SMOKING CESSATION Smoking Cessation Sandi Mabry, CFNP Gretchen Johnson, PharmD 1 Dr Ammar Shah 2 An Old Arab Proverb Goals Smoking is good for you. The dogs will not bite you because you smell so bad; Thieves will not rob you at night because you cough in your sleep; You will not suffer the indignities of old age because you will die when you are relatively young. Dr Ammar Shah 3 Epidemiology Health/Financial consequences Strategies to help Pharmacology 4 Objectives 1. Awareness of the scope of the problem, both in numbers and in dollars 2. Identify health consequences of smoking 3. Be aware of counseling needs and how to assist in smoking cessation 4. Understand the benefits, side effects, efficacy,, and appropriate use of available pharmacology tools Epidemiology 2001 46.2 million adults current smokers with 81% being daily smokers Prevalence highest in the 9-129 years education group-61% Prevalence lowest >16 years education 10.9% More prevalent among the poor 32.5% More prevalent in 25-44 year age group 30% Trends in Tobacco Use,, American Association Epidemiology and Statistics Unit Research and Scientific tools 5 Affairs, June 2003 6 1
Of the current smokers ****************** 32 MILLION WANT TO QUIT! 1 million new smokers replace the 2 million who quit or die each year Epidemiology Kid Concerns 6000 youngsters try cigarettes daily By age 13, more than half of kids have tried smoking and 11% are smoking regularly By age 17, 77% have tried, and 28% smoke regularly Use of smokeless tobacco has grown 10 fold in 16-19 19 year old, is more common in rural areas, and more common in some sports 90% of adults who smoked started by age 21 and half of them had become regular smokers by age 18 Cigs 28%, cigars 14%, smokeless tobacco 6.6%, kreteks (4.2%), bidis (4.1%), pipes 3.3% 7 Thomas, Houston and Gabel, Lawrence, Treating Nicotine Dependence 8in Youngsters, Family Practice Recertification, Vol 17, No. 5, June 1995 Cigarette advertisement and teenagers There are multiple factors involved in the decision of young people to smoke (most people first smoke in adolescence). The reasons include: To identify with and to fit in with a peer group As an act of rebellion or independence, To promote a sensual image, or Because smoking is allowed or encouraged in the adolescent s family. Tobacco companies know this and base their marketing decisions in a given market on the prevalence of consumers at the different stages in that market. 9 Other Concerns Highest usage state: West VA 30% (all ages) Lowest usage state: NY 10.3% (all ages) Nevada highest death rate in adults attributed to smoking: 414 /100,000 Utah lowest death rate in adults attributed to smoking 150/100,000 If current figures persist, approx 6.4 million children (8,830/100,000) will die prematurely from smoking related disease Trends in Tobacco Use,, American Association Epidemiology and Statistics Unit Research and Scientific Affairs, June 2003 10 Other Concerns Smoking is the number 1 cause of preventable death in USA 10 million deaths since Surgeon General s s warning in 1964 440,000 deaths each year in US from tobacco Average of 13.2/14.5 yrs of life for males/females Only 37% smokers receive advice about quitting Trends in Tobacco Use,, American Association Epidemiology and Statistics Unit Research and Scientific Affairs, June 2003 11 Biggest Concerns Only 37% smokers receive advice about quitting, yet 2-5% of pts will quit with a single request If the provider spends 3-53 5 min counseling the pt, 5-8% smoke free in 1 yr Just these these two step translates into millions of pts stopping Danis,, Peter and Seaton, Terry, American Family Physician, Helping your Patients to Quit Smoking:, March 1997 12 2
Comparison Brief advice about smoking cessation is 30 times more effective than treating mild htn and 100 times more effective than treating hypercholesterolemia Economic Costs $150 billion dollars annually in medical cost, including $81.9 billion in mortality-related related productivity losses and $75 billion in excess medical expenditures Trends in Tobacco Use,, American Association Epidemiology and Statistics Unit Research and Scientific Affairs, June 2003 Danis,, Peter and Seaton, Terry, American Family Physician, Helping your Patients to Quit Smoking:, March 1997 13 14 The Health Risks of Cigarette Smoking Stroke Cancers of the mouth, throat and oesophagus Cancers of the larynx Coronary heart disease Chronic obstructive pulmonary disease Lung cancer Pancreatic cancer Ulcer Bladder cancer Cervical cancer Low birth weight baby Peripheral artery disease Prevalence of Smoking Cessation By 2001, close to 49.2 % of ever smokers 18 yrs and older had quit Proportion of former smokers higher among men: 51.1% men vs. 46.9% for women Proportion of former smokers increases with higher levels of education By 2001, 44.8 million adults were former smokers 15 Source: Smoke-free for Health, DOH (1994), from US Office on Smoking and Health, Centres for Disease Control and Prevention Report, (1990) Trends in Tobacco Use,, American Association Epidemiology and Statistics Unit Research and Scientific Affairs, June 2003 16 Indeed, it is difficult to identify any other condition that presents such a mix of lethality, prevalence, and neglect,, despite effective and readily available interventions 17 Fiore et al, U.S. Dept of Health and Human Services, June 2000 18 Figure from the Smokescreen project, Foothill College, Los Altos, California 3
