Guidelines for Treating Tobacco Use and Dependence

1. Guidelines for TreatingTobacco Use and Dependence Linda A. Thomas, MS UMHS Tobacco Consultation Service

2. Today’s Objectives • Become familiar with the National and Ohio related health and financial costs of tobacco • Discuss nicotine addiction and best practices treatment • Describe the clinical practice guidelines • Examine the 5As approach to implementation

3. Toll of Tobacco in the U.S. • Over 440,000 people die each year from their own cigarette smoking • 38,000 to 67,500 die each year from other’s smoking • 6,000,000+ Youth under 18 alive today who will ultimately die from smoking (@ current smoking rates) • Smoking kills more people than alcohol, AIDS, MVAs, illegal drugs, murders, and suicides COMBINED 12/7/05

4. Toll of Tobacco in the U.S. (cont.) • Total annual public and private healthcare cost due to smoking equals $89.0 billion • Annual healthcare cost from secondhand smoke exposure equals $4.98 billion • Productivity losses caused by smoking equal $93.6 billion • Taxpayers yearly tax burden from smoking-caused gov’t spending equals $64.6 billion ($596 per household) • Smoking-caused costs/losses per pack sold in US equals $9.42 per pack 12/7/05

5. Ohio Monetary Costs • Annual healthcare costs directly caused by smoking equals $4.02 billion • Smoking-caused productivity losses equals $4.44 billion • Tax payers burden from smoking-caused gov’t expense equals $602 per household Tobacco Free Kids, 2006

6. Smoking causes: • 30% of all cancer deaths • 22% of all heart disease • 90% of all chronic obstructive • lung disease deaths

7. Inpatient Morbidity • Twice the rate of wound infections • Retards wound healing, both surgical and traumatic, including bed sores • Longer stays and 20% higher cost in recovery room • Most common form pulmonary morbidity during surgery and anesthesia • Greater incidence of gastrointestinal disease, prenatal/perinatal complications, orthopedic • Spinal fusions 30% less effective with patients who don’t stop smoking

8. Inpatient Morbidity (cont.) • Direct medical cost of a complicated birth for a smoker is 66% higher than that of a nonsmoker • Using 1987 dollars, $7 billion represents 11% of the total medical expenditures for all complicated births related to smoking • Smokers with smoking-related diseases use services for nonsmoking-related diseases at a higher rate • Smokers tend to need more medications and have more procedures performed

9. One Quarter of All Deaths in the U.S. are Smoking Related • There is a 70% higher risk of Coronary Heart Disease in smokers compared to non-smokers and a 2-4 fold increased risk of sudden death • A smoker’s risk of Stroke is 4X higher than a non-smoker • Smokers with Type II Diabetes progress to ESRD twice as rapidly as non-smoking diabetics

10. Other Health Problems Due to Smoking • Pregnancy complications • Earlier onset of menopause • Duodenal and gastric ulcers • Impotence • Skin wrinkling • Osteoporosis

11. Determinants of Tobacco Use • Lower educational achievement (9-11 yrs) • Lower SES – below poverty level • Other Chemical Dependency use • Psychiatric Co-morbidity • Genetic predisposition (neuroreceptor gene abnormality) • Certain behavioral traits e.g. rebelliousness, impulsiveness, identity assertion, reward dependence, harm avoidance, novelty seeking Ferry, L. (1998). Nicotine dependence: American’s “Drug of Choice”

12. Adolescent Initiation Risk Factors • Older same sex sibling who smokes • Parental smoking • Peer influences that are positive toward smoking • Poor school achievement • Depression • Poor integration into social peer groups (isolation, withdrawn) • Attention Deficit Disorder

13. Reasons for Wide Acceptance of Nicotine use in Society • Unlike cocaine, heroin, and alcohol, nicotine has little positive effect on mood or mental performance • Nicotine is not intoxicating • Continued use is primarily to relieve repeated symptoms of withdrawal, not to enhance mood • Still viewed by public and many medical professionals as a habit or lifestyle choice

14. Tobacco Addiction Psychological Addiction Physical Addiction Social Factors

15. What is Nicotine? • The most common cause of drug addiction in the world • Naturally occurring in the tobacco plant • A colorless alkaloid that turns brown when burned • Toxic levels 40-60mg; each cigarette delivers 1- 2mg • Nicotine is absorbed through the mucosal membrane, skin, and lungs National Institute on Drug Abuse Research Report, 1998

