Tobacco Cessation: Priority for Health Providers. Acknowledgements. Tobacco Cessation: Secondhand Smoke. Smoke-Free Environment & CA

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2 Acknowledgements Smoking Cessation Leadership Center Rx for Change Tobacco Use and Dependence: 2008 Update Tobacco Cessation: Priority for Health Providers Leading preventable cause of death in U.S. 480,320 die each year 37,000 in CA each year Substantial costs $175.9 billion in annual smoking-attributable health costs 16.8% of U.S. adults are current smokers 40.0 million adults CDC, MMWR, 2015; SGR 2014 Tobacco Cessation: Secondhand Smoke Causes an additional 41,280 deaths per year California Adult Cigarette Smoking Prevalence: % 25% California one of only two states to reach the federal Healthy People 2020 target of reducing the adult smoking prevalence rate to 12 percent Causal health harms Myocardial Infarction and other cardiovascular disease Lung and other cancers Asthma and URI disorders in children Low birthweight and sudden infant death syndrome SGR 2006, % 15% 10% 5% 0% 1988: 22.7% 2013: 11.7% CA Dept of Public Health, Basic Ways to Get Smokers to Quit Increase the price of tobacco Ban smoking in public places Effective countermarketing Ban tobacco advertising and promotion Provide smoking cessation treatment Schroeder, JAMA, 2005 Smoke-Free Environment & CA American Lung Association State of Tobacco Control 2016: CA gets an B for smoke free air B but loopholes likely to be closed F for tobacco prevention & cessation F for cigarette tax UC campuses are tobacco-free as of 2014 UCLA was tobacco-free as of April 22, 2013 First full campus

3 Tobacco Cessation: Priority for Health Providers Most smokers want to quit 69% of current smokers want to quit 52% tried to quit in the past year Only 32% of those who tried to quit got help 30% got medications, 6% got counseling, 4% got both Less than half of smokers (48%) who saw a health provider in the past year reported receiving advice to quit 70% of smokers saw health providers in the past year CDC, MMWR, 2011 Tobacco Cessation: Barriers Against Interventions 1. Too busy 2. Lack of expertise 3. No financial incentive 4. Most smokers can t/won t quit 5. Stigmatizing smokers 6. Respect for privacy 7. Negative message might scare away patients 8. I smoke myself Schroeder, JAMA, 2005 Tobacco Cessation: Clinical Practice Guideline The 5 A s Update issued in 2008 Review of current guidelines 5 A s Behavioral treatments (quitlines) Pharmacotherapy Nicotine replacement, bupropion, varenicline ASK ADVISE ASSESS ASSIST ARRANGE about tobacco USE tobacco users to QUIT readiness to make a QUIT attempt with the QUIT ATTEMPT FOLLOW-UP care Fiore et al.,treating Tobacco Use and Dependence. Clinical Practice Guideline, 2008 Streamlining the Steps Quitlines ASK ADVISE REFER about tobacco USE tobacco users to QUIT to a QUITLINE or internal resource Schroeder, JAMA, QUIT-NOW Routes to state quitline California: NO-BUTTS Effectiveness Odds Ratio of quitting: 1.56 NRT Odds Ratio: 1.74

4 California Quitline Available in multiple languages English, Spanish, Mandarin, Cantonese, Korean, Vietnamese Hours of Operation: 7 am to 9 pm Closed: Sundays and Holidays UC Quits Can now request California Smokers Helpline in CareConnect Both outpatient and inpatient workflows Helpline encounter reports go to your Results inbox Phone counseling: usually six sessions Initial session: 35 minutes Five 8-minute follow up sessions after quitting 1, 3, 7, 14, 28 days post quit Other Resources: Internet, Text Internet sites: Little evaluation to determine effectiveness Text program (txt2stop) in UK shown to be effective in 6 month abstinence 10 7% txt2stop vs 4 9% control, relative risk: 2.20 Civljak, Cochrane, 2010; Free, Lancet, 2011 Pharmacotherapy Nicotine Replacement Therapy gum, patch, lozenge, nasal spray, inhaler Bupropion Varenicline Nicotine Gum Nicotine Lozenge Gum use may satisfy oral cravings Gum use may delay weight gain Patients can titrate therapy to manage withdrawal symptoms Gum may not be socially acceptable Gum is difficult to use with dentures Patients must use proper chewing technique to minimize adverse effects Lozenge use may satisfy oral cravings The lozenge is easy to use and conceal Patients can titrate therapy to manage withdrawal symptoms Gastrointestinal side effects (nausea, hiccups, and heartburn) may be bothersome