The Five A s s of a Three-Minute Intervention Smoke-Free Families: www.smokefreefamilies.org 1) Ask about tobacco use 2) Advise patient to quit 3) Assess willingness to make quit attempt now 4) Assist by helping patient formulate quit plan 5) Arrange follow-up contact 1. Ask patients about tobacco use It is important to identify and document smoking status for every patient at each visit 19 20 2. Advise patient to quit Stress the importance of quitting Personalize your advice Example: This is the fourth time you have had bronchitis this year. Your smoking is affecting your health. Deliver a strong message Example: Quitting smoking is the most important way you can reduce your health risk. 21 3. Assess willingness to make quit attempt now, e.g., within next 30 days Establish how motivated the patient is can use a scale of 1 to 10 If your patient is willing to quit, make sure to provide assistance and make sure to offer intensive treatment (or refer patient if needed) If patient is unwilling to quit try to give motivation by looking at risks, rewards, and roadblocks Don t forget to see where your patient is in the Patient Stages of Change Figure from the Smokescreen project, Foothill College, Los Altos, California 22 4. Assist by helping patient formulate quit plan Encourage patient to: Set quit date within a few weeks Share decision with family and friends for support Anticipate challenges such as withdrawal during first few weeks Remove all tobacco products from environment 23 5. Arrange follow-up contact in person or by phone Timing of follow up Preferably during first week with the next follow-up contact by the end of first month Actions during follow-up contact Always congratulate success, no matter how small Assess pharmacotherapy use; consider more intensive treatment if needed If tobacco use has occurred, review circumstances surrounding this and try to get recommitment to total abstinence Remind patient a lapse can be a learning experience and review the lesson learned 24 4
The best way to stop smoking is to carry wet matches. Anonymous (Prochaska,, J. O. & DiClemente,, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, Vol. 51, pp. 390-395. 395.) Pre-contemplation - not interested in quitting Contemplation - more open to the possibility of quitting and how to do it Preparation - taking small steps in learning more about quitting, cutting down Action - quitting the habit, seeking social support, coping mechanisms Maintenance - smoke-free Relapse - return to smoking 25 26 Pre-contemplation Use relationship building skills Personalize risk factors Use teachable moments Educate in small bits, repeatedly, over time Contemplation Elicit reasons to change/consequences of not changing Explore ambivalence; praise client for considering the difficulties of change Question possible solutions for one barrier at a time Pose advice gently as a solution Figure from the Smokescreen project, Foothill College, Los Altos, California 27 Figure from the Smokescreen project, Foothill College, Los Altos, California 28 Preparation Encourage client efforts Ask which strategies the client has decided on for risk situations Ask for a change date Action Start the plan of action- possibly medications 29 Figure from the Smokescreen project, Foothill College, Los Altos, California 30 5
Maintenance Ask what s s been helpful and what s s been problematic Continue positive reinforcement 31 Relapse Remember, most patients DO relapse! Relapse is often accompanied by feelings of discouragement and seeing oneself as a FAILURE Patient should not see themselves as having failed.. Rather, they should analyze how the slip happened and use it as an opportunity to learn how to cope differently 32 Patient will incorporate change into daily lifestyle Patient will take decisive action client exits Stages of Change (adapted from DiClemente and Prochaska) Stage V Maintenance Stage IV Action Stage III Preparation Patient will discover elements necessary for decisive action Client enters Stage II Contemplation Patient not interested changing Patient will examine benefits & barriers to change 33 Motivational Interviewing (M.I.) (Rollnick,, S., & Miller, W.R. 1995) Motivational Interviewing is a directive, client-centered centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Motivational Interviewing uses empathy rather than confrontation. It acknowledges that the patient, not the physician, is responsible for changing behavior. 34 Five Principles of M.I. 1. Express Empathy 2. Develop Discrepancy 3. Avoid Arguments 4. Roll with Resistance 5. Support Self-Efficacy 1. Express Empathy Stage I Precontemplation Create a supportive, warm, patient- friendly atmosphere Acceptance fosters change Pressure to change blocks it Empathic, reflective listening is essential 35 36 6
