Smoking Cessation

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  • Medications used in tobacco dependence treatment are classified as first-line and second-line medications depending on how safe and effective they are. Except for sustained release Bupropion all medications classified as first-line replace the mode of nicotine delivery, so they are called nicotine replacement therapy.
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  • Smoking Cessation

    1. 1. Smoking Cessation Gamal Rabie Agmy ,MD ,FCCP Professor of Chest Diseases, Assiut University
    2. 2. Facts about Smoking  Most of those killed by tobacco are not particularly heavy smokers and most started as teenagers.  Approximately 50 percent of smokers die prematurely from their smoking, on average 14 years earlier than non-smokers.  Smoking kills one in two of those who continue to smoke past age 35.  There is evidence that smoking can cause about 40 different diseases.  the preventable mortality attributed to smoking is 8 percent of deaths in females and 19 percent in males.  Smoking is socioeconomically patterned with higher rates of smoking in lower socio-economic groups. Thus tobacco smoking produces a greater relative burden of disease and premature death in lower socioeconomic groups and is a major contributor to socioeconomic inequalities in health.
    3. 3. Facts (cont.) Smoking, especially current smoking, is a crucial and extremely modifiable independent determinant of stroke. Second-hand smoke (also called environmental tobacco smoke) is a Class A carcinogen and contains approximately 4,000 chemicals. Exposure of children to second-hand smoke: ▫ can cause middle ear effusion ▫ increases the risk of croup, pneumonia and bronchiolitis by 60 percent in the first 18 months of life ▫ increases the frequency and severity of asthma episodes ▫ is a risk factor for induction of asthma in asymptomatic children.
    4. 4. Benefits of Smoking Cessation These points may be helpful in motivating people to quit smoking. Many smokers deny being at increased risk of cancer and heart disease and more accurate perception of risk may assist cessation efforts.  It is beneficial to stop smoking at any age. The earlier smoking is stopped, the greater the health gain.  Smoking cessation has major and immediate health benefits for smokers of all ages. Former smokers have fewer days of illness, fewer health complaints, and view themselves as healthier.  Within one day of quitting, the chance of a heart attack decreases.  Within two days of quitting, smell and taste are enhanced.  Within two weeks to three months of quitting, circulation improves and lung function increases by up to 30 percent.
    5. 5. Excess risk of heart disease is reduced by half after one year’s abstinence. The risk of a major coronary event reduces to the level of a never smoker within five years. In those with existing heart disease, cessation reduces the risk of recurrent infarction or death by half. Former smokers live longer: after 10 to 15 years’ abstinence, the risk of dying almost returns to that of people who never smoked. Smoking cessation at all ages, including in older people, reduces risk of premature death. Men who smoke are 17 times more likely than non-smokers to develop lung cancer. After 10 years’ abstinence, former smokers’ risk is only 30 to 50 percent that of continuing smokers, and continues to decline.
    6. 6. Women who stop smoking before or during the first trimester of pregnancy reduce risks to their baby to a level comparable to that of women who have never smoked. Around one in four low birth weight infants could be prevented by eliminating smoking during pregnancy. The average weight gain of three kg and the adverse temporary psychological effects of quitting are far outweighed by the health benefits.
    7. 7. Evidence for Effectiveness of Health Professional Intervention  A Cochrane review of 16 RCTs found simple advice from doctors had a significant effect on cessation rates (OR for quitting 1.69; 95% confidence interval 1.45–1.98).  When trained providers are routinely prompted to intervene with people who smoke, they achieve significant reductions in smoking prevalence (up to 15 percent cessation rates compared with 5 to 10 percent in non-intervention sites).  Doctors and other health professionals using multiple types of intervention to deliver individualized advice on multiple occasions produce the best results. Frequent and consistent interventions over time are more important than the type of intervention.
    8. 8. Smoking Cessation Program The only way any country can substantially reduce smoking and other tobacco use within its borders is to establish a well-funded and sustained comprehensive tobacco prevention program that employs a variety of effective approaches. Nothing else will successfully compete against the addictive power of nicotine and the tobacco industry's aggressive marketing tactics.
