Practical Smoking Cessation

1. Practical Smoking Cessation Allan Prochazka, M.D., M.Sc. Denver VAMC

2. Outline • 5 A’s Approach • Ask • Advise • Assess • Assist • Arrange

3. AHQR Guidelines • Released 6/00 • Based on review of > 3,000 studies • Nearly all are RCT’s • Probably the most evidence-based guideline in medicine • Resulted in the 5A’s approach

4. Ask • Ask all patients at each visit whether they smoke • Why every visit? • Relapse among ex-smokers occurs even years after quitting • Makes smoking salient for patients and providers • Triggers quit attempts by patients and advice/interventions by providers

5. Implementation • Electronic records • VA is all electronic, reminders are automatically triggered, documentation of smoking status and advice is a performance measure for the hospital director • Paper System • Decide who will be responsible and how one will track compliance

6. Advise • Strongest data are for physician advice • Other clinicians also likely to be effective • Ideal to have a consistent approach across providers to reinforce the message • Patients will receive advice from multiple sources

7. Simple, direct message • ‘I’m your (doctor, nurse, therapist, health educator…) and the best thing you can do for your health is to quit smoking’ • Avoid equivocation • ‘You might want to think about someday perhaps considering quitting smoking’

8. Increasing Advice Effectiveness • Link to patient’s health • Make the connection to other health problems • Asthma/Bronchitis/Emphysema • Heart disease • Reflux, ulcers • Skin changes • Vision—macular degeneration • Diabetes—accelerating effect of smoking on renal dysfunction, cardiovascular effects • Peripheral Vascular Disease

9. Use Ancillary Testing to Enhance Motivation to Quit • Pulmonary function testing and lung age • Portable units have greatly increased test quality • $500 - $1500, can be billed • Expired carbon monoxide testing • Instant feedback • No teaching required on meaning of CO • Low initial costs ($500-800)

10. Assess • Identify willingness to quit • Do you want to quit smoking? • If yes, when do you want to quit? • If ready now, then provide assistance on quitting at this visit and deal with other problems at the next visit • If not ready, then work on motivation and on barriers

11. Assess • Identify Tobacco Dependence • DSM IV R criteria • Withdrawal with cessation • Smoking in the face of medical illness • Fagerstrom • How soon after awakening do you smoke your first cigarette? • If < 5 minutes, then highly dependent

12. Why bother with dependence? • Reminder to providers • Identifies those who surely need more than advice • Reminder to patients when the diagnosis is shared with them

13. Increasing Motivation • Relevance • Risks • Rewards • Roadblocks • Repetition

14. Relevance • Personalize the effects of smoking • Consider influence on family members (e.g. parents smoking aggravating child’s asthma) • Risks • Generic risks are not as influential as personal risk • Short term risks are more salient than long term risks, especially for young people • Risks without benefits, sometimes lead to paralysis, so emphasize the improvements that are possible

15. Rewards • Personal • Taste/smell improve • Clothes, home, breath smell better • Health • Improvement in current medical conditions • Avoidance of complications • Economic • Out of pocket costs of smoking can be significant expense for those on fixed income • Social • Example for children • Self-control, mastery

16. Roadblocks • Weight gain • Fear of failure • Withdrawal symptoms • Lack of support from family/friends • ‘The only thing I have left is smoking’

17. Repetition • Key point is that messages need to be repeated over time • A person may not be ready to take action today, that doesn’t mean he/she won’t be ready next week, next month or next year • Smokers also need to know that relapse after a quit attempt is normal, most will need several solid efforts to be successful

18. Assist • Behavioral • Drug Therapy • Smokers wanting to quit need both • Dose of each one can be tailored to the patient’s needs

19. Behavioral • Key element is time with patient and empathic counselor • More time, more benefit, but get results even with small investments • Goals • Set a quit date • Tell family, friends, coworkers • Make the home smoke free, start acting like a non-smoker • Identify barriers to cessation

20. Goal: total abstinence after quit day • Review prior quit attempts, learn from them • Anticipate triggers and challenges • Encourage others in the home to quit • Provide options • Referral • Quitline • Self-help materials

