Smoking Cessation Kevin Scott Ferentz, M.D. Associate Professor Department of Family Medicine University of MD School of M...
Cigarette smoking is the single most important cause of disease and premature death in the United States
Cigarette-related deaths <ul><li>440,000 per year </li></ul><ul><li>12 million dead since first surgeon general’s report i...
Smoking in the U.S. - 2006 <ul><li>21% of adults (43% in 1966) </li></ul><ul><ul><li>Kentucky 27.4%, Utah 10.5% </li></ul>...
Grade 9 Grade 10 Grade 11 Grade 12 Male Female Grade 10 Grade 11 Grade 12 Grade 9 Current cigarette smoking among HS stude...
The politics of tobacco <ul><li>States that grow tobacco: </li></ul><ul><ul><li>lowest taxes, highest rates of smoking </l...
Smoking worldwide <ul><li>1.3 billion smokers </li></ul><ul><li>Expected to rise to 1.7 in 2025 </li></ul><ul><li>Kills 5 ...
Increased Cancer Risk <ul><li>90% of lung cancer deaths </li></ul><ul><li>40% of all cancers </li></ul><ul><li>mouth, lary...
Heart disease <ul><li>leading cause of death </li></ul><ul><li>smoking is major risk factor </li></ul><ul><li>3 times more...
Lung Disease <ul><li>90% of COPD deaths </li></ul><ul><li>asthma </li></ul><ul><li>bronchitis </li></ul><ul><li>pneumonia ...
Female smokers <ul><li>infertility </li></ul><ul><li>earlier menopause </li></ul><ul><li>osteoporosis </li></ul><ul><li>bi...
Pregnant smokers <ul><li>spontaneous abortion </li></ul><ul><li>placenta previa </li></ul><ul><li>placental abruption </li...
Children of smokers <ul><li>respiratory illness </li></ul><ul><li>SIDS </li></ul><ul><li>cognitive development </li></ul><...
Involuntary smoking is a cause of disease in  non-smokers
Smokeless tobacco <ul><li>“ spit” tobacco </li></ul><ul><li>cancer of mouth, pharynx, esophagus </li></ul><ul><li>tooth di...
Other problems <ul><li>fire accidents </li></ul><ul><li>gingivitis </li></ul><ul><li>skin wrinkles </li></ul><ul><li>impot...
Health effects from smoking <ul><li>Heart disease </li></ul><ul><li>Lung disease – COPD, asthma </li></ul><ul><li>Cancer <...
Smoking kills more people each year than <ul><li>alcohol  </li></ul><ul><li>cocaine </li></ul><ul><li>crack </li></ul><ul>...
©
What’s in a cigarette? <ul><li>4,000 chemicals </li></ul><ul><li>tar </li></ul><ul><li>carbon monoxide </li></ul><ul><li>n...
“ ...cigarettes and other forms  of tobacco are addicting in the same sense as are drugs such as heroin and cocaine.”   C....
Criteria for addicting drug <ul><li>Dependence </li></ul><ul><li>Tolerance </li></ul><ul><li>Withdrawal </li></ul><ul><li>...
Nicotine - immediate effects <ul><li>sympathetic stimulation </li></ul><ul><li>parasympathetic stimulation </li></ul><ul><...
The effects on health from smoking are reversible if a smoker stops smoking
Health benefits after quitting <ul><li>cough, DOE resolve in weeks </li></ul><ul><li>exercise tolerance improves rapidly <...
How are we doing with our patients? <ul><li>1991:  </li></ul><ul><ul><li>< 50% of patients reported ever being told to sto...
Why counsel all smokers? <ul><li>90% want to quit </li></ul><ul><li>minimal physician input almost doubles quit rate 1 </l...
Physician influence <ul><li>position of authority </li></ul><ul><li>credible source </li></ul><ul><li>personalize health e...
Patient resources <ul><li>printed materials (still need counseling) </li></ul><ul><li>National Cancer Institute ( 1-800-4-...
A minimum amount of time spent with more smokers will yield more ex-smokers than intensive efforts with a few
Minimum counseling <ul><li>firm, unambiguous advice </li></ul><ul><li>written materials </li></ul><ul><li>set a quit day <...
