Transcript In the Clinic Smoking Cessation

In the Clinic
Smoking
Cessation
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
What health problems have definite links
to tobacco use?
 Cancer (≈ 1/3 U.S cancer deaths attributable to smoking)
 COPD and asthma exacerbations
 CAD, cerebrovascular disease, PVD, aortic aneurysms
 Low birthweight and premature babies, possible increased risk
for miscarriage
 Ectopic pregnancy and orofacial clefts
 Heart attack, stroke, and VTE while on birth control pills
 GERD
 Type 2 diabetes
 Age-related macular degeneration, cataracts
 Compromised immune system
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
Which health problems are associated with
secondhand smoke exposure?
 Adults
 Cancer
 CAD, stroke
 Adult-onset asthma
 Children
 Asthma, respiratory infection, reduced lung function
 Chronic otitis media
 Sudden infant death syndrome
 Low birthweight, premature birth
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
What health benefits can smokers who
quit anticipate?
 Symptoms
 Minutes-days: Lower BP; lower carbon monoxide; better
stamina, smell, taste
 Lung function
 2–4 weeks: Decreased respiratory infections
 4–12 weeks: Improved lung function
 Cardiovascular disease
 2–3 months: Improved circulation
 1 year: 50% reduction for heart attack
 5–15 years: Cardiovascular risk = never-smokers
 Cancer
 10 years: risk for lung cancer reduced by half
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
Is there an age after which smoking
cessation no longer yields benefit?
 Smoking cessation benefits people of all ages
 Regardless of smoking history
 Older smokers may have:
 Increased motivation from health concerns and symptoms
of tobacco-related illness
 Experience with what has been successful in past quit
attempts
 Better access to treatment resources.
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
CLINICAL BOTTOM LINE: Health
Consequences of Smoking...
 Tobacco use affects nearly every organ system in the body
 Leads to heart disease, stroke, cancer, vascular disease,
respiratory infections, diabetes, GERD
 Second-hand smoke also increase health risks
 Benefits of quitting start in minutes and continue for years
 Even after decades of smoking, stopping significantly
reduces risk for death, slows deterioration of lung function
 Risk-reduction benefits especially significant for smokers
with CAD, COPD, or those who are pregnant
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
Why is it difficult for smokers to quit?
 Nicotine is highly addictive
 Severity of dependence often predicted by number of
cigarettes smoked + time to first cigarette of the day
 Withdrawal symptoms include:
 Depressed mood, anxiety, irritability, restlessness,
insomnia, increased appetite, difficulty concentrating
 Symptoms peak in first week, can continue ≥6 weeks
 Psychological cravings for nicotine can last longer
 Quitting smoking also requires behavior change
 Smoking is a comforting habit to many smokers
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
How should clinicians screen for tobacco
use, and when should they provide
cessation counseling?
 Send a clear message to patients that the best
prevention strategy is never to start
 Ask all patients if they smoke
 Most adults smokers became daily users before age 18, so
opportunities for primary prevention greater for physicians
who care for children
 For tobacco users seen in clinical settings: use “5 As”
 Brief clinical intervention: see next slide
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
The 5 As
 ASK—About tobacco use at every encounter
 Identify and document tobacco use
 Consider systematic process (e.g., vital signs)
 ADVISE—To quit tobacco use
 Strong, clear, personalized message
 ASSESS—Willingness to quit
 If not ready, offer motivational counseling
 ASSIST—In quitting
 Set a quit date
 Address behavioral changes, pharmacotherapy, support
 ARRANGE—follow-up
 Monitor progress, side effects, withdrawal
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
What effects do electronic cigarettes
(e-cigarettes) have on public health?
 FDA: does not regulate these “tobacco products”
 No standardization in manufacturing process
 E-cigarette vapor
 Contains some toxins also found in tobacco smoke but at
much lower levels
 No combustion of tobacco, thus no smoke or Carbon
monoxide
 Because of the chemicals found in e-cigarette vapor,
they cannot be declared safe
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
Public health concerns about e-cigarettes
 What are the long-term health effects of e-cigarette use?
 Are they substantially less harmful than tobacco
cigarettes?
 Could “less harmful” be misinterpreted as “safe”?
 Do the flavored e-cigarettes appeal to young people?
 Could they act as a “gateway product” to tobacco
cigarettes or lead former smokers back to cigarettes?
 Do they renormalize smoking behavior in public?
 Could dual-use e-cigarettes with tobacco cigarettes
maintain addiction in person who might otherwise quit?
 Are e-cigarettes useful as a smoking cessation product?
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
CLINICAL BOTTOM LINE: Prevention
of Smoking-Related Disease...
 Routinely ask all patients if they use tobacco
 Send a clear message that no level of tobacco use is safe
 Stopping smoking is most important health improvement
smokers can achieve
 Physicians should utilize tobacco treatment resources
 E-cigarettes pose challenging public health issue not only for
current smokers but for society in general
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
What is the role of health care
professionals in tobacco treatment?
