Transcript Treating Tobacco Use and Dependence

Pharmacotherapy for the
Treatment of Nicotine
Dependence
Donna Shelley, MD, MPH,
Columbia University Mailman
School of Public Health
[email protected]
Submitted by the
NY/NJ AETC
Outline
System changes to increase tobacco use
treatment
 Pharmacotherapy
 Referral sources

Why should I treat tobacco use?

I in 5 deaths in the US are due to smoking

1 in 3 cancer deaths are caused by smoking

70% of smoker want to quit

64% of New Yorkers who smoke tried to quit
in the past 12 months NYC Community Health Survey
2001

Less than 10% succeed without assistance
ROLE OF THE HEALTH CARE TEAM
Multiple Influences on a Tobacco User
Provider
Family
Co-workers
Faith Community
Friends
Newspapers,
Magazines
Community
TV, Radio
Internet
MD assisted quit rates at one yr are 10-30%
“Not enough time”
“Minimal interventions
lasting less than 3
minutes increase
overall tobacco
abstinence rates.”
The PHS Guideline
(Strength of Evidence = A)
“I can’t help patients stop.”

Effective interventions
exist:
 Pharmacotherapy
 Brief
counseling
 System
changes
Guideline available at www.ahrq.gov
Tobacco use results in a
true drug dependence

Tobacco dependence exhibits classic
characteristics of drug dependence

Nicotine:
 Nicotine is as addictive as heroin
 Causes physical dependence
characterized by withdrawal symptoms
upon cessation
 Smokers use tobacco to regulate their
moods and emotions
Tobacco dependence is a
chronic disease

Tobacco dependence requires ongoing rather
than acute care

Relapse is a component of the chronic nature
of the nicotine dependence — not an
indication of personal failure by the patient or
the clinician
The 5 A’s
For Patients Willing To Quit
ASK about tobacco use.
 ADVISE to quit.
 ASSESS willingness to
make a quit attempt.
 ASSIST in quit attempt.
 ARRANGE for follow-up.

Smoking as a vital sign (SVS) ASK:
Ask every patient at every visit
“Do you currently use any tobacco products?”
Progress note vital signs
BP: __________ Weight: _______
Ht: _______
Tobacco Use:
Advise to quit
Ready to quit?
Rx given
Referral made
BMI:_____
Yes 
Y
Y
Y
Y
No 
N
N
N
N
Former 
Impact of smoking status identification
system on rates of clinician intervention:
Intervention
rate
(95% C.I.)
No Screening System
Screening system in
place to ID smoking
status
OR
(95% C.I.)
Cessation
Rates
38.5 %
1.0
3%
65.6%
3.1
6.4%
BASED ON 9 RANDOMIZED STUDIES
AHRQ GUIDELINES, 2000
Progress
Note
Vital signs
Date: ___________
Temp: __________
BP: ___________
Pulse: __________
Height: _______ Weight: ______ BMI: _______





Tobacco Use
Advice Given
Ready To Quit
Referral Made
Rx Given
Yes
No
□
□
□
□
□
□
□
□
□
□
ADVISE
Advice should be: clear, strong,
personalized
Progress note vital signs
BP: __________ Weight: _______
Ht: _______
Tobacco Use:
Advise to quit
Ready to quit?
Rx given
Referral made
BMI:_____
Yes  No 
Y N
Y N
Y N
Y N
Former 
ADVISE

Even brief advice to quit results in greater
quit rates
“As your health care
provider, I must tell you that
the most important thing you
can do to improve your
health is to stop smoking.”
Physician Advice can increase quit
rates by 30%
Advice
Odds Ratio
(95%) CI
No advice to quit
(reference group)
1.0
Physician advice
1.3
to quit
(1.1-1.6)
Fiore M, PHS guideline 2000
Estimated
Abstinence Rate
7.9%
10.2%
Assess willingness to quit
“Are you willing to try to quit at this time? I can help you.”
Progress note vital signs
BP: __________ Weight: _______
Ht: _______
Tobacco Use:
Advise to quit
Ready to quit?
Rx given
Referral made
BMI:_____
Yes  No 
Y N
Y N
Y N
Y N
Former 
ASSIST
Help set a quit date
 Provide practical counseling
(alcohol, other smokers in home)
 Past quit experiences
 Anticipate challenges

Counsel your patients to quit:
Minimum advice increases quit rates
by 30%
Level of contact
No contact
Estimated Est.
odds ratio abstinence
rate
1.0
10.9
Min counseling < 3 min 1.3
13.4
Low intensity
3-10 min
>10 minutes
1.6
16
2.3
22.1
Assist: Pharmacotherapy
Progress note vital signs
BP: __________ Weight: _______
Ht: _______
Tobacco Use:
Advise to quit
Ready to quit?
Rx given
Referral made
BMI:_____
Yes  No 
Y N
Y N
Y N
Y N
Former 
“Pharmacotherapy should be
offered to all smokers trying to
quit except where
contraindicated.”
Fiore 2000
First-line pharmacotherapy
Nicotine Replacement Therapy

Patch


Gum
Lozenge

Inhaler

Nasal spray
Non nicotine replacement
Bupropion (Zyban)
Pharmacotherapy
Estimated odds ratio for long term
abstinence
2.35
2.5
2.14
2 1.81
2.05
2.1
1.66
1.5
1
0.5
0
Patch
Fiore 2000
Gum
Inhaler
Spray
Lozenge Bupropion
Nicotine Replacement Therapy
(NRT)



