Smoking Cessation and Chronic Mental Illness

1. Smoking Cessation and Chronic Mental Illness CSAM May 15, 2009 David Kan, M.D. E-mail: David.Kan2@va.gov San Francisco VA Medical Center Asst. Clinical Professor, UCSF

2. Overview • Epidemiology • Nicotine & Tobacco • Aka: Dr. Jekyll & Mr. Hyde • Smoking Cessation • Psychosocial • Pharmacological

3. Epidemiology • Total • 47.2 million adults (24.1%) were current smokers • 24.8 million men and 22.4 million women. • 82.4% of all smokers were everyday smokers • Age • The highest rate of smoking was in 18-24 year olds: 27.9% and 25-44 year olds: 27.5%. • Smoking rates drop with Age Source: CDC 1998 Survey

4. Epidemiology • Ethnicity • Native Americans/Alaska Natives: 40%, • 25% of Caucasians and 24.7% of African Americans smoke. • Hispanics: 19.1% and Asians/Pacific Islanders:13.7%. • Education and income • More Education = Less Smoking • More Income = Less Smoking Source: CDC Survey 1998

5. Smoking and Mental Illness, Lasser, et al. JAMA. 2000;284:2606-2610.

6. Smoking Rates & Mental Illness • In general 2x Non-Mentally Ill National Comorbidity Study – 1989 US NHIS

7. Nicotine vs. Tobacco

8. Nicotine • Ideal CNS Drug • Very Effective • Very Safe

9. Neurochemical Effects Slide Courtesy: David Sachs, M.D.

10. Why Cigarettes? • Ideal Drug Delivery System • Very Rapid Delivery • High Dose • Highly Concentrated

11. What is the Problem with Cigarettes? • Toxic Delivery System

12. SMOKE is the PROBLEMNOT NICOTINE!!!

13. Smoking Related Illness 1/3rd of Smokers will die prematurely of tobacco-related illness

14. Tobacco – Drug Interactions • Pharmacokinetic • Polycyclic aromatic hydrocarbons (PAHs) are some of the major lung carcinogens found in tobacco smoke • PAHs - potent inducers of the hepatic cytochrome P-450 (CYP) isoenzymes 1A1, 1A2, and, possibly, 2E1 • CYP 1A2 – largest effect Kroon, L “Drug interactions with smoking.” Am J Health Syst Pharm. 2007 Sep 15;64(18):1917-21

15. Tobacco – Drug Interactions • Drugs Affected • Clozapine • Fluvoxamine • Olanzapine • Caffeine • Tacrine UP TO 50% REDUCTION IN BLOOD LEVELS Kroon, L “Drug interactions with smoking.” Am J Health Syst Pharm. 2007 Sep 15;64(18):1917-21

16. Tobacco – Drug Interactions • Hormone Contraceptives • Increased risk of Stroke and Heart Attack • Inhaled Corticosteroids • Decreased Efficacy Kroon, L “Drug interactions with smoking.” Am J Health Syst Pharm. 2007 Sep 15;64(18):1917-21

17. What About Quitting?

18. Tobacco Dependence In Perspective • Approximately 35% try to quit each year • 70% to 80% try to quit “cold turkey” • Most Relapse — 95% • Cold turkey quit rates at 1 year are 5% • Physician-assisted quit rates (short-term counseling + medications) at 1 year are 10% to 30% Fiore MC, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Dept of Health & Human Services. Public Health Service. June 2000. (www.surgeongeneral.gov/tobacco/default.htm)

21. Acute Disease Short-Term Disorder Severe Sudden in Onset Single, Time-limited intervention Examples: Common Cold Broken Bone Chronic Disease Long-Term Disorder Periods of relapse and remission Requires ongoing rather than acute care Examples: Diabetes Hypertension Addiction Smoking! Disease Model of Tobacco Dependence

23. Psychiatric Conditions • Psychiatric Conditions • 2x as likely to smoke • Depressed Smokers • More Depression less likely to quit • Psychiatric Conditions • Data mixed or lacking as to long-term outcomes • Many studies show interventions work as well as with those not mentally ill Ranny, et al: Systematic review: smoking cessation intervention strategies for adults and adults in special populations. Ann Intern Med. 2006 Dec 5;145(11):845-56. Epub 2006 Sep 5. Review.

