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Rx for CHANGE. Clinician-Assisted Tobacco Cessation for Patients with Cancer. is the chief, single, avoidable cause of death in our society and the most important public health issue of our time.”. “CIGARETTE SMOKING…. C. Everett Koop, M.D., former U.S. Surgeon General.

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rx for change

Rx for CHANGE

Clinician-Assisted Tobacco Cessationfor Patients with Cancer

cigarette smoking
is the chief, single, avoidable cause of death

in our society and the most important public health issue of our time.”

“CIGARETTE SMOKING…

C. Everett Koop, M.D., former U.S. Surgeon General

trends in adult smoking by sex u s 1955 2006
TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2006

Trends in cigarette current smoking among persons aged 18 or older

20.8% of adults are current smokers

Male

Percent

23.9%

Female

18.0%

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.

2004 report of the surgeon general health consequences of smoking
2004 REPORT of the SURGEON GENERAL:HEALTH CONSEQUENCES OF SMOKING

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.

FOUR MAJOR CONCLUSIONS:

U.S. Department of Health and Human Services. (2004). The Health Consequences of Smoking: A Report of the Surgeon General.

health consequences of smoking
HEALTH CONSEQUENCES of SMOKING

Cancers

Acute myeloid leukemia

Bladder and kidney

Cervical

Esophageal

Gastric

Laryngeal

Lung

Oral cavity and pharyngeal

Pancreatic

Pulmonary diseases

Acute (e.g., pneumonia)

Chronic (e.g., COPD)

Cardiovascular diseases

Abdominal aortic aneurysm

Coronary heart disease

Cerebrovascular disease

Peripheral arterial disease

Reproductive effects

Reduced fertility in women

Poor pregnancy outcomes (e.g., low birth weight, preterm delivery)

Infant mortality

Other effects: cataract, osteoporosis, periodontitis, poor surgical outcomes

U.S. Department of Health and Human Services. (2004). The Health Consequences of Smoking: A Report of the Surgeon General.

health consequences of smokeless tobacco use
HEALTH CONSEQUENCES of SMOKELESS TOBACCO USE

Periodontal effects

  • Gingival recession
  • Bone attachment loss
  • Dental caries

Oral leukoplakia

Cancer

  • Oral cancer
  • Pharyngeal cancer

Oral Leukoplakia

Image courtesy of Dr. Sol Silverman -

University of California San Francisco

Use of alcohol in combination with moist snuff increases the risk of oral cancers.

slide7

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.

nicotine distribution
NICOTINE DISTRIBUTION

Arterial

Venous

Nicotine reaches the brain within 11 seconds.

Henningfield et al. (1993). Drug Alcohol Depend33:23–29.

slide9

DOPAMINE REWARD PATHWAY

Prefrontal cortex

Dopamine release

Stimulation of nicotine receptors

Nucleus accumbens

Ventral tegmental area

Nicotine enters brain

nicotine pharmacodynamics withdrawal effects
NICOTINE PHARMACODYNAMICS: WITHDRAWAL EFFECTS
  • Irritability/frustration/anger
  • Anxiety
  • Difficulty concentrating
  • Restlessness/impatience
  • Depressed mood/depression
  • Insomnia
  • Impaired performance
  • Increased appetite/weight gain
  • Cravings

Most symptoms manifest within the first 1–2 days, peak within the first week, and subside within 2–4 weeks.

HANDOUT

Hughes. (2007). Nicotine Tob Res 9:315–327.

quitting health benefits
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

smoking cessation reduced risk of death
SMOKING CESSATION: REDUCED RISK of DEATH
  • Prospective study of 34,439 male British doctors
  • Mortality was monitored for 50 years (1951–2001)

On average, cigarette smokers die approximately

10 years younger than do nonsmokers.

Years of life gained

Among those who continue smoking, at least half will die due to a tobacco-related disease.

