Tobacco & Nicotine: Addiction and Treatment

Transcription

1 Tobacco & Nicotine: Addiction and Treatment Tim McAfee, MD, MPH Chief Medical Officer - Free & Clear tim.mcafee@freeclear.com Affiliate Assistant Professor, University of Washington, School of Public Health 47 million US smokers 440,000 deaths/year >8 million disabled Smokers die ~ 8-13 years earlier 5 million smoking deaths/year in world Vital Statistics More than 440,000 Annual Deaths Attributable to Cigarette Smoking United States Ischemic Heart Disease 82,000 Other Cancers 31,000 Lung Cancer 125,000 Quitting Stats 19+ % of Americans smoke tobacco 70+% want to quit One in 20 quit attempts succeed Stroke 17,000 Chronic Lung Disease Other Diagnoses 105,000 Of those making a quit attempt: ~20% use a medication ~2% use behavioral support 82,000 Source: MMWR, 2005 Impact of Quitting Smoking Prospective study of 34,439 male British MDs Mortality monitored for 50 years ( ) Addiction Years of life gained Sir Richard Doll Age at cessation (years) Doll et al. (2004). BMJ 328(7455):

2 Nicotine Tertiary amine pyridine and pyrrolidine ring strongly alkaline Evolved as insecticide in tobacco Binds to nicotinic-cholinergic receptors stimulus effect in locus ceruleus reward effect in limbic system releases acetylcholine, norepinephrine, dopamine, serotonin, vasopressin, beta-endorphin, growth hormone & ACTH The Masters Speak We are in the business of selling nicotine, an addictive drug effective in the release of stress mechanisms Brown & Williamson, VP Addison Yeaman, 1963 Your turn Is nicotine addictive? How is it different and the same as other substances classically thought of as addictive? Drug Dependence Criteria Tolerance Psychoactive effects Withdrawal Use despite harm to self or others Cravings with compulsive use How is nicotine the same/ different from other addictive drugs? 85+% who use nicotine, use daily 10% of cocaine/etoh users Withdrawal not life-threatening Can be for alcohol Most severe consequences delayed? The Opportunity Most tobacco users want to quit Half make a serious attempt each year 5-7% who quit on their own succeed Assistance increases absolute success 15-40% Only one in 5 use meds one in 50 get counseling 80% see a HCP each year 2

3 MPH Treatment Perspective MD/HCP MPH: How do we increase quit success in a population (total quitters)?? Increase quit attempts Population prevalence Individual treatment Sweet Spot Greatest good from available resources Maximize the probability of success Compare costs to: Compare costs to: Raising taxes Clean indoor air regulation Product regulation Denormalization Lung cancer treatment Cancer screening Substance abuse treatment Road repair Increase use of evidence-based support during quit attempts Increase effectiveness of evidence-based support Task Force on Community Preventive Services Independent, nonfederal Task Force evidence-based focus on non-clinical interventions Reviewed 14 interventions to:* reduce ETS exposure reduce tobacco use initiation increase tobacco use cessation Strategies to increase tobacco use cessation Increasing unit price: strongly recommend Mass media campaigns (combine w other) - strongly recommend Health Care System-level interventions provider reminders: recommended provider education: insuff evidence provider remind + education: strong rec reduce patient out-of-pocket costs: rec multicomponent phone support: str. rec *Am J Prev Med February 2001 WHO recommends 3 treatment services for all countries Primary-care advice to quit Low-cost pharmacotherapy Easily accessible and free quitlines 3

4 Case Study: Mr G 53 y.o male with gradually increasing trouble breathing Past History: High blood pressure Smokes 1 pack/day Social: Married, 2 children, non-smokers Insured Through Work: No cessation benefit A long-term condition Stakes are high Relapse is part of nicotine dependence 19/20 relapse without treatment 2/3 relapse even with best treatment not an indication of personal failure The 5 A s ASK about tobacco use ADVISE to quit ASSESS willingness to make quit attempt ASSIST in quit attempt ARRANGE follow-up Treatment Methods In Use Counseling Group Counseling Telephone-based counseling 1:1 counseling Pharmacotherapy OTC Pharmacotherapy Rx Pharmacotherapy 4

5 25 Washington State Quit Line Available to all Half-hour coaching Triage Available to some Intensive Benefit: 4 calls & patches Pharmacotherapy Increases cessation rates Can increase use of behavioral therapies Pharmacologic Methods First-line Therapies Three classes of FDA-approved drugs for smoking cessation Nicotine replacement therapy (NRT) Nicotine gum, patch, lozenge, nasal spray, inhaler Psychotropics Sustained-release bupropion Partial nicotinic receptor agonist Varenicline Nicotine Patch Available in 7mg, 14mg, 21mg doses Easy to use, conceal Provides consistent Not recommended in patients with serious skin conditions 5

6 Available in 2mg, 4mg doses Nicotine Gum Patients can titrate Requires correct technique Not recommended in patients with dentures Available in 2mg, 4mg doses Nicotine Lozenge Patients can titrate A bit easier to use than nicotine gum Can have GI side effects What is Currently Approved? Front Line Treatments available with Rx only: Nicotine Inhaler Nicotine Spray bupropion varenicline Mimics hand to mouth action of smoking Nicotine Inhaler Patient can titrate Possible initial throat and mouth irritation Nicotine Spray Patient can titrate Easy to use bupropion Quick onset of action May be more effective than other forms of NRT Can result in dependence Side effects can be significant As effective as patch Might be useful in patients with depression Slight risk of seizure Contraindicated in a number of conditions 6

7 varenicline Reduces craving and withdrawal High efficacy Different mechanism than NRT Can cause nausea varenicline FDA Advisory Use with caution in patients with a history of psychiatric illness (includes depression). May cause changes in behavior or mood. May impair ability to drive or operate heavy machinery. NRT: Can you use in combination? Patch in combination with short acting (gum or spray) more effective than either alone Bupropion can be used with patch + = Increased Success Common Misconceptions I should use as little NRT as possible. Medications are a Magic Bullet. Nicotine will give me a heart attack. Maximizing Treatment Success NRT for Pregnancy and Youth Evidence is inconclusive Determine if benefits outweigh the risks. Medication plus counseling is the most effective treatment US PHS Guidelines 7

8 Patient preference is important. What Should I Recommend? Side-effect profiles vary. Treatment Access: Convenient for us Inconvenient for smokers Past experience may predict future experience. Combination therapy is effective. Model for treating tobacco dependence Why variation in reach? Size of service and promotion budget Efforts to markedly increase reach use via revenue from tobacco taxes, health insurance or other sources have worked (up to 5-12%) Editorial comment: Taxing tobacco users on tobacco products and for healthcare while not providing treatment is a human rights and policy issue! Treatment Challenges Who does it? Who pays? Mainstreaming Overcoming Tobacco Control antitreatment biases Avoiding hyper-medicalization What the H*** are those 5 As again? 8

9 In Conclusion Effective treatments for tobacco dependence exist When made available without barriers and publicized, treatments are used Gap between effectiveness and use is a social justice issue 9