Transcript SMOKING CESSATION - Mike`s Medical Stuff

SMOKING CESSATION –
The #1 Health Priority for our smoking patients
Mike Murchie
Health Risks
• Early DEATH!!!
• On average smokers
die 10 years earlier
than nonsmokers
Health Risks
• Pulmonary – COPD / Emphysema
• Vascular – CVA, CAD, AAA, PVD, Buerger’s
• Other - catarcts, chronic cough, skin damage,
poor oral health, low bone density, gerd, firerelated injury, pregnancy related, second-hand
smoke, female infertility, cataracts, macular
degeneration
• Cancer
– lung, mouth, esophagus, stomach, pancreas, bladder,
kidney, cervix, AML, +/- colon
Smoking Related Deaths
Other
Cancers
8%
Respiratory
causes
24%
CV disease
37%
Lung
Cancer
31%
Public Health Consequences of
Smoking
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#1 preventable cause of death in the US
440,000 deaths per year in US
5 million deaths per year worldwide
8.6 million in US are disabled from
smoking-related diseases.
• 2x as many deaths as HIV/AIDS, alcohol
abuse, MVA’s and suicide COMBINED!!!
Benefits of Quitting
• Longer life
– If quit before 50yo, ½ risk for dying within next 15years
– 2 Large Studies – Smokers aged 65 and up who continue to
smoke have higher mortality and cv, neoplasia at 5 yr f/u than
those who quit.
– Patients >65yo who quit add 4 years to their life on average
• Chronic cough –
– 94-100% resolves or decreases.
– 50% resolve within a few weeks
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Lung function – improves within 3 months
Shortness of Breath improves within 1-9 months
Skin, breath, teeth, gum effects reverse
Smell, taste improve
Source - “In the Clinic: Smoking Cessation”, Laine et al, Annals of Internal Medicine, Volume 146(3), 2/6/2007, pgs ITC2-1-ITC2-16
Benefits of Quitting
Public Health
• Reduction of Second Hand Smoking’s Effects
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~3000 lung ca related deaths a year
Assoc w/ nasal sinus, cervix, breast, bladder CA
Assoc w/ chronic cough, decr lung funct
60,000 annual heart disease deaths in adult
nonsmokers attributable to 2nd hand smoking
– In Kids, increased risk of sids, severe asthma,
pneumonia, ear infections
• Cost of smoking cessation efforts per life-year
saved = $2000
(Mammogram = $50,000)
Benefits of Quitting
Financial
• Cost Savings
Cost of a Pack of Cigarettes in Indiana =
$
3.81
1month
6months
1year
5 years
10 years
20 years
30 years
40 years
.5ppd
$57.15
$342.90
$685.80
$3,429.00
$6,858.00
$13,716.00
$20,574.00
$27,432.00
1 ppd
$114.30
$685.80
$1,371.60
$6,858.00
$13,716.00
$27,432.00
$41,148.00
$54,864.00
1.5ppd
$171.45
$1,028.70
$2,057.40
$10,287.00
$20,574.00
$41,148.00
$61,722.00
$82,296.00
2 ppd
$228.60
$1,371.60
$2,743.20
$13,716.00
$27,432.00
$54,864.00
$82,296.00
$109,728
• Doesn’t include: Health care savings
• Doesn’t adjust for inflation or increasing taxes
Benefits of Quitting
Financial
• Duke Health Economists estimated the
cost of smoking (including all factors) to be
$40 per pack
– $33 of the $40 paid for by the individual
– Costs to society in general pretty much
neutral due to early death of smokers
“The Price of Smoking”, Sloan et al, December 2004.
Benefits of Quitting
Financial
• Health and life insurance rates decrease
• Employment options may increase
• Worker productivity may increase
– 20 cigarettes in a pack, about 10 minutes to
smoke each cigarette = 3 hours and 20
minutes of smoking a day
Why is it so difficult to quit?
• Nicotine is Highly addictive
– 1/3 of people exposed to
nicotine become addicted
• Mood-elevating response
• Withdrawal syndrome, weight
gain, etc
• Habit
• Smokers claim it provides
short term “Stress relief”
Why aren’t physicians better at
helping their patients to quit?
