Cardiology Rx for ChangeClinician-Assisted Tobacco Cessation

Funded by the Flight Attendant Medical Research Institute (FAMRI)

TRAINING OVERVIEW

Epidemiology of Tobacco Use Tobacco & Second-hand Smoke: CVD Risk Nicotine Addiction and Withdrawal Medications for Quitting Smoking Changing Behavior: How You Can Help

Ad campaigns from the 1950s featured physicians and assured the public that

cigarettes were safe.

STATE-SPECIFIC PREVALENCE of SMOKING among ADULTS, 2007

Centers for Disease Control and Prevention. (2008). MMWR 58:221–226.

< 18.0%18.0 – 19.9%20.0 – 21.9%22.0 – 23.9%≥ 24.0%

Prevalence of current smoking (2007)

TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2009

Trends in cigarette current smoking among persons aged 18 years or older

Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2009 NHIS. Estimates since 1992 include some-day smoking.

Per

cen

t

Male

Female 23.51%

17.9%

20.6% of adults are current smokers.

Year

70% want to quit

PREVALENCE of SMOKING by INSURANCE STATUSU.S. ADULTS AGED 18-64, 2007

17% Privately insured

33% Medicaid

26% Other

32% Uninsured

Centers for Disease Control and Prevention. (2007). MMWR 56:1157–1161.

FORMS of TOBACCO

Cigarettes are, by far, the most common form of tobacco used in the U.S.

Other forms of tobacco exist, and some are increasing in popularity.

All forms of tobacco are harmful.

Attention to all forms of tobacco is needed.

CIGARS: 1950–2007U.S. CONSUMPTION

Data from U.S.D.A. (2004 & 2007)

One cigar can deliver enough nicotine to establish and maintain dependence

TOBACCO and SECOND-HAND SMOKE: CARDIOVASCULAR DISEASE RISK

HEALTH CONSEQUENCES of SMOKING

Cancers Acute myeloid leukemia Bladder and kidney Cervical Esophageal Gastric Laryngeal Lung Oral cavity and pharyngeal Pancreatic

Pulmonary diseases Acute (e.g., pneumonia) Chronic (e.g., COPD) Tuberculosis

Cardiovascular diseases Abdominal aortic aneurysm Coronary heart disease Cerebrovascular disease Peripheral arterial disease Sudden death Heart failure

Reproductive effects Reduced fertility in women Poor pregnancy outcomes Infant mortality

Other effects: type 2 diabetes, peptic ulcer, cataract, osteoporosis, periodontitis, poor surgical outcomes (occlusion of bypass grafts & stents)

USDHHS. (2004). The Health Consequences of Smoking: A Report of the Surgeon General.

USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.

There is no safe level of second-hand

smoke.

Second-hand smoke (SHS) causes premature death and disease in nonsmokers: Immediate adverse effects on the

cardiovascular system Increased risk for coronary heart disease

and lung cancer

2006 REPORT of the SURGEON GENERAL: INVOLUNTARY EXPOSURE to TOBACCO SMOKE

ANNUAL U.S. DEATHS ATTRIBUTABLE to TOBACCO USE & SHS, 2000-2004

Centers for Disease Control and Prevention. (2008). MMWR 57:1226–1228.

32%

29%

21%

8%

10%

Cardiovascular diseases are the #1 cause of death among smokers.

Cardiovascular diseases

141,900

Lung cancer 128,900

Respiratory diseases 92,900

Cancers other than lung

35,300

Other 44,000

Total deaths annually: 443,000

Percentage of all smoking-attributable deaths*

* In 2005, it was estimated that nearly 50,000 persons died due to SHS exposure.

BRITISH MALE DOCTORS’

STUDY

On average, cigarette smokers die about 10 years younger than do

nonsmokers.

At least half of chronic smokers will die due to a tobacco-related disease.

Doll et al. (2004). BMJ 328(7455):1519–1527.