Factors which influence smokers to make an attempt to quit
Influence to quit <ul><li>firm, unambiguous advice </li></ul><ul><li>“ as your doctor, I’m telling you to QUIT!” </li></ul...
Personalizing effects - history <ul><li>shortness of breath </li></ul><ul><li>cold hands and feet </li></ul><ul><li>fatigu...
Personalizing effects - physical <ul><li>gingivitis </li></ul><ul><li>tar stains </li></ul><ul><li>bad breath </li></ul><u...
Personalizing effects - labs <ul><li>carboxyhemoglobin </li></ul><ul><li>pulmonary function tests </li></ul><ul><li>peak f...
Influence to quit <ul><li>firm, unambiguous advice </li></ul><ul><li>“ as your doctor, I’m telling you to QUIT!” </li></ul...
Non-health reasons for quitting <ul><li>COST!!! </li></ul><ul><li>inconvenience </li></ul><ul><li>self-esteem </li></ul><u...
Influence to quit <ul><li>firm, unambiguous advice </li></ul><ul><li>“ as your doctor, I’m telling you to QUIT!” </li></ul...
Building confidence <ul><li>express your confidence </li></ul><ul><li>millions of others have quit </li></ul><ul><li>more ...
Influence to quit <ul><li>firm, unambiguous advice </li></ul><ul><li>“ as your doctor, I’m telling you to QUIT!” </li></ul...
Common concerns <ul><li>Withdrawal   </li></ul><ul><ul><li>short lived </li></ul></ul><ul><li>Cravings </li></ul><ul><ul><...
At a minimum, tell all patients how important you feel it is that they  quit (not cut down)
Refer patients who are interested to a group program
Accentuate the positive aspects of quitting  rather than dwelling  on the dangers of  continuing to smoke
Factors which help  smokers quit once the decision is made Behavior Modification
Components of addiction <ul><li>physiological </li></ul><ul><li>psychological </li></ul><ul><li>behavioral </li></ul>
Behavior modification <ul><li>review reasons for quitting (index card) </li></ul><ul><li>identify triggers (4 day diary) <...
Sample plan <ul><li>Trigger </li></ul><ul><li>after meals </li></ul><ul><li>on the phone </li></ul><ul><li>in the car </li...
Behavior modification <ul><li>review reasons for quitting (index card) </li></ul><ul><li>identify triggers (4 day diary) <...
Set a follow-up visit  with all patients at  one month
Pharmacological treatment <ul><li>nicotine replacement - “methadone for the smoker” </li></ul><ul><ul><li>Gum, Patch, loze...
Nicotine replacement - gum <ul><li>available since 1984 </li></ul><ul><li>2 mg. and 4 mg. strength </li></ul><ul><li>“ che...
Nicotine replacement - patches <ul><li>4 patches on market - OTC </li></ul><ul><li>wean - 8 weeks </li></ul><ul><li>first ...
©
©
Nicotine lozenges (Commit ®) <ul><li>2 and 4 mg strengths </li></ul><ul><li>4 mg if smoke w/in 30 minutes of waking </li><...
Shiffman S, Dresler CM, et al.  Arch Intern Med . 2002;162:1267-1276.  ©
Nicotine nasal spray <ul><li>one dose: 2 sprays (1 mg) </li></ul><ul><li>minimum: 8 doses/day </li></ul><ul><li>maximum: 4...
Nicotine inhaler <ul><li>nicotine deposited in mouth </li></ul><ul><li>2 mg absorbed per insert </li></ul><ul><li>80 puffs...
Nicotine replacement should  always  be used in conjunction with behavior modification
Bupropion (Zyban  ) <ul><li>Probably works by increasing dopamine in nucleus accumbens </li></ul><ul><li>150 mg qd X 3 da...
Rates of Continuous Abstinence  Buproption and nicotine patch  Bupropion  Nicotine patch  Placebo Jorenby  NEJM 1999
Bupropion – cautions/contraindications <ul><li>insomnia - last dose 6 hours before sleep </li></ul><ul><li>Activating but ...
Varenicline (Chantix ®) <ul><li>[alpha]4[beta]2 nicotinic acetylcholine receptors reinforce effects of nicotine, maintain ...
* weeks 9–52: varenicline vs placebo,  P <.001; varenicline vs bupropion, P  = .004; bupropion vs placebo,  P  = .08. Jore...
