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Rx for CHANGE Clinician-Assisted Tobacco Cessation

Rx for CHANGE Clinician-Assisted Tobacco Cessation. EPIDEMIOLOGY of TOBACCO USE. “CIGARETTE SMOKING…. is the chief, single, avoidable cause of death in our society and the most important public health issue of our time.”. C. Everett Koop, M.D., former U.S. Surgeon General.

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Rx for CHANGE Clinician-Assisted Tobacco Cessation

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  1. Rx for CHANGEClinician-Assisted Tobacco Cessation

  2. EPIDEMIOLOGYof TOBACCO USE

  3. “CIGARETTE SMOKING… is the chief, single, avoidable cause of death in our society and the most important public health issue of our time.” C. Everett Koop, M.D., former U.S. Surgeon General All forms of tobacco are harmful.

  4. PREVALENCE of ADULT SMOKING, by RACE/ETHNICITY—U.S., 2015 Multiple race 21.9% 20.2% American Indian/Alaska Native White 16.7% Black 16.6% Hispanic 10.1% Asian 7.0% Percent Centers for Disease Control and Prevention (CDC). (2016). MMWR 65:1205–1211.

  5. PREVALENCE of ADULT SMOKING, by EDUCATION—U.S., 2015 24.2% No high school diploma 34.1% GED diploma 19.8% High school graduate 18.5% Some college 7.4% Undergraduate degree 3.6% Graduate degree Percent Centers for Disease Control and Prevention (CDC). (2016). MMWR 65:1205–1211.

  6. COMPOUNDS in TOBACCO SMOKE An estimated 4,800 compounds in tobacco smoke, including 16 proven human carcinogens Gases Particles • Carbon monoxide • Hydrogen cyanide • Ammonia • Benzene • Formaldehyde • Nicotine • Nitrosamines • Lead • Cadmium • Polonium-210 Nicotine is the addictive component of tobacco products, but it does NOT cause the ill health effects of tobacco use.

  7. ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, 2005–2009 Percent of all smoking-attributable deaths 33% 27% 23% 9% 7% <1% TOTAL: >480,000 deaths annually U.S. Department of Health and Human Services (USDHHS). (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.

  8. Cancers Bladder/kidney/ureter Blood (acute myeloid leukemia) Cervix Colon/rectum Esophagus/stomach Liver Lung Oropharynx/larynx Pancreatic Pulmonary diseases Asthma COPD Pneumonia/tuberculosis Chronic respiratory symptoms Cardiovascular diseases Aortic aneurysm Coronary heart disease Cerebrovascular disease Peripheral vascular disease Reproductive effects Reduced fertility in women Poor pregnancy outcomes (e.g., congenital defects, low birth weight, preterm delivery) Infant mortality Other:cataract, diabetes (type 2), erectile dysfunction, impaired immune function, osteoporosis, periodontitis, postoperative complications, rheumatoid arthritis HEALTH CONSEQUENCES of SMOKING U.S. Department of Health and Human Services (USDHHS). (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.

  9. HEALTH CONSEQUENCES of SMOKELESS TOBACCO USE Periodontal effects Gingival recession Bone attachment loss Dental caries Oral leukoplakia Cancer Oral cancer Pharyngeal cancer Oral Leukoplakia Image courtesy of Dr. Sol Silverman - University of California San Francisco

  10. 2006 REPORT of the SURGEON GENERAL: INVOLUNTARY EXPOSURE to TOBACCO SMOKE • Second-hand smoke causes premature death and disease in nonsmokers (children and adults) • Children: • Increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma There is no safe level of second-hand smoke. • Respiratory symptoms and slowed lung growth if parents smoke • Adults: • Immediate adverse effects on cardiovascular system • Increased risk for coronary heart disease and lung cancer • Millions of Americans are exposed to smoke in their homes/workplaces • Indoor spaces: eliminating smoking fully protects nonsmokers • Separating smoking areas, cleaning the air, and ventilation are ineffective U.S. Department of Health and Human Services (USDHHS). (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.

