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Cease Smoking Today (CS2day) An Evidence-Based Approach To Treating Tobacco Dependence Focus on the Psychiatric Patient Scott M. Strayer, MD, MPH, FAAFP Associate Professor Departments of Family Medicine and Public Health Sciences University of Virginia Health System Question

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Cease Smoking Today (CS2day)An Evidence-Based Approach To Treating Tobacco DependenceFocus on the Psychiatric Patient

Scott M. Strayer, MD, MPH, FAAFP

Associate Professor

Departments of Family Medicine and Public Health Sciences

University of Virginia Health System


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Question

Which of the following statements

regarding tobacco dependence and

smoking cessation in patients with

psychiatric disorders is/are correct?


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Answers

Rates of smoking are similar to individuals without psychiatric illness.

Because of possible decompensation, smoking cessation is discouraged.

Most psychiatric patients are highly motivated to quit smoking.

Risks of most pharmacologic interventions outweigh the benefits.

Smoking cessation may cause adverse reactions to psychiatric medications.


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Smokers With Psychiatric Disorders

Consume nearly ½ cigarettes smoked in US

Spend nearly 40% of income on cigarettes

Patients seeking tobacco dependence treatment

30 – 60% with past history of depression

≥ 20% with history of alcohol abuse or dependence

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Smokers With Psychiatric Disorders

Chemical dependence

> 70% smoke

Increased mortality from tobacco-related diseases

1 study

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Smokers With Psychiatric Disorders

May have greater sensitivity to nicotine dependence symptoms at lower levels of smoking

Failing to address nicotine withdrawal may compromise psychiatric care for inpatients on smoke-free units.

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Answers

Rates of smoking are similar to individuals without psychiatric illness.

Because of possible decompensation, smoking cessation is discouraged.

Most psychiatric patients are highly motivated to quit smoking.

Risks of most pharmacologic interventions outweigh the benefits.

Smoking cessation may cause adverse reactions to psychiatric medications.


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Answers

Rates of smoking are similar to individuals without psychiatric illness.

Because of possible decompensation, smoking cessation is discouraged.

Most psychiatric patients are highly motivated to quit smoking.

Risks of most pharmacologic interventions outweigh the benefits.

Smoking cessation may cause adverse reactions to psychiatric medications.


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Outline

  • Assessment

    • 5 As

  • Interventions

    • Counseling

    • Pharmacotherapy


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Case

22 yo Latino M, psychology student at local college, here for medication refill

History of bipolar disorder

Currently stable

Several full blown episodes of mania and depression

Hospitalized at age 19 during manic episode

Depakote, Lithium


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Case

Past medical and surgical history

Otherwise unremarkable

Lives in an apartment with his girlfriend who smokes and a 2 year-old daughter


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Case

Smokes 1 pack/day cigarettes since 16 yo

Recently increased to 2 packs/day

Cope with stress at college

Smokes when he drinks alcohol

Wants to quit

Unsure if he can

Concerned about impact on bipolar disorder


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Question

At this time, all of he following interventions

are recommended EXCEPT:

Decrease cigarette intake by 25% every 1 to 2 weeks

Initiate pharmacotherapy

Follow-up with phone call 1 week after stopping

Abstain from drinking beer

Convince wife to stop smoking


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Assessment of Tobacco Use

Patient presents to a healthcare provider

Does patient currently use tobacco?

Yes

No

Is the patient currently willing to quit?

Did the patient previously use tobacco?

Yes

No

Yes

No

Provide appropriate treatments

(5 As)

Promote motivation to quit

(5 Rs)

Prevent relapse

Encourage continuedabstinence


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The 5 As

For Patients Willing to Quit

  • ASK about tobacco use

  • ADVISE to quit

  • ASSESS willingness to make a quit

    attempt

  • ASSIST in quit attempt

  • ARRANGE for follow-up

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Ask

  • 70% of smokers want to quit

  • 81% have tried to quit at least once

  • Only 7 to 15% very reluctant to discuss quitting smoking

  • EVERY patient at EVERY visit

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Vital Signs Stamp

VITAL SIGNS

Blood Pressure:

Pulse:

Weight:

Temperature:

Respiratory Rate:

Tobacco Use:

Current Former Never

(circle one)

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Advise

  • Advice should be clear, strong and personalized.