Age at cessation (years)

Doll et al. (2004). BMJ 328(7455):1519–1527.

tobacco cancers caused by tobacco
TOBACCO: CANCERS CAUSED by TOBACCO
  • Bladder and kidney
  • Cervix
  • Stomach
  • Bone marrow(acute myeloid leukemia)
  • Lung
  • Larynx
  • Oral cavity and pharynx
  • Esophagus
  • Pancreas

Sufficient evidence exists to infer a CAUSAL relationship between tobacco use and these cancers.

USDHHS. (2004). The Health Consequences of Smoking: A Report of the Surgeon General.

tobacco and cancer carcinogens in tobacco products
TOBACCO and CANCER: CARCINOGENS in TOBACCO PRODUCTS

An estimated 4,800 compounds in tobacco smoke,

including 11 proven human carcinogens

  • Polycyclic aromatic hydrocarbons (PAHs)
    • Benzopyrene
    • Benzanthracene
  • Tobacco-specific nitrosamines (TSNAs)
  • Aromatic amines
  • Formaldehyde
  • Benzene
  • Vinyl chloride
  • Cadmium
  • Radioactive polonium-210

Nicotine does NOT cause the ill health effects of tobacco use.

tobacco and cancer mechanism of carcinogenesis
TOBACCO and CANCER: MECHANISM of CARCINOGENESIS
  • Compounds in tobacco function as
    • Carcinogens
      • Initiate tumor growth
    • Tumor promoters
      • Stimulate the development of established tumors
    • Co-carcinogens
      • Enhance the mutagenic potential of carcinogens; possess little or no direct carcinogenic activity
    • Irritants
      • Induce inflammation and compromise tissue integrity
tobacco and cancer cell division
TOBACCO and CANCER: CELL DIVISION

A cancer cell dividing its chromosomes (shown in white) into two new cells

Image courtesy of Dr. Paul D. Andrews / University of Dundee

tobacco and cancer mechanism of carcinogenesis cont d
TOBACCO and CANCER: MECHANISM of CARCINOGENESIS (cont’d)
  • Formation of DNA adducts
    • Covalent binding product of carcinogen (or its metabolite) to DNA
    • Leads to miscoding and point mutations
    • Mutations of oncogenes or tumor suppressor genes can lead to uncontrolled cellular growth and development of cancer
tobacco and cancer mechanism of carcinogenesis cont d1
TOBACCO and CANCER: MECHANISM of CARCINOGENESIS (cont’d)

Nicotine

addiction

PAHs

TSNAs

Other carcinogens

Tobacco use

Metabolic

detoxification

Excretion

Metabolic activation

Repair

DNA adducts

Normal DNA

Persistence/miscoding

Apoptosis

Cancer

Mutations

Other changes

Reprinted with permission. Hecht. J Natl Cancer Inst 1999;91:1194–1210.

tobacco use and the development of cancer summary
TOBACCO USE and the DEVELOPMENT of CANCER: SUMMARY
  • Tobacco products cause a variety of cancers
  • Carcinogens present in tobacco products are responsible for these cancers
  • Carcinogenesis likely involves a multistep process:
    • Formation of DNA adducts
    • Permanent cellular mutations
    • Unregulated cellular growth
prevalence of smoking among patients with cancer
PREVALENCE of SMOKING AMONG PATIENTS with CANCER
  • A large proportion of patients are current or former smokers at the time of cancer diagnosis
    • Prevalence of ever smoking is highest among patients with tobacco-related cancers
      • 90% -- lung cancer
      • 80% -- head and neck cancer
  • 20–50% of patients with cancer continue to smoke after diagnosis
  • A large proportion of patients who quit smoking will relapse after completing their treatment

Cancer diagnosis provides an important “window of opportunity” for promoting tobacco cessation.

annual number of cancer deaths attributable to smoking 1997 2001
ANNUAL NUMBER of CANCER DEATHS ATTRIBUTABLE to SMOKING, 1997-2001

Centers for Disease Control and Prevention. (2005). MMWR 54:625–628.