    9. 9. ESSENTIAL COMPONENTS The following elements must all be included to maximize the success of any program to reduce tobacco use. Conducted in isolation, each of these elements can reduce tobacco use, but done together they have a much more powerful impact: Public Education Efforts Community-Based Programs Helping Smokers Quit (Cessation) School-Based Programs Enforcement Monitoring and Evaluation Related Policy Efforts
    10. 10. Guidelines for Individual Smoking Cessation
    11. 11. Tobacco dependence is a chronic condition that often requires repeated intervention. However, effective treatments exist that can produce longterm abstinence. These guidelines are designed for smoking cessation providers to assist all clients with smoking cessation.
    12. 12. Promoting Smoking Cessation THE FIVE A’S: ASK ASSESS ADVISE ASSIST ARRANGE
    13. 13. ASK
    14. 14. ASSESS
    15. 15. Ask
    16. 16. ADVISE
    17. 17. ASSIST
    18. 18. Ranking of nicotine in relation to other drugs in terms of addiction Dependence among users nicotine>heroin>cocaine>alcohol>caffeine Difficulty achieving (alcohol=cocaine=heroin=nicotine)>caffeine abstinence Tolerance (alcohol=heroin=nicotine)>cocaine>caffeine Physical alcohol>heroin>nicotine>cocaine>caffeine withdrawal severity Deaths nicotine>alcohol>(cocaine=heroin)>caffeine Importance in user's daily life (alcohol=cocaine=heroin=nicotine)>caffeine Prevalence caffeine>nicotine>alcohol>(cocaine=heroin) 27
    19. 19. Tobacco Effects on Psychiatric Medication Blood Levels  Smoking induces the P450’s 1A2 isoenzyme secondary to the polynuclear aromatic hydrocarbons  Smoking increases the metabolism of some medications – Haldol, Prolixin, Olanzapine, Clozapine, Mellaril, Thorazine, etc  Caffeine is metabolized through 1A2  CHECK for medication SE or relapse to mental illness with changes in smoking status  Nicotine does not change medication blood levels (2D6)  NRT doesn’t affect medication blood levels  Nicotine may modulate cognition, psychiatric symptoms, and medication side effects 28
    20. 20. First-Line Medications  Nicotine Replacement Therapy (NRT) -Patch (OTC) -Gum (OTC) -Lozenge (OTC) -Oral Inhaler (Rx) -Nasal Spray (Rx)  Non-Nicotine Medications -Varenicline (Chantix, Rx) -Bupropion Hydrochloride (Rx) 29
    21. 21. 30
    22. 22. Reasons for Using NRT It 31 works: roughly doubling success rates. It helps the person feel more comfortable (treats nicotine withdrawal syndrome). It is very safe: the person is getting “clean” nicotine instead of “dirty” nicotine with 4000 plus chemicals.
    23. 23. Nicotine withdrawal  Withdrawal syndrome is a collection of signs and symptoms caused by abstinence  Nicotine  Nicotine 32 or cigarette withdrawal? replacement reduces severity of withdrawal symptoms
    24. 24. Sign of Nicotine Toxicity • 33 Extremely RARE IN SMOKERS & thus even more rare in NRT use. • Nausea and/or vomiting • Sweating • Vertigo and/or Light-headedness • Tremors • Confusion • Weakness • Racing heart
    25. 25. Nicotine Patch Dosing: < 10 cigs/day: 14 mg patch ≥ 10 cigs/day: 21 mg patch Length of Treatment: Up to 12 weeks (PDR) Use: Apply to clean skin area (upper trunk/ arms) 24 or 16 hour dosing, try 24 to dec. morning craving Watch for nightmares Given with or without taper  34 Pros: -Easy, good compliance -Continuous nicotine delivery -OTC Cons: -Slow onset of action -Skin reaction, Insomnia
    26. 26. Nicotine Gum Dosing: 2mg < 25 cigarettes/day 4mg > 25 cigarettes/day  Length of Treatment: 8-10 weeks (PDR) Use: Chew and park (oral absorption) Slow, buccal absorption Acidic foods ↓ absorption Pros: Flexible dosing (every 1-2 hours, up to 24 pieces/day) Keeps mouth busy OTC Cons: Need to use correctly (chew and park) Nausea, Heartburn Mouth and throat burning 35 
