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Kevin Scott Ferentz, M.D. Associate Professor Department of Family Medicine University of MD School of Medicine. Smoking Cessation. Cigarette smoking is the single most important cause of disease and premature death in the United States. Cigarette-related deaths. 440,000 per year

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slide1
Kevin Scott Ferentz, M.D.

Associate Professor

Department of Family Medicine

University of MD School of Medicine

Smoking Cessation
slide2

Cigarette smoking is the single most important cause of disease and premature death in the United States

cigarette related deaths
Cigarette-related deaths
  • 440,000 per year
  • 12 million dead since first surgeon general’s report in 1964
  • Smokers die 13-14 years earlier
  • Medical costs: $ 75 billion
  • Lost productivity: $ 82 billion
  • Costs: $ 40/pack
smoking in the u s 2006
Smoking in the U.S. - 2006
  • 21% of adults (43% in 1966)
    • Kentucky 27.4%, Utah 10.5%
  • men (24%) women (18%)
    • < HS education 3X likely than w/ college degree
  • rate dropped little in 1990’s
  • Rate dropping by < 1% per year
  • 1.3 million quit each year
  • 3,000 teens start each day
    • adolescent smoking may be dropping
  • more ex-smokers than current smokers
  • 2010 goal: 12% smokers
slide5

Current cigarette smoking among HS students by sex, frequency, and grade level: US, 2003

Frequent smoking

Male

Grade 9

Grade 10

Grade 11

Grade 12

Female

Grade 9

Grade 10

Grade 11

Grade 12

0

10

20

30

40

Percent

Current smoking = smoked on 1 or more days of the 30 days preceding survey;

Frequent smoking = smoked on 20 or more of the 30 days preceding the survey.

Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

the politics of tobacco
The politics of tobacco
  • States that grow tobacco:
    • lowest taxes, highest rates of smoking
  • Most Tobacco Restitution Funds are NOT going to tobacco control
  • California: 1988
    • 23% smoking rate
    • Voters approve 25¢ tax for anti-smoking campaign
  • California: 2003
    • 15% smoking rate
    • 13% of HS students smoke (22% nationally)
  • Phillip Morris profits up 10% in 2004
smoking worldwide
Smoking worldwide
  • 1.3 billion smokers
  • Expected to rise to 1.7 in 2025
  • Kills 5 million yearly
  • 1 death every 6.5 seconds
  • May double in 20 years
  • 84% of smokers are in developing countries
  • 95 billion cigarettes sold in India each year!

World Health Organization – 2004

increased cancer risk
Increased Cancer Risk
  • 90% of lung cancer deaths
  • 40% of all cancers
  • mouth, larynx, esophagus, stomach
  • kidney, bladder
  • Pancreas
  • Cervix
  • Acute myeloid leukemia
  • more women die of lung than breast cancer!
heart disease
Heart disease
  • leading cause of death
  • smoking is major risk factor
  • 3 times more likely to die of heart disease
  • step-wise increase with other risk factors
lung disease
Lung Disease
  • 90% of COPD deaths
  • asthma
  • bronchitis
  • pneumonia
female smokers
Female smokers
  • infertility
  • earlier menopause
  • osteoporosis
  • birth control pills
  • vaginitis
pregnant smokers
Pregnant smokers
  • spontaneous abortion
  • placenta previa
  • placental abruption
  • premature rupture of membranes
  • preterm labor
  • restricted fetal growth
  • increased fetal respiratory rate
  • placental abnormalities
children of smokers
Children of smokers
  • respiratory illness
  • SIDS
  • cognitive development
  • behavioral development
  • cancer
  • increased risk of smoking
smokeless tobacco
Smokeless tobacco
  • “spit” tobacco
  • cancer of mouth, pharynx, esophagus
  • tooth discoloration
  • gingival recession
  • periodontal bone destruction
  • death from juice ingestion
other problems
Other problems
  • fire accidents
  • gingivitis
  • skin wrinkles
  • impotence
  • decreased stamina
  • colds, flu
health effects from smoking
Heart disease