• We’re “too busy” taking care of the other
problems their smoking has contributed too
• Rx given without much behavioral counseling or
before patients motivated to quit
• Myths
– Fatalism, i.e. “he’ll never quit”
– “She’s too old to quit, it wouldn’t make any difference
at this point”
• Smoking Cessation counseling reimbursement
is sporadic
– Medicare part B covers only for patients with
diseases/health effects related to smoking
Smoking Cessation Game Plan
Be nonjudgemental and truthful
• Ask
• Advise
• Assess
• Assist
• Arrange
• Anticipate
Techniques
• Cold Turkey
• Behavioral Interventions
• Medications
Cold Turkey
• No difference between gradual versus
abrupt cessation
• Quit rates are better with intervention, but
clearly there is a subset that this works for
Behavioral Interventions
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Brief Physician Advice
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Self-Help Therapy (websites, leaflets, etc)
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Not useful alone
Individual Therapy
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More time and more sessions better than less but
even a small amount is effective
Consider an entire appointment for smoking
cessation strategies
Behavioral Interventions
• Quitlines
– Best are those with call-back counseling
• Group Therapy / Smoking Cessation
Classes
• Exercise, acupuncture, hypnosis, aversive
smoking
– Reviews don’t show benefit, but certain
individuals may benefit
Medications
• Nicotine Replacement
• Wellbutrin
• Varenicline
Medications
Cost Per Day
Cost at PCC
Pharmacy (before
discount)
Nicotine Replacement
(patch)
$3.75
$1.65
Wellbutrin
$3.33
$1.56
Varenicline
$4.00
$2.92
Medications
Nicotine Replacement
• Alleviates symptoms of withdrawl
– Gum/patch/lozenge/inhaler/nasal spray/sublingual tablet
– 1.5-2.5x increased quit rate over placebo at 6months for
motivated patients
– Start using on the person’s quit date (not before)
– Duration
• Usual Length Tx is 12-16 weeks
• Can step down gradually or abruptly withdraw when patient is ready.
No proven benefit to either approach
• Safety, efficacy of long term tx unknown
– Patch, gum cheapest out of pocket
– SE- skin irritation, throat irritation
– CI- MI within last month, severe angina, life-threatening
arrhythmia, pregnancy (category D).
– Safe for stable ischemic heart disease patients
Medications
Nicotine Replacement
Adapted from “Interventions to Facilitate Smoking Cessation”, American Family Physician
Pro’s
Con’s
QuitRate@6mo Cost per day
Less Potential for
addiction
Can use 24hr patch
overnight to decr am
cravings
Cheapest
Compliance
Skin irritation
Sleep disruption
Lower quit rate
8-21%
$3.60 – $4
Spray
Fastest delivery
Highest potential for
addiction
Frequent dosing
needed
Nose/eye irritation
Need rx
30%
$16.00 ??
Inhaler
Hand to Mouth
Few side effects
Need rx
Mouth/throat irritation
23%
$9.50 ??
Frequent dosing
No food/drink 15 min
before use
Dyspepsia
24%
$8.88
Higher potential for
addiction
No food/drink 15
minutes before use
Jaw pain, dyspepsia,
hiccups
24%
$9.33 - $10.33
Patch (16
hours or 24 hour
preparations
available)
Lozenge
Gum
Fast nicotine delivery
Medications
Bupropion
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Inhibits serotonin, NE, DA
Mechanism: Inhibits cravings, decreases withdrawal
One study showed bupropion 30% 1year quit rate vs 15% for nicotine
replacement
It’s NOT magical. Must be used in a motivated patient and with a specific
quit date to be effective!