  11. QUITTING: HEALTH BENEFITS Time Since Quit Date Circulation improves, walking becomes easier Lung function increases Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing, fatigue, shortness of breath decrease 2 weeks to 3 months 1 to 9 months Excess risk of CHD decreases to half that of a continuing smoker 1 year Risk of stroke is reduced to that of people who have never smoked 5 years Lung cancer death rate drops to half that of a continuing smoker Risk of cancer of mouth, throat, esophagus, bladder, kidney, pancreas decrease 10 years Risk of CHD is similar to that of people who have never smoked after 15 years

  12. BENEFICIAL EFFECTS of QUITTING: PULMONARY EFFECTS AT ANY AGE, there are benefits of quitting. Never smoked or not susceptible to smoke 100 75 Stopped smoking at 45 (mild COPD) Smoked regularly and susceptible to effects of smoke FEV1 (% of value at age 25) 50 Disability 25 Stopped smoking at 65 (severe COPD) Death 0 25 50 75 Age (years) COPD = chronic obstructive pulmonary disease Reprinted with permission. Fletcher & Peto. (1977). BMJ 1(6077):1645–1648.

  13. 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.

  14. FINANCIAL IMPACT of SMOKING Buying cigarettes every day for 50 years at $6.16 per pack* (does not include interest) $755,177 $338,335 $503,451 $225,570 Packs per day $112,785 $251,725 Dollars lost, in thousands * Average national cost, as of January 2017. Campaign for Tobacco-Free Kids, 2017.

  15. NICOTINE PHARMACOLOGY and PRINCIPLES of ADDICTION

  16. NICOTINE ADDICTIONU.S. Surgeon General’s Report • Cigarettes and other forms of tobacco are addicting. • Nicotine is the drug in tobacco that causes addiction. • The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine. U.S. Department of Health and Human Services. (1988). The Health Consequences of Smoking: Nicotine Addiction. A Report of the Surgeon General.

  17. PHARMACOLOGY Pharmacokinetics Effects of the body on the drug • Absorption • Distribution • Metabolism • Excretion Effects of the drug on the body Pharmacodynamics

  18. NICOTINE ABSORPTION Absorption is pH dependent • In acidic media • Ionized  poorly absorbed across membranes • In alkaline media • Nonionized well absorbed across membranes • At physiologic pH (7.4), ~31% of nicotine is nonionized At physiologic pH, nicotine is readily absorbed.

  19. Alkaline media (significant absorption) Pipes, cigars, spit tobacco, oral nicotine products Acidic media (limited absorption) Cigarettes Beverages can alter pH, affect absorption. NICOTINE ABSORPTION: BUCCAL (ORAL) MUCOSA The pH inside the mouth is 7.0.

  20. Dopamine Norepinephrine Acetylcholine Glutamate Serotonin -Endorphin GABA Pleasure, appetite suppression Arousal, appetite suppression Arousal, cognitive enhancement Learning, memory enhancement Mood modulation, appetite suppression Reduction of anxiety and tension Reduction of anxiety and tension NEUROCHEMICAL and RELATED EFFECTS of NICOTINE N I C O T I N E Benowitz. (2008). Clin Pharmacol Ther 83:531–541.

  21. WHAT IS ADDICTION? ”Compulsive drug use, without medical purpose, in the face of negative consequences” Alan I. Leshner, Ph.D. Former Director, National Institute on Drug Abuse National Institutes of Health Nicotine addiction is a chronic condition with a biological basis.

  22. DOPAMINE REWARD PATHWAY Prefrontal cortex Dopamine release Stimulation of nicotine receptors Nucleus accumbens Ventral tegmental area Nicotine enters brain

  23. NICOTINE PHARMACODYNAMICS: WITHDRAWAL EFFECTS • Irritability/frustration/anger • Anxiety • Difficulty concentrating • Restlessness/impatience • Depressed mood/depression • Insomnia • Impaired performance • Increased appetite/weight gain • Cravings Most symptoms manifest within the first 1–2 days, peak within the first week, and subside within 2–4 weeks. Hughes. (2007). Nicotine Tob Res 9:315–327.