No evidence that nicotine causes cancer
No evidence of increased cardiovascular risk
with NRT
Medical contraindications:
 immediate myocardial infarction (< 2
weeks)
 serious arrhythmia
 serious or worsening angina pectoris
 accelerated hypertension
Joseph 1996, Ford 2005, Working Group 1994 Arch Int Med
Plasma nicotine levels after a cigarette
vs. different types of pharmacotherapy
30
25
20
15
10
5
Cigarette
Patch
Gum
0
12
0
10
80
60
40
20
0
0
Nasal Spray
Withdrawal Symptoms








Anxiety/Irritability
Poor concentration
Restlessness
Craving
Headaches
Drowsiness
Depression
Hunger
NRT: Nicotine patch

24 hr (21, 14, 7mg) Nicoderm/generic or

16 hr (15, 10, 5 mg) Nicotrol

Available OTC

A new patch is applied each morning

Rotating placement site can reduce irritation

6 weeks for 1st dose-taper over 4-6 weeks

Side effects: Insomnia, local rash
NRTs: Patches Need to be
Individualized





<10 CPD may consider 7mg
10-15 CPD = 14-21 mg/day patch
15-20 CPD = 21 mg/day
21mg=21 cigs/d
14mg=14 cigs/d
NRT: Nicotine gum






2 mg (<25 cigs) vs 4 mg (>24 cigs)
1-2 per hour for first 6 weeks-taper
Chew (release peppery taste) and park,
continue for 30 minutes
Absorbed in a basic environment, avoid acidic
beverages 15 minutes pre and during dose
(coffee, soda, juice)
Use enough pieces each day (max 24)
Side effects: dyspepsia, mouth soreness
Nicotine Lozenge (OTC)
2 mg smoke cig >30 minutes on waking
 4 mg smoke <30 minutes
 Allow to dissolve 30 min
 Cannot drink or eat 15 minutes before
using
 First 6 weeks take one q1-2 hr (9-20 /day)
than taper up to 6 weeks

NRT: Nicotine inhaler

Available by prescription

Continuous puffing over 20 minutes per dose
(80 puffs per dose delivers 4 mg)

6-16 cartridges per day for 12 weeks

Eating or drinking before and during
administration should be avoided
NRT: Nicotine nasal spray

Available by prescription

Patient should not sniff, swallow, or inhale
the medication

A dose is 2 squirts, one to each nostril

Initial dosing should be 1 to 2 doses per
hour, increasing as needed up to 6-8 weeks
and than taper

Dosing should not exceed 40 doses per
day
Bupropion SR (Zyban®)

Mechanism of action: presumably blocks
neural reuptake of dopamine and/or
norepinephrine

Dosing:
 start
2 weeks before quit date
 150 mg orally once daily x 3 day
 150 mg orally twice daily x 7-12 weeks
 no taper necessary at end of treatment

Maintenance - efficacious as maintenance
medication for 6 months post-cessation
Bupropion SR (Zyban®)

Contraindications
 Seizure
disorder
 Current use of Wellbutrin
 Bulimia/anorexia
 MAO inhibitor in past 14 days
 Heavy alcohol use

Side effects:
 Dry
mouth
 Insomnia (avoid bedtime dose)
Factors to Consider When Choosing
a Pharmacotherapy
 Patient
preference
 Clinician familiarity with the medications
 Contraindications for selected patients
 Previous patient experiences with a
specific agent (positive or negative)
 Patient characteristics (concern about
weight gain, history of depression)
Reimbursement

ICD9: 305.1 AND

CPT code 99401 (15-minute physicianprovided counseling)
OR
CPT code 99211 (nurse counseling)
NYS Medicaid benefit: NRT, Zyban are
reimbursed (two 3 mo courses per year,
may prescribe more than one
medication)


Reimbursement

Medicare
2
cessation attempts per year including max 4
sessions, up to 8 sessions per 12 months
 Must wait 11 months from the 1st of the 8
sessions
 G0375 3-10 minutes
 G0376 >10 min
 1800 633 4227 (1 800 MEDICARE)
ASSIST: Next Steps
Progress note vital signs
BP: __________ Weight: _______
Ht: _______
Tobacco Use:
Advise to quit
Ready to quit?
Rx given
Referral made
BMI:_____
Yes  No 
Y N
Y N
Y N
Y N
Former 
http://www.nysmokefree.com/newweb/fax/ReferFormRV1-05-05II.pdf
Resources
www.nysmokefree.org
Resources
Smoking cessation programs in NYC
http://www.nyc.gov/html/doh/html/smoke/quit
.shtml
How do I treat tobacco users who are
not willing to make a quit attempt?
Treating patients who are not ready
to make a quit attempt

RELEVANCE: Tailor advice and discussion to each
patient.

RISKS: Outline risks of continued smoking.

REWARDS: Outline the benefits of quitting.

ROADBLOCKS: Identify barriers to quitting.

REPETITION: Reinforce the motivational message
at every visit.
Resources
Physician resources


AHRQ www.ahrq.gov or 800-358 9295
 Physician guides
 Patient tear sheets free
NYCDOH: City Health Information
http://www.nyc.gov/html/doh/html/smoke/smoke.html
http://www.nyc.gov/html/doh/pdf/chi/chi21-6.pdf
Patient websites/materials


www.quitnet.com, www.smokeclinic.com
http://www.nyc.gov/html/doh/html/smoke/smoke2cess1.html
Medication – Daily Cost
Bupropion 150 SR
Transdermal 7 to 21
Lozenge 2mg or 4 mg
$3.00 /day
$4.00 / patch ($40/box
14)
$7.00 / 10 pieces
Gum 2 mg or 4 mg
$5.00 / 10 pieces
Nasal Spray
$6.00 / 12 sprays
Inhaler
$11.00 / 10 cartridges