Graph provided by American Cancer Society, 2008.

smoking and cancer treatment survival quality of life
SMOKING and CANCER:TREATMENT, SURVIVAL, QUALITY of LIFE

SMOKING…

  • Negatively impacts cancer treatment response
    • Surgery
    • Radiation
    • Chemotherapy
  • Increases odds for development of second primary tumors
  • Negatively impacts survival outcomes
  • Reduces quality of life

Clinicians can impact cancer outcomes by assisting

patients and their family members with quitting smoking.

effects of smoking on cancer therapy surgery
EFFECTS of SMOKING on CANCER THERAPY: SURGERY
  • Smoking is associated with poor surgical outcomes
    • Respiratory complications during anesthesia
    • Cardiopulmonary complications
    • Infections and impaired wound healing
    • Cerebrovascular complications
    • Increased post-operative intensive care admissions
  • Cessation interventions before surgery can reduce risk of complications
    • Best when offered at least 6 weeks prior to surgery
effects of smoking on cancer therapy radiation
EFFECTS of SMOKING on CANCER THERAPY: RADIATION
  • Smoking reduces treatment efficacy
  • Patients who smoke experience increased incidence of complications
    • Toxicity
    • Side effects
    • Overall morbidity
  • Smoking is associated with reduced survival rates
effects of smoking on cancer therapy chemotherapy
EFFECTS of SMOKING on CANCER THERAPY: CHEMOTHERAPY
  • Smoking may decrease the therapeutic effects of chemotherapy and other medications
    • Drug interactions with smoking -- increased hepatic metabolism (e.g., irinotecan, erlotinib)
  • More research is needed to delineate effects of smoking on chemotherapy outcomes

HANDOUT

  • What is nicotine’s effects on cancer cells, and how does it impact treatment?
  • Does the lack of smoking data in patient charts impact our ability to understand the relationship between smoking and outcomes?
  • How does smokers’ increased risk of co-morbid disease impact their likelihood for entry into clinical trials?
effects of smoking on second primary tumors
EFFECTS of SMOKING onSECOND PRIMARY TUMORS
  • Continued smoking after diagnosis increases risk for second primary tumors -- this applies to:
    • The initial tumor site and other sites
    • Malignancies related to smoking
    • Malignancies not related to smoking
  • Dose-response relationship of intense cigarette use increases the risk for second primary tumors
  • Continued exposure to tobacco after cancer diagnosis may be the more important risk factor
effects of smoking on cancer survival outcomes
EFFECTS of SMOKING on CANCER SURVIVAL OUTCOMES
  • Survival is reduced in patients who smoke
    • As a direct result of malignancy
    • As a consequence of other smoking-related disease(s)
  • Smoking history
    • >30 pack-years has been shown to be an independent prognostic factor for both short- and long-term survival rates
  • Tobacco mutagenicity may play a role in the growth and extension of certain cancers
    • Presents further obstacles for survival

Quitting smoking before diagnosis and treatment

can positively influence survival.