  24. NICOTINE ADDICTION CYCLE Reprinted with permission. Benowitz. (1992). Med Clin N Am 2:415–437.

  25. NICOTINE ADDICTION • Tobacco users maintain a minimum serum nicotine concentration in order to • Prevent withdrawal symptoms • Maintain pleasure/arousal • Modulate mood • Users self-titrate nicotine intake by • Smoking/dipping more frequently • Smoking more intensely • Obstructing vents on low-nicotine brand cigarettes Benowitz. (2008). Clin Pharmacol Ther 83:531–541.

  26. FACTORS CONTRIBUTING toTOBACCO USE Individual • Sociodemographics • Genetic predisposition • Coexisting medical conditions Pharmacology • Alleviation of withdrawal symptoms • Weight control • Pleasure, mood modulation Tobacco Use Environment • Tobacco advertising • Conditioned stimuli • Social interactions

  27. The addiction to nicotine The habit of using tobacco Treatment Treatment Medications for cessation Behavior change program TOBACCO DEPENDENCE:A 2-PART PROBLEM Tobacco Dependence Physiological Behavioral Treatment should address the physiological and the behavioral aspects of dependence.

  28. NICOTINE PHARMACOLOGY and ADDICTION: SUMMARY • Tobacco products are effective delivery systems for the drug nicotine. • Nicotine is a highly addictive drug that induces a constellation of pharmacologic effects, including activation of the dopamine reward pathway in the brain. • Tobacco use is complex, involving the interplay of a wide range of factors. • Treatment of tobacco use and dependence requires a multifaceted treatment approach.

  29. ASSISTING PATIENTS with QUITTING

  30. CLINICAL PRACTICE GUIDELINE for TREATING TOBACCO USE and DEPENDENCE • Update released May 2008 • Sponsored by the U.S. Department of Health and Human Services, Public Heath Service with: • Agency for Healthcare Research and Quality • National Heart, Lung, & Blood Institute • National Institute on Drug Abuse • Centers for Disease Control and Prevention • National Cancer Institute

  31. EFFECTS of CLINICIAN INTERVENTIONS With help from a clinician, the odds of quitting approximately doubles. Compared to patients who receive no assistance from a clinician, patients who receive assistance are 1.7–2.2 times as likely to quit successfully for 5 or more months. n = 29 studies 2.2 1.7 1.1 1.0 Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

  32. The NUMBER of CLINICIAN TYPES CAN MAKE a DIFFERENCE, too Compared to smokers who receive assistance from no clinicians, smokers who receive assistance from two or more clinician types are 2.4–2.5 times as likely to quit successfully for 5 or more months. n = 37 studies 2.5 2.4 Estimated abstinence rate at 5+ months 1.8 1.0 Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

  33. WHY SHOULD CLINICIANS ADDRESS TOBACCO? • Tobacco users expect to be encouraged to quit by health professionals. • Screening for tobacco use and providing tobacco cessation counseling are positively associated with patient satisfaction (Barzilai et al., 2001; Conroy et al., 2005). Failure to address tobacco use tacitly implies that quitting is not important. Barzilai et al. (2001). Prev Med 33:595–599; Conroy et al. (2005). Nicotine Tob Res 7 Suppl 1:S29–S34.

  34. The 5 A’s ASK ADVISE ASSESS ASSIST ARRANGE Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

  35. ASK about tobacco use • “Do you ever smoke or use other types of tobacco or nicotine, such as e-cigarettes?” • “I take time to ask all of my patients about tobacco use—because it’s important.” • “Condition X often is caused or worsened by smoking. Do you, or does someone in your household smoke?” • “Medication X often is used for conditions linked with or caused by smoking. Do you, or does someone in your household smoke?” The 5 A’s (cont’d)

  36. ADVISE tobacco users to quit (clear, strong, personalized) • “It’s important that you quit as soon as possible, and I can help you.” • “Cutting down while you are ill is not enough.” • “Occasional or light smoking is still harmful.” • “I realize that quitting is difficult. It is the most important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan.” The 5 A’s (cont’d)