2. Develop Discrepancy 3. Avoid Arguments Develop discrepancies between a patient s present behavior and the behaviors desired People are much more highly motivated to change when discrepancies exist between current behavior and desired personal goals Arguing tends to increase resistance rather than increasing motivation to change More resistance = Less likely to change 37 38 4. Roll with Resistance 5. Support Self-efficacy efficacy Don t Push!!! Opposing the patient s s resistance usually just reinforces the resistance. Rather.. Roll with the resistance while trying to shift the patient s s perceptions. Patients have to believe that they have the knowledge and skills or abilities to carry out the treatment plan Remember it is always the patient s choice whether or not to change 39 40 5 A s Precontemplation Contemplation Preparation Action Maintenance Stages of Change ASK Smoking status ADVISE Health effects Need for change ASSESS Readiness to quit Motivational Interviewing Express Empathy Develop Discrepancy Avoid Argumentation ASSIST In quitting Roll with Resistance ARRANGE Follow-up Documentation phone call (2 wks.) (Motivational Enhancement Therapy Manual, Vol. 2, 1999) Support Self-efficacy 41 It s the first time I ve seen him without a cigarette in his mouth. 42 7
As ye smoke, so shall ye reek. Ever wonder what happened to Joe Camel? - Anonymous, Reader's Digest 1949 Dr Ammar Shah 43 44 EBM Approach to Evaluating Drugs: Follow the STEPS Safety- ADRs, contraindications, drug interactions Tolerability- Pooled drop-out out rates Efficacy- RCTs with POEM outcomes Price- Overall cost of treatment Simplicity- Ease of administration Pharmacotherapy of Smoking Cessation Nicotine replacement therapy Bupropion (Zyban R ) 45 46 Nicotine Replacement Therapy: Safety Use in CV disease Don t t smoke while using NRT Try nonpharmacologic therapy first in pregnancy and lactation Keep patches in a safe place Dependence concerns with nasal spray Use inhaler with caution in bronchospastic disease 47 Nicotine Replacement Therapy: Tolerability Gum: nausea and dyspepsia Patch: mild skin irritation and insomnia Inhaler: mouth and throat irritation Nasal spray: mouth and throat irritation, rhinorrhea,, and nausea 48 8
Nicotine Replacement Therapy: Effectiveness All forms of NRT are effective Patient preference should guide choice of dosage form Not as effective as bupropion No additional benefit in adding NRT to bupropion alone USPHS Report. The tobacco use and dependnce clinical practice guideline. JAMA 2000;283:3244-54. Jorenby DE, et al. N Engl J Med 1999;340:685-91 91 49 Nicotine Replacement Therapy: Price Comparable to treatment with bupropion Patches are available OTC Drop in the bucket compared to long- term costs of continued smoking 50 Nicotine Replacement Therapy: Dosing and Administration Gum Chew and Park method 4mg strength is most effective Initial use of 10-15 15 pieces daily Taper use for 8-128 weeks of treatment Patch Apply to clean hairless site Taper dose down after 4-64 6 weeks for 8-128 weeks of treatment 51 Nicotine Replacement Therapy: Dosing and Administration Nasal spray: Start with 4 sprays per hour with max of 80 sprays per day Gradual taper of use for 8-128 weeks of treatment Inhaler: Best results seen with q 20 min puffing Start with 4 inhalers per day (500 puffs per inhaler) Gradual tapering of use for 8-128 weeks of treatment 52 Bupropion (Zyban R ): Safety Risk of seizures is small and can be minimized Don t t use > 300mg/d Don t t use in patients with a self or family history of seizures or with other risk factors for seizures, or with h/o psychosis Don t t use with MAOIs Bupropion (Zyban R ): Tolerability Patients dropped out of studies due to tremors and rashes Common side effects: insomnia, agitation, dry mouth 53 54 9
Bupropion (Zyban R ): Effectiveness Bupropion is more effective than nicotine patch No difference in efficacy between bupropion alone and bupropion/nicotine patch combination Bupropion (Zyban R ): Price Comparable to NRT Requires a prescription Insurance company reimbursement issues Cheaper than cost of continuing to smoke Jorenby DE, et al. N Engl J Med 1999;340:685-91. 91. 55 56 Bupropion (Zyban R ): Dosing and Administration Start while patient is still smoking Start with 150mg qd x 3 days, then increase to 150mg BID Stop smoking on Day 8 Treatment duration is 8-128 weeks If still smoking at 8 weeks, DC No need to taper The Bottom Line Bupropion should be first line therapy No need to combine NRT and bupropion 57 58 10