effects of smoking on quality of life in patients with cancer
EFFECTS of SMOKING on QUALITY OF LIFE in PATIENTS WITH CANCER
  • Smoking after diagnosis negatively impacts
    • Overall quality of life (QOL)
    • Risk for co-morbid diseases, which independently have a negative impact on QOL
    • Symptom distress
      • Higher in persistent smokers, compared to never smokers
how does smoking cessation improve cancer prognosis
HOW DOES SMOKING CESSATION IMPROVE CANCER PROGNOSIS?
  • Quitting prior to diagnosis and treatment has a positive influence on prognosis and survival
  • Examples
    • Head and neck cancer
      • Quitting 12 weeks and 1 yr prior to diagnosis reduces mortality by 40% and 70%, respectively
    • Non-small cell lung cancer
      • Quitting at any point prior to lung operation is beneficial to prognosis and long-term survival
what factors positively influence quitting in patients with cancer
WHAT FACTORS POSITIVELY INFLUENCE QUITTING in PATIENTS WITH CANCER?
  • Patient awareness of the link between smoking and their diagnosed smoking-related cancer
  • Patient concern about recurrent disease and the effects of smoking on treatment success
  • Advice given in the context of medical care
more intensive or tailored interventions may be needed
MORE INTENSIVE or TAILORED INTERVENTIONS MAY BE NEEDED
  • Patients with cancer tend to have:
    • Higher levels of nicotine dependence
    • Higher levels of psychiatric co-morbidity
    • Higher need for treatment support
    • High percentage of household smokers
    • Poorer general health and physical functioning
    • More stress and emotional distress
  • Cancer disease-related issues need to be taken into account in treatment decisions and patient monitoring
    • Impact of smoking on surgery, radiation, and chemotherapy
  • Systematic advice (from multiple providers), with stepped-care approach for patients experiencing difficulty with quitting
relapse in patients with cancer
RELAPSE in PATIENTS WITH CANCER
  • Up to one third or one half of patients will either continue to smoke after diagnosis or relapse after an initial quit attempt
  • Relapse is often delayed in patients with cancer, compared to healthy patients
    • Follow-up and monitoring is needed
    • In relapsers:
      • Encourage a subsequent quit attempt, to avoid additional post-diagnosis risk due to smoking
summary reasons to quit for patients with cancer
SUMMARY: REASONS TO QUIT for PATIENTS WITH CANCER
  • Reduced risk for complications related to cancer therapy and surgery
  • Improved survival
  • Improved quality of life
  • Reduced risk of second primary tumor(s)

TOBACCO CESSATION is an essential

component of treatment for patients with cancer.

tobacco dependence a 2 part problem

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.

pharmacologic methods first line therapies
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

pharmacotherapy
PHARMACOTHERAPY

“Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations* for which there is insufficient evidence of effectiveness.”

* Includes pregnant women, smokeless tobacco users, light smokers, and adolescents.

Medications significantly improve success rates.

Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.

Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

pharmacotherapy use in pregnancy
PHARMACOTHERAPY: USE in PREGNANCY

The Clinical Practice Guideline makes no recommendation regarding use of medications in pregnant smokers

Insufficient evidence of effectiveness

Category C: varenicline, bupropion SR

Category D: prescription formulations of NRT

“Because of the serious risks of smoking to the pregnant smoker and the fetus, whenever possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit.” (p. 165)

Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

pharmacotherapy other special populations
PHARMACOTHERAPY: OTHER SPECIAL POPULATIONS

Pharmacotherapy is not recommended for:

Smokeless tobacco users

No FDA indication for smokeless tobacco cessation

Individuals smoking fewer than 10 cigarettes per day

Adolescents

Nonprescription sales (patch, gum, lozenge) are restricted to adults ≥18 years of age

NRT use in minors requires a prescription

Recommended treatment is behavioral counseling.

Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

nrt rationale for use
NRT: RATIONALE for USE

Reduces physical withdrawal from nicotine

Eliminates the immediate, reinforcing effects of nicotine that is rapidly absorbed via tobacco smoke

Allows patient to focus on behavioral and psychological aspects of tobacco cessation

NRT products approximately doubles quit rates.

nrt products
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)

Patients should stop using all forms of tobacco

upon initiation of the NRT regimen.

plasma nicotine concentrations for nicotine containing products
PLASMA NICOTINE CONCENTRATIONS for NICOTINE-CONTAINING PRODUCTS

Cigarette

Moist snuff

0 10 20 30 40 50 60

Time (minutes)

nrt precautions
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.

nicotine gum nicorette glaxosmithkline generics
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; original, cinnamon, fruit, mint (various), and orange flavors

nicotine gum dosing
NICOTINE GUM: DOSING

Dosage based on current smoking patterns:

nicotine gum chewing technique summary
NICOTINE GUM:CHEWING TECHNIQUE SUMMARY

Chew slowly

Stop chewing at first sign of peppery taste or tingling sensation

Chew again when peppery taste or tingle fades

Park between

cheek & gum

nicotine lozenge commit glaxosmithkline generics
NICOTINE LOZENGECommit (GlaxoSmithKline); generics

