Smoking Cessation. MariBeth Kuntz, PA-C Duke Center for Smoking Cessation
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1 Smoking Cessation MariBeth Kuntz, PA-C Duke Center for Smoking Cessation
2 Objectives Tobacco use at population level Tobacco use and control around the world What works for managing tobacco use Common myths and misconceptions
3 U.S. Statistics 15.1% percent of US population Drops 0.58% per year 70% would like to quit Mean attempts = 7 Banks et al., BMC Medicine, 2017; CDC 2015
4 Who Smokes? Income Status Prevalence Education Level Prevalence GED 43.0% High school graduate 21.7% Some college 19.7% Associate degree 17.1% Undergraduate degree 7.9% Postgraduate degree 5.4% Below poverty level 26.3% At or above poverty level 15.2% Mental Health Conditions: 40% of men and 34% of women with a mental health condition smoke 31% of all cigarettes are smoked by adults with a mental health condition
5 Lung Cancer 137,989 (29%) Other Cancers 36,000 (7%) Over 540,000 US Deaths Each Year From Smoking Chronic Obstructive Pulmonary Disease 100,600 (21%) Heart Disease 158,750 (33%) 67% of smokers die from smoking Stroke 15,300 (3%) Other Diagnoses 31,681 (7%) Banks et al. 2015
6 2014 Surgeon General s Report Pulmonology: COPD, asthma exacerbation, pneumonia recurrence Cardiovascular: CV Events (non-linear response), cardiac arrest, stroke, DVT/PE (OR = 1.17), PAD (OR = 5.1). Diabetes: (OR = 1.3) Ophthalmology: Cataracts (OR = 1.6), macular degeneration Obstetrics: Preterm delivery (OR = 1.7), stillbirth, ectopic pregnancy
7 CANCERS CAUSED BY SMOKING Smokers vs. Non- Smokers Former Smokers vs. Non-Smokers Bladder RR = 2.77 ( ) RR = 1.72 ( ) Breast RR = 1.32 ( ) RR = 1.09 ( ) Cervical RR = 1.83 ( ) RR = 1.26 ( ) Lung RR = 8.43 ( ) RR = 3.85 ( ) Colorectal RR = 1.70 ( ) RR = 1.20 ( ) Esophageal RR = 2.50 ( ) RR = 2.03 ( ) Renal RR = 1.52 ( ) RR = 1.25 ( ) Leukemia RR = 1.60 ( ) RR = 1.40 ( ) Gastric RR = 1.64 ( ) RR = 1.31 ( ) Pancreatic RR = 1.74 ( ) RR = 1.20 ( ) Liver RR = 1.70 ( ) RR = 1.49 ( ) Oral RR = 3.43 ( ) RR = 1.40 ( ) Gandini, S., E. Botteri, S. Iodice et al Tobacco smoking and cancer: a meta-analysis. International Journal of Cancer 122: Lee, P.N., B.A. Forey, & K.J. Coombs Systematic review with meta-analysis of the epidemiological evidence in the 1900s relating smoking to lung cancer. BMC Cancer 12: 385. Musselman, J.R.B., C.K. Blair, J.R. Cerhan et al Risk of adult acute and chronic myeloid leukemia with cigarette smoking and cessation. Cancer Epidemiology 37 (4): Theis, R.P., S.M. Dolwick Grieb, D. Burr, T. Siddiqui, and N. R. Asal Smoking, environmental tobacco smoke, and risk of renal cell cancer: a population based case-control study. BMC Cancer 8: 387. USDHHS The Health Consequences of Smoking 50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health
8 Smoking Abstinence Rates Self-directed quit attempt < 5% abstinence Provider Advice and Treatment = 10-12% Quitline = 11% Specialized Treatment = 40-50% Fiore, Clinical Practice Guideline, 2008; Lee et al. Anesth Analg, 2015; Davis et al. 2017
9 Evaluation and Individual Variation High-level Dependence Genetics - 10,000 genes High Stress/ Poor Coping Skills High correlation to relapse Anxiety/Depr./PTSD/Bip/Sc hiz. 30.9% of smokers Alcohol or Drug Use 30% smokers drink 85% relapse Low Self-Efficacy High correlation, pre-quit, post quit Weight Gain 15% put on 30 lbs (major risk) Poor Social Support Health Literacy Economic Challenges Uhl, et al. Arch Gen Psychiatry, 2008; Brandon, et al. Psych Addict Behav, 1996; Aubin, et al. BMJ, 2012; CDC MMWR Vital Signs, 2013; Cohen, et al. 1990; García-Rodríguez, et al. Drug Alcohol Depend, 2013; Ochsner, et al. Annals of Behavioral Medicine, 2014; Slopen, et al. Cancer Causes Control, 2013; Smit, et al. Addictive Behaviors, 2014
10 Relative Risk Abstinence Rate for placebo = 10% Varenicline RR = % Patch + Immediate Release Nicotine RR = % Nicotine Patch RR = % Nicotine Gum RR = % Nicotine Lozenge RR = % Nicotine Inhaler RR = % Nicotine Nasal Spray RR = % Bupropion RR = % Nortriptyline RR = % Clonidine RR = % Cahil 2013, Cochrane Review
