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Smoking CessationSmoking Cessation
Kevin Scott Ferentz, M.D.
Associate Professor
Department of Family Medicine
University of MD School of Medicine
Cigarette smoking is the single most
important cause of disease and
premature death in the United States
Cigarette smoking is the single most
important cause of disease and
premature death in the United States
Cigarette-related deaths
440,000 per year 12 million dead since first surgeon
general’s report in 1964 Smokers die 13-14 years earlier Medical costs: $ 75 billion Lost productivity: $ 82 billion Costs: $ 40/pack
Smoking in the U.S. - 2006Smoking in the U.S. - 2006 21% of adults (43% in 1966)
Kentucky 27.4%, Utah 10.5% men (24%) women (18%)
< HS education 3X likely than w/ college degree rate dropped little in 1990’s Rate dropping by < 1% per year 1.3 million quit each year 3,000 teens start each day
adolescent smoking may be dropping more ex-smokers than current smokers 2010 goal: 12% smokers
Grade 9
Grade 10
Grade 11
Grade 12
Male
Female
Grade 10
Grade 11
Grade 12
Grade 9
Current cigarette smoking among HS students by sex, frequency, and grade level: US, 2003
Current smoking = smoked on 1 or more days of the 30 days preceding survey; Frequent smoking = smoked on 20 or more of the 30 days preceding the survey. Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004
Percent
Frequent smoking
0 10 20 30 40
The politics of tobacco States that grow tobacco:
– lowest taxes, highest rates of smoking Most Tobacco Restitution Funds are NOT
going to tobacco control California: 1988
– 23% smoking rate– Voters approve 25¢ tax for anti-smoking
campaign California: 2003
– 15% smoking rate– 13% of HS students smoke (22% nationally)
Phillip Morris profits up 10% in 2004
Smoking worldwide
1.3 billion smokers Expected to rise to 1.7 in 2025 Kills 5 million yearly 1 death every 6.5 seconds May double in 20 years 84% of smokers are in developing countries 95 billion cigarettes sold in India each year!
World Health Organization – 2004
Increased Cancer RiskIncreased Cancer Risk
90% of lung cancer deaths 40% of all cancers mouth, larynx, esophagus, stomach kidney, bladder Pancreas Cervix Acute myeloid leukemia more women die of lung than breast cancer!
Heart disease
leading cause of death smoking is major risk factor 3 times more likely to die of heart disease step-wise increase with other risk factors
Lung Disease
90% of COPD deaths asthma bronchitis pneumonia
Female smokersFemale smokers
infertility earlier menopause osteoporosis birth control pills vaginitis
Pregnant smokersPregnant smokers
spontaneous abortion placenta previa placental abruption premature rupture of membranes preterm labor restricted fetal growth increased fetal respiratory rate placental abnormalities
Children of smokersChildren of smokers
respiratory illness SIDS cognitive development behavioral development cancer increased risk of smoking
Involuntary smoking is a cause of disease in
non-smokers
Involuntary smoking is a cause of disease in
non-smokers
Smokeless tobaccoSmokeless tobacco
“spit” tobacco cancer of mouth, pharynx, esophagus tooth discoloration gingival recession periodontal bone destruction death from juice ingestion
Other problems
fire accidents gingivitis skin wrinkles impotence decreased stamina colds, flu
Health effects from smoking Heart disease Lung disease – COPD,
asthma Cancer
– Lung, ENT, pancreas– Cervix– Skin (squamous cell)
Vascular disease – impotence, AAA
Stroke Cataracts Macular degeneration Gum disease Tooth decay
Osteoporosis Wound healing Anxiety & Depression Miscarriage SIDS Hearing loss Rheumatoid arthritis Lupus Dementia Multiple sclerosis
Smoking kills more people each year than
alcohol cocaine crack heroin
homicide suicide car accidents fires AIDS
C O M B I N E D!!!
©
What’s in a cigarette?
4,000 chemicals tar carbon monoxide nicotine
©
“...cigarettes and other forms of tobacco are addicting in the
same sense as are drugs such as heroin and cocaine.”
C. Everett Koop, MD 1988 Surgeon General’s
Report
Criteria for addicting drug
Dependence Tolerance Withdrawal
Nicotine yield/cig increased 11% from 1998-20051
1Harvard School of Public Health, 2007
Nicotine - immediate effects
sympathetic stimulation parasympathetic stimulation feelings of:
stimulation better concentration pain tolerance
The effects on health from smoking are reversible if a smoker stops
smoking
The effects on health from smoking are reversible if a smoker stops
smoking
Health benefits after quitting cough, DOE resolve in weeks exercise tolerance improves rapidly bladder cancer: 50% reduction in 5 years lung cancer: 50% reduction in 10 years heart disease: 50% reduction in 1 year! No increased risk of heart disease by 10-15 yrs vascular disease: 50% reduction in 5 years mortality rates same as never smokers by 10-15 yrs
How are we doing with our patients?