16. Nicotine • In pure state, clear, oily liquid • Toxic and addictive • Nicotine poisoning symptoms: • Nausea, salivation, abdominal pain, vomiting, sweating, dizziness, mental confusion, rapid heart beat • Convulsions, respiratory failure due to paralysis of respiratory muscles

17. Nicotine Metabolism • Metabolized in liver to cotinine • Nicotine half-life is 2 hours, cotinine is 20 hours • Some individuals have more rapid metabolisms, leading to more cigarettes smoked per day and potentially earlier addiction as a teenager • For example: males > females Caucasian > African American Swan, G.E, Handbook of Psychiatric Genetics, 1997: pp. 379-398

18. Effects of Neurotransmitters & Hormones Released by Nicotine Dopamine  Pleasure, Appetite Suppressor Norepinephrine  Arousal, Appetite Suppressor Acetylcholine  Arousal, Cognitive Enhancement NICOTINE Vasopressin  Memory Improvement Serotonin  Mood Modulation, Appetite Suppressor Beta-Endorphin  Reduction of Anxiety & Tension Benowitz, N. (1999).

19. Effects of Nicotine POSITIVE EFFECTS • Stimulates memory and alertness • Mood altering agent that tends to alleviate boredom and reduce stress • Can reduce aggressive responses to stressful events • Appetite suppressant, specifically for simple carbohydrates (sweets) • Euphoric and mood enhancing effects

20. Effects of Nicotine (cont.) NEGATIVE EFFECTS • Increases the blood level of glucose and insulin production • Tends to enhance platelet aggregation which can lead to thrombotic events • Chronic exposure to nicotine may cause acceleration of coronary artery disease, peptic ulcer disease, reproductive disturbances, esophageal reflux, hypertension, fetal illness and death, and delayed wound healing

21. Effects of Nicotine (cont.) • Increased risk for cancer of various body organs • Nicotine is both a stimulant and depressant on the body • Introduction of nicotine to the body increases bowel tone and activity, saliva and bronchial secretions, heart rate, blood pressure, and may also increase sweating, nausea, and diarrhea • Decreased blood flow especially to extremities and skin

22. Best Treatment Practices in Nicotine Addiction • Use of nicotine replacement therapy and/or bupropion • Cognitive-Behavioral intervention • High level of motivation to quit • Implementation of an exercise program

23. Nicotine in Tobacco Products(delivered to brain) 1 cigarette = 1-2mg 1 can spit tobacco = approx. 60 - 80mg 1 average size dip = approx. 3 - 5mg 1.5 ounce stogie = 12 - 24mg the same as a one pack cigarettes

24. Pharmacological Aidsand Understanding Withdrawal • Withdrawal begins a few hours after the last cigarette peaks on the third day • Symptoms of withdrawal: • Craving • Anxiety • Restlessness • Irritability • Depressed mood • Difficulty concentrating • Increased appetite • Stomach cramps • Coughing • Constipation • Mouth sores

25. Nicotine Replacement Therapy (NRT) Why use it? • Using NRT gets rid of the carbon monoxide and numerous other toxic chemicals in the cigarette smoke • The smoker is gradually weaned from the physical addiction, making it easier to deal with the mental, emotional and behavioral aspects of the behavior

26. NRT: Indications • Any one who smokes > 10 cigarettes a day • Anyone who reports withdrawal symptoms during a previous quit attempt • Each quit attempt is different; if NRT didn’t help before, it’s OK to try it again; motivation may have shifted • All NRTs are better than placebo • All NRTs are category D for pregnancy except • nicotine gum is category C

27. Efficacy of NRTs • Efficacy enhanced when in combination with a cognitive-behavioral support program • All forms NRTs double abstinence rates (15-25%) over placebo (3-10%) at 12 months

28. NRT: Contraindications • Use in Pregnancy is contraindicated. No studies have addressed the safety of NRT or bupropion in pregnancy • FDA Pregnancy category ratings: C - gum D - patch/spray/inhaler • Plastic tape allergies • Unstable CAD* • *Stable CAD is not a contraindication

29. Typical Smoking Pattern Nicotine level before bedtime 1 -1.5 hours First 2 hours

30. Nicotine Treatment Products • Nicotine Gum 2mg & 4mg • Nicotine Patch 5mg, 7mg, 10mg, 14mg, 15mg, 21mg • Nicotine Inhaler • Nicotine Spray • Nicotine Lozenge • bupropion

31. Combination Nicotine Therapy • Use of a “passive” and “ad libitum” NRT product • Increases long-term abstinence rates than use of only one NRT • More studies are being completed on combination therapy