11 CHARLIE TABLE Relative risk Abstinence rate Studies Citation Nicotine Matching RR = % 10 smaller trials Brokowski 2014 Varenicline + Bupropion RR = 1.35 vs. Varenicline 33% 2 trials OR = 1.52 (Ebbert); OR = 1.89 (Rose) Varenicline + Patch RR = 1.41 vs. Varenicline 34% 2 trials Koegelenberg 2014; Ramon 2014; Chang 2015 Adaptive Treatment RR = % 2 trials Rose 2014 Rose 2016
12 Why Use Tobacco Many different reasons to initiate, but continuous use and inability to stop due to Dependence and tolerance Cue-induced cravings Withdrawal Alleviated by 1) using tobacco 2) use NRT 3) wait for selfresoluotion
13 Long acting medications Treatment options Nicotine patch, varenicline, bupropion Short acting medications Nicotine gum, lozenge, inhaler or spray Second line therapies Nortriphytline, clonidine Nicotine vaccines
14 EAGLES TRIAL: Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders Robert M Anthenelli, Neal L Benowitz, Robert et al. (April 2016) 8144 participants: 4028 to the non-psychiatric cohort; 4116 to the psychiatric cohort Assessed for moderate and severe neuropsychiatric adverse events. Non-psychiatric cohort: 13 (1 3%) of 990 participants varenicline group, 22 (2 2%) of 989 in the bupropion group 25 (2 5%) of 1006 in the nicotine patch group 24 (2 4%) of 999 in the placebo group Psychiatric cohort: 67 (6.5%) of 1026 participants in the varenicline group 68 (6 7%) of 1017 in the bupropion group 53 (5 2%) of 1016 in the nicotine patch group 50 (4 9%) of 1015 in the placebo group Differences were non-significant Abstinence rates vs. placebo: Varenicline OR = 3.61 Nicotine Patch OR = 1.68 Bupropion = 1.75
15 FDA revises description of mental health side effects for Chantix (varenicline) and Zyban (bupropion) : As a result of our review of the large clinical trial, we are removing the Boxed Warning, FDA s most prominent warning, for serious mental health side effects from the Chantix drug label. The language describing the serious mental health side effects seen in patients quitting smoking will also be removed from the Boxed Warning in the Zyban label.
16 Evidence-Based Behavioral Treatment Motivational Interviewing (OR = 1.2) Contracting (OR = 1.2) Skills Training (CBT) (OR = 1.7) Mindfulness (OR = 1.6) Social Support (OR = 1.5) Cohen, et al.1990; Lindson-Hawley et al. Cochrane Review, 2012; Fiore, Clinical Practice Guideline, 2008
17 Follow-Up 1 year of Phone/IVR/SMS/ vs. no Follow Up Ottawa Model (29.4% vs.18.3%) Harvard Model (26.0% vs. 15.0%) Joseph et al. 2011; Reid et al. 2010; Rigotti et al. 2014
18 What Improves Outcomes? Evaluation Medications Behavioral Treatment Follow up Fiore, Clinical Practice Guideline, 2008; Cahill et al. Cochrane Review, 2013; Stead & Lancaster, Cochrane Review, 2012
19 Relapses Considerations Smoking relaxes me when I smoke Medications are dangerous and I don t need them to quit? Chantix horror stoies Whole person treatment E-cigarettes
20 The Duke Smoking Cessation Program 1. Arrival written evaluation, CO, spirometry. 2. Medical provider visit (PA, TTS) 3. Behavioral provider as needed 4. Phone based follow up (MA, TTS)
21 The Duke Smoking Cessation Program Fagerström Test for Nicotine Dependence
22 Other Assessments Nicotine withdrawal mood and physical symptoms scale (2 items) Alcohol use - AUDIT-c Drug abuse drug abuse screening testing Depresttion PHQ-9 Anxiety- GAD-7 Stress perceived stress scale
23 Follow Up Visits Carbon monoxide trending Checking on behavioral changes Expectations for withdrawal Explain realistic length of treatment plan Lung cancer screening discussion
24 Insurance Coverage for Services Visits Covered by Medicaid, Medicare, and private insurances Behavioral Treatments Covered by insurance Medications Medicaid covers all meds Medicare/Private covers prescription medications Patient assistance programs available
25 Duke Center for Smoking Cessation The Duke Center for Smoking Cessation is committed to researching novel treatments to help smokers break the addiction of nicotine QUIT (7848) 2424 Erwin Rd, Ste 201 Durham, NC
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