Prospective study of 34,439 male doctors studied from 1951 to

2001

EFFECTS of SMOKING & SHS on the CARDIOVASCULAR SYSTEM

Platelet activation Endothelial

dysfunction Inflammation &

infection Atherosclerosis

Low HDL levels Platelet instability Increased oxidized

LDL Increased oxidation

stress Decreased energy

metabolism

Increased insulin resistance

Outcome measures Increased infarct

size Decreased heart

rate variability Increased arterial

stiffness Increased risk of

coronary disease events

Barnoya & Glantz. (2005). Circulation111:2684-2698

META-ANALYSIS of CHD RISK DUE to CHRONIC SHS among NEVER-SMOKERS

Overall RR = 1.78 for active smokers

Overall RR = 1.31 for passive nonsmokers 1

1.2

1.4

1.6

1.8

2

NeverSmoker

SHSNever

Smoker

ActiveSmoker

Barnoya & Glantz. (2005). Circulation111:2684–2698.

Long-term SHS exposure in the work or home is associated with a 30% increased risk for CHD in adult nonsmokers.

Rel

ativ

e ri

sk

N = 29 studies

Copyright ©2004 BMJ Publishing Group Ltd.

Whincup et al. (2004). BMJ 329:200-205.

"Light passive" refers to the lowest quarter of cotinine concentration among nonsmokers(0-0.7 ng/ml), "heavy passive" to the upper three-quarters of cotinine concentration combined

(0.8-14.0 ng/ml), "light active" to men smoking 1-9 cigarettes a day.

PROPORTION of MEN with MAJOR CHD by YEARS of FOLLOW-UP: LIGHT ACTIVE, HEAVY PASSIVE, LIGHT PASSIVE

After the last cigarette…< 30 min

8 hr

24 hr

48 hr

72 hr

2-12 weeks

1 year

3 years

5-15 years

Blood pressure and pulse return to normal

O2 and CO levels in blood return to normal

Chance of heart attack decreases

Nerve endings begin regrowth

Breathing becomes easier; lung capacity increases

Lung function increases 30%; circulation improves

Risk of CHD is half that of a smoker

MI risk is similar to that of never-smokers

Stroke risk reduced to that of never-smokers

Standard treatments reduce the risk of death in patients with CVD by 15–35% Aspirin = 15% Beta blockers = 23% ACE inhibitors = 23% Statins = 29–35%

Smoking cessation reduces the risk of death by 36% and reduces the risk of future cardiac events by 50%

TOBACCO CESSATION as TREATMENT for CVD

SUMMARY: REASONS to ADDRESS TOBACCO in CARDIOLOGY

Smoking and SHS act synergistically with other CVD risk factors

Smoking increases risk for surgical complications

Quitting smoking improves survival Quitting smoking improves quality of life Quitting reduces risk of future CVD events

TOBACCO CESSATION is an essential component of prevention and treatment for CVD.

NICOTINE ADDICTION and WITHDRAWAL

NICOTINE DISTRIBUTION

Henningfield et al. (1993). Drug Alcohol Depend 33:23–29.

0

10

20

30

40

50

60

70

80

0 1 2 3 4 5 6 7 8 9 10

Minutes after light-up of cigarette

Pla

sma n

icoti

ne (

ng/m

l) Arterial

Venous

Nicotine reaches the brain within 11 seconds.

Nicotine enters brain

Stimulation of nicotine receptors

Dopamine release

DOPAMINE REWARD PATHWAYPrefrontal

cortex

Nucleus accumbens

Ventral tegmental

area

NEUROCHEMICAL and RELATED EFFECTS of NICOTINE

Dopamine

Norepinephrine

Acetylcholine

Glutamate

Serotonin

-Endorphin

GABA

N

I

C

O

T

I

N

E

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

Benowitz. (2008). Clin Pharmacol Ther 83:531–541.