 Variety of health care providers can reduce the impact of
tobacco use in our society
 Physicians, dentists, psychologists, social workers,
nurses, licensed professional counselors, respiratory
therapists, pharmacists, health educators, addiction
counselors, family therapists, health coaches
 Treatment team also includes certified tobacco
treatment specialists
 Advanced training in evidence-based treatment
 Deliver interventions in individual and group settings
 Smoking cessation training programs increase
likelihood physicians perform smoking cessation tasks
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
Can smokers quit without any
intervention?
 Some smokers succeed in stopping on their own
 Abstinence rate for unaided cessation < 5%
 Even simple advice from a physician or basic clinical
interventions can aid cessation
 For more meaningful abstinence rates, comprehensive
tobacco dependence treatment is best
 Strong dose-response relationship between duration and
frequency of contact and successful treatment
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
What behavioral interventions are
effective?
 Utilize the “5 As” at every clinic visit
 Self-help therapy
 Apps, Web, and mobile interventions
 Motivational interviewing (collaborative, goal-oriented style of
communication with focus on personal reasons for change)
 Individual therapy (training in practical problem-solving skills)
 Telephone therapy (quitlines provide access to support, and
call-back counseling enhances their usefulness)
 Group therapy (provides mutual support from others)
 Acupuncture, hypnosis (evidence is insufficient)
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
Which pharmacologic therapies are effective?
 Nicotine replacement therapy
 OTC: gum, patch, and lozenge form
 Prescription: oral inhaler and nasal spray
 Alleviate cravings and withdrawal symptoms
 Bupropion
 Nonnicotine drug inhibits serotonin, norepinephrine, and
dopamine
 Varenicline
 Nonnicotine drug acts at the α4-β2–nicotinic receptor as a
partial agonist and antagonist
 Pharmacotherapy + behavioral therapy increases success
 Combining some of these medications may have added benefit
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
When should clinicians consider
pharmacologic interventions, and how
should they select a therapy?
 All smokers should receive pharmacotherapy unless it
is contraindicated
 Efficacy of all 1st-line FDA-approved medications similar
 Choice should be guided by patient preference, clinician
familiarity, comorbidities and side effect profile, patient
experiences, access, cost
 When patients are paying out-of-pocket, generic patch and
gum are less expensive options
 Explain how each of these medications work and show
patient how to use them
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
Are there conditions that contraindicate or
caution against pharmacologic therapy?
 NRT
 Concern re: concomitant smoking less valid than believed
 Use caution within 2 weeks of recent MI, severe angina, or
life-threatening arrhythmias
 Bupropion
 Contraindicated: recent history of seizures
 Drug interactions with antipsychotics and MAO inhibitors
or drugs with MAO inhibitor-like activity
 Associated with hypertension (monitor blood pressure)
 Varenicline
 Concerns regarding neuropsychiatric effects (erratic and
hostile behavior) and possibly cardiovascular events
 Use cautiously in patients with renal impairment
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
How long should patients use pharmacologic
therapy before it is considered ineffective?
 Use for as long as clinically necessary
 NRT: typically prescribed for 8-12 weeks
 Some who quit continue to use NRT to prevent relapse
 Bupropion: typically prescribed for 8-12 weeks
 Safely used for long periods in treatment of depression
 Approved for long-term maintenance of cessation
 Varenicline: can be used up to 24 weeks to prevent relapse
 Safety established for up to 1 year
 Pretreatment with varenicline may be beneficial
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
What strategies are effective to prevent
relapse after quitting?
 Relapse is part of natural history of tobacco dependence
 Many patients require several attempts before achieving
durable abstinence
 Relapse prevention can be useful in certain settings
 Behavioral intervention: insufficient evidence to support
the use of any specific intervention to avoid relapse
 Strongest evidence is for interventions focused on
identifying and resolving tempting situations
 Pharmacotherapy: mixed evidence for extended
treatment
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
Should patients switch to other tobacco
products or e-cigarettes if they are unable
to stop tobacco use?
 Overall goal: abstain from all forms of tobacco
 Combusted tobacco products likely the most harmful
 But less harmful is not equivalent to safe
 Smokeless tobacco products sometimes perceived as “safer
than cigarettes”
 Amount of nicotine, carcinogens, other toxins varies
 Associated with CVD, cancer, dental and periodontal
disease, pregnancy-related problems, nicotine addiction
 E-cigarettes: evidence needed that they’re both safe and
effective for increasing tobacco cessation rates
 Focus treatment on evidence-based, FDA-approved treatments
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
Are there adverse effects of smoking
cessation that clinicians should prepare
patients for?
 Weight Gain
 Can trigger resumption of smoking, and often used as an
excuse not to quit in the first place
 Depression
 Depressive symptoms may develop due to nicotine
withdrawal and may be severe enough to warrant treatment
 Bupropion and nortriptyline recommended for smokers
with depression who are trying to quit
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.
CLINICAL BOTTOM LINE: Treatment...
 Routinely ask all smokers about tobacco use, advise them to
quit, and assess their readiness to do so
 Tobacco dependence is a chronic condition
 Not just “bad habit” that can be ameliorated by willpower
 Dopamine release makes nicotine extremely addictive
 Use comprehensive, evidence-based treatment
 FDA-approved medications
 Behavioral counseling
 Social support
 Consider patient preferences, medical comorbidities, side
effects, cost, access, smoking behaviors, prior quit attempts
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (3): ITC3-1.