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SMOKING CESSATION

SMOKING CESSATION. Leading Preventable Cause of Death 400,000 to 500,000 deaths per year in USA 3 Million deaths world wide 1 of every 6 deaths in USA Directly attributable to smoking Yet — 46 Million continue to smoke. SMOKING. “A cigarette is a finely tuned drug delivery system”

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SMOKING CESSATION

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  1. SMOKING CESSATION • Leading Preventable Cause of Death • 400,000 to 500,000 deaths per year in USA • 3 Million deaths world wide • 1 of every 6 deaths in USA Directly attributable to smoking • Yet — 46 Million continue to smoke

  2. SMOKING “A cigarette is a finely tuned drug delivery system” Katherine E. Hartman, MD

  3. SMOKING “Smoking is not a bad habit --- It is a chronic medical condition” Michael C. Fiore, MD

  4. SMOKING CESSATION • Why do we smoke? • Why should we stop/benefits? • How do we stop?

  5. Nicotine Dependence slide “As an addictive substance, nicotine, on a milligram for milligram basis, is 10 times more potent than heroin…” Sachs DPL. Advances in Smoking Cessation Treatment In: Simmons, ed. Current Pulmonology, Chicago; Year Book Medical Publishers, 1991, 12:139-198

  6. SMOKING CESSATION Why Do We Smoke? 3-Pronged Dependency • Physiological • Psychological • Behavioral

  7. Why Do We Smoke? Physiological • Nicotine to brain – 7 seconds • Binds to nicotine receptors resulting in secretion of Dopamine • Causes a pleasurable sensation and cognitive arousal

  8. Physiological Increased Levels of: Norepinephrine Beta-Endorphin Acetylcholine Serotonin Glutamate Vasopressin

  9. Physiological • Enhance: • Concentration • Alertness • Memory • Decrease: • Tension • Anxiety Promotes feeling of well being

  10. SMOKING CESSATION Why should we stop smoking? Benefits: General Cardio-cerebrovascular Cancer Pulmonary

  11. SMOKING CESSATION • Long term tobacco use raises the risk of premature death by 50% * • Quitting at any age increases longevity • Those who quit smoking by age 50 decrease their risk of dying over the next 15 years by 50% compared with those who do not stop ** * W.H.O. Tobacco Dependency Fact Sheet #222 1999 ** U.S. Dept of Health & Human Services publication #90-8416

  12. SMOKING CESSATION Why should we stop smoking? Benefits: General Cardio-cerebrovascular Cancer Pulmonary

  13. Why should we stop smoking? • 30% of all Cancer Deaths related to Smoking • 4000 Chemicals in Tar • 43 Carcinogenic

  14. Why should we stop smoking? • Lung Cancer – Most Common in Cancer • Oral 9 fold increase • Throat 9 fold increase • Esophagus 75% in smokers • Bladder 7 fold increase • Kidney 5 fold increase • Pancreas 2 fold increase • Stomach 1.5 fold increase

  15. Why should we stop smoking? Lung Cancer • Life Long risk in Non-Smoker – 1% • 15-25% risk in heavy smokers • Each Cigarette cuts 6 minutes off of life

  16. SMOKING CESSATION Why should we stop smoking? Benefits: General Cardio-cerebrovascular Cancer Pulmonary

  17. How Do We Stop Smoking? Problems • Patient Motivation • Physician Interest • Medications • Support Systems

  18. SMOKING CESSATION Patient Motivation • 70% want to quit • 2 large studies • Appropriate moment

  19. SMOKING CESSATION The Right Moment Acute MI Intervention Minimal 55% 34% Dornelas, E.A. Prev Med 2000; 30, 216-228

  20. The Negatives • Physicians advising patients to stop 1975 – 38% 1983 – 42% 1991 – 48% • 1672 Ex-Smokers • 3.6% Physician Helped • 70% smokers see physician yearly

  21. SMOKING • 38 Family Practices • 2963 Smokers - Addressed in 21% • Increased to 58% if Doctor used standard forms for recording smoking status • When smokers identified • smoking cessation therapy started in only 38% • 68% of the offices had smoking cessation material J. Fam. Pract. 2001; 50: 688-9

  22. Physicians Role in Smoking Cessation The Positives • Admit Nicotine is an Addiction • Provide information • Show an interest • Train office personnel • Select the opportunity

  23. SMOKING CESSATION The 5 A’s Ask Advise Assess Assist Arrange

  24. Planning a Program • Establish degree of nicotine dependency • Serum Cotinine Level • Fagerstrom Test • Quit Date • Support Group • Behavioral Modification • Discuss Relapses & Weight Gain

  25. Pharmacologic • Nicotine Replacement • Bupropion

  26. Planning A Program • Low Dependency • Nicotine Replacement • High Dependency • Bupropion + • Nicotine Replacement x 2

  27. Nicotine Replacement N=504 Patch 21% Gum 20% Spray 24% Inhaler 24% Arch. Int. Med. September 27, 1999

  28. Nicotine Replacement Gum – 1984 • Disadvantages • Heartburn and Indigestion • Throat and Mouth Irritation • Sore Jaw • Flatulence • Advantages • Neutral PH • More Rapid • Adjunct

  29. Nicotine Replacement Patch – 1991 • Advantages • Convenient • Best Compliance • 30-40% while on patch • 10% at 1 year • Disadvantages • Skin Irritation • Over the counter

  30. Nicotine Replacement Nasal Spray • Advantages • Alone or Combination • Fast Acting - Urge • Disadvantages • Irritation • Low Compliance

  31. Nicotine Replacement Inhaler • Advantages • Hand-Mouth • Disadvantages • Low Compliance • Less Nicotine • Delivery

  32. Nicotine Replacement Lozenge – 2002

  33. Bupropion • Placebo 23% • Nicotine Replacement 36% • Bupropion 300 MA 49% • Bupropion + Nicotine 58% • Long Term 25-35%

  34. SMOKING CESSATION N12 MOKG • Placebo 160 15.6% 2.1 • Nicotine Patch 244 16.4% 1.6 • Bupropion 244 30.3% 1.7 • Bupropion + patch 245 35.5% 1.1 JORENBY - N.E.J.M. 3/4/99

  35. SMOKING CESSATION BUPROPION 450 Smokers (Failed Treatment) Again Placebo 27% 5% • Gonzales DH, Clin. Pharm Therapy 2001; 69

  36. SMOKING CESSATION BUPROPION Duration 784 PATIENTS 7 WEEKS TREATMENT PLACEBO 12 MONTHS 55% 42% • Hays, JT. Ann Intern Med. 2001 135

  37. SUMMARY • Smoking KILLS • Physicians can and should play a role in helping patients stop smoking • Effective tools are available and they work

  38. SUMMARY • Include Smoking as a Vital Sign • Use the 5 A’s • Use multiple modalities • Use them long enough • Be Persistent

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