5 Nicotine Gum and Lozenge: Dosing Transdermal Nicotine Patch Recommended Usage Schedule Weeks 1 6 Weeks 7 9 Weeks piece q 1 2 h 1 piece q 2 4 h 1 piece q 4 8 h DO NOT USE MORE THAN 24 PIECES OF GUM (20 LOZENGES) PER DAY. The patch provides consistent nicotine levels The patch is easy to use and conceal Fewer compliance issues are associated with the patch Patients cannot titrate the dose Allergic reactions to adhesive may occur 16-hr patch may lead to morning nicotine cravings Patients with dermatologic conditions should not use Nicotine Patch: Dosing Nicotine Nasal Spray Product Light Smoker Heavy Smoker NicoDerm CQ Generic (formerly Habitrol) 10 cigarettes/day Step 2 (14 mg x 6 weeks) Step 3 (7 mg x 2 weeks) 10 cigarettes/day Step 2 (14 mg x 6 weeks) Step 3 (7 mg x 2 weeks) >10 cigarettes/day Step 1 (21 mg x 6 weeks) Step 2 (14 mg x 2 weeks) Step 3 (7 mg x 2 weeks) >10 cigarettes/day Step 1 (21 mg x 4 weeks) Step 2 (14 mg x 2 weeks) Step 3 (7 mg x 2 weeks) Patients can easily titrate therapy to rapidly manage withdrawal symptoms Nasal/throat irritation Dependence can occur Patients must wait 5 minutes before driving or operating heavy machinery Patients with chronic nasal disorders or severe reactive airway disease should not use Nicotine Inhaler Bupropion SR Patients can easily titrate therapy to manage withdrawal symptoms The inhaler mimics hand-to-mouth ritual of smoking Initial throat or mouth irritation Can t store cartridges in very warm conditions or use in very cold conditions Patients with underlying bronchospastic disease must use with caution Easy to use Bupropion SR can be used with NRT Might be beneficial for patients with depression Seizure risk is increased Caution in patients with seizures or cranial trauma history, meds lowering seizure threshold, abrupt stop of alcohol/sedatives, anorexia / bulimia nervosa Black box warning for suicidality risk Caution in patients with neuropsychiatric issues MAO use, liver disease 29 contraindications

6 Bupropion: Dosing Varenicline Initial dose titration Patients should begin therapy 1 to 2 weeks PRIOR to their quit date. Treatment Day Day 1 to day 3 Day 4 to end of treatment* Dose 150 mg qam 150 mg bid * Up to7 to 12 weeks Easy to use oral formulation Offers a new mechanism of action for persons who have failed other agents 4 2 nicotinic acetylcholine receptor partial agonist Black box warning for suicidality risk Caution in patients with neuropsychiatric issues Nausea in up to one third of patients Other side effects insomnia, abnormal dreams, constipation, flatulence, vomiting Varenicline and Bupropion (Zyban): FDA Black Box Warning Depressed mood, agitation, changes in behavior, suicidal ideation, and suicide reported in varenicline and Zyban users Black Box warning issued February 2008 Over 40% of current smokers have an active alcohol, drug, or mental disorder Patients should tell their health care provider about any history of psychiatric illness prior to starting this medication Health care providers should monitor patients for changes in mood and behavior elicit information on their patients psychiatric history Initial dose titration Varenicline: Dosing Patients should begin therapy 1 week PRIOR to their quit date. Gradual dose increase to minimize treatmentrelated nausea and insomnia Treatment Day Day 1 to day 3 Day 4 to day 7 Day 8 to end of treatment* Dose 0.5 mg qd 0.5 mg bid 1 mg bid * Up to 12 weeks Patients not ready to quit? RCT of 1510 patients not willing to quit or reduce use by 1 month but willing to quit at 3 months 6 months of varenicline vs. placebo 27% cessation in varenicline arm vs. 10% cessation in placebo arm at 1 year Ebbert, et al., JAMA, 2015 Combination Therapy Combination NRT Long-acting formulation (patch) Produces relatively constant levels of nicotine PLUS Short-acting formulation (gum, inhaler, nasal spray) Allows for acute dose titration as needed for nicotine withdrawal symptoms Bupropion SR + Nicotine Patch (+ gum) Varenicline + Nicotine Patch Counseling with all medication approaches