    27. 27. 36
    28. 28. Nicotine Lozenge  Dosing: Based on Time To First  Length of Treatment: 12 weeks (PDR) Cigarette (TTFC) 4 mg ≤ if 30 mins TTFC 2mg > if 30 mins TTFC Use: Allow to dissolve (Don’t Chew but Suck like a hard candy.)  Pros: Flexible dosing (Up to 20 lozenges/ day) More discreet than gum; Keep mouth busy; OTC;  Cons: Need to use correctly (don’t chew, suck) May cause insomnia, some nausea, hiccups, heartburn, coughing 37
    29. 29. Nicotine Nasal Spray  Dosing: 1-2 doses per hour 1 does = 2 spays (1 spray/nostril) Use enough to control withdrawal symptoms  Length of Treatment: 3-6 months weeks (PDR) 38
    30. 30. Nicotine Nasal Spray  Use: Spray (don’t sniff, swallow, or inhale) PRN or fixed-schedule (1-2 doses/hour)  Pros: Rapid delivery though nasal mucosa Flexible dosing (up to 40 doses)  Cons: Nasal irritation, rhinitis, coughing, & watering eyes. Some dependence liability Rx needed 39
    31. 31. Nicotine Medications  Use 40 high enough dose  Scheduled better than PRN  Use long enough time period  Can be combined with Bupropion  Don’t combine with Varenicline  Can be combined with eachother  Have very few contraindications  Have no drug-drug interactions
    32. 32. Efficacy of NRT medications 2.5 1.73 1.66 1.76 2.08 2.27 2 1.5 1 0.5 0 Odds Ratio of 6 month abstinence Overall 41 Gum Patch Inhaler Nasal spray
    33. 33. Withdrawal Symptoms and NRT *** N.S. ** *** *** N.S. * N.S. Placebo Gum Patch Combo 50 P < 0.05 ** P < 0.01 100 Smoking Total Withdrawal 150 *** * 200 *** *** P < 0.001 0 42 Total withdrawal in mm (calculated by averaging each symptom over the 11 ratings and adding the 9 symptoms) for the 4 treatments and baseline smoking with P-values adjusted for multiple testing (Bonferoni correction). Adapted from: Fagerström et. al. Psychopharmacology, 1993, 111:3, 271-7
    34. 34. Some strategies  Recommended doses of nicotine replacement therapy are inadequate for many smokers  In heavy smokers, under dosing may limit the effectiveness of patch  Patch plus Gum – Improves abstinence rates (Kornitzer 1995, Puska 1995) – Decreased withdrawal (Fagerstrom 1993) – Well tolerated  UMass uses up to 42mg patch or patch plus 43 GUM
    35. 35. Odds Ratios for the Efficacy of Higher Doses and NRT Combinations Gum (4mg vs 2 mg) Patch (21mg vs 14) Comb vs single ttt Comb vs patch only 44 1.98 (1.30-3.00) 1.27 (1.03-1.57) 1.64 (1.22-2.21) 1.87 (1.17-2.99)
    36. 36. Smoking with NRT Relatively safe Harm Reduction Less reinforcing effects Not a distraction from quit attempts (Benowitz 1997, Hartman 1991, Slade 1995) 45
    37. 37. Smoking and NRT: IS THAT SAFE?   Concern about this is not supported by data. Joseph took a high risk cardiac group and put them on patch or placebo. – – – – – – – – – 49% with active angina 40% with history of heart attack 35% with history of cardiac bypass No increase in cardiac events for the patient group 21% of the patients were not smoking at the end vs 9% of the placebo group. Jiminez-Ruiz put severe COPD patients on nicotine gum Most patients continued to smoke, though less. No adverse events attributed to nicotine. COPD (chronic obstructive pulmonary disease) got better (Joseph AM. NEJM 335:1792-8, 1996 & Jiminez-Ruiz. Slide copied from OASAS. 46 Respiration 69:452-6, 2002 )
    38. 38. Conclusions  47 Nicotine Replacement Therapy is being provided to assist tobacco users to become tobacco free.  NRT is not a treatment in itself, but is intended to complement the other assessments and treatments provided.  NRT works by reducing craving and withdrawal severity, enabling the patient to feel comfortable and able to concentrate on other psychosocial treatments.