32. A Suggested FormulaPack-a-day smoker • Simultaneous use of Zyban, Patch, and Gum • Can use Inhaler, Lozenge or Spray • Patch: 21mg 4-8 weeks, 14mg 4 weeks, 7mg 4 weeks • Gum: 1 piece every 30 minutes first 2 hours of day • bupropion: 3 months

33. Psychological Addiction • Tobacco use is a learned behavior • Tobacco use is a triggered behavior • Tobacco use is an automatic behavior • 40% smokers have an underlying depressive disorder • Used to decreased anxiety and increased stimulation

34. Psychological Addiction (cont.) Smokers are the experts of a behavior: 20 cigarettes X 10 puffs per cig = 200 puffs/day 200 puffs X 365 days = 73,000 puffs/year 73,000 puffs/year X 20 years = 1,460,000 puffs What have you done more than 1,460,000 times?

35. Social Factors • Smokers know smokers • Smoking is an important part of socializing, especially at work sites • Many smokers started smoking because of social factors as adolescents - those reasons often continue to be present in adulthood

36. Prochaska & DiClemente's Model of The Stages of Change • Allows more realistic goals for change • Reduces patient and physician frustration • Physician is in-step with the patient rather than in conflict • Provides framework for physician to intervene instead of “one intervention fitting all”

37. Stages of Change Model Pre-contemplation Relapse Contemplation Action Preparation Maintenance

38. Key Concepts of the Stages of Change Model • Smokers move through different stages in attempting to quit • Change is a process that takes time rather than being a single event (The average smoker averages 7 quit attempts before total abstinence) • At different stages, smokers need different intervention processes to affect change

39. Pre-contemplation • 40% of smokers • Not intending to change in • the foreseeable future • Un-informed or under-informed about the consequences of smoking Stages of Change Pre-contemplation Relapse Contemplation Action Preparation Maintenance • “Worn out quitter” – lack of efficacy to change • People in this stage exhibit: • Avoidance, don’t talk, read or think about • quitting • Rationalization to help them avoid • Rebellion: “nobody can tell me what to do”

40. Contemplation Stages of Change Pre-contemplation Relapse Contemplation Action Preparation Maintenance • 40% of smokers • Thinking about quitting in • the next 6 months • Very ambivalent, weighing • pros and cons of quitting • People in this stage: • Feel very stuck • Are waiting for the “right” reason(s) to quit • Need information and incentives

41. Preparation Stages of Change Pre-contemplation Relapse Contemplation Action Preparation Maintenance • 10% of smokers • Thinking about quitting in • the next month • Engage in a preparation • behavior (i.e. cutting back • # of cigs, switching brands) • Action • 10% of smokers • They have quit in the last month – total abstinence • They are actively using strategies to avoid relapsing • to the behavior

42. Maintenance • This stage may last from 6 months to EOL • After 12 months of abstinence, on the average, 43% relapse to continuous smoking • Only 15% of smokers relapse all the way back to pre-contemplation • People in this stage need help with preventing • relapse • -Formulate an action plan for relapse -Reinforce decision to stay smoke-free Stages of Change Pre-contemplation Relapse Contemplation Action Preparation Maintenance

43. Clinicians should not expect that patients who are in pre-contemplative or contemplative stages will agree to a cessation attempt • The goal is to help them move to the next stage by increasing their motivation to stop

44. Assisting patients in the cessation process, relapse stage, and ex-users stage is chronic disease service • Patients in these stages require follow-up as they would for hypertension, diabetes, glaucoma, or any other chronic disease or condition

45. Chronic Disease Management • Chronic diseases are prolonged conditions that often do not improve and are rarely completely cured • Chronic diseases are the leading causes of death and disability in US • Although most common and most costly of health problems – they are also the most preventable

46. “Somebody has to do something…it’s amazing it has to be us”Jerry Garcia “The Grateful Dead”

47. NCI-supported studies have demonstrated that a few brief, simple methods routinely used by clinic teams can significantly increase patient smoking quit rates when compared with self-help methods

48. If 75% of U.S. Clinicians routinely identified and assisted their tobacco-using patients and achieved only a 10% long-term quit rate (more than 6 months of abstinence), there would be at least 2 million more ex-users each year

49. “Every patient” means everyone age 8 and older, including the parents or guardians of patients who are minors. This is easier than trying to second-guess who is using tobacco

50. IMPORTANT !! • Clinic teams should treat tobacco use prevention and cessation advice as a brief, routine activity during every visit