Tobacco Cessation: Curb the Deadliest Epidemic

Tobacco Cessation:Curb the Deadliest Epidemic

Keith Bradley, MDDirector,

Research Associates Program at St. Vincent’s National Alliance of Research Associates Programs

(NARAP)

Nicotine-Related Pathology

• coronary artery • peripheral vascular disease• hypertension • peptic ulcer disease• fetal mortality and morbidity• cancer

Lung Cancer

All lung cancers begin as small focus of

uncontrolled cell division

→ thickening/piling up of bronchial mucosa.

Lung Cancer

• Small cell

• Adenocarcinoma

• Squamous carcinoma

• Large cell carcinoma

Small Cell Carcinoma

Small Cell Carcinoma

• 20% of all lung cancers

Small Cell Carcinoma

• 20% of all lung cancers

• highly aggressive, metastasizing early.

Small Cell Carcinoma

• 20% of all lung cancers

• highly aggressive, metastasizing early.

• only 1% of cases occur in non-smokers

Small Cell Carcinoma

• 20% of all lung cancers

• highly aggressive, metastasizing early.

• only 1% of cases occur in non-smokers

• incurable by surgery

Small Cell Carcinoma

• 90% of small cell carcinomas begin in central airways

Small Cell Carcinoma

• 90% of small cell carcinomas begin in central airways– consistent with smoking association

Small Cell Carcinoma

• 90% of small cell carcinomas begin in central airways– consistent with smoking association

• Small cell staged as limited or extensive (spread outside chest)

Small Cell Carcinoma

• 90% of small cell carcinomas begin in central airways– consistent with smoking association

• Small cell staged as limited or extensive (spread outside chest) – 70% are extensive at diagnosis

Adenocarcinoma

Adenocarcinoma

• About 40% of lung cancer cases in the US

Adenocarcinoma

• About 40% of lung cancer cases in the US • The most common lung cancer among

women

Adenocarcinoma

• About 40% of lung cancer cases in the US • The most common lung cancer among

women– number of new cases is increasing

Adenocarcinoma

• About 40% of lung cancer cases in the US • The most common lung cancer among

women– number of new cases is increasing

• Usually starts near the outer edges of the lungs

Adenocarcinoma

• About 40% of lung cancer cases in the US • The most common lung cancer among

women, – number of new cases is increasing

• Usually starts near the outer edges of the lungs

• Often metastasized at diagnosis

Squamous Carcinoma

Squamous Carcinoma

• 25-30% of lung cancer cases in the US

Squamous Carcinoma

• 25-30% of lung cancer cases in the US • Occurs most frequently in men and the

elderly

Squamous Carcinoma

• 25-30% of lung cancer cases in the US • Occurs most frequently in men and the

elderly • Usually starts in one of the larger breathing

tubes

Squamous Carcinoma

• 25-30% of lung cancer cases in the US • Occurs most frequently in men and the

elderly • Usually starts in one of the larger breathing

tubes • Tends to grow relatively slowly

Squamous Carcinoma

• 25-30% of lung cancer cases in the US • Occurs most frequently in men and the

elderly • Usually starts in one of the larger breathing

tubes • Tends to grow relatively slowly • Tends to remain localized in the chest longer

than other types of lung cancer

Squamous Carcinoma

• 25-30% of lung cancer cases in the US • Occurs most frequently in men and the

elderly • Usually starts in one of the larger breathing

tubes • Tends to grow relatively slowly • Tends to remain localized in the chest longer

than other types of lung cancer • Does not metastasize early

Large Cell Carcinoma

Large Cell Carcinoma• “Other”

– tend to have larger cells than other types of lung cancer

Large Cell Carcinoma• “Other”

– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing

– may be due to improvements in determining the types of lung cancer

Large Cell Carcinoma• “Other”

– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing

– may be due to improvements in determining the types of lung cancer

• 10-15% of lung cancer cases in the US

Large Cell Carcinoma• “Other”

– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing

– may be due to improvements in determining the types of lung cancer.

• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes

Large Cell Carcinoma• “Other”

– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing

– may be due to improvements in determining the types of lung cancer

• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes • May occur in any part of the lung

Large Cell Carcinoma• “Other”

– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing

– may be due to improvements in determining the types of lung cancer.

• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes • May occur in any part of the lung • Tumors are usually large at diagnosis

Large Cell Carcinoma• “Other”

– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing

– may be due to improvements in determining the types of lung cancer.

• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes • May occur in any part of the lung • Tumors are usually large at diagnosis• Tends to invade the mediastinum

(chest area behind the breastbone)

Large Cell Carcinoma• “Other”

– tend to have larger cells than other types of lung cancer • Incidence appears to be decreasing

– may be due to improvements in determining the types of lung cancer.

• 10-15% of lung cancer cases in the US • Usually starts in the smaller breathing tubes • May occur in any part of the lung • Tumors are usually large at diagnosis• Tends to invade the mediastinum

(chest area behind the breastbone)• Metastasizes to the central nervous system

Nicotine Addiction

Nicotine Addiction• Psychoactive

Nicotine Addiction• Psychoactive

– dose-related changes in mood and feeling

Nicotine Addiction• Psychoactive

– dose-related changes in mood and feeling – transient

Nicotine Addiction• Psychoactive

– dose-related changes in mood and feeling – transient

• Euphoriant

Nicotine Addiction• Psychoactive

– dose-related changes in mood and feeling – transient

• Euphoriant – dose-related increases in scores on standard

measures of euphoria. •

Nicotine Addiction• Psychoactive

– dose-related changes in mood and feeling – transient

• Euphoriant – dose-related increases in scores on standard

measures of euphoria. • Reinforcer

Nicotine Addiction• Psychoactive

– dose-related changes in mood and feeling – transient

• Euphoriant – dose-related increases in scores on standard

measures of euphoria. • Reinforcer• Neuroadaptation

Nicotine Addiction• Psychoactive

– dose-related changes in mood and feeling – transient

• Euphoriant – dose-related increases in scores on standard

measures of euphoria. • Reinforcer• Neuroadaptation

– leading to tolerance and physiologic dependence.

Nicotine Addiction

nicotine from the use of tobacco has≈ physical addiction potential as morphine

Nicotine Addiction

nicotine from the use of tobacco has≈ physical addiction potential as morphine≈ psychic dependence as cocaine

Smokeless Tobacco

• pharmacokietics of nicotine

(i.e., absorption, distribution, and elimination)

from smoking and from smokeless tobacco

→ magnitude of nicotine exposure similar

Tobacco Cessation

Tobacco Cessation

• Treating Tobacco Use and Dependence. U.S. Public Health Service. http://www.surgeongeneral.gov/tobacco/smokesum.htm

• Guideline, Treating Tobacco Use and Dependence– based on the literature review and expert panel

opinion

Which Smokers Offered Cessation ?

• Because effective tobacco dependence treatments are available, every patient who uses tobacco should be offered at least one of these treatments:– Patients willing to try to quit tobacco use should

be provided treatments identified as effective in this guideline.

– Patients unwilling to try to quit tobacco use should be provided a brief intervention designed to increase their motivation to quit.

Which Smokers Offered Cessation ?

“It is essential that clinicians and

health care delivery systems …

institutionalize the consistent

identification, documentation, and

treatment

of every tobacco user seen in a health

care setting.”

Brief Tobacco Dependence Tx

Brief Tobacco Dependence Tx

• should be: – effective

Brief Tobacco Dependence Tx

• should be: – effective– offered to every patient who uses tobacco

Brief Tobacco Dependence Tx

• should be: – effective– offered to every patient who uses tobacco

• Quitlines

Brief Tobacco Dependence Tx

• should be: – effective– offered to every patient who uses tobacco

• Quitlines:– mandated by tobacco company settlements

Brief Tobacco Dependence Tx

• should be: – effective– offered to every patient who uses tobacco

• Quitlines:– mandated by tobacco company settlements– about 30-40% effective

Tx Dose-Response Relationship

Tx Dose-Response Relationship• strong relationship between

intensity of tobacco dependence counseling and its effectiveness

Tx Dose-Response Relationship• strong relationship between

intensity of tobacco dependence counseling and its effectiveness

• person-to-person treatments (individual, group, or telephone counseling)

