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Smoking Cessation Pulmonary Grand Rounds

Smoking Cessation Pulmonary Grand Rounds. Sidharth Bagga MD MBA. Financial Disclosure. BIG tobacco pays me, so I can keep quiet about smokers!! In actuality: I pay BIG tobacco, so I can keep quiet about smokers!!

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Smoking Cessation Pulmonary Grand Rounds

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  1. Smoking CessationPulmonary Grand Rounds Sidharth Bagga MD MBA

  2. Financial Disclosure • BIG tobacco pays me, so I can keep quiet about smokers!! • In actuality: • I pay BIG tobacco, so I can keep quiet about smokers!! • We all are paying a tax in form of SocSec to keep quiet and tolerate smokers because if they don’t quit we are paying for their care, and BIG tobacco is walking away with a profit.

  3. Outline • Who started? • Who spread smoking? • Why we still smoke, despite knowing harms? • Its really not that addictive? • Does stopping even help? • Have any interventions made a difference? • What works? What doesn’t? • What can physicians do? • What can patients do? • Clinic best practices? • Financial impact? To patient? To Physician?

  4. Smoking History (ancient) • As early as 5000 BC in Shamanistic rituals • Babylonians, Indians, Chinese • Used to contact the spirit world • Medicinal purposes (Ayurveda) • Social Activity in Middle East (Hookah) • Weddings, funerals, etc. • Started with Cannabis  transitioned to Tobacco • Traders brought to Africa • Europeans to Americas

  5. Smoking History (recent) • 1920s • Increased life expectancy, showed signs of tobacco abuse • Nazi Germany develops advocacy against tobacco (Der Tabakgegner) • 1929 • [] published statistical link with tobacco and lung cancer • WWII • Nazis condemned smoking • Women smoker unfit for child bearing, and shunned from society • Post WWII • Marshall Plan (American) • Free tobacco to Germany • 24000 tons in 1948 • 69000 tons in 1949 • Bought by American government for Germans • Per capita (460 to 1523) • 1950 • Doll et al, BMJ (CA link) • 1954 • British Doctors Study • 1964 • US Surgeon General’s report suggesting CA link

  6. Smoking Current & Trends • 1.1 billion worldwide • 1/3rd adult population • “There is a new Marlboro land, not of lonesome cowboys, but of social-spirited urbanites, united against the perceived strictures of public health.”

  7. Smoking Current & Trends

  8. Smoking Current & Trends World map of countries by number of cigarettes smoked per adult per year

  9. Smoking Current & Trends

  10. Smoking Current & Trends

  11. Why, despite known harms? • Imagine a drug that can: • Enhance concentration, alertness, and memory • Decrease tension and anxiety • Promote a feeling of well-being • No immediate side effects • Nicotine delivery • Within seconds of inhalation, a bolus of nicotine is in brain to bind to receptor and release dopamine

  12. Why, despite known harms? 1972

  13. Why, despite known harms? Tobacco Master Settlement (1998)- payment by the companies of $365.5 billion over 25 years Grades Tobacco bonds states dependent on tobacco for income

  14. ‘

  15. Why, despite known harms?

  16. Why, despite known harms?

  17. Addiction: Physiologic / Social • Physiologic • Cigarette smoke is the perfect nicotine delivery device • Quick (< 1 sec) and effective means of delivering small amount of nicotine • Alkalization of smoke aids in efficient delivery of drug • Inhibition of MonoAmine Oxidase • Social • Smokers claim decreased stress levels (stress created by nicotine dependence) • Rationalization (going to die anyways, stress relief worth risk of CA) • Smokers community • Camaraderie, especially in locations with ban on indoor smoking

  18. Addiction: Genetic • Genetics • Without proper genetics patient cannot be addicted • 90% smokers have these genes and are dependent • Only 10% alcoholics, and 50% of heroin addicts are dependent. • Ten Towns Heart health Study • Decreased nicotine metabolism (dec fxn of CYP2A6 enzyme) • Higher risk of dependance • Dopaminergic genotypes • Regulate nicotine dependance • Differences in nicotine metabolism across ethnic groups