24. Substance Abuse • Alcohol & Tobacco • Alcohol Use Triggers / exacerbates tobacco use • Quitting both led to higher quit rates for both Joseph, AM et al A randomized trial of concurrent versus delayed smoking intervention for patients in alcohol dependence treatment. Stud Alcohol. 2004 Nov;65(6):681-91

25. Indications for Longer/More Intensive Treatment • High Nicotine Dependence • FTQ >5 • High Serum Cotinine • >250ng/ml • Depression • Beck Depression Inventory > 9 • Smoker in Household • Decreases chances by 50% Sachs DPL. “Tobacco Dependence: Pathophysiology & Treatment” Pulmonary Rehabilitation Guidelines to Success, 3rd Edition 2000:261-301

26. Indications for Longer/More Intensive Treatment • Smoking Initiation at Younger Age • <17 years old • Heavy Smoker • >1 Pack Per Day • # of Prior quit attempts • Alcohol or Drug Abuse • Psychotic Spectrum Illness Sachs DPL. “Tobacco Dependence: Pathophysiology & Treatment” Pulmonary Rehabilitation Guidelines to Success, 3rd Edition 2000:261-301

27. Treatment Recommendations

28. Psychosocial Interventions • Counseling • Behavioral Therapy • Quit Line (1-800-NO-BUTTS) • Motivational Enhancement

29. FDA Approved Medications • CONTROLLER MEDICATIONS • Bupropion SR (Zyban, Wellbutrin SR, Wellbutrin XL) • Nicotine Patch • Varenicline (Chantix) • RESCUE MEDICATIONS • Nicotine Inhaler • Nicotine Nasal Spray - Fastest • Nicotine Polacrilex Gum (Nicorette) – pH dependent • Nicotine Polacrilex Lozenge (Commit) – pH dependent

30. Slide Courtesy: David Sachs, MD

31. Success Strategies • Combined Strategies • Behavioral + Medication • Always at least 1 controller • Almost always need Rescue

32. Nicotine Replacement“Clean vs. Dirty”1 • Start with Patch • Add lozenge, gum, nasal spray, inhaler • Target 30-60 days smoke free prior to tapering • Taper short acting first • Weeks to YEARS! 1. Peter Banys, MD – Personal Communication

33. Nicotine Replacement • Dosing? • 80% of 1-PPD smokers not adequately replaced with 21mg nicotine patch • Clear Dose-Response Curve1 • Serum Cotinine • 24-Hour half-life of nicotine metabolism • Dose to level • No absolute maximum • 10-15% smoke free at one year 1. Sachs DPL. J Smoking-Related Dis 1994;5: 183-193

34. Bupropion(Wellbutrin/Zyban) • Mechanism • Affects dopaminergic projections • Dosing • Start 1 week before quit date • 150mg SR x 3-6 days then 150mg BID • Psychosocial treatment recommended • Contraindications • Seizure Disorder • Eating Disorder

36. Bupropion(Wellbutrin/Zyban) • Common SE • Insomnia – 28-35% vs. 22%* • Headache – 30% vs. 28% • Dry Mouth – 15% vs. 5%* • Dizziness – 8-9% vs. 8% • Nausea – 5-7% vs. 5% • Uncommon SE • Seizures (1/1000 patients) • Psychosis • Hypertension • Suicidal Ideation * Statistically significant

37. Varenicline(Chantix) • Mechanism • Α4β2- Nicotinic Receptor Partial Agonist • Dosing • 0.5mg PO qd x 3 days • 0.5mg PO BID x 4 days • 1mg BID thereafter • Quit date is day #8

38. Varenicline(Chantix) • Duration • 3 months initial • 6 months total (if pt. can get 10 days smoke-free in first 3 months

39. Varenicline Warnings • Common SE: • Nausea • Abnormal Sleep / Dreams • Dizziness • Fatigue • Uncommon AE but reported: • Aggressive and erratic behavior • Suicidal thoughts • Possible suicide attempts

40. Varenicline vs. BupropionWeeks 9-52 Abstinence

41. Varenicline Maintenance

42. Conclusions & Recommendations • Tobacco Use is the #1 preventable cause of death • Psychiatric Patients carry a large disease burden both medical and physical • Tobacco is the problem - NOT Nicotine • Tobacco Use Disorder is a Chronic Illness needing repeated intervention • Smoking Cessation Works • Combine your treatments