with changes in smoking status

44. For patients with a history of cardiovascular disease • Nicotine replacement therapy -caution for drug class if MI within two weeks, severe arrhythmias or cardiovascular disease

45. Pregnant smokers • Counseling is best choice • Risks of premature birth or stillbirth caused by smoking may be higher than the potential risk of birth defects caused by NRT use • Buproprion SR and varenicline are both pregnancy category C • Prescription NRT is category D

46. Can pharmacotherapies be used long term? • Yes. • Helpful with smokers with persistent withdrawal systems • Long-term use of NRT does not present a known health risk • FDA approved the use of bupropion SR for up to 6 months • Varenicline recommended for 12 weeks. May repeat for 12 more

47. Can pharmacotherapies be combined? • Yes. • Evidence that combining nicotine patch with gum or nasal spray increase long-term abstinence • Combining nicotine patch with buproprion is more effective than patch alone

48. Treatment follow-up • Congratulate success! • Schedule counseling intervention within first 3 months • Encourage the patient to talk about the process • Success the patient has achieved • Difficulties encountered

49. Benefit from a relapse • A relapse provides useful information • Information about the cause of the event • A formerly unknown stressful situation • How to correct it occurrence in the future • An action plan for that event • Relapse is a normal part of the recovery process

50. Relapse prevention • Tobacco Dependence is a Chronic Disease • MDs and patients often have unrealistic expectations for treatment of chronic disease, too often using a short treatment course