Transcript 6_Ferentz_Stop Smoking Now!_v3_all good can use

Stop Smoking Now!
Kevin Scott Ferentz, MD
Associate Professor
Department of Family & Community Medicine
University of Maryland School of Medicine
Cigarette smoking is
the single most
important cause of
disease and
premature death in
the United States!
Cigarette-Related Deaths
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440,000 per year
12 million dead since first surgeon general’s
report in 1964
Smokers die 13-14 years earlier
Half of all long-term smokers will die a
tobacco-related death
Medical costs: $96 billion
Lost productivity: $97 billion
Costs: $ 40/pack
Smoking in the U.S. - 2009
 20.6% of adults (43% in 1966)
 Unchanged since 2004
 West Virginia 26.6%, Utah 9.2%
 men (23.5%), women (17.9%)
 < HS diploma: 28.5%, graduate degree: 5.6%
Rate dropping by < 1% per year
 1.3 million quit each year
 4,800 teens start each day
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 adolescent smoking rate stable
 More ex-smokers than current smokers
 2020 goal: 12% smokers
Smoking Worldwide
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1.3 billion smokers (1.7 by 2025)
Kills 5 million yearly; 10 million by 2020
84% of smokers are in developing countries
China - 300 million smokers
– 1.7 trillion cigarettes/year (3 million/min)
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Worldwide –
– 10 million cigarettes purchased each minute
– 15 billion sold each day
– 5 trillion produced and used annually
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One billion people will die this century unless
serious global anti-smoking efforts are made!
World Health Organization – 2007
Risks of Smoking
Increased Cancer Risk
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90% of lung cancer deaths
40% of all cancers
Mouth, larynx, esophagus, stomach
Kidney, bladder
Pancreas
Cervix
Acute myeloid leukemia
More women die of lung than breast cancer!
Heart Disease
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Leading cause of death
Smoking is major risk factor
3 times more likely to die of heart disease
Step-wise increase with other risk factors
Lung Disease
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90% of Emphysema deaths
Asthma
Bronchitis
Pneumonia
Female Smokers
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Infertility
Earlier Menopause
Osteoporosis
Birth Control Pills
Vaginitis
Pregnant Smokers
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Miscarriage
Placenta problems
Premature rupture of membranes
Preterm labor
Smaller babies
Increased fetal respiratory rate
Children of Smokers
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Respiratory Illness
SIDS
Cognitive Development
Behavioral Development
Cancer
Increased Risk of Smoking
Second-Hand Smoke
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3,400 lung Cancer deaths, 22,700-69,600 cardiac
deaths/yr
430 SIDS deaths in U.S./yr
35% of kids live with smokers
50-75% of kids in U.S. have detectable levels of cotinine
No risk-free level of exposure to smoke
– Platelets stick together
– Damages lining of blood vessels
– Decreases blood flow to coronary arteries
– Increasing risk of heart attack
Don’t walk through a cloud of cigarette smoke!
American Lung Association, 2008
Smokeless Tobacco
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“Spit” tobacco
Cancer of mouth, pharynx, esophagus
Tooth discoloration
Gums recede
Periodontal bone destruction
Death from juice ingestion
SNUS
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Moist powder tobacco product
Placed under upper lip for hours
No need for spitting
Steam-cured (not fire-cured), not fermented
Much lower concentrations of nitrosamines
More nicotine than cigarettes
Probably less harmful than cigarettes
Other Problems
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Fire Accidents
Gingivitis
Skin Wrinkles
Impotence
Decreased Stamina
Colds, Flu
Health Effects from Smoking
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Stroke
Dementia
Multiple Sclerosis
Anxiety & Depression
Cataracts
Macular Degeneration
Hearing Loss
Sinus Problems
Gum Disease
Tooth Decay
Heart Disease
Lung Disease – COPD,
asthma
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Osteoporosis
Rheumatoid Arthritis
Lupus
Wound Healing
Miscarriage
SIDS
Vascular Disease –
Impotence, AAA
Cancer
– Lung, ENT, pancreas
– Cervix
– Skin (squamous cell)
Smoking kills more
people each year than
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alcohol
cocaine
crack
heroin
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homicide
suicide
car accidents
fires
AIDS
C O M B I N E D!!!