Nicotine polacrilex formulation

Delivers ~25% more nicotine than equivalent gum dose

Sugar-free mint (various), cappuccino or cherry flavor

Contains buffering agents to enhance buccal absorption of nicotine

Available: 2 mg, 4 mg

nicotine lozenge dosing
NICOTINE LOZENGE: DOSING

Dosage is based on the “time to first cigarette” (TTFC) as an indicator of nicotine addiction

Use Commit Lozenge 2 mg:

If you smoke your first cigarette more than 30 minutes after waking up

Use Commit Lozenge 4 mg:

If you smoke your first cigarette of the day within 30 minutes of waking up

nicotine lozenge directions for use
NICOTINE LOZENGE:DIRECTIONS for USE
  • Use according to recommended dosing schedule
  • Place in mouth and allow to dissolve slowly (nicotine release may cause warm, tingling sensation)
  • Do not chew or swallow lozenge.
  • Occasionally rotate to different areas of the mouth.
  • Lozenge will dissolve completely in about 2030 minutes.

Do NOT eat or drink for 15 minutes BEFORE or while using the nicotine lozenge.

transdermal nicotine patch nicoderm cq glaxosmithkline generic
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

transdermal nicotine patch directions for use
TRANSDERMAL NICOTINE PATCH:DIRECTIONS for USE

Choose an area of skin on the upper body or upper outer part of the arm

Make sure skin is clean, dry, hairless, and not irritated

Apply patch to different area each day

Do not use same area again for at least 1 week

transdermal nicotine patch additional patient education
TRANSDERMAL NICOTINE PATCH:ADDITIONAL PATIENT EDUCATION
  • Water will not harm the nicotine patch if it is applied correctly; patients may bathe, swim, shower, or exercise while wearing the patch
  • Do not cut patches to adjust dose
    • Nicotine may evaporate from cut edges
    • Patch may be less effective
  • Keep new and used patches out of the reach of children and pets
  • Remove patch before MRI procedures
nicotine nasal spray nicotrol ns pfizer
NICOTINE NASAL SPRAYNicotrol NS(Pfizer)

Aqueous solution of nicotine in a 10-ml spray bottle

Each metered dose actuation delivers

50 mcL spray

0.5 mg nicotine

~100 doses/bottle

Rapid absorption across nasal mucosa

nicotine inhaler nicotrol inhaler pfizer
NICOTINE INHALERNicotrol Inhaler (Pfizer)

Nicotine inhalation system consists of:

Mouthpiece

Cartridge with porous plug containing 10 mg nicotine and 1 mg menthol

Delivers 4 mg nicotine vapor, absorbed across buccal mucosa

bupropion sr zyban glaxosmithkline generic
BUPROPION SRZyban (GlaxoSmithKline); generic

Nonnicotine cessation aid

Sustained-release antidepressant

Oral formulation

bupropion mechanism of action
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

bupropion contraindications
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)

bupropion warnings and precautions
BUPROPION:WARNINGS and PRECAUTIONS

Bupropion should be used with 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

Patients with depressive or psychiatric disorders

varenicline chantix pfizer
VARENICLINE Chantix (Pfizer)

Nonnicotine cessation aid

Partial nicotinic receptor agonist

Oral formulation

varenicline mechanism of action
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

varenicline warning
VARENICLINE: WARNING
  • In 2008, Pfizer added a warning label advising patients and caregivers:

Patients should stop taking varenicline and contact their healthcare provider immediately if agitation, depressed mood, or changes in behavior that are not typical for them are observed, or if the patient develops suicidal ideation or suicidal thoughts.

varenicline dosing
VARENICLINE: DOSING

Patients should begin therapy 1 week PRIOR to their

quit date. The dose is gradually increased to minimize treatment-related nausea and insomnia.