Lung disease – COPD, asthma

Cancer

Lung, ENT, pancreas

Cervix

Skin (squamous cell)

Vascular disease – impotence, AAA

Stroke

Cataracts

Macular degeneration

Gum disease

Tooth decay

Osteoporosis

Wound healing

Anxiety & Depression

Miscarriage

SIDS

Hearing loss

Rheumatoid arthritis

Lupus

Dementia

Multiple sclerosis

Health effects from smoking
smoking kills more people each year than
alcohol

cocaine

crack

heroin

homicide

suicide

car accidents

fires

AIDS

Smoking kills more people each year than

C O M B I N E D!!!

what s in a cigarette

©

What’s in a cigarette?
  • 4,000 chemicals
  • tar
  • carbon monoxide
  • nicotine
slide21

“...cigarettes and other forms

of tobacco are addicting in the same sense as are drugs such as heroin and cocaine.” C. Everett Koop, MD 1988 Surgeon General’s Report

criteria for addicting drug
Criteria for addicting drug
  • Dependence
  • Tolerance
  • Withdrawal

Nicotine yield/cig increased 11% from 1998-20051

1Harvard School of Public Health, 2007

nicotine immediate effects
Nicotine - immediate effects

sympathetic stimulation

parasympathetic stimulation

feelings of:

stimulation

better concentration

pain tolerance

health benefits after quitting
Health benefits after quitting
  • cough, DOE resolve in weeks
  • exercise tolerance improves rapidly
  • bladder cancer: 50% reduction in 5 years
  • lung cancer: 50% reduction in 10 years
  • heart disease: 50% reduction in 1 year!
  • No increased risk of heart disease by 10-15 yrs
  • vascular disease: 50% reduction in 5 years
  • mortality rates same as never smokers by 10-15 yrs
how are we doing with our patients
How are we doing with our patients?
  • 1991:
    • < 50% of patients reported ever being told to stop1
  • 1998:
    • 67% Ask, 74% Advise, 35% Assist, 8% Follow-up2
  • 2003: (patients that got prescription)3
    • 36% told to set quit date, 25% counseled,

13% advised to follow up

Many smokers do not get the

advice and help they need!!!

1Frank,E., Winkleby, M.A.,Altman, D.G., et al. JAMA 1991;266:3139-3134.

2Goldstein MG, et al. Preventive Medicine. 27(5 Pt 1):720-9, 1998 Sep-Oct.

3Solberg LI, et al. Archives of internal medicine, 2005;165:656

why counsel all smokers
Why counsel all smokers?
  • 90% want to quit
  • minimal physician input almost doubles quit rate1
  • most quit without intensive assistance once they make the decision
  • moving patients through the process2
    • precontemplation
    • contemplation
    • preparation
    • action
    • maintenance

1Cochrane Database of Systematic Reviews. 2004

2J of Cons & Clin Psych. 51(3):390-5, 1983 Jun

physician influence
Physician influence
  • position of authority
  • credible source
  • personalize health effects
  • face-to-face counseling
  • multiple contacts
  • good role models
patient resources
Patient resources
  • printed materials (still need counseling)
  • National Cancer Institute(1-800-4-CANCER)
  • www.smokefree.gov
  • Smokingstopshere.com
  • 1–800–QUIT–NOW

(quit lines improve chances of quitting)

slide30

A minimum amount of time spent with more smokers will yield more ex-smokers than intensive efforts with a few

