Clearing the Smoke - Bladder Cancer Advocacy Network · Tobacco Addiction Most of the harms of...

Clearing The Smoke:

An Effective Smoking Cessation Intervention Led By

Specialists

Courtney M.P. Hollowell, M.D., FACS

Chairman, Department of Urology

Cook County Health and Hospitals System

Chicago, Illinois

Smoking: Public Enemy #1 The single most important preventable health risk

Cigarette smoking accounts for an estimated 443,000 deaths in the

U.S. annually, nearly one of every five deaths.

Causes more deaths than motor vehicle injuries, illegal drug use,

alcohol use, HIV, suicides, and murders combined.

Costs U.S. $289 billion in direct-healthcare expenditures and lost

productivity due to premature mortality each year.

Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report; 2008; 57(45):1226-9.

<http://www.cdc.gov/tobacco/data_Statistics/fact_sheet/health_effects/effects_cig_smoking>

Smoking: Public Enemy #1

The World Health Organization estimates that tobacco use kills

nearly 6 million people worldwide each year

Increases risk of:

Coronary heart disease by 2-4 times

Stroke by 2-4 times

Lung cancer by 23 times in men, 13 times in women

Bladder cancer by 2-4 times

Dying from chronic obstructive lung disease by 12-13 times

Smoking: Public Enemy #1

Many of these risks are reversible:

Excess risk of coronary heart disease halves within one year of

stopping smoking

Excess risk of stroke is reduced to that of a nonsmoker within 5-15 yrs

of stopping smoking

Risk of bladder cancer decreases at a rate of 40% in the first four years

after cessation

Continued smokers after bladder cancer diagnosis have a 2.2 fold

greater risk of recurrence compared to those who quit

WHO report on the global tobacco epidemic, 2011: warning about the dangers of tobacco.

Chen et al. BJU Int; 100, 281-286. 2007.

Brennan P et al. Int J Cancer; 86(2): 289-194. 2000

Prevalence of cigarette smoking

Percentage of adult

smokers has fallen from

42.9% in 1965 to 19.3% in

Prevalence has remained

stagnant around 20% for

the past 10 years.

Despite declines, there are

still 43.4 million smokers

in U.S.

Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report; 2008; 60(44):1513-19.

There has been a positive trend in cigarette smoking habits

Prevalence of cigarette smoking Worse among those with bladder cancer

Approximately 45% of newly diagnosed bladder cancer

patients are current smokers

The diagnosis of cancer may represent a window of

opportunity during which patients are receptive to quit

advice

The opportunity to intervene is often missed

Ostroff JS et al. J Cancer Educ. 2000; 15:86-90

Bjurlin MA and Hollowell et al. J Urol. 2010; 184(5):1901-6

Even a problem for our commander in chief

Do doctors smoking give mixed messages?

Nicotine

Pharmacokinetics and

Tobacco Addiction

Nicotine Pharmacokinetics and

Tobacco Addiction

Most of the harms of smoking are due to the many chemical compounds and carcinogens

Addiction is due to nicotine

Nicotine physiology provides a foundation for treatment

The Surgeon General Report: Health Consequences of Smoking. - Rockville, Md. : U.S. Dept. of Health and

Human Services, Public Health Service. 2004.

Tobacco Addiction

Nicotine is particularly addictive because it is absorbed

through the pulmonary circulation

Nicotine reaches the brain in ≤10 seconds

Smoking allows fingertip dose titration

Tobacco Addiction

Nicotinic cholinergic receptors:

α2–α10 subunits

β2-β4 subunits

The α4β2 receptor is the principal mediator of nicotine dependence

Receptor activation promotes the release of dopamine

Tobacco Addiction

Psychoactive effects of nicotine:

Pleasure

Stimulation

Relaxation

Reduced anxiety

Stress control

Craving

Alleviation of withdrawal symptoms

Appetite suppression

Cognitive enhancement

Tobacco Addiction

Psychoactive effects of nicotine withdrawal:

Anger/ Irritability – 80%

Anxiety – 90%

Cravings – 62%

Difficulty concentrating – 73%

Hunger/ Weight gain – 70%

Restlessness – 71%

Sleep disturbances – 25%

Depression – 60%

Headache – 22%

GI upset – 21%

Urges to smoke – 70%

Impaired task performance – 25%

Hughes JR et al. Psychopharmacology. 1984; 83:82-87.