1991: – < 50% of patients reported ever being told to stop1
1998: – 67% Ask, 74% Advise, 35% Assist, 8% Follow-up2
2003: (patients that got prescription)3
– 36% told to set quit date, 25% counseled,
13% advised to follow up
Many smokers do not get the
advice and help they need!!!1Frank,E., Winkleby, M.A.,Altman, D.G., et al. JAMA 1991;266:3139-3134. 2Goldstein MG, et al. Preventive Medicine. 27(5 Pt 1):720-9, 1998 Sep-Oct.3Solberg LI, et al. Archives of internal medicine, 2005;165:656
Why counsel all smokers?Why counsel all smokers? 90% want to quit minimal physician input almost doubles quit rate1
most quit without intensive assistance once they make the decision
moving patients through the process2
precontemplation contemplation preparation action maintenance
1Cochrane Database of Systematic Reviews. 2004 2J of Cons & Clin Psych. 51(3):390-5, 1983 Jun
Physician influencePhysician influence
position of authority credible source personalize health effects face-to-face counseling multiple contacts good role models
Patient resources
• printed materials (still need counseling)• National Cancer Institute
(1-800-4-CANCER)• www.smokefree.gov• Smokingstopshere.com• 1–800–QUIT–NOW (quit lines improve chances of quitting)
A minimum amount of time spent with more
smokers will yield more ex-smokers
than intensive efforts with a few
A minimum amount of time spent with more
smokers will yield more ex-smokers
than intensive efforts with a few
Minimum counselingMinimum counseling
firm, unambiguous advice written materials set a quit day set follow-up visit
(or warn patient you will ask about
progress at a future visit)
Factors which influence smokers to make an attempt
to quit
Factors which influence smokers to make an attempt
to quit
Influence to quitInfluence to quit
firm, unambiguous advice “as your doctor, I’m telling you to
QUIT!” personalize damaging health effects effects reversible with quitting
Personalizing effects - historyPersonalizing effects - history
shortness of breath cold hands and feet fatigue decreased stamina colds and flu bronchitis, sinusitis teeth, gums kids’ problems
Personalizing effects - physicalPersonalizing effects - physical
gingivitis tar stains bad breath diminished breath sounds wheezing, rhonchi peripheral pulses fundal height wrinkling
Personalizing effects - labsPersonalizing effects - labs
carboxyhemoglobin pulmonary function tests peak flow chest x-ray
Influence to quitInfluence to quit
firm, unambiguous advice “as your doctor, I’m telling you to QUIT!” personalize damaging health effects effects reversible with quitting non-health reasons
Non-health reasons for quittingNon-health reasons for quitting
COST!!! inconvenience self-esteem role model
Influence to quitInfluence to quit
firm, unambiguous advice “as your doctor, I’m telling you to QUIT!” personalize damaging health effects effects reversible with quitting non-health reasons confidence
Building confidenceBuilding confidence
express your confidence millions of others have quit more ex-smokers than smokers most try many times before succeeding past attempts are learning experiences ways to deal with physical and
psychological dependence
Influence to quitInfluence to quit
firm, unambiguous advice “as your doctor, I’m telling you to QUIT!” personalize damaging health effects effects reversible with quitting non-health reasons confidence address concerns
Common concernsCommon concerns
Withdrawal short lived
Cravings last 3-5 minutes, diminish rapidly
Tension validate, normalize find other ways to cope
Weight gain - not inevitable! 1/3 gain: 5-8 lbs.