Irritability/frustration/anger Anxiety Difficulty concentrating Restlessness/impatience Depressed mood/depression Insomnia Impaired performance Increased appetite/weight gain Cravings

NICOTINE PHARMACODYNAMICS: WITHDRAWAL EFFECTS

Hughes. (2007). Nicotine Tob Res 9:315–327.

Most symptoms manifest within the first 1–2 days, peak

within the first week, and subside within 2–

4 weeks.

HANDOUT

NICOTINE ADDICTION CYCLE

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

TOBACCO DEPENDENCE:A 2-PART PROBLEM

Tobacco Dependence

Treatment should address the physiologic and the behavioral

aspects of dependence.

Physiologic Behavioral

Treatment Treatment

The addiction to nicotine

Medications for cessation

The habit of using tobacco

Behavior change program

MEDICATIONS for QUITTING SMOKING

PHARMACOLOGIC METHODS

First-line (FDA approved) Nicotine replacement therapy (NRT) Bupropion SR (Zyban) Varenicline (Chantix)

Second-line (evidence based but not FDA approved) Nortriptyline Clonidine

PLASMA NICOTINE CONCENTRATIONS for NICOTINE-CONTAINING PRODUCTS

0

5

10

15

20

25

1/0/1900 1/10/1900 1/20/1900 1/30/1900 2/9/1900 2/19/1900 2/29/1900

Pla

sma

nic

oti

ne

(mcg

/l)

Cigarette

Moist snuff

Nasal spray

Inhaler

Lozenge (2mg)

Gum (2mg)

Patch

0 10 20 30 40 50 60

Time (minutes)

Cigarette

Moist snuff

NRT: PRECAUTIONS

Patients with underlying CVD: Recent MI (within past 2 weeks) Serious arrhythmias Serious or worsening angina

NRT may be appropriate for these patients if they are under medical supervision

Experts believe the risks of NRT in heart patients are small in relation to the risks of continued tobacco use.

TRANSDERMAL NICOTINE PATCH

DISADVANTAGES Patients cannot titrate

the dose Allergic reactions to

adhesive may occur Vivid/disturbing dreams

may occur with nocturnal patch use (can remove before sleep)

ADVANTAGES The patch

provides consistent nicotine levels

The patch is easy to use and conceal

Fewer compliance issues are associated with the patch

PATIENT EDUCATION :Nicotine Patch

Apply patch to hairless area—new location daily

Water will not harm the nicotine patch if it is applied correctly; patients may bathe, swim, shower, or exercise while wearing the patch

Do not cut patches to adjust dose Nicotine may evaporate from cut edges Patch may be less effective

Keep new and used patches out of the reach of children and pets

NICOTINE GUM & LOZENGE

DISADVANTAGES Gastrointestinal side

effects may be bothersome

Gum may be socially unacceptable and difficult to use with dentures

Patients must use proper chewing technique to minimize adverse effects

ADVANTAGES Patients can titrate

therapy to manage withdrawal symptoms

May satisfy oral cravings

May delay weight gain

NICOTINE GUM:

CHEWING TECHNIQUE SUMMARY

Park between cheek & gum

Stop chewing at first sign of peppery taste or tingling sensation

Chew slowly

Chew again when peppery taste or tingle fades

Do not eat or drink 15 min before or

after use.

NICOTINE INHALERDISADVANTAGES

Initial throat or mouth irritation can be bothersome

Cartridges should not be stored in very warm conditions or used in very cold conditions

Patients with underlying bronchospastic disease must use the inhaler with caution

ADVANTAGES Patients can easily

titrate therapy to manage withdrawal symptoms

The inhaler mimics hand-to-mouth ritual of smoking

NICOTINE NASAL SPRAY

DISADVANTAGES Nasal/throat

irritation may be bothersome

Dependence can result*

Patients must wait 5 min before driving or operating heavy machinery

* The data on higher dependence are not definitive and are based on small trials.

