PHARMACOTHERAPY for SMOKING CESSATION

1. PHARMACOTHERAPY forSMOKING CESSATION

2. “CIGARETTE SMOKING… is the chief, single, avoidable cause of death in our society and the most important public health issue of our time.” C. Everett Koop, M.D., former U.S. Surgeon General

3. TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2005 Trends in cigarette current smoking among persons aged 18 or older 20.9% of adults are current smokers Male Percent 23.9% Female 18.1% Year 70% want to quit Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2005 NHIS. Estimates since 1992 include some-day smoking.

4. ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, 1997–2001 Percentage of all smoking-attributable deaths* 32% 28% 23% 9% 8% <1% TOTAL: 437,902 deaths annually * In 2005, it was estimated that nearly 50,000 persons died due to second-hand smoke exposure. Centers for Disease Control and Prevention. (2005). MMWR 54:625–628.

5. ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTS—U.S., 1995–1999 Prescription drugs, $6.4 billion Other care, $5.4 billion Medical expenditures (1998) Ambulatory care, $27.2 billion Hospital care, $17.1 billion Nursing home, $19.4 billion Societal costs: $7.18 per pack Annual lost productivity costs (1995–1999) Men, $55.4 billion Women, $26.5 billion Billions of dollars Centers for Disease Control and Prevention. (2002). MMWR 51:300–303.

6. Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general. Quitting smoking has immediate as well as long-term benefits, reducing risks for diseases caused by smoking and improving health in general. Smoking cigarettes with lower machine-measured yields of tar and nicotine provides no clear benefit to health. The list of diseases caused by smoking has been expanded. 2004 REPORT of the SURGEON GENERAL:HEALTH CONSEQUENCES OF SMOKING FOUR MAJOR CONCLUSIONS: U.S. Department of Health and Human Services. (2004). The Health Consequences of Smoking: A Report of the Surgeon General.

7. 2006 REPORT of the SURGEON GENERAL: INVOLUNTARY EXPOSURE to TOBACCO SMOKE • Second-hand smoke causes premature death and disease in nonsmokers (children and adults) • Children: • Increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma There is no safe level of second-hand smoke. • Respiratory symptoms and slowed lung growth if parents smoke • Adults: • Immediate adverse effects on cardiovascular system • Increased risk for coronary heart disease and lung cancer • Millions of Americans are exposed to smoke in their homes/workplaces • Indoor spaces: eliminating smoking fully protects nonsmokers • Separating smoking areas, cleaning the air, and ventilation are ineffective USDHHS. (2006).The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.

8. QUITTING: HEALTH BENEFITS Time Since Quit Date Circulation improves, walking becomes easier Lung function increases up to 30% Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing, fatigue, shortness of breath decrease 2 weeks to 3 months 1 to 9 months Excess risk of CHD decreases to half that of a continuing smoker 1 year Risk of stroke is reduced to that of people who have never smoked 5 years Lung cancer death rate drops to half that of a continuing smoker Risk of cancer of mouth, throat, esophagus, bladder, kidney, pancreas decrease 10 years Risk of CHD is similar to that of people who have never smoked after 15 years

9. The addiction to nicotine The habit of using tobacco Treatment Treatment Medications for cessation Behavior change program TOBACCO DEPENDENCE:A 2-PART PROBLEM Tobacco Dependence Physiological Behavioral Treatment should address the physiological and the behavioral aspects of dependence.

10. CLINICAL PRACTICE GUIDELINE for TREATING TOBACCO USE and DEPENDENCE • Released June 2000 • Sponsored by the Agency for Healthcare Research and Quality of the U.S. Public Heath Service with • Centers for Disease Control and Prevention • National Cancer Institute • National Institute for Drug Addiction • National Heart, Lung, & Blood Institute • Robert Wood Johnson Foundation www.surgeongeneral.gov/tobacco/

11. Compared to smokers who receive no assistance from a clinician, smokers who receive such assistance are 1.7–2.2 times as likely to quit successfully for 5 or more months. n = 29 studies 2.2 (1.5,3.2) 1.7 (1.3,2.1) 1.1 (0.9,1.3) 1.0 Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS. EFFECTS of CLINICIAN INTERVENTIONS

12. The 5 A’s ASK ADVISE ASSESS ASSIST ARRANGE HANDOUT Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

13. ASK • Ask about tobacco use • “Do you ever smoke or use any type of tobacco?” • “I take time to ask all of my patients about tobacco use—because it’s important.” • “Medication X often is used for conditions linked with or caused by smoking. Do you, or does someone in your household smoke?” • “Condition X often is caused or worsened by smoking. Do you, or does someone in your household smoke?” The 5 A’s (cont’d)

14. ADVISE • tobacco users to quit (clear, strong, personalized, sensitive) • “It’s important that you quit as soon as possible, and I can help you.” • “I realize that quitting is difficult. It is the most important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan.” The 5 A’s (cont’d)