Strategies For Smoking

Cessation Assistance

Smoking Cessation Strategies

Advice from the physician has been shown to increase the

number and success of quit attempts

Brief advice (≤5 mins.) to all smokers has been shown to be

effective

Carson KV et al. Cochrane Database Syst Rev. 2012; 5:1-144

Smoking Cessation Strategies: Clinical Practice Guideline Treating Tobacco Use and Dependence

Identify and document the tobacco use of every patient at

every visit

If patient is a former smoker remind them of the many

health benefits of not using tobacco

Smoking Cessation Strategies Strong Predictors of Nicotine Dependence

How many cigarettes do you

smoke per day?

1-10 (score 0)

11-20 (score 1)

21-30 (score 2)

31+ (score 3)

Heavy Smoking Index score ≥ 4 indicates high level of dependence

How soon after waking do

you smoke your first

cigarette?

Within 5 mins. (score 3)

6-30 mins. (score 2)

31-60 mins (score 1)

61+ mins. (score 0)

ADVISE

In a clear, strong and personalized manner advise every

smoker to quit

“Smoking is the most likely

cause of your bladder cancer

and quitting may reduce

recurrence.”

“I need you to know that

quitting smoking now is the

most important thing that you

can do to protect your health

and I can help you.”

ASSESS

Is the patient willing to make a quit attempt at this time?

Use motivational interviewing (5Rs)

Smoking Cessation Strategies Treatment For Those Not Willing To Quit

ASSESS

Smoking Cessation Strategies Treatment For Those Willing To Quit

ASSESS

Is the patient willing to make a quit attempt at this time?

Provided smoking cessation assistance

ASSIST

Develop an individualized Quit Plan

Offer Medication

Provide or Refer for Counseling

Personalized Quit Plan:

Set a quit date

Tell friends, family and coworkers

Anticipate challenges

Remove tobacco products from environment

ASSIST

Offer Medication

ASSIST

Offer Medication

Counseling Resources:

Smoking cessation clinics

Local cessation programs

ACS and ALA

1-800-QUIT-NOW

Trained cessation

counselors available wt

advice

New FAX referral

Goals:

Identify a strong reason

Bolster belief in ability

Develop a solid plan

Adopt a new view of self

Keep trying

ARRANGE

Follow up soon after the quit date

Successful abstinence (congratulate)

Unsuccessful quit attempt (view as a learning experience)

Encourage patient to try again

Tobacco dependence is a chronic disease

Remission Relapse

Tobacco Dependence

Pharmacotherapy

Smoking Cessation Strategies Nicotine Pharmacotherapy

Rationale for NRT:

Partially replace nicotine to reduce severity of withdrawal

Allows patient to focus on behavioral aspects

All forms of NRT are equally effective

Approximately doubles the chances of quitting

Nicotine Gum:

Precautions/ Contraindications

Side Effects Dosage Duration Availability

- Post MI (within 2 wks) - Serious arrhythmias - Unstable angina

-Mouth soreness -Dyspepsia -Hiccups -Jaw ache

1 piece every h

2 mg < 25 cigs/d 4 mg ≥ 25 cigs/d

≤ 24 pieces/d

≥ 12 weeks OTC

Nicotine Lozenge:

- Post MI (within 2 wks) - Serious arrhythmias - Unstable angina

-Nausea -Hiccups -Dyspepsia -Sore throat

and mouth

2mg if 1st cig

≥30 min after

waking 4mg if 1st cig

< 30 min after

waking

≤ 24 pieces/d

1 lozenge q 1-2 hrs

x 6 weeks, then 1

lozenge q 2-4hrs x

7-9 weeks, then 1

lozenge q 4-8 hrs x

10-12 weeks

Nicotine Gum and Lozenge:

Advantages Disadvantages

User controls nicotine dose More rapid satisfaction than patch Lozenge can be used with dentures May satisfy oral craving May delay post cessation weight gain Combination may increase success rate: Nicotine patch + gum Nicotine patch + lozenge

May not be socially acceptable Gum is difficult to use with dentures Improper usage decreases efficacy Chew and park technique Interference with absorption

Nicotine Nasal Spray:

- Post MI (within 2 wks) - Serious arrhythmias -Unstable angina

-Reactive airway disease

-Nasal irritation

-Sneezing

-Teary eyes

-Highest

dependence

potential

1-2mg dose/hr

≤ 40 applications

3-6 months RX Only

Nicotine Inhaler:

-Irritation of

mouth and

throat -Coughing

6-16 cartridges/d ≤ 6 months RX Only

Nicotine Patch:

-Local skin

reactions

-Insomnia

-Vivid dreams

21 mg/24 hours 14 mg/24 hours 7 mg/24 hours

15 mg/16 hours

4 weeks 2 weeks 2 weeks

Smoking Cessation Strategies Non-Nicotine Pharmacotherapy

Bupropion SR:

- History of seizure and

eating disorders -Use of MAO Inhibitor

-FDA warning regarding

depressed mood, change

in behavior and suicidal

thoughts

-Insomnia -Dry mouth

150 mg for 3 days,

then 150 mg bid x

7-12 weeks

Begin drug 1-2 wks

prior to quite date

Duration of

therapy up to

6 months

RX Only

Varenicline:

-Renal dose creatinine

clearance < 30 mL/min

thoughts

-Nausea -Vivid dreams -Insomnia -Headache

0.5 mg daily x 3

days, 0.5 mg bid x 4 days,

then 1 mg bid x 3 months

Begin drug 1 week

prior to quit date

Duration of

therapy up to

6 months

RX Only

Varenicline: Agonist and Antagonist

α4β2 receptor partial agonist

Acts by partially stimulating the

receptor to reduce cravings and

withdrawal.

Blocks the α4β2 receptor to blunt

the positive reinforcing effects of

nicotine

Varenicline:

-Renal dose creatinine

clearance < 30 mL/min

thoughts

-Nausea -Vivid dreams -Insomnia -Headache

0.5 mg daily x 3

days, 0.5 mg bid x 4 days,

then 1 mg bid x 3 months

Begin 1 week prior

to quit date

Duration of

therapy up to

6 months

RX Only

Smoking Cessation Pharmacotherapy

Effectiveness and Abstinence Rates:

Medication No. of Arms Estimated Odds Ratio

(95% C.I.) Estimated Abstinence

Rates (95% C.I.)

-Placebo

-Nicotine Gum <14wks

-Nicotine Gum >14wks

-Nicotine Lozenge

-Nicotine Nasal Spray

-Nicotine Inhaler

-Nicotine Patch

-Bupropion SR

-Varenicline

80 15 6 6 4 6 32 26 5

1.5 (1.2-1.7)

2.2 (1.5-3.2)

2.0 (1.6-2.4)

2.3 (1.7-3.0)

2.1 (1.5-2.9)

1.9 (1.7-2.2)

2.0 (1.8-2.2)

3.1 (2.5-3.8)

19.0 (16.5-21.9)

26.1 (19.7-33.6)

24.2 (19.2-34.4)

26.7 (21.5-32.7)

24.8 (19.1-31.6)

23.4 (21.3-25.8)

24.2 (22.2-26.4)

33.2 (28.9-37.8)

Fiore, MC et al. 2008 Update. Rockville, MD: US Dept of Health and Human Services; 2008.

Electronic Cigarettes More research is needed before any conclusions can be drawn

Microprocessor

activates LED

Lithium Ion

battery

Activation module

turns on heating

element

Heater

vaporizes

nicotine

and PEG

in cartridge

Cigarette-shaped devices aerosolize

nicotine

Currently not regulated

FDA has proposed extending its

authority to cover

There is very little known:

Potential risks or benefits?

How much nicotine inhaled?

Benefits as a cessation aid?

Gateway to cigarettes?

Barriers to Quit

Mental illness or dual addiction – refer to specialists

Additional smoker(s) in home – include in recommendations

Alcohol – refrain from drinking during initial quit

Craving and withdrawal – must address or doomed to fail

Fear of gaining weight – a modest health threat compared to

continued smoking

Take Home Points

Tobacco use continues to be the leading cause of preventable

disease and death in US

Smokers cite physicians’ advice as an important motivator for

attempting to stop smoking

Use of the PHS Guidelines are a proven effective 5-step algorithm

for cessation assistance

Those who don’t receive assistance represent a missed opportunity

Clearing the Smoke - Bladder Cancer Advocacy Network · Tobacco Addiction Most of the harms of...

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