ADVANTAGES Most rapidly

absorbed form of nicotine replacement

Patients can easily titrate therapy to rapidly manage withdrawal symptoms

BUPROPION SRDISADVANTAGES Should be avoided in

patients with an increased risk for seizures

Side effects:Common: dry mouth, anxiety, insomnia (avoid bedtime dosing)

Less common: tremor, skin rash

ADVANTAGES Easy to use Can be used with

NRT or varenicline May delay cessation-

related weight gain May be beneficial in

patients with coexisting depression

BUPROPION: CONTRAINDICATIONS and PRECAUTIONS

History of seizure Current or prior eating disorder History of cranial trauma, stroke, or neurosurgical

intervention Treatment with medications that lower the seizure

threshold (e.g., antipsychotics, antidepressants, theophylline)

Treatment with MAOIs in the past 2 weeks Abrupt discontinuation of alcohol or sedatives

(including benzodiazepines) Severe hepatic cirrhosis

BUPROPION:MECHANISM OF ACTION

Atypical antidepressant thought to affect levels of various brain neurotransmitters Dopamine

Norepinephrine

Clinical effects craving for cigarettes

symptoms of nicotine withdrawal

BUPROPION SR: DOSING for SMOKING CESSATION

Initial treatment 150 mg po q AM x 3 days

Then, if tolerated… 150 mg po bid x 7–12 weeks

If 300 mg is not well tolerated… Reduce dose to 150 mg and reassure that

150 mg dose is still efficacious (Swan et al., 2003)

Patients should begin therapy one week PRIOR to quitting to assure therapeutic plasma levels

of drug are achieved when patient is no longer

smoking.

BUPROPION: ADDITIONAL PATIENT EDUCATION

Can be safely used with NRT or varenicline Dose tapering is not necessary when

discontinuing treatment If no significant progress toward abstinence

by 7th week, therapy is unlikely to be effective Discontinue treatment Reevaluate and restart at later date

FDA boxed warning added in July 2009

VARENICLINE

DISADVANTAGES Common side effects:

Nausea (in up to 33% of patients)

Sleep disturbances (insomnia, abnormal dreams)

Constipation Flatulence Vomiting

ADVANTAGES Oral formulation with

twice-a-day dosing Offers a new

mechanism of action for persons who previously failed using other medications

Early industry-sponsored trials suggest this agent is superior to bupropion SR

VARENICLINE:MECHANISM of ACTION

Binds with high affinity and selectivity at 42 neuronal nicotinic acetylcholine receptors Stimulates low-level agonist activity

Competitively inhibits binding of nicotine

Clinical effects symptoms of nicotine withdrawal

Blocks dopaminergic stimulation responsible for reinforcement & reward associated with smoking

VARENICLINE: DOSINGPatients should begin therapy 1 week PRIOR to

theirquit date. The dose is increased gradually to

minimize treatment-related nausea and insomnia.Treatment Day Dose

Days 1–3 0.5 mg qd

Days 4–7 0.5 mg bid

Day 8 – week 12 1 mg bid

Initial dose titration

VARENICLINE: ADDITIONAL PATIENT EDUCATION

Do not combine with NRT—increase in side effects, including nausea, headache, vomiting, fatigue

Doses should be taken after eating, with a full glass of water

Nausea and insomnia are side effects that are usually temporary

Dose tapering is not necessary when discontinuing treatment

FDA BOXED WARNINGS

On July 1, 2009, varenicline and bupropion received Boxed Warnings concerning the risk of serious neuropsychiatric symptoms:

Patients should be advised to stop taking varenicline or bupropion and to contact a health-care provider immediately if they experience agitation, depressed mood, and any changes in behavior that are not typical of nicotine withdrawal, or if they experience suicidal thoughts or behavior.