15. ASSESS • Assess readiness to make a quit attempt • Assist with the quit attempt • Not ready to quit: provide motivation (the 5 R’s) • Ready to quit: design a treatment plan • Recently quit: relapse prevention ASSIST The 5 A’s (cont’d)

16. The 5 A’s (cont’d) • Arrange follow-up care ARRANGE * 5 months (or more) postcessation PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

17. 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 The 5 A’s: REVIEW

18. Yes No Is the patient now ready to quit? Did the patient once use tobacco? No Yes Yes No Promote motivation Provide treatment The 5 A’s Prevent relapse* Encourage continued abstinence *Relapse prevention interventions not necessary if patient has not used tobacco for many years and is not at risk for re-initiation. IS a PATIENT READY to QUIT? Does the patient now use tobacco? Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

19. PHARMACOTHERAPY “All patients attempting to quit should be encouraged to use effective pharmacotherapies for smoking cessation except in the presence of special circumstances.” Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

20. PHARMACOLOGIC METHODS: FIRST-LINE THERAPIES Three general classes of FDA-approved drugs for smoking cessation: • Nicotine replacement therapy (NRT) • Nicotine gum, patch, lozenge, nasal spray, inhaler • Psychotropics • Sustained-release bupropion • Partial nicotinic receptor agonist • Varenicline Currently, no medications have an FDA indication for use in spit tobacco cessation.

21. NRT: RATIONALE for USE • Reduces physical withdrawal from nicotine • Allows patient to focus on behavioral and psychological aspects of tobacco cessation NRT APPROXIMATELY DOUBLES QUIT RATES.

22. NICOTINE PHARMACODYNAMICS: WITHDRAWAL EFFECTS • Depression • Insomnia • Irritability/frustration/anger • Anxiety • Difficulty concentrating • Restlessness • Increased appetite/weight gain • Decreased heart rate • Cravings* Most symptoms peak 24–48 hr after quitting and subside within 2–4 weeks. HANDOUT American Psychiatric Association. (1994). DSM-IV. Hughes et al. (1991). Arch Gen Psychiatry 48:52–59. Hughes & Hatsukami. (1998). Tob Control 7:92–93. * Not considered a withdrawal symptom by DSM-IV criteria.

23. Polacrilex gum Nicorette (OTC) Generic nicotine gum (OTC) Lozenge Commit (OTC) Generic nicotine lozenge (OTC) Transdermal patch Nicoderm CQ(OTC) Generic nicotine patches (OTC, Rx) NRT: PRODUCTS Nasal spray • Nicotrol NS (Rx) Inhaler • Nicotrol (Rx)

24. PLASMA NICOTINE CONCENTRATIONS for NICOTINE-CONTAINING PRODUCTS Cigarette Moist snuff 0 10 20 30 40 50 60 Time (minutes)

25. NRT: PRECAUTIONS • Patients with underlying cardiovascular disease • Recent myocardial infarction (within past 2 weeks) • Serious arrhythmias • Serious or worsening angina NRT products may be appropriate for these patients if they are under medical supervision.

26. NRT: PRECAUTIONS (cont’d) • Patients with other underlying conditions • Active temporomandibular joint disease (gum only) • Pregnancy • Lactation NRT products may be appropriate for these patients if they are under medical supervision.

27. NRT: OTHER CONSIDERATIONS • NRT is not FDA-approved for use in children or adolescents • Nonprescription sales (patch, gum, lozenge) are restricted to adults ≥18 years of age • NRT use in minors requires a prescription • Patients should stop using all forms of tobacco upon initiation of the NRT regimen

28. NICOTINE GUMNicorette (GlaxoSmithKline); generics • Resin complex • Nicotine • Polacrilin • Sugar-free chewing gum base • Contains buffering agents to enhance buccal absorption of nicotine • Available: 2 mg, 4 mg; regular, FreshMint, Fruit Chill, mint, & orange flavor

29. NICOTINE GUM: SUMMARY DISADVANTAGES • Gum chewing may not be socially acceptable. • Gum is difficult to use with dentures. • Patients must use proper chewing technique to minimize adverse effects. ADVANTAGES • Gum use may satisfy oral cravings. • Gum use may delay weight gain. • Patients can titrate therapy to manage withdrawal symptoms.

30. NICOTINE LOZENGECommit (GlaxoSmithKline); generics • Nicotine polacrilex formulation • Delivers ~25% more nicotine than equivalent gum dose • Sugar-free, mint or cherry flavor (boxed or POP-PAC) • Contains buffering agents to enhance buccal absorption of nicotine • Available: 2 mg, 4 mg

31. NICOTINE LOZENGE: SUMMARY DISADVANTAGES • Gastrointestinal side effects (nausea, hiccups, and heartburn) may be bothersome. ADVANTAGES • Lozenge use may satisfy oral cravings. • The lozenge is easy to use and conceal. • Patients can titrate therapy to manage withdrawal symptoms.

32. TRANSDERMAL NICOTINE PATCHNicoderm CQ(GlaxoSmithKline); generic • Nicotine is well absorbed across the skin • Delivery to systemic circulation avoids hepatic first-pass metabolism • Plasma nicotine levels are lower and fluctuate less than with smoking

33. TRANSDERMAL NICOTINE PATCH: SUMMARY ADVANTAGES • The patch provides consistent nicotine levels. • The patch is easy to use and conceal. • Fewer compliance issues are associated with patch use. DISADVANTAGES • Patients cannot titrate the dose. • Allergic reactions to the adhesive may occur. • Patients with dermatologic conditions should not use the patch.

34. NICOTINE NASAL SPRAYNicotrol NS(Pfizer) • Aqueous solution of nicotine in a 10-ml spray bottle • Each metered dose actuation delivers • 50 µl spray • 0.5 mg nicotine • ~100 doses/bottle • Rapid absorption across nasal mucosa

35. NICOTINE NASAL SPRAY:SUMMARY ADVANTAGES • Patients can easily titrate therapy to rapidly manage withdrawal symptoms. DISADVANTAGES • Nasal/throat irritation may be bothersome. • Nasal spray has higher dependence potential. • Patients with chronic nasal disorders or severe reactive airway disease should not use the spray.

36. NICOTINE INHALERNicotrol Inhaler (Pfizer) • Nicotine inhalation system consists of • Mouthpiece • Cartridge with porous plug containing 10 mg nicotine • Delivers 4 mg nicotine vapor, absorbed across buccal mucosa • May satisfy hand-to-mouth ritual of smoking

37. NICOTINE INHALER:SCHEMATIC DIAGRAM Air/nicotine mixture out Sharp point that breaks the seal Aluminum laminate sealing material Sharp point that breaks the seal Mouthpiece Porous plug impregnated with nicotine Nicotine cartridge Air in Reprinted with permissionfrom Schneider et al. (2001). Clinical Pharmacokinetics 40:661–684. Adis International, Inc.

38. NICOTINE INHALER: SUMMARY ADVANTAGES • Patients can easily titrate therapy to manage withdrawal symptoms. • The inhaler mimics the hand-to-mouth ritual of smoking. DISADVANTAGES • The 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.

39. BUPROPION SRZyban (GlaxoSmithKline); generic • Nonnicotine cessation aid • Sustained-release antidepressant • Oral formulation

40. 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

41. BUPROPION:CONTRAINDICATIONS • Patients with a seizure disorder • Patients taking • Wellbutrin, Wellbutrin SR, Wellbutrin XL • MAO inhibitors in preceding 14 days • Patients with a current or prior diagnosis of anorexia or bulimia nervosa • Patients undergoing abrupt discontinuation of alcohol or sedatives (including benzodiazepines)

42. BUPROPION:WARNINGS and PRECAUTIONS Bupropion should be used with extreme caution in the following populations: • Patients with a history of seizure • Patients with a history of cranial trauma • Patients taking medications that lower the seizure threshold (antipsychotics, antidepressants, theophylline, systemic steroids) • Patients with severe hepatic cirrhosis

43. Category C drug Use only if clearly indicated Attempt nondrug treatment first BUPROPION:USE in PREGNANCY

44. BUPROPION SR: DOSING Patients should begin therapy 1 to 2 weeks PRIOR to their quit date to ensure that therapeutic plasma levels of the drug are achieved. Initial treatment • 150 mg po q AM x 3 days Then… • 150 mg po bid • Duration, 7–12 weeks

45. BUPROPION:ADVERSE EFFECTS Common side effects include the following: • Insomnia (avoid bedtime dosing) • Dry mouth Less common but reported effects: • Tremor • Skin rash

46. BUPROPION: ADDITIONAL PATIENT EDUCATION • Dose tapering not necessary when discontinuing treatment • If no significant progress toward abstinence by seventh week, therapy is unlikely to be effective • Discontinue treatment • Reevaluate and restart at later date

47. BUPROPION SR: SUMMARY ADVANTAGES • Bupropion is an oral formulation with twice-a-day dosing. • Bupropion might be beneficial for patients with depression. DISADVANTAGES • The seizure risk is increased. • Several contraindications and precautions preclude use.

48. Nonnicotine cessation aid Partial nicotinic receptor agonist Oral formulation VARENICLINE Chantix (Pfizer)

49. VARENICLINE:MECHANISM of ACTION • Binds with high affinity and selectivity at 42 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

50. Category C drug Use only if potential benefit justifies potential risk Attempt nondrug treatment first Unknown if drug excreted in human breast milk VARENICLINE :USE in PREGNANCY and LACTATION