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S
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
2010
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?
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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.
Nicotine Pharmacokinetics and
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
Nicotine Pharmacokinetics and
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
Nicotine Pharmacokinetics and
Tobacco Addiction
Psychoactive effects of nicotine:
Pleasure
Stimulation
Relaxation
Reduced anxiety
Stress control
Craving
Alleviation of withdrawal symptoms
Appetite suppression
Cognitive enhancement
Nicotine Pharmacokinetics and
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.
S
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
Smoking Cessation Strategies
ASK
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
ASK
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)
Smoking Cessation Strategies
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.”
Smoking Cessation Strategies
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
Smoking Cessation Strategies Treatment For Those Willing To Quit
ASSIST
Develop an individualized Quit Plan
Offer Medication
Provide or Refer for Counseling
Smoking Cessation Strategies Treatment For Those Willing To Quit
Personalized Quit Plan:
Set a quit date
Tell friends, family and coworkers
Anticipate challenges
Remove tobacco products from environment
Smoking Cessation Strategies Treatment For Those Willing To Quit
ASSIST
Develop an individualized Quit Plan
Offer Medication
Provide or Refer for Counseling
Smoking Cessation Strategies Treatment For Those Willing To Quit
ASSIST
Develop an individualized Quit Plan
Offer Medication
Provide or Refer for Counseling
Smoking Cessation Strategies Treatment For Those Willing To Quit
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
Smoking Cessation Strategies Treatment For Those Willing To Quit
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
S
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
Smoking Cessation Strategies Nicotine Pharmacotherapy
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
Smoking Cessation Strategies Nicotine Pharmacotherapy
Nicotine Lozenge:
Precautions/ Contraindications
Side Effects Dosage Duration Availability
- 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
OTC
Smoking Cessation Strategies Nicotine Pharmacotherapy
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
Smoking Cessation Strategies Nicotine Pharmacotherapy
Nicotine Nasal Spray:
Precautions/ Contraindications
Side Effects Dosage Duration Availability
- 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
daily
3-6 months RX Only
Smoking Cessation Strategies Nicotine Pharmacotherapy
Nicotine Inhaler:
Precautions/ Contraindications
Side Effects Dosage Duration Availability
- Post MI (within 2 wks) - Serious arrhythmias -Unstable angina
-Irritation of
mouth and
throat -Coughing
6-16 cartridges/d ≤ 6 months RX Only
Smoking Cessation Strategies Nicotine Pharmacotherapy
Nicotine Patch:
Precautions/ Contraindications
Side Effects Dosage Duration Availability
- Post MI (within 2 wks) - Serious arrhythmias -Unstable angina
-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
OTC
Smoking Cessation Strategies Non-Nicotine Pharmacotherapy
Bupropion SR:
Precautions/ Contraindications
Side Effects Dosage Duration Availability
- 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
Smoking Cessation Strategies Non-Nicotine Pharmacotherapy
Varenicline:
Precautions/ Contraindications
Side Effects Dosage Duration Availability
-Renal dose creatinine
clearance < 30 mL/min
-FDA warning regarding
depressed mood, change
in behavior and suicidal
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
Smoking Cessation Strategies Non-Nicotine Pharmacotherapy
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
Smoking Cessation Strategies Non-Nicotine Pharmacotherapy
Varenicline:
Precautions/ Contraindications
Side Effects Dosage Duration Availability
-Renal dose creatinine
clearance < 30 mL/min
-FDA warning regarding
depressed mood, change
in behavior and suicidal
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
1.0
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
LED
light
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