  19. Addiction:

  20. Addiction: Chemical • Degrees of Nicotine dependency • Fagerstrom Tolerance Questionnaire or Fagertrom Test for Nicotine Dependence • Serum Cotinine levels

  21. Addiction: Chemical (low tar/nicotine) LIGHTS

  22. Does Stopping Help? • Two Goals • Decrease disease development • Decrease disease progression • Long Latency period • keeps smokers at risk despite stopping decades earlier • Chronic Bronchitis • Cough / expectoration improve slowly over weeks/months • COPD • Improves overall prognosis • Increases life span • Lung Cancer • Reduced risk of Lung CA • 92-96% over 10-20 years • Small Cell CA • Continued smoking at greater risk of second primary • Early stage NSCLC • Improved mortality from decreased cancer progression • CAD • Decrease risk of AMI by 33% in first year • Smoking > 40 years age • 3 months life for each year smoked

  23. When did we start stopping? • Oldest attempt in Ottoman Empire / China • Banned for being a threat to public moral and health. US Smoking rates • 1965 - 42% • 2006 – 20.8% • Most quitters affluent white males • Increase in number of cig consumed per person suggests that light smokers quit, and heavy smokers moved to light cigs. • Stagnant over last 3 years! • Target unwilling quitters.

  24. What works? • Prohibition (ancient china) • Social shunning (Nazi Germany) • Behavioral retraining • Nicotine replacement • Gum, patch, lozenge, inhaler, nasal spray • Alpha4beta2 partial agonist/antagonists • Varenicline, Cytisine • Anti-depressants • Bupropion, Nortriptyline • Persistence

  25. What works?

  26. What doesn’t? • Unaided / ‘Cold Turkey’ • > 90% relapse rates after 3 months • SSRIs (OR 1.0) • Anxiolytics / Benzodiazepines • Beta blockade • Mecamylamine (old anti-hypertensive, Nicotine receptor Antagonist) • Accupuncture (OR 1.1) • Typically receiving 50% of recommended dose, and completing < 50% of counseling sessions

  27. What can physicians do? “All patients should be asked if they use tobacco and should have their tobacco use status documented regularly. Evidence has shown that this significantly increases rate of clinician intervention.” Strength of Evidence = A

  28. What can physicians do? Screen: The Fifth Vital Sign

  29. What can physicians do? As ASK Do you currently use tobacco? YES NO ASK Have you ever used tobacco? ADVISEto quit YES NO ASSESS Are you willing to quit now? ASSESS Have you recently quit? Any challenges? YES NO YES NO ASSIST Provide appropriate tobacco dependence treatment ASSIST Intervene to increase motivation to quit ASSIST Provide relapse prevention ASSIST Encourage continued abstinence ARRANGE FOLLOW-UP

  30. Minimal intervention (< 3mins) Meta-analysis (1996): Effectiveness of and estimated abstinence rates for advice to quit by a physician (n = 7 studies)

  31. Minimal Intervention (> 3 mins) Intensity of Clinical Interventions Meta-analysis (2000): Effectiveness of and estimated abstinence rates for total amount of contact time (n = 35 studies)

  32. Patient is willing to quit

  33. Patient is unwilling to quit? 5Rs • Review the personal relevance of quitting • “Smoking is raising your blood pressure” • “It’s important to me that you not smoke” • Review the risks of continued use • “Your family has a history of lung cancer” • Review the rewards of cessation • “We might be able to get you off of BP meds” • Review roadblocks to success • “I can help you be comfortable while you quit” • Repeat the message • Empathy, understanding, and support