Second-line medications <ul><li>Clonidine: 0.15 – 0.75 mg/d for 3 – 10 weeks </li></ul><ul><li>Nortriptyline: 75 – 100 mg/...
Factors which help  ex-smokers remain  ex-smokers Maintenance
Relapse <ul><li>rates are same as for heroin, alcohol </li></ul><ul><li>at least 70% relapse within first year </li></ul><...
Preventing Relapse <ul><li>use and refinement of coping strategies </li></ul><ul><ul><li>“ if you don’t want to slip, stay...
The future <ul><li>Nicotine vaccine (NicVAX) </li></ul><ul><ul><li>Block nicotine from getting into brain </li></ul></ul><...
AHCPR Guidelines - The 5 “A’s” <ul><li>ASK - identify tobacco users at all visits </li></ul><ul><li>ADVISE - strongly urge...
For Those Unwilling to Quit – the 5 “R’s” <ul><li>Relevance -  why quitting is personally relevant </li></ul><ul><li>Risks...
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Smoking Cessation Kevin Scott Ferentz, M.D.

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  • all three active treatments were superior to placebo (P&lt;0.001), bupropion alone and in combination with the nicotine patch was superior to the nicotine patch alone (P&lt;0.001), and there was no significant difference between bupropion alone and bupropion in combination with the nicotine patch (P=0.61).
  • Smoking Cessation Kevin Scott Ferentz, M.D.

    1. 1. Smoking Cessation Kevin Scott Ferentz, M.D. Associate Professor Department of Family Medicine University of MD School of Medicine
    2. 2. Cigarette smoking is the single most important cause of disease and premature death in the United States
    3. 3. Cigarette-related deaths <ul><li>440,000 per year </li></ul><ul><li>12 million dead since first surgeon general’s report in 1964 </li></ul><ul><li>Smokers die 13-14 years earlier </li></ul><ul><li>Medical costs: $ 75 billion </li></ul><ul><li>Lost productivity: $ 82 billion </li></ul><ul><li>Costs: $ 40/pack </li></ul>
    4. 4. Smoking in the U.S. - 2006 <ul><li>21% of adults (43% in 1966) </li></ul><ul><ul><li>Kentucky 27.4%, Utah 10.5% </li></ul></ul><ul><li>men (24%) women (18%) </li></ul><ul><ul><li>< HS education 3X likely than w/ college degree </li></ul></ul><ul><li>rate dropped little in 1990’s </li></ul><ul><li>Rate dropping by < 1% per year </li></ul><ul><li>1.3 million quit each year </li></ul><ul><li>3,000 teens start each day </li></ul><ul><ul><li>adolescent smoking may be dropping </li></ul></ul><ul><li>more ex-smokers than current smokers </li></ul><ul><li>2010 goal: 12% smokers </li></ul>
    5. 5. Grade 9 Grade 10 Grade 11 Grade 12 Male Female Grade 10 Grade 11 Grade 12 Grade 9 Current cigarette smoking among HS students by sex, frequency, and grade level: US, 2003 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 Percent Frequent smoking 0 10 20 30 40
    6. 6. The politics of tobacco <ul><li>States that grow tobacco: </li></ul><ul><ul><li>lowest taxes, highest rates of smoking </li></ul></ul><ul><li>Most Tobacco Restitution Funds are NOT going to tobacco control </li></ul><ul><li>California: 1988 </li></ul><ul><ul><li>23% smoking rate </li></ul></ul><ul><ul><li>Voters approve 25 ¢ tax for anti-smoking campaign </li></ul></ul><ul><li>California: 2003 </li></ul><ul><ul><li>15% smoking rate </li></ul></ul><ul><ul><li>13% of HS students smoke (22% nationally) </li></ul></ul><ul><li>Phillip Morris profits up 10% in 2004 </li></ul>