At a minimum, tell all patients how
important you feel it is that they quit(not cut down)
At a minimum, tell all patients how
important you feel it is that they quit(not cut down)
Refer patients who are interested to a
group program
Refer patients who are interested to a
group program
Accentuate the positive aspects of quitting rather than dwelling on the dangers of
continuing to smoke
Factors which help smokers quit once the
decision is made
Behavior Modification
Components of addiction
physiological psychological behavioral
Behavior modification
review reasons for quitting (index card) identify triggers (4 day diary) plans to avoid or cope with each trigger
Sample plan
Triggerafter meals
on the phone
in the car
at desk
tension
coffee breaks
other smokers
crisis
Techniqueleave table
draw
chew gum
carrot sticks
deep breathing
juice
non-smokers
self-talk
Behavior modification
review reasons for quitting (index card) identify triggers (4 day diary) plans to avoid or cope with each trigger change habit: packs only, different brands develop support system (tell everyone) self rewards (day, week, month, year) written commitment to quit day
Set a follow-up visit with all patients at
one month
Pharmacological treatment nicotine replacement - “methadone for the
smoker” Gum, Patch, lozenge, nasal spray, inhaler
Bupropion (Zyban®) Varenicline (Chantix®) all decrease cravings, withdrawal 20-25% quit rates at 1 year
Nicotine replacement - gum
available since 1984 2 mg. and 4 mg. strength “chew, park, chew, park” 2 mg. - 30 pieces/day maximum 4 mg. - 20 pieces/day maximum wean after 3 months, 6 months maximum use in conjunction with patches, bupropion
Nicotine replacement - patches
4 patches on market - OTC wean - 8 weeks first patch - night before quit day rashes, abnormal dreams no euphoria - no stimulant effect no increased risk of MI
©
©
Nicotine lozenges (Commit®)
2 and 4 mg strengths 4 mg if smoke w/in 30 minutes of waking 12 week program Weeks 1-6: 1 lozenge every 1 to 2 hours Weeks 7-9: 1 lozenge every 2 to 4 hours Weeks 10-12: 1 lozenge every 4 to 8 hours at least 9 per day for the first 6 weeks hiccups, heartburn, nausea no more than 5 in 6 hours, 20 per day Can work when patch, gum failed
Shiffman S, Dresler CM, et al. Arch Intern Med. 2002;162:1267-1276.
©
Nicotine nasal spray
one dose: 2 sprays (1 mg) minimum: 8 doses/day maximum: 40 doses/day (1/2 bottle) if not abstinent by week 4 - stop use for 3 months, six maximum nasal irritation limits use
Nicotine inhaler
nicotine deposited in mouth 2 mg absorbed per insert 80 puffs in 20 minutes 6 - 16 cartridges/day 3 months then wean over 3 months 40% throat irritation 20% quit at 6 months, 13% at 1 year
Nicotine replacement should always be used in conjunction with behavior
modification
Bupropion (Zyban)
Probably works by increasing dopamine in nucleus accumbens
150 mg qd X 3 days, 150 mg b.i.d. X 4 days, then QUIT
continue for 7 - 12 weeks if not stopped by 8 weeks, discontinue Can use with nicotine replacement
Rates of Continuous Abstinence
Buproption and nicotine patchBupropionNicotine patchPlacebo
Jorenby NEJM 1999
Bupropion – cautions/contraindications
insomnia - last dose 6 hours before sleep Activating but well-tolerated seizure disorder prior or current eating disorder concurrent use of Wellbutrin®
Varenicline (Chantix®)
[alpha]4[beta]2 nicotinic acetylcholine receptors reinforce effects of nicotine, maintain smoking
partial agonist, antagonist (blocks binding) 0.5 mg X 3 d, 0.5 mg b.i.d. X 4 d, 1 mg b.i.d. Stop smoking after 7 days on medicine Can use for up to 6 months Probably higher rates of quitting Nausea, constipation, abnormal dreams Costs about $ 4/day
*weeks 9–52: varenicline vs placebo, P<.001; varenicline vs bupropion, P = .004; bupropion vs placebo, P = .08.Jorenby DE, et al JAMA. 296(1):56-63, 2006 Jul 5.
Continuous Smoking Abstinence Rates
Second-line medications
Clonidine: 0.15 – 0.75 mg/d for 3 – 10 weeks Nortriptyline: 75 – 100 mg/d for 12 weeks
Factors which help ex-smokers remain
ex-smokers
Maintenance
Relapse
rates are same as for heroin, alcohol at least 70% relapse within first year
2/3 within first 3 months largest group within first week
factors: early: withdrawal, cravings, habit late: other smokers, food, alcohol, coffee
negative emotions, crisis
Preventing Relapse
use and refinement of coping strategies “if you don’t want to slip, stay away from slippery
places”
positive self-talks in response to slips Slips happen: Hungry, Angry, Lonely Tired
continued commitment (one day at a time) praise and encouragement by physician (“ex-smoker” on problem list)
The future
Nicotine vaccine (NicVAX)– Block nicotine from getting into brain– Phase two trials are promising
Different forms of nicotine replacement Rimonabant
– cannabinoid receptor antagonist– Also treats obesity– Probably won’t be released in US for smoking
AHCPR Guidelines - The 5 “A’s”
ASK - identify tobacco users at all visits ADVISE - strongly urge all smokers to quit ASSESS - willing to make an attempt? ASSIST - information, medication ARRANGE - schedule follow-up visit
For Those Unwilling to Quit – the 5 “R’s”
Relevance - why quitting is personally relevant
Risks - patient identifies negative consequences of tobacco use
Acute, long-term, environmental risks
Rewards - patient identifies benefits of stopping
Roadblocks - patient identifies barriers to quitting
Repetition - motivational intervention every visit