Transcript No Slide Title

Assessment and
Pharmacological Treatment of
Tobacco Dependence
Jill Williams, M.D.
Associate Professor of Psychiatry
UMDNJ-Robert Wood Johnson Medical School,
UMDNJ-School of Public Health
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Smoking = Big Health Problem
#1 preventable cause morbidity/ mortality
1 in 5 deaths in US
But….Treatment Improves Outcomes
~50% of smokers try to quit/ year
Advice from MD ↑ quitting
Double success with treatment
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This Lecture will Cover
Epidemiology /consequences
Nicotine pharmacology
Assessment
Pharmacological treatments
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Epidemiology of Tobacco Use
Cigarettes > 95% of all tobacco use
>1 billion tobacco users worldwide
Stable or ↓ in US/ developed nations
Increasing in developing countries
Higher rates in ↓ SES
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Smoking Prevalence Rates
70%
60%
50%
40%
30%
Smoking
Rates
20%
10%
0%
MDs
2005
1960
MI or SUD
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Women and Smoking
Rates men ~ women
Highest in those living below the poverty level
Lung cancer # 1 cancer death
Cancer Death Rates in Women after 1950
MMWR 1993
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Smoking
A Pediatric Epidemic
>5 million children will die
prematurely from cigarettes
Most adults started < age 18
During grades 6-9
If start age 14- 16 1.6x more
dependence
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Tobacco-Caused Illness
~90% of all lung cancers
~100% COPD
2X death from stroke/ CAD
Half of all smokers die from a
tobacco-caused disease
Surgeon General’s Report 2004
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Other Consequences
Other Cancers
Oral
Esophagus (cigars/ chew)
Cervix
Bladder
Pancreas (cigars)
Costs > $100 billion annually
Primary cause of fatal house fires
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It’s the Smoke that Kills
Cigarette smoke > 4000
compounds
Acetone, Cyanide, Carbon Monoxide,
Formaldehyde
> 60 Carcinogens
Benzene, Nitrosamines
(CDC
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2003)
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Environmental Tobacco Smoke
ETS is a known human
carcinogen (Class1A), in the
same class as asbestos
50,000 additional deaths/ year in
non-smokers
~3000 from lung cancer
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This Lecture will Cover
Epidemiology /consequences
Nicotine pharmacology
Assessment
Pharmacological treatments
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Nicotine Pharmacology
Pharmacology depends on delivery route
Reaches brain in 10 sec
Arterial levels 6-10x higher than venous
Half-life 2 hours
Metabolized to cotinine in liver
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Russell et al., BMJ, 1983
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Nicotine
Possible therapeutic effects:
Alzheimer's
Attention deficit disorder
Autism
Schizophrenia
Ulcerative colitis
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Nicotine Safety
Smokers misinformed about
safety/efficacy of nicotine


Not a carcinogen
Not a significant risk factor for
cardiovascular events
Risk-benefit ratio supports nicotine
medications over using tobacco
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This Lecture will Cover
Epidemiology /consequences
Nicotine pharmacology
Assessment
Pharmacological treatments
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Nicotine Dependence
≥ 90% smokers meet dependence criteria
– withdrawal
– tolerance
– desire or efforts to cut down/ control use
– great time spent in obtaining/using
– reduced occupational, recreational activities
– use despite problems
– larger amounts consumed than intended
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Nicotine Withdrawal
Depressed mood
Insomnia
Irritability, frustration or anger
Anxiety
Difficulty concentrating
Restlessness
Decreased heart rate
Increased appetite or weight gain
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Heaviness of Smoking Index=
Measure of Dependence
Number of cigarettes per day (cpd)
AM Time to first cigarette (TTFC)
≤ 30 minutes = moderate
≤ 5 minutes = severe
(Heatherton 1989)
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Hard to Quit Without Treatment
70% of smokers want to quit
Few quit without treatment
< 1/3 remain abstinent for 2 days
< 5% ultimately successful per
quit attempt
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Role of Physician
5As
Ask, Advise, Assess, Assist, Arrange
Brief physician advice ↑ quitting
10% quit rates with < 3 minutes
20% quit rates >10 minutes
Tobacco dependence = chronic condition
< 25% successful on first attempt
> 8 quit attempts before successful
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This Lecture will Cover
Epidemiology /consequences
Nicotine pharmacology
Assessment
Pharmacological treatments
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Pharmacological Treatment
Rationale
Reduce or eliminate withdrawal
Block reinforcing effects of nicotine
Manage negative mood states
Unlearn smoking behaviors
Cost-effective treatment
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Pharmacological Treatment
Nicotine Replacement
Patch
Gum
Lozenge
Inhaler
Nasal Spray
Bupropion
Varenicline
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Nicotine Replacement Therapy
(NRT)
Nicotine absorption poorer than cigs
Lower dose delivered
Poorly orally absorbed; ↑ first pass
metabolism
Less rewarding than smoking
Under dosing common
Worsened by poor compliance
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Few Contraindications to NRT
With caution if:
Recent MI
Smokes < 10 cpd
Pregnant/breastfeeding
Adolescents (Not FDA approved)
Mild side effects
Mostly local
Systemic, less common
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Nicotine Patch
Slow onset
Continuous delivery
24 or 16 hour dosing
Easy, good compliance
Gradual taper
Side effects- skin, insomnia
OTC
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Nicotine Gum
Use every 1 hour
Bite and “park”
Slow, buccal absorption
Acidic foods ↓ absorption
Slight mouth, throat burning
Dose: 2mg < 25 cpd
4mg > 25 cpd
OTC
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Nicotine Lozenge
Don’t chew
2 and 4mg dose
Up to 20 lozenges/ daily
Dose based on TTFC
2mg if > 30 mins
4 mg< 30 mins
OTC; No generics
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Nicotine Inhaler
6-16 cartridges/day
Puff for 20-30 minutes
Misnomer (Oral puffer)
Acidic foods ↓ absorption
Slight throat irritation,
cough
Rx needed
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Nicotine Nasal Spray
Rapid delivery
Most side effects (nasal
irritation, rhinitis, coughing,
watering eyes)
2 sprays= 1 dose
Up to 40 doses/day
Some dependence liability
Rx needed
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Bupropion SR
Nonsedating/ activating
Affects NE and DA, nicotine receptor
Side effects- headache, insomnia
Don’t use: seizures/ eating disorder
Start 10-14 days prior to quit date
300mg dose has least weight gain
Rx needed
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Efficacy of Medications
NRT 2x success vs. placebo
25-30% Efficacy
Efficacy NRT ≃ bupropion
Patient preference, cost, tolerability
Combinations Improve Outcomes
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Varenicline
• Nicotinic partial agonist
• 1mg BID dose superior to placebo or
bupropion in 12 week trials
• Additional 12 weeks prevented relapse
• Nausea, headache, insomnia and
abnormal dreams- most common side
effects
• Discontinuation rate similar to placebo
Gonzales et al., 2006; Tonstad et al., 2006; Jorenby et al., 2006
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Conclusions
It’s the smoke that kills – not the
nicotine
All practitioners should treat tobacco
Treatments ↑success
Six FDA approved treatments:
effective and well tolerated
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Free Resources
1. PHS Guidelines
www.surgeongeneral.gov/tobacco/treating_t
obacco_use.pdf
2. Surgeon General Report (2004)
www.hhs.gov/surgeongeneral/library/
smokingconsequences/
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