VARENICLINE USE in PATIENTS with CVD: EFFICACY & SAFETY

Study of 714 patients with stable, documented CVD (other than hypertension alone) diagnosed for > 2 months 51% angina, 49% MI, 49% coronary

revascularization Randomized to 12 weeks varenicline or

placebo Monitored over 52 weeks Multisite trial funded by Pfizer, Inc.

Rigotti et al. (2010). Circulation; 121:221-9.

CONTINUOUS ABSTINENCE RATES: VARENICLINE vs. PLACEBO

Rigotti et al. (2010). Circulation; 121:221-9.

VARENICLINE: ADVERSE EVENTS

Most frequent events in the varenicline group: Nausea (30%), headache (13%), insomnia (12%),

vomiting (8%), and abnormal dreams (8%) 9.6% stopped the drug because of an adverse

event; compared to 4.3% receiving placebo

Serious adverse events occurred in 6.5% of participants in the varenicline group and 6.0% in the placebo group

No reported depression, suicidality, or abnormal behavior

LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS

0

5

10

15

20

25

30

Nicotine gum Nicotinepatch

Nicotinelozenge

Nicotinenasal spray

Nicotineinhaler

Bupropion Varenicline

Active drugPlacebo

Data adapted from Cahill et al. (2008). Cochrane Database Syst Rev; Stead et al. (2008). Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev.

Per

cen

t q

uit 18.0

15.8

11.3

9.9

16.1

8.1

23.9

11.8

17.1

9.1

19.0

10.3 11.2

20.2

Varenicline vs. NRT

Aubin et al. (2008). Thorax 63:717-724.

OR = 1.40 (95% CI = 0.99–1.99)

Pe

rce

nt q

uit

smok

ing

COMBINATION PHARMACOTHERAPY

Combination NRT

Long-acting formulation (patch)

Produces relatively constant levels of nicotine

PLUS

Short-acting formulation (gum, inhaler, nasal spray)

Allows for acute dose titration as needed for nicotine withdrawal symptoms

Bupropion SR + Nicotine Patch

Regimens with enough evidence to be “recommended” first-line

EXTENDED TREATMENTS

STANDARD TREATMENT (ST)12 weeks: group counseling, NRT, and bupropion

EXTENDED CBT (E-CBT)ST + 11 individual CBT sessions over 40 weeks

EXTENDED NRT (E-NRT)ST + 40 weeks of nicotine gum availability

EXTENDED CBT+ NRTE-CBT + 40 weeks NRT

N = 402 older adult smokers (50+ yrs old), motivated to quit, 10+ cpd at baseline

Hall et al. (2009). Addiction 104:1043-1052.

TREATMENT TIMELINES

Bupropion

NRT

NRT + BUPR

Varenicline

Clinical contacts

QUIT DATE

1 WEEK PRIOR 12 WEEKS POST 150 mg 300 mg

Patch and consider prn gum/lozenge

0.5 mg qd 0.5 mg bid 1 mg bid

150 mg 300 mg Patch and consider prn gum/lozenge

$0

$1

$2

$3

$4

$5

$6

$7

$8

Trade $6.58 $5.26 $3.89 $5.29 $3.72 $7.40 $4.75

Generic $3.28 $3.66 $1.90 - - $3.62 -

Gum Lozenge Patch Inhaler Nasal sprayBupropion

SRVarenicline

COMPARATIVE DAILY COSTS of PHARMACOTHERAPY

$/d

ay

Average cost/pack of cigarettes, $4.32

MEDICARE COVERAGE

Medicare Part D covers cessation medications prescribed by a physician; OTC products not covered

Affordable Care Act: any Medicare beneficiary who smokes will be able to receive counseling from a "qualified physician or other Medicare-recognized practitioner" who can help them quit smoking 4 sessions per quit attempt Up to 2 covered quit attempts per year

TOBACCO DEPENDENCE:A 2-PART PROBLEM

Tobacco Dependence

Treatment should address the physiologic and the behavioral

aspects of dependence.