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Advise

  • 37.5% of preventable causes of death are tobacco-related

  • 1/3 of all tobacco users will have a decreased life span

    • 13.2 years in men

    • 14.5 years in women

  • Someone dies from tobacco use every 8 seconds

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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AdviseSmokers With Psychiatric Disorders

Chemical dependence

Increased mortality from tobacco-related diseases versus other patient populations

1 study

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Advise

  • Never too late to quit

    • Age 40: gain 9 years

    • Age 50: gain 6 years

    • Age 60: gain 3 years

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Assist

  • S et a quit date to stop completely

    • Ideally within 2 weeks

  • T ell family & friends

  • A nticipate challenges

  • R emove tobacco products from environment (home, work, car)

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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AssistTriggers & Challenges

Where, when, why does patient smoke

Alcohol

Other smokers

“Urges” and “Cues”

Withdrawal symptoms

Prior quit experience

Build on success

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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AssistTriggers & Challenges

Concern about weight gain

Negative affect, stressors

Mental illness

Increased risk of relapse

Lack of support

Lack of self efficacy

Lack of knowledge

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Assist

  • Counseling & behavioral therapies

  • Pharmacotherapy

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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AssistSmokers With Psychiatric Disorders

Smoking cessation and/or nicotine withdrawal may exacerbate underlying psychiatric condition.

Consider waiting until psychiatric symptoms stabilized before initiating smoking cessation interventions.

Case by case basis

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Arrange

Relapse

Most likely within 1st 3 months

Especially 1st 2 weeks

Recommended follow-up

Ideally within 1st week after quitting

2nd contact within 1st month

Further follow-up based on need

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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ArrangeSmokers With Psychiatric Disorders

Increased risk of relapse

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Askabout tobacco use.

Adviseto quit.

Assesswillingness to make a quit attempt.

Assistin quit attempt.For patients unwilling to quit at the time, provide motivational interventions designed to increase future quit attempts.

Arrangefollow-up.For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit.

The “5 As” Model – 2008 Update

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Question

At this time, all of he following interventions

are recommended EXCEPT:

Decrease cigarette intake by 25% every 1 to 2 weeks

Initiate pharmacotherapy

Follow-up with phone call 1 week after stopping

Abstain from drinking beer

Convince wife to stop smoking


Question32 l.jpg
Question

At this time, all of he following interventions

are recommended EXCEPT:

Decrease cigarette intake by 25% every 1 to 2 weeks

Initiate pharmacotherapy

Follow-up with phone call 1 week after stopping

Abstain from drinking beer

Convince wife to stop smoking


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Question

Of the following statements

regarding the non-pharmacologic

treatment of this patient’s tobacco

dependence, which is correct?


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Answers

Quit lines alone are effective in achieving abstinence.

The addition of counseling to medications does not increase abstinence rates.

Physicians are much more effective than non-physician clinicians at delivering treatment.

Individual counseling alone is ineffective in achieving abstinence.

Teaching problem solving and skills training alone is ineffective in achieving abstinence.


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Counseling

Strong dose-response relationship

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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CounselingIntensity of Clinical Interventions

Fiore MC, et al. U.S. DHHS Public Health Service 2000. Meta-analysis (n = 43 studies).


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Estimating Likelihood of Abstinence

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Smokers With Psychiatric Disorders

May have greater sensitivity to nicotine dependence symptoms at lower levels of smoking

Increased risk of relapse

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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CounselingComponents of Intensive Treatment

Population

Program clinicians

Program intensity

Program format

Type of counseling and behavioral therapies

Medication

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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CounselingComponents of Intensive Treatment

Population

All tobacco users willing to participate in such efforts

Optimizes likelihood of abstinence

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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CounselingComponents of Intensive Treatment

Program clinicians

Physicians and non-physician clinicians equally effective

2 clinician types optimal

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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CounselingComponents of Intensive Treatment

One counseling strategy

Physician

Delivers strong message to quit

Discusses health benefits of quitting

Prescribes medications

Non-physician clinician

Delivers additional counseling & behavioral interventions

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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CounselingComponents of Intensive Treatment

Program intensity

Session length

> 10 minutes

Number of sessions

≥ 4 sessions

Total contact time

30 – 90 minutes

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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CounselingComponents of Intensive Treatment