Initial dose titration

* Up to 12 weeks

varenicline adverse effects
VARENICLINE:ADVERSE EFFECTS

Common (≥5% and 2-fold higher than placebo)

Nausea

Sleep disturbances (insomnia, abnormal dreams)

Constipation

Flatulence

Vomiting

long term 6 month quit rates for available cessation medications
LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS

23.9

20.2

19.0

18.0

17.1

16.1

15.8

Percent quit

11.8

11.3

11.2

10.3

9.1

9.9

8.1

Data adapted from Cahill et al. (2008). Cochrane Database Syst Rev;Stead et al. (2008).

Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev

combination pharmacotherapy
COMBINATION PHARMACOTHERAPY

Combination NRT

Long-acting formulation (patch)

Produces relatively constant levels of nicotine

PLUS

Short-acting formulation (gum, inhaler, nasal spray)

Allows for acute dose titration as needed for nicotine withdrawal symptoms

Bupropion SR + Nicotine Patch

Regimens with enough evidence to be ‘recommended’ first-line

compliance is key to quitting
COMPLIANCE IS KEY to QUITTING
  • Promote compliance with prescribed regimens.
    • Under-dosing of NRT is common and can contribute to relapse
  • Use according to dosing schedule, NOT as needed.
  • Consider telling the patient:
    • “When you use this medication, it’s important to read all the directions thoroughly. The products work best in alleviating withdrawal symptoms when used correctly, and according to the recommended dosing schedule.”
compliance is key to quitting1
COMPLIANCE IS KEY to QUITTING

Promote compliance with prescribed regimens.

Use according to dosing schedule, NOT as needed.

Consider telling the patient:

“When you use a cessation product it is important to read all the directions thoroughly before using the product. The products work best in alleviating withdrawal symptoms when used correctly, and according to the recommended dosing schedule.”

comparative daily costs of pharmacotherapy
COMPARATIVE DAILY COSTS of PHARMACOTHERAPY

Average $/pack of cigarettes, $4.32

$/day

tobacco dependence a 2 part problem1

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.

tobacco cessation requires behavior change
TOBACCO CESSATION REQUIRES BEHAVIOR CHANGE
  • Fewer than 5% of people who quit without assistance are successful in quitting for more than a year.
  • Many patients under-estimate the impact that counseling can have on their ability to quit
  • Few patients adequately PREPARE and PLAN for their quit attempt.
  • Many patients assume they can just “make themselves quit” when they are ready to do so.

Behavioral counseling is a key component of treatment for tobacco use and dependence.

clinicians can make a difference
CLINICIANS CAN MAKE a DIFFERENCE

With help from a clinician, the odds of quitting approximately doubles.

Compared to patients who receive no assistance from a clinician, patients who receive assistance are 1.7–2.2 times as likely to quit successfully for 5 or more months.

n = 29 studies

2.2

1.7

1.1

1.0

Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.

Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

the number of clinicians can make a difference too
The NUMBER of CLINICIANS CAN MAKE a DIFFERENCE, too

Compared to smokers who receive assistance from no clinicians, smokers who receive assistance from two or more clinicians are 2.4–2.5 times as likely to quit successfully for 5 or more months.

n = 37 studies

2.5

(1.9,3.4)

2.4

(2.1,3.4)

Estimated abstinence rate at 5+ months

1.8

(1.5,2.2)

1.0

Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.

Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

cancer diagnosis a teachable moment
CANCER DIAGNOSIS: A TEACHABLE MOMENT
  • Interest and motivation to quit is increased after cancer diagnosis
    • Particularly for cancers closely related to smoking, such as lung and head & neck cancer
  • Health-care providers should routinely address smoking with patients and family members during this window of opportunity

“The window of opportunity remains open throughout treatment and into the period of cancer survivorship.”

-- Ellen R. Gritz, PhD

The University of Texas MD Anderson Cancer Center

slide81

WHY SHOULD CLINICIANS ADDRESS TOBACCO?