May delay post-cessation weight gain
Start 1-2 weeks before quit date
Duration - continue for 8-12 weeks or longer
SE- nausea, dry mouth
CI- Seizures (rate is 1/1000 persons treated), eating d/o, MAO or MAO-like
agents within the past 14 days, antipsychotics, cocaine, psychostimulants,
sodium phosphate, theophylline, tramadol, systemic corticosteroids
Monitor BP
Category B in pregnancy
Medications
Varenicline
• Binds nicotine receptor, blunting the relaxing effect of nicotine
leading to reduced cravings
• 2 rct’s Varenicline vs Bupropion vs Placebo
– Abstinence at 4 weeks – 44% vs 30% vs 18%
– Abstinence at 9-52 weeks – 23% vs 16% vs 9%
• Another trial showed benefit of 12 additional weeks (total 24weeks)
for maintaining abstinence
• Start taking 1 week before quit date
• Duration- 12weeks with consideration of an additional 12weeks
• SE- Nausea (in 28.1% of patients in the above study) and Vomiting,
abnormal dreams, constipation, flatulence
• CI/Caution – Caution in renal impairment w/dose adjustments for
CrCl <50, Category C in pregnancy, probably excreted in breast milk
**Quit line available for varenicline users at no additional charge**
Medications
Others
• Approved - Clonidine, Nortryptiline
• Off-label- Naltrexone, Alprazolam, silver
acetate, mecamylamine, lobeline
Medications
Combination Therapy
• Effective for the most part
– Patch + Gum, Inhaler, or Spray increases
success by up to 50% over patch alone
– Veterans study showed no benefit for combo
NRT + Bupropion over Bupropion alone
• Consider for:
– A) those who have failed monotherapy, or
– B) initial treatment for those who have
multiple pack-years
Picking the right therapy for your
Patient
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Contraindications
Financial considerations
H/o Depression
Compliance
Combination Therapy
Patient Preference
Multi-Pronged Approach
Know and Use All Available Resources
• Quitlines
• Smoking Cessation Classes
• Medicine
Prepare Patients for Side Effects of Quiting
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Withdrawal Syndrome
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Most intense sx in first 72 hours after quitting. Syndrome lasts 2-8 weeks
Mild depression, anxiety
Headache
Nausea
“The shakes”
Hunger
Fatigue or insomnia.
Weight gain (Men averaged 4.4kg gain, Women 5.0kg)
– Naltrexone may be more weight neutral
– Nicotine gum and bupropion have been shown to delay, but not prevent weight
gain
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Depression
– Especially patients with prior MDD
Care After Quitting
• Continue to ask about abstinence after
they have “quit”
• Don’t give up when relapse occurs. Most
people that eventually quit permanently do
so after multiple attempts (on average, 8
attempts!)
• Set a new quit date when relapse occurs
and consider a new approach
• Urine cotinine testing in some
SUMMARY
• Smoking cessation is:
– The greatest thing smokers can do for their health
– The greatest piece of assistance a doctor can offer for their
patients who smoke
– Extremely cost effective
– Important for smokers of ANY # pack-years
– An achievable goal (with perseverance from patient and doctor)
– Best achieved with an individualized, multi-pronged approach
– Encouraged effectively through brief interventions, but better
success is seen with longer, more intensive measures
– Accompanied by withdrawal symptoms that patients should be
prepared for in advance
Resources
• Quit Lines
– 1-800-QUIT-NOW
• Local Resources
– Marion County HD free smoking cessation
classes schedule:
http://www.mchd.com/tobcess.htm
• Calculator - Personal cost of smoking
– http://www.cancer.org/docroot/PED/ped_10_C
igCostCalc.asp?sitearea=PED
References
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“Interventions to Facilitate Smoking Cessation”, Kolawole et al, American
Family Physician, Vol 74(2), 7/15/2006, pgs 262-271
“What to Do With a Patient Who Smokes”, Schroeder, JAMA, Vol 294(4),
7/27/2005, pgs 482-487
“In the Clinic: Smoking Cessation”, Laine et al, Annals of Internal Medicine,
Volume 146(3), 2/6/2007, pgs ITC2-1-ITC2-16
“Randomized Comparative Trial of Nicotine Polacrilex, a Transdermal
Patch, Nasal Spray, and an Inhaler”, Hajek et al., Annals of Internal
Medicine, Volume 159(17), 27 September 1999, pp 2033-2038
“Overview of Smoking Cessation”, Rennard et al, Up To Date Online
“A controlled trial of sustained-release bupropion, a nicotine patch, or both
for smoking cessation,” Jorenby et al., New England Journal of Medicine,
340(9):685-91, 3/4/1999.
http://www.quitsmokingsupport.com
“The Price of Smoking”, Sloan et al, December 2004.