minimum counseling
Minimum counseling
  • firm, unambiguous advice
  • written materials
  • set a quit day
  • set follow-up visit
  • (or warn patient you will ask about progress at a future visit)
influence to quit
Influence to quit
  • firm, unambiguous advice
  • “as your doctor, I’m telling you to QUIT!”
  • personalize damaging health effects
  • effects reversible with quitting
personalizing effects history
Personalizing effects - history
  • shortness of breath
  • cold hands and feet
  • fatigue
  • decreased stamina
  • colds and flu
  • bronchitis, sinusitis
  • teeth, gums
  • kids’ problems
personalizing effects physical
Personalizing effects - physical
  • gingivitis
  • tar stains
  • bad breath
  • diminished breath sounds
  • wheezing, rhonchi
  • peripheral pulses
  • fundal height
  • wrinkling
personalizing effects labs
Personalizing effects - labs
  • carboxyhemoglobin
  • pulmonary function tests
  • peak flow
  • chest x-ray
influence to quit37
Influence to quit
  • firm, unambiguous advice
  • “as your doctor, I’m telling you to QUIT!”
  • personalize damaging health effects
  • effects reversible with quitting
  • non-health reasons
non health reasons for quitting
Non-health reasons for quitting
  • COST!!!
  • inconvenience
  • self-esteem
  • role model
influence to quit39
Influence to quit
  • firm, unambiguous advice
  • “as your doctor, I’m telling you to QUIT!”
  • personalize damaging health effects
  • effects reversible with quitting
  • non-health reasons
  • confidence
building confidence
Building confidence
  • express your confidence
  • millions of others have quit
  • more ex-smokers than smokers
  • most try many times before succeeding
  • past attempts are learning experiences
  • ways to deal with physical and psychological dependence
influence to quit41
Influence to quit
  • firm, unambiguous advice
  • “as your doctor, I’m telling you to QUIT!”
  • personalize damaging health effects
  • effects reversible with quitting
  • non-health reasons
  • confidence
  • address concerns
common concerns
Common concerns
  • Withdrawal
    • short lived
  • Cravings
    • last 3-5 minutes, diminish rapidly
  • Tension
    • validate, normalize
    • find other ways to cope
  • Weight gain - not inevitable!
    • 1/3 gain: 5-8 lbs.
slide45

Accentuate the positive

aspects of quitting

rather than dwelling

on the dangers of

continuing to smoke

components of addiction
Components of addiction
  • physiological
  • psychological
  • behavioral
behavior modification
Behavior modification
  • review reasons for quitting (index card)
  • identify triggers (4 day diary)
  • plans to avoid or cope with each trigger
sample plan
Trigger

after meals

on the phone

in the car

at desk

tension

coffee breaks

other smokers

crisis

Technique

leave table

draw

chew gum

carrot sticks

deep breathing

juice

non-smokers

self-talk

Sample plan
behavior modification50
Behavior modification
  • review reasons for quitting (index card)
  • identify triggers (4 day diary)
  • plans to avoid or cope with each trigger
  • change habit: packs only, different brands
  • develop support system (tell everyone)
  • self rewards (day, week, month, year)
  • written commitment to quit day
pharmacological treatment
Pharmacological treatment

nicotine replacement - “methadone for the smoker”

Gum, Patch, lozenge, nasal spray, inhaler

Bupropion (Zyban®)

Varenicline (Chantix®)

all decrease cravings, withdrawal

20-25% quit rates at 1 year

nicotine replacement gum
Nicotine replacement - gum

available since 1984

2 mg. and 4 mg. strength

“chew, park, chew, park”

2 mg. - 30 pieces/day maximum

4 mg. - 20 pieces/day maximum

wean after 3 months, 6 months maximum

use in conjunction with patches, bupropion

nicotine replacement patches
Nicotine replacement - patches

4 patches on market - OTC

wean - 8 weeks

first patch - night before quit day

rashes, abnormal dreams

no euphoria - no stimulant effect

no increased risk of MI

nicotine lozenges commit
Nicotine lozenges (Commit®)
  • 2 and 4 mg strengths
  • 4 mg if smoke w/in 30 minutes of waking
  • 12 week program
  • Weeks 1-6: 1 lozenge every 1 to 2 hours
  • Weeks 7-9: 1 lozenge every 2 to 4 hours
  • Weeks 10-12: 1 lozenge every 4 to 8 hours
  • at least 9 per day for the first 6 weeks
  • hiccups, heartburn, nausea
  • no more than 5 in 6 hours, 20 per day
  • Can work when patch, gum failed
slide58

©

Shiffman S, Dresler CM, et al. Arch Intern Med. 2002;162:1267-1276.

nicotine nasal spray
Nicotine nasal spray

one dose: 2 sprays (1 mg)

minimum: 8 doses/day

maximum: 40 doses/day (1/2 bottle)

if not abstinent by week 4 - stop

use for 3 months, six maximum

nasal irritation limits use

nicotine inhaler
Nicotine inhaler

nicotine deposited in mouth

2 mg absorbed per insert

80 puffs in 20 minutes

6 - 16 cartridges/day

3 months then wean over 3 months

40% throat irritation

20% quit at 6 months, 13% at 1 year

bupropion zyban
Bupropion (Zyban)

Probably works by increasing dopamine in nucleus accumbens

150 mg qd X 3 days, 150 mg b.i.d. X 4 days, then QUIT

continue for 7 - 12 weeks

if not stopped by 8 weeks, discontinue

Can use with nicotine replacement

slide63

Rates of Continuous Abstinence

Buproption and nicotine patch

Bupropion

Nicotine patch

Placebo

Jorenby NEJM 1999

bupropion cautions contraindications
Bupropion – cautions/contraindications

insomnia - last dose 6 hours before sleep

Activating but well-tolerated

seizure disorder

prior or current eating disorder

concurrent use of Wellbutrin®

varenicline chantix
Varenicline (Chantix®)
  • [alpha]4[beta]2 nicotinic acetylcholine receptors reinforce effects of nicotine, maintain smoking
  • partial agonist, antagonist (blocks binding)
  • 0.5 mg X 3 d, 0.5 mg b.i.d. X 4 d, 1 mg b.i.d.
  • Stop smoking after 7 days on medicine
  • Can use for up to 6 months
  • Probably higher rates of quitting
  • Nausea, constipation, abnormal dreams
  • Costs about $ 4/day
slide66

Continuous Smoking Abstinence Rates

*weeks 9–52: varenicline vs placebo, P<.001; varenicline vs bupropion,

P = .004; bupropion vs placebo, P = .08.

Jorenby DE, et al JAMA. 296(1):56-63, 2006 Jul 5.

second line medications
Second-line medications
  • Clonidine: 0.15 – 0.75 mg/d for 3 – 10 weeks
  • Nortriptyline: 75 – 100 mg/d for 12 weeks
relapse
Relapse

rates are same as for heroin, alcohol

at least 70% relapse within first year

2/3 within first 3 months

largest group within first week

factors:

early: withdrawal, cravings, habit

late: other smokers, food, alcohol, coffee negative emotions, crisis

preventing relapse
Preventing Relapse
  • use and refinement of coping strategies
    • “if you don’t want to slip, stay away from slippery places”
  • positive self-talks in response to slips
    • Slips happen: Hungry, Angry, Lonely Tired
  • continued commitment (one day at a time)
  • praise and encouragement by physician

(“ex-smoker” on problem list)

the future
The future
  • Nicotine vaccine (NicVAX)
    • Block nicotine from getting into brain
    • Phase two trials are promising
  • Different forms of nicotine replacement
  • Rimonabant
    • cannabinoid receptor antagonist
    • Also treats obesity
    • Probably won’t be released in US for smoking
ahcpr guidelines the 5 a s
AHCPR Guidelines - The 5 “A’s”
  • ASK - identify tobacco users at all visits
  • ADVISE - strongly urge all smokers to quit
  • ASSESS - willing to make an attempt?
  • ASSIST - information, medication
  • ARRANGE - schedule follow-up visit
for those unwilling to quit the 5 r s
For Those Unwilling to Quit – the 5 “R’s”

Relevance - why quitting is personally relevant

Risks - patient identifies negative consequences of tobacco use

  • Acute, long-term, environmental risks

Rewards - patient identifies benefits of stopping

Roadblocks - patient identifies barriers to quitting

Repetition - motivational intervention every visit