Physiological Behavioral

Treatment Treatment

The addiction to nicotine

Medications for cessation

The habit of using tobacco

Behavior change program

Changing Behavior:How You Can Help

HANDOUT

TOBACCO CESSATION REQUIRES BEHAVIOR CHANGE

Fewer than 5% of people who quit without assistance are successful in quitting for more than a year

Many patients underestimate the impact that counseling can have on their ability to quit

Few patients adequately PREPARE and PLAN for their quit attempt

Many patients assume they can just “make themselves quit” when they are ready to do soBehavioral counseling is a key component of treatment

for tobacco use and dependence.

0

10

20

30

No clinician Self-helpmaterial

Nonphysicianclinician

Physicianclinician

Type of Clinician

Est

imate

d a

bst

inence

at

5+

month

s

1.0 1.11.7

2.2

N = 29 studies

Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.

With help from a clinician, the odds of quitting approximately double.

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.

CLINICIAN ADVICE MAKES a DIFFERENCE

Esti

mate

d a

bsti

nen

ce

rate

at

5+

mon

ths

0

10

20

30

None One Two Three or more

Number of Clinician Types

1.0

1.8(1.5-2.2)

2.5(1.9-3.4)

2.4(2.1-3.4)

N = 37 studies

The NUMBER of CLINICIANS CAN MAKE a DIFFERENCE, TOO

Compared to smokers who receive assistance from no clinicians, smokers who receive assistance from two or more clinicians are 2.4–2.5 times as likely to quit successfully for 5 or more months.

Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.

The 5 A’s

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

HANDOUT

Ask about tobacco use “Do you, or does anyone in your household, ever

smoke or use any type of tobacco?”

“We ask all of our patients about tobacco use and secondhand smoke exposure, because it is so important for good cardiovascular health.”

ASK

STEP 1: ASK

tobacco users to quit “Quitting tobacco is a critical component of your

care.”

“Quitting smoking is the best thing you can for your heart.”

“Patients who continue to smoke after a heart attack have lower survival than patients who quit smoking.”

“It will be important for your family and close friends to either quit with you or be supportive of your quitting.”

“Creating a smoke-free environment at home is critical to your heart health and success with quitting smoking.”

ADVISE

STEP 2: ADVISE

STEP 3: ASSESS

readiness to quit Ask every tobacco user if s/he is willing to quit at this

time.

If willing to quit, provide resources and assistance See STEP 4, ASSIST

If NOT willing to quit at this time, provide resources and enhance motivation. Ask three questions:

“Do you ever plan to quit?” [If yes, continue with…] “How will it benefit you to quit later, as opposed to

now?” “What is the worst thing that could happen if you were

to quit tomorrow?”

ASSESS

STEP 4: ASSIST

tobacco users with a quit plan Discuss reasons for quitting and benefits of quitting

Review past quit attempts—what helped, what led to relapse

Discuss support from family, friends, and coworkers

Set a quit date—within 2 weeks

Encourage use of pharmacotherapy when not contraindicated

Anticipate challenges, particularly during the first few weeks Nicotine withdrawal, stress-related smoking, etc.

ASSIST

STEP 5: ARRANGE

follow-up care Status of attempt

Ask about support from friends, family, coworkers Identify ongoing temptations and triggers for relapse

(stress, negative affect, smokers, eating, alcohol, cravings)

Slips and relapse Has the patient used tobacco at all—even a puff?

Cessation medication compliance, plans for termination

Is the regimen being followed? Are withdrawal symptoms being alleviated?

ARRANGE

PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT.