21. Drug Therapy • Nicotine Replacement Therapy (NRT) • Nicotine Gum • Nicotine Patch • Nicotine Nasal Spray • Nicotine Inhaler • Nicotine Lozenge • Non-Nicotine Therapy • Bupropion (Zyban)

22. NRT • Overall success rate comparable among the products • Doubles the quit rate over advice alone • (e.g. 5-8% to 10-15%) • Selection based on side effects, patient preference, insurance coverage • PDR duration of therapy 8-12 weeks • Selected patients need longer therapy or higher doses

23. Nicotine Gum • 2 forms (2 mg and 4mg), 4 mg best for most smokers • Available OTC and in Generic forms • Absorption is buccal, so park and chew • Regular dosing better than ad lib • Typical patient will use 5-8 pieces per day • Cost $35-50 for 108 pieces

24. Side Effects • Dental trauma, jaw pain, nausea, upset stomach • Duration of Use • 8-12 weeks • 2-5% have trouble quitting gum • Long term use combined with behavioral therapy (up to 5 years) safe and effective, 25% validated quit rate in Lung Health Study

25. Transdermal Nicotine • 3 strengths (21, 14, 7 mg/24hr) • Some patients require higher doses (e.g. very heavy smokers), but for typical pack a day smoker 21mg is the starting dose • 4-6 weeks on 21 mg, 2-4 weeks on 14 mg, then 2-4 weeks on 7 mg • Costs $35-50 per 14 day supply

26. Side Effects • Skin irritation (30%) • Skin allergy (1-4%) • Poor sleep/nightmares (10%) • Arm pain (2-4%)

27. Nasal Nicotine Spray • Very rapid absorption of nicotine • Dosing 0.5 mg per spray, one spray in each nostril is one dose (about the amount of nicotine in one cigarette) • Typical patient uses 3-6 doses per day • Side Effects: mostly irritation, face pain, perhaps more likely to result in difficulty stopping use due to fast absorption • Costs $46.99 per 10 ml vial (100 doses)

28. Nicotine Inhaler • Each cartridge 10 mg nicotine, 4 mg released, 2 mg absorbed • Best with continuous puffing (80 deep inhalations over 20 minutes give 2 mg nicotine) • Dosage 6-16 cartridges per day • Side Effects: mouth/nose irritation • Costs $51.69 per 42 cartridges

29. Nicotine Lozenge • Approved 11/02 • Available OTC, 2 mg and 4 mg • Allow lozenge to slowly dissolve, no chewing or swallowing of the lozenge—need to be careful not to develop too much saliva • 20-30 minutes per lozenge • Dose 20 max per day • Side effects: hiccups, nausea, stomach upset, palpitations • Cost $42.00 for box of 72 lozenges

30. Non-Nicotine Therapy • Bupropion (Zyban) • Antidepressant, works in normal, non-depressed smokers • Slower onset of action (7-10 days) • Dosage: 150 mg a day for 3 days, then 150 mg bid, but not much difference in effectiveness between 150 and 300 mg /day • Duration: 3 months, but longer term therapy is safe and effective

31. Costs VA $53 for one month • Side Effects • Common • Shaky,tremor • Headache • Dry mouth • Rare but serious • Seizures • Avoid in those with epilepsy, active drug use, concomitant psychiatric medications, bulemia, MAOI use

32. Combined with NRT • Borderline significance, but 9% better with patch combined with bupropion • Very useful in healthy populations (e.g. worksite) and in those with active cardiac disease • Hard to use in populations with lots of psychiatric comorbidity/substance abuse due to risk of seizures, precipitation of mania and need to add to already complex drug regimens • May be better in those with a depressive tendency • Less weight gain than with patch

33. Has been tested in several populations including patients with COPD, African Americans; effect appears to be robust • Bottom Line: very useful agent for many populations

34. Arrange • Followup greatly enhances cessation results • Can be in person or on the telephone • Linkage to Quitline in Colorado and other states may allow more intensive followup that would usually be available in primary care settings

35. Congratulate on success • Review lapses • Emphasize total abstinence • Review drug therapy • Consider referral if needed

36. Cost Effectiveness$ per QALY

37. Conclusions • Implement the 5A’s • Use combined drug and behavioral approaches • Select drugs based on patient preference and associated medical conditions • Followup and allow patients to recycle • Make a long term commitment