Tx Dose-Response Relationship• strong relationship between

intensity of tobacco dependence counseling and its effectiveness

• person-to-person treatments (individual, group, or telephone counseling):– consistently effective

Tx Dose-Response Relationship• strong relationship between

intensity of tobacco dependence counseling and its effectiveness

• person-to-person treatments (individual, group, or telephone counseling):– consistently effective– effectiveness increases with treatment intensity

(e.g., minutes of contact)

Types of Counseling and Behavioral Tx

Types of Counseling and Behavioral Tx

1. Provision of practical counseling (problem solving/skills training)

Types of Counseling and Behavioral Tx

1. Provision of practical counseling (problem solving/skills training)

2. Provision of social support as part of tx (intra-treatment social support)

Types of Counseling and Behavioral Tx

1. Provision of practical counseling (problem solving/skills training)

2. Provision of social support as part of tx (intra-treatment social support)

3. Help in securing social support outside of tx (extra-treatment social support)

Pharmacotherapies

Pharmacotherapies

Reliably increase long-term smoking abstinence

Pharmacotherapies

Reliably increase long-term smoking abstinence• Nicotine

– gum– inhaler – nasal spray– patch

Pharmacotherapies

Reliably increase long-term smoking abstinence• Nicotine

– gum– inhaler – nasal spray– patch

“Over-the-counter nicotine patches are effective relative to placebo, and their use should be encouraged.”

Pharmacotherapies

Reliably increase long-term smoking abstinence• Nicotine

– gum– inhaler – nasal spray– patch

“Over-the-counter nicotine patches are effective relative to placebo, and their use should be encouraged.”

• Bupropion (Wellbutrin) SR • Other anti-depressants

Effective Pharmacotherapies

Except in the presence of contraindications,

these should be used with all patients

attempting to quit smoking.

$ ?

$ ?

Insurers should include as a reimbursedbenefit:

$ ?

Insurers should include as a reimbursedbenefit:• counseling and pharmacotherapeutic

treatments identified as effective in this guideline.

$ ?

Insurers should include as a reimbursedbenefit:• counseling and pharmacotherapeutic

treatments identified as effective in this guideline.

• clinicians for providing tobacco dependence treatment just as they are reimbursed for treating other chronic conditions.

Clinicians and Tobacco Cessation

• About 20 years ago, data indicated that clinicians too frequently failed to intervene with their patients who smoke.

Clinicians and Tobacco Cessation

• About 20 years ago, data indicated that clinicians too frequently failed to intervene with their patients who smoke.

• Recent data confirm this has not changed markedly over the past two decades.

Clinicians and Tobacco Cessation

One recent study reported: • only 15 percent of smokers who saw a

physician in the past year were offered assistance with quitting

Clinicians and Tobacco Cessation

One recent study reported: • only 15 percent of smokers who saw a

physician in the past year were offered assistance with quitting

• only 3 percent were given a follow-up appointment to address this topic.

Bottom LineThese evidence-based guidelines reveal:

Bottom LineThese evidence-based guidelines reveal: 1. multiple efficacious tobacco cessation tx exist

Bottom LineThese evidence-based guidelines reveal: 1. multiple efficacious tobacco cessation tx exist 2. these tx can double or triple the likelihood of long-

term cessation

Bottom LineThese evidence-based guidelines reveal: 1. multiple efficacious tobacco cessation tx exist 2. these tx can double or triple the likelihood of long-

term cessation 3. many cessation tx are appropriate for the

primary care setting

Bottom LineThese evidence-based guidelines reveal: 1. multiple efficacious tobacco cessation tx exist 2. these tx can double or triple the likelihood of long-

term cessation 3. many cessation tx are appropriate for the

primary care setting4. cessation tx are more cost-effective than many

other reimbursed clinical interventions

Bottom LineThese evidence-based guidelines reveal: 1. multiple efficacious tobacco cessation tx exist 2. these tx can double or triple the likelihood of long-

term cessation 3. many cessation tx are appropriate for the

primary care setting4. cessation tx are more cost-effective than many

other reimbursed clinical interventions5. utilization and impact of cessation treatments can

be increased by supportive health system policies (e.g., coverage through insurance)

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