RELAPSE in PATIENTS with CARDIOVASCULAR DISEASE

Less than half of patients will be tobacco free 6 months following an MI hospitalization

Predictors of relapse: Not receiving a discharge recommendation

for cardiac rehabilitation (OR = 1.80) Depressive symptoms during hospitalization

(OR = 1.75) Treating hospital does not have a smoking

cessation program (OR = 1.71)Dawood et al. (2008). Arch Intern Med 168:1961-1967.

patients to other resources: A doctor, nurse, pharmacist, or other clinician, for

additional counseling Local program: [insert your med center’s

program] The support program provided free with each smoking

cessation medication Web sites like smokefree.gov or quitnet.org The toll-free national quit line: 1-800-QUIT-NOW

REFER

IN the ABSENCE of TIME or EXPERTISE: REFER

REFERRAL to a TOLL-FREE TELEPHONE QUIT LINE

Referring patients to a toll-free quit line is simple and easily integrated into routine patient care

Quit line callers receive one-on-one coaching from trained counselors

Follow-up counseling is provided Quit lines are effective and are provided at no cost to

the caller

1-800-QUIT-NOW

TREATING TOBACCO DEPENDENCE in HOSPITALIZED CVD PATIENTS

• Meta-analysis: 11 RCTs (N = 2,751), 1990–2007

• Quit rates: intervention (42%) vs. usual care (34%)

• Greater quit rates: • > 6 interactions: OR = 1.67• Greater duration & intensity: OR = 3.17• Concurrent use of NRT or bupropion: OR =

2.13Behavioral smoking cessation interventions initiated during hospitalization result in a significantly higher

quit rate compared to usual smoking cessation advice. Aziz et al. (2009). Int J Cardiology.

TOBACCO CESSATION TREATMENT in PATIENTS with CHD

• Meta-analysis: 16 RCTs (N = 2,677), 1974–2003

• Positive treatment effect at 6–12 mos: OR = 1.66• Brief interventions: OR = 0.92 (not significant)• Telephone support: OR = 1.58• Self-help: OR = 1.48• Behavioral therapies: OR = 1.69• Intense interventions (follow-up after 1 month): OR = 1.98

Behavioral smoking cessation interventions in patients with CHD are effective in promoting abstinence at

1 year, provided they are of sufficient duration.Barth et al. (2008). Cochrane Reviews.

Mills et al. (2009). Nicotine Tob Res.

SMOKE-FREE HOMES SUPPORT TOBACCO CESSATION

Prevalence of smoke-free homes has been increasing over time

Review of 16 longitudinal and 7 cross-sectional studies: Smokers with smoke-free home were

significantly more likely to make a quit attempt and be abstinent

THE CARDIOLOGY TEAM’s RESPONSIBILITY

The cardiology team has a professional obligation

to address tobacco use and can have an important role in helping patients with

CVD, and their family members,plan for their quit attempts.

TOBACCO CESSATION is an essential component of CVD TREATMENT

for ALL PATIENTS who use tobacco.

TOBACCO TREATMENTS with DEMONSTRATED EFFICACY

Physician advice Formal smoking cessation programs

Individual counseling Web and telephone counseling:

www.smokefree.gov 1-800-QUIT-NOW (national toll-free quit line)

Group programs Aversion therapy NRT, bupropion, varenicline, Nortriptyline, clonidine

TOBACCO TREATMENTS LACKING EVIDENCE of EFFICACY

SSRIs and SNRI

Anxiolytics: Sedative, hypnotics,

buspirone

Homeopathic treatments

Hypnotherapy

Herbal supplements

Lobeline

Massage therapy

Acupuncture

Laser therapy

Nicotine Anonymous

SET REALISTIC EXPECTATIONS

It’s a learning process. Reframe success! Most people make

multiple quit attempts before they are successful.

Longer prior quit attempts predict future success.Hall et al. (2009). Addiction, 104:1043-1052.

Address tobacco use with all patients.

At a minimum, commit to incorporating brief tobacco interventions as part of routine patient care:

Ask, Advise, and Refer.

Become an advocate for smoke-free hospitals and clinics, workplaces, and public places.

MAKE a COMMITMENT…