    7. 7. Smoking worldwide <ul><li>1.3 billion smokers </li></ul><ul><li>Expected to rise to 1.7 in 2025 </li></ul><ul><li>Kills 5 million yearly </li></ul><ul><li>1 death every 6.5 seconds </li></ul><ul><li>May double in 20 years </li></ul><ul><li>84% of smokers are in developing countries </li></ul><ul><li>95 billion cigarettes sold in India each year! </li></ul>World Health Organization – 2004
    8. 8. Increased Cancer Risk <ul><li>90% of lung cancer deaths </li></ul><ul><li>40% of all cancers </li></ul><ul><li>mouth, larynx, esophagus, stomach </li></ul><ul><li>kidney, bladder </li></ul><ul><li>Pancreas </li></ul><ul><li>Cervix </li></ul><ul><li>Acute myeloid leukemia </li></ul><ul><li>more women die of lung than breast cancer! </li></ul>
    9. 9. Heart disease <ul><li>leading cause of death </li></ul><ul><li>smoking is major risk factor </li></ul><ul><li>3 times more likely to die of heart disease </li></ul><ul><li>step-wise increase with other risk factors </li></ul>
    10. 10. Lung Disease <ul><li>90% of COPD deaths </li></ul><ul><li>asthma </li></ul><ul><li>bronchitis </li></ul><ul><li>pneumonia </li></ul>
    11. 11. Female smokers <ul><li>infertility </li></ul><ul><li>earlier menopause </li></ul><ul><li>osteoporosis </li></ul><ul><li>birth control pills </li></ul><ul><li>vaginitis </li></ul>
    12. 12. Pregnant smokers <ul><li>spontaneous abortion </li></ul><ul><li>placenta previa </li></ul><ul><li>placental abruption </li></ul><ul><li>premature rupture of membranes </li></ul><ul><li>preterm labor </li></ul><ul><li>restricted fetal growth </li></ul><ul><li>increased fetal respiratory rate </li></ul><ul><li>placental abnormalities </li></ul>
    13. 13. Children of smokers <ul><li>respiratory illness </li></ul><ul><li>SIDS </li></ul><ul><li>cognitive development </li></ul><ul><li>behavioral development </li></ul><ul><li>cancer </li></ul><ul><li>increased risk of smoking </li></ul>
    14. 14. Involuntary smoking is a cause of disease in non-smokers
    15. 15. Smokeless tobacco <ul><li>“ spit” tobacco </li></ul><ul><li>cancer of mouth, pharynx, esophagus </li></ul><ul><li>tooth discoloration </li></ul><ul><li>gingival recession </li></ul><ul><li>periodontal bone destruction </li></ul><ul><li>death from juice ingestion </li></ul>
    16. 16. Other problems <ul><li>fire accidents </li></ul><ul><li>gingivitis </li></ul><ul><li>skin wrinkles </li></ul><ul><li>impotence </li></ul><ul><li>decreased stamina </li></ul><ul><li>colds, flu </li></ul>
    17. 17. Health effects from smoking <ul><li>Heart disease </li></ul><ul><li>Lung disease – COPD, asthma </li></ul><ul><li>Cancer </li></ul><ul><ul><li>Lung, ENT, pancreas </li></ul></ul><ul><ul><li>Cervix </li></ul></ul><ul><ul><li>Skin (squamous cell) </li></ul></ul><ul><li>Vascular disease – impotence, AAA </li></ul><ul><li>Stroke </li></ul><ul><li>Cataracts </li></ul><ul><li>Macular degeneration </li></ul><ul><li>Gum disease </li></ul><ul><li>Tooth decay </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Wound healing </li></ul><ul><li>Anxiety & Depression </li></ul><ul><li>Miscarriage </li></ul><ul><li>SIDS </li></ul><ul><li>Hearing loss </li></ul><ul><li>Rheumatoid arthritis </li></ul><ul><li>Lupus </li></ul><ul><li>Dementia </li></ul><ul><li>Multiple sclerosis </li></ul>
    18. 18. Smoking kills more people each year than <ul><li>alcohol </li></ul><ul><li>cocaine </li></ul><ul><li>crack </li></ul><ul><li>heroin </li></ul><ul><li>homicide </li></ul><ul><li>suicide </li></ul><ul><li>car accidents </li></ul><ul><li>fires </li></ul><ul><li>AIDS </li></ul>C O M B I N E D!!!
    19. 19. ©
    20. 20. What’s in a cigarette? <ul><li>4,000 chemicals </li></ul><ul><li>tar </li></ul><ul><li>carbon monoxide </li></ul><ul><li>nicotine </li></ul>©
    21. 21. “ ...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
    22. 22. Criteria for addicting drug <ul><li>Dependence </li></ul><ul><li>Tolerance </li></ul><ul><li>Withdrawal </li></ul><ul><li>Nicotine yield/cig increased 11% from 1998-2005 1 </li></ul>1 Harvard School of Public Health, 2007
    23. 23. Nicotine - immediate effects <ul><li>sympathetic stimulation </li></ul><ul><li>parasympathetic stimulation </li></ul><ul><li>feelings of: </li></ul><ul><ul><li>stimulation </li></ul></ul><ul><ul><li>better concentration </li></ul></ul><ul><ul><li>pain tolerance </li></ul></ul>
    24. 24. The effects on health from smoking are reversible if a smoker stops smoking
    25. 25. Health benefits after quitting <ul><li>cough, DOE resolve in weeks </li></ul><ul><li>exercise tolerance improves rapidly </li></ul><ul><li>bladder cancer: 50% reduction in 5 years </li></ul><ul><li>lung cancer: 50% reduction in 10 years </li></ul><ul><li>heart disease: 50% reduction in 1 year! </li></ul><ul><li>No increased risk of heart disease by 10-15 yrs </li></ul><ul><li>vascular disease: 50% reduction in 5 years </li></ul><ul><li>mortality rates same as never smokers by 10-15 yrs </li></ul>
    26. 26. How are we doing with our patients? <ul><li>1991: </li></ul><ul><ul><li>< 50% of patients reported ever being told to stop 1 </li></ul></ul><ul><li>1998: </li></ul><ul><ul><li>67% Ask, 74% Advise, 35% Assist, 8% Follow-up 2 </li></ul></ul><ul><li>2003: (patients that got prescription) 3 </li></ul><ul><ul><li>36% told to set quit date, 25% counseled, </li></ul></ul><ul><ul><li>13% advised to follow up </li></ul></ul><ul><li>Many smokers do not get the </li></ul><ul><li>advice and help they need!!! </li></ul>1 Frank,E., Winkleby, M.A.,Altman, D.G., et al. JAMA 1991;266:3139-3134. 2 Goldstein MG, et al. Preventive Medicine. 27(5 Pt 1):720-9, 1998 Sep-Oct. 3 Solberg LI, et al. Archives of internal medicine, 2005;165:656
    27. 27. Why counsel all smokers? <ul><li>90% want to quit </li></ul><ul><li>minimal physician input almost doubles quit rate 1 </li></ul><ul><li>most quit without intensive assistance once they make the decision </li></ul><ul><li>moving patients through the process 2 </li></ul><ul><ul><li>precontemplation </li></ul></ul><ul><ul><li>contemplation </li></ul></ul><ul><ul><li>preparation </li></ul></ul><ul><ul><li>action </li></ul></ul><ul><ul><li>maintenance </li></ul></ul><ul><ul><li>1 Cochrane Database of Systematic Reviews. 2004 </li></ul></ul><ul><ul><li>2 J of Cons & Clin Psych. 51(3):390-5, 1983 Jun </li></ul></ul>
    28. 28. Physician influence <ul><li>position of authority </li></ul><ul><li>credible source </li></ul><ul><li>personalize health effects </li></ul><ul><li>face-to-face counseling </li></ul><ul><li>multiple contacts </li></ul><ul><li>good role models </li></ul>
    29. 29. Patient resources <ul><li>printed materials (still need counseling) </li></ul><ul><li>National Cancer Institute ( 1-800-4-CANCER) </li></ul><ul><li>www.smokefree.gov </li></ul><ul><li>Smokingstopshere.com </li></ul><ul><li>1–800–QUIT–NOW </li></ul><ul><li>(quit lines improve chances of quitting) </li></ul>
    30. 30. A minimum amount of time spent with more smokers will yield more ex-smokers than intensive efforts with a few
    31. 31. Minimum counseling <ul><li>firm, unambiguous advice </li></ul><ul><li>written materials </li></ul><ul><li>set a quit day </li></ul><ul><li>set follow-up visit </li></ul><ul><li>(or warn patient you will ask about progress at a future visit) </li></ul>
    32. 32. Factors which influence smokers to make an attempt to quit
    33. 33. Influence to quit <ul><li>firm, unambiguous advice </li></ul><ul><li>“ as your doctor, I’m telling you to QUIT!” </li></ul><ul><li>personalize damaging health effects </li></ul><ul><li>effects reversible with quitting </li></ul>
    34. 34. Personalizing effects - history <ul><li>shortness of breath </li></ul><ul><li>cold hands and feet </li></ul><ul><li>fatigue </li></ul><ul><li>decreased stamina </li></ul><ul><li>colds and flu </li></ul><ul><li>bronchitis, sinusitis </li></ul><ul><li>teeth, gums </li></ul><ul><li>kids’ problems </li></ul>
    35. 35. Personalizing effects - physical <ul><li>gingivitis </li></ul><ul><li>tar stains </li></ul><ul><li>bad breath </li></ul><ul><li>diminished breath sounds </li></ul><ul><li>wheezing, rhonchi </li></ul><ul><li>peripheral pulses </li></ul><ul><li>fundal height </li></ul><ul><li>wrinkling </li></ul>
    36. 36. Personalizing effects - labs <ul><li>carboxyhemoglobin </li></ul><ul><li>pulmonary function tests </li></ul><ul><li>peak flow </li></ul><ul><li>chest x-ray </li></ul>
    37. 37. Influence to quit <ul><li>firm, unambiguous advice </li></ul><ul><li>“ as your doctor, I’m telling you to QUIT!” </li></ul><ul><li>personalize damaging health effects </li></ul><ul><li>effects reversible with quitting </li></ul><ul><li>non-health reasons </li></ul>
    38. 38. Non-health reasons for quitting <ul><li>COST!!! </li></ul><ul><li>inconvenience </li></ul><ul><li>self-esteem </li></ul><ul><li>role model </li></ul>
    39. 39. Influence to quit <ul><li>firm, unambiguous advice </li></ul><ul><li>“ as your doctor, I’m telling you to QUIT!” </li></ul><ul><li>personalize damaging health effects </li></ul><ul><li>effects reversible with quitting </li></ul><ul><li>non-health reasons </li></ul><ul><li>confidence </li></ul>
    40. 40. Building confidence <ul><li>express your confidence </li></ul><ul><li>millions of others have quit </li></ul><ul><li>more ex-smokers than smokers </li></ul><ul><li>most try many times before succeeding </li></ul><ul><li>past attempts are learning experiences </li></ul><ul><li>ways to deal with physical and psychological dependence </li></ul>
    41. 41. Influence to quit <ul><li>firm, unambiguous advice </li></ul><ul><li>“ as your doctor, I’m telling you to QUIT!” </li></ul><ul><li>personalize damaging health effects </li></ul><ul><li>effects reversible with quitting </li></ul><ul><li>non-health reasons </li></ul><ul><li>confidence </li></ul><ul><li>address concerns </li></ul>
    42. 42. Common concerns <ul><li>Withdrawal </li></ul><ul><ul><li>short lived </li></ul></ul><ul><li>Cravings </li></ul><ul><ul><li>last 3-5 minutes, diminish rapidly </li></ul></ul><ul><li>Tension </li></ul><ul><ul><li>validate, normalize </li></ul></ul><ul><ul><li>find other ways to cope </li></ul></ul><ul><li>Weight gain - not inevitable! </li></ul><ul><ul><li>1/3 gain: 5-8 lbs. </li></ul></ul>
    43. 43. At a minimum, tell all patients how important you feel it is that they quit (not cut down)
    44. 44. Refer patients who are interested to a group program
    45. 45. Accentuate the positive aspects of quitting rather than dwelling on the dangers of continuing to smoke
    46. 46. Factors which help smokers quit once the decision is made Behavior Modification
    47. 47. Components of addiction <ul><li>physiological </li></ul><ul><li>psychological </li></ul><ul><li>behavioral </li></ul>
    48. 48. Behavior modification <ul><li>review reasons for quitting (index card) </li></ul><ul><li>identify triggers (4 day diary) </li></ul><ul><li>plans to avoid or cope with each trigger </li></ul>