©
What’s in a cigarette?
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4,000 chemicals
Tar
Carbon Monoxide
Nicotine
 Cigarette: 8-9 mg
(1-2 mg inhaled)
 Cigar: 100-400 mg
Criteria for Addicting Drug
 Dependence
 Tolerance
 Withdrawal
The effects on
health from
smoking are
reversible if a
smoker stops
smoking.
Health Benefits after Quitting
 Cough, shortness of breath resolve in weeks
 Exercise tolerance improves rapidly
 Bladder cancer: 50% reduction in 5 years
 Lung cancer: 50% reduction in 10 years
 Vascular disease: 50% reduction in 5 years
 Heart disease: 50% reduction in 1 year!
 No increased risk of heart disease by 10-15 years
 Mortality rates same as never smokers by 10-15
years
Resources
• printed materials
• National Cancer Institute
(1-800-4-CANCER)
• www.smokefree.gov
• Smokingstopshere.com
• 1–800–QUIT–NOW
(quit lines improve chances of quitting)
Non-Health Reasons for Quitting
 COST!!!
 $ 6.50/pack/day = $ 2,372/year
 inconvenience
 Self-esteem
 Role Model
Of course you can quit!
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millions of others have quit
more ex-smokers than smokers
most try many times before succeeding
past attempts are learning experiences
ways to deal with physical and
psychological dependence
Common Concerns
 Withdrawal
 short lived
 Cravings
 last 3-5 minutes, diminish rapidly
 Tension
 validate, normalize
 find other ways to cope
 Weight gain - not inevitable!
 1/3 gain: 5-8 lbs.
You have to quit!!!
(cutting down doesn’t work)
Go to a group if you
think it will help
(but you can do it alone!)
Think about the
positive aspects of
quitting – don’t focus
on the dangers of
continuing to
smoke…
Behavior Modification
Components of Addiction
 Physiological
 Psychological
 Behavioral
Behavior Modification
 Review reasons for quitting (index card)
 Identify triggers (4 day diary)
 Plans to avoid or cope with each trigger
Sample Plan
Trigger
Technique
after meals
on the phone
in the car
at desk
tension
coffee breaks
other smokers
crisis
leave table
draw
chew gum
carrot sticks
deep breathing
juice
non-smokers
self-talk
Behavior Modification
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Review reasons for quitting (index card)
Identify triggers (4 day diary)
Plans to avoid or cope with each trigger
Change habit: packs only, different brands
Develop support system (tell everyone)
Self rewards (day, week, month, year)
Written commitment to quit day
START - Behavior Modification
S = Set quit date (within 2 weeks)
T = Tell family, friends, co-workers
A = Anticipate and plan for challenges
you’ll face while quitting
R = Remove cigarettes - home, car, work
T = Talk to your doctor
Pharmacological Treatment
 All smokers should consider taking medication
 NRT - “methadone for the smoker”
 Gum
 Patch
 Lozenge
 Nasal Spray
 Inhaler
 Bupropion (Zyban®)
 Varenicline (Chantix®)
 All decrease cravings, withdrawal
 20-25% quit rates at 1 year
Nicotine Replacement - Gum
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Available since 1984
2 mg., 4 mg. (for > 25 cigs/day)
“chew, park, chew, park”
Use one every 1-2 hours
24 pieces maximum/day
Wean after 3 months, 6 months maximum
$ 0.50/piece
Use with patches, bupropion
Nicotine Replacement - Patches
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21, 14, 7 mg: wean over 8 weeks
22 mg, 11 mg single dose regimen
First patch - night before quit day
Rashes, abnormal dreams
No increased risk of heart attack
$ 3.50 per patch
©
Nicotine Nasal Spray
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One dose: 2 sprays (1 mg)
Minimum: 8 doses/day
Maximum: 40 doses/day (1/2 bottle)
If still smoking by week 4 - stop
Use for 3 – 6 months
Nasal irritation limits use
$ 0.50 per dose
Nicotine Inhaler
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nicotine deposited in mouth
80 puffs in 20 minutes
6 - 16 cartridges/day