Program format

Effective

Individual or group counseling

Proactive telephone counseling, including Quit lines

1 – 800 – QUIT – NOW

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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CounselingComponents of Intensive Treatment

Program format

Optional

Self help materials and cessation Web sites

Multiple formats optimal, with use of 3 – 4 types especially effective

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Type of counseling & behavioral therapy

Practical counseling

Problem solving/skills training/stress management

Intra-treatment social support

Direct contact with clinician

CounselingComponents of Intensive Treatment

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Types of counseling & behavioral therapies recommended by 2000 but not 2008 guideline

Extra-treatment social support

Smoker’s environment

Aversive smoking procedures

Rapid smoking, rapid puffing, other smoking exposure

CounselingComponents of Intensive Treatment

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Practical Counseling 2000 but Problem Solving/Skills Training

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Counseling 2000 but Intra-treatment Supportive Treatment

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Combination of Counseling and Medication Superior to Either Treatment Alone

Fiore MC, et al. DHHS Public Health Service 2008. Meta-analysis, Combination vs medication alone (n = 18 studies) and vs counseling alone (n = 9 studies).


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Answers Treatment Alone

Quit lines alone are effective in achieving abstinence.

The addition of counseling to medications does not increase abstinence rates.

Physicians are much more effective than non-physician clinicians at delivering treatment.

Individual counseling alone is ineffective in achieving abstinence.

Teaching problem solving and skills training alone is ineffective in achieving abstinence.


Answers52 l.jpg
Answers Treatment Alone

Quit lines alone are effective in achieving abstinence.

The addition of counseling to medications does not increase abstinence rates.

Physicians are much more effective than non-physician clinicians at delivering treatment.

Individual counseling alone is ineffective in achieving abstinence.

Teaching problem solving and skills training alone is ineffective in achieving abstinence.


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Question Treatment Alone

Of the following pharmacologic

treatment options for this patient’s

tobacco dependence, which would

you choose?


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Question Treatment Alone

Nicotine patch (21 mg)

Nicotine gum (4 mg)

Bupropion SR 150 mg bid

Sertraline 100 mg once a day

Nortriptyline 50 mg qhs

Varenicline 1 mg bid

Clonidine 0.2 mg patch/24 hrs


Question55 l.jpg
Question Treatment Alone

Of the following statements

regarding the pharmacologic

treatment of this patient’s tobacco

dependence, which is correct?


Question56 l.jpg
Question Treatment Alone

2nd line agents are contraindicated because of drug-drug interactions.

Varenicline is contraindicated because of the risk of suicide.

Bupropion SR may cause mood destabilization.

Pharmacotherapy should be initiated at lower than usual doses.

Pharmacotherapy tailored to the psychiatric disorder is superior to standard therapy.


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Pharmacotherapy Treatment Alone

1st line agents

Nicotine replacement therapy (NRT)

Patch, gum, nasal spray, inhaler, lozenge

Sustained-release bupropion (Zyban)

Varenicline (Chantix)

2nd line agents

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Pharmacotherapy Treatment Alone

2nd line agents

Nortriptyline, Clonidine

Contraindications to, failure of 1st line agents

Not FDA approved

Concern about potential side effects

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Candidates for Pharmacotherapy Treatment Alone

  • All smokers trying to quit except

    • When contraindicated

    • Pregnant women

    • Smokeless tobacco users

    • Adolescent smokers

    • Patients smoking <10 cigarettes/day

      • If prescribe NRT, ½ usual dose

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Pharmacotherapy Treatment Alone

Summary of results

6 month abstinence rate

19.0 to 33.2%

Odds Ratio

1.5 to 3.1

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Meta-analysis of Abstinence Rates for Monotherapies Compared to Placebo at 6-Months Postquit

(+ 95% CI)

80

5

4

4

6

3

6

3

26

32

10

5

15

Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD:

U.S. Department of Health and Human Services. Public Health Service.; 2008. Number of study arms indicated within the bar.

This information concerns a use that has not been approved by the US Food and Drug Administration.