    49. 49. Sample plan <ul><li>Trigger </li></ul><ul><li>after meals </li></ul><ul><li>on the phone </li></ul><ul><li>in the car </li></ul><ul><li>at desk </li></ul><ul><li>tension </li></ul><ul><li>coffee breaks </li></ul><ul><li>other smokers </li></ul><ul><li>crisis </li></ul><ul><li>Technique </li></ul><ul><li>leave table </li></ul><ul><li>draw </li></ul><ul><li>chew gum </li></ul><ul><li>carrot sticks </li></ul><ul><li>deep breathing </li></ul><ul><li>juice </li></ul><ul><li>non-smokers </li></ul><ul><li>self-talk </li></ul>
    50. 50. Behavior modification <ul><li>review reasons for quitting (index card) </li></ul><ul><li>identify triggers (4 day diary) </li></ul><ul><li>plans to avoid or cope with each trigger </li></ul><ul><li>change habit: packs only, different brands </li></ul><ul><li>develop support system (tell everyone) </li></ul><ul><li>self rewards (day, week, month, year) </li></ul><ul><li>written commitment to quit day </li></ul>
    51. 51. Set a follow-up visit with all patients at one month
    52. 52. Pharmacological treatment <ul><li>nicotine replacement - “methadone for the smoker” </li></ul><ul><ul><li>Gum, Patch, lozenge, nasal spray, inhaler </li></ul></ul><ul><li>Bupropion (Zyban ®) </li></ul><ul><li>Varenicline (Chantix ®) </li></ul><ul><li>all decrease cravings, withdrawal </li></ul><ul><li>20-25% quit rates at 1 year </li></ul>
    53. 53. Nicotine replacement - gum <ul><li>available since 1984 </li></ul><ul><li>2 mg. and 4 mg. strength </li></ul><ul><li>“ chew, park, chew, park” </li></ul><ul><li>2 mg. - 30 pieces/day maximum </li></ul><ul><li>4 mg. - 20 pieces/day maximum </li></ul><ul><li>wean after 3 months, 6 months maximum </li></ul><ul><li>use in conjunction with patches, bupropion </li></ul>
    54. 54. Nicotine replacement - patches <ul><li>4 patches on market - OTC </li></ul><ul><li>wean - 8 weeks </li></ul><ul><li>first patch - night before quit day </li></ul><ul><li>rashes, abnormal dreams </li></ul><ul><li>no euphoria - no stimulant effect </li></ul><ul><li>no increased risk of MI </li></ul>
    55. 55. ©
    56. 56. ©
    57. 57. Nicotine lozenges (Commit ®) <ul><li>2 and 4 mg strengths </li></ul><ul><li>4 mg if smoke w/in 30 minutes of waking </li></ul><ul><li>12 week program </li></ul><ul><li>Weeks 1-6: 1 lozenge every 1 to 2 hours </li></ul><ul><li>Weeks 7-9: 1 lozenge every 2 to 4 hours </li></ul><ul><li>Weeks 10-12: 1 lozenge every 4 to 8 hours </li></ul><ul><li>at least 9 per day for the first 6 weeks </li></ul><ul><li>hiccups, heartburn, nausea </li></ul><ul><li>no more than 5 in 6 hours, 20 per day </li></ul><ul><li>Can work when patch, gum failed </li></ul>
    58. 58. Shiffman S, Dresler CM, et al. Arch Intern Med . 2002;162:1267-1276. ©
    59. 59. Nicotine nasal spray <ul><li>one dose: 2 sprays (1 mg) </li></ul><ul><li>minimum: 8 doses/day </li></ul><ul><li>maximum: 40 doses/day (1/2 bottle) </li></ul><ul><li>if not abstinent by week 4 - stop </li></ul><ul><li>use for 3 months, six maximum </li></ul><ul><li>nasal irritation limits use </li></ul>
    60. 60. Nicotine inhaler <ul><li>nicotine deposited in mouth </li></ul><ul><li>2 mg absorbed per insert </li></ul><ul><li>80 puffs in 20 minutes </li></ul><ul><li>6 - 16 cartridges/day </li></ul><ul><li>3 months then wean over 3 months </li></ul><ul><li>40% throat irritation </li></ul><ul><li>20% quit at 6 months, 13% at 1 year </li></ul>
    61. 61. Nicotine replacement should always be used in conjunction with behavior modification
    62. 62. Bupropion (Zyban  ) <ul><li>Probably works by increasing dopamine in nucleus accumbens </li></ul><ul><li>150 mg qd X 3 days, 150 mg b.i.d. X 4 days, then QUIT </li></ul><ul><li>continue for 7 - 12 weeks </li></ul><ul><li>if not stopped by 8 weeks, discontinue </li></ul><ul><li>Can use with nicotine replacement </li></ul>
    63. 63. Rates of Continuous Abstinence  Buproption and nicotine patch  Bupropion  Nicotine patch  Placebo Jorenby NEJM 1999
    64. 64. Bupropion – cautions/contraindications <ul><li>insomnia - last dose 6 hours before sleep </li></ul><ul><li>Activating but well-tolerated </li></ul><ul><li>seizure disorder </li></ul><ul><li>prior or current eating disorder </li></ul><ul><li>concurrent use of Wellbutrin® </li></ul>
    65. 65. Varenicline (Chantix ®) <ul><li>[alpha]4[beta]2 nicotinic acetylcholine receptors reinforce effects of nicotine, maintain smoking </li></ul><ul><li>partial agonist, antagonist (blocks binding) </li></ul><ul><li>0.5 mg X 3 d, 0.5 mg b.i.d. X 4 d, 1 mg b.i.d. </li></ul><ul><li>Stop smoking after 7 days on medicine </li></ul><ul><li>Can use for up to 6 months </li></ul><ul><li>Probably higher rates of quitting </li></ul><ul><li>Nausea, constipation, abnormal dreams </li></ul><ul><li>Costs about $ 4/day </li></ul>
    66. 66. * 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. Continuous Smoking Abstinence Rates
    67. 67. Second-line medications <ul><li>Clonidine: 0.15 – 0.75 mg/d for 3 – 10 weeks </li></ul><ul><li>Nortriptyline: 75 – 100 mg/d for 12 weeks </li></ul>
    68. 68. Factors which help ex-smokers remain ex-smokers Maintenance
    69. 69. Relapse <ul><li>rates are same as for heroin, alcohol </li></ul><ul><li>at least 70% relapse within first year </li></ul><ul><ul><li>2/3 within first 3 months </li></ul></ul><ul><ul><li>largest group within first week </li></ul></ul><ul><li>factors: </li></ul><ul><ul><li>early: withdrawal, cravings, habit </li></ul></ul><ul><ul><li>late: other smokers, food, alcohol, coffee negative emotions, crisis </li></ul></ul>
    70. 70. Preventing Relapse <ul><li>use and refinement of coping strategies </li></ul><ul><ul><li>“ if you don’t want to slip, stay away from slippery places” </li></ul></ul><ul><li>positive self-talks in response to slips </li></ul><ul><ul><li>Slips happen: H ungry, A ngry, L onely T ired </li></ul></ul><ul><li>continued commitment (one day at a time) </li></ul><ul><li>praise and encouragement by physician </li></ul><ul><li>(“ex-smoker” on problem list) </li></ul>
    71. 71. The future <ul><li>Nicotine vaccine (NicVAX) </li></ul><ul><ul><li>Block nicotine from getting into brain </li></ul></ul><ul><ul><li>Phase two trials are promising </li></ul></ul><ul><li>Different forms of nicotine replacement </li></ul><ul><li>Rimonabant </li></ul><ul><ul><li>cannabinoid receptor antagonist </li></ul></ul><ul><ul><li>Also treats obesity </li></ul></ul><ul><ul><li>Probably won’t be released in US for smoking </li></ul></ul>
    72. 72. AHCPR Guidelines - The 5 “A’s” <ul><li>ASK - identify tobacco users at all visits </li></ul><ul><li>ADVISE - strongly urge all smokers to quit </li></ul><ul><li>ASSESS - willing to make an attempt? </li></ul><ul><li>ASSIST - information, medication </li></ul><ul><li>ARRANGE - schedule follow-up visit </li></ul>
    73. 73. For Those Unwilling to Quit – the 5 “R’s” <ul><li>Relevance - why quitting is personally relevant </li></ul><ul><li>Risks - patient identifies negative consequences of tobacco use </li></ul><ul><ul><li>Acute, long-term, environmental risks </li></ul></ul><ul><li>Rewards - patient identifies benefits of stopping </li></ul><ul><li>Roadblocks - patient identifies barriers to quitting </li></ul><ul><li>Repetition - motivational intervention every visit </li></ul>

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