    39. 39. Non-Nicotine Pharmacotherapy  First-line non-nicotine medications -Bupropion (Zyban/Wellbutrin)** -Varenicline (Chantix)**  Others (nortriptyline, clonidine ) **FDA Approved for smoking cessation 48
    40. 40. Bupropion Hydrochloride  Dopamine and norepinephrine (noradrenaline) effects  Reduces cravings, withdrawal  Improved abstinence rates in trials  Less weight gain while using (Need to gain 100 pounds to diminish health benefit)  Start 7-10 days prior to quit date  Continue 7-12 weeks or longer ( > 6 months) 49
    41. 41. Bupropion Precautions  Contraindicated: seizure disorder, eating disorders, electrolyte abnormalities, MAO use – OK with SSRIs  NOT dangerous to smoke while taking  Monitor blood pressure  Side effects: – Insomnia (40%)  – – 50 – 2nd dose early evening helps Dry mouth Headaches Rash
    42. 42. Bupropion Efficacy 50 40 * * Placebo 30 * * 100 mg 150 mg 20 300 mg 10 0 7 week abstinence 51 1 year abstinence Hurt, 1997
    43. 43. Varenicline (Chantix)  Action at α4β2 nicotine receptor  Partial agonist/antagonist  Releases lower amounts of dopamine into brain than smoke – – Reduces withdrawal Not as addictive as smoke  Blocks – nicotine from binding to receptor Prevents reward of smoking
    44. 44. Varenicline (Chantix)  Action at α4β2 nicotine receptor  Partial agonist/antagonist  Releases lower amounts of dopamine into brain than smoke – – Reduces withdrawal Not as addictive as smoke  Blocks – 53 nicotine from binding to receptor Prevents reward of smoking
    45. 45. Dosing  Titrate CHX 0.5 Pfizer 54 dose from 0.5 mg daily to twice daily to 1 mg twice daily over 1 week  Abstinence rates better vs. placebo and Bupropion at 1 year  Optimal duration 12-24 weeks  Most common side effect is nausea
    46. 46. Abstinence by medication use 100% 74% 80% 64% 60% 40% 20% 82% 52% 37% 31% 37% 42% 42% 20% 0% No m eds 1 m ed 2 m eds 4-week abstinence 55 3 m eds 4+ m eds 6-month abstinence
    47. 47. Serious Mental Illness  Reduced Cessation -Schizophrenia/Schizoaffective disorder -Bipolar disorder -PTSD -Alcohol use disorder 56
    48. 48. Smoking and Schizophrenia  High prevalence of smoking (about 90%, OR = 5.9)  Highly nicotine dependent (FTND = 7 or higher)  Nicotine produces cognitive or other benefit  Smoking ameliorates medication side effects (e.g., lower rates of neuroleptic-induced Parkinsonism) 57
    49. 49. Smoking and Schizophrenia (Continued)  Smokers with schizophrenia take in more nicotine per cigarette than smokers without this disorder  Higher levels of positive symptoms and decreased negative symptoms  Ad libitum smoking increases after initiation of haloperidol  SCZ tend to smoke less on clozapine 58
    50. 50. Neurobiology of Smoking and Schizophrenia  Decreased low affinity and high affinity nAChRs  Abnormal P50 responses are normalized  Improved Spontaneous Pursuit Eye Movement and decreased Saccades with nicotine  Improved cognition and attention 59
    51. 51. Smoking & Bipolar Disorder  High prevalence of smoking: 61-80%  Findings are inconsistent regarding the prevalence of smoking between bipolar disorder with and without psychotic features  Bupropion is contraindicated  Quit rates are comparable to general population and durable  Quit rates enhanced with CBT 60
    52. 52. Smoking and Depression  The prevalence of smoking: 37-60%  Leads to more severe nicotine withdrawal symptoms - High risk for relapse in first week - Female > Male  30%  risk of relapse to MDE after quitting if past history present Depressed smokers have higher suicide rates than depressed nonsmokers (Bruce, 1994; Lohr, 1992; Yassa, 1987) 61
    53. 53. Link Between MDD and Smoking 60 50 Lifetime Prevalence of Major Depression (%) 40 30 20 10 0 None 1 to 5 6 to 10 11 to 20 >21 Average Daily Cigarette Consumption 62 Adapted from Kendler KS, 1993