  34. Physician counseling • Metanalysis of 14 RCT • Motivation interviewing increase 6m quit rates by 30%, compared to usual care • 2 studies have shown • Physician counselors (>2h training) were successful in 8% with motivational interviewing vs 2% with brief advice or usual care • Debunking Myths • Risk of AMI with NRT • Metanalysis of 9000 pts with no increased risk of cardiovascular events • Pregnancy • Two studies with no worsening, One with near statistical significance of congenital malformations. • Breastfeeding • 21mg patch same as smoking, otherwise lower nicotine levels

  35. Patient is still unwilling to quit? • Still prescribe nicotine patch • Meta-analysis of 7 RCTs (2767 unwilling pts) randomized to NRT had 6 month cessation rates of 9% v 5% in control group • Another study, 1154 pts given gum/patch for 2 months, had 6m quit rate of 17% v 10% control • If continued, smoking decreased by 50% in fifth of population • Nausea was only stat sig adv event (8.7% v 5.3%)

  36. Clinic best practices? • Provide on site care • If treatment delayed or at separate location, only 10% will initiate • 33% will enter treatment that is readily available • Insurance approvals expedited for medications • Multiple offers of treatment • May have benefit as smokers’ interest in quitting can change quickly. • On site samples

  37. What can patients do? With friends like these…

  38. What can patients do? • Costs • Harms • Patterns • Instructions

  39. Patient Financial Impact? • Cost of continued smoking • Pack a day ($10/pack -> $3,650) • A new wardrobe / TV every 3-6 months • Doesn’t include ancillary purchases, non-productive time, time spent taking care of chronic illnesses, hospitalizations • $50-73 billion per year in medical costs • Financial incentives to quit • NEJM 2009, 878 employees of multinational company • Study incentivized workers ($750) for completing counseling, quitting, staying smoke free for 6 months and 1 year. • Smoking cessation 9-12m (15% v 5%) and 15-18m (10% v 4%)

  40. Physician Financial Impact? Outpatient followup: Level 2 (29), Level 3 (50), Level 4 (74) Outpatient Consult: Level 3 (99), Level 4 (145), Level 5 (180) Initial Visit: Level 4 (111), Level 5 (141) Assumes – 42% average collection rate, > 50% time in counseling

  41. Physician Financial Impact? • Smoking Cessation • Average 3 to 4 pts/wk • Minimal clinic resource • Billing is time based • No physical exam required • No special training / setup requirements • F/U – 15 mins, level 3 - $50 collected • Consult – 30 mins, level 3 - $99 collected • Add On to regular visit • Average 40% of pts are active smokers • Counsel 3 mins • On top of regular billing - $12/$35 collected • Avg over 200 pts/wk, extra ~ $1200-3500 • Altruistic goal: return collections back to patients as financial incentive to be smoke free.

  42. Social Impact? • Leading cause of preventable death and disability in the world • Over 10 million premature deaths in the US since 1964 • Average loss of life: 7 years • Directly responsible for 1 in 5 deaths • BIG tobacco advertising expenditure: $8 billion on domestic market

  43. Horizon: vaccine (NicVax) • Nabi Biopharmaceuticals (Rockville, MD) • 3'-aminomethylnicotine molecule • Attached to Pseudomonas aeuroginosa exoprotein A • Body generates antibodies to Nicotine (look-alike) and binds all nicotine after exposure • Bound nicotine too large to enter blood-brain barrier • Bye-Bye Dependancy • Phase II Trials • 2005, 68 smokers • Safe and well tolerated • Headaches, colds, URTIs • Most kept smoking • 2006, 301 smokers • High nicotine Ab (61 pts) • 25% abstinent 6 mos • 13/100 placebo abstinent 5 mos

  44. Horizon: vaccine (NicVax) • Phase III Trials • 2010, double blind RCT, 1000 pts • Similar quit rates 11% at 16 weeks & 12 mos • 2011, double blind RCT, 1000 pts • Again, no difference • Combination with Varenicline in Netherlands

  45. Horizon: E-cigarettes

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