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Pharmacotherapy Compared to Placebo at 6-Months Postquit

Recommended combination therapy

Long term nicotine patch (> 14 weeks) + ad libitum nicotine gum or spray

OR: 1.9 (95% CI: 1.3 – 2.7)

Nicotine patch + Bupropion SR

OR: 1.3 (95% CI: 1.0 – 1.8)

Nicotine patch + inhaler

OR: 1.1 (95% CI: 0.7 – 1.9)

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Meta-analysis of Abstinence Rates for Combination Therapies Compared to Placebo at 6-Months Postquit

(+ 95% CI)

80

3

3

2

2

3

Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD:

U.S. Department of Health and Human Services. Public Health Service.; 2008. Number of study arms indicated within the bar.

This information concerns a use that has not been approved by the US Food and Drug Administration.


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Tobacco Dependence Treatment Compared to Placebo at 6-Months PostquitImpact on Concurrent Medications

Nicotine

Metabolized by CYP2A6

Does not induce liver enzymes

Nicotine replacement therapy does not impact drug metabolism

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Tobacco Dependence Treatment Compared to Placebo at 6-Months PostquitImpact on Concurrent Medications

Nicotine

Activates sympathetic nervous system

Decreases sedative effects of benzodiazepines, opioid analgesia, effect of beta blockers, subcutaneous absorption of insulin

NRT not contraindicated in patients with cardiovascular disease

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Tobacco Dependence Treatment Compared to Placebo at 6-Months PostquitImpact on Concurrent Medications

Polycyclic aromatic hydrocarbons in cigarette smoke

Induce isoforms of CYP450

Metabolizes

Fluvoxamine, olanzapine, clozapine

Caffeine, theophylline

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Tobacco Dependence Treatment Compared to Placebo at 6-Months PostquitImpact on Concurrent Medications

Bupropion SR

Metabolized by CYP2B6

Inhibits CYP2D6

Metabolizes tricyclic antidepressants, antipsychotics

Contraindications

MAO inhibitor last 14 days

History of seizures, eating disorder

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Tobacco Dependence Treatment Compared to Placebo at 6-Months PostquitImpact on Concurrent Medications

Varenicline

Eliminated unchanged in urine

No drug-drug interactions

Caution with creatinine clearance < 30 ml/min

Consider 1 mg/day

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Pharmacotherapy Compared to Placebo at 6-Months PostquitFactors to Consider

Contraindications/precautions/warnings/ side effects/drug-drug interactions

Patient preference

Prior effectiveness?

Clinician familiarity, experience

Adherence

Patch > gum > nasal spray, vapor inhaler

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Pharmacotherapy Compared to Placebo at 6-Months PostquitFactors to Consider

Highly dependent/severe withdrawal symptoms

Nicotine replacement therapy

4 mg gum & lozenge

21 mg patch

Combination therapy

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Clues to nicotine addiction l.jpg
Clues to Nicotine Addiction Compared to Placebo at 6-Months Postquit

Smokes > 1 pack per day

1st cigarette within ½ hour of awakening

Symptoms of withdrawal with previous quit attempts

Anxiety, irritability, restlessness, difficulty concentrating, insomnia, depression, craving, hunger

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Pharmacotherapy Compared to Placebo at 6-Months PostquitFactors to Consider

Concerned about weight gain

Bupropion SR

4mg gum & lozenge

Varenicline

Woman

Nicotine replacement therapy may be less effective

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Pharmacotherapy factors to consider73 l.jpg
Pharmacotherapy Compared to Placebo at 6-Months PostquitFactors to Consider

Cardiovascular disease

Hospitalized patients

Nicotine replacement therapy, especially patch, safe

? ICU patients

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Pharmacotherapy Compared to Placebo at 6-Months PostquitFactors to Consider

Long term use

≥ 6 months OK

Preferred to continued smoking

Pragmatic

Dentures with gum

Dermatitis with patches

Insurance coverage

Cost

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Slide75 l.jpg

Increased risk of relapse Compared to Placebo at 6-Months Postquit

Insufficient evidence that treatment tailored to psychiatric diagnoses/symptoms is superior to traditional treatment

Smokers With Psychiatric Disorders

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Slide76 l.jpg

Past history of depression Compared to Placebo at 6-Months Postquit

Bupropion SR & nortriptyline vs placebo

OR: 3.42 (95% CI: 1.70 – 6.84)

Bipolar disorder

Antidepressants may cause mood destabilization

Smokers With Psychiatric Disorders

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Slide77 l.jpg

Patients being treated for non-nicotine chemical dependence Compared to Placebo at 6-Months Postquit