    54. 54. Smoking and Depression (Continued)  NRT 63 alone insufficient treatment for smokers with current and/or past MDD  Combining NRT with non-NRT pharmacotherapy appear to be promising for smokers with depression (Ait-Daoud et al., 2006)  CBT that emphasizes group cohesion and social support appears to be particularly effective for depressed smokers with or without alcohol dependence
    55. 55. Smoking and Anxiety D/O  The prevalence of smoking: About 35-50%  Smokers have greater anxiety and panic symptoms than non-smokers  Heavy smoking in adolescent is associated with higher risk of developing Agoraphobia, GAD, and Panic Disorder  PTSD: – – – 64 Increased risk for relapse in first two weeks of quit attempt – Increased the risk of smoking and nicotine dependence lower rates for quitting smoking & remission from nicotine dependence Stopping smoking not associated with worsening of PTSD – Bupropion tolerated and effective treatment
    56. 56. SSRIs and Smokers with Anxiety Disorder  No benefit for smoking cessation  Can reduce likelihood of emergent anxiety and panic during quit attempt  Bupropion is not appropriate as only medication  Can be combined with NRT/Bupuropion  Can be combined with varnicline 65
    57. 57. Smoking and Alcohol Dependence  High prevalence of smoking: 80-95%  Two studies reporting similar outcomes of NRT in alcoholics compared with nonalcoholics (e.g., Grant et al., Alcohol, 2007)  Tobacco dependence treatment does not cause abstinent alcoholics to relapse (Hughes & Callas, 2003)  Smoking cessation reduces the risk of alcohol relapse (Sobell et al., 1995) 66
    58. 58. Smoking and Alcohol Dependence (Continued)  Bupropion added to nicotine patch did not improve smoking outcomes  Topiramate group was significantly more likely to become abstinent (OR = 4.46) compared with placebo group (Johnson et al., 2003)  Topiramate group reported more weight loss compared with placebo group (44% vs. 18%) 67
    59. 59. Percentage of Patinets With or Without Specific Metal Illness Who Had Quit Smoking at the end of Tobacco Dependence Treatment 45 39.6 Percent Who Quit Smoking 40 39.3 36 35.9 37 35 34 37 30 25 With Diagnosis 20.5 Without Diagnosis 20 15 10 5 0 Schizophrenia Bipoloar Disorder MDD PTSD Psychiatric Disorders 68 Adapted from Grand et al., J Clin Psychiatry, 2007
    60. 60. Benefits of Treating Tobacco Dependence in Mental Healthcare Settings  Emerging evidence shows that morbidity is reduced  May enhance abstinence from other substances  Reduced financial burden  Increased self-confidence 69
    61. 61. Future Medication Options FDA. Rimonabant is a cannabinoid receptor inhibitor that blocks the reinforcing effects of nicotine and also suppresses appetite. Now in phase 3 trials, it has already receive much attention for its potential to attack 2 major public health epidemics; smoking and obesity.
    62. 62. Electronic cigarette
    63. 63. E-cigarettes were found to have immediate adverse physiologic effects after short time use that are similar to some of the effects seen with tobacco smoking ; however, the long term health effects of e-cigarette use are unknown but potentially adverse effects are worthy of further investigation.  CHEST 2012 ; 141 (6) 1400-1406.
    64. 64. MPOWER • • • • • M onitor tobacco use. P rotect people from tobacco use. O ffer help to quit tobacco use. W arn about the damages of tobacco . E nforce bans on tobacco advertising, promotion and sponsorship. • R aise taxes on tobacco products,
    65. 65. Conclusions Pharmacotherapy works and is relatively safe Many options now available Patients should be given accurate expectations (no magic bullet) 75

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