Transcript SMOKING CESSATION

SMOKING CESSATION
• Leading Preventable Cause of Death
• 400,000 to 500,000 deaths per year in
USA
• 3 Million deaths world wide
• 1 of every 6 deaths in USA Directly
attributable to smoking
• Yet — 46 Million continue to smoke
SMOKING
“A cigarette is a finely tuned drug
delivery system”
Katherine E. Hartman, MD
SMOKING
“Smoking is not a bad habit ---
It is a chronic medical condition”
Michael C. Fiore, MD
SMOKING CESSATION
• Why do we smoke?
• Why should we stop/benefits?
• How do we stop?
Nicotine Dependence slide
“As an addictive substance,
nicotine, on a milligram for
milligram basis, is 10 times
more potent than heroin…”
Sachs DPL. Advances in Smoking Cessation Treatment In: Simmons, ed. Current Pulmonology, Chicago;
Year Book Medical Publishers, 1991, 12:139-198
SMOKING CESSATION
Why Do We Smoke?
3-Pronged Dependency
• Physiological
• Psychological
• Behavioral
Why Do We Smoke?
Physiological
• Nicotine to brain – 7 seconds
• Binds to nicotine receptors resulting in
secretion of Dopamine
• Causes a pleasurable sensation and
cognitive arousal
Physiological
Increased Levels of:
Norepinephrine
Beta-Endorphin
Acetylcholine
Serotonin
Glutamate
Vasopressin
Physiological
• Enhance:
– Concentration
– Alertness
– Memory
• Decrease:
– Tension
– Anxiety
Promotes feeling of well being
SMOKING CESSATION
Why should we stop smoking?
Benefits:
General
Cardio-cerebrovascular
Cancer
Pulmonary
SMOKING CESSATION
• Long term tobacco use raises the risk of
premature death by 50% *
• Quitting at any age increases longevity
• Those who quit smoking by age 50
decrease their risk of dying over the next
15 years by 50% compared with those who
do not stop **
* W.H.O. Tobacco Dependency Fact Sheet #222 1999
** U.S. Dept of Health & Human Services publication #90-8416
SMOKING CESSATION
Why should we stop smoking?
Benefits:
General
Cardio-cerebrovascular
Cancer
Pulmonary
Why should we stop smoking?
• 30% of all Cancer Deaths related to
Smoking
• 4000 Chemicals in Tar
– 43 Carcinogenic
Why should we stop smoking?
• Lung Cancer – Most Common in Cancer
– Oral
– Throat
– Esophagus
– Bladder
– Kidney
– Pancreas
– Stomach
9 fold increase
9 fold increase
75% in smokers
7 fold increase
5 fold increase
2 fold increase
1.5 fold increase
Why should we stop smoking?
Lung Cancer
• Life Long risk in Non-Smoker – 1%
• 15-25% risk in heavy smokers
• Each Cigarette cuts 6 minutes off of life
SMOKING CESSATION
Why should we stop smoking?
Benefits:
General
Cardio-cerebrovascular
Cancer
Pulmonary
How Do We Stop Smoking?
Problems
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Patient Motivation
Physician Interest
Medications
Support Systems
SMOKING CESSATION
Patient Motivation
• 70% want to quit
• 2 large studies
• Appropriate moment
SMOKING CESSATION
The Right Moment
Acute MI
Intervention
55%
Minimal
34%
Dornelas, E.A. Prev Med 2000; 30, 216-228
The Negatives
• Physicians advising patients to stop
1975 – 38%
1983 – 42%
1991 – 48%
• 1672 Ex-Smokers
– 3.6% Physician Helped
• 70% smokers see physician yearly
SMOKING
• 38 Family Practices
• 2963 Smokers - Addressed in 21%
• Increased to 58% if Doctor used standard
forms for recording smoking status
• When smokers identified
– smoking cessation therapy started in only 38%
• 68% of the offices had smoking cessation
material
J. Fam. Pract. 2001; 50: 688-9
Physicians Role in
Smoking Cessation
The Positives
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Admit Nicotine is an Addiction
Provide information
Show an interest
Train office personnel
Select the opportunity
SMOKING CESSATION
The 5 A’s
Ask
Advise
Assess
Assist
Arrange
Planning a Program
• Establish degree of nicotine dependency
– Serum Cotinine Level
– Fagerstrom Test
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Quit Date
Support Group
Behavioral Modification
Discuss Relapses & Weight Gain
Pharmacologic
• Nicotine Replacement
• Bupropion
Planning A Program
• Low Dependency
– Nicotine Replacement
• High Dependency
– Bupropion +
– Nicotine Replacement x 2
Nicotine Replacement
N=504
Patch
Gum
Spray
Inhaler
21%
20%
24%
24%
Arch. Int. Med. September 27, 1999
Nicotine Replacement
Gum – 1984
Advantages
Disadvantages
•Neutral PH
•Heartburn and Indigestion
•More Rapid
•Throat and Mouth Irritation
•Adjunct
•Sore Jaw
•Flatulence
Nicotine Replacement
Patch – 1991
Advantages
Disadvantages
•Convenient
•Skin Irritation
•Best Compliance
•Over the counter
•30-40% while on patch
•10% at 1 year
Nicotine Replacement
Nasal Spray
Advantages
Disadvantages
•Alone or Combination
•Irritation
•Fast Acting - Urge
•Low Compliance
Nicotine Replacement
Inhaler
Advantages
Disadvantages
•Hand-Mouth
•Low Compliance
•Less Nicotine
•Delivery
Nicotine Replacement
Lozenge – 2002
Bupropion
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Placebo
Nicotine Replacement
Bupropion 300 MA
Bupropion + Nicotine
Long Term
23%
36%
49%
58%
25-35%
SMOKING CESSATION
• Placebo
N
160
12 MO
15.6%
KG
2.1
• Nicotine Patch
244
16.4%
1.6
• Bupropion
244
30.3%
1.7
• Bupropion + patch
245
35.5%
1.1
JORENBY - N.E.J.M. 3/4/99
SMOKING CESSATION
BUPROPION
450 Smokers
(Failed Treatment)
Again
Placebo
27%
5%
Gonzales DH, Clin. Pharm
Therapy 2001; 69
SMOKING CESSATION
BUPROPION
Duration
784 PATIENTS
7 WEEKS
TREATMENT
PLACEBO
12 MONTHS
55%
42%
Hays, JT. Ann Intern Med. 2001
135
SUMMARY
• Smoking KILLS
• Physicians can and should play a role in
helping patients stop smoking
• Effective tools are available and they work
SUMMARY
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Include Smoking as a Vital Sign
Use the 5 A’s
Use multiple modalities
Use them long enough
Be Persistent