3 months then wean over 3 months
40% throat irritation
$ 1.15 per cartridge
Nicotine Lozenges (Commit®)
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2 mg, 4 mg (if smoke w/in 30 min of waking)
12 week program
Weeks 1-6: 1 lozenge every 1 to 2 hours
Weeks 7-9: 1 lozenge every 2 to 4 hours
Weeks 10-12: 1 lozenge every 4 to 8 hours
At least 9 per day for the first 6 weeks
Hiccups, heartburn, nausea
No more than 5 in 6 hours, 20 per day
$ 0.50 per lozenge
Can work when patch, gum failed
E Cigarette
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Looks like a traditional cigarette
No tar or chemicals
Non –flammable; produces water vapor
Rechargeable lithium battery
No second-hand smoke
Nicotine cartridges: 0, 6, 11, 16 mg
– 20 cigarettes worth
– $ 100 per cigarette
– $ 2 per cartridge
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No efficacy data
Bupropion (Zyban)
 Increases dopamine in “pleasure center”
 150 mg a day for 3 days then 150 mg twice a
day for 4 days, then QUIT
 Continue for 7 - 12 weeks
 If not stopped by 8 weeks, discontinue
 Can use with nicotine replacement
 $ 3/day
Bupropion - Contraindications
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seizure disorder
prior or current eating disorder
MAO inhibitors
concurrent use of Wellbutrin®
Varenicline (Chantix®)
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Stimulates nicotine receptor and blocks binding
of other nicotine
“like inhaling sandpaper”
0.5 mg for 3 days, then 0.5 mg twice a day for 4
days, then 1 mg twice a day – quit day
Stop smoking after 7 days on medicine
Use for up to 6 months – preferable
Nausea, constipation, abnormal dreams
Black box warning: watch for behavior change,
hostility, agitation, depression, and suicidality
– possibly due to nicotine withdrawal
Cost: $ 3-4/day
Varenicline (Chantix®)
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6/2011 – Chantix may increase the risk
of cardiac events in people with and
without a history of heart disease
Stay tuned…
Pharmacotherapies for smoking cessation:
a meta-analysis of randomized controlled
trials (70 trials, 32,908 patients)
Therapy
varenicline
nicotine nasal spray
nicotine inhaler
bupropion
nicotine lozenge
transdermal nicotine
nicotine gum
Odd ratio
2.55(1.99-3.24)
2.37 (1.57-3.60)
2.18 (1.38-3.45)
2.12 (1.76-2.56)
2.06 (1.47-2.87)
1.88 (1.60-2.22)
1.65 (1.37-2.01)
Eisenberg MJ, et al. CMAJ. 2008; 179(2):135-44
Medications should always
be used in along with
behavior modification.
Factors which help
ex-smokers remain
ex-smokers
Maintenance
Relapse
 Rates are same as for heroin, alcohol
 At least 70% relapse within first year
 2/3 within first 3 months
 largest group within first week
 Factors:
 Early: withdrawal, cravings, habit
 Late: other smokers, food, alcohol, coffee
negative emotions, crisis
Preventing Relapse
 use and refinement of coping strategies
 “if you don’t want to slip, stay away from slippery
places”
 positive self-talks in response to slips
 Slips happen: Hungry, Angry, Lonely Tired
 continued commitment (one day at a time)
The Future
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Nicotine vaccine (NicVAX)
• Five shots in six months
• Antibodies attach to nicotine in
bloodstream, prevent crossing blood-brain
barrier
• Six months after last shot —
– 14-16% quit rate, 6% w/placebo
The 5 “A’s”
 ASK - identify tobacco users at all visits
 ADVISE - strongly urge all smokers to quit
 ASSESS - willing to make an attempt?
 REFER
 ASSIST - information, medication
 ARRANGE - schedule follow-up visit
For Those Unwilling to Quit – the 5 “R’s”
Relevance - why quitting is personally relevant
Risks - patient identifies negative consequences of
tobacco use
 Acute, long-term, environmental risks
Rewards - patient identifies benefits of stopping
Roadblocks - patient identifies barriers to quitting
Repetition - motivational intervention every visit