  • Tobacco users expect to be encouraged to quit by health professionals.
  • Screening for tobacco use and providing tobacco cessation counseling are positively associated with patient satisfaction (Barzilai et al., 2001).

Failure to address tobacco use tacitly implies that

quitting is not important.

Barzilai et al. (2001). Prev Med 33:595–599.

the 5 a s

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

HANDOUT

step 1 ask

ASK

  • Ask about tobacco use
    • “Do you, or does anyone in your household, ever smoke or use any type of tobacco?”
      • “We ask all of our patients about tobacco use, because it can negatively impact your [surgery, radiation, chemotherapy] treatment.”
STEP 1: ASK
step 2 advise
STEP 2: ADVISE

ADVISE

  • tobacco users to quit
    • “Quitting is an important component of your treatment for cancer.”
      • “Smoking slows the healing process after surgery.”
      • “Patients who smoke during radiation therapy have reduced treatment efficacy and lower survival than non-smokers.”
      • “Smoking interacts with many of the chemotherapy medications, and can reduce its effects.”
    • “It will be important for your family and close friends to either quit with you or to be supportive of your quitting.”
step 3 assess
STEP 3: ASSESS
  • readiness to quit
    • Ask every tobacco user if s/he is willing to quit at this time.
    • If willing to quit, provide resources and assistance
      • See STEP 4, ASSIST
    • If NOT willing to quit at this time, provide resources and enhance motivation. Ask three questions:
      • “Do you ever plan to quit?” [If yes, continue with…]
      • “How will it benefit you to quit later, as opposed to now?”
      • “What is the worst thing that could happen if you were to quit tomorrow?”

ASSESS

step 4 assist
STEP 4: ASSIST

ASSIST

  • tobacco users with a quit plan
    • Discuss reasons for quitting and benefits of quitting
    • Review past quit attempts -- what helped, what led to relapse
    • Discuss support from family, friends, and coworkers
    • Set a quit date -- within 2 weeks
    • Encourage use of pharmacotherapy when not contraindicated
    • Anticipate challenges, particularly during the first few weeks
      • Nicotine withdrawal, stress-related smoking, etc.
step 5 arrange
STEP 5: ARRANGE
  • follow-up care
    • Status of attempt
      • Ask about support from friends, family, co-workers
      • Identify ongoing temptations and triggers for relapse(stress, negative affect, smokers, eating, alcohol, cravings)
    • Slips and relapse
      • Has the patient used tobacco at all -- even a puff?
    • Medication compliance, plans for termination
      • Is the regimen being followed?
      • Are withdrawal symptoms being alleviated?

ARRANGE

PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT

in the absence of time or expertise refer

REFER

  • patients to other resources

Referral options:

    • A doctor, nurse, pharmacist, or other clinician, for additional counseling
    • A local group program
    • The support program provided free with each smoking cessation medication
    • Websites like www.quitnet.org
    • The toll-free telephone quit line: 1-800-QUIT-NOW
IN THE ABSENCE OF TIME OR EXPERTISE: REFER
referral to a toll free telephone quit line

Sample cards, for distribution to patients.

1-800-QUIT-NOW

REFERRAL to a TOLL-FREE TELEPHONE QUIT LINE
  • Referring patients to a toll-free quit line is simple and easily integrated into routine patient care.
    • Quit line callers receive one-on-one coaching from trained counselors
    • Follow-up counseling is provided
    • Quit lines are effective and are provided at no cost to the caller
the cancer care team s responsibility
THE CANCER CARE TEAM’s RESPONSIBILITY

The cancer care team has a professional obligation

to address tobacco use and can have

an important role in helping patients with cancer, and their family members,

plan for their quit attempts.

TOBACCO CESSATION

is an essential component of CANCER TREATMENT

for ALL PATIENTS who use tobacco.

dr gro harlem bruntland former director general of the who
DR. GRO HARLEM BRUNTLAND, FORMER DIRECTOR-GENERAL of the WHO:

“If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.”

USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS.