Smoking Cessationin theRepublic of Georgia Christopher Dodd, M.D. Department of Medicine, Jackson Memorial Hospital Jay Weiss Center for Social Medicine and Health Equity University of Miami School of Medicine
Goals 1. The Problem: Global and Local 2. Pilot Testing Smoking Survey 3. Three Levels of Intervention 4. The Role of the Health Care Worker 5. Smoking Cessation Counseling 6. Smoking Cessation Pharmacotherapy 7. A National Tobacco Control Program *Focus: Health Professionals and Students
Smoking: It’s Bad For Your Health • On average, smokers die 10 years earlier than non-smokers1 • We know that smoking causes:2 • Cardiovascular Disease (~33%) • Lung Cancer (~28%) • Respiratory Causes: COPD / Emphysema (~22%) • Other Cancers: Mouth, Throat, Esophageal, Bladder, etc. (~7%) • Environmental Tobacco Smoke (Definition) • ~9% of deaths attributable to smoking occur in non-smokers, caused by exposure to secondhand smoke3 • NEW STUDY: Non-smoking workers exposed to secondhand smoke were 24% more likely to develop lung cancer4 Doll R, et al. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ 2004; 328: 1519. Cigarette smoking-attributable mortality - United States, 2000. MMWR Morb Mortal Wkly Rep. 2003;52:842-844. Annual smoking-attributable mortality, years of potential life lost, and economic costs - U.S. 1995-1999. MMWR Morb Mortal Wkly Rep. 2002; 51:300-303. Stayner L, et al. Lung cancer risk and workplace exposure to environmental tobacco smoke. Am J Pub Health 2007; 17: 1-5.
Environmental Tobacco Smoke • Parents who smoke subject their children (and unborn children) to a range of health risks that can be divided into prenatal, post-natal and longer term • Pre-Natal: Low Birth-weight / Miscarriage / Premature Delivery / Stillbirth / SIDS • Post-Natal: Increased Pnuemonia /Bronchitis / O.M./ Ashtma rates • Longer-Term: Decreased Pulmonary Function, Increased Hospitalizations, Increased Absenteeism from School • Young people make up some of the 53,000 deaths / year in the U.S. from exposure to Environmental Tobacco Smoke (ETS) Health Effects of Exposure to Environment Tobacco Smoke. Smoking and Tobacco Control Monograph No. 10 National Cancer Institute; 1999. NIH Pub. No. 99-4645. Women and Smoking: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2001.
The Global Problem • Tobacco-induced morbidity and mortality has reached pandemic proportions: ~5 million deaths per year1 • Economic Costs • Increased absenteeism and decreased productivity in the workplace2 • In one study, smokers utilized 18% higher health care charges compared to those who didn’t smoke3 • By 2002, lung cancer represented 12.4% of all new cancer cases worldwide • Tobacco smoking accounts for an estimated 85% of lung cancer in men and 47% in women4 Schroeder SA. Tobacco control in the wake of the 1998 master settlement agreement. NEJM 2004; 350: 293-301. Halpern MT, Shikiar R, et al. Impact of smoking status on workplace absenteeism and productivity. Tobacco Control. 2001; 10: 233-238. Pronk NP, Goodan MJ, et al. Relationship between modifiable health risks and short-term health care charges. JAMA. 1999; 282: 2235-2239. Parkin DM, et al. Global cancer statistics, 2002. CA Cancer J Clin 2005; 55: 74-108.
The Local Problem • Although recent figures are not available, prevalence is thought to be extremely high here in the Republic of Georgia • A Pack of Cigarettes: $ 1. 60 GeL • At 1 pack consumed per day, a week’s cost: $11.20 GeL • One Month: $44.80 GeL • One Year: $2,329.60 GeL • The Economic Cost to the Average Georgian Family • Expenditure on tobacco accounted for nearly 2 % of total monthly spending in Georgian households1 1. Djibuti M, Gotsadze G, Mataradze G, Zoidze A. Ifluence of household demographic and socio-economic factors on household expenditure on tobacco in six new independent states. 2006. Pending Publication.
World Health Organization (WHO) • WHO Framework Convention for Tobacco Control (FCTC)1 • Adopted by the 56th World Health Assembly in May 2003 • The 1st International Public Health Treaty on Tobacco Control • Signed by Georgia • Blueprint for a global response to the pandemic • Calls for standard methods and procedures for surveillance • 2005 WHO World No Tobacco Day • Highlighted the role of health professionals 1. Framework Convention for Tobacco Control (FCTC), World Health Organization; May 2003.
Pilot Testingof a Smoking Surveillance Surveyin the Republic of Georgia • When? August - September 2007 • Where? 3 hospitals, 1 medical school, 1 school of public health • How Many People? 500, with 20% coming from 1:1 interviews • Why? To obtain preliminary estimates of: • Smoking prevalence among Georgian healthcare workers and health professions students • Differences in smoking prevalence across subgroups (nurses, physicians, medical students, public health students, etc.) • Differences in prevalence between urban and rural settings • Exposure to environmental tobacco smoke • Attitudes toward laws against smoking and the role of the health professional in cessation • Existence of a formal curriculum on smoking cessation in health professional schools • The Hope: A better understanding of the problem should lead to more effective targeting of interventions • Future Directions • Scale up the survey • Begin strategizing for the creation of a National Tobacco Control Program • Do any of you want to help make Georgia Smoke-Free?
Three Levels of Intervention1 • Health Professional - Patient Encounter • The System Level: Health Care Policy • Insurance coverage for tobacco dependence treatment • Societal and Community Level • Laws against smoking in public places • Make tobacco advertising and promotion illegal • Telephone Quit Lines • Increased taxes on cigarette sales • Mass media campaigns 1. Fiore MC, Hatsukami DK, et al. Effective Tobacco Dependence Treatment. JAMA 2002; 288(14): 1768-1771.
The Role of the Health Professional • Definition of Professionalism • A specialized body of knowledge • Self-Regulation • Preventing what you treat • The Health Professional as a respected source of information • Turn Within • Sending an inconsistent message to our patients • Regaining and retaining the public trust • Take Advantage of the Clinical Encounter (In-Patient and Out-Patient Settings, especially the former)
The Bad News • Smoking is an Addiction1 • Nicotine is psychoactive, tolerance producing and it causes physical dependence • When smokers try to quit on their own, their long-term success rate is only ~5%.2 The Good News • New interventions (including counseling and pharmacotherapy) can boost long-term cessation rates (> 6 months) to 35%.3 • Smoking-Related Illness is the #1 preventable cause Schroeder SA. What to do with a patient who smokes. JAMA 2005; 295(4): 482-487. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, MD: US Dept of Health and Human Services; 2000. Jorenby DE, et al. A controlled trial of SR bupropion, a nicotine patch, or both for smoking cessation. NEJM 1999; 340: 685-691.
The Benefits of Quitting1 • Within 20 Minutes • BP and Heart Rate decrease; Temp. of hands/feet increase to normal • 8-24 Hours • CO in blood returns to normal, O2 level increases and chance of MI decreases • 48 Hours • Nerve endings start re-growing and ability to smell/taste improves • 72 Hours • Bronchials relax, making breathing easier • 2 Weeks to 3 Months • Circulation improves and lung function increases up to 30 percent • 1 Month to 12 Months • Coughing, sinus congestion, fatigue, and SOB all decrease • Cilia re-grow in the lungs, increasing your ability to handle mucus and clean lungs • Risk of coronary disease falls to 1/2 that of smokers (at one year)2 • 5 Years • Lung cancer death rate for the average smoker is cut in half • 10 -15 Years • Risk of lung cancer is almost as low as for those who never smoked • Risk of coronary disease has fallen to rate of never smokers2 American Cancer Society; FreshStart Program. Anthonisen NR, et al. Smoking and lng function of Lung Health Study participants after 11 years. Am J Respir Crit Care Med. 2002; 166: 675-679.
Smoking Cessation Counseling • The 5 A’s1 • Ask about tobacco use. • Advise to quit. • Assess willingness to make a quit attempt. • Assist in quit attempt. • Arrange for follow-up. 1. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, MD: US Dept of Health and Human Services; 2000.
Smoking Cessation CounselingAsk • If they don’t smoke, congratulate them and encourage them tell all their friends and family members who smoke about the health benefits of not smoking. • If they smoke… ASK YOUR PATIENT’S IF THEY SMOKE
Smoking Cessation CounselingAdvise ADVISE THEM TO QUIT SMOKING IN A CLEAR AND STRONG MANNER • Speak clear and with confidence • Let them know that quitting is the single most important action they can take to improve their health (the way they feel) and longevity (people don’t want to die prematurely),1 no matter how old they are2 • Make it Personal: Connect the consequences of smoking to something important in their life (children and spouse) • Why advise? Advice from a physician has been shown to more than double quit rates3 1. Centers for Disease Control and Prevention. Reducing Tobacco Use: A Report of the Surgion General. Atlanta, Ga: US Dept of Health and Human Services; 2000. 2. Rimer B, Orleans C, et al. The older smoker: status, challenges and opportunities for intervention. Chest. 1990; 97: 225-229. 3. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, MD: US Dept of Health and Human Services; 2000.
Smoking Cessation CounselingAssess and Assist ARE YOU READY TO QUIT NOW ? • If your patient is not ready to quit: • Discuss concerns and perceived barriers • Fear of Failure / Nicotine Withdrawal / Loss of Coping Tool / etc. • Identify reasons to quit (personal, family, work, etc.) • Keep things personally relevant • Focus on benefits to children • “Can you think of any good things that might happen if you were to quit?” (finances, health, ability to work uninterrupted, appearance, etc.) • Build confidence and reinforce the benefits of cessation1,2 • Keep at it… Miller W, Rollnick S. Motivational interviewing: preparing people to change addictive behavior. New York: Guilford, 1991. Colby SM, et al. Brief motivational interviewing in a hospital setting for adolescent smoking. J consult Clin Psychology 1998; 66: 574-578.
Pre-contemplation Relapse Contemplation Determination Maintenance Action Stages of Change Model
Smoking Cessation CounselingAssess and Assist ARE YOU READY TO QUIT NOW ? • If your patient isready: • Set a quit date within 2 weeks • Advise TOTAL ABSTINANCE • Remove all tobacco products, lighters, ashtrays from home and office • Discuss Coping Strategies: Anticipate triggers and challenges • Plan for dealing with smokers in the home and office • The 5 Ds: Drink water / Deep breath / Do something else / Discuss / Delay • Don’t Allow: Hunger / Anger / Lonliness / Tiredness (Eat, Talk, Sleep, Reward Yourself • Identify Supports: Family, health professional, former smokers • Make a list of people to call • Decide on appropriate pharmacotherapy treatment(s)
Smoking Cessation PharmacotherapyFirst-Line FDA-Approved Therapies* • Nicotine Replacement Therapy 1. Nicotine Gum* 2. Nicotine Transdermal Patch* 3. Nicotine Inhaler* 4. Nicotine Nasal Spray* 5. Nicotine Lozenge (NEW) • Non-Nicotine Therapy 1. Bupropion SR* 2. Varenicline (NEW)
Clinical Guidelines for Prescribing Pharmacotherapy for Smoking Cessation1 • Q: Who should receive pharmacotherapy for smoking cessation? A: All smokers trying to quit, except in the presence of special circumstances (medical contraindications, < 10 cigs/day, pregnant or breastfeeding women, adolescent smokers). • Q: Should nicotine replacement therapies be avoided in patients with a history of cardiovascular disease? A: No. The patch in particular has shown to be safe. • Q: May tobacco dependence pharmacotherapies be used for > 6 months? A: Yes. This approach may be helpful with smokers who report persistent withdrawal symptoms. • Q: May pharmacotherapies be combined? A: Yes. 1. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, MD: US Dept of Health and Human Services; 2000.
Nicotine Gum1 • Pros: OTC, Convenience, Faster delivery, Few side effects • Cons: Frequent use necessary • Dose: 2 mg, 4 mg • Flavors: Orange, Mint, Regular • Method: Chew slowly until a tingling sensation is felt, then place gum between cheek and teeth until the tingling resolves, then repeat • Should not eat or drink during use • Mechanism of Action: Nicotine absorbed by the oral mucosa and binds to various CNS and peripheral nicotinic-cholinergic receptors • Duration: 30 minutes • Dosing: Based on cigarettes / day (<20: 2 mg; >20: 4 mg) and/or time to first cigarette of day (>30 minutes: 2 mg; <30 min: 4 mg) • RecommendedFrequency for Heavy Smokers:(>10 cigarettes / day): q1-2 hours x 6 weeks, then q4-8 x 3 weeks • TheEvidence when compared to Placebo (> 6 Months): • 19.7% vs. 11.5 % 2,3 Ebbert JO, et al. Treating Tobacco Dependence: Review of the best and latest treatment options. Journal of Thoracic Oncology. 2007: Vol 2, No 3: 249-256. Silagy C. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2000(2): CD000146. Hughes JR, et al. Anxiolytics and antidepressants for smoking cessation. Cochrane Database Syst Rev. 2000(2): CD00031.
Nicotine Patch1 • Pros: OTC, Convenience (1X / day), Achieve high levels of nicotine • Cons: Less flexible dosing, slow onset, mild skin rashes / irritation • Dose: 7 / 14 / 21 mg 24 hour delivery; 15 mg 16 hour delivery • Method: Place anywhere on upper body; Rotate locations • Mechanism of Action: Nicotine absorbed through skin and binds to various CNS and peripheral nicotinic-cholinergic receptors • Duration: 24 or 16 hours (sleep) • Dosing: Based on cigarettes / day (<10: 7 mg; 10-20: 14-21 mg; 21-39: 28-35 mg; >40: 42 mg) • Adjust based on withdrawal symptoms, urges and comfort • After 4-6 weeks of abstinence, taper q2-4 weeks in 7-14 mg steps • Contraindicatioins: MI <2 wks, serious arrythmia, > angina/htn • The Evidence when compared to Placebo (>6 Month): • 14.4 vs. 8.4 % 2,3 Ebbert JO, et al. Treating Tobacco Dependence: Review of the best and latest treatment options. Journal of Thoracic Oncology. 2007: Vol 2, No 3: 249-256. Silagy C. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2000(2): CD000146. Hughes JR, et al. Anxiolytics and antidepressants for smoking cessation. Cochrane Database Syst Rev. 2000(2): CD00031.
Bupropion SR1 • Pros: Convenience, Pill form, Few side effects, Used in combination • Cons: Slight risk of seizure (contraindicated if history of Seizure Disorder, Anorexia / Bulimia, using an MAO Inhibitor) • Dose: 150 mg Sustained Release (SR) Tab • Mechanism of Action: Weak inhibitor of neuronal uptake of Norepinephrine and Dopamine (both activated by nicotine) • Duration: 12 hours • Dosing: Start 2 weeks prior to the Target Quit Date (TQD) • 150 mg q24 for 3 days, then.. • 150 mg q12 for 11 days, then.. • On The Quit Date, STOP SMOKING • Continue at 150 mg q12 until they stop smoking • May stop abruptly (no need to taper) • The Evidence when compared to Placebo (>6 Month): • 19.3 vs. 10.2 % 2,3 Ebbert JO, et al. Treating Tobacco Dependence: Review of the best and latest treatment options. Journal of Thoracic Oncology. 2007: Vol 2, No 3: 249-256. Silagy C. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2000(2): CD000146. Hughes JR, et al. Anxiolytics and antidepressants for smoking cessation. Cochrane Database Syst Rev. 2000(2): CD00031.
Combination Therapy • Not FDA-approved, but has been shown to be more effective than single-agent therapy • Combination NRT (Patch and Gum, Patch and Spray) increases long-term smoking abstinence rates compared with single-agent therapy1,2 • Treatment with Bupropion SR alone or in combination with a nicotine patch results in significantly higher long-term cessation rates than either the patch alone or placebo3 • Bupropion SR plus Nicotine Patch(35.5%) • Bupropion SR alone (30.3%) • Patch alone (16.4%) • Placebo (15.6%) Kornitzer M, et al. Combined use of nicotine patch and gum in smoking cessation: a placebo-controlled clinical trial. Preventive Medicine 1995; 24: 41-47. Blondal T, et al. Nicotine nasal spray with nicotine patch for smoking cessation: randomized trial with six-year follow-up. BMJ 1999; 318: 285-288. Jorenby DE, et al. A controlled trial of SR bupropion, a nicotine patch, or both for smoking cessation. NEJM 1999; 340: 685-691.
Smoking Cessation CounselingArrange For a Follow-Up Visit • Within 2 Weeks: See the patient in clinic or call the patient • Reinforce the benefits of quitting • Be prepared to address RELAPSE1,2 • Most smokers attempt to quit an average of 8 times before successfully quitting3 • Reassure your patient that relapse is common and is NOT a failure • Identify causes and develop a strategy to overcome them • Ask for a re-commitment to TOTAL ABSTINANCE • Assess pharmacotherapy use • Smoking should be approached as a Chronic Disease4 • Relapse seen as an opportunity to try different medications, increase dosages and try different combinations (like HTN, DM, HF) Brandon TH, Tiffany ST, et al. Post-cessation cigarette use: the process of relapse. Addict Behav 1990; 15: 105-114. Carroll KM. Relapse prevention as a psychosocial treatment: a review of controlled clinical trials. Exp Clin Psychopharmacol 1996; 4: 46-54. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, MD: US Dept of Health and Human Services; 2000. Ebbert JO, et al. Treating Tobacco Dependence: Review of the best and latest treatment options. Journal of Thoracic Oncology. 2007: Vol 2, No 3: 249-256.
ImagineA Smoke-Free Georgia • My Hope is that you will lead the way.. • It all starts at the level of the… Health Professional - Patient Encounter • Tracking the Data • Train the Trainer • Intervene while patients are sick in the hospital • Health Care System (Policy) • Insurance coverage for tobacco dependence treatment • Societal of Community Level • Smoking bans in public places (especially hospitals and clinics) • Ban tobacco advertising and promotion • Create a National Telephone Quit Line • Increased taxes on cigarette sales • Mass media campaigns