7 Special Populations All tobacco users are recommended for intervention with medications, except other tobacco users light smokers pregnant women Adolescents (NRT ok) Smokers with comorbid alcohol, drug, or mental disorders Fiore et al.,treating Tobacco Use and Dependence. Clinical Practice Guideline, 2008 Other forms of tobacco E-cigarettes Hookahs Snus (wet snuff) Dry snuff Spit/chew tobacco Cigars Pipes Kreteks Bidis Roll-your-own Special Populations: Noncigarette Tobacco Users Key population due to increasing numbers Treatments Few studies with these users Recent study showing success among snus users with varenicline Counseling is recommended Based on few studies, other medications (bupropion and NRT) equivocal Fagerstrom et al., BMJ, 2010; Ebberts et al., Cochrane Reviews, 2011 Hookah Also known as waterpipe, shisha, narghile, hubble-bubble Flavored tobacco is burned in a smoking bowl covered with foil and coal Smoke is cooled by filtration through a basin of water and consumed through a hose Prevalent in North Africa, Mediterranean region, parts of Asia Shafey et al.,the Tobacco Atlas, 2009 Hookah Increasing problem at U.S. colleges 9.6% of college students in National College Health Assessment Survey used hookah in the past 30 days 22.9% had ever used hookah 16.3% smoked cigarettes in the past 30 days 48.7% of hookah users also smoked cigarettes Increasing problem in California In 2008, 24.5% of men and 10.0% of women aged have used hookah Jarrett et al.,nicotine & Tobacco Research, 2012, Smith et al., American Journal of Public Health, 2011 Hookah Perceived as, but not safer than cigarettes Estimated by WHO that one hour of smoking hookah equivalent to smoking 100 cigarettes Hookah smoke is associated with lung cancer, respiratory illness, low birth weight, periodontal disease, and heart disease Intervention studies lacking for hookah use Little focus until now User profiles not exactly like cigarette users Jarrett et al.,nicotine & Tobacco Research, 2012; Maziak et al., Cochrane Reviews, 2007

8 Electronic cigarettes AKA e-cigarettes or vaping CA young adult: 2.2% in 2012, 8.6% in 2013 Combination of disposable nicotine cartridge and aerosolizing device US FDA classified as tobacco product April 2011 Courts blocked regulating as drug delivery device Proposed regulations 2014 CTCP, 2015; Grana et al, Circulation, 2014 Electronic cigarettes Current debate whether these could be used for cessation or harm reduction products USPSTF 2015 review: insufficient evidence to recommend for cessation Recent meta-analysis shows reduced likelihood of quitting (OR 0.72) if using electronic cigarettes Variability in manufacturer of these devices No long term studies on propellants in devices Should we focus on cessation or transfer to products with safer profile? Don t we have these already with NRT? Siu et al. Ann Intern Med, 2015; Patnode et al., Ann Intern Med, 2015; Kalkoran & Glantz, Lancet Resp Med, 2016; Grana et al., Circulation, 2014; Benowitz & Goniewicz, JAMA, 2013 Learning Objectives Recap Review current approaches for primary care providers to assist patients with tobacco use cessation Ask, advise, refer; remember quitlines Review pharmacologic aids for tobacco use cessation NRT, bupropion, varenicline Review other forms of tobacco whose use are becoming increasingly prevalent Remember to ask about other tobacco use