Evidence-based Strategies to Help YOUR Patients Live Tobacco-Free

Janie Heath PhD, APRN-BC, FAAN

Associate Dean , Academic Affairs Clinical Operations Director, Tobacco Cessation Clinic Medical College of Georgia, School of Nursing

Respiratory Therapy

Objectives

Identify the importance of integrating tobacco cessation in DAILY practice Recognize bio-behavioral & pharmacotherapy strategies in treating nicotine dependence Identify essential resources for integrating tobacco cessation in DAILY practice
VISIT: www.nurses4tobaccocontrol.org

Counseling + Pharmacotherapy = Best Outcomes

Fiore MC et al., US DHHS, U.S. Public Health Service, 2008 Update

Why Integrate Tobacco Cessation Practices:

HEIDIS says to do it! JCAHO says to do it! The Surgeon General says to do it!

The NY Health Commissioner says to do it! The wife says to do it!

TRENDS in ADULT SMOKING, by SEXU.S., 19552006

Trends in cigarette current smoking among persons aged 18 or older
60 50 40

Male

20.8% of adults are current smokers

23.9% 18.0%

Percent

30 20 10 0
1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999 2003

Female

45.3 Million Adults are Addicted to Cigarettes

The BAD News: <News: 36% Receive Information onquit HOW to quit TheThe GOOD EBP Strategies Available GOOD News: 70% want to
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 19652005 NHIS. Estimates since 1992 include some-day smoking.

Year

STATE-SPECIFIC PREVALENCE of SMOKING among ADULTS, 2007

NY = 18.9%; $2.75

NTL AVERAGE = 19.8% The RIGHT Rx = Cigarette Excise TAX!

Prevalence of current smoking (2007) < 18.0% 18.0 19.9% 20.0 21.9% 22.0 23.9% 24.0%
RANGE: 8.7% - 31.1%

GA = 19.3%; $0.37

CA = 14.3%; $0.87

KY = 28.3%; $0.60

Centers for Disease Control and Prevention. (2009). MMWR 58(09); 221-226

PREVALENCE of ADULT SMOKING, by RACE/ETHNICITYU.S., 2006

32.4% American Indian/Alaska Native* 23.0% Black*

21.9% White*
15.2% Hispanic 10.4% Asian*
0% 10% 20% 30% 40% 50%
* non-Hispanic

Centers for Disease Control and Prevention. (2007). MMWR 56:11571161.

PUBLIC HEALTH versus BIG TOBACCO

The biggest opponent to tobacco control efforts is the tobacco industry itself.
Nationally, the tobacco industry is outspending our state tobacco control funding.

For every $1 spent by the states, the tobacco industry spends $18 to market its products.

COMPOUNDS in TOBACCO SMOKE

An estimated 4,800 TOXINS in tobacco smoke plus 11 proven human carcinogens
Gases (~500 isolated)

Particles (~3,500 isolated)

Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde

Nicotine Nitrosamines Lead Cadmium Polonium-210

Marketing Strategy: Light and Ultra-Light Cigarettes

The difference between Marlboro and Marlboro Lights

15mg tar, 1.1 mg nicotine

10mg tar, 0.8 mg nicotine

an extra row of ventilation holes

Image courtesy of Mayo Clinic Nicotine Dependence Center - Research Program / Dr. Richard D. Hurt
The Marlboro and Marlboro Lights logos are registered trademarks of Philip Morris USA.

The Safer Cigarette NOT!

Unveiling the SMOKING gun about Safe Cigarettes!

ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, 19972001

Percentage of all smokingattributable deaths*

Cardiovascular diseases Lung cancer Respiratory diseases Second-hand smoke* Cancers other than lung Other

137,979 123,836 101,454 38,112 34,693 1,828

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 54:625628.

2006 REPORT of the SURGEON GENERAL:

INVOLUNTARY EXPOSURE to TOBACCO SMOKE

Approximately 50,000 adults & infants die / year from secondhand smoke TWENTY YEARS later we FINALLY have evidencethe right of smokers to smoke ends There is no where their behavior affects 126 million nonsmokers in safe level of the health and well-being of the U.S. are exposed to second-hand others secondhand smoke smoke. Secondhand smoke contains more than 50 carcinogens
Surgeon General Koop, USDHHS Surgeon General Report, 1986

USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.

ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTSU.S., 19951999

Prescription drugs, $6.4 billion Other care, $5.4 billion

Medical expenditures (1998)

Ambulatory care, $27.2 billion

Hospital care, $17.1 billion

Nursing home, $19.4 billion

Societal costs: $7.18 per pack

Annual lost productivity costs (19951999)
Men, $55.4 billion Women, $26.5 billion

10

20

30

40

50

60

70

80

Billions of dollars
Centers for Disease Control and Prevention. (2002). MMWR 51:300303.

QUITTING: HEALTH BENEFITS

Time Since Quit Date
Circulation improves, walking becomes easier Lung function increases up to 30% Excess risk of CHD decreases to half that of a continuing smoker Lung cancer death rate drops to half that of a continuing smoker Risk of cancer of mouth, throat, esophagus, bladder, kidney, pancreas decrease
2 weeks to 3 months 1 to 9 months 1 year 5 years 10 years after 15 years

Lung cilia regain normal function

Ability to clear lungs of mucus increases Coughing, fatigue, shortness of breath decrease Risk of stroke is reduced to that of people who have never smoked

Risk of CHD is similar to that of people who have never smoked

BENEFICIAL EFFECTS of QUITTING: PULMONARY EFFECTS

AT ANY AGE, there are benefits of quitting.
FEV1 (% of value at age 25)
100 Never smoked or not susceptible to smoke

75 Smoked regularly and susceptible to effects of smoke Disability 25 Death 0 25 50 75 Stopped smoking at 65 (severe COPD) Stopped smoking at 45 (mild COPD)

50

Age (years)
COPD = chronic obstructive pulmonary disease

Reprinted with permission. Fletcher & Peto. (1977). BMJ 1(6077):16451648.

FINANCIAL IMPACT of SMOKING

Buying cigarettes every day for 50 years @ $4.32 per pack Money banked monthly, earning 4% interest

$755,177
$503,451 $503,451
Packs per day
0

$755,177

$251,725 $251,725
200 400 600 800

Dollars lost, in thousands

SMOKING CESSATION: REDUCED RISK of DEATH

15

Prospective study of 34,439 male British doctors Mortality was monitored for 50 years (19512001)
On average, cigarette smokers die approximately 10 years younger than do nonsmokers. Among those who continue smoking, at least half will die due to a tobacco-related disease.
Doll et al. (2004). BMJ 328(7455):15191527.

Years of life gained

10

0 30 40 50 60

Age at cessation (years)

CIGARETTES

Most common form of tobacco used in U.S. 360 billion cigarettes consumed in 2007

3.2% less than in 2006

Per-capita consumption was 1,691 in 2006

SMOKELESS TOBACCO
Chewing tobacco

Looseleaf Plug Twist

Snuff

Moist Dry

The Copenhagen and Skoal logos are registered trademarks of U.S. Smokeless Tobacco Company, and Red Man is a registered trademark of Swedish Match.

Other Tobacco Products

CIGARS

KRETEKS / CLOVE CIGARETTES

Other Tobacco Products

BIDIS

HOOKAH PIPE,

POTENTIALLY REDUCED-EXPOSURE PRODUCTS (PREPs)

Tobacco formulations altered to minimize exposure to harmful chemicals in tobacco

Cigarette-like delivery devices

Eclipse Quest Ariva, Marlboro Snus, Stonewall, Camel Snus

Modified tobacco products

Oral noncombustible tobacco products

No evidence to prove that PREPs reduce the risk of developing tobacco-related disease

Breaking the NICOTINE DEPENDENCE Cycle at ANY age!

A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

The BEHAVIOR

The EMOTIONAL

The PHYSICAL

Automatic learned behavior with cigarettes

Role of cigarettes in life pleasure, stress, social

Physical addiction of cravings & withdrawals

Adapted from Legacys GSD&M Presentation 12/5/03

DOPAMINE REWARD PATHWAY

Prefrontal cortex
Within 7 11 seconds I feel good

Dopamine release

Nucleus accumbens Ventral tegmental area

Stimulation of nicotine receptors Nicotine enters brain

NICOTINE BEHAVIORAL EFFECTS: Do the Math!

An individual smokes 1 pack per day x 20 yrs 20 cigarettes / pack 10 puffs / cigarette = ?? puffs / day
200 HITS of THATs ____ NICOTINE per DAY

Now Multiply that # by days / year THEN multiply that number by years smoking!

73,000

1.4 million

YIKES! No wonder it is SO difficult to QUITAverage attempts = 7-10 per smokers lifetime

NEUROCHEMICAL and RELATED EFFECTS of NICOTINE

N Dopamine I
Pleasure, appetite suppression Arousal, appetite suppression Arousal, cognitive enhancement Learning, memory enhancement Mood modulation, appetite suppression Reduction of anxiety and tension Reduction of anxiety and tension
Benowitz. (2008). Clin Pharmacol Ther 83:531541.

Norepinephrine
Acetylcholine Glutamate Serotonin

C
O T I E

N -Endorphin
GABA

NICOTINE PHARMACODYNAMICS: WITHDRAWAL EFFECTS

Depression Insomnia Irritability/frustration/anger Anxiety Difficulty concentrating Restlessness Increased appetite/weight gain Decreased heart rate Cravings*
American Psychiatric Association. (1994). DSM-IV. Hughes et al. (1991). Arch Gen Psychiatry 48:5259. Hughes & Hatsukami. (1998). Tob Control 7:9293.

Most symptoms peak 2448 hr after quitting and subside within 24 weeks.

* Not considered a withdrawal symptom by DSM-IV criteria.

Most symptoms peak 2448 hr after quitting and subside within 24 weeks.

ASSESSING NICOTINE DEPENDENCE

How soon after you wake up do you smoke your first cigarette Do you find it difficult to refrain from smoking in restricted areas Which cigarette do you hate to give up most

Fagerstrm Test for Nicotine Dependence (FTND)

How many cigarettes do you smoke per day

Do you smoke more frequently during the first hours after waking Do you smoke if you are so ill that you are in bed most of the day
Scores range from 0 to 10; a score of greater than 5 indicates substantial dependence

The 5 As
ASK ADVISE ASSESS
IF time does not allow. do 3 As and REFER

ASSIST ARRANGE
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

BRIEF COUNSELING: ASK, ADVISE, REFER

Brief interventions have been shown to be effective In the absence of time or expertise:

Ask, advise, and refer to other resources, such as local programs or the toll-free quitline 1-800-QUIT-NOW
This brief intervention can be achieved in 30 seconds.

Application of the Transtheoretical Model of Change for Smoking Cessation

Over time most patients, cycle into and out of the different stages. Most smokers require 7 10 quit attempts before quitting for good.
Precontemplation

Maintenance

Relapse Prevention

Former tobacco user In quit process or recent quitter

Not thinking about it

Not ready to quit: Use 5 Rs

Relevance Risks

Action

Thinking about it, not ready

Contemplation

Rewards Roadblocks Repetition

Ready to quit
Preparation

Quitting is HARD to do!

A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

The BEHAVIOR

The EMOTIONAL

The PHYSICAL

Automatic learned behavior with cigarettes

Role of cigarettes in life pleasure, stress, social

Physical addiction of cravings & withdrawals

Adapted from Legacys GSD&M Presentation 12/5/03

FDA APPROVALS: SMOKING CESSATION

Rx nicotine inhaler Rx bupropion SR Rx transdermal nicotine patch; OTC, 1996 Rx nicotine gum; OTC, 1996

2006

1997

1997

2002
Rx varenicline

1996
1991
Rx nicotine nasal spray

OTC nicotine lozenge

1984

LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS

30 25

Active drug Placebo

18.0 15.8 16.1

23.9 19.0 17.1

Percent quit

20 15

20.2

11.3

11.8 9.9 8.1 9.1 10.3

11.2

10 5 0 Nicotine gum

Nicotine patch

Nicotine lozenge

Nicotine nasal spray

Nicotine inhaler

Bupropion

Varenicline

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

PLASMA NICOTINE CONCENTRATIONS for NICOTINE-CONTAINING PRODUCTS

25

Cigarette

Cigarette
20

Moist snuff

Plasma nicotine (mcg/l)

Moist snuff
Nasal spray
15

Inhaler
10

Lozenge (2mg)

Gum (2mg)
5

Patch
0 1/0/1900 0 1/10/1900 10 1/20/1900 20 1/30/1900 30 2/9/1900 40 2/19/1900 50 2/29/1900 60

Time (minutes)

NICOTINE ABSORPTION
Absorption is pH dependent

In acidic media

Ionized poorly absorbed across membranes Nonionized well absorbed across membranes At physiologic pH (7.37.5), ~31% of nicotine is unionized

In alkaline media

At physiologic pH, nicotine is readily absorbed.

NRT: Rationale for Use

Reduces physical withdrawal from nicotine

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

NRT APPROXIMATELY DOUBLES QUIT RATES.
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS

NRT Precautions

Patients with underlying cardiovascular disease

Patients with other underlying conditions

Recent myocardial infarction (within past 2 weeks) Serious arrhythmias Serious or worsening angina

Active temporomandibular joint disease (gum only) Pregnancy-Category D Lactation

NRT products may be appropriate for these patients if they are under medical supervision.
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS

OTC Nicotine Patch: Dosing TIPS

May bathe/swim Do NOT cut Rotate sites Remove @ HS if sleep disorder

> 10 cigs / day = higher dose < 10 cigs / day = lower dose/no dose

OTC Nicotine Gum: Dosing TIPS

pH sensitive: no food/beverage 15 min AC, during, and 15 min PC

Chew slow & park when taste/tingling occurrepeat @ least 20 minutes

>25 cigs/ day = higher dose < 25 cigs/day = lower dose

OTC Nicotine Lozenge: Dosing TIPS

pH sensitive: no food/beverage 15 min AC, during, and 15 min PC Dissolve slow & do not bite/chew occasionally rotate @ least 20 minutes

1st Cig in a.m. < 30 min = higher dose 1st Cig in a.m. > 30 min = lower dose

Rx Nicotine Nasal Spray

Best for high dependence

Rx Nicotine Inhaler

Best for high dependence

NRT Dosing TIPS

Combination Therapy Recommended NRT Patch plus Bolus with Gum or Lozenge for breakthrough cravings/withdrawal OR bolus with NRT Spray or Inhaler if HIGHLY depended

Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS

ZYBANTM (Bupropion SR)

CONTRAINDICATIONS Patients with a seizure disorder Patients taking Wellbutrin, Wellbutrin SR, Wellbutrin

PRECAUTIONS

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

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)

Pregnancy Category C

Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS

ZYBANTM (Bupropion SR)

Dosing: 150mg q d x 3 days; then 150mg BID Must Start 2 Weeks PRIOR To QUIT Date

BEST practice = Use as combination therapy with NRT plus counseling

HOORAY!

CHANTIXTM (Varenicline)
TITRATE UP x 7days while still smoking: 0.5 mg q d x 3days THEN 0.5 mg BID x 4 days

STOP SMOKING Day #8 And start 1.0 mg BID x 3-6 mths

Take AFTER eating and with FULL glass of water

Dosage Adjustment for Renal Impairment

COMPARATIVE DAILY COSTS of PHARMACOTHERAPY

Average $/pack of cigarettes, $4.32
$8 $7 $6 $5

$/day

$4 $3 $2 $1 $0 Gum Lozenge $5.26 $3.66 Patch $3.89 $1.90 Inhaler $5.29 Nasal spray $3.72 Bupropion SR $7.40 $3.62

Varenicline $4.75 -

Trade Generic

$6.58 $3.28

EFFECTS of CLINICIAN INTERVENTIONS

With help from a clinician, the odds of quitting approximately doubles.
Estimated abstinence at 5+ months
30

n = 29 studies

Compared to patients who receive no assistance from a clinician, patients who receive assistance are 1.72.2 times as likely to quit successfully for 5 or more months.

20

10

1.7 1.0
No clinician

2.2

1.1
Self-help material Nonphysician clinician Physician clinician

Type of Clinician
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

Estimated abstinence rate at 5+ months
30

n = 37 studies

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.

20

10

(1.5,2.2)

1.8

(1.9,3.4)

2.5

(2.1,3.4)

2.4

1.0
None One Two Three or more

Number of Clinician Types

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

Breaking the NICOTINE DEPENDENCE Cycle

A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

The BEHAVIOR

The EMOTIONAL

The PHYSICAL

Automatic learned behavior with cigarettes

Role of cigarettes in life pleasure, stress, social

Physical addiction of cravings & withdrawals

Adapted from Legacys GSD&M Presentation 12/5/03

WHAT IF
a patient asks you about your use of tobacco?

The RESPONSIBILITY of HEALTH PROFESSIONALS

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.
DR. GRO HARLEM BRUNTLAND, FORMER DIRECTOR-GENERAL of the WHO
USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS.

The RESPONSIBILITY of HEALTH PROFESSIONALS

It is inconsistent to provide health care and at the same time remain silent (or inactive) about a major health risk. REMEMBER, tobacco dependence is a CHRONIC DZ, we need to treat it as such!

TOBACCO CESSATION is an important component of THERAPY.

Help Make a DIFFERENCE

Use the 5 As and REFER Today 1-800-QUIT NOW 1-866-NY-QUITS 1-866-697-8487

Thank You Questions...

Advances in Evidence-Based Strategies

Majority of Slides and References Provided by Rx for Change: Clinician Assistant Tobacco Cessation Available at http://rxforchange.ucsf.edu And Nurses for Tobacco Control Available at http://nurses4tobaccocontrol.org

Janie Heath PhD, APRN-BC, NP Associate Dean, AcademicAffairs Medical College of Georgia
jaheath@mcg.edu