Pharmacotherapy and counseling for nicotine dependence are effective

Treating concurrently does not interfere with outcomes

Except possibly alcohol abstinence outcome (1 study)

Smokers With Psychiatric Disorders

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Slide78 l.jpg

Schizophrenia Compared to Placebo at 6-Months Postquit

Bupropion SR and NRT may be effective

May improve negative and depressive symptoms

Patients on atypical antipsychotics may be more responsive to Bupropion SR than those on standard antipsychotics

Smokers With Psychiatric Disorders

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Slide79 l.jpg

Varenicline Compared to Placebo at 6-Months Postquit

NOT contraindicated

Reports of depressed mood, agitation, changes in behavior, suicidal ideation, suicide

FDA recommendation

Elicit psychiatric history

Monitor for changes in mood, behavior

Smokers With Psychiatric Disorders

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Question80 l.jpg
Question Compared to Placebo at 6-Months Postquit

2nd line agents are contraindicated because of drug-drug interactions.

Varenicline is contraindicated because of the risk of suicide.

Bupropion SR may cause mood destabilization.

Pharmacotherapy should be initiated at lower than usual doses.

Pharmacotherapy tailored to the psychiatric disorder is superior to standard therapy.


Question81 l.jpg
Question Compared to Placebo at 6-Months Postquit

2nd line agents are contraindicated because of drug-drug interactions.

Varenicline is contraindicated because of the risk of suicide.

Bupropion SR may cause mood destabilization.

Pharmacotherapy should be initiated at lower than usual doses.

Pharmacotherapy tailored to the psychiatric disorder is superior to standard therapy.


Question82 l.jpg
Question Compared to Placebo at 6-Months Postquit

Nicotine patch (21 mg)

Nicotine gum (4 mg)

Bupropion SR 150 mg bid

Sertraline 100 mg once a day

Nortriptyline 50 mg qhs

Varenicline 1 mg bid

Clonidine 0.2 mg patch/24 hrs


Question83 l.jpg
Question Compared to Placebo at 6-Months Postquit

Nicotine patch (21 mg)

Nicotine gum (4 mg)

Bupropion SR 150 mg bid

Sertraline 100 mg once a day

Nortriptyline 50 mg qhs

Varenicline 1 mg bid

Clonidine 0.2 mg patch/24 hrs


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Obtaining the 2008 Guideline Compared to Placebo at 6-Months Postquit

The full text of the 2008 Guideline, www.ahrq.gov/path/tobacco.htm#clinic

To order the 2008 Guideline and the various supplemental materials go to www.ahrq.gov/clinic/tobacco/order.htm

UW-CTRI

www.ctri.wisc.edu

CS2day

www.ceasesmoking2day.org


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Patient Unwilling to Quit Compared to Placebo at 6-Months PostquitMotivational Interviewing

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Slide87 l.jpg

Patient Unwilling to Quit Compared to Placebo at 6-Months PostquitMotivational Interviewing

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Slide88 l.jpg

Patient Unwilling to Quit Compared to Placebo at 6-Months PostquitMotivational Interviewing

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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The 5 Rs Compared to Placebo at 6-Months Postquit

RELEVANCE: tailor advice and discussion

to each patient

RISKS: outline risks of continued smoking

REWARDS: outline the benefits of quitting

ROADBLOCKS: identify barriers to

quitting

REPETITION: reinforce the motivational

message at every visit

To Motivate Patients Unwilling to Quit at This Time

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Slide90 l.jpg

Patient Unwilling to Quit (The 5Rs) Compared to Placebo at 6-Months Postquit

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Slide91 l.jpg

Patient Unwilling to Quit (The 5Rs) Compared to Placebo at 6-Months Postquit

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Slide92 l.jpg

Patient Unwilling to Quit (The 5Rs) Compared to Placebo at 6-Months Postquit

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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Patient Who Has Recently Quit Compared to Placebo at 6-Months Postquit

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Slide94 l.jpg

Patient Who Has Recently Quit Compared to Placebo at 6-Months Postquit

Fiore MC, et al. U.S. DHHS Public Health Service 2008


Slide95 l.jpg

Patient Who Has Recently Quit Compared to Placebo at 6-Months Postquit

Fiore MC, et al. U.S. DHHS Public Health Service 2008


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