  37. ASSESS readiness to make a quit attempt ASSIST with the quit attempt • Not ready to quit: enhance motivation (the 5 R’s) • Ready to quit: design a treatment plan • Recently quit: relapse prevention The 5 A’s (cont’d)

  38. The 5 A’s (cont’d) follow-up care ARRANGE * 5 months (or more) postcessation Provide assistance throughout the quit attempt. Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

  39. ASK about tobacco USE ADVISE tobacco users to QUIT ASSESS READINESS to make a quit attempt ASSIST with the QUIT ATTEMPT ARRANGE FOLLOW-UP care The 5 A’s: REVIEW

  40. The (DIFFICULT) DECISION to QUIT • Faced with change, most people are not ready to act. • Change is a process, not a single step. • Typically, it takes multiple attempts. HOW CAN I LIVE WITHOUT TOBACCO?

  41. HELPING PATIENTS QUIT IS a CLINICIAN’S RESPONSIBILITY TOBACCO USERS DON’T PLAN TO FAIL. MOST FAIL TO PLAN. Clinicians have a professional obligation to address tobacco use and can have an important role in helping patients plan for their quit attempts. THE DECISION TO QUIT LIES IN THE HANDS OF EACH PATIENT.

  42. ASSESSING READINESS to QUIT Patients differ in their readiness to quit. STAGE 1: Not ready to quit in the next month STAGE 2: Ready to quit in the next month STAGE 3: Recent quitter, quit within past 6 months STAGE 4: Former tobacco user, quit > 6 months ago Assessing a patient’s readiness to quit enables clinicians to deliver relevant, appropriate counseling messages.

  43. ASSESSING READINESS to QUIT (cont’d) For most patients, quitting is a cyclical process, and their readiness to quit (or stay quit) will change over time. Not thinking about it Former tobacco user Not ready to quit Relapse Thinking about it, not ready Recent quitter Assess readiness to quit (or to stay quit) at each patient contact. Ready to quit

  44. ASSESSING READINESS to QUIT (cont’d) STAGE 1: Not ready to quit Not thinking about quitting in the next month • Some patients are aware of the need to quit. • Patients struggle with ambivalence about change. • Patients are not ready to change, yet. • Pros of continued tobacco use outweigh the cons. GOAL: Start thinking about quitting.

  45. DO Strongly advise to quit Provide information Ask noninvasive questions; identify reasons for tobacco use Raise awareness of health consequences/concerns Demonstrate empathy, foster communication Leave decision up to patient STAGE 1: NOT READY to QUITCounseling Strategies DON’T • Persuade • “Cheerlead” • Tell patient how bad tobacco is, in a judgmental manner • Provide a treatment plan

  46. STAGE 1: NOT READY to QUITCounseling Strategies (cont’d) Consider asking: “Do you ever plan to quit?” “What might be some of the benefits of quitting now, instead of later?” “What would have to change for you to decide to quit sooner?” Advise patients to quit, and offer to assist (if or when they change their mind). If NO If YES Most patients will agree: there is no “good” time to quit, and there are benefits to quitting sooner as opposed to later. Responses will reveal some of the barriers to quitting.

  47. STAGE 1: NOT READY to QUITCounseling Strategies (cont’d) The 5 R’s—Methods for enhancing motivation: • Relevance • Risks • Rewards • Roadblocks • Repetition Tailored, motivational messages Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

  48. ASSESSING READINESS to QUIT (cont’d) STAGE 2: Ready to quit Ready to quit in the next month • Patients are aware of the need to, and the benefits of, making the behavioral change. • Patients are getting ready to take action. GOAL: Achieve cessation.

  49. STAGE 2: READY to QUITThree Key Elements of Counseling • Assess tobacco use history • Discuss key issues • Facilitate quitting process • Practical counseling (problem solving/skills training) • Social support delivered as part of treatment

  50. Praise the patient’s readiness Assess tobacco use history Current use: type(s) of tobacco, amount Past use: duration, recent changes Past quit attempts: Number, date, length Methods/medications used, adherence, duration Reasons for relapse STAGE 2: